This is a common plastic surgical technique for breast reconstruction which involves the insertion of a prosthesis in a one stage operation or two stage operation. One stage operation involves using a definitive implant to reconstruct the breast. The two stage operation involves initially putting an expander in the breast (usually under the muscle). This is slowly increased in size by filling it up with saline. When it reaches an acceptable size, the expander is eventually removed and replaced with a definitive implant.
The two stage procedure is the commoner of the two procedures, as it give more flexibility in relation to size, contour and enventual shape of the breast. I shall discuss with you the various options and we can work out the most appropriate method together. Implant based reconstruction is preferred if your breast has not had or will not have future radiotherapy. Those patients who have radiotherapy and a pure implant reconstruction have a well documented high rate of implant related complications. For this reason, patients with breast cancer who need radiotherapy will preferably require a flap of tissue to protect the implant.
The results are generally excellent with high satisfaction rates. In this description I shall take you through the operation, hospital stay, recovery and the complications. Once you have met me for the initial consultation, I would be quite happy to see you again for a second consultation, so that you can clarify any of your doubts.
Expander and Implants
There is a range of expanders and implants available. Basically an expander is an empty bag which can be filled up with fluid to slowly increase the size of the breast. The expanders come in either a round or tear-drop shape. It can have a smooth surface or a rough surface. The site of injection into the expander can be either integrated in the device itself or a port which runs into a tube which goes into the expander. The expander can be either inserted below the breast tissue or below the muscle which underlies the breast. The latter technique is the common method.
Once the expander device has been inserted, it can be expanded at intervals to expand the size of the breast progressively. Once the breast is fully expanded, I can insert the definitive implant after a minimum period of 3 months.
There are different implants which can be used including round implants or tear drop shaped implants. The implant can have a smooth or rough surface. Also the implants can have silicone of different consistency. The implants can be placed below the breast tissue or below the muscle which lies below the breast. This is done in the same plane as the primary expander. I will discuss with you the different implants and the site of implant placement. The implant type, shape and site of placement is chosen after careful discussion and evaluation, to get you the best result after your surgery.
Procedure / Hospital Stay
It is advisable to stop smoking for 4 weeks and stop contraceptive pill and hormone replacement therapy for 4 weeks prior to the procedure. On the day of the operation, the surgeon will do skin markings over the breasts. The procedure is done under general anaesthetic and involves different types of incisions depending on the problem. While you are in hospital you will have blood tests, fluids through a drip and pain killers. The stitches are all dissolving in nature. At the end there is a fairly bulky dressing on the breasts and potentially a drain on each side. You will feel bruised and swollen after the operation and this settles in due course. This is more so after expander or implants are placed below the muscle. We take precautions to prevent clots in your calves by putting on stockings and giving you a blood thinning injection. The hospital stay is conventionally 2 days and depends on recovery and drain removal.
Recovery After Surgery and Expansion Process
At discharge the dressing stays on and you will need to attend the dressing clinic in a weeks time. The dressing will then be removed and the nurse will assess you for expansion. This is done at a point when you feel comfortable. The first expansion is a bit of an event and is due to the ‘fear of the unknown’. The doctor will look for the site of the port for injection of saline. The remote port is located by feel, while the integral port is detected by using a magnet. When you leave hospital, you should be given the magnet to bring with yourself in the clinic. Don’t worry if you forget to get it, as there are usually a few spare in the clinic. Once the port is located, the doctor will wipe the area with some antiseptic and then insert a needle into the port. The expander is completely safe and you will notice a feeling of stretching as the fluid goes in. The expansion is stopped at the point you start having perceptible discomfort. Following this you come back every 2 weeks for further expansion. Desired expansion may take a few visits, after which I shall discuss with you the next stage. This involves leaving the expander in for a few months to let tissues stretch adequately. This is then followed by removal of the expander and insertion of definitive implant.
You should avoid smoking for 4 weeks after the procedure. The recovery is individual, but most patients get back to work and driving in 2-3 weeks time. Aerobics and more vigorous exercise, especially with implants under the muscle should be done only around 3 months after the procedure.
Overall results are excellent but there are some well know limitations, risks and complications which you should be aware about.
- I cannot promise you the ultimate cup size and there is wide variation among bra manufacturers.
- Breasts are asymmetrical and this difference will persist after surgery.
- Breasts are never static and will change with age, weight changes and pregnancy.
- Scars heal well but can become rarely lumpy.
- Infection can occur which may require antibiotics and implant removal.
- Bleeding straight after surgery may necessitate a return to theatre.
- Implants can rupture and then need to be replaced.
- Occasionally silicone leakage can result in lumps in the breast, which are harmless.
- It is common to feel the implant edge and occasional ripples.
- Tear drop shaped implants can occasionally rotate or get displaced to the side.
- Implants always develop a capsule of scar tissue around them, but in some it can become quite hard and painful and may require further treatment. Capsule formation is more common if you have had radiotherapy.
- The life expectancy of implants is unknown, though manufacturers have suggested that they last for 10 years. It is frequent to see patients who have had implants for much longer.
- Clots in the calf and clots going to the lung are known to occur after any operation.
- Silicone is completely safe and has no relationship to breast cancer or any connective tissue disorder. This matter has been ratified in USA and in a wide ranging study in the UK (Department of Health, UK).
- Nipple reconstruction and tattooing are recommended procedure which can make a big difference to the appearance of the breast.
- Mastopexy (breast lift) procedure on the normal breast may be necessary to give good symmetry.