How is breast reconstruction performed?
The majority of breast reconstruction procedures are outpatient surgery; however, some may require a hospital stay for the initial procedure (especially if done in conjunction with the initial mastectomy). There are three main options for performing breast augmentations.
- Using breast implants (saline or silicone)
- Reconstructing the breast using your own skin, fat and muscle
- A combination of these methods
Most breast reconstruction methods involve several steps. If your surgeon inserts your implant or expander at the time of your mastectomy, you may not require extra hospital time.
What are my breast reconstruction options?
There are several breast reconstruction options to consider. Your aesthetic plastic surgeon will help you weigh the pros and cons and select the method to benefit you the most.
Breast Reconstruction Using Implants
- Breast reconstruction using implants is the most popular option following mastectomy surgery and it's usually a two-or three-step process.
- In the initial procedure, your surgeon makes an incision and inserts a tissue expander beneath the skin and chest muscle, forming a skin-muscle pocket. The tissue expander is a modified saline implant with a valve that allows the surgeon to add more saline after the first surgery. After the initial visit, you’ll need to return to your surgeon’s office over the next two to six months so your surgeon can give you additional injections of saline through the skin into the valve to slowly fill the implant, which subsequently expands your breast mound. During this time, your skin-muscle envelope will slowly stretch until it reaches the size you desire for the final implant.
- In the next stage, you will undergo outpatient surgery during which your surgeon removes the expander and replaces it with a softer breast implant (saline or silicone).
- It is rare for a woman to have an implant (saline or silicone) inserted directly without first having tissue expansion. In this situation, the size of the skin-muscle envelope at the time of mastectomy is large enough to fit the desired final implant.
Breast Reconstruction With Implants Using an Acellular Dermal Matrix
- Acellular dermal matrix (ADM) is a sheet of tissue that had its cells removed leaving a framework of collagen and elastin for support and cover. This tissue is prepared to allow your body tissues to gradually grow into this material. Ultimately, your own collagen and blood vessels replace it.
- The acellular dermal matrix acts like a hammock under the mastectomy skin-muscle envelope that supports the tissue expander and can also improve implant placement. This framework of molecules allows your body's cells to grow into the matrix, promoting the regenerative process that takes place during tissue expansion. ADM is usually combined with your chest muscle to cover the expander and maintain its position, and subsequently the position of the implant.
- The ADM procedure can be less invasive than other techniques, allowing a larger breast mound to be created at the time of the mastectomy and decreasing the number of office visits needed to reach the desired implant volume. When the surgeon uses ADM, they can often replace the expander with the final implant sooner than with other tissue-expansion techniques. In rare circumstances, you won’t need an expander and your surgeon can place the final implant into the created hammock at the time of the mastectomy with no further surgery required.
- ADM products have allowed plastic surgeons to offer immediate breast reconstruction to more patients and improve overall breast reconstruction results. The quality of your mastectomy skin envelope determines whether or not you're a candidate for this technique.
- ADM has been available since 1994 and has become a popular breast reconstruction technique. Different ADM products have different properties, and your surgeon may recommend one over the other, depending on your situation.
Breast Reconstruction Using Natural Grafts/Tissue Flap surgery
- In certain circumstances, especially if you have radiation-damaged tissues, your surgeon may recommend using a flap of your own tissue to cover or replace the damaged tissues with healthy, non-irradiated tissue.
- Breast reconstruction using skin and tissue flaps from your own body (autologous tissue) can look and feel more like a natural breast than reconstruction with implants. However, these procedures are more complex and invasive, usually prolonging the hospital stay and leaving scars in the areas from which the tissue was taken.
- The most common natural flap procedures use tissue from the back, abdomen or buttocks. In some procedures, the surgeon will need to move an entire muscle to reconstruct the breast, causing weakness in that area of the body.
- Autologous fat grafting or fat transfer is another option for treating radiation-damaged tissues or small areas of contour irregularities. Fat transfer has pros and cons, including graft loss and fatty cysts, and may require multiple surgical sessions. Your surgeon can discuss the advantages and limitations of this surgery with you after evaluating you. Surgeons sometimes use autologous fat grafts to improve your implant reconstruction results or fill in deformities left by lumpectomies and mastectomies.
Skin-Sparing Mastectomy
- If you are having immediate breast reconstruction, your surgeon may perform a skin-sparing mastectomy to keep as much of your breast skin intact as possible.
- Your surgeon removes the tumor and clean margins (areas free of cancer cells) along with the nipple, areola (pigmented skin surrounding the nipple), fat, and other tissue that make up the breast. The surgeon can use the remaining healthy skin that surrounds the breast to cover a tissue flap or an implant.
- The major benefit of a skin-sparing mastectomy is that you don’t have to use skin from other body parts for reconstruction, which can have a different color, texture, and thickness compared with natural breast skin.
- If you have large or droopy breasts, you may be at a potential disadvantage as the loose skin may continue to sag and compromise the reconstructive result. It is best to discuss your options with your plastic surgeon before your mastectomy surgery if you are considering breast reconstruction.
Nipple-Sparing Mastectomy
- Nipple-sparing mastectomy is a newer procedure in which the surgeon removes the tumor and clean margins as well as the fat and other tissue in the breast, but leaves the nipple and areola intact, improving the overall look of the reconstructed breast.
- Not all women are candidates for nipple-sparing mastectomy, and there may be complications. The nipple will likely lose sensation and some projection. In some cases, the tissues may break down and your surgeon will have to remove some or all of the nipple and areola.
- There is some risk of breast cancer recurrence when leaving the nipple and areola. You should discuss your options with your surgeon and oncologist, who can assess your individual risk based on your tumor type, family history, and other factors.
Nipple Reconstruction With Implant
- Nipple reconstruction is possible if the surgeon inserts the permanent implant in the operating room as a third step in the cancer surgery. Recreating the nipple and areola gives the reconstructed breast a more natural look and can help hide scars.
- The surgeon is usually able to recreate the nipple by lifting a flap of skin from the reconstructed breast itself and folding it in such a way as to create a small piece of tissue with projection. There are several methods to achieve this and most can be done in an office setting under local anesthesia. Many surgeons prefer to delay the nipple reconstruction until the breast implant has settled into its final position, since this may affect the final position of the reconstructed nipple.
- The surgeon usually creates the areola by tattooing the area or grafting skin from the groin area, which has a tone similar to the areola’s skin. The scar from where your surgeon takes the skin is hidden in the bikini line.
What type of breast implants are there?
There are a lot of breast implant choices for breast reconstruction. Your aesthetic plastic surgeon will help you select an option based on your desired breast size and shape and medical history.
You can choose between saline implants and silicone implants. Silicone better mimics the look and feel of the breast. An advantage of saline is that you immediately notice an implant rupture because the breast deflates, whereas with silicone, you may need further testing to confirm this. There are advantages and disadvantages to each type of implant that you should discuss with your surgeon.
Saline-Filled Breast Implants
Saline breast implants are filled with sterile saltwater. They may be prefilled at a predetermined size or filled during the surgery to allow for minor modifications in the implant size.
Structured Saline-Filled Breast Implants
Structured saline breast implants are filled with sterile saltwater but contain a structure inside so they behave as if they are filled with soft, elastic silicone gel. These implants hold their shape better than traditional saline implants. The FDA and Health Canada approved these implants in 2014, and they have been available since 2015.
Silicone Gel-Filled Breast Implants
Silicone gel breast implants are filled with soft, elastic gel and are available in various shapes and degrees of firmness. All silicone gel breast implants are pre-filled. If you are getting a larger implant placement, you’ll likely have a longer incision.
Cohesive Gel Silicone Gel-Filled Breast Implants (also known as “gummy bear” or “form-stable” implants)
Cohesive gel silicone breast implants are filled with a cohesive gel, made of crosslinked molecules of silicone, which makes them a bit thicker and firmer than traditional silicone gel implants. They hold their shape better than traditional silicone gel implants too. The FDA approved these implants for use in the United States in 2012. These implants have been available in many areas of the world since 1992.