Postmastectomy Breast Reconstruction: Current Techniques

, , Department of Surgery at the H. Lee Moffitt Cancer Center & Research Institute at the University of South Florida, Tampa, Florida

Cancer Control. 2001;8(5) 

In This Article

Implant Reconstruction

All breast reconstructions require more than one operation, and the process may extend over many months. Breast reconstruction using implants is the simplest technique and is the approach chosen by three fourths of the patients undergoing breast reconstruction at our institution. Reconstruction of the breast form begins with the placement of a tissue expander beneath the pectoralis muscle and laterally beneath the anterior aspect of the serratus anterior muscle. The tissue expander is a saline-filled envelope to which saline can be added in stages postoperatively. Some fluid is placed in the tissue expander at the time of expander placement. The patient is usually hospitalized overnight if immediate tissue expander reconstruction is performed. When the tissue expander is placed in a delayed fashion sometime after the mastectomy, the operation is performed on an outpatient basis.

Following complete healing in 3 to 4 weeks, additional volumes of saline are added at the rate of 60 mL per visit, which usually occurs on a weekly basis. The tissue expander is removed, and the permanent implant is placed at least 3 months following the initial procedure or after the completion of chemotherapy. The removal of the tissue expander and the placement of the permanent implant are performed on an outpatient basis.

The permanent implants may be filled with either saline or silicone gel. In 1992, the US Food and Drug Administration established a moratorium on the use of silicone gel-filled implants for breast augmentation. Since that time, these implants have been available under protocol from the companies for reconstructive purposes.

Over the last 10 years, the majority of breast reconstructions have utilized saline implants. Several problems have been associated with the use of saline implants. Wrinkling of the implant in the upper quadrant of the breast due to the thin soft-tissue cover occurs in 30% of patients undergoing reconstruction. Recommendations have been made to overfill the saline implant in an effort to reduce the incidence of wrinkling. While this may reduce wrinkling of the breast implant, the overfill technique produces a breast form that is excessively firm. Perhaps the best breast contour patient can be achieved with anatomical or teardrop-shaped saline implants. However, overfill of the anatomical implants may cause a loss of the anatomical shape.

All breast implants are synthetic products with a finite life span. If the saline breast implant ruptures, the saline is absorbed by the surrounding tissues over a period of a few hours. This is not dangerous, but the implant should be removed and/or replaced within a few weeks. Long-term studies have defined the expected life span of the saline implants. A multicenter study reviewed the outcome of 882 saline-filled breast implants placed in 450 patients between 1980-1986 with a mean patient follow-up of 13 years. Excluding known iatrogenic or traumatic deflations, the implant actuarial survival was 98.8%-99.5% at 5 years and 97.9%-99.5% at 10 years (95% confidence interval).[8]

We believe the silicone gel-filled implant provides a more satisfactory breast reconstruction for patients requiring implants of 350-500 mL and in whom the soft-tissue coverage is relatively thin. The silicone gel-filled implant provides a softer breast form, and the anatomical shapes available have been acceptable to many of our patients.

The systemic safety of silicone gel-filled implants has been confirmed by several studies over the past 10 years in addition to a satisfactory clinical experience of nearly 40 years. A recent extensive meta-analysis[9] reviewed nine cohort studies, nine case-control studies, and two cross-sectional studies that met stringent inclusion criteria. No evidence was found to indicate that silicone gel-filled breast implants were associated with a significant increase in the summary adjusted relative risk of individual connective tissue diseases, including systemic lupus erythematosus, scleroderma, Sjögren's syndrome, all connective tissue diseases combined or other autoimmune or rheumatic conditions.[9]

Silicone gel-filled breast implants may rupture at some point in time. If the implant should fail, the silicone gel can be expected to be contained by the scar tissue capsule that forms around the implant. The intracapsular free gel may stimulate an increased thickness of the scar tissue capsule. The patient may notice increased firmness of the breast, which may cause soreness in the breast area. Mammography, ultrasonography, or magnetic resonance imaging can reveal a rupture of a silicone gel-filled implant. However, radiology techniques may yield false-negative or false-positive results. Intraoperative examination is the only certain method to evaluate implant integrity. Removal and replacement of the implant are indicated if rupture occurs.

Nipple areola reconstruction begins 3 months after placing the permanent implant. The nipple is constructed using a bowtie-type flap procedure of the breast skin. Three months later, the areola is created using a tattoo technique (Fig 1).

Right breast reconstruction with submuscular 660-mL saline-filled implant, bowtie nipple reconstruction, and tattoo of nipple areola complex.

There are practical limits to the size of the breast that can be reconstructed using implant techniques. The risk of wound-healing problems and late breakdown of the relatively thin overlying soft tissue increases if the implant volume exceeds 600 mL.

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