BREAST RECONSTRUCTION - BREAST IMPLANTS
Breast implants provide a very attractive option when reconstructing the breast after mastectomy. The operative time is shorter than the other methods of breast reconstruction and there are no extra scars. However, there are drawbacks. If the implant becomes exposed or infected, then it will need to be removed, although it may be replaced later. All implants develop a capsule around them of scar tissue, which in time can contract (capsular contracture) and make the implant feel hard, look unsightly and may be uncomfortable. If capsular contracture occurs, then you may choose to have the capsule removed and the implant exchanged. If there has been radiotherapy to the chest wall, then the formation of the capsule is accelerated and so implant only reconstructions are not recommended if radiotherapy has been given or is planned.
There is a limitation to the size of implant that can be used based on the diameter of the chest wall and so implant reconstructions are best suited to patients with small breasts. One of the other drawbacks of implant reconstruction is the lack of ptosis or droop. This means that there may be some asymmetries when out of a bra, with the reconstructed breast not moving and the other breast having a natural flow. For this reason, a patient with small breasts needing a bilateral breast reconstruction is an ideal candidate for implants.
When reconstructing the breast with an implant, the implant is placed underneath the pectoralis major muscle so that it has some extra soft tissue covering it. This space may be tight and so an expandable implant may be used. These have an injection port that can be gradually inflated in the outpatient department on a weekly basis for 3-6 weeks.
One-stage implant reconstruction
The one-stage procedure involves the use of an adjustable implant, which is placed underneath the skin and pectoralis major muscle (the pec). The aim is to get as complete a muscle coverage as possible to minimise the risk of visible or palpable knuckles or ripples (rippling) in the implant. These implants are composed of silicone gel with a central chamber that can be inflated with saline, usually through a remote port. The port is attached to the implant with a tube and is placed underneath the skin where it can be easily accessed and inflated with a needle and syringe (often in the armpit). Once the implant has reached the desired volume, the injection port can be removed with a short operation under local anaesthetic.
Two-stage implant reconstruction
My preference is to perform the operation in two stages. The first stage involves putting in an tissue expander to stretch the skin and the second stage involves replacing the expander with a fixed volume implant. Expansion of the implant is done through and injection port, which is usually part of the implant itself. You may be given a magnet to bring with you to the outpatient clinic to aid location of the metal port lying underneath the skin. The implant can then be inflated a small needle and syringe.
This has the advantage over the one-stage technique of allowing adjustments to the breast pocket in the second stage, such as repositioning the implant or redefining the inframammary fold. It has the disadvantage of needing two operations.
One-stage implant reconstruction with Strattice®
Strattice® is a material that allows a one stage reconstruction without the need for any tissue expansion. This is because tissue expanders are used, not to expand the skin (there is enough skin available in an immediate reconstruction) but to expand the muscle. When an implant is used for breast reconstruction, it is put underneath the pectoralis major muscle to give an extra layer of protection between the implant and the skin. When Stattice® is used, the lower edge of the muscle can be divided to allow a larger volume implant of a fixed volume to be placed and a piece of Strattice® is used to cover the exposed lower pole of the implant.
This has the advantage of avoiding repeated visits to clinic to expand the implant and it also avoids the second stage procedure to replace the expander for an implant.
The major stages of the one or two-stage procedure are performed under a general anaesthetic and you will have at least one overnight stay. You may stay for 3-5 days if the reconstruction is done at the same time as mastectomy (immediate reconstruction) and a drain is used.
Limitations and Complications
Infection – wound infection needs to be treated aggressively with antibiotics because if the infection reaches the implant, it will need to be removed. The infection is then allowed to settle and the implant can be replaced after a period of a few months
Wound breakdown – this is a particular problem in cases of immediate reconstruction. Following the mastectomy, the skin that is left behind is often quite thin and may die, leaving a raw patch that can take some time to heal. Occasionally, a skin graft is required in order to speed up the healing. If the implant becomes exposed when the skin dies, then it will need to be removed. Once things have healed, it can be replaced after a few months. Wound breakdown is much more common in smokers and patients who are overweight (BMI over 30).
Capsular contracture – all implants will become surrounded by scar tissue, called a capsule. Initially this will not be palpable, but over time, the capsule will contract. The natural history of the capsule is that first it will become palpable in that the patient may say that the implant feels hard. As time goes on, the capsule may become visible and the patient may complain that the shape of the breast has changed and it has become more globular. Finally, the capsule can be come uncomfortable. This process usually takes 5-10 years, although it is accelerated if radiotherapy is given and so an implant only reconstruction is not recommended in the presence of radiotherapy. At any stage of the capsular contracture process, you may chose to undergo surgery to have the capsule removed and the implant replaced.