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Direct to Implant Reconstruction

Congratulations for making this far and seeking to understand your reconstructive procedure better. Immediate prosthetic breast reconstruction utilizes prosthetic silicone implants to reconstruct your breast.

Immediate prosthetic reconstruction is mostly offered to patients as a risk reducing procedure or patients with early stage tumour that will not require radiation. Radiation therapy adversely affects a prosthetic reconstruction.

All patients receiving immediate prosthetic reconstruction will have a sentinel lymph node biopsy before the mastectomy and reconstruction. The sentinel lymph node biopsy will stage the disease process and anticipate additional treatments needed, for example radiation or chemotherapy.

The breast cancer surgeon performs the skin sparing mastectomy. A skin sparing mastectomy is a procedure where most of the breast tissue is removed maintaining the skin of the breast which will serve as an envelope for the reconstruction. 98% of breast tissue is removed via the skin sparing mastectomy. It is important to note that it is impossible to remove all the breast tissue as some breast tissue will still be attached to the breast flaps. This emphasizes the importance of radiological screening even if you have had a skin sparing mastectomy. You would still have to go for a breast ultrasound once a year.

The nipple areola complex has a major aesthetic implication, not only the presence or absence thereof, but also the symmetry between the two breasts. The oncological surgeon will removed the nipple areola complex depending on tumour factors if so indicated and/or patient requests. All nipples that are left behind will have intra-operative histology to make sure there is no disease in the nipple. All normal breasts will also have an axillary lymph node sampling to exclude any underlying tumour.

In our unit we perform the skin sparing mastectomy via different incisions. The type of incision depends on the size of the breast, the grade of ptosis (drooping) of the breast, previous operations and patient requests. The incision may be a lasy-S incision, an inverted T or anchor incision, infra-mammary fold incision, infra or peri-areolar or along previous incisions.

The decision process during direct to implant reconstruction.

The Size of the Implant

Prior to surgery it is important to give your reconstructive surgeon an idea of the breast size you prefer. Although an exact size can never be guaranteed we may be able to work together to give you an acceptable breast size.

The size of the implant depends on various factors. The pre-operative breast size, the size of the opposite breast and the intra-operative oncological findings. Generally it is better to choose an implant slightly smaller, larger or the same size as your current breast size. A radical change in size and shape is associated with a poor cosmetic result and increased complication rate.

The decision to keep the nipple and areola is an oncological decisions. Thus a nipple will only be removed if:

  • There is cancer in the nipple
  • There is cancer close to the nipple
  • The nipple cannot survive once the inside of the breast have been removed.

Prior to the procedure the breast cancer surgeon will inform you if the nipple and areola will be removed. A decision is made on how to manage the nipple and areola on the non-cancerous breast prior to the surgery. We may be either leaving the nipple areola complex behind or leaving the areola (darker circle) while removing the nipple. Definitive reconstruction will be done 3 to 6 months later.

 

The type of incision depends on the pre-operative size of the breast, oncological management of the nipple and areola, tumour position, previous scars and patient preference. You may use the following incisions for a direct to implant reconstruction:

  • Lazy S.

This incision leaves a scar on the outer aspect of the breast which may or may not encircle the nipple leaving part of the areola behind depending on the oncology. This type of incision is suitable for women of small and medium size breasts with adequate skin elasticity which will allow some degree of tissue retraction.

  • IMF or Inferior mammary fold incision. This is a perfect incision for whom previously had a breast augmentation via this incision. It allows for a well-hidden scar in the fold.
  • Peri-areaolar, around the nipple. The incision may become completely unnoticeable over time
  • Wise Patter Incision /Inverted T Incision- for patients with sagging breasts.

This type of incision is used for patients with large breast, excess skin or poor skin elasticity. The inverted T incision in cases of direct to implant reconstruction is associated with an increased complication rate.

In cases where the nipple and areola needs to be removed a skin disc will be used to reconstruct the area where the future nipple and areola will be reconstructed are just the brown area or areola may be left behind.

You will receive a general anaesthetic. The reconstructive surgeon draws the appropriate access incisions on your breast either before or during the procedure.

 

Firstly the breast cancer surgeon removes the breast tissue and necessary lymph nodes via the predetermined access incisions. The pathologist determines adequate tumour removal intra-operatively and once the margins are clear the reconstructive surgeon proceeds. The nipples, if left behind will be biopsied.

The implant is placed partially beneath the muscle and partially behind the remaining breast tissue. Drains are placed and the wound closed in layers.

Immediately post-surgery there will be dimpling around the closure site due to the underlying sutures needed to keep the implant in place. The dimpling around the incision will gradually disappear as the wound heals.

You would have to stay in hospital for a period of 2 -3 days post-surgery. You will be taught how to keep record of the drainage. Antibiotics and pain tables will be given to take home. The drains will be removed once it drains less than 60 ml in two consecutive days.

Do not rush to get back to work allow yourself a period of 4 weeks for recovery. You will not be allowed to drive for 2 weeks following the procedure. I would recommend 2 – 4 weeks off work and no gym for 6 to 8 weeks.

Below follows a list of some of the more frequent complications associated with immediate prosthetic reconstruction

Local compilations i.e. around the breast……

  • Haematoma formation
  • Seroma formation-
  • Delayed wound healing
  • Wound sepsis
  • Peri-implant infection
  • Sensory changes in the breast
  • Pain

Systemic complication…. your body

  • Fluid and electrolyte abnormalities
  • Deep vein thrombosis
  • Post operative lung complications

Long term and cosmetic complications… the way it looks

  • Rippling and contour deformities
  • Malposition and displacement of the implants
  • Asymmetries of the breast
  • Capsular Contracture (hardening of  the implant, often painful caused by fibrous tissue around the implant)
  • Visibility of the implant around its edges
  • Implant rupture, which can cause the silicone gel to leak out into the neighboring tissue or even parts of the body
  • Pain, from many causes including muscles spasms and nerve injury
  • Secondary procedures to improve the appearance eg. fat fills and nipple reconstruction.

It is important to note that you will always feel the implant. Initially you will have a heavy pressure feeling on your chest. You gradually become accustom to the feeling. Your breast will always move and contract with muscle movement of your pecs, the feeling and movement lessen over time but never ever disappears. The movement result is an unattractive anatomical deformity of the breast. That cannot be avoided or corrected.  The implant is covered superiorly by skin and muscle and inferiorly by skin only, the muscle at the top causes the unattractive appearance.

 Please remember this is a reconstructive procedure and not a cosmetic procedure. Should something go wrong with the reconstruction you will not have any breasts as you had mastectomies, breast removal. In case of reconstructive failure you will have to wait for a period of 6 -12 months before we may attempt another reconstruction. The next reconstruction will start with the insertion of a tissue expander and will follow protracted course. Please see the section on tissue expansion.

Our aim is breast cancer treatment and prevention and not cosmetics. The most difficult patients are those that have had previous cosmetic procedures. I cannot emphasize enough that this is a reconstructive procedure.

Most importantly, silicone is a product not inherent to your body. As tires for your car, kitchen appliances or paint, sooner or later it may need replacement. The time of replacement is unknown.

The longer you have implants the greater the chances of developing complications, which will require more surgery. The “life” of these devises varies according to the individual. Some may need replacement surgery within 2 years, others may last 10-20 years and some even a lifetime. There are several different reasons why patients may need implant replacement surgery. Sometimes it is a matter of choice like size or implant style change and sometimes removal and replacement is necessary because of a complication such as deflation, capsular contracture (hardening), pain or shifting of the implant.

You may wish to have a procedure to improve the cosmetic appearance of the implant. Please note every time you operate on your breast the breast tissue get thinner and thinner and the greater the chances of compilations. During any subsequent procedure even fat fills there is a risk of puncturing the prosthesis and/or infection.
If this happens you may need removal of the implant, have a period of 6 to 12 months without a prosthesis and start reconstruction via the tissue expansion method.

There are many reasons as to why you may develop chronic pain after the procedure. A mastectomy is the removal of an organ. The brain perceives it as such and may express it as phantom pain. The procedure may cause pain, any surgical incision is painful over time especially when it is cold think about your Cesar scar. In addion the prosthesis itself may cause pain as it is a foreign body. It is important to seek treatment early so as to prevent the formation of chronic regional pain syndrome.

You will need to have ultrasound examination once a year to assess the integrity if of the implant and to evaluate the residual breast tissue. I would recommend both a clinical and ultrasound examination once a year.

If you feel that your implants are getting hard or firm please see me immediately as there is a specific protocol that we follow to decrease the development of capsular contracture

There will be complete sensory loss in both the nipples and breasts after the procedure. All the nerves are removed. Some ladies still report some degree of sensation however this is completely unpredictable. The feeling may increase or decrease and be different in different areas. The sensory changes may be temporary or permanent.

Risk reducing surgery and close surveillance have the same outcome. It is important to understand that by choosing risk reducing surgery you are exchanging once set of complications (breast cancer) which may kill you, for another set of complications (prosthesis related.) which may feel like it’s killing you. Once again it is important that your choice is a cancer decision and not a cosmetic decision.

I hope I have explained the procedure in an understandable manner and have address some of your questions. Please feel free to ask any additional questions or concerns.

Thank you

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011 482 2196
dr.mventer@gmail.com