Breast Reconstruction Using Implants

Mastectomy removes the entire breast, but the skin and nipple can sometimes be saved. Using a breast implant is one option for reconstructing the shape of your breast after mastectomy.

This usually means having at least two operations.

• The first surgery places a tissue expander, a flat “water balloon” that will be gradually filled (expanded) during office visits until a desired size is reached.
• The second surgery replaces the tissue expander with a breast implant. Additional procedures could be done to reconstruct the nipple-areola area or revisions to improve the overall look.

There are a few different types of breast implants, and other factors to consider before you make your choice.

What types of implants are used for breast reconstruction?

Several types of breast implants can be used to rebuild the breast. Most implants in the US are made of a flexible silicone outer shell, and they can contain saline or silicone gel. Other types of implants that have different shells and are filled with different materials are being studied, but these are only available if you are taking part in a clinical trial.

It's important to discuss the benefits and risks of the different types of implants with your doctor. 

Saline breast implants

Saline implants are filled with sterile (germ-free) salt water. These types of implants have been used the longest. A newer type, called a structured saline implant, is also filled with sterile salt water, but is made with an inner structure to help give the reconstructed breast a more natural look and feel.

Silicone breast implants

Silicone gel implants tend to feel a bit more like natural breast tissue. All silicone breast implants in the US are made of cohesive gel, which is a thicker type of silicone implant. Form-stable implants, the thickest ones, are sometimes called gummy bear or highly cohesive breast implants. The name means that they keep their shape even if the shell is cut or broken. They are firmer than regular implants and might be less likely to rupture (break), although this still might happen.

There are different shapes and sizes of saline and silicone implants, and they can have either a smooth or textured (rough) surface. Any type of implant might need to be replaced at some point if it leaks or ruptures.

How are implant procedures done?

You might have a choice between having breast reconstruction at the same time as the surgery to treat the cancer (immediate reconstruction) or later (delayed reconstruction). 

Immediate breast reconstruction

Immediate breast reconstruction starts at the same time as the mastectomy. It is usually completed in stages and at least two operations are needed. The first stage is during the mastectomy, when the plastic surgeon places a tissue expander (“water balloon”) under the skin or muscle on your chest. Mesh is sometimes used to hold the expander in place, much like a hammock or sling. The water balloon starts off flat and is then expanded during office visits until the desired size is reached. The second stage removes the tissue expander and replaces it with a permanent breast implant. The timing of the second stage (implant placement) can be planned and safely postponed if needed, because of cancer treatments such as chemotherapy. If necessary, additional procedures could recreate the nipple-areola area or could be revisions to improve the overall look.

A small number of women might be candidates for a direct to implant breast reconstruction. This means the breast implant is put in place at the same time as the mastectomy. Women most often suitable for this type of reconstruction are young, have small breasts, and have no health problems. In this situation, a tissue expander is not used.  After the surgeon removes the breast tissue, a plastic surgeon puts in a breast implant. The implant can be put under the skin or muscle on your chest. Mesh is sometimes used to hold the implant in place, much like a hammock or sling.

Delayed breast reconstruction

Delayed breast reconstruction means that rebuilding happens later, often months, after the mastectomy. The reconstruction starts when the chest is flat. A tissue expander is placed under the chest wall muscle or skin. This will help to make a pocket to put the implant into at a later date. The tissue expander is a balloon-like sac that starts off flat and is slowly expanded to the desired size to allow the skin to stretch. Once the skin over the breast area has stretched enough, a second surgery is done to remove the expander and put in the permanent implant.

If radiation therapy after mastectomy is part of your cancer treatment, you might not be a good candidate for implant reconstruction and should discuss other reconstruction options, such as tissue flaps, with your plastic surgeon.

Tissue expanders are filled by the surgeon injecting a salt-water solution through a tiny valve under the skin at regular intervals (every 1, 2, or 3 weeks) to fill the expander over several months.

You might choose to delay breast reconstruction if:

• You don’t want to think about reconstruction while coping with the cancer treatment. If this is the case, you might choose to wait until after your breast cancer surgery to decide about reconstruction.
• You have other health problems. Your surgeon might suggest you wait for one reason or another, especially if you smoke or have other health problems. It’s best to quit smoking at least 2 months before reconstructive surgery to allow for better healing.
• You need radiation therapy. Many doctors recommend that women not have immediate reconstruction if they will need radiation treatments after surgery. Radiation can cause problems after surgery such as delayed healing and scarring, and can lower the chances of success. Flap reconstruction surgery (using other body tissues to create the new breast) is often delayed until after radiation.

Your surgical team will discuss your best reconstruction options, taking into account your medical history, body shape, cancer treatment, and personal goals.

Tissue support for implants

Some plastic surgeons choose to use donated human skin or pig skin to support tissue expanders or implants. These are known as acellular dermal matrix (ADM) products because they have had the human or pig cells removed. This reduces any risk that they carry diseases or that the woman's body will reject them. They are mainly made of collagen so the person’s own connective tissue can grow over the framework to extend and support natural tissues and help them grow and heal. ADMs can help support and position the tissue expander or implant. 

The use of acellular matrix products in breast surgery first started in the early 2000s. Studies that look at outcomes are still being done, but they have been promising overall. This type of tissue is not used by every plastic surgeon, but it is becoming more widely available. Talk with your doctor about whether these materials will be used in your reconstruction and about their benefits and risks.

Risks of illness from breast implants

In the past, there were concerns about possible health issues from ruptured silicone-filled implants, such as connective tissue disease, breast cancer, or reproductive problems. So far, studies show that silicone implants do not increase the risk of these health problems. Some people with breast implants may have symptoms of joint pain, memory loss, or fatigue. It is not clear if these symptoms are related to the breast implants and more research is being done.

Rare cancers

Breast implants have been linked with some rare types of cancer, which can develop in the scar tissue (capsule) around the implant.

For example, breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare type of non-Hodgkin lymphoma that can develop several years after the implant is placed. It occurs more often when the implants have textured (rough) surfaces rather than smooth surfaces. BIA-ALCL can show up as a collection of fluid, a lump, pain, or swelling near the implant, or as asymmetry (uneven breasts). If you have any concerning symptoms, discuss them with your doctor.

Early-stage BIA-ALCL is often treated with surgery to remove the implant and capsule. Radiation therapy may be used if the lymphoma can’t be removed completely. More advanced disease might require chemotherapy and/or other treatments.

There have also been rare reports of other types of cancer forming in the scar tissue around a breast implant, including some types of lymphomas (other than BIA-ALCL) and squamous cell carcinoma. These reports are fairly recent, so not much is known about these cancers at this time.

Things to think about before getting implants

Most women will do well with implants. But there are some important factors to keep in mind if you are thinking about having implants to reconstruct the breast and/or to make the other breast match the reconstructed one:

• The longer you have breast implants, the greater the chance you might need more surgery to remove and/or replace your implant later.
• You might have problems with breast implants. They can break (rupture) or cause infection or pain. Scar tissue may form around the implant (called capsular contracture), which can make the breast hard or change shape, so that it no longer looks or feels like it did just after surgery. Most of these problems can be fixed with surgery, but others might not.
• Breast MRIs may be recommended every few years to make sure silicone gel implants have not broken. Your health insurance might not cover this. Talk to your plastic surgeon if you have any questions regarding the indication for breast MRIs.