Implant Based Reconstruction

Good candidates for immediate single-stage implant reconstruction include women who are healthy, in good physical condition, non-smokers and have tumours appropriate for immediate breast reconstruction or are considering risk-reducing surgery for strong family history or BRCA genes. Many women can have nipple-sparing mastectomy provided there is not a specific cancer-related indication to remove the nipple and areola.

I would not offer this surgery to women who are smokers, have poorly-controlled diabetes, a history of steroid use, or certain other medical problems. All these interfere with wound healing and increase the incidence of infection and a two-stage or delayed reconstruction is appropriate in these circumstances. Immediate single-stage implant reconstruction may not be appropriate for women with advanced or rapidly growing tumours and those who are psychologically unprepared for reconstruction.

Nipple sparing mastectomy (NSM) is a technique for mastectomy that preserves all of the breast skin in addition to the nipple and areolar complex. NSM removes the entire breast through an incision either around the lower half of the areola or in the infra-mammary fold (the crease under the breast). NSM can be performed in selected patients such as those seeking prophylactic mastectomy or ladies with small tumours remote from the nipple.

NSM requires gentle tissue-handling and preservation of blood supply to the nipple. A sample is taken from behind the nipple and sent for testing. In a few cases this shows disease, which means that the nipple has to be removed at a second operation under local anaesthetic.

Women with large or droopy breasts can have an implant reconstruction with preservation of the nipple and areola provided a smaller, perkier breast reconstruction is planned. The nipple and areola can either be moved on a bridge of skin or as a free graft. The mastectomy is done using incisions normally used for a breast reduction. Your options can be discussed once you have been assessed.

A breast implant is a foreign body and as such is subject to a number of disadvantages not associated with flap (own tissue) reconstruction. If a breast implant develops an infection it is often necessary to remove the implant in order to treat the infection. Your body will naturally form a wall around the implant and this is called the capsule. With time this capsule can gradually shrink (called capsular contracture) and cause an alteration in the shape, size and position of the breast. In some cases it may become painful. As a result a major disadvantage of implant-based reconstruction is that most women will require at least one, possibly more, further operations during their lifetime. The process of capsular contracture is generally accelerated by radiotherapy and I do not therefore recommend implant-based reconstruction in ladies who have had or are likely to need radiotherapy.

There is a huge variety of available breast implants. They vary in size, shape, surface and fill.

Implant size varies from 50 to 800cc. Implants are designed to fit the width and height of your chest wall. The variation in volume comes from the projection of the implant; it may be low, moderate, high or very high projection. The height and width of your chest wall are fixed but the volume that is required to achieve your desired result can be discussed at consultation.

Implant shape is either round or anatomical (tear drop). For breast reconstruction I normally recommend an anatomical implant as this produces a more natural shape to the reconstructed breast.

The outer shell of all implants is made of silicone. Silicone is a natural element and an inert solid that is biochemically most similar to carbon (the element that makes us “organic”). Silicone is used safely in lots of different implantable medical devices. The shell may be smooth, textured (rough appearance) or polyurethane-coated.

Implants can be either saline filled or silicone filled. Most patients opt for silicone filled as they look more natural, feel more like breast tissue and are less likely to develop folds and ripples longer term. Additionally in the event of rupture a saline implant is more likely to deflate whereas a silicone implant will maintain its shape as it is in the form of a cohesive gel. Very recently an additional type of silicone implant has been added to the market that incorporates air pockets within the silicone gel resulting in a lighter weight implant for the same given volume. If appropriate this type of implant can be discussed at consultation.

The most appropriate implant for you depends on many factors including your age, chest width and height, breast volume, breast density, skin elasticity, weight and aesthetic goals. There is no “one-size fits all” and as part of the consultation all these factors will be considered to formulate a unique treatment plan for you to achieve the result that you desire.

I encourage all patients to educate themselves about the safety and science of breast implants before considering a surgical procedure. Breast implants are made from medical grade silicone. Silicone is one of the most widely used soft implantable materials in medicine. It has been used for decades in medical devices such as grommet tubes in children’s ears, pacemakers and artificial joints. Silicone breast implants are the most extensively studied implantable medical device. The FDA approved silicone gel-filled breast implants after reviewing a large amount of scientific data, and clinical research supporting the safety of silicone breast implants.

In rare cases implants may fail and the silicone gel may leak out. Small amounts of silicone may leave your implants and be taken up in the lymph glands. However there is no evidence that a ruptured breast implant and the resulting leakage cause ill health. It may cause symptoms such as pain and deformity of the breast. It will require re-operation to remove and replace the implants.  Removal of silicone from the lymph glands is rarely necessary.

An acellular dermal matrix (ADM) is a device used in breast reconstruction to help provide coverage to the implant. It is a sheet of collagen derived from either cows or pigs with all of the cells removed leaving behind the collagen structure. Collagen is the basic building block of all living tissue. When an ADM is used it acts as a collagen framework into which your own tissue grows so that the ADM ultimately becomes incorporated into your own tissue. Advantages include the addition of a layer of tissue to help disguise the implant, control of the crease under the breast and ability to secure the implant where we want it to sit on the chest wall. Disadvantages include a higher infection rate compared to non-ADM reconstructions and a requirement for the drains to be in place for longer.

Breast implants for reconstruction can be placed either under the pectoralis major muscle (sub-pectoral) or on top of the muscle (pre-pectoral). I use both techniques for different patients and the choice of which technique is best for you is based on your unique anatomy, lifestyle, past medical history and aspirations.

Pre-pectoral implants are usually fully covered by one or two sheets of ADM, which not only offers an additional layer of coverage but also helps to secure the implant so that it sits exactly where we want it. Implants placed on top of the muscle move as expected with changes in body position and do not develop animation deformity. If you are someone who uses your pectoralis muscles a lot either during recreational activities or at work you are likely to be troubled by animation with sub-pectoral implants. Pre-pectoral implants however may be more likely to develop obvious rippling over time depending on your skin thickness.

For sub-muscular implants the edge of the pectoralis major muscle is lifted and a pocket created under the muscle. The muscle is released from some of its attachments to the ribs and breastbone to allow it to lift. The muscle will only cover the upper part of the implant therefore an ADM is often still used to cover the lower half. The benefit of the sub-pectoral plane is the additional coverage that it gives to the upper half of the breast. The disadvantages include animation and chronic contraction of the pectoralis muscle around the implant that may create physical discomfort in the neck, upper back or shoulder area. Sub-muscular procedures may negatively affect muscle strength and function.

As a female surgeon I only ever recommend options that I would be happy to have myself.

At your initial consultation I will take a full medical history including all the details of your cancer diagnosis, treatments so far and any intended additional treatments. I will also ask about lifestyle and family support. I will examine you and assess your chest wall, breast size, and tissue to assess which reconstructive options are available to you. Depending on this assessment I will discuss the options that are available to you and suggest which I feel is best suited to you having spent some time getting to know you.

Following our consultation you will have further opportunities to discuss your options with your breast care nurse and make a decision. You will be able to discuss your proposed surgery helping you to understand and consider the options open to you and what support is available to you. Some patients, for whom the surgery is urgent, have only a short period of time in which to decide on what is the best procedure for them. Although I will explain everything to you it can be difficult to absorb all the relevant information at one visit therefore you may have more questions so I always arrange a further consultation before you make a final decision.

Following your consultation and the decision for surgery you will have some pre-operative tests. The anaesthetist will review your medical history and assess whether there are any additional tests that need to be carried out to check your fitness for surgery.

It will assist if you stop taking any herbal remedies, homeopathic or complementary medicine not prescribed by your GP. Some of these tablets can cause excessive bleeding during surgery. They should be stopped at least 3 weeks before surgery but can be resumed when you are discharged. You must also tell me if you are taking aspirin, warfarin or other blood thinning medication. Smoking is detrimental to this type of surgery therefore you are advised to stop smoking prior to embarking on surgery.

You will need a bra that is supportive and without wires, ideally with a front fastening. The bra is worn from the day of surgery, day and night for 6 weeks. This gives your reconstructed breast support. You should buy one and bring it with you to hospital.

On the day of surgery I will draw some markings on you to be used as a guide for surgery. You will also see the anaethetist who will discuss the anaesthetic and post-operative pain management plan.

After the mastectomy is complete your breast tissue is weighed and the empty pocket is measured to aid the final choice of implant. A permanent implant or expander is placed in the space either on top or beneath the Pectoralis Major muscle. An ADM is secured with stitches and the wounds closed with a drain in the cavity.

You will return to the ward around an hour after the operation and be encouraged to eat, drink and mobilise. You will normally stay in the hospital for one or two nights following this procedure.

You will have some tape dressings on the wounds and will put the bra on once back on the ward to support the reconstruction.

You will go home with drains and you will be seen back in the clinic one week after surgery. The drains are usually removed at this first post-op visit. I would expect you to be virtually healed at this stage but you will be seen weekly until you are healed. The stitches are all dissolving so will not need to be removed.

On discharge you will still not be using the arm on the operated side for any lifting or carrying and you may still feel a little weak on that side. Continue to do the shoulder exercises that you have been given in hospital and begin any new exercises as directed. You should continue shoulder exercises until twelve weeks after your operation.

Scar tissue is vital to the healing process however scars can tighten, limit movements and become uncomfortable. Massage helps to encourage the scar tissue to form in the correct lines and make a more functional rather than restrictive scar. Massage also makes the scar less sensitive and prevents adhesions.

To massage apply a small amount of simple un-perfumed moisturizing cream to the scar. Use the thumb or index finger to massage in small circular motion along the scar. Use a firm pressure and massage several times a day. Only start the massage once the wounds are fully healed (nurses will provide you with guidance on this).

There are no strict rules for when you return to work, driving or sports and this will depend upon you as an individual, how you heal and the nature of your work or hobbies. I will give you guidance in the clinic, the following information gives you a generalized idea of what to expect.

Two weeks after your operation you can use the arm on the affected side for light activities eg lifting a full kettle or brushing your hair. Over the next 4 weeks you can build up the use of this arm by doing light household activities such as dusting and preparing light meals. At 6 weeks after the operation you should have returned to most normal daily activities such as carrying shopping and hovering.

Return to work will depend on the type of work you do. For office jobs or other non-physical work you can probably return at 4 weeks. If your work is physical and involves heavy lifting you could return on light duties if possible at 8 weeks post-operatively but you should not do any heavy lifting until at least 12 weeks post-operatively and you will need to gradually build up your strength so may benefit from a phased return.

You should avoid driving for 2-4 weeks after surgery. You should not return to driving until you feel 100% alert and able to react in an emergency. You must have regained full shoulder movement before attempting to drive. You must always wear your seatbelt when in the car.

Provided you have healed you can return to gentle exercise at 3 - 4 weeks but you should start with less vigorous activities and gradually build up your level of activity. You should listen to your body and if it feels like you are straining, avoid activities or movements that still create discomfort. You will be unfit and will need to build slowly. You must always wear a supportive bra when exercising. You should not participate in contact sports or raquet sports until 3 months after your surgery. It takes many months up to a full year for your body to fully recover after any type of surgery. Breast reconstruction is no different.

I know that this may be a difficult time for you. It often helps to talk to family and friends about how you are feeing. The team is here to offer support. If you feel that you need some additional support after discharge your breast care nurse will be your first point of contact. If it is felt necessary you will be offered the opportunity to meet one of our psychotherapy and counseling team for additional support. You are also welcome to request this if you feel in need of additional support.

Early complications of implant-based breast reconstruction include include bleeding or haematoma that may require return to theatre, infection, delayed wound healing, seroma (a collection of tissue fluid) and post-operative pain. There is also a risk of implant infection or rotation. If an implant becomes infected it usually needs to be removed and the infection treated with antibiotics. This means a temporary loss of reconstruction. Another operation will be required a few months later, which often needs to be a staged operation with a tissue expander first then a permanent implant later. As shaped implants are primarily used for breast reconstruction, there is a small risk of implant rotation that requires a second operation to re-position it. Potential complications also include those related to having a general anaesthetic such as cardiac or respiratory compromise, blood clots in the leg (DVT) or the lung (PE).

You will feel swollen and bruised for the first few weeks and the reconstruction will initially feel high up on the chest wall. As this starts to resolve the implant settles and by six weeks is usually starting to look and feel how it will in the future. It will however continue to change over the first few months and it can take many months for the final result to be apparent. You will experience numbness over the skin (and nipple) of the breast that will recover slowly over many months but is unlikely to fully recover. The scars will be red/pink initially but should fade over time. In rare cases patients develop abnormal thickened scars, which may require additional treatment.

Your body will form a scar around the breast implant called a capsule. Over time this capsule can slowly contract and eventually cause the implant to change size, position or even become painful. This is called capsular contracture and is the most common reason for a lady to need implant maintenance surgery. It occurs at different rates in different ladies so there is no definite time interval as which you implant needs changing. With long-term follow-up I can assess your result and any changes and as and when required we can talk about surgery to remove the capsule and replace the implant.

In the long-term there may be a degree of asymmetry requiring “touch-up” surgery or contralateral symmetrising surgery, listed below.

The entire process of breast reconstruction may take many months and you will often require additional procedures to achieve the final result. Other procedures that may be offered to you are;

Nipple-Areolar Reconstruction & Tattoo

If your nipple needed to be removed as part of the cancer treatment, nipple reconstruction is typically offered at least 3 months after your breast reconstruction. It is a local anaesthetic, day-case procedure that takes around 30 minutes. It involves lifting an area of skin on the flap and suturing it to create a prominence. It does not give any colour to the nipple / areola and to achieve this you will require a tattoo.

Nipple tattooing can be done once the scars in the area are mature (no longer pink). It is a simple outpatient procedure that takes around 40 minutes.  A coloured semi-permanent pigment is applied using a small needle. The area is then covered with a dressing and you will be advised when to remove it. It can fade with time and may need a top-up from time to time.

Lipofilling / Autofat Injection

This involves taking fat from other areas of the body (by liposuction) and injecting it into the reconstructed breast to fill out any contours / dips in the reconstructed breast or to give additional volume. Usually 50% of the fat is absorbed so the procedure may need repeating.

Reduction Mammaplasty

After reconstruction there may be a difference in the size of the breasts as the natural breast is larger. If this is the case it can be reduced to match the reconstructed side. This is usually a day-case procedure but you may require one night in hospital.

Good candidates for immediate single-stage implant reconstruction include women who are healthy, in good physical condition, non-smokers and have tumours appropriate for immediate breast reconstruction or are considering risk-reducing surgery for strong family history or BRCA genes. Many women can have nipple-sparing mastectomy provided there is not a specific cancer-related indication to remove the nipple and areola.

I would not offer this surgery to women who are smokers, have poorly-controlled diabetes, a history of steroid use, or certain other medical problems. All these interfere with wound healing and increase the incidence of infection and a two-stage or delayed reconstruction is appropriate in these circumstances. Immediate single-stage implant reconstruction may not be appropriate for women with advanced or rapidly growing tumours and those who are psychologically unprepared for reconstruction.