Breast Reconstruction

When it comes to implant based reconstruction the options are either an immediate insertion of the breast implant (Direct to implant reconstruction) or insertion of a tissue expander with later insertion of the final implant. 

Although direct to implant reconstruction has obvious attractions not all patients are suitable and there are some risks. Small to moderate breasted women requiring an implant no more than 300 to 400 grams maybe suitable on a case by case basis. 

Advantages of Direct to implant (DTI) reconstruction

1. One operation only
2. Patients wake up with the final result

Disadvantages of Direct to implant reconstruction

1. Higher risk of wound healing issues such as skin or nipple necrosis
2. Patients may not get as much input into what size implant they receive
3. A further procedure may be required to obtain optimal positioning of the implant or swapping to a more desirable size

Two stage breast implant reconstruction involves initially inserting a tissue expanders either in front or behind the pectoralis muscle and then a second procedure to remove the tissue expand and insert the final implant. This technique is used more often in larger breasted women to minimise complications.

Advantages of Direct to implant reconstruction

1. Less risk of wound complications such as skin and nipple necrosis
2. The opportunity to discuss breast size and shape prior to insertion of the definitive implant
3. The opportunity to adjust the implant position at the second procedure

There are a number of options for performing implant based reconstruction including the positioning of the implant as well as a choice of the materials used.

Historically the implant would be placed behind the pectoralis muscle (subpectoral) as it was felt that the implant was more protected in this position and resulted in a better cosmetic result. More recently placing the implant under the skin and fat of the chest wall but in front of the muscle, prepectoral reconstruction has gained popularity. This results in less movement of the implant when the pectoralis muscle contracts (animation). It also allows better positioning of the implant centrally so that the cleavage is improved. There may be less post-operative pain with this technique over the subpectoral technique. A disadvantage of pre-pectoral reconstruction is that there may be more visibility of the implant as it is closer to the skin. Fat grafting may go some way to improving the contours and cosmesis in this situation. There may also be more risk of skin healing issues and potential loss of the implant.

Commonly now implant based reconstruction will be aided with the use of meshes to allow optimal placement of and support to the implant. These measures may be synthetic which are permanent or biological which will generally dissolve after a period of months.

Implants and tissue expanders are made from silicone. Silicone has not been shown to cause any specific diseases and is safe. Implants do have a lifespan though and after 10 years there is an increasing chance of complications necessitating removal or replacement. These complications may include rupture or capsular contracture (hardening of the fibrous capsule around the implant).

Anaplastic large cell lymphoma (ALCL) is a rare form of cancer that has been associated with textured implants. The risk of this complication with the style of implants used at Breastcare is thought to be one in 80,000 or less. With such a low incidence, ALCL is thought to occur only when a combination of factors come together including bacteria colonisation of the implant and in the setting of certain types of patient immune systems. Social media has coined the phrase “breast implant illness”, including a host of non-specific symptoms or conditions such as chronic fatigue, lethargy, arthralgias and irritable bowel symptoms. This is a misnomer in the medical literature with no real scientific basis to the association of implants with these non-specific or poorly defined conditions. This is further complicated by the placebo affect which may occur when patients have their implants removed.

With any surgery there is a risk of wound healing problems. With breast reconstruction as there are often thin large skin flaps created there is a risk of skin or nipple necrosis (death of tissue) due to reduction in blood supply to the tissues. In this setting is skin may need to be excised potentially requiring also removal of the tissue expand or implant for a period of time which can be quite distressing for the patient. The risk of this complication maybe 5 to 10% with a higher risk in those having radiotherapy and chemotherapy. 

The infection risk is typically fairly low when appropriate measures are taken to minimise this complication however if a deep infection occurs around the implant or expand removal of the device is usually required for a period of months before re-insertion.

It is important to discuss with your surgeon all the significant or relevant complications that may occur with your procedure so that you can be fully informed when consenting to the procedure.

In the immediate post operative recovery phase resting and not being over active are important measures to reduce these complications. 

These include a variety of techniques that utilise your own body tissues to create a breast. These can result in very good, natural looking reconstructions. They typically take longer than implant based reconstructions and may require more than one surgeon to perform the techniques at the time of mastectomy. In the immediate setting it may be difficult for the patient to consider a lengthy operation particularly when the requirement for post-operative therapies such as chemotherapy or radiotherapy is not fully clear.

These techniques may be a patient’s preference particularly if they want to avoid a foreign body. They are also good techniques in large breasted women and if abdominal tissue is used then a more feminine body shape may be achieved as opposed to implant based reconstruction. After radiotherapy on the chest wall, these techniques may be preferable over implant based reconstruction due to the scarring that is created from the radiotherapy. It should be remembered that autologous reconstructions will result in another scar at the donor site which may be on the abdomen or the back.

Options for Autologous Breast Reconstruction

These include:

1. Latissimus Dorsi reconstruction: Utilising back muscle 
2. TRAM flap : Transverse Rectus Abdominus Muscle flap utilising abdominal skin fat and some muscle
3. DIEP flap : Deep inferior epigastric perforator flap utilising abdominal skin and fat and sparing the muscle