Breast reconstruction using implants

Breast implants is one of the main types of breast reconstruction. It can be used to make a breast shape. A breast implant can be put in front of or sometimes behind the chest muscle to make a new breast shape.

Breast implants may be used:

• for immediate breast reconstruction
• when both breasts are being reconstructed.

The breast shape made by implants will feel firmer and not move as naturally as breasts reconstructed using your own tissue. This can mean it is more difficult to get a natural shape when only 1 breast is being reconstructed. So, implants are often used when both breasts are being reconstructed. This may be the case if you do not have enough tissue to reconstruct both breasts.

The surgeon makes a breast shape by putting breast implants either in front of the chest (pectoral) muscle or behind it. When an implant is behind the chest muscle, it is called a sub-pectoral implant. With newer surgical techniques, it is now more common for implants to be in front of the chest muscle. This is called a pre-pectoral implant.

The surgeon puts in a permanent silicone implant to create a new breast shape. This can either be in front of the chest muscle or sometimes behind the chest wall muscle .

Surgical mesh

The surgeon may use a surgical mesh or a product called an acellular dermal matrix (ADM). This supports the implants and help keep them in place. The mesh can be made from animal tissue or synthetic material. Some meshes are made from a material that is absorbed into the body. This is called an absorbable mesh.

Perm implant in front of the muscle (with mesh)

Perm implant behind chest muscle (with mesh)

Supporting sling

Occasionally, the surgeon may use your own tissue to make a supporting sling for the implants. This is called a dermal sling. It may be used if you have larger breasts that are being reduced in size.

The surgeon places the implant under the chest wall muscle. They then attach the supporting tissue to the edge of the chest muscle. This acts as a sling for the lower part of the implant and keeps it in place.

Your surgeon can explain the possible benefits and disadvantages of using a supporting sling.

You may have an expander implant put in at the same time as a mastectomy. These are also called tissue expander implants. Your surgeon can use an expander implant if your skin and chest wall muscle need to be stretched. An expander implant has an outer chamber of silicone gel and an inner chamber. This inner chamber can be filled with saline through a valve (port). This makes the implant expand.

You may have expander implants if you are having a delayed reconstruction and the skin needs to be expanded more. Expander implants may also be used when the surgeon does not want to overstretch the skin. For example, if the surgeon is trying to keep the nipple, overstretching the skin can reduce the blood supply to the nipple area. Putting in an expander implant and not fully inflating it helps the blood supply to the nipple while it is healing.

Some surgeons may use these implants if radiotherapy treatment might be needed after reconstruction.  This is because expander implants can be deflated during radiotherapy and then re-inflated after radiotherapy.

If you have already had radiotherapy, some surgeons may use these implants to make sure the skin heals before it is stretched.

The surgeon may put the expander implants in front of your chest muscle to stretch the skin. Or they may place it behind the chest muscle to stretch the muscle and skin. You will then wait a few weeks for the tissues to heal. After this, the muscle and skin can begin to be stretched to form your new breast shape. This is done by injecting saline into the implants.

Saline injections

Your nurse or doctor injects saline into the implant every 1 to 2 weeks to stretch the area. They do this through a valve under the skin. This may be placed:

• in the underarm area
• under your breast
• on your chest wall.

After each injection, you may feel some aching or tightness in the breast area for 1 or 2 days.

This process continues over several weeks to form your new breast shape.

Expander implants can be temporary or permanent.

Permanent expander implant

Permanent expander implants are sometimes called Becker implants or expanders. They can be left in place when fully expanded. They have an outer chamber of silicone gel and an inner chamber. The inner chamber is gradually filled with saline through a valve to stretch the skin or both the skin and muscle.

The nurse or doctor may then remove some saline through the valve to get a more natural breast shape. A surgeon can remove the valve later during a small operation. This may be under a local or general anaesthetic. The implant remains in place.

Temporary expander implant

A temporary expander implant has a hollow inner chamber that can be filled with saline. It does not have the silicone gel outer chamber that a permanent expander implant has.

The implant is gradually expanded with saline over time and then replaced with a permanent silicone implant. This is often described as a two-stage procedure.

Reconstruction with implants is usually a simpler operation than other types of breast reconstruction. But it can be more difficult to match the natural breast to the breast reconstruction if only 1 breast is being reconstructed with an implant.

• It has a slightly shorter recovery time than other types of breast reconstruction.
• It leaves less scarring on the breast and no scars elsewhere on your body.
• Depending on the size and shape of your breasts, it can be a good option – especially if you are having both breasts reconstructed.

With any operation, there are risks, such as infection. There are also some risks specific to implants.

Up to 1 in 10 women (10%) need to have an implant removed within the first 3 months after surgery. After 9 months, this increases to 1 in 7 women (15%). An implant may need to be removed because of:

• wounds not healing properly
• an infection
• smoking
• radiotherapy after a mastectomy and implant reconstruction.

If an implant needs to be removed, you will usually have to wait a few months before you can have surgery to have a new implant put in. During this time, the breast will be flat. The delay is needed to give the tissues time to heal and to treat any infection. You may also need to have lipomodelling before having another implant put in.

The new implant may become infected. Or you may develop further wound-healing problems. The implant could also develop another tight capsule around it. This means it may also need to be removed. Your surgeon may talk to you about the benefits of having a surgery breast reconstruction using your own tissue reconstruction using your own tissue instead of having the implant replaced.

It is not common to have an infection in the tissue around the implant. But if this happens, the implant usually needs to be removed until the infection clears. The implant can be replaced several months later. You will be given antibiotics at the time of your operation to reduce the risk of infection.

If an implant needs to be removed because of infection and then is replaced, the reconstructed breast may not be as good. It is important to follow any advice your treatment team gives you about preventing infection.

Breast implants are not a natural part of your body. Because of this, your body reacts by forming a ‘capsule’ of scar tissue around them.

Over a few months, the scar tissue can get smaller (contract) as part of the natural healing process. But sometimes as the capsule contracts, the tissue tightens around the implant. This is called capsular contracture. It can happen any time after having a breast implant operation.

A small amount of capsular contracture is common. But, occasionally, it can be more severe and make the reconstructed breast feel hard and painful. It may also change the shape of the implant. The risk of capsular contracture increases if you:

• have radiotherapy to the chest
• have an infection in the reconstructed breast
• smoke.

If the contracture is not severe, you may not need treatment. Doctors may treat it by taking fat from another part of your body and injecting it around the implant. This is called lipomodelling. Or you may have an operation to:

• release the capsule (capsulotomy)
• remove some or all of the capsule or scar tissue (capsulectomy) and insert a new implant.

Some people choose to have the breast reconstructed with a flap of their own tissue instead of having the implant replaced.

Most surgeons put the implant in front of the chest muscle. This means it is close to the skin. Rippling is when you can see creases in the implant through the skin.

When the implants are behind the chest muscle, they may change in shape. Or they may crease when you move and the muscles contract.

If you have rippling of your implant, your surgeon may suggest lipomodelling to thicken the tissue over the implant. This can reduce the look of rippling. Your body absorbs up to half (50%) of the fat injected. So you may need to have lipomodelling more than once to get the best results. Sometimes lipomodelling can cause lumpiness under the skin. If this happens, your doctor may arrange a scan to check this.

It is difficult to damage an implant. You can continue with your normal activities, including sports and air travel, without worrying whether it will affect your implant. Implant rupture is now rare. Less than 1 in 20 women (5%) will have an implant rupture within 10 years of having firm or solid gel implants.

Occasionally, an implant might split or tear. Most silicone implants contain a firm gel. This is unlikely to leak in large amounts, even if the outer cover is damaged. If this happens, it should not affect your health. But the implant will need to be replaced.

If saline leaks out of an expander implant, it will not cause any harm. But the implant will go flat quickly and will need to be replaced.

You should tell your doctor if you notice a change in the shape or feel of your implant. They may do a scan to check it.

Implants can make mammograms (breast x-rays) more difficult to read. You may need more x-rays to look at all of your breast tissue.

If you have a mastectomy, you will not need to have mammograms of the reconstructed breast. If you have an implant put in after breast-conserving surgery, you still need to have mammograms of that breast. If you decide to have an implant in your other breast to match it with your reconstructed breast, you will still need mammograms of that breast as well.

It is important to tell the person doing the mammogram you have an implant. This is so they can use the best screening method for you.

Quality control

A few years ago, there were concerns about the quality of the silicone used to fill breast implants. This happened because unapproved silicone was found in breast implants made in France by a company called Poly Implant Prostheses (PIP). PIP implants have not been used in the UK since 2010.

Breast implants used in the UK must be approved by the Medicines and Healthcare Products Regulatory Agency (MHRA). This organisation is responsible for making sure that medical devices, including breast implants, are safe and fit for use.

Since 2016, everyone who has had a breast reconstruction using a tissue expander or breast implant in England, Scotland and Wales is automatically recorded on a national registry. If you live in Northern Ireland, you will be asked for your permission (consent) to record this.

This is called the Breast and Cosmetic Implant Registry (BCIR). Registries help find people with implants if any safety concerns are raised. If you are worried about having breast implants, it is important to discuss this with your surgeon before your operation. They will be able to tell you the type of implants they use and who makes them.

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL)

Anaplastic large cell lymphoma (ALCL) is a very rare type of non-Hodgkin lymphoma that can sometimes affect the tissue around the implant. People with textured breast implants have an increased risk of developing ALCL in the tissue around an implant. This is called breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). It is not breast cancer.

BIA-ALCL usually develops about 7 to 10 years after implant surgery. But it can happen earlier or later than this. The risk of BIA-ALCL is extremely small with implants currently used. Although the risk is thought to be linked to textured implants, there is not enough evidence to be certain. The textured implants thought to be of the highest risk are no longer being used.

BIA-ALCL usually shows up as a swelling or an increase in the size of the breast due to a build-up of fluid. There may also be a lump near the implant.

Early-stage BIA-ALCL can be treated by surgery to remove the implant and the capsule of tissue surrounding it. A non-textured implant can be put in. If the ALCL spreads outside the capsule, other cancer treatments may be needed. Your surgeon can talk to you about:

• the risk of BIA-ALCL
• the risks and benefits of different implants
• the most up-to-date recommendations.

Breast implant illness (BII)

Breast implant illness (BII) is a term used by some people who feel they have symptoms linked to their silicone breast implants. BII is not a medical diagnosis. There is currently no evidence to suggest the symptoms reported are linked to the breast implants. Research is continuing to look into this.

Symptoms that have been reported to be related to this condition include:

• tiredness
• joint aches
• depression
• headaches
• hair loss
• rash
• neurological issues.

But these symptoms can have many causes.

If you have symptoms you feel might be because of your implants, contact your doctor. Some people ask for the implant to be removed. But removing breast implants will not necessarily improve symptoms. About half of people affected (50% ) feel their symptoms improve.