Breast implant procedures can be performed on an outpatient basis or at a hospital. Breast implant surgery can be done under local anesthesia or under general anesthesia. Breast implant surgery can last from one to several hours depending on whether the implant is inserted behind (submuscular) or in front of (subglandular) the chest muscle and whether surgery is performed on one or both breasts. If the surgery is done in a hospital, the length of the hospital stay will vary according to the type of surgery, the development of any postoperative complications, and your general health. It may also depend on the type of coverage your insurance provides. Before surgery, your doctor should discuss with you the extent of surgery, the estimated time it will take, and the choice of drugs for pain and nausea. See Breast Implant Information page for more information regarding breast implants.

Your consideration of breast implants, for reconstruction or for augmentation, should be based on realistic expectations of the outcome. You may also want to talk with women who have had this surgery at least a year ago by the same surgeon. Keep in mind, however, that there is no guarantee that your results will match those of other women.

Your results will depend on many individual factors, such as

• your health
• chest structure and body shape
• healing capabilities (which may be hindered by radiation and chemotherapy, smoking, alcohol, and medications)
• the skill and experience of the surgical team
• the type of surgical procedure
• the type and size of implant

Scarring is a natural outcome of surgery, and your doctor can describe the location, size, and appearance of the scars you can expect to have. For most women, scars will fade over time to thin lines, although the darker your skin, the more prominent the scars are likely to be. You should ask your doctor about the types of surgical procedures, where your scar will be, and what to expect after surgery.

The type of breast reconstruction procedure available to you depends on your medical situation, breast shape and size, general health, lifestyle, and goals. Women with small or medium sized breasts are the best candidates for breast reconstruction.

Breast reconstruction can be accomplished by the use of a breast implant, your own tissues (a tissue flap), or a combination of the two. A tissue flap is a section of skin, fat and/or muscle which is moved from your stomach, back or other area of your body, to the chest area and shaped into a new breast.

Whether or not you have reconstruction with or without breast implants, you will probably undergo additional surgeries to improve symmetry and appearance. For example, after your breast has healed from the original implant surgery, you may want to build a new nipple and darken the areola (skin around the nipple). This procedure can usually be performed on an outpatient basis. Ask your doctor to explain the various ways this can be done, such as using a skin graft from the opposite breast or by tattooing the area.

Ask your doctor about the pros and cons of each implant technique. If you decide to have reconstruction for one breast, you may need to think about surgery on the other breast to achieve a similar appearance.

Breast Reconstruction with Breast Implants

Your surgeon will decide whether your health and medical condition makes you an appropriate candidate for breast implant reconstruction. Women with larger breasts may require reconstruction with a combination of a tissue flap and an implant. Your surgeon may recommend breast implantation of the opposite, uninvolved breast in order to make them more alike (maximize symmetry) or he/she may suggest breast reduction (reduction mammoplasty) or a breast lift (mastopexy) to improve symmetry. Mastopexy involves removing a strip of skin from under the breast or around the nipple and using it to lift and tighten the skin over the breast. Reduction mammoplasty involves removal of breast tissue and skin. If it is important to you not to alter the unaffected breast, you should discuss this with your surgeon, as it may affect the breast reconstruction methods considered for your case.

Timing of Breast Implant Reconstruction

The following description applies to reconstruction following mastectomy, but similar considerations apply to reconstruction following breast trauma or for reconstruction for congenital defects. The breast reconstruction process may begin at the time of your mastectomy (immediate reconstruction) or weeks to years afterwards (delayed reconstruction). Immediate reconstruction may involve placement of a breast implant, but typically involves placement of a tissue expander, which will eventually be replaced with a breast implant. It is important to know that any type of surgical breast reconstruction may take several steps to complete.

Two potential advantages to immediate reconstruction are that your breast reconstruction starts at the time of your mastectomy and that there may be cost savings in combining the mastectomy procedure with the first stage of the reconstruction. However, there may be a higher risk of complications such as deflation with immediate reconstruction, and your initial operative time and recuperative time may be longer.

A potential advantage to delayed reconstruction is that you can delay your reconstruction decision and surgery until other treatments, such as radiation therapy and chemotherapy, are completed. Delayed reconstruction may be advisable if your surgeon anticipates healing problems with your mastectomy, or if you just need more time to consider your options. There are medical, financial, and emotional considerations to choosing immediate versus delayed reconstruction. You should discuss with your surgeon, plastic surgeon, and oncologist, the pros and cons with the options available in your individual case.

Surgical Considerations to Discuss

Discuss the advantages and disadvantages of the following options with your surgeon and your oncologist:

Immediate Reconstruction:

• One-stage immediate reconstruction with a breast implant (implant only).
  
• Two-stage immediate reconstruction with a tissue expander followed by delayed reconstruction several months later with a breast implant.
  
  

• Two-stage delayed reconstruction with a tissue expander followed several months later by replacement with a breast implant.
  

One-Stage Immediate Breast Implant Reconstruction
Immediate one-stage breast reconstruction may be done at the time of your mastectomy. After the general surgeon removes your breast tissue, the plastic surgeon will then implant a breast implant that completes the one-stage reconstruction.

Two-Stage (Immediate or Delayed) Breast Implant Reconstruction
Breast reconstruction usually occurs as a two-stage procedure, starting with the placement of a breast tissue expander, which is replaced several months later with a breast implant. The tissue expander placement may be done immediately, at the time of your mastectomy, or be delayed until months or years later.


Tissue Expansion

During a mastectomy, the general surgeon often removes skin as well as breast tissue, leaving the chest tissues flat and tight. To create a breast shaped space for the breast implant, a tissue expander is placed under the remaining chest tissues.

The tissue expander is a balloon-like device made from elastic silicone rubber. It is inserted unfilled, and over time, sterile saline fluid is added by inserting a small needle through the skin to the filling port of the device. As the tissue expander fills, the tissues over the expander begin to stretch, similar to the gradual expansion of a woman's abdomen during pregnancy. The tissue expander creates a new breast shaped pocket for a breast implant.

Tissue expander placement usually occurs under general anesthesia in an operating room. Operative time is generally one to two hours. The procedure may require a brief hospital stay, or be done on an outpatient basis. Typically, you can resume normal daily activity after two to three weeks.

Because the chest skin is usually numb from the mastectomy surgery, it is possible that you may not experience pain from the placement of the tissue expander. However, you may experience feelings of pressure or discomfort after each filling of the expander, which subsides as the tissue expands. Tissue expansion typically lasts four to six months.

Mastectomy Reconstruction with Implants

After the tissue expander is removed, the breast implant is placed in the pocket. The surgery to replace the tissue expander with a breast implant (implant exchange) is usually done under general anesthesia in an operating room. It may require a brief hospital stay or be done on an outpatient basis.

Post Mastectomy

Stage 1: Tissue Expander

Stage 2: Breast Implant and Nipple/Areola Reconstruction

Mastectomy Reconstruction Without Implants: Tissue Flap Procedures

The breast can be reconstructed by surgically moving a section of skin, fat, and muscle from one area of your body to another. The section of tissue may be taken from such areas as your abdomen, upper back, upper hip, or buttocks.

The tissue flap may be left attached to the blood supply and moved to the breast area through a tunnel under the skin (a pedicled flap), or it may be removed completely and reattached to the breast area by microsurgical techniques (a free flap). Operating time is generally longer with free flaps, because of the microsurgical requirements.

Flap surgery requires a hospital stay of several days and generally a longer recovery time than implant reconstruction. Flap surgery also creates scars at the site where the flap was taken and possibly on the reconstructed breast. However, flap surgery has the advantage of being able to replace tissue in the chest area. This may be useful when the chest tissues have been damaged and are not suitable for tissue expansion. Another advantage of flap procedures over implantation is that alteration of the unaffected breast is generally not needed to improve symmetry.

The most common types of tissue flaps are the TRAM (transverse rectus abdominus musculocutaneous flap which uses tissue from the abdomen and the Latissimus dorsi flap which uses tissue from the upper back.

It is important for you to be aware that flap surgery, particularly the TRAM flap, is a major operation and more extensive than your mastectomy operation. It requires good general health and strong emotional motivation. If you are very overweight, smoke cigarettes, have had previous surgery at the flap site, or have any circulatory problems, you may not be a good candidate for a tissue flap procedure. Also, if you are very thin, you may not have enough tissue in your abdomen or back to create a breast mound with this method.

The TRAM Flap (Pedicle or Free)
During a TRAM flap procedure, the surgeon removes a section of tissue from your abdomen and moves it to your chest to reconstruct the breast. The TRAM flap is sometimes referred to as a "tummy tuck" reconstruction because it may leave the stomach area flatter.

A pedicle TRAM flap procedure typically takes three to six hours of surgery under general anesthesia; a free TRAM flap procedure generally takes longer. The TRAM procedure may require a blood transfusion. Typically, the hospital stay is two to five days. You can resume normal daily activity after six to eight weeks. Some women, however, report that it takes up to one year to resume a normal lifestyle. You may have temporary or permanent muscle weakness in the abdominal area. If you are considering pregnancy after your reconstruction, you should discuss this with your surgeon. You will have a large scar on your abdomen and may also have additional scars on your reconstructed breast.

Post Mastectomy

TRAM Flap

Final Result with Nipple/Areola Reconstruction

The Latissimus Dorsi Flap With or Without Breast Implants
During a Latissimus Dorsi flap procedure, the surgeon moves a section of tissue from your back to your chest to reconstruct the breast. Because the Latissimus Dorsi flap is usually thinner and smaller than the TRAM flap, this procedure may be more appropriate for reconstructing a smaller breast.

The Latissimus Dorsi flap procedure typically takes two to four hours of surgery under general anesthesia. Typically, the hospital stay is two to three days. You can resume daily activity after two to three weeks. You may have some temporary or permanent muscle weakness and difficulty with movement in your back and shoulder. You will have a scar on your back, which can usually be hidden in the bra line. You may also have additional scars on your reconstructed breast.

Questions to ask your plastic surgeon about Breast Reconstruction

• What are my options for mastectomy reconstruction?
• What are the risks and complications of each type of breast reconstruction surgery and how common are they?
• What if my cancer recurs or occurs in the other breast?
• Will reconstruction interfere with my cancer treatment?
• How many steps are there in each procedure, and what are they?
• How long will it take to complete my reconstruction?
• How much experience do you have with each procedure?
• Do you have before and after photos I can look at for each procedure and what results are reasonable for me?
• What will my scars look like?
• What kind of changes in my implanted breast can I expect over time?
• What kind of changes in my implanted breast can I expect with pregnancy?
• What are my options if I am dissatisfied with the cosmetic outcome of my implanted breast?
• Would you suggest other patients I could talk to about their experiences?
• What is the estimated total cost of each procedure?
• How much pain or discomfort will I feel, and for how long?
• How long will I be in the hospital?
• When will I be able to resume my normal activity?
• General Description of Breast Implant Surgery

Postoperative Care

Your doctor should describe the usual postoperative (after surgery) recovery process, the possible complications that can arise, and the expected recovery period. Following the operation, as with any surgery, some pain, swelling, bruising, and tenderness can be expected. These complications may last for a month or longer, but they should disappear with time.

Medications for pain and nausea can be prescribed. Some women may experience bleeding and some may experience fever, warmth, or redness of the breast, or other symptoms of infection. These symptoms should be reported immediately to your doctor. You should be told about wound healing and how to care for your wound. Drains may be used for a few days.

Post-operative care may involve the use of a post-operative bra, compression bandage, or jog bra for extra support and positioning while you heal. At your doctor's recommendation, you will most likely be able to return to work within a few days, although you should avoid any strenuous activities that could raise your pulse and blood pressure for at least a couple of weeks. Your doctor may also recommend breast massage exercises.

Ask your doctor about a schedule of follow-up examinations, limits on your activities, precautions you should take, and when you can return to your normal routine. (If you are enrolled in a clinical study, your doctor should give you a schedule for follow-up examinations set by the study plan.)

Source: http://www.fda.gov/cdrh/breastimplants/biissues.html and http://www.fda.gov/cdrh/breastimplants/bisurgery.html

Satisfaction Rates of Breast Reconstruction

An article released by the American Society of Plastic Surgeons states that:

More than 180,000 women in the United States will be diagnosed with breast cancer this year, many of whom will have mastectomies. Nearly 79,000 breast reconstruction procedures following mastectomy were performed last year, a 166 percent increase since 1992, according to the American Society of Plastic Surgeons (ASPS.) At the ASPS 70th Annual Scientific Meeting in Orlando, Fla., four papers exploring various aspects of breast reconstruction will be presented.

The first study examined reconstruction in women who have or are at a high-risk for developing cancer in both breasts. These women chose to have both breasts removed. Overall, the women were found to be happy with the result. The study, which looked at 74 women, surveyed patients on their physical, emotional, social and general well being as well as on body image and breast and scar appearance.

"Women are understandably reluctant to have a healthy breast removed," said Richard Redett, MD, fellow of plastic surgery at Johns Hopkins Hospital. "But we now can show them that women who do undergo bilateral mastectomies do very well. Along with possibly extending their life, they are happy with their body."

The study concluded that there was no significant difference in quality of life between the different types of reconstruction. But women who had a bilateral pedicle TRAM flap (where the reconstructed breast comes from a portion of skin, fat and muscle taken from the abdomen and is tunneled beneath the skin to the chest while still connected to its original blood supply) scored higher in the areas of general body image, appearance of the reconstructed breast, how the breast feels to the touch and its appearance in a bra, compared to women who had other types of reconstruction.

The second study looked into the possibility of using implants for breast cancer patients who require radiation after reconstruction. It had previously been accepted that the use of skin expanders and implants (where an expandable balloon-like device is inserted beneath the skin, and over several weeks, the expander is gradually filled with salt water causing the overlying skin to stretch) did not work well in women whose treatment included radiation. It had been previously concluded that radiation did not allow the skin to expand, as well as possibly injuring the skin and losing the implant to infection.

In the study of 81 patients who had implant reconstruction followed by radiation, more than 80 percent had a good to excellent result. Eighty-two percent of the patients would choose the same method of reconstruction again. The rate of capsular contracture (when scar tissue forms around the implant, tightening and squeezing it) was 49 percent, but exhibited a very low level of distortion.

Source: http://www.plasticsurgery.org/mediactr/breast_reconstruction_studies.cfm

According to the European Journal of Plastic Surgery:

Delayed breast reconstruction following mastectomy for cancer is widely accepted because of a high satisfaction rate. Immediate breast reconstruction offers an even more satisfactory solution, especially related to recovery and self-esteem. In our study, immediate breast reconstruction was performed for three indications: breast cancer, high risk for development of breast cancer and chronic cystic breast disease. Forty-eight consecutive patients with a mean age of 48 years were evaluated. In 37 cases malignant disease, in eight patients prophylaxis, and in three patients benign disease were the reasons for mastectomy. In 42 patients, primary reconstruction was performed, using tissue expanders, followed by prosthetic replacement. Of the other six patients, three were reconstructed with a definitive prosthesis and three with a musculocutaneous flap. At the end of the follow-up period, 42 patients had a definitive prosthesis and two patients had their breasts reconstructed with autologous tissue only. Four patients stopped the procedure following infection and extrusion of their implants. These infections accounted for an overall complication rate of 24%. After starting perioperative antibiotic prophylaxis from the 20th patient onwards, the complication rate was reduced to 12%. Thirty-three patients could be interviewed to assess satisfaction: nine patients were very satisfied, 18 were satisfied and six were moderately satisfied with the end result. Thus, 82% of the patients were satisfied.

Source: http://link.springer-ny.com/link/service/journals/00238/bibs/0023004/00230211.htm

The Institute of Medicine reports:

In the group of 100 women implanted by van Heerden et al. (1987) 85% would recommend implant reconstruction to other women, and 73% rated it 6-10 on a scale of 1-10 (32 women rated it a 10). However, this questionnaire was administered by the operating service during the post-operative period. Spear and Majidian (1998) asked patients to express their degree of satisfaction, and 98% of 42 consecutive women rated themselves somewhat to completely satisfied with their breast implants. Again, this rating was carried out by the operating team, presumably shortly after surgery. A survey by Francel et al. (1993) of 197 implant reconstruction patients, with a 50% response rate, found that 100% of women who had been reconstructed immediately would try it again and 90% of them were satisfied. Of women who had undergone delayed reconstruction with implants, 90% would try it again and 80% were satisfied. This is another example of a survey performed by the surgical group after an unspecified, but clearly short, postoperative interval.

Source: http://www.nap.edu/books/0309065321/html/27.html

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Information provided is for general education about breast reconstruction and cosmetic plastic surgery procedures. This information is subject to change. Smart Plastic Surgery.com does not guarantee that it is accurate or complete, and is not responsible for any actions resulting from the use of this information. General information provided in this fashion should not be construed as specific medical advice or recommendation, and is not a substitute for a consultation and physical examination by a physician. Only discussion of your individual needs with a qualified physician will determine the best method of treatment for you. All board certified plastic surgeons listed are board certified by the American Board of Plastic Surgery and/or the Royal College of Physicians and Surgeons of Canada. Board certified plastic surgeons are verified by the American Board of Medical Specialties.

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