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PROCEDURES / BREAST RECONSTRUCTION
IMPLANT-BASED BREAST RECONSTRUCTION
Breast implants are often used to restore the volume and shape of the breast after mastectomy. Typically, the procedure is done in stages with the placement of a temporary implant—or tissue expander—into the breast at the time of mastectomy. This device is partially filled with saline solution at the time of the mastectomy and subsequently filled to its final capacity in the office with a small needle inserted through the skin into an integrated port in the tissue expander. A planned second surgery is then performed as an outpatient within a few months of the primary surgery to exchange the tissue expander for a more permanent breast implant, usually a silicone filled implant.
With the increasing popularity of nipple sparing surgery—which preserves all of the breast skin envelope—direct-to-implant surgery can be offered in appropriate cases, avoiding a planned second procedure. The determination regarding suitability for direct-to-implant reconstruction is made through the shared decision-making process. Technology that allows for real-time assessment of blood supply to the breast skin at the time of mastectomy can help with intraoperative decision making.
Increasingly, the implants are being placed in the PREPECTORAL space rather than partially behind the pectoralis muscle, as was more routine in implant reconstruction over the past 2 decades. This shift in technique was prompted by the desire to limit the dynamic deformity that can be seen in the upper pole of the breasts after partial submuscular placement of the implants, when the pectoralis muscle is contracted. Post-operative recovery can be more rapid because muscle dissection is avoided. The use of intraoperative anesthetic muscle blocks and Enhanced Recovery After Surgery (ERAS) protocols have revolutionized post-operative pain management, diminishing the need for narcotics and reducing hospital stays after implant-based reconstruction.
The safety of silicone breast implants has been exhaustively studied, with the FDA finding no association of silicone breast implants and systemic illness. As the implants are mechanical devices, they need to be monitored over the years following reconstruction for implant shell rupture (incidence of approximately 1% per year), development of scar tissue, or capsular contracture following implant placement (which can lead to implant hardening or displacement within the breast). Annual physical exams and occasional MRI studies are performed to assess the integrity of the implants. Reoperation after implant-based breast reconstruction can be necessary if these conditions are diagnosed over the years after reconstruction.
If a mastectomy is performed on one side only, procedures to improve symmetry of the remaining breast—such as breast lift or reduction, or placement of a breast implant to the remaining breast—can be done. Based on the Women’s Health and Cancer Reconstruction Act, a federal law enacted in 1998, these symmetrizing procedures are considered part of the reconstruction and these federal mandates ensure insurance coverage.
Implant-based breast reconstruction typically requires an overnight stay in the hospital, with an anticipated return to driving within 2 weeks. Second stage or revision surgery is performed as an outpatient with recovery expected within 1 week.