Introduction
Implants
Overview
Who is it suitable for?
Pros and Cons
The Operation
Possible Complications
Latissimus Dorsi
Pedicled TRAM
Free TRAM
DIEP
Gluteal
The Other Breast
Nipple Reconstruction
UK & EIRE Centres
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Overview

Until the last few decades, implant reconstruction was the only option available to women seeking a permanent breast mound following mastectomy. It is still a popular method of reconstructing a breast, as reasonable cosmetic results can be obtained without operating on healthy tissue. The surgery is shorter and recovery from surgery is also faster.

After mastectomy, a prosthetic implant is inserted under the ‘pec' muscle to create the shape of the breast. In most women, the muscle and overlying skin are too tight to allow a full-size implant to be inserted immediately so a tissue expander is often needed.

A tissue expander is a saline (sterile salt-water) filled prosthesis attached to an inflation port. Additional saline is gradually added in the out-patient clinics over 3 to 6 months following surgery, increasing the volume of the expander to match the volume of the remaining natural breast. As the volume of the expander increases, the muscle and overlying skin gently expand to provide enough space for the final implant. When the required volume is attained, the breast is allowed to settle for a few months, and then a further operation is performed to replace the saline filled expander with a permanent silicone breast implant.

During the last month of inflation, the expander will be deliberately filled to a volume larger than the remaining natural breast. Breasts reconstructed using an implant alone are affected less by gravity than a natural breast, and the technique of over-inflation allows a certain laxity to develop in the reconstructed breast, so that when the final, correctly sized implant is inserted, the reconstructed breast develops a degree of droop to better match the remaining natural breast.

A silicone implant is used for the final reconstruction, as it gives a softer, more natural feel to the breast. Silicone implants are commonly used in the U.K. and are safe. In the past, there have been concerns about rupture of implants and silicone leakage. In 1998, the Silicone Gel Breast Implants Independent Review Group conducted an investigation into the safety of silicone implants and found no relationship between silicone gel implants and immune reactions or systemic illness. Permanent saline implants can be used, although they tend to have the feel of a stretched balloon, and do not have the resilience of a silicone implant.

Over the last 10 years, there have been dramatic improvements in safety and design of silicone implants. The silicone is a cohesive gel rather than a liquid, which will not run into the body if the implant wall is compromised (even if entirely cut open as shown in the photograph), and the implant wall itself is thicker and stronger than in earlier models. Traditionally implants required replacing every 10-15 years, but it is hoped that with the design improvements, modern implants will not need replacing. Most implants used today have a roughened surface to minimise the risk of capsular contracture, the most common complication of implant surgery.

Another option for implant reconstruction is the use of a permanent expandable implant. This consists of a front layer of silicone gel and an expandable pocket for the saline at the back of the implant. These give cosmetic results comparable with silicone-only implants and have the advantage of only requiring one operation.

There are some drawbacks with implant-only breast reconstruction. This technique cannot create a large or droopy breast. The breast may appear fuller in the upper half compared with the natural side, will almost certainly have less of the natural droop than the non-operated side and will not drop to the side when you lie on your back, as a breast normally would.

In contrast with autogenous reconstruction, during which skin is moved from the tummy or back to the breast, implant or expander based reconstruction cannot provide any additional skin to fill the hole created when the nipple is removed. This can either be filled with a skin graft, or, more commonly, it is sutured directly, leaving a straight-line scar in either a vertical or horizontal direction.

Breast reconstruction using an implant alone gives a breast mound and is the simplest type of reconstruction, avoiding major surgery and surgery to healthy tissue elsewhere in the body, but gives the least natural and least symmetrical results. It is also a good option for bilateral reconstruction, where excellent symmetry is possible with this technique.

Who is it suitable for

• Women who would like a permanent reconstruction but who would like the most minor type of surgery
• Women who are not opposed to having prosthetic material in their bodies
• Women who don't mind going through a few months of tissue expansion
• Women who wish to avoid an operation to healthy tissue
• Small-breasted women who are seeking larger breasts and would also like an implant in the healthy breast
• Women undergoing bilateral mastectomy and reconstruction
• Women who cannot endure a long operation because of ill-health

Pros and cons

Advantages Short and relatively simple surgery Short anaesthetic and recovery time No operating on healthy tissue or extra scars No missing tissue missing elsewhere in the body

Disadvantages Slow reconstructive process with expansion of implants Less symmetrical shape match with remaining natural breast Less natural breast texture Unsuitable for reconstructing large breasts Artificial material can become infected and may need to be removed to clear the infection

Operation

The patient is placed on her back and the breast surgeon performs the mastectomy. When this has been completed, the reconstructive surgeon makes a hole in the ‘pec' muscles and lifts the ‘pec' muscles away from the ribs below, creating a 'pocket' in which the implant can lie. When the size of the pocket is correct, the surgeon inserts the implant and covers it by closing the hole in the ‘pec' muscle. Often, at this point, the head and chest of the patient will be raised to a semi-sitting position to compare the two breasts under the influence of gravity. Any adjustments to the position and size of the implant pocket are made and, in the case of a tissue expander, it may be partially inflated. The wounds are then closed, generally with dissolving sutures. A drain may be inserted to stop any ooze from accumulating around the implant.

Complications you should be aware of

• Infection – this ranges from a superficial wound infection, easily treated with antibiotics to an infection of the implant. Implant infections are especially troublesome as, generally, the implant must be removed to fully treat the infection, and only re-inserted several months after the infection is entirely resolved.
• Capsular Contracture - this is the commonest complication following implant reconstruction. A capsule is a normal reaction of the body to the foreign material and consists of a thin layer of fibrous tissue. Over the few months following the operation, this capsule shrinks as part of the normal healing process. but the extent of the shrinkage varies from person to person. In about 10% of women, it can become hard and contract against the implant, causing discomfort and a change in shape of the breast. Capsule contraction is more common after radiotherapy. If capsular contraction is a problem, the contracted capsule can be surgically removed to restore the breast shape.
• Bleeding – it is normal to have a small degree of oozing at the wound edges. It is possible that you may develop a collection of blood (haematoma) under the skin, despite careful cautery to any bleeding points during the procedure. Haematoma after insertion of an implant increases the risk of capsular contracture and infection, so your surgeon may wish to take you back to theatre to remove the collection of blood.
• Revision Surgery – As your breasts change over the years following your reconstruction, the reconstructed breast will not age in the same way as your remaining natural breast and any asymmetry between the breasts is likely to increase. You may decide to undergo a balancing procedure at a later date to maintain the symmetry of your reconstruction.
• Recurrence – although this is not strictly a complication of the reconstruction, it should be mentioned that having a breast reconstruction must not interfere with treatment for the breast cancer and having a reconstruction would not stop a recurrence of the cancer, if it were to occur.