Implant Reconstruction

Breast implants, both saline and silicone, have been used for breast reconstruction surgery for more than thirty years. After a mastectomy, implant reconstruction is achieved by inserting a breast implant into the vacant breast envelope after the breast tissue is removed. There are three different techniques that can be utilized:

  • Expander-implant
  • Direct-to-implant
  • Pre-pectoral reconstruction

In these techniques, acellular dermal matrix (ADM) (a supportive medical product for soft tissue reconstruction) may be required. It is important to consult with Dr. Tanna to decide which implant and reconstruction operation will be most appropriate for your unique condition.

Expander-Implant Breast Reconstruction

The most common approach to implant based breast reconstruction is with a two-stage technique. In this approach, inserting the final breast implant requires two different procedures. During the first surgery at the time of the mastectomy, a temporary saline-filled device (tissue expander), capable of stretching the overlying skin, is inserted under the breast skin and the pectoralis muscle. This will create a soft pocket that will eventually contain the breast implant.

After healing, typically a few weeks after surgery, expansion of the device starts. This is an in-office procedure that proceeds over a period of 2 to 3 months through simple injections of saline or air into the valve of the expander. Expansion will be completed once the expander reaches the desired size of the implant to be placed. During a second, outpatient surgery, the expander will be removed and replaced with the permanent saline or silicone implant.

Direct-to-Implant Breast Reconstruction

This procedure is a single-stage reconstruction that directly inserts the implant at the time of the mastectomy. Women who are ideal candidates for this option do not require tissue expansion because the size of the soft pocket at the time of mastectomy is healthy and safe enough to fit the final implant. While the implant is most commonly placed under the pectoralis major muscle, the use of an acellular dermal matrix (ADM) is often required to help hold the implant in place.

Pre-pectoral Reconstruction

In this breast reconstruction surgery, implants are typically placed under the chest muscle (pectoralis major) to cover the implant with as much soft tissue as possible. Since the implant is placed under the muscle, chest muscle will be manipulated during the operation, which can lead to increased pain or discomfort. As the chest muscle heals, it may cause an animation deformity (excessive movement or shape distortion) in some select patients.

This means that the implant may move or stiffen every time a patient uses specific chest muscles. Pre-pectoral implant insertion places the implant above the chest muscle and uses an acellular dermal matrix to cover the implant. This reconstruction does not require surgeons to cut through the chest muscle and can limit the complications that can occur during healing. However, not all women are ideal candidates of pre-pectoral implant insertion. It is necessary to consult with Dr. Tanna to discuss this highly specialized option.

Acellular Dermal Matrix: Breast Reconstruction Support

When inserting implants into the breast envelope, it is important to ensure that the implants do not move or fall out of place after insertion. This will help reduce the risk of certain complications that could potentially require additional surgery. To facilitate this, a product called acellular dermal matrix (ADM) is used as an internal supportive layer that protects and holds the implants in place.

ADM is created from a collagen layer of human skin derived from donated skin tissue. Once ADM is placed in the correct position, it will be incorporated into the surrounding tissue by the body's regenerative processes. The use of ADM offers many advantages, such as more precise pocket development and better coverage of the implant. In addition, ADM comes in different sizes and shapes, which allows surgeons to customize it to the specific needs of a patient. It is important to remember that there is risk when using ADM, including seroma (fluid infection), infection, and erythema (red breast skin).

Type of Implants Used in Breast Reconstruction Surgery

There are two basic types of breast implants: saline and silicone. In both types of implants, the outer shell is composed of silicone, but they differ in the substance used to fill the implant. Saline implants are filled with saline, a saltwater solution that is found in IV fluids.

When reconstruction is performed, the saline implants come deflated and are then filled to the desired volume during surgery. Silicone implants come pre-filled with silicone gel. The implants are then placed into the soft pocket of the breast envelope during surgery.

Shapes and Sizes of Breasts in Breast Reconstruction

Breast implants also come in a variety of shapes and sizes that vary in projection and base width. During your consultation with Dr. Tanna, the best implant type, size, and shape for you will be determined. Factors affecting the type of implant selection include your body shape, breast skin, and characteristics of the soft tissue envelope formed by the breast skin and chest muscle after a mastectomy.

Complications from Implant-Based Breast Reconstruction

Breast implants are "safe," according to the best information available today. That does not mean that the body will not react to this foreign material. There are three risks associated with implants. These include:

  • Infection
  • Capsular contracture
  • Implant leak

Unlike reconstruction using natural breast tissue, the body reacts to a breast implant by isolating it (forming a capsule or scar around the implant). This is a normal response to any foreign material. However, in certain instances, this normal capsule can tighten and abnormally harden, squeezing the implant into the smallest possible space. This is called capsular contracture, and can be both physically uncomfortable and aesthetically unattractive.

Both implant manufacturers and plastic surgeons take elaborate steps to try and avoid breast implant associated complications. Even with advances in breast implant technology and surgical techniques, a breast reconstructed with an implant can become hard, contracted, and misshapen. The firmness also can be uncomfortable in many women. Breast implant infections and leaks can also occur.

Implants vs. Flap Reconstruction: Pros and Cons

The following summarizes the two different types of breast reconstruction techniques:

Implant Reconstruction:

  • Less able to look and feel natural
  • Breast volume can be decided by the patient
  • Some loss of sensation
  • Shorter surgery (4 to 6 hours)
  • Implants need replacement after several years
  • 1 to 2 nights in the hospital, with 2 to 4 weeks of recovery time
  • Complications are infection, hardening of implant (capsular contracture), and implant leakage

Flap Reconstruction:

  • Looks and feels more like natural breast
  • Flap donor site determines volume
  • Some loss of sensation in breast and flap donor site
  • Longer surgery (6-8 hours)
  • Tissue flaps do not need to be replaced.
  • 2 to 3 nights of hospital stay, with 4 to 6 weeks of recovery time
  • Complications are flap loss (<1%) or those from the flap donor site

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