Breast Reconstruction with Implants
Contemporary implants are either saline (salt water) or silicone gel; both are contained in a silicone shell. Saline implants are placed empty into the chest and then filled; silicone implants are pre-filled by the manufacturer. Silicone gel implants are used more frequently than their saline counterparts, primarily because they have a resilience and bounce that more closely mimics the feel of natural breast tissue.
Your surgeon will choose the model that will best fit your chest, but it is always a good idea to discuss your implant options before your reconstruction surgery.
Breast implants, like all man-made devices, tend to wear out and don't last forever (replacement requires anesthesia and takes an hour or so for each breast). They sometimes leak or rupture, although newer generations of implants are thought to minimize these problems. The most common problem with breast implants is capsular contracture, a condition that develops when the natural scar tissue that forms around the implant hardens. In some cases, this might not be problematic or even noticeable, but it can become painful and distort the shape of the new breast. When this occurs, the implants must be removed and either replaced with new implants or a tissue flap; a flat chest without reconstruction is also an option.
While virtually all studies have failed to link silicone implants to serious diseases, concerns remain over how often implants rupture and what happens when and if silicone migrates beyond the breast. The FDA recommends an MRI three years after placement of silicone implants and every two years thereafter to determine whether a "silent" rupture has occurred. Unlike saline implants, which noticeably deflate when they rupture (the saline is harmlessly absorbed by the body), the rupture of a silicone implant may not be apparent.
According to the American Society of Plastic Surgeons, 80% of breast reconstruction involves implants; 94% of implant reconstruction involves silicone devices.
Compared to natural tissue flap procedures, implant surgery is shorter, requires less surgical skill, and leaves fewer scars. Recovery is less intense and quicker, but the entire reconstructive process can take longer to complete.
If you're having a nipple-sparing mastectomy and you prefer implant reconstruction, you may be able to complete your entire reconstruction in a single trip to the operating room.
Many plastic surgeons now perform direct-to-implant ("one-step") reconstruction by using an acellular dermal matrix (ADM)--donor tissue from which the cellular structure has been removed, leaving primarily collagen--to streamline the reconstructive process. Stitching patches of an ADM to the edges of the pectoral muscle or along the inframammary fold (the crease beneath the breast) creates an instant pocket for an implant (see image below, left), eliminating the need for expansion. Some women need a secondary procedure to correct problems or improve cosmetic result.
Direct-to-implant reconstruction offers distinct benefits over traditional implant reconstruction:
- It doesn't require tissue expansion.
- Women who combine this procedure with nipple-sparing mastectomy can complete their entire reconstruction in a single step.
- An ADM provides more complete coverage of the implant. This is an added advantage, because without an ADM, implant edges and rippling are often noticeable beneath the skin.
- The ADM promotes a healthy network of new blood vessels and integrates into a woman's healthy tissue.
- Use of an ADM appears to reduce the incidence of capsular contracture.
Although plastic surgeons increasingly offer direct-to-implant reconstruction, most still prefer traditional implant reconstruction with expansion. (Slower expansion is a more conservative and safe reconstructive method for some women, including those who have healing problems, very thin breast skin, and those with breast tissue that has previously been irradiated.)
Some surgeons use an ADM to support traditional expansion. And more frequently, using an ADM allows surgeons to place breast implants over the muscle, providing a cushioning layer between the implant and the breast skin, and thus avoiding the necessity of cutting the muscle and expanding the pocket beneath to accomodate an implant.
So when consulting with a surgeon who reconstructs with an ADM, be sure to clarify whether he/she performs direct-to-implant or traditional reconstruction with expansion.
Acellular dermis creates an instant pocket, eliminating
the need for expansion. (image: LifeCell)