IMPLANT-BASED RECONSTRUCTION- Orange County, CA
What is Implant-Based Breast Reconstruction?
Implant-Based Breast Reconstruction is exactly what it sounds like - reconstruction of the breasts using implants. Although the final product will be the breast implants, the process of getting there may require the use of tissue expanders, artificial dermis, and/or fat grafting. We'll talk about each of these below.
Who is a Good Candidate for Implant-Based Breast Reconstruction?
Whether you should get implants or use your own tissue for breast reconstruction can be a complicated discussion. To start down this path, you should generally be okay with getting breast implants in the first place. Some patients don't like the idea of having a foreign body inside them and would prefer to use their own tissue.
Patients who get implant-based reconstruction should also be healthy enough to undergo general anesthesia. Some patients who desire autologous breast reconstruction are unable to tolerate the risks, duration, and stress of a much larger surgery, and so their only option may be getting implants instead. Patients who prefer shorter surgeries with quicker recovery times should consider implant-based reconstruction.
The limit of implant size available at the moment is 800 cc. For some larger patients, this may not be enough volume for them to restore adequate shape and size. These patients may be better served by using autologous tissue for reconstruction. Several companies are currently testing implants as large as 1200 cc to 1600 cc for breast reconstruction, but these are not available to the public just yet.
If your cancer team is planning to give you radiation therapy, you will likely need to get autologous breast reconstruction instead. Radiation generally damages tissue to the point where it becomes a hazard to use breast implants. This is not always the case, but it is the general rule of thumb. This can be discussed further with your plastic surgeon.
What is Involved in the Surgeries?
Reconstruction can be performed during the same surgery as the mastectomy, or it can be delayed until almost any later date when the patient is ready. Factors for doing one or the other depend on cancer status, the need for radiation, patient's desires, surgeon availability, etc. Talk to your plastic surgeon about which is available and best for you.
If the reconstruction is started during the same surgery as your mastectomy, your breast cancer surgeon's team will finish their portion of the operation, removing the breast tissue and any lymph nodes needed. If the reconstruction is performed at a later date, the skin will have already healed down to the chest wall. Your plastic surgeon will need to excise your scar and re-dissect down to create the pocket for your tissue expander.
Your surgeon will dissect underneath your pectoralis major muscle (the push-up muscle). This muscle will be used to cover the upper half of your tissue expander. A piece of artificial dermis (usually Alloderm) will be sewn into your body to help cover the lower portion of your tissue expander and hold it in place. Alloderm is an ADM, or "artificial dermal matrix," which is the material that acts as a scaffold for your normal skin. Your body eventually grows into this scaffold and replaces it with its own tissue over time. The tissue expander is then placed into the pocket created by the pectoralis major muscle and Alloderm.
In some cases, your surgeon may be able to place the final implant in at the time of mastectomy. This is typically only possible for patients with small breasts who wish to have a similar size after reconstruction. Additionally, your surgeon may elect to make the pocket entirely out of Alloderm, placing it above the muscle. This is also known as "prepectoral" breast reconstruction.
After 1st Stage, Before 2nd Stage
After the tissue expander has been allowed to heal in place for 2-3 weeks, you will start receiving "fills" in clinic. A needle will be used to access the port in the tissue expander in your chest, and saline will be injected to enlarge the expander and stretch your breast tissue. Approximately 60 cc to 100 cc can be injected each time depending on how much you can tolerate.
You will decide your final size by looking at the size of the tissue expanders in your chest as they get filled. You will continue to receive fills until your tissue expanders become 50-100cc larger than the final size you would like them to be. After the tissue expanders reach their final size, your surgeon will typically leave it in place 2-3 months before the next surgery in order to help prevent your tissue from shrinking down after they are removed.
Your tissue expander has been in place for several months now and has been filled to approximately 50-100 cc larger than your expected implant size. During your second surgery, your surgeon will remove the tissue expanders and feel your pocket to make sure no new masses have formed. Depending on the location and size of the pocket, it may be dissected to improve the final position of the implant. The breast implant (typically silicone) will be placed into the pocket and the tissue will be closed over it.
If needed, your surgeon may decide to fat graft your breast at this time to help improve the contour. This involves injecting the fat around your abdomen with tumescent fluid (normal saline with lidocaine and epinephrine). This fluid helps reduce pain after the surgery as well as minimize any bleeding. The fat is then liposuctioned from your belly and processed. It is re-injected back into your breast to help smooth out any contour irregularities and/or to add thickness to certain areas of your remaining breast tissue that are thin.
3rd Stage or Further
At this stage, you may opt to have another round of fat grafting to your breasts if you and your surgeon think it would help improve contour. Fat grafting can be done may times as long as you have fat remaining in other areas of your body to donate.
You may also opt to have your nipples and areolas reconstructed. This can be done under local anesthesia only in a procedure room. Your plastic surgeon will lift a small area of skin and fold it together to make a new nipple. He or she can then return in 3 months after it has healed to tattoo the areolar color onto that area. You may also wish to see a tattoo artist who can create a 3D nipple and areolar complex without any cutting.
Finally, the FDA recommends exchanging your implants every 10 years to help prevent capsular contracture and rupture. These are usually fairly quick surgeries with minimal pain due to the fact that not much dissection is needed.
Why Do You Use Silicone Implants for Breast Reconstruction? Can I Get Saline if I Wanted to?
Breast implants come with either silicone or saline filling inside a silicone shell. Although both options are readily available for Breast Augmentations, the use of saline usually is not recommended for breast reconstruction.
The main reason for not using saline is that water (saline is essentially salt water) cannot hold its form well. This makes it poorly suited to recreate the shape of a breast when so much tissue has been removed as in the case of a mastectomy. If saline implants were used, patients would end up with "rippling." This is exactly what it sounds like. The ripples that form when you disturb water would be visible along the top of your reconstructed breasts. Most patients don't want or like this look.
Silicone breast implants are now available in more cohesive types. The silicone is "cross-linked" more than in the older versions, which means that they hold their shape much better (and have less risk of spreading if they rupture). Because of this, there is much less risk of rippling.
What is the Healing Time from Each Surgery?
Usually, the placement of the tissue expanders is the most difficult surgery. Because the pectoralis major muscle is lifted and the artificial dermis is sutured to the chest wall, patients can have quite a bit of pain. They will also usually have drains that need to be taken care of during the first surgery, adding to the overall discomfort. Despite this, patients will usually feel back to normal by 2 weeks after the surgery. They should still refrain from strenuous activity for a total of 6 weeks, but they are able to return to work relatively quickly.
In regards to exchanging tissue expanders for implants, fat grafting, nipple reconstruction, and implant replacement, there is much less pain from each of these surgeries. Patients are usually back to normal daily activity in a matter of days. This generally contrasts with autologous tissue reconstruction (using your own tissue), which usually involves only one major surgery that can require up to 6 weeks to recover.
What are the Risks of Implant-Based Breast Reconstruction?
As with any surgery, breast reconstruction risks include bleeding and infection as well as the risks of general anesthesia. Other risks include implant rupture, capsular contracture, asymmetry, implant malposition, contour deformity, animation deformity, and tissue loss among others.
An issue that can occur specifically with implant-based breast reconstruction is a higher rate of infection. Because the breast tissue is removed and the remaining ducts provide a pathway for bacteria to go directly to the implant, these reconstructions can have infection rates as high as 30%. Sometimes the infections can resolve with oral or intravenous antibiotics alone.
In the case of more severe infections, the tissue expander or implant may have to be removed completely. Another tissue expander or implant may not be able to be replaced immediately because it would likely get re-infected right away. The remaining breast skin is allowed to scar down to the chest and heal for a period of 3 to 6 months. This also gives your body a chance to clear the infection completely.
Once you have healed, your plastic surgeon can attempt to start the reconstructive process again. Unfortunately, this does mean that you may have to start over again completely. This involves getting a new tissue expander, getting weekly fills, exchanging the expander to an implant, and any final revisions that may be required. Unfortunately, patients who acquire infections once are more likely to have an infection again in the future. You will need to discuss the risks and benefits of starting the reconstructive process again with your surgeon as it is usually handled on a case-to-case basis.
We know that breast cancer can be a very scary experience for you, and the reconstructive process can be just as daunting. We wish you the best of luck on your journey, and we encourage you to reach out to Dr. Nguyen with any questions you may have. God Bless!
Learn more about the alternative to Implant-Based Breast Reconstruction here.