Breast reconstruction by implant
The strong points
- This is a simple and quick method of breast reconstruction that does not add scars.
- We prefer to use it on slim women who have not had radiotherapy
- The prior realization of one or two sessions of lipofilling before the reconstruction by implant greatly improves the result, especially in case of irradiation
Principles
The purpose of this procedure is to reconstruct the volume and contours of the breast by placing an internal prosthesis under the pectoral muscle. It can be performed at the same time as the removal of the breast (immediate breast reconstruction) or in a second phase (secondary breast reconstruction). This internal prosthesis is, in the simplest cases, the permanent prosthesis. In some cases, it may be a temporary tissue expansion prosthesis designed to increase the amount of covering tissue (skin, muscle) of the permanent prosthesis, which can give a more natural appearance to the reconstructed breast.
The prostheses are all made of a silicone elastomer envelope that can be smooth or more or less rough (textured or covered with polyurethane foam) to reduce the risk of shell formation.
There are several shapes of prostheses: round or "anatomical" (see Breast Augmentation - Round or Anatomical Prostheses) whose thickness is greater in the lower part and simulates the profile of a natural breast. In breast reconstruction, we use anatomical breast implants covered with polyurethane foam in 95% of our cases in order to avoid the risk of rotation and to limit shells.
In immediate breast reconstruction, an implant is placed just after the removal of the breast, under the pectoral muscle. In some cases, if the tumor is located at a distance from the areola, we keep it and all the surgery is performed by a scar under the breast identical to that used in cosmetic surgery.
During a secondary breast reconstruction, if the tissues are refined at the level of the scar, we start with one to two lipofilling sessions spaced 2 months apart. The mastectomy scar is used to place the implant. We then perform an abdominal advancement flap that increases the amount of skin available in the lower portion of the breast and perfectly defines the lower breast fold (submammary fold). The pectoral muscle is then lifted to hide the upper portion of the implant.
In practice
The procedure is performed under general anesthesia. This requires a pre-anesthetic consultation at least 48 hours before the procedure.
It lasts 1 hour and requires a hospitalization of 2 to 4 days mainly because of the need for a postoperative drainage.
A return to work can be envisaged 2 weeks after the operation.
Physical therapy sessions are very useful to limit pain and improve the flexibility of the reconstructed breast.
Questions / Answers
Are there any contraindications to breast reconstruction with implants?
Yes, breast reconstruction by prosthesis is not suitable for all patients. The usual failure rate for breast reconstruction with a prosthesis can be considered to be between 2 and 3% of cases. Heavy smoking and obesity increase the complication rate by almost 3 times. A mastectomy (removal of the breast) is often completed by radiotherapy of the thorax if the lymph nodes were invaded. This can lead to significant burning of the skin of the thorax, which makes it impossible to place the implant. In these cases, we turn to DIEP or grand dorsal flap techniques. However, the new lipofilling techniques can be used to counterbalance the effect of radiation and to consider the placement of implants.
To sum up, breast reconstruction by prosthesis is primarily intended for thin women who have not received radiation.
I am hesitating between saline or silicone gel implants for my breast reconstruction. What do you recommend?
Serum breast implants are very good breast prostheses with a good safety profile (few shells, no risk of siliconoma in case of rupture of the deflated implant).
Their use in breast reconstruction is nevertheless limited by some disadvantages related to the nature of these implants.
Since the implant is placed just under the skin and muscle in breast reconstruction, its folds are visible at the upper edge of the serum implants.
Serum breast implants also feel harder than silicone implants.
Finally, serum implants are only available in a round shape and do not exist in an anatomical shape that is very useful in breast reconstruction.
In conclusion, we most often use anatomical silicone implants covered with polyurethane foam in breast reconstruction.
We reserve serum implants for skin expansion procedures or as a standby implant during immediate breast reconstruction.
I have had radiation therapy, is breast reconstruction by implant a good option?
Overall, no.
Thoracic radiotherapy after mastectomy causes a burn of the skin, of varying severity, which results in a retraction of the tissue.
The body can no longer stretch to accept the internal breast prosthesis. The failure rate for the insertion of a breast implant is very high.
If the operation is an immediate success, the body will often cause an excessive fibrous reaction around the prosthesis or shell with a frequency of between 20 and 30%. If this shell is severe, the implant must be removed.
It all depends on the intensity of the burn caused by the radiotherapy. The new techniques of conformal irradiation (with calculation of the doses of radiation delivered according to a scanner) make it possible to reduce the after-effects and to place breast implants with an acceptable success rate.
In addition, a new strategy consisting of repeated lipofilling of the mastectomy area reduces the number of complications. However, it postpones reconstruction by several months.
What are the possible complications?
There are immediate and distant complications.
Immediate complications are hematoma, infection, and scar opening, which can lead to reconstruction failure in 2 to 3% of cases.
Remote complications are capsular contracture or shells, implant malposition (too small, too high, rotation), and implant rupture.
Is the result stable over time?
No, and this is the main flaw of this technique. The breast reconstructed by an implant will remain fixed while the non-diseased breast will tend to fall over time. Thus, a breast plastic surgery of the non-diseased breast is often necessary with sometimes unsightly scars.
In addition, the implant will tend to wear out over time causing deformities of the reconstructed breast that will require a change of the implant usually between 10 and 12 years after its installation.
How much does a breast reconstruction by prosthesis cost?
Breast reconstruction by prosthesis is covered by health insurance after the opinion of the doctor advising the social security. We charge additional fees of 1200 to 1500 € depending on the case, which may be covered by your health insurance.
Have a question? Please contact us!
The firm
Docteur Yaël Berdah and Docteur Marc-David Benjoar
Plastic surgeons in Paris France