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BREAST RECONSTRUCTION
WITH PROSTHESIS

Reconstructive surgery:
This document has been conceived under the authority of the French Society of Plastic, Reconstructive and Aesthetic Surgery (SOFCPRE).

DEFINITION

Mastectomy or mammectomy (the terms are synonymous) corresponds to the removal of the mammary gland, a zone of skin and areola.

It is unfortunately necessary in some forms of breast cancer.

A demand for breast reconstruction after mastectomy is legitimate.

In the cases where the quality of the skin and underlying pectoral muscle allows it, the easiest mode of breast reconstruction is the breast reconstruction by prosthesis. It may be preceded by a period of tissue expansion if the amount of skin is insufficient.

The skin expansion is defined as the possibility of increasing the surface of coverage by the skin of the permanent prosthesis under the effect of traction exerted during a short period.

This reconstruction is supported by health insurance.

AIMS

The surgery aims to restore the volume and contour of the breast by the placement of an internal prosthesis below the pectoral muscle.

It is just a time of the complete breast reconstruction, which according to the wishes of the patient also comprises a reconstruction of the nipple and areola and possibly an intervention on the opposite breast to improve symmetry.

ALTERNATIVES

Breast reconstruction is never mandatory. The use of an external prosthesis can be significant enough for some women. Reconstruction remains a personal choice.

Although breast reconstruction by prosthesis is the simplest technique to propose, there are other techniques providing tissue from another part of your body (latissimus dorsi, rectus of the abdomen) that are more sophisticated techniques which have their advantages as their own drawbacks.

PRINCIPLES

The operation can be realized at the same time as the mastectomy, it is called immediate reconstruction, or remotely after complementary treatments that have been necessary have been done, then is called secondary or delayed reconstruction.

The mastectomy scar is reused as approach in case of reconstruction; although it can sometimes be improved, it is impossible to make it completely disappear.

The intervention consists of the placement, usually under the skin and pectoral muscle, of an internal prosthesis. This internal prosthesis is, in the simplest cases, the permanent prosthesis. This can be in some cases a temporary prosthesis for tissue expansion to increase the amount of covering tissue (skin, muscle) of the permanent prosthesis, which may give a more natural appearance to the reconstructed breast.

This expansion of the skin is best illustrated during pregnancy. Under the effect of the progressive thrust of the child, the abdominal skin is distended to allow an excess persist after birth. By analogy, in the case of breast reconstruction a temporary implant is gradually inflated to obtain an excess of skin that is used to cover the permanent prosthesis.

Tissue expansion has the disadvantage of requiring two surgical times.

At the same time of the implantation of the permanent prosthesis, it is possible to reshape the opposite breast if this is necessary.

The nipple-areola complex (areola + nipple) will be rebuilt more often in a second time, when the volume of the breast is stabilized.

Breast reconstruction does not affect the oncologic surveillance.

THE IMPLANTS or PROSTHESES

There are several manufacturers as well as several types of breast implants.

The implants are all made in a silicone elastomer envelope that can be smooth or somewhat rough (textured) to reduce the risk of forming a shell or capsule.

This prosthesis may be filled; either with saline (salt water) or silicone gel that have a consistency closer to the mammary gland.

There are several types of prostheses: rounded, more or less than projected, or anatomical, whose thickness is greater in the lower pole simulating a natural breast.

As for the temporary prosthesis for expansion, the filling is realized with saline.

BEFORE THE OPERATION

A pre-operative assessment is performed in accordance with the usual requirements.

The anaesthetist will be seen for consultation at the latest 48 hours before surgery.

In all cases, the surgeon should check the breast imaging (mammography, ultrasound) of the other breast, if the last review of control is not recent enough.

No medication containing aspirin should be taken within 10 days preceding the intervention.

It is possible that the anaesthetist may prescribe you anti-embolism stockings (for prevention of phlebitis) that you should wear before the intervention until you leave the hospital.

Stop smoking is essential. It could be a cause of delay or failure of healing.

TYPE OF ANAESTHESIA AND HOSPITAL STAY

Type of anaesthesia

This is a classic general anaesthesia during which you sleep completely.

Hospital stay

Hospitalization for several days is usually required. The discharge will be conditioned to the removal of drains, if used.

THE PROCEDURE

The intervention may take one to two hours. A modelling bandage with elastic bands shaped like a bra is made up in at the end of surgery.

 

AFTER THE OPERATION: POSTOPERATIVE CARE AND FOLLOW-UP

The immediate postoperative period is generally quite painful for a few days, may require strong painkillers.

These painkillers are relayed later by less powerful analgesics prescribed to the request for a fortnight.

Beyond, if pain persists you should be examined by your surgeon.

Swelling (edema), ecchymosis (bruising) of the reconstructed breast is possible in the postoperative period.

Some discomfort on the elevation of the arm that most often does not need reeducation (except when a lymphadenectomy has been performed in the same time) can be observed.

Wearing a bra (night and day) is necessary for several weeks. The bandages will be regularly changed.

Consideration should be given to a recovery time of two to three weeks. It is advisable to wait one to two months to resume sporting activity.

If the choice of prior expansion has been chosen, the inflation of the prosthesis can begin in some cases during hospitalization.

THE RESULT

After implantation of a permanent prosthesis

The reconstruction by prosthesis immediately restores volume and shape permitting the patient to dress normally with a low cut.

However, the final result is not acquired from the outset.

At the first dressing change, the reconstructed breast will look a bit static, and the overlying skin can be very sensitive. Patients sometimes describe pectoral muscle contractures.

This aspect will gradually evolve. It will take two to three months to appreciate the result of the reconstruction and the eventual symmetrisation.

After implantation of a expansion prosthesis

The inflation of the prosthesis is made usually once a week with saline (salt water).

In 4 to 8 weeks, a large volume is achieved, up to exceed the volume of the other breast.

At the end of inflation, it will be necessary to wait at least another three months to avoid a secondary retraction of the skin.

The second operation occurs between 4 and 6 months after the first. It allows the replacement of the temporary expander prosthesis that gives a tense look for the permanent prosthesis, which will give a more natural shape.

The goal of this surgery is to provide a clear improvement but cannot claim to perfection. If your wishes are realistic, the result obtained should give you great satisfaction.

DISAPPOINTING RESULTS

It is unfortunately impossible to reconstruct a breast perfectly symmetrical to the other with prosthesis.

It will always remain a certain asymmetry of the breasts, whether of:

volume: the base of the breast will never be perfectly identical. Weight changes may accentuate this difference.

shape: in the lying-down position, the prosthesis does not spread like a normal breast.

height: the no-operated breast will undergo the normal evolution to ptosis accentuating the asymmetry.

and palpation: the patient can feel the prosthesis, because of the low thickness of the covering tissues.

The scars will be closely monitored; it is very common that they take a pink and swelled aspect during the first post-operative month. Beyond, they generally fade over time, becoming barely visible. However, they cannot completely disappear.

The scars can sometimes stay a little too visible, presenting different unsightly aspects (hyper-pigmentation, thickening, retraction, adhesion or enlargement), which may require specific treatment.

In this regard, we shouldn’t forget that if is the surgeon who performs the sutures, the scar itself is the fact of the patient.

POSSIBLE COMPLICATIONS

Breast reconstruction by prosthesis or implant is a real surgery, which involves the inherent risks to any surgical act. However, the surgical aftercare is generally quite simple. Nevertheless, complications can occur, some of general order, inherent to any surgery, others loco-regional, more specific of the reconstruction of the breast with implants.

We must distinguish the risk of complications related to the anaesthesia from those related with the surgery.

Regarding the anaesthesia

A consultation at least 48 hours before your hospitalization is required.

During this consultation, the anaesthetist will explain to you the risks of general anaesthesia and will present the different ways to manage post-operative pain.

Regarding the surgery

By choosing a competent and qualified Plastic Surgeon, with experience in this type of intervention, you will limit these risks, although they will not completely disappear.

Fortunately, real complications are infrequent after breast reconstruction with prostheses. In practice, the majority of interventions occur without any problem.

Complications may occur after breast reconstruction by prosthesis:

Infection: that requires antibiotic treatment, and sometimes a surgical temporary removal of the implant.

Hematoma: that may require surgical evacuation.

Necrosis of the skin: where the risk is especially high after radiotherapy, can lead to exposure of the prosthesis and require its removal. Smoking also makes this risk higher.

Formation of a contractile capsule: the formation of a capsule around the implant is constant. In some cases, the capsule contracts leading to a feeling of painful hardening. This contraction can sometimes result in visible distortion of the breast that is "like a balloon" and at the same time becomes firmer. This risk has decreased significantly in recent years because of the use of new prostheses but remains completely unpredictable for each patient. It is increased if radiotherapy should be administered on the prosthesis itself.

Waves and folds: when the skin covering the prosthesis is fine, it may reveal the envelope of the prosthesis in the form of waves or folds.

Displacement of the implant: a displacement of the implant is always possible under the effect of muscle contractions. It is not advisable to perform excessive pectoral muscle exercises in the post-operative period. Revision surgery may be necessary.

The traumatic rupture or deflation by external manoeuvres: the risk is real in a severe trauma, or at an excessive compression during a mammogram. The replacement of the prosthesis is then necessary.

Wear and aging of the implant: it is essential to understand that no prosthesis can be implanted for life. Indeed, any prosthesis has its aging and life span necessarily limited.

Over time, the envelope gradually wears away, which may cause leakage of contents with varying consequences:

With a prosthesis filled with saline, there, in case of breakage, sagging breast usually occurs within hours or days, corresponding to a deflation of the prosthesis.

With a prosthesis pre-filled with silicone gel, the clinical diagnosis is less obvious. With the gel with important cohesiveness, now more commonly used, you are protected from a rapid diffusion of silicone gel outside of the prosthesis.

Because of the very gradual nature of the gel migration outside of the prosthesis, the clinical signs corresponding to the tear of a prosthesis pre-filled with silicone gel are most often delayed as a deformation of the breast or the appearance of a capsular contracture.

The period of onset is unpredictable.

Digital mammography makes the diagnosis of such a failure.

The delayed presentation of the clinical signs of the wear and tear of a prosthesis prefilled with silicone gel reflects the compulsory nature of a regular surveillance of the reconstructed breast by your surgeon.

Whether the wear and tear is from a prosthesis filled with saline or gel, in both cases, we must proceed with the replacement of the prosthesis.

There is no quantifiable risk of autoimmune disease with silicone gel.

The presence of the implant can sometimes complicate the interpretation of mammograms. It is necessary to tell the radiologist, so that the technique is adapted.

In total we should not overstate the risks and, in the vast majority of cases, the reconstructive surgery if performed correctly, will give a good result, even if the scarring is inevitable.

You can be assured that if you are operated on by a qualified Plastic Surgeon, he will have the experience and skill required to avoid these complications, or to treat them successfully if necessary.

These are the facts that we wish to bring to your attention, to complement what you were told during the consultation.

Our advice is for you to keep this document and to read it and think it over carefully after your consultation.

Once you have done this you will perhaps have further queries, or require additional information.

We are at your disposal should you wish to ask questions during your next consultation, or by telephone, or even on the day of the operation, when we will meet in any case, before the anaesthesia.


"Copyright", © "All Rights Reserved" SOFCPRE, any reproduction, even partial, of these texts is prohibited without permission from the French Society of Plastic Reconstructive and Aesthetic Surgery. A copy or reproduction by any means whatsoever, including photocopying, photography, screen capture, copy, paste, recording or otherwise, constitutes an infringement punishable under the Act of March 11, 1957 on the protection of copyright.
Authorization for reproduction of March 10, 2009, for: MCEI (www.chirurgiens-plasticiens.info).


This factsheet has been designed under the auspices of the French Society of Plastic Reconstructive and Aesthetic Surgery (SOF.CPRE) as a complement to your first consultation; to try to answer any questions you can ask yourself if you intend to use a surgical lipo-filling.

The purpose of this paper is to bring you all the information necessary and essential for you to make your decision with full knowledge of the facts. So is it advisable to read with the greatest attention.