Implant Reconstruction

Your breast can be surgically reconstructed by putting in an artificial breast mound, known as an implant.

• Implant surgery
• Saline vs. silicone implants
• Advantages of implants
• Disadvantages of implants
• Risks of implants

How is Breast Reconstruction Using Implants Performed?

Synthetic implants are usually teardrop-shaped pouches that are placed under a layer of chest muscle to create the shape of a breast. The outside of the implant is made of silicone and it is filled with silicone gel or saline. Saline is another word for salt water. Silicone is an artificial material that feels like natural breast tissue.

The process of breast reconstruction using implants may involve one or two stages, often depending on the individual patient's breast size. For smaller breasted women, a single stage reconstruction may be possible. With this approach, the plastic surgeon places the silicone gel or saline implant in a pocket beneath the skin and muscle layers, at the location of the new breast. This surgery is usually performed through the old mastectomy scar.

Most commonly, implant breast reconstruction is carried out in two stages. The first stage consists of placement of a device called a " tissue expander." An expander is a silicone-walled pouch that resembles an empty balloon with a small valve in its front wall. This valve allows the surgeon to fill the implant with saline in the weeks following this initial operation. During the second stage, the tissue expander is replaced with an implant.

During the first surgery, the tissue expander is placed in a pocket beneath a chest muscle (the pectoralis major) and the overlying skin. The tissue expander must be used to enlarge the implant pocket to accommodate the size of the implant needed to match the opposite breast. This initial surgery takes approximately one to two hours.

At the end of the surgery, the side of the chest undergoing reconstruction will still be flat. Depending on your doctor's recommendations, this procedure can be performed on an outpatient basis or may require a hospital stay of one to two days.

Approximately 10 to 21 days following placement of the tissue expander, the process of tissue expansion will begin. Every one to two weeks, you will visit your plastic surgeon. During these 20- to 30-minute visits, approximately two to four ounces of saline (salt water) will be injected through the overlying skin into the valve located on the front wall of the tissue expander.

With each visit, the tissue expander is gradually inflated. The growing tissue expander enlarges the pocket, inducing growth of the overlying skin. In essence, this tissue expander grows the skin for the new breast. While the expansion process causes slight soreness or discomfort in some women, others report simply a feeling of "tightness" for several days following each expansion.

Approximately one to three months after the tissue expander has reached the correct size, you will undergo a second operation. During this surgery, the expander is removed and an implant is inserted in its place. The surgery lasts about one to two hours and is followed by a hospital stay of four to 24 hours.
This is done in a single operation that takes about one to two hours. Since a small implant is used, the surgeon may be able to insert it without additional operations to stretch the skin and muscles of the chest wall. The implant is placed under a layer of muscle, rather than directly under the skin, to ensure the most natural shape and feel of the reconstructed breast. This also helps to reduce formation of scar tissue around the implant.

In some smaller-breasted women, an implant may be placed in a space directly under a layer of chest muscle.

Saline vs. Silicone Implants

Should I Have a Silicone Gel or a Saline Implant?

Many plastic surgeons believe that silicone gel-filled implants have a more natural look and feel than saline implants. Silicone gel has a texture that is very similar to natural breast tissue. Saline implants, on the other hand, do not feel as soft.

However, silicone gel also has certain disadvantages. For example, silicone gel implant ruptures are harder to detect. When saline implants rupture, they flatten visibly. When silicone gel-filled implants leak, the breast often looks and feels the same. As a result, silicone gel may begin leaking into surrounding areas of the breast unnoticed. Also, replacing a ruptured silicone gel implant is more difficult than repairing a saline implant. This is because the silicone gel that has leaked outside of the implant should be removed (if possible).

There have been some reports in the media of various health problems as a result of silicone gel. In these reports, silicone gel has been associated with lupus, rheumatoid arthritis, scleroderma, neurological disorders, and other conditions. Silicone gel-filled implants were removed from the market to give scientists time to study the effects of silicone. However, researchers have found no evidence thus far supporting the connection between silicone gel breast implants and medical problems. Women who have silicone gel implants appear to have the same risk of disease as women who do not. Because of this information, silicone gel implants are beginning to be offered again by certain doctors. Still, the vast majority of breast reconstruction is done with saline-filled implants. You should be aware that even the saline implants are made of a silicone pouch filled with saline.

Advantages of Implants

• Implant surgery requires a shorter hospital stay and shorter recovery time compared with most other reconstruction options
  Because this approach requires less extensive surgery than other reconstruction methods, usually less recovery time is necessary. If you choose to have immediate reconstruction, you will likely stay in the hospital for one to two days after the combined mastectomy and tissue expander or implant surgery. When the reconstruction is delayed, your hospital stay will probably be about 24 hours. If you have a tissue expander, the second operation, in which the tissue expander is replaced with an implant, will require a hospital stay of four to 24 hours. Although every woman's recovery time is different, most women will be able to resume many of their regular activities after one week. After implant placement surgery, three to four weeks may be required before patients can perform more strenuous activities or return to work.

• Implant surgery produces relatively predictable breast shapes in most women
  Since implants are made in pre-set shapes, it may be easier (compared with flap reconstructions) to predict what the reconstructed breast will look like. Therefore, you may have more realistic expectations about the surgery.

• Implant surgery leaves fewer scars
  Reconstruction with implants usually results in only one or two scars around the breast. Often the mastectomy scar is used as the site of the new incision so you will have no additional scars after the reconstruction.

Disadvantages of Implants

• Implant surgery may give a less natural breast shape
  It may be more difficult to ensure that both breasts are the same shape when implants are used. Implants do not allow the same degree of sculpting and shaping as natural tissue. As a result, the breast with the implant and the natural breast may not look exactly the same. Implants also do not feel completely natural to the touch.

• Implant surgery may be time consuming and inconvenient
  If a tissue expander is needed, additional surgery and frequent doctor visits will be necessary. You must consider if you have the time and patience to undergo another surgery, hospitalization, and recovery period. You also need to think about whether you can attend doctor appointments every one to two weeks.

• The results of implant surgery may not be immediate
  If a tissue expander is needed, you will not wake up from the initial surgery with a new breast. This can be disappointing if you are eager to see your new breast. If a tissue expander is required, it takes four to six months for breast reconstruction to be completed. During this time, one breast is bigger than the other, creating a "lopsided" effect. This may make you feel awkward or uncomfortable with your body. It may also limit the clothing you wear and the activities in which you participate. You may choose to wear a prosthesis or pad your bra to make your breasts the same size. However, this may not work if you are especially active.

• If you have had radiation therapy, your skin may not respond well to the tissue expander
  Radiation tends to cause scarring in the radiated skin on your chest. This skin may not stretch well during tissue expansion, making the process more difficult.

• Complications with the implant may develop
  About two to four women in 100 develop an infection near their surgical incision soon after the operation. Another two in 100 may experience bleeding ("hematoma") or fluid collection ("seroma") under the breast skin after surgery.

• Implants may also develop complications over the long term
  The most common complication is leakage or rupture. This happens in approximately 10% of cases over the first 10 years. (No data yet exist to track the life of an implant after the first 10 years.) When this occurs, the implant must be removed or replaced. This surgery lasts from 30 minutes to 1 hour. It may be done on an outpatient basis or require an overnight stay. If the implant was filled with silicone gel, more extensive surgery, lasting at least one hour per implant, may be needed to remove as much silicone as possible from the breast area.
  
  The second most common complication is encapsulation or "capsule formation." Scar tissue forms on the outside of all artificial implants when placed in the body. Usually, this does not pose a problem. However, in approximately 5-10% of cases, too much scar tissue forms. This may occur more frequently with silicone implants than with saline implants. The scar tissue may cause pain and discomfort and make the implant feel hard to the touch. When this happens, surgery may be necessary to break up or remove the scar tissue. It may also be necessary to remove or replace the implant. Capsules can form at any time, from a few weeks to many years after the implants are inserted.
  In about 7 cases out of 100, the implant shifts relative to the breast tissue sometime after the surgery, causing a "wrinkle" or "dent" in the shape of the final breast reconstruction ("contour irregularity").

• Silicone gel-filled implants are not available at all hospitals
  There have been some reports in the media of various health problems as a result of silicone gel. In these reports, silicone gel has been associated with lupus, rheumatoid arthritis, scleroderma, neurological disorders, and other conditions. Silicone gel implants were removed from the market to give scientists time to study the effects of silicone gel. However, researchers have found no evidence thus far supporting the connection between silicone gel breast implants and medical problems. Women who have silicone gel-filled implants appear to have the same risk of disease as women who do not. Because of this information, silicone gel implants are beginning to be offered again by certain doctors. Still, the vast majority of breast reconstruction is done with saline-filled implants. You should be aware that even the saline implants are made of a silicone pouch filled with saline.

• Implants do not change to match changes in body weight
  Implants do not change size or shape. This means that the size and shape of your reconstructed breast will also remain the same, regardless of changes that may occur elsewhere in your body. Consequently, if you lose or gain weight, your breasts may seem disproportionate to your new body shape.

Implants: What are the risks?

• Rupture and Leakage
  The silicone shell of the implant may break, causing the saline or silicone gel inside to leak out into the surrounding breast tissue. This happens to about 10% of women during the first 10 years after implant surgery. (No data exist to track the frequency of ruptures after the first 10 years.) Another surgery must then be done to remove or replace the implant.

• Capsular Contracture
  Too much scar tissue may form around the outside of the implant, causing discomfort and making the breast feel hard. This can happen at any time, from several weeks to several years after the surgery. Another surgery must then be done to remove or replace the implant.

• Contour Irregularity (Wrinkling)
  The implant may shift relative to the breast tissue, causing a "wrinkle" or "dent" to form in the shape of the finished breast reconstruction.

• Infection
  The surgical incision may become infected soon after the surgery.

• Hematoma or Seroma
  A pocket of blood ("hematoma") or blister fluid ("seroma") may form under the breast skin soon after the surgery.