Pharmacological enhancement of tissue expansion for breast reconstruction

Tissue expander-based breast reconstruction is widely used following mastectomy due to its relative technical simplicity, minimal additional anesthesia, and reversibility. However, complications such as tissue necrosis, impaired vascularity, postoperative pain, and infections are frequent. Pharmacological interventions have been explored to improve tissue viability and reduce these complications. A literature search was performed in PubMed, Scopus, and Cochrane Library, focusing on clinical and preclinical studies investigating pharmacologic agents applied topically or systemically in tissue expander breast reconstruction. Studies on autologous reconstruction, direct-to-implant procedures, cosmetic surgeries, systemic antibiotic prophylaxis, or unrelated drug effects were excluded. Eight studies met the inclusion criteria, including retrospective cohort studies, prospective trials, randomized controlled trials, and preclinical investigations. Agents examined included botulinum toxin, deferoxamine, nitroglycerine, dimethyl sulfoxide, and local antibiotics [absorbable beads or polymethyl methacrylate (PMMA) disks]. Botulinum toxin showed limited evidence for postoperative pain reduction. Deferoxamine increased vascularity and tissue elasticity, especially in irradiated tissue. Nitroglycerine paste reduced mastectomy flap necrosis. Topical Dimethyl sulfoxide (DMSO) improved expansion dynamics and dermal collagen architecture. Local antibiotic delivery significantly decreased infection rates and expander loss, including in patients with skin necrosis. Overall, pharmacological strategies demonstrate potential to enhance tissue viability, minimize complications, and optimize outcomes in tissue expander-based breast reconstruction. Local antibiotic prophylaxis, topical agents, and vascular modulators appear particularly promising. Nevertheless, evidence remains limited by small sample sizes, heterogeneity of study designs, and the inclusion of some preclinical data. Further prospective, controlled trials are warranted to standardize protocols, confirm safety, and evaluate long-term clinical efficacy.