Implant Based Reconstruction
This is the simplest method of breast reconstruction and reproduces the skin envelope by stretching the remaining skin and muscle of the chest wall. This is done in 2 short operations about 8 -12 weeks apart. In the first operation, under general anaesthetic, the old mastectomy scar is opened and a tissue expander placed beneath the skin and muscle.
A tissue expander consists of an inflatable silicone bag with an inflation port attached via a tube. The expander is inflated by injecting saline through skin into the port, which stretches the overlying skin. This stretched skin becomes tight but not painful. Over the following few days the skin relaxes allowing a further expansion the following week. Serial inflation commences in the outpatient department about two weeks postoperatively and continues on a weekly basis until the skin has been sufficiently stretched – usually by eight to twelve weeks. Most patients continue working during this period of expander inflation.
Once the inflation process is completed and a sufficiently large skin envelope has been created, a second operation is performed under general anaesthetic. The saline filled expander is removed and replaced with a silicone implant which produces a more natural feel and appearance than the saline filled bag.
Each operation takes about one hour, the patient stays in hospital for one or two days and usually recovers by two weeks.
Although a two-stage procedure has been described, newer tissue expanders are now available which consist of a tissue expander inside a silicone implant. This device can be used to expand the skin creating a skin envelope but as it contains silicone too it also feels like breast tissue and therefore does not need exchanging for a silicone implant – thus avoiding a second operation.
Advantages and disadvantages
- Simplest method of breast reconstruction
- Reasonable shape:
- Good volume match possible with small and medium sized breasts
- Very little additional scarring to the breast.
Its main disadvantages are that it requires:
- Multiple outpatient visits for expansion,
- Two separate operations: although with the newer implant/expanders this second operation can be avoided
- Has a higher complication rate due to the foreign nature of the prosthesis.
- Not usually advised for patients with marked radiotherapy damage or for patients with poor condition skin of the chest wall.
- Exposure of the Expander: The overlying skin thins to some extent with tissue expansion, occasionally the skin may thin so much the expander becomes exposed and subsequently infected. This may result in failure and may lead to an alternative method of breast reconstruction.
- Infection: This is the commonest complication of tissue expansion, it may be managed with antibiotics and rest but occasionally it results in failure of the operation and requires removal of the tissue expander. In this event, several months later once the infection has completely settled tissue expansion can be reattempted. The infection rate following the second operation is about 3% and whilst some settle with antibiotics, others require surgical removal of the implant, which can then be replaced several months later once the infection has completely settled.
- Capsule Formation: Insertion of any foreign material into the human body results in the body forming a wall of scar, known as a capsule, around that material. In about 10-15% of patients with a silicone implant, this capsule contracts around the prosthesis resulting in a painful, hard, distorted breast. Severe capsular contracture requires surgical treatment and, occasionally, removal of the silicone breast prosthesis.
- Slow Leak or Rupture: Is an infrequent event occurring in 0.5 – 5% of cases and usually results from direct, substantial trauma to the breast. Minor blows to the breast and flying at altitude are insufficient to rupture a silicone breast prosthesis and are perfectly safe. Although silicone leakage can sometimes causes swelling of the lymph nodes in the arm pit, in the majority of cases it causes no problems.
- Permanence: It is not known how permanent the new generation of silicone breast implants is, but the manufacturers suggest the implants may require changing after 10-15 years.