Breast reconstruction with implants is so often sold to patients as being the “simple” solution to their complex problems.
The reality is that implant-based reconstruction is a sometimes fraught process, with the potential for both niggling complications, as well as catastrophic cock-ups. It is more than a little bit cheeky for anyone to suggest that implant based reconstruction is just a walk in the park.
So, we have discussed at length the potential complications associated with DIEP flaps. I think it best to balance this discussion by going through the many and varied potential complications associated with implants.
If we break this down, the problems with implant reconstruction can relate to:
1. The prostheses (the implant, the ADM etc.)
The implant is a non-biological space filler. Which is to say, a bit of silicone. The body’s natural reaction to having a bit of silicone stuffed into it is to wall that silicone off with a “capsule”. That is all fine (provided the capsule doesn’t contract) but the issue that really plagues implants is when a minor infection sets in. The body’s tissue, with good blood supply, can fight off infection by supplying the area with the necessary immune cells and chemicals. Obviously, an implant can’t do anything of the sort. So, even a tiny infection, which in any other circumstance might only require some antibiotic tablets, can in the context of an implant reconstruction, be a total disaster. If the infection gets around the implant, the body simply can’t fight it off and the implant may have to be removed. Which takes us right back to square one.
If there is an ADM in there as well, then things get a bit more involved. The ADM is basically artificial skin. Unlike the implant itself, the ADM eventually develops a bloody supply (a bit like a skin graft does) and this is thought to be protective in the longer term against capsular contracture and so on. But if the ADM cannot develop its bloody supply due to infection or fluid collections, then it can simply add to the problem.
The other potential problem with ADMs is the so called “red-breast syndrome” (feel free to google this). There are a lot of different ideas about this, but basically after an ADM has been used, the breast can become red, mimicking an infection. The reaction may have to do with the way the ADM is processed in manufacturing. Regardless, the red breast tends to settle with time of its own accord, but obviously this can lead to many anxious days waiting, wondering, and hoping. More than one implant has been removed because it was felt (incorrectly) that the red breast was an infection.
2. Fluid collection
Fluid collections really are the bane of implant based reconstruction. Nature abhors a vacuum, and your body abhors empty space. It wants to fill that space, and so after surgery, if there is any empty space (and there frequently is after the mastectomy), then your body will fill that space initially with fluid, or a SEROMA. Seromas are a pain for me and a bigger pain for you. The seroma gets in the way of ADMs developing their blood supply, and they form the perfect medium for low grade infections to develop. So obviously, seromas are bad.
This is the reason that every patient has drains after implant based reconstruction. To suck out the fluid, and also to apply negative pressure inside the breast to avoid that empty space (we call it “dead space”, but that doesn’t sound so great I guess). The drains can stay in for a while (up to several weeks in some cases), but having drains in for so long can be a problem in itself.
If a seroma forms after your drains are removed, then it may require needle aspiration (which requires an ultrasound to prevent damage to the implant).
3. Mastectomy skin flap necrosis
This is probably the single biggest disaster than can occur after an implant based reconstruction. Unfortunately for both me and my patients, the risk of mastectomy skin flap necrosis is entirely dependent on the breast surgeon (not the plastic surgeon), becuase it is the quality of the mastectomy performed which determines the chances of this complication.
A mastectomy is performed to remove or prevent cancer. It mandates that the entire breast is removed. The breast is a subcutaneous organ (that is, the breast tissue is all under the skin) and to remove the entire breast often means that the skin left behind is very (very!) thin….which is a problem because the bloody supply to that very thin skin can be compromised.
Now, if a patient has had a DIEP flap reconstruction for example, and the skin of the breast dies, then this is a problem, but because there is new tissue (the flap) with a good blood supply under the skin, then it is possible to deal with this problem with dressings (allowing the body to heal itself – one of the biggest benefits of the DIEP flap is that it is your own tissue with all of the same properties as tissue anywhere else in the body, including the ability to heal) or even a skin graft if necessary. But if the breast skin dies, and an implant is underneath (which can’t heal itself), then it often will mean that the implant has to be removed: a total disaster in other words.
4. Longer term problems
The longer term problems are things like capsular contracture, which we have discussed at some length before. Capsular contracture is the most common reason for re-operation in the longer term, and it is the most common reason for dissatisfaction with implant based reconstruction due to distortion of the breast, poor cosmetic outcomes and pain.
Not infrequently, women come seeking a DIEP flap reconstruction some time after their implant reconstruction, and the most common reason to request a free flap is to deal with the problems of capsular contracture.
So, is breast reconstruction with implants simple? NO.
If your surgeon tells you it is a simple procedure, they’re either lying, or very inexperienced.
Do you need a Plastic Surgeon to do you implant based reconstruction? Not necessarily. But if there is a problem with that reconstruction, I would be inclined to suggest that the best person to deal with that problem is a Plastic Surgeon. The process of consent means that you should be warned about all of the above before you have an implant based reconstruction. It also means you have every right to ask your surgeon how those problems are going to be dealt with.
Be very sure you are happy with the answers you are given.