Breast implants are made of a silicone shell filled with silicone, saline (salt water) or a mixture of both. Tissue expanders are silicone shells that don’t have any silicone inside but can be expanded after surgery by injecting saline. Silicone is an inactive material that is safe for use inside the body.
Implant reconstruction is the simplest form of breast reconstruction and has the benefit that it doesn’t take as much time to carry out as the other, more complex forms of reconstruction. Implant reconstruction also doesn’t result in scars on any other part of your body and because it is not moving tissue from any other area is also the quickest form of breast reconstruction to recover from. There tends to be less pain after surgery than with autologous reconstruction and stay in hospital after surgery is shorter.
Implants do not feel as soft as normal breast tissue, however, and will not move in the same way as your natural tissue. A breast reconstructed with an implant can also feel cooler than a natural breast, or an autologous reconstruction, particularly after, for instance, swimming. An implant reconstruction will not change in size if you gain or lose weight in the future as a natural breast or an autologous reconstruction might, and this can lead to asymmetry over time. Implants will generally create a breast that is more youthful in appearance, without the normal droop that many breasts develop with age and therefore maybe more suited to people who have smaller breasts. However, if you have a large breast but would appreciate being smaller you may be suitable for the ‘dermal sling’ technique of implant reconstruction (see below). No form of breast reconstruction is considered a one-off operation, and this is particularly true of implant reconstruction; over time about half of the people having implant reconstruction will undergo further surgery, either because of complications (see below) or to match up the other side (symmetrisation).
Technique of implant reconstruction
If implant reconstruction is carried out at the same time as mastectomy then usually the skin of the breast is kept with the nipple and breast tissue being removed (skin-sparing mastectomy). Once the breast tissue has been removed a pocket is created by lifting up the main chest wall muscle (pectoralis major) and the implant or tissue expander is placed underneath. The implant has to be put under this muscle because it is important that the implant is kept as far away from the skin as possible to give a more natural feel and to reduce the risk of infection.
The muscle is usually detached at its lower end and drapes over the implant, this leaves the lower part of the implant uncovered and a material is sutured in place to create a ‘hammock’ to support the implant here. This material can be an ‘acellular dermal matrix’ (ADM), a synthetic mesh, or some of your own skin (‘dermal sling’).
An acellular dermal matrix is a soft material made of animal (cow or pig) skin from which all cells and animal tissue has been removed. The resultant protein scaffold is like soft leather and is able to left inside the body where it is incorporated into your own tissue. A mesh is entirely synthetic and will also be incorporated into your own tissue over time. If your breast is quite large and/or has a droop to it, your surgeon may suggest a dermal sling technique instead. In this operation the skin envelope of the breast is deliberately reduced to give a more uplifted and smaller breast. The extra skin that is not needed, which is in the lower part of your breast, is trimmed so that it can be left inside the breast to cover the lower part of the implant. Using a dermal sling technique will require more scarring to the breast than the ADM or mesh techniques with a potential for delayed healing where the scars join (‘T’-junction) and your Surgeon will discuss this with you. You will be able to see photographs of patients who have had all of these techniques done in this unit.
The type of implant that is going to be placed will be discussed with you prior to surgery. Often this is a mixed silicone and saline implant which allows the size of the implant to be adjusted after surgery. This allows us to only partially expand the implant at first to keep the pressure off the skin while things are healing, and then to enlarge the implant later if needed. This type of implant comes with a ‘port’ which is like a button that is placed under the skin, usually just beneath your bra line. This port connects to the implant through a fine tube. When you have healed up following your surgery the implant can be expanded by putting a fine needle into the port and injecting sterile saline. Some people find the port uncomfortable, but once you are happy with the size of the implant the port can simply be removed under local anaesthetic or a short general anaesthetic. The implant itself is designed to be left in place permanently. Sometimes your surgeon may feel able to insert a purely silicone implant which is non-adjustable; this might be possible if you have fairly small breasts and your surgeon is happy that you have healthy tissue at the time of surgery. Another form of implant is a tissue expander. This is a form of implant that is likely to be changed at a later date for a final implant. Tissue expanders are empty silicone shells that can be filled with saline after surgery either through a valve that feels like a biggish disc on the surface of the tissue expander (‘integral port’), or through a remote port that is like a button under the skin. If you have an implant reconstruction as a delayed procedure after a mastectomy you will normally have a tissue expander placed that will be expanded up gradually in out-patient clinic during the weeks after surgery to stretch the skin before changing the implant to a silicone one.
After any type of implant reconstruction you will have one or two soft tube drains to drain away any extra fluid from the area of surgery, and these may stay in place for a week or more. You will need to stay on antibiotics until the drains are removed, but you won’t need to stay in hospital until then. When you go home a nurse from our Hospital at Home team will continue to visit you and will remove the drains when they have stopped draining so much.
Complications of implant reconstruction
One of the most serious complications of implant reconstruction is infection. This is because the implant is a foreign material that is separate to your blood supply. This means that infections around an implant can’t be readily treated as antibiotics in your blood stream won’t necessarily get to the area of the implant. If an implant gets infected it may need to be removed, and often can’t be replaced for some months, meaning that you may not get as good a cosmetic result. Sometimes the implant can never be replaced and you will need to consider whether you would like another form of reconstruction. Nationally around 9% of implant reconstructions are lost within the first three months after surgery, mainly because of implant infection. You will be given antibiotics around the time of surgery and until the tube drains are removed to try to reduce the risk of infection. The chance of infection is higher if you are a smoker and if you have either been treated with radiotherapy in the past or need radiotherapy as part of your post-operative treatment. Your surgeon and Breast Care nurse will discuss these risks with you and may recommend delaying reconstruction or using another form of reconstruction if you are smoking.
Implants also develop a ‘capsule’ around them over time. This is formed by your own body and is like scar tissue. Sometimes this capsule becomes thick and hard, in which case the implant may feel firmer and uncomfortable. Capsule formation is more common if you have had radiotherapy in the past or if you require it as treatment after the surgery. If you have problems with capsule formation you may require further surgery to try to improve it, which can include lipomodelling and changing the implant. In some, severe, cases the reconstruction may have to be changed for an autologous reconstruction to solve the problem. Other problems with implants are that they can move position or rupture, and these can also require further surgery to correct. Implants don’t routinely have to be changed as they get older if they aren’t causing any problems, however. All patients having a breast implant placed should be made aware of the rare chance of Breast Implant associated Lymphoma that has been identified. This is a form of cancer that occurs very rarely (1 in 20,000 with a breast implant) and which looks to be readily treatable by removal of the breast implant and any scar tissue surrounding it. Please let your GP or Breast Team know if you experience any sudden swelling of a breast that has a breast implant in it.