The most common type of breast reconstruction is performed with breast implants. These typically are silicone-based breast implants, that in many cases can look and feel very natural. This type of operation typically involves two major steps, the placement of a tissue expander and then the replacement of this tissue expander with a permanent breast implant. The end result in most women is a breast that has a natural shape and feel.
What is the process involved with this?
The start of breast reconstruction is usually at the time of the mastectomy or bilateral mastectomies. After a general surgeon has removed the breast, we are able to preform our portion of the operation. We begin by creating a pocket underneath the pectoralis muscle in order to insert an appropriately sized tissue expander.
A tissue expander is a specialized, temporary, implant that is designed to allow a needle to be placed through the skin, into the tissue expander to inject a saline solution. This will stretch the skin of the breast back to its original shape and volume.
After the tissue expander is placed underneath the pectoralis muscle, a acellular dermal matrix product is used to cover the lower portion of the tissue expander and attach this to the chest wall. This allows complete coverage of the tissue expander that will give the greatest, most natural shape after the operation. At this point, a surgical drain is placed and then the remaining skin on the breast is closed over top of the muscle and tissue expander. The tissue expander is filled to the maximal volume possible without compromising the blood supply to the overlying skin.
After a short stay in the hospital, usually one night for single-sided breast reconstruction, and two nights for bilateral breast reconstruction, the patient will go home with pain medications and antibiotics. The surgical drains usually are removed around two weeks after the initial operation.
Starting approximately 3 weeks after the operation, tissue expansion begins. This involves injecting fluid into the tissue expander and stretching the overlying skin. Once we’ve achieved the desired size (at this point the shape is less importance), we will start planning for exchange to a permanent breast implant. This is usually performed 3 months after the final tissue expansion. This delay allows the skin to relax and soften.
Another return to the operating room for a short and quick operation allows the tissue expander to be removed, and a permanent breast implant to be placed. This is a great improvement to the breasts as they immediately become much softer, and the shape improves greatly.
Nipple reconstruction and subsequent tattooing can be performed as short outpatient procedures once all incisions are healed.
What are the types of implants that can be used?
Both tissue expanders and permanent breast implants have silicone shells. The interior of tissue expanders and saline implants contained a saltwater solution.
Saline breast implants have a silicone gel and are filled during the operation to the desired volume with a saltwater solution. As with silicone breast implants, great care is taken to prevent infection of the implants including washing them with a triple antibiotic solution, minimal contact with the skin and meticulous care of the overlying tissues that will be closed on top of the implant.
“Silicone” breast implants not only have a silicone shell, but also contain a silicone polymer gel. Both permanent saline breast implants and silicone implants can offer a patient a soft breast with a natural appearing contour but there are pluses and minuses to both.
Although silicone breast implants have a controversial history, recent studies have concluded that these are very safe. These implants have been used for breast reconstruction continuously since the 1970s. There was a 15 year period until 2006 when they were not allowed to be used for breast augmentation due to concerns of a correlation between the placement of silicone breast implants and autoimmune disorders. During this period, there are some large Scandinavian studies, which demonstrated that there was no increased risk of autoimmune disorders from silicone breast implants. In 2006, the FDA re authorized use of silicone breast implants for breast augmentation surgery as well.
A recent advancement of the silicone gel implant is the “gummy bear” implant. This is a cohesive gel implant that is anatomically shaped similar to a breast. This implant can offer a more natural contour and transition from the upper portion of the breast to the lower portion of the breast.
During your consultation we will have a lengthy discussion about the risks and benefits of the different types of implants. In general we prefer the use of silicone breast implants for breast reconstruction. With the loss of the overlying breast tissue, there is less “natural “breast tissue overlying the implant. Saline breast implants have a higher likelihood of being palpable as well as the possibility of seeing ripples in the implant.
For some women, autologous tissue, may either be preferred or may offer a better option for breast reconstruction. There are a few options for this type of reconstruction. In each of these types, volume from the breast is replaced with skin and fat from another location in the body.
TRAM flap reconstruction
This surgery involves using the skin and fatty tissue form the lower abdomen to reconstruct the breast. After the mastectomy is performed, this tissue is separated from the surrounding tissue in the lower abdomen, but remains connected to the underlying blood supply though connections to one of the two rectus abdominus muscles. This connection is maintained as the TRAM flap is brought up into the pocket where the breast used to be. This gives an immediate reconstruction to the side involved.
The belly is closed by bringing the skin back together with a horizontal incicion. This gives the added benefit of getting an improvement in the shape and contour of your belly similar to a tummy tuck.
This operation is a longer operation (about 4 hours) than implant based reconstruction and usually requires a 3-4 night stay in the hospital after the surgery. Despite the removal of one of the two rectus abdominus muscles, studies have shown that there is no increased weakness in the abdominal wall. There is a small chance of a hernia after this operation.
The pedicled TRAM flap is a common operation to perform for breast reconstruction and has been used for over three decades. This is a safe and reliable operation that can achieve remarkable results when properly performed.
Latissumus Dorsi Flap reconstruction
The Latissimus Dorsi muscle is a large muscle in the back that supports a large amount of skin overlying it. This can be brought around to the front of the chest to reconstruct the breast. The volume of tissue from this skin and muscle is usually less than the breast tissue that has been removed and therefore often requires that additional use of an implant. With the combination of this tissue and an implant, the reconstructed breast can look and feel very natural.
This surgery also requires a stay in the hospital for 3-4 days after the operation.