After breast cancer and mastectomy (surgical removal of the breast tissue), breast reconstruction is performed to restore a natural breast size and shape. With implant-based breast reconstruction, the breast mound is generated by an implant. The patient’s own skin that remains after the mastectomy is on the outside and covers the implant.
The final implant may be placed under the skin immediately at the time of mastectomy, which is referred to as “one-step” or “direct-to-implant” breast reconstruction. However, most women first require the placement of a tissue expander at the time of the mastectomy to produce the best shape and safest breast reconstruction process. The tissue expander is subsequently filled with saline, thus stretching the overlying skin. When the skin has the appropriate dimensions, the tissue expander is replaced with the final implant.
Both silicone and saline implants are options for breast reconstruction. Almost all women opt for silicone-filled breast implants because they lead to a softer and more natural breast look and feel. Acellular dermal matrix (ADM) is also a powerful tool to provide natural and durable results. Both implants and ADM are discussed in further detail later.
What Is Direct-to-Implant (DTI) Breast Reconstruction?
The direct-to-implant method of breast reconstruction, also known as one-step breast reconstruction, takes advantage of the more modern mastectomy techniques available. Skin-sparing and nipple-sparing mastectomies remove the fat and glandular tissue from the breast but leave behind all or almost all of the breast skin. In certain individuals, the final implant and ADM can be placed at the time of the mastectomy. In theory, this technique works best for women with A, B, or C cup sizes and minimal to no ptosis (sagging) and the willingness to potentially have smaller breasts. Many women find this option favorable since only one operation is needed to remove the cancerous tissue and recreate the breast mound. However, DTI reconstruction has significant risks and Dr. Weinfeld rarely recommends this option.
Are There Risks With Direct-to-Implant Reconstruction?
When considering direct-to-implant breast reconstruction, it is important to know that it comes with much higher risks than tissue expander reconstruction. The biggest risk is death of the skin that remains after mastectomy. This is especially true for nipple-sparing mastectomies. A mastectomy removes much of the breast tissue and, thus, much of the blood supply to the skin. The skin is fragile and prone to conditions that further limit blood flow and cause tissue death. One of those conditions is pressure. Pressure on tissue clamps down on blood flow. In direct-to-implant breast reconstruction, because of the size, shape, and weight of the implant, it places more pressure on the skin than a partially filled tissue expander. This increases the potential for skin death.
Another potential issue is that the implant position and, thus, the final breast appearance, is more difficult to control in a direct-to-implant approach. Many patients who undergo direct-to-implant breast reconstruction require additional surgeries to change the size of the implant or fat grafting to modify the shape of the reconstructed breast. So, while one-step breast reconstruction can be advantageous in limiting the number of surgeries, more than one procedure may eventually be needed to get the final result.
What Is Tissue Expander Reconstruction?
Tissue expander reconstruction is a method of breast reconstruction where a tissue expander is placed beneath the breast skin. This device expands the skin to a dimension that will permit a breast implant beneath it. The tissue expander is generally placed under the skin at the time of the mastectomy in what is known as immediate reconstruction. However, the tissue expander can be placed later during a procedure after the mastectomy, which is referred to as delayed reconstruction.
How Do Tissue Expanders Work for Breast Reconstruction?
The tissue expander is a silicone rubber bag with a valve. The valve allows either air or saline to be placed into the bag. After a period of healing from the surgery in which the expander was placed, the expansion period begins. A small needle is placed through the skin into the valve. Most women report minimal to no discomfort. As saline solution (salt water) is added to the bag, it gets bigger and stretches the overlying skin. After the desired amount of expansion, a second, relatively minor operation is scheduled for the tissue expander to be removed and replaced with a permanent silicone or saline breast implant.
Why Are Tissue Expanders Needed?
With modern methods of mastectomy including skin-sparing and nipple-sparing techniques, little, if any, skin is removed. Thus, one might ask why it is necessary to use a tissue expander to stretch the skin and wonder if there is enough skin after the mastectomy to reconstruct the breast. The answer is yes, there is enough skin to reconstruct the breast, but it is very fragile because a mastectomy removes a lot of the blood supply to the skin. The basic principle is that a tissue expander allows the breast skin to rest while it is recovering from the mastectomy.
One significant advantage of placing a tissue expander at the time of the mastectomy is that it can be left partially full, which places less pressure on the fragile skin. Another advantage of a tissue expander is that it can be filled with air at first. Air is light, so when a woman is standing or sitting, a tissue expander filled with air does not place a lot of pressure on the skin in the lower part of the breast.
The skin regains blood flow and becomes more resistant to pressure by about three weeks after the mastectomy. Thus, at about that time, the air is removed and replaced with saline. This is because the tissue expander will slowly leak air, but saline leakage is rare. At three weeks, the volume the expander filled to is increased in order to re-capture the size and shape that was lost during the mastectomy.
How Many Times Will My Tissue Expander Be Filled?
This process of filling the tissue expander to get to the desired size often takes more than one expansion. Three is the average. However, some women only require one fill, and some women require many more than three. The factors that lead to the number of expansions needed are the size desired and the amount that can comfortably be added during each expansion.
Does Filling Tissue Expanders Hurt?
In some women, adding saline can cause an unpleasant stretching or pressure sensation. When that happens, it is temporary, and reducing the amount of saline added limits those sensations. However, with less saline added at each expansion, more expansions are needed.
Each woman will discover what works best for her, and the expansion process is customized to her preferences.
Other Benefits of Tissue Expander Reconstruction
Another benefit of the two-step/two-stage tissue expander approach is that women can have control over the final size of her reconstructed breast. There are some limitations, but a woman can choose to have her reconstructed breast be smaller, the same size, or larger than her breast was before her mastectomy. This control exists because she can guide the surgeon’s team regarding how much expansion is performed.
What Are the Most Common Complications After Implant Reconstruction?
Infection and device exposure are two of the most common and serious complications of implant-based reconstruction techniques. Due to appropriate patient selection and infection reduction techniques developed and practiced by Dr. Weinfeld, he has reduced his rates of these two complications to below national averages, which, depending on the study, can be as high as 20 percent.
Dr. Weinfeld is extremely focused on minimizing the risk of infection and works hard to keep his infection rate low. In fact, industry representatives rely on Dr. Weinfeld for advice and information to help other surgeons reduce their infection rates. His technique can be described as abundantly cautious and involves, among other things, multiple glove changes, significant antibiotic irrigation, terminal wound irrigation, complete control of instrument handling, limited room access, extended drain tunnels, post-operative oxygenation, and systemic antibiotic usage.
What Type of Implant Is Best for Reconstruction?
The most commonly used implant in breast reconstruction is a smooth round silicone implant.
Why Are Silicone Implants Preferred for Reconstruction?
The two major categories of breast implants are known as silicone and saline. However, this can be a little misleading, especially to women who favor saline implants because they only want natural materials in their bodies. Both types of implants have a silicone rubber shell that contains the filling material. Silicone implants are filled with a silicone gel, and saline implants are filled with salt water. Thus, there is a difference in the “naturalness” of the material inside the implant that may be important to some women. Having said that, the use of saline implants is exceedingly rare at present. The reason for this is that silicone implants provide a result where the appearance and feel of the reconstructed breast is far more like natural tissue than would be possible with a saline implant.
Women often worry about implant rupture and the possibility of silicone gel leakage and migration. This is a theoretical concern but one that is rarely experienced with the modern generation of implants. The rarity of this event is related to two features of the contemporary implants that distinguish them from implants of the past. The shell of modern implants is much thicker and stronger; thus, rupture of the implant is less likely. Additionally, the gel that is contained within the implant is much thicker; therefore, if the implant shell does develop a hole, the gel is very unlikely to leak out and migrate within the body. The gel is described as highly cohesive and similar to the consistency of a gummy bear, which gives it an exceptionally low potential of flowing out of a torn shell.
What Are Textured Implants?
In the recent past, anatomic (shaped) implants played a prominent role in breast reconstruction. These implants were shaped like a teardrop and, thus, were more like a natural breast shape than the hemisphere (half of a ball) shape of smooth round implants. For a shaped implant to look like a natural breast under the skin, the sloped portion must be pointed up toward the woman’s shoulder. Implants have the tendency to rotate within the body space they are located unless measures are taken to prevent that movement. Implant texturing was an innovation created to prevent rotation and non-anatomic positioning of the anatomic implants, among other purposes. Implant texturing refers to the process of adding many little raised bumps or, in some cases, small nooks and crannies on the outer surface of the implant shell.
Can Textured Implants Be Used for Reconstruction?
Unfortunately, there is a possibility that some forms of texturing may have a relationship with a rare form of cancer called breast implant-associated acute large cell lymphoma (BIA-ALCL). This is a white blood cell (immune cell) cancer that can develop in the body’s scar capsule that forms around the breast implant. It is rare and generally treated well with surgery to remove the tissue capsule in which it forms. Textured implants were removed from the marketplace in the United States in an abundance of caution due to the increased potential for BIA-ALCL. Because shaped implants generally need to be textured to prevent rotation, anatomically shaped breast implants are no longer available for breast reconstruction. This might seem like a disadvantage, but very natural-appearing results can be achieved with smooth round implants. This is because when a woman is sitting or standing, the impact of gravity on the implant makes it take on a shape that is similar to that of an anatomic implant. There still is a lot to learn about BIA-ALCL, but most studies suggest that it is very unlikely, but not impossible, to occur when smooth implants are used. The process of fat grafting to the upper part of the reconstructed breast also contributes to a more natural slope and breast shape.
What Is ADM in Breast Reconstruction?
Acellular dermal matrix (ADM) refers to a collagen sheet used in breast reconstruction when soft tissue support and supplementation is needed. In the case of breast reconstruction, the tissue that most frequently requires support is the skin. After a mastectomy, the tissue left behind is skin with a thin layer of fat behind it. The tissue is fragile and lacks the strength to support an implant well in the long run. For that reason, ADM is added as a layer under the skin and over the tissue expander, where it will remain and later serve as an extra layer of support for the implant. Blood vessels in the skin grow into the ADM and incorporate it as a part of the body in which it was placed.
Can ADM Decrease the Risk of Capsular Contracture With Radiation Therapy?
Breast conservation therapy is where a woman undergoes a lumpectomy to remove the breast tumor, leaving most of the breast in place. Then, the woman undergoes radiation therapy to the breast. Radiation has the potential to cause significant contracture (thick internal scarring) to the normal breast tissue that surrounds a pre-existing implant. This can potentially be very problematic for women who have had a breast augmentation in the past and have chosen to have breast conservation therapy. Significant capsular contracture can result, leading to breast distortion and even discomfort.
The Use of ADM for Pre-Existing Implants or The Desire For Breast Implants and Breast Conservation Therapy (Oncoaugmentation).
Some studies suggest that the presence of ADM can decrease capsular contracture in general and in response to radiation therapy. Thus, in some select patients undergoing breast conservation therapy, their existing implants are removed and replaced with implants wrapped in ADM. The thought behind this is that if the device is covered by ADM, the long-term potential for contracture and breast distortion from the radiation is decreased. In some cases, a tissue expander wrapped in ADM is used instead of an implant. The reasons for this choice are many and complex; therefore, this strategy is best discussed at the time of a consultation.
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