Implant Breast Reconstruction
What is Implant Breast Reconstruction?
Implant Breast Reconstruction provides a solution for restoration of volume and shape with silicone or saline filled breast implants. The implant is inserted at the time of mastectomy and is placed beneath the pectoral muscle. It is supported by a “sling” or “internal bra” made up of collagen sheeting known as “dermal matrix”. The material is composed of “collagen” much like that used to inject into the face and lips for cosmetic enhancement. Its purpose is to keep the implant in position so that it doesn’t fall to the side of the chest. The dermal matrix also helps protect the skin that is left fragile at the time of mastectomy. The improved coverage thickness in the lower part of the breast can make the implant less palpable and it is thought to help reduce the risk of capsular contracture.
Implant breast reconstruction works best when completed at the same time the mastectomy is done (“immediate reconstruction”). This is appropriate for women who do not require removal of their breast skin and a skin sparing or nipple sparing mastectomy is planned. This allows direct to implant or what is sometimes referred to as “single stage” implant reconstruction. This technique allows your surgeon to avoid the use of “tissue expanders” and to position the proper implant right away on the day the mastectomy is completed. The benefits of this approach are numerous and are explained below.
Surgeons at the Center For Restorative Breast Surgery are of the general opinion that implants should very rarely, if ever, be considered as the first choice for women who have undergone mastectomy with excision of their breast skin prior to seeking reconstruction. This is known as “delayed reconstruction” and implants tend to perform poorly for most women who attempt reconstruction with an implant only in the “delayed setting.” This is primarily the result of the fact that most women who undergo mastectomy without immediate reconstruction have most, if not ALL, of the breast skin cut away with the breast tissue. The initial benefit of this smooth chest wall allows for easier prosthesis placement in the bra but the downside is that the remaining skin has to be “expanded” to fit an implant under it. “Tissue expanders” and the expansion process are used to stretch the remaining chest skin. Expanders are basically temporary implants that are put in flat and then inflated with a needle over several weeks after surgery. The expansion process is often painful, takes weeks if not months to complete, and typically produces a dome-like shape that is disappointing in the end. Expansion also tends to distort the underlying rib cage as pressure is increased and in rare instances, rib fractures have been reported.
For women who seek “delayed reconstruction”, natural living tissue tends to work better overall. The DIEP, APEX FlapSM, SGAP, BODY LIFT FLAP®, and Hybrid Breast Reconstruction procedures are much more suited to provide quality outcomes for delayed reconstruction because they allow replacement of breast shape, volume, AND the skin that was removed on the day of the original mastectomy. This completely avoids the expansion process is more effective, more efficient, and generally, produces better long-term outcomes.
Even very thin women seeking “delayed reconstruction” may benefit from natural tissue reconstruction techniques such as those pioneered at The Center For Restorative Breast Surgery.
Either silicone or saline filled implants may be used for Implant Breast Reconstruction. Saline implants tend to be more palpable and gel implants tend to feel more natural. Both may have ridges or wrinkles that are detectable to the touch. Gel implants come in a wide variety of shapes and textures. Most silicone implants on the market today are “cohesive” which means that the internal gel is stable and prone to stay in place even if the implant leaks. Style “410” or “gummy bear” implants are even more structurally stable to support their “teardrop” shaped design. They are a bit firmer to the touch than an ordinary cohesive gel implant as a result. Consult with your surgeon to determine the best choice for you.
Other options for the thin woman who prefers a breast made up entirely of natural tissue without implants are the BODY LIFT Flap®, SGAP, & Stacked FlapSM breast reconstruction procedures.
The surgeons who make up our team at The Center For Restorative Breast Surgery are experts at ALL forms of breast reconstruction, including implant reconstruction. This allows the best possible procedure to be tailored to you individually.
When is Implant Breast Reconstruction Used?
Implant Breast Reconstruction is used when the conditions are favorable after mastectomy to produce a quality outcome with a breast implant. This is generally in the setting of “immediate reconstruction” as explained in the section above. Immediate reconstruction is made possible by the preservation of the breast skin which is then closed over the implant. Skin-sparing and Nipple-sparing mastectomy provide the proper conditions for an immediate implant reconstruction. Better candidates are those with moderate sized breasts, thick skin, non-smokers, and those with early breast cancer or need for prophylactic mastectomy. Larger implants tend to be heavier and produce more stress on the surrounding tissues. Natural tissue breast reconstruction is often a better choice for the very large breasted patient.
For women seeking Nipple Sparing Mastectomy (NSM) as a part of their treatment plan, special considerations are worth noting relative to Implant Breast Reconstruction. NSM and immediate reconstruction may be considered in women with active disease as well as those seeking risk reduction mastectomy. If the nipple is very low on the breast before mastectomy (“ptosis”), you should understand that an implant reconstruction won’t allow the nipple to be raised up on the breast mound after surgery. In cases with significant breast drooping, implant breast reconstruction alone may require cutting the nipple away with the mastectomy to tighten the skin around the implant. This is where natural tissue reconstruction with living fat provides a special advantage for women who desire a Nipple Sparing Mastectomy and have low nipples or breast sagging.
In 2015 our surgeons at The Center For Restorative Breast Surgery pioneered a technique that allows women with every degree of breast droop, ptosis, nipple position, and breast size to be candidates for nipple sparing mastectomy. The addition of natural tissue gives new blood supply to the preserved nipple and allows complete breast lift, reduction, and any shaping desired to occur after a nipple-sparing mastectomy. This cannot be done effectively with implant reconstruction since the implant under the nipple gives no blood supply to it. Attempts at significantly repositioning the nipple higher on the breast after implant reconstruction risks complete nipple necrosis. For further explanation, see video below:
READ TRANSCRIPT
Dr. Frank Dellacroce (00:10):
Hello, I’m Dr. Frank Dellacroce, founding partner at the Center for Restorative Breast Surgery. Today I’m gonna share with you an important discovery we’ve just published that concerns an advancement that allows us to produce results that were once thought impossible. In the world of reconstructive microsurgery for mastectomy, this discovery concerns nipple sparing mastectomy and the evolution of breast cancer care. Nipple sparing mastectomy and breast reconstruction is fairly straightforward when the breasts are near perfect shape to begin with. But what about women with imperfect breasts? Breasts that sag drew or have shapes that don’t lend themselves well to nipple sparing mastectomy. In the case of the well shaped breast, the mastectomy surgeon simply makes an access incision and removes the breast tissue from beneath the skin, preserving the properly positioned nipple and the surrounding skin envelope. The plastic surgeon simply places the implant in the preserved pocket with a spared nipple and closes the skin over it.
(01:14):
But breast cancer isn’t just a disease of women with well shaped breast and proper proportions. Women with breasts that drew are our oversize historically have been excluded from the benefits of nipple sparing mastectomy. That is up until now. Today we’re very excited to present our discovery recently published in the Journal of Plastic and Reconstructive Surgery. In it, we describe a technique that allows us to include these women, and it further describes why implant reconstruction is not always the best method for someone who’s seeking the benefits of a nipple sparing mastectomy. So let’s look at these women who are excluded in the first place and find out what we did to include them. It starts with the fact that mastectomy not only removes breast tissue, but it also removes the blood supply that that breast tissue brings to the overlying skin and nipple. And so without that blood supply, surgeons have had no way to reposition the nipple without losing the last remaining source of blood flow from the surrounding skin.
(02:27):
Since breast implants add no support of the nipples blood supply needs, tightening the skin or reducing the breast size has typically required cutting the nipple away and tightening the remaining skin around the implant. So that means that implants are not always the best way to rebuild a breast, particularly when you want to have a nipple sparing mastectomy. The breast issue is still removed from beneath the skin. A nipple just as was shown a few moments ago, but instead of using an implant to rebuild the breast, we use living tissue that is transplanted from excess in the tummy or hip region. And over the years, with careful study, we realized that these procedures bring an unexpected, surprising and almost magical benefit to nipple sparing mastectomy that implants cannot deliver. And up until now, no one was aware of this. Living tissue creates new blood vessels that grow into the breast skin and nourish the preserved nipple just as the breast tissue did before it was removed.
(03:33):
So these sophisticated microsurgical procedures create a fully living breast that we can then reshape and remodel just like a natural breast. This means we found a way to combine nipple sparing mastectomy and breast reconstruction in a way that allows us to fully lift and reshape the breast to produce results that were once thought unachievable. So let’s consider a patient with right breast cancer and a drooping breast shape. With this breakthrough, we are now able to offer her the benefit of nipple sparing mastectomy and rebuild her breasts for her with micro surgically transplanted living fat, all while preserving her nipple and producing a transformative result. A second young lady with bilateral mastectomy with large sagging breasts. With this discovery, we’re able to offer her nipple sparing mastectomy. Now she’s thin, so we transplant a bit of tissue from her hip and micro surgically rebuild her breast, allowing the production of a result that is otherwise unachievable.
(04:45):
I cannot overstate the importance of this discovery. So I’m gonna leave you with three takeaway points that I hope will help you are that you’ll share with someone who might benefit from this breakthrough. First, long incisions across the chest no longer have a place in modern breast cancer care, and many if not most women are candidates for nipple sparing mastectomy, whether it be for preventive reasons or to treat active breast cancer. Secondly, implants are not always the best choice to rebuild a breast loss to cancer, particularly if you want to have a nipple sparing mastectomy. In the United States, implant reconstructions are performed on more than five times the number of women who have reconstruction with their own living tissue. This is largely because we don’t do a good enough job explaining the benefits that living tissue can bring to a reconstructed breast and the magical impact it has for a woman seeking nipple sparing mastectomy. Third and last is the good news that women with sagging or drooping breast shapes are a large size are now to be included as candidates for nipple sparing mastectomy. It’s been a pleasure sharing this information with you today. For more detail, look for us on the web at www.breastcenter.com. I’m Dr. Frank Dellacroce, and in the spirit of health, wellbeing and progress, I wish you well.
When the breast skin has been previously removed with mastectomy in the past, natural tissue reconstruction is a better choice in most every case. The surgeons at The Center For Restorative Breast Surgery do not generally recommend efforts at implant reconstruction for women seeking “delayed breast reconstruction” as noted above.
Implant Breast Reconstruction is appropriate to consider for women with breast cancer as well as those seeking risk reduction surgery and mastectomy for BRCA gene positivity.
Women who require radiation after mastectomy or who have had radiation in the past are generally poor candidates for implant reconstruction. Radiation tends to make the skin more fragile and less pliable and, as a result, increases capsular contracture (firming up/distorting/chronic pain) significantly with implant reconstruction. There is agreement, among most experts, that the combination of implant reconstruction and radiation therapy makes unsatisfactory long-term results much more likely. When radiation is a part of the treatment plan, or it has occurred in the past, natural tissue reconstruction provides many benefits and is usually a better choice over implant reconstruction.
What are the Benefits?
There are several benefits of Implant Breast Reconstruction. For women who understand the risks of breast implants and are proper candidates for their use, implants can provide the opportunity to restore breast volume and shape after a mastectomy. Implant breast reconstruction is usually a slightly shorter procedure than natural tissue reconstruction techniques. Our Center surgeons are experts at both methods and very efficient with technique, so the time differences are not substantial. Implant reconstruction doesn’t require healing in a separate donor site and hospitalization is usually a day or so less than natural tissue procedures. Time back to activities is usually around 3-4 weeks compared to 4-6 with most natural tissue techniques.
Implants come in all sizes, so those who are thin, with little extra fat, may benefit from consideration of implant reconstruction. Recent advances pioneered at The Center For Restorative Breast Surgery, including the Stacked FlapSM, BODY LIFT Flap®, and Hybrid breast reconstruction procedures have opened the door to women who are thin and desire reconstruction with their own natural tissue and may be considered as an alternative to implant reconstruction.
What are the Risks?
Women who choose Implant Breast Reconstruction should understand the risks and potential maintenance requirements of modern breast implants. The FDA recommends screening for “silent rupture” of silicone implants using MRI. Women are advised to undergo imaging at 3 years post-implantation and then every 2 years thereafter. You should also continue to receive routine follow-up with your physician as recommended by your care team.
As with any surgery, the risks of surgery can be minimized by carefully following your pre-surgical and post-surgical instructions. Implant Breast Reconstruction must be very carefully monitored after surgery to minimize the risk of infection. If an infection does occur after implant reconstruction, the implant usually has to be removed for a period of time before it can be replaced. Antibiotics alone, are often not enough to clear an infection around a breast implant. Natural tissue reconstructions tend to perform better in the face of minor infections as they have their own internal blood supply to deliver medications and oxygen throughout the structure of the new breast.
Breasts reconstructed with implants typically have a tendency to move and distort shape when flexing the chest muscle. This “Dynamic distortion” is seen when the skin of the breast over the implant wrinkles and becomes misshapen with the movement of the pectoral muscles. This isn’t harmful but is something that should also be anticipated. A special benefit of combining natural tissue with an implant reconstruction can be the reduction of “dynamic distortion”.
The Hybrid Breast Reconstruction technique helps minimize this phenomenon when an implant is part of the reconstructive plan by placing a layer of living fat between the skin and the pectoral muscle. This softens the look of the implant reconstruction and provides better softness and touch characteristics to the new breast compared to implant-only reconstructive techniques.
Other specific risks of adding a breast implant to your reconstructive plan can include “capsular contracture” which is the body’s response to a foreign material implanted beneath the skin. Although relatively rare, the result can be a distorted shape and in some cases chronic pain. Women who undergo radiation therapy as a part of their overall treatment have a very high incidence of capsular contracture with implant reconstruction.
Additional risks include the possibility of implant rupture. Modern implants are more durable than those of the past but they can still fail and need replacement. The likelihood of this for an individual is unpredictable and varies patient to patient. If your implant ruptures, it is replaced surgically with a new one at your convenience. Saline implants show volume loss in the breast if the fluid leaks out. The liquid content is salt water and is absorbed harmlessly by the body. Silicone implant leaks can be harder to detect and MRI screening for “silent rupture” is recommended by the FDA as noted above.
Implants have not been determined to interfere with cancer screening and have been judged to be otherwise safe a part of modern breast reconstruction
If you have other medical problems or items that increase your risk, we will work with you to educate you on proper preparation and arrange your clinical care to maximize your safety and proper recovery.
If you have other medical problems or items that increase your risk, we will work with you to educate you on proper preparation and arrange your clinical care to maximize your safety and proper recovery.
What to Expect Throughout the Implant Reconstruction Procedure Process
PRE-SURGERY OFFICE VISIT
In most cases, you will be seen in our office 1-2 days prior to your surgery. At that time, we will go over the planned procedure, review consents, answer any questions you may have, and apply any surgical planning markings as may be required.
THE OPERATION
When you arrive at the hospital, you will be escorted to the preoperative holding area where you will change into a gown and be given foot coverings. The nurse or anesthesiologist will start an IV so that fluids and necessary medications may be given to you. Family members will be allowed to visit with you in the preoperative area once you are prepared for surgery. After your surgery is complete, you will awaken in the recovery room under warm blankets with a dedicated nursing attendant at your side. You will be carefully monitored and kept comfortable. You will then be transferred to a private inpatient room that is prepared to allow you to rest and recover under the supervision of your attending physician and nurses. One adult caregiver may stay with you overnight during your hospitalization. A fold-out Murphy bed has been integrated into your room for their individualized comfort.Your procedure will be performed in a state-of-the-art operating suite that is part of a fully accredited hospital that has been recognized by the American College of Surgeons for Excellence in care quality. Highly trained professionals using the most modern equipment and techniques will attend to you. In addition to your surgeons, the surgical team includes anesthesiologists, operating room technicians, nurses, and physician assistants.
Returning Home Post-Operation
If you are traveling from out of state or internationally for care with us, your caregiver will need to be with you throughout your stay post-discharge and on the same flight home to assist you in the airport. Your caregiver’s education will be provided by our nursing staff during your time with us and our team is available to you and your assistant 24 hours/day should any questions arise after you are released from the hospital. Your arrangements for assistance after surgery should include an estimated seven to ten days of availability from your caregiver.
We Are Here For You
Be reassured that you are being attended to by some of the most highly skilled and dedicated healthcare providers in the world. Do your best to relax knowing that we are going to take excellent care of you from the moment you enter our facility. Do not hesitate to ask for any special needs you may have.
