June 26, 2022
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By Dr. Andrew Campbell-Lloyd

Breast reconstruction with implants

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Information

Breast reconstruction with implants may be performed using a fixed-volume definitive silicone implant OR using an inflatable tissue-expander which must then be replaced with a defintive breast implant at a second stage.

When the reconstruction is performed with a definitive implant, this is referred to as direct-to-implant (DTI) reconstruction.

An implant may be placed over, or under the Pectoralis major muscle. The under-the-muscle approach is an older fashioned technique with numerous problems associated with it. Dr Campbell-Lloyd prefers the over-the-muscle (prepectoral) technique.

COSTS:
Plastic surgeon’s fee: from $6,990.

Total approximate cost (insured patient where item number applicable): from $ TBC.

Please note, Dr Campbell-Lloyd offers this surgery privately to insured patients only.

Associated item number: 45539, 45542 (tissue expander-to-implant 2-stage reconstruction) |  45527 (direct-to-implant reconstruction).

May be performed with: MASTECTOMY

LENGTH OF PROCEDURE/HOSPITAL STAY:
3-4 hours

2-3 days in hospital

All patients will be discharged with drain(s)

Reconstructing a breast after mastectomy with breast implants may sound straight-forward, but it may prove a more complicated process than a reconstruction with a DIEP flap.

It is vital to understand that the outcome of an implant-based reconstruction is totally dependent on the quality of the mastectomy performed by your breast surgeon.

A number of issues relating to the mastectomy can compromise the success of an implant-based reconstruction:

  • if there is any irregularity in the thickness of the skin that is preserved,
  • if there is any problem with blood flow to the skin that is preserved,
  • or if the natural ligaments that form the supportive boundaries of the breast are disrupted, then the reconstruction may be significantly affected.

These issues are totally beyond Dr Campbell-Lloyd's control. It is important that you discuss with your breast surgeon the risks associated with a mastectomy, and how they might impact on an implant based reconstruction.

Key Features

Immediate reconstruction:

Dr Campbell-Lloyd recommends an immediate implant-based breast reconstruction in selected cases, including in young patients who are having a bilateral mastectomy without any need for radiotherapy (eg. risk-reducing cases or ladies with small, good prognosis tumours), in small busted ladies with minimal breast droop, and in ladies who do not wish to have a "donor site" associated with a flap reconstruction.

The appearances of the breast with implant-based reconstruction are best when the nipple is preserved. If your breast surgeon has recommended removal of the nipple for any reason, Dr Campbell-Lloyd would typically suggest a DIEP flap reconstruction for a more natural result.

Generally, implants offer a poor form of reconstruction in delayed cases.

Prepectoral:

Dr Campbell-Lloyd prefers prepectoral reconstruction. This means the implant is placed on top of the Pectoralis major muscle. This reduces the pain and longer-term discomfort of implant reconstruction, and prevents implant animation.

ADM or mesh:

Dr Campbell-Lloyd will wrap the implant or tissue expander in a biological matrix or a dissolving mesh. This offers support for the implant, decreases the risk of capsular contracture, and helps with future fat grafting procedures.

No "donor-site":

One the major benefits of an implant-based reconstruction is the lack of a donor site.

Ladies having DIEP flap reconstruction will always have a large, "tummy-tuck" style scar on the lower abdomen. The absence of a donor site means no scar, and a different recovery from surgery as there won't be a second operative site that needs to heal prior to resuming full activity.

Can be converted to DIEP flap (or other flap) in the future:

We are seeing an increasing number of young ladies having mastectomies, sometimes before having children, or with young children. For these ladies, their focus (both appropriately and necessarily) is different to those ladies who present later in life with breast cancer. Our younger patients are far more conscious of the impact of the abdominal donor site that comes from having a DIEP flap, and for them, implants may be an ideal option, at least in the short-term.

One of the aspects of implant-based reconstruction that we emphasise is the ready conversion to an autologous reconstruction with a DIEP flap at some stage in the future. The implant has often done its job in preserving the breast skin shape after mastectomy, and it is often just a case of replacing the volume of the implant with a similar volume of abdominal tissue down the track.

Implant-to-autologous conversion is an option that we are considering with increasing frequency.

Associated procedures:

All implant-based reconstruction requires multiple procedures, without exception.

Depending on whether the reconstruction is direct-to-implant or 2-stage with a tissue expander, there may be a requirement for a second procedure as a planned event.

In most cases, we recommend fat transfer as an adjunct to the reconstruction, and this may require multiple procedures at various points. Fat transfer cannot be performed at the time of mastectomy.

Over time, all implants will need corrective procedures. The time-frame for this is variable, but it is worth considering what increases the risk of early corrective surgery being required:

  • Ladies with deflated breasts, even if modest in size, will tend to stretch under the influence of an implant more than ladies with a firmer breast. The breast tissue contains ligaments which provide support to the natural breast. Once the breast tissue is removed in a mastectomy, the only support for the implant is the breast skin, which will easily stretch, and this is far more likley when the breast is already a little stretched. Once the breast stretches due to the implant, the breast takes on a "tennis ball in a sock" appearance (excuse the terminology but it provides the necessary visual!) and this will require a tightening procedure.
  • Ladies who develop mild infections are at increased risk for capsular contracture and they will tend to require earlier revision. Most of these ladies' infections will settle with antibiotic tablets, but the inflammatory stimulus of that process will still lead to contracture.
  • Ladies who have slow wound healing for any reason are at increased risk of capsular contracture.
  • Ladies who develop seromas (fluid collections), even if only small, will have an increased risk of capsular contracture.

Key Risks

When considering an implant-based reconstruction, Dr Campbell-Lloyd will spend more time considering the risks of the surgery than with other forms of reconstruction. The reason for this is that if a patient has an implant-based reconstruction, the potential for that reconstruction to fail is substantially higher than with other forms of reconstruction (most especially, it is far higher than a DIEP flap).

A failed implant-based breast reconstruction is a catastophic outcome for a patient, both mentally and physically.

Dr Campbell-Lloyd has previously written about the challenges of implant-based reconstruction, and it is worthwhile taking some time to understand the risks. Please do follow the link to read more.

Reasons To Consider This Procedure

Younger patients:

Younger patients who present with breast cancer, or those considering risk-reducing surgery due to genetic factors (BRCA1 or 2 for example) or a strong family history, are often well suited to implant-based reconstruction, at least in the shorter term. These ladies will typically have long lives after their breast cancer treatment, and so it is to be expected that they will, over their lifetimes, require multiple procedures to manage their breast reconstruction. For these ladies, an initial implant-based reconstruction may be a slightly simpler consideration, representing a lower barrier to reconstruction for an age group who are used to the idea of breast implants through their social settings and in medial portrayal.

Small, firm breasts:

Ladies with a smaller, firm or perky breast will do better with an implant-based reconstruction than those ladies with a deflated breast after pregnancy which may show some signs of tissue stretch before their mastectomy. The firmness of the breast is an indirect indicator of the elastic recoil of the breast skin, and hence the ability of the breast skin to hold the weight of a breast implant, leading to better aesthetic results.

Bilateral surgery, or happy to have an implant augmentation of the other side:

Ladies in the above two groups will very frequently consider bilateral mastectomy. In the younger population who present with cancer, given their potentially long survivorship, the lifetime accumulated risk of developing cancer in the opposite breast after a first cancer is treated, is higher than in older patients, potentially justifying the bilateral treatment. In the risk-reducing group, bilateral treatment is necessary. In both contexts, ladies who are candidates for implant-based reconstruction will always achieve better aesthetic results when both breasts are treated. Symmetry is very difficult to achieve when trying to match a breast reconstructed with an implant to a natural breast.

In some ladies who choose to treat a single breast, if they are candidates for implant-based reconstruction, the opposite breast can be augmented with an implant if modest in size. This will better allow the two breasts to match.

Not ready to consider the donor site associated with DIEP flaps:

Some ladies feel that the magnitude of the DIEP flap is too great for them to consider when also having to confront a cancer diagnosis. This is understandable, and in these cases, an initial implant-based reconstruction not only offers the benefits of reconstruction, but also allows these ladies time to further consider their choices, knowing that they can have their implants replaced with DIEP flaps in the future.

Delayed-immediate reconstruction:

This final group present a distinct consideration. Delayed-immediate reconstruction represents a newer concept in reconstruction which may offer the best of both worlds.

In this form of reconstruciton, at the time of mastectomy a tissue-expander or silicone implant is placed. This ensures that the patient wakes up with some form of breast reconstruction, but more importantly, this allows us to preserve the natural breast shape and the breast skin. We then replace the tissue-expander or implant about 3-6 months after the mastectomy, with a DIEP flap.

The rationale for this approach is that is allows a patient's cancer treatment to take place, including things such as radiotherapy and chemotherapy, without the patient having to grapple with the magnitude of the DIEP flap. Once the cancer treatment is complete, and when the patient feels psychologically ready, the DIEP flap can be performed.

The significant benefit to this approach is the fact that it provides a patient with time.

Frequently, patients present with a new breast cancer diagnosis and they are simply overwhelmed. Trying to also consider the complexities of reconstruction can be too great a challenge, and sometimes patients will experience decision regret: that is, they view their choice of reconstruction in retrospect in a negative light, feeling that they were rushed or pushed into a decision that they wish they could reverse.

We also see ladies who are told they they must have an urgent mastectomy, when in reality they could take a bit of extra time to make a suitable reconstructive decision. This time pressure comes from multiple sources, but it may also create logistical challenges in ensuring that a breast surgeon and a plastic surgeon can be in the same place at the same time.

The delayed-immediate approach removes this time pressure, and allows ladies the benefit of the DIEP flap, on their terms, and with the stress of the breast cancer diagnosis and treatment behind them.

What To Expect

During surgery, Dr Campbell-Lloyd must assess the breast skin carefully after the breast surgeon has finished the mastectomy. There is always a chance that the blood flow to the breast skin has been irrevocably damaged during the mastectomy. If this is the case, then it will not be safe to proceed with an implant-based reconstruction.

The blood flow is assessed with a special form of imaging called fluorescence angiography. This involves a dye injection into a drip, which can then be seen flowing through the blood vessels in the skin using an infra-red camera. This technique is vital to the success of implant-based reconstruction.

If the blood flow is seriously damaged by the mastectomy, Dr Campbell-Lloyd will have to alter the reconstructive plan. If there is a less serious problem, you may need to have treatment with topical medication to improve the blood flow. This involves application of an ointment. Dr Campbell-Lloyd may also choose to use a deflated tissue expander rather than an inflated expander or definitive silicone implant, to ensure there is less pressure on the skin if the blood flow is less than ideal.

Drains:

All patients will have drains. Dr Campbell-Lloyd uses two drains in each breast to ensure that no fluid can build up between the breast skin and the mesh wrap around the implant. The drains also help to suck the skin down onto the mesh which helps the tissues to heal.

One drain will be removed prior to discharge from hospital. The other drain will normally remain in for 7-10 days, but could be in for up to 3 weeks. You will be educated in the care of your drains prior to discharge from hospital. You will also have detailed instructions on how the drains work, and how to manage them.

Negative pressure dressing (Prevena):

Different applications of "Prevena" negative pressure wound dressings after mastectomy and reconstruction.

Dr Campbell-Lloyd uses negative pressure dressings in all cases. These dressings involve a foam which is applied to the breast and a small, portable pump which creates a continuous suction. This suction creates the "negative pressure", and the foam conforms to the shape of the breast.

These devices offer numerous benefits to patients and will remain on for 2 weeks. During this period of time you won't be able to shower and you will have to have a careful sponge bath to avoid wetting the dressing.

Dr Campbell-Lloyd will explain how these dressings work, and you will have detailed instructions on discharge from hospital.

General post-op care:

All sutures are dissolving sutures, under the skin. A layer of glue may be applied to any incisions.

After breast reconstruction with implants, patients are discharged home discharged with antibiotic tablets, and pain-relief medications.

Patients are discharged home with detailed instructions. The instructions include emergency contact details for Campbell-Lloyd, instructions for your dressings and also instructions for your drains.

Routine follow-up appointments are made for (although patients may be seen more frequently):

  • 3-4 days post-discharge,
  • 2 weeks post-op (to remove your Prevena dressings)
  • 4-6 weeks post-op,
  • and 3-4 months post-op

There will be some pain. Most patients will experience pain at the incision sites for the first 7-10 days. Some patients will experience occasional discomforts relating to movement after that time as the healing process continues.

The nature of this surgery is such that patients should expect to require pain relief medication for at least the first 2-3 weeks. Some patients will require simple pain relief (such as Nurofen) for up to 6 weeks as they increase activity.

It is vital to maintain a decreased level of activity for 6 weeks after surgery breast reconstruction.

It will take at least 3-4 months for full recovery. Final results can only be appreciated after that time, once scars have softened and relaxed. Scars may only fade after 6-12 months on the breast.

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