Prosthetic
breast reconstruction refers to the use of a breast implant.
The majority of prosthetic breast reconstruction's are done
in two stages. A tissue expander is placed at the first operation.
After a period of expansion, a permanent breast implant is placed
at the second operation.
Why
Is A Tissue Expander Needed?
Because
there has been a loss of skin from the mastectomy, some form
of expansion is almost always needed to stretch out the remaining
tissue prior to placement of the permanent implant. This process
starts with placement of a tissue expander.
How
Does A Tissue Expander Work?
The
tissue expander is gradually filled with a series of saline
(salt-water) injections. This is usually done in the doctors
office.
The
duration of expansion depends on multiple factors, including
the initial tissue deficiency, the degree of scarring, the level
of patient comfort during the injections, and the volume needed
to match the opposite breast. The timing varies, but the injections
are often done weekly for approximately twelve weeks.
What
Is Done At The Second Operation?
In
most cases, the patient returns to the operating room at the
end of the expansion period for the second stage of the reconstruction,
placement of the permanent breast implant.
The
previous scar is reopened, the expander is removed, and the
permanent implant is placed. Some modification of the scar and
breast shape can also be done at this time.
Are
Two Stages Always Necessary With Prosthetic Reconstruction?
An
exception to the two-stage process involves the use of a combined
expander/implant that is placed, expanded, and then left in
position.
The
patient does have to undergo a minor procedure to remove the
injection port and tubing attached to the implant. This method
requires predetermination of the implant size and assumes that
no scar or shape revision will be necessary. The implant shape
options are also limited.
What
Are The Advantages Of Prosthetic Reconstruction?
Prosthetic
breast reconstruction has several advantages over other methods.
The main advantage is that both stages of the surgery can be
done through the mastectomy wound without any additional scar.
As
a result, there is not much pain beyond that of the mastectomy
itself. The risks and additional recovery issues involved with
a second wound at the donor site of an autologous reconstruction
are also avoided. When done as an immediate reconstruction,
expander placement usually does not add to the mastectomy hospital
stay.
The
second stage is usually done as on and outpatient basis and
is associated with relatively little pain. Patients are back
to full functioning within the first few weeks.
These
issues become more of an advantage in patients with medical
conditions limiting more extensive surgery. In patients undergoing
bilateral mastectomies, issues at the donor sites of autologous
reconstruction's can be more problematic, and bilateral implants
can provide excellent, symmetrical results.
What
Are The Disadvantages Of Prosthetic Reconstruction?
Some
women choose not to have a prosthesis (implant) in their bodies.
Such concerns have been compounded by the silicone scare produced
over the gel-filled implants. This topic is too extensive for
the discussion here.
Ongoing
studies with the gel-filled implants have not yet demonstrated
an increase in the autoimmune diseases previously attributed
to them. Gel-filled implants are again being used experimentally
in patients, but the vast majority of implants being used in
the United States are still saline-filled implants with a silicone
shell.
Saline-filled
implants do have a small risk of deflation. Infection can also
occur, as well as wound healing problems from pressure from
the underlying implant. In rare cases, this can lead to extrusion
(penetration of the implant through the skin).
These
problems may require additional surgery, including removal of
the implant. In such cases, a new implant can often be placed
once the underlying problem has fully resolved.
What
Is A Contracture?
Like
any foreign substance, an implant produces scar formation. In
this case, the scar is in the form of a capsule that forms around
the breast implant. These scar capsules can become pronounced
in some patients and form a contracture.
The
degree of contracture can vary from an area of firmness to a
visible distortion in the shape of the reconstructed breast.
They are occasionally associated with pain. Contractures occur
more often in patients undergoing radiation.
What
Are The Limitations Of Reconstruction With An Implant?
As
with any form of breast reconstruction, problems with matching
the shape of the breast to the opposite side can occur with
an implant. Matching the contour of a sagging opposite breast
is more difficult with an implant.
The
feel of the implant is generally not as natural as an autologous
reconstruction. Other problems with implant positioning and
later shifts in location are infrequent but can occur.
In
the majority of patients, an implant can provide a naturally
appearing breast with a good shape and size match to the opposite
side. Patient satisfaction is generally very high. Patients
considering breast reconstruction should be evaluated by a plastic
surgeon to discuss their options further.
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