Reconstructive Implant / Tissue Expander

Breast Reconstruction

Breast reconstruction with implants uses an implant to replace the breast tissue removed during a mastectomy or wide local excision. If a patient has already had a mastectomy, there will not be adequate skin to cover an implant. Therefore, I will need to place a tissue expander into the breast pocket at the first procedure using either the mastectomy scar or an additional scar in the crease underneath the breast.

Tissue expansion is a process that stretches the remaining breast skin and soft tissues to make room for the breast implant. A balloon like tissue expander is placed in the breast pocket and this is gradually inflated on a weekly basis by injecting saline into the tissue expander valve. This process takes up to 6 weeks. Once the desired size is reached, the tissue expander is replaced with a definitive implant.

For patients who are having the implant reconstruction at the same time as the mastectomy or wide local excision, the implant can be placed directly into the pocket.

What does the operation involve?

An implant reconstruction or tissue expander insertion takes approximately an hour and is either performed through an incision in the crease underneath the breast or through the mastectomy incision.

The implant can be placed above (pre-pectoral) or below the pectoral muscle (sub-pectoral). The advantage of placing the implant below the muscle is that there is an extra layer of tissue covering the upper pole to reduce the risk of you seeing wrinkles and ripples. However, surgeons have now realised that placement above the muscle gives a better aesthetic result and avoids the implant moving up and down with muscle movement (animation deformity). It is often performed with second stage fat grafting to increase the soft tissue cover and risk of seeing the edge of the implants.

It is not always possible to put the implant above the muscle if the skin has a poor blood supply or is too thin. In patients who have droopy or ptotic breasts then the implant reconstruction can be combined with an uplift (mastopexy augmentation reconstruction) and in unilateral reconstructions an uplift will be performed of the other breast to symmetrise the result
 The procedure takes an hour to perform under general anaesthetic and you can go home the same day.

I use a long-acting local anaesthetic block during the surgery, which is used to temporarily stop pain from the nerves that supply the breast. This lasts for 72 hours and should provide pain relief making surgery as comfortable as it can be. Usually only simple analgesia such as Tylenol and ibuprofen are needed in the initial post-operative period.

What types of implants are there?

Breast implants are available in a variety of types, with different shapes and sizes. Some are round and some are more of a teardrop shape. Implants are made of an outer casing of silicone or polyurethane and filled with a silicone gel. For more information please see my guide below on implant selection.

Selection of the correct size and shape of implant will be done with you at your first appointment. Using Crisalix, we can create a 3D image and you can see yourself and compare simulations with what you may look like after surgery. This experience is enhanced by using Virtual Reality goggles. We can then see what different implant sizes and shapes will look like on you. You will then be able to use the sizing kit to confirm this. If you need further clarification you can try different implant sizes yourself at home using the ‘rice test’. It is important that you take your time in deciding what shape and size of implant you would like. We will help guide you with this decision.

What are the risks and side effects of surgery?

Having cosmetic surgery can be a very positive experience. Complications are infrequent and usually minor. However no surgery is without risk and you should be aware of any possible problems.

Scars

Scars are hidden in the crease under the breast and tend to settle remarkably well, so that the scars are barely perceptible. However some people heal with thick scars and this can make them more noticeable.

Bruising and swelling

A degree of swelling and bruising is normal, and this may take approximately 3 weeks to settle.

Haematoma

This is a collection of blood in the pocket created by the implant. It occurs in between 1% to 4% of women who undergo a breast augmentation procedure. It tends to occur within 1 to 3 days post-surgery.

Any increase in swelling or pain should be reported immediately for assessment. Should the haematoma be significant, it will have to be washed out in theatre and any bleeding vessel(s) identified and cauterised. This does not normally delay your recovery or change the cosmetic result.

Infection

The risk of infection is inherent with any surgical procedure; this can be either:

Superficial (does not involve the implant) and should respond to oral antibiotics.
Deep (involves the implant) and requires temporary removal of the implant.

The deep infection risk is less than 1% but on the rare occasion, when infection occurs, the breast implant may have to be removed to allow the antibiotics to work effectively for the infection to settle. The implant will be replaced once the infection has resolved.

I use a no touch technique during surgery with Keller funnels to introduce the implant and minimise any possible infection risk.

You will also be given antibiotics when you are put to sleep and post-operatively to reduce the risk of infection.

Numbness, reduced sensation or oversensitivity

A reduction in nipple sensation may occur, which may improve to some degree with time. However, this may never completely return to normal. Occasionally patients feel that nipples become more sensitive.

Wound healing problems

Fortunately, these are very rare with implant surgery. However, it is possible that the incision opens and needs re-suturing.

Asymmetry

Each breast is slightly different and will continue to be so following surgery. Remember, “they are sisters and not twins”. However, if you have noticeable asymmetry prior to your surgery, then this can be corrected as part of the surgery as discussed with you.

Stretching of your breast tissue

The larger the implant you choose, the more likely it is that your skin will stretch with time, and you may require an uplift at a later stage. Occasionally breast augmentation is associated with stretch marks, which are permanent but fade with time.

Rotation/displacement

Occasionally implants can sit in the wrong position or may move in the post-operative period. A further procedure may be required to correct this.

Implant rippling or wrinkling

This can be more prevalent in very slim patients or those with very little breast tissue. This is reduced if the implant is placed behind the chest muscles, or a fat graft is performed to increase the soft tissue cover.

Rupture

I use Motiva breast implants, which are all guaranteed. However, as a medical product, they can still fail. If an implant is known to have ruptured, then it should be removed. The ruptured implant is contained within the capsule of scar tissue so it will not ‘spill out’ into your breast tissue.

Capsular contracture

Following breast augmentation, the body makes a capsule of scar tissue around the implant. Sometimes this tissue can shrink and contract (capsular contracture). If this happens, it can make the breasts feel abnormally hard and may require further surgery to remove the capsule.

Many studies show that the risk of this is approximately 20% after 10 years with silicone implants.

DVT/PE

Following any surgical procedure it is possible to develop a blood clot in your legs, which could potentially break off and travel to your lungs. If the blood clot is large enough, it could prove fatal.

The overall risk for cosmetic surgery is less than 1%, but to reduce any risks of a DVT/PE, you will be provided with special stockings to wear in bed together with a blood thinning injection, if you are not mobile or have previously had a DVT or PE.

Anaplastic Large Cell Lymphoma (ALCL)

In January 2016, the United States FDA announced a possible association between breast implants and the development of ALCL, a rare type of non-Hodgkin’s lymphoma. According to the World Health Organization, BI-ALCL is not a breast cancer or cancer of the breast tissue; it is a lymphoma, which is a cancer of immune cells. Women with breast implants have a very low, but increased risk of developing ALCL. In women with breast implants, ALCL is generally found next to the implant itself and is usually contained within the fibrous capsule that the body forms around the implant. The exact risk of ALCL is unknown and health organisations from around the world are pooling data to try and establish this risk. An observation of reported cases indicates a predominance of textured device involvement. The association with breast implants is likely multifactorial and is currently being extensively studied.

Most of the breast implant patients found to have ALCL were diagnosed after they sought medical treatment for implant-related symptoms such as pain, lumps, swelling, or asymmetry that developed after their initial surgical sites had fully healed. In most cases, the ALCL was treated with surgery to remove the implant and surrounding scar tissue. Some patients also received radiation therapy, chemotherapy or both. The condition has a very good prognosis and a high probability of cure if it is treated appropriately.

I recommend that you seek medical help if you notice swelling, fluid collection or sudden and unexpected changes in breast shape either from myself or another suitably qualified healthcare professional. If you require more information then please feel free to contact me at any stage.

For more information on what is known about BI-ALCL please visit these useful links from the American Society of Plastic Surgeons or the FDA website. FDA Patient Information - Breast Implant Complications
Joint-ASPS-ASAPS-Statement-On-Breast-Implant-Associated-ALCL.pdf

Breast Cancer

There is no evidence linking silicone or saline filled implants to breast cancer. You will still be able to examine your breasts, with the implants in place and have a mammogram/ultrasound as normal. Breastfeeding is still possible with implants, as the implant sits behind the breast tissue, leaving all the milk ducts untouched.

What happens after the operation?

Your incisions will be closed with dissolvable sutures, which do not require removal. I use a waterproof dressing which will be removed after 1 to 2 weeks following surgery. You can shower as soon as you like after surgery, and you will be given spare dressings in case they become wet and need changing.

I will prescribe you 7 days of antibiotics to be taken after surgery to reduce any risks of infection as the incision heals.

You must wear a support bra for 6 weeks and I recommend that you purchase 2 bras, so you have one to wear and one in the wash. These are worn day and night for approximately 6 weeks post-surgery, before returning to any bra of your choice. You will need to purchase these prior to your surgery, and I will provide the relevant details in clinic. Details can also be found in the compression garment guide below.

Initially, your breasts may seem larger than you expected. This is normal and it is partly due to swelling and it takes time for you to get used to your new appearance.

Before you leave the hospital, you will be given a follow up appointment to see the nurses at one week to check your incisions and an appointment to see me in 2 weeks. You will not be able to drive yourself home from hospital and, ideally, you should have someone to stay with you for a few days to assist you. If you have any concerns during this period, do contact the clinic for advice.

Once the dressings are removed, I recommend that you massage the incisions, using small circular motions at least twice a day for 5 minutes. You can use any moisturising cream of your choice and apply firm pressure until it blanches.

The scars will also benefit from Silicone scar gel (ScarAway® or Kelo-Cote®) twice a day, which will soften and fade them, as well as applying sunblock for 12 months to provide sun protection. The ScarAway® can be purchased from Healthcare Pharmacy at Governors Square in Grand Cayman.

What is the estimated time for recovery, absence from work and return to usual activities?

When you return home, you should take it easy for the first 2 weeks or so. Most people take approximately 1 to 2 weeks off from work. You should be able to start driving after 2 weeks, return to the gym for lower body exercises at 4 weeks, and begin upper body workouts at 6 weeks.

To help shape and support your breasts as they settle, you will need to wear your support bra day and night for 6 weeks.