The implant is placed in a pocket that is made between the chest muscle (pectoralis major) and the rib. The cut (incision) to make the pocket is done through the scar from the mastectomy. The muscle and skin are closed and allowed to heal for 2–3 weeks. Implant based reconstruction can be done in a single stage (one surgery under a general anesthetic) or in two stages (two surgeries under a general anesthetic).
- Surgery time: About 1 hour to place the implant
- Hospital stay: Day surgery — occasionally one night stay
- Home care: Dressing changes
- Recovery time: 2–3 weeks to fully heal the incision
- To expand the pocket: 2–3 months, weekly or bi-weekly visits
When it is used
- In one sided (unilateral) or two sided (bilateral) breast reconstruction
- If there is not enough extra skin, fat and muscle available from your own body (autologous tissue)
- If an implant matches the other breast well
- If you have health problems where shorter surgery times are safer
- If this is what you want
When it is not used
- If there is too little or very thin skin after the mastectomy
- If radiotherapy has been used in the area. Breast implants have been used in areas that had radiation but this has a higher risk of complications
- If you are not healthy enough for surgery
- In smokers who do not heal very well
- Straightforward and simple
- Short surgery: about 1 hour
- No new scars
- No overnight stay in hospital
- Within certain limits, you can choose your new breast size
- If the implant fails, there are other options
- Short recovery time — about 3 weeks
- Scar tissue around the implant (Capsular contracture): The body may react to the implant. This can cause scarring, deformity, and pain.
- Implant size does not change if you gain or lose weight
- Implant problems — leaks or breaks
- Balancing surgery on the other breast (breast lift, breast reduction) is often needed to match the side of the implant
Note: Government health programs cover the cost
- Rippling effect may be seen through thin skin
- Does not look or feel the same as your own natural breast
Type of implants
The "saline implant" and the "silicone gel" implant. Both types have an outside shell made from silicone. Silicone is a soft material that feels like a "gummy-bear".
This implant's shape comes from being filled with a salt-water solution (saline). It comes in two forms:
- Ready-made in many sizes and shapes and cannot be adjusted once it is placed in the body
- Adjustable "expander-implant"
It can also have a round injection port attached to the implant or the port can be built right into the implant. The size can be adjusted. The port is used to fill the implant with a small amount of saline. Each time it is filled, the implant gets a little bigger. This type of implant is also called an "expander". It is used if the pocket needs to be made bigger or stretched.
- Can easily see if there is a break or tear. The size of the breast gets smaller right away.
- Less expensive
- Feels less natural
- "Rippling" effect may be seen through the skin
- Some women notice a "sloshing" feeling
Silicone Gel Implant:
This implant gets its shape from a silicone gel filling. The size or shape cannot be changed.
- Feels softer and more natural
- Less "rippling" effect
- A small break will not always need to be fixed by surgery
- Cannot easily see if there is a break or tear. The filling is a gel that feels like a "gummy-bear". It will not empty quickly like salt-water solution does. The size of the breast does not change right away.
- Possible increased risk of scarring around implant (capsular contracture)
With One Surgery
This is done in one surgery under a general anesthetic.
1) Implant that can change in size after surgery
A saline "expander-implant" with a small port attached is placed in the pocket. Every week after surgery, the port is used to fill the implant with a small amount of saline. This is done over the next few months in the clinic. This allows the pocket to slowly stretch and get larger over time. This will continue until the pocket is a little larger than the ideal size. Saline will then be drawn out through the port until the right size is reached. The port is then taken out through the original breast scar. The implant is left in place and is now permanent. This is done in the clinic under a local anesthetic.
- One surgery under a general anesthetic
- Can be done with larger breast sizes
- When the implant is being adjusted, you can decide on final size
- Clinic visits every week for a few months
- Small surgery with local freezing is needed to remove the port. May leave a second scar.
- The chance that the implant moves out of position is higher
2) Non-adjustable implant
Before the surgery, the size of the implant is picked to match the size of the pocket. The volume of the implant cannot be adjusted once it is put in the pocket. This will be the permanent implant.
- One surgery under general anesthetic
- Do not have to return every week to expand the implant
- Final breast size limited by the pocket size and how tight the skin is
- The chance of the implant moving out of position is higher
- Rate of problems with wound healing may be higher
With Two Surgeries
Two surgeries under a general anesthetic are needed.
In the first surgery, a “saline implant” with a small injection port built into it is placed in the pocket. This is called an “expander”. Every week after surgery, the port is used to fill the implant with a small amount of saline. This is done over the next few months in the clinic. This allows the pocket to slowly stretch and get larger over time. This will continue until the pocket is a little larger than the ideal size. This implant will stay in place for at least 1–6 months.
When the skin is soft and the pocket has stretched enough, a new implant is chosen to match the ideal size. In the second surgery, the “expander” is taken out through the original breast scar. The new implant is placed in the pocket. This will be the permanent implant.
- More size, shape, and texture options
- Second operation can be used to balance the look of both sides
- Clinic visits every week for a few months
- Need two surgeries under a general anesthetic
- Final implant size is not adjustable
You will need antibiotics and surgery. Doctors will likely take out the implant.
Bleeding or Hematoma
Iron supplements are needed in most patients. Blood transfusions will be needed if a lot of blood is lost. Surgery is needed to drain a hematoma.
Pulmonary embolus (PE), deep vein thrombosis (DVT)
Blood clots may form in the legs and lung. For long surgeries, anti-clotting medication is given after surgery to protect against this. Long-term anti-clotting medication is needed if this occurs.
Scarring around the implant in the pocket (Capsular contracture)
Surgery to deal with the scar. Implant may need to be changed.
Implant moves (Implant malposition)
Surgery to reposition the implant
Implant leaks or breaks (Implant rupture)
Surgery to remove and change the implant.
Implant breaks through the skin (Implant exposure)
Surgery to remove the implant.
Fluid that collects in a space (Seroma)
Fluid may need to be drained.
Effect of radiation
A “delayed reconstruction” may not be possible. Radiation after an “immediate reconstruction” can harm the site of the surgery. Over time, this may put you at higher risk for problems to that area. In order to fix them, another surgery would be needed.
Both sides do not look the same (Asymmetry)
There will be a difference in size and shape between the two breasts. It is nearly impossible to match the other breast in shape and position. A second surgery (balancing surgery) to fix this may be needed.
Scars are present. Scars may be raised, red and very itchy. Surgery to fix the scar may be needed.
Surgery that is done to correct a problem with an implant is done under a general anesthetic. The original scar is used to take out the implant. Repairs to the pocket are made and a new implant is put in. The muscle and skin are closed.
- How long will the implant last?
In majority, your implant will not last forever. Some implants will need to be changed at 5 years and some at 25 years, but most of them will last 10–15 years.
- What happens if I need the implant changed?
You do not have to go through the entire process again. The scar around the implant and the implant is removed and exchanged for a new implant during a short surgery under general anesthesia.
- If I had radiation before the implant, will it cause more problems?
Most likely. Short term, your implant is at more risk of infection. Your skin may be more sensitive to the stretching. You will develop more scar around your implant. This can change the shape of your breast or cause pain.
Special Considerations: Surgery to Balance the Other Breast
The main goal of breast reconstruction is to create a breast that looks nice and matches the other one. It is hard to make them match perfectly. Every effort is made to make them match as closely as possible. Surgery to correct the shape and size of the other breast is often done to help match the new breast. This type of surgery can also be used in women who had only a part of their breast removed (lumpectomy, partial mastectomy) to improve the shape of the partial breast defect.
Breast Lift (Balancing mastopexy)
The nipple and breast tissue are placed in a higher position with some skin removal to match the reconstructed breast. The overall effect is a higher and firmer breast mound. Fat and breast tissue are not removed; therefore there is very little change in size.
Breast Reduction (Balancing reduction mammoplasty)
Through the same incisions as a mastopexy, skin, fat, and breast tissue are removed in order to match the size of the other breast or the size desired by the patient.
Balancing augment mammoplasty “Breast Implants”
In women with small breasts, putting an implant in the other breast can help to create balance. This can be done at the same time as the reconstruction or at a later date. This should not interfere with cancer treatment or follow-up.
Special Considerations: Nipple and Areola Reconstruction
Nipple and areola reconstruction are the last steps of breast reconstruction. This is done after the breast mound reconstruction is finished and the woman is happy with the way it looks. This is usually done six months to one year after the breast mound reconstruction.
There are generally two parts:
- Making the nipple mound
- Adding colour
For women who do not want any more surgery, tattooing alone is an option to add color and shading.
In certain cases, at the time of the mastectomy, the nipple and areola can be saved. This should be discussed with the breast cancer surgeon.
Nipple Mound Reconstruction
There are many techniques that can be used. Most commonly, the tissue in the breast mound is raised and folded to create the nipple. This is a small surgery. It can be done in an operating room but is often done in the clinic using local freezing. Some examples are shown below.
The nipple is created using only the skin and fat over the breast mound. Examples of flaps may include the “C-V” flap, and the “Double Opposing Tab” flap.
- Easy to do. Done under local anesthetic.
- No skin grafts are needed
- Smaller nipple mound long-term, may flatten over time
- Coloring needed to match the natural areola
Local Flaps with Skin Grafting
Skin and fat are taken from the breast mound to make the nipple. A skin graft is needed to cover the area taken. This is usually taken from an area where a scar already exists such as the abdomen or other breast. It is also used to reconstruct the areola. An example is the “Skate” flap.
- Nipple is more visible and lasts longer over time.
- Skin graft needed, possibly creating a new scar
- Often needs to be done in the operating room under a general anesthetic.
- Risk of graft loss
- Bulky dressings that cover the area
- Coloring often needed to match the natural areola
Free nipple graft
In certain cases, a part of the nipple on the other breast may be taken to create a new nipple on the reconstructed breast.
- Better match to the natural areola
- Small scar on the nipple donor site
- Risk of graft loss
- Donor nipple may lose some sensation
The areola may be reconstructed using the skin from the other nipple. The goal is to get both areolas to match as closely as possible. A skin graft from the abdomen may also be used to create the new areola. Tattooing may be needed to match the color.
The nipple/areola color is added as a tattoo on the flap skin to match the natural color. Tattooing can be done with or without a nipple mound creation. Usually a local anesthetic is used before the tattooing starts. Touch-up tattooing may be needed to reach or maintain the desired color.
- Tattoo time: 20–30 minutes each nipple
- Recovery time: 1–2 days, Moisturizing ointment and dressings are applied for several days