Despite this, a phenomenon that I come across (frequently) is the apparent discomfort that many women present with regarding the use of silicone implants for their breast reconstruction.
Women will often present with discomfort at the thought of having a “foreign body” inserted to reconstruct the breast. They express concerns about the safety of such a procedure; they worry that they are, in some way, doing the “wrong thing” or that they will be judged by others for having breast implants, particularly if they have a small implant placed under the unaffected breast for symmetry.
...women worry that they are, in some way, doing the “wrong thing” or that they will be judged by others for having breast implants.
The purpose of this article is to debunk as many of these judgements as I can. Implant reconstruction is a fantastic form of breast reconstruction with many benefits, and it would be my first choice in selected patients.
First, lets consider how this operation works (and how it differs from having a “boob job”).
At the time of your mastectomy, the breast gland is removed from on top of the pectoralis major muscle. To place the implant, there are two options: the implant can be placed ABOVE, or BELOW the pec major muscle.
My preference is to place the implant above the muscle, or what is referred to as a “pre-pectoral” reconstruction. There are a few reasons for this, but by far the most important one relates to avoiding the effect of muscle contraction on the implant. Muscle contraction leads to “animation” deformity, and I believe it also leads to increased pain and a higher risk of capsular contracture. In nearly all cases of pre-pectoral reconstruction, I use a complete 360 degree wrap of the implant with an ADM or biological matrix (more on this below).
A recent area of innovation in breast surgery has been the use of “acellular dermal matrices” (ADMs) to cover the lower part of the implant. These products are a layer of “tissue substitute” which over time allow blood vessels to grow into them (in this way, they act like a skin graft or fat graft). When used to wrap the implant, it means the the thickness of well vascularised and vital tissue covering the implant is increased (the ADM + skin) and this is of particular importance when we consider problems like wound healing, and resistance to radiotherapy.
The way this differs from a cosmetic breast augmentation is that in the case of a simple “boob job”, the breast gland remains, and this provides a thick layer of healthy tissue over the implant which means that the breast feels more “natural”. Once the breast gland is removed, the only tissue between the implant and the skin is the thin fat under the skin which is left behind after a mastectomy, and the ADM. This does mean that the implant is more visible and palpable than after a cosmetic procedure.
In many cases, rather than a silicone implant being placed straight away, an implant is used that consists of a silicone shell with an inflatable component. This is called a tissue expander. The benefit of using an expander is that by sequentially inflating this device with air or water (this involves simple injections done in rooms), there is some control over the final size of the breast, and the expander can stretch the scars that arise from previous surgery including the mastectomy. It has also been shown in recent studies that this 2 stage process may be safer than a single stage, direct to implant procedure, with fewer wound problems and a lower rate of implant loss. Whilst this water filled implant is in place, the shape of the breast can be a little odd, becuase the expander is not shaped like a normal breast. Once we have achieved a desired volume however, the expander is removed and a shaped or round silicone implant can be placed.
The long-term problems with implant based breast reconstruction are two-fold. On the one hand, the problem is subjective. A breast reconstructed with a silicone implant does not feel like a normal breast. Often, the shape is totally wrong. The implant gives a little too much fullness in the upper part of the breast, and the surgeon performing the mastectomy has often destroyed the small ligaments which form the boundary of the breast. A breast which is reconstructed with an implant never looks like a natural breast, and when used to reconstruct only one breast it is almost impossible to match the remaining natural breast to the shape of the reconstructed breast, except in very small busted women who can have the natural breast augmented (also with an implant) for symmetry.
On the other hand, perhaps the greatest problem with implant based reconstruction is the longevity of the reconstruction, particularly in the face of radiotherapy. I have alluded to this problem before: the impact of radiotherapy on a reconstructed breast is often to displace the implant and distort the shape of the reconstructed breast. With or without radiotherapy, shape change and distortion of the breast is the most common reason for re-operation after implant reconstruction.
The underlying process behind this is called capsular contracture. The body will surround any foreign body such as a breast implant with a scar capsule. This scar capsule will often tighten, with the result being that the capsule around the implant is smaller than the implant itself. The consequence of such being that the implant can become folded, rippled and displaced in various directions, and ultimately this will result in visible distortion of the breast. Capsular contracture is a risk whenever a breast implant is used, be it for cosmetic or reconstructive purposes.
We know that the risk of capsular contracture when used for reconstruction is about 2-3 x higher than when used for cosmetic purposes, and the risk is amplified with any subsequent revisionary procedure. We also know that if radiotherapy is required, the chance of capsular contracture is higher still. It is expected that up to one half of patients with implant reconstruction who receive post-operative radiotherapy will develop a significant contracture requiring treatment.
Additionally, it must be mentioned that in the event of wound healing problems, or infection, the chance that a patient may require the removal of her implant is significant.
Of course, having said all of that, most women who actually undergo implant based breast reconstruction experience satisfactory outcomes both functionally and aesthetically.
Where implants really come into their own is when used for a bilateral reconstruction in a patient undergoing either nipple sparing or skin sparing mastectomy. This scenario is becoming more common. We are seeing more ladies diagnosed early with good prognosis tumours, who don't need radiotherapy. And we are also seeing more women undergo prophylactic mastectomy due to either their genetic status (BRCA1 or 2) or strong family history leading to a high lifetime risk of cancer.
The problems of symmetry are alleviated when both breasts are treated the same way, and there is no requirement for radiotherapy to either breast. The recent case of Angelina Jolie has dramatically altered public appreciation of prophylactic mastectomy and immediate reconstruction. The so-called “Angelina Effect” is widely reported in the literature, with a well demonstrated increase in awareness and understanding of breast reconstruction options. Public campaigns such as the BRA Day campaign recently (both here and internationally) are leveraging this increased awareness to continue to educate the public.
I think the benefits of implant based reconstruction are often under-sold. These include a lack of a donor site, possibly a decreased hospital stay, costs may be less and perhaps most importantly, in the event of problems, it is always possible to convert to an autologous reconstruction at a later stage.
This last point is rarely discussed but deserves more attention. It is entirely reasonable that a young woman undergoing a bilateral mastectomy chooses an implant based reconstruction. Over a 10-15 year period, there may be some capsular contracture, perhaps radiotherapy adversely affects the implant, or perhaps the patient’s preferences change. In that same 10-15 year period, a woman may gain some weight or develop sufficient laxity in the abdomen for a DIEP flap to become a possibility. Or she may simply be ready to accept the scars and the practicalities of having a DIEP flap procedure. The option to convert an implant based reconstruction to an autologous flap reconstruction is always available. By choosing initially to have an implant based reconstruction, patients maintain the option of a flap for later in their lives when this option may be more appropriate.
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