IMPLANT BASED RECONSTRUCTION
BREAST IMPLANT | TISSUE EXPANDER
Implant reconstruction can be performed immediately if there is sufficient skin available to insert a breast implant underneath. The breast implant can be placed subcutaneously, if the amount of skin is sufficient and thick enough to obtain a satisfactory result.
If the skin flap is very thin after the mastectomy we prefer to place the implant behind the pectoral muscle and we sometimes use a mesh or acellular dermal matrix to keep the muscle in position and to cover the lower and lateral part of the implant under the skin.
In a few selected cases we can perform a delayed reconstruction with a breast implant without stretching the skin with a tissue expander beforehand. This option depends on the available skin quality and quantity.
Risks and complications of implant and expander based reconstructions are mainly due to the fact that implants are foreign body materials. Our body tries to separate the normal tissue from the implant surface and forms a capsule around it. In ideal circumstances this capsule will be a thin and soft layer of connective tissue. The capsule can on the other hand become thick and fibrotic, leading to a hard, deformed and painful breast. This condition is called capsular fibrosis and can become a capsular contracture. Multiple studies and trials have shown that complications are increased after implant based breast reconstructions compared to breast enlargements with implants. The complication rate is the highest if the breast has been or will be irradiated in the context of breast cancer treatment. The mechanisms are not fully understood yet and there is no indication beforehand to determine what patient will develop these complications. Treatment of capsular contracture is removal of the implant and capsulectomy. A new implant can be inserted, and if this occurs repeatedly own tissue options should be considered for breast reconstruction. If there is not sufficient skin we first insert a tissue expander under the mastectomy skin to stretch the skin and increase the amount of skin available until we are able to insert a permanent breast implant. This is a two-stage procedure. The expander is postoperative filled with Saline in two-weekly intervals. It is recommended to overfill the expander slightly. Once the final volume is reached we allow 2 months for the tissue to settle and then the second stage can take place.