Types of procedure
Implant reconstruction is a relatively simple procedure and involves the placement of a silicone or saline implant beneath the muscle of the chest wall. Surgery can be completed within 2-3 hours and recovery time can be shorter as surgery is confined to one area of the body.
Implant reconstruction is suitable if you are having surgery on both breasts at the same time, or if you are unable to withstand a lengthy surgical procedure.
An implant can occasionally be inserted as a delayed reconstruction if the implant is small, otherwise an expander would need to be inserted first to stretch the skin. An expander can also be used as a temporary solution if you require radiotherapy.
Scars are usually placed in the central portion of the breast but in the case of nipple sparing mastectomy, the incision will be underneath the breast.
The results can be very nice for smaller pert breasts with firm skin. On the other hand, if the other breast is large, droopy and has softened from breast feeding several children, the result achieved will be symmetry in a bra, unless you have something done to the other side. In such cases the other breast can be firmed up with an implant as well, or lifted or reduced if you want to obtain a better match.
Implants are man-made, and will feel firmer than normal breasts. As such you will not have the same droop as a natural breast, and may look quite different without a bra. It is worth remembering that implants do require replacing after a period of time. This will depend on the quality of implant used, the build up of scar tissue round the implant (capsular contracture) and potential damage or rupture to the implant.
There may be some limitations in arm movement for four to six weeks. Complications can include bleeding, infection, asymmetry, extrusion of the implant and progressive firmness of the reconstructed breast capsule (capsular contracture).
Often the placement of an implant is not possible because the skin is too tight after a mastectomy. In this case new tissue must be created either by expansion of the chest wall muscle and overlying skin, or transfer of a flap of healthy tissue from elsewhere on the body.
Tissue expansion is accomplished under a general anaesthetic by the placement of a “tissue expander” beneath the muscle of the chest wall.
Expanders initially resemble a flat balloon. During visits to the outpatient clinic over six to twelve weeks, sterile salt water is injected into the expander to stretch the surrounding skin to the point where the pocket is big enough to accept the appropriate sized implant.
Effectively this slowly stretches the skin. There is some discomfort with each expansion but you can usually continue normal activity.
Removal of the expander and placement of the final permanent implant is done during a second anaesthetic. Some types of expander don’t need to be changed and they can stay in. They are usually a mixture of silicone and saline. This will be discussed with you by your breast/plastic surgeon.
Patients with irradiated skin or excessively thin skin are not usually candidates for tissue expansion as the tissues will not stretch but this can be discussed with your individual surgeon. Complications are unusual but can include breakdown of the tissue during expansion, infections, bleeding, asymmetry and firmness of the reconstructed breast.
A newer technique with implant reconstruction employs a material derived from pig or cow skin that has been treated, processed and preserved so it can safely be left in the human body. The surgical mesh (called an acellular dermal matrix) looks like a very thin white leather and provides a ‘hammock’ that cradles the breast implant, helping to create a natural droop shape and contour.
The mesh is attached to the pectoralis muscle in the chest making a cavity in which the implant can be placed. This method can be used to achieve a one stage implant reconstruction with mastectomy. Sometimes tissue expansion is still needed. The technique is not available in all hospitals.
The most commonly used ADMs in UK hospitals are Strattice® (porcine) and Surgimend® (bovine). Other synthetic meshes are available in some centres e.g. TiLOOP® (titanised mesh), Vertias, BioDesign and TIGR Mesh.
The most appropriate mesh for you will be discussed during your consultation.
These techniques are most suitable for patients who do not need or wish to undergo flap based autologous reconstruction; patients requesting bilateral mastectomy with immediate breast reconstruction; risk-reducing surgery.
The reported benefits are better aesthetic outcome (more natural look) and a shorter timescale to the final result (potentially one procedure and fewer outpatient visits).
These techniques are not often recommended in patients needing post-operative radiotherapy, patients with a high body mass index (>30); smokers. All of these factors carry an increased risk of complications.
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