From the moment you begin considering breast reconstruction, you will be faced with a bewilderingly large array of reconstruction types. In the past, implants were less popular than autologous reconstruction options (using a woman’s own tissue to recreate the new breast). Partially that was because from 1992-2006, silicone implants were removed from the U.S. market, leaving women with only saline implants as an option. As these implants feel less “natural,” it is not surprising that they were also less popular. Thankfully today women have more implant options available.
In fact, a recent study has shown that today implant usage is growing. Implants can be an excellent option, especially for women with low BMIs who may not have significant excess tissue in other places or active women who are worried about the loss of muscle involved in many of the autologous flaps. Another advantage is that reconstruction with implants tends to involve less scarring, though the reconstructed breasts may feel less “alive” to the woman or her partner, meaning that they are colder, harder, or less mobile.
If you are considering this option, this article will help you understand the different types of implants, frequently used methods of placing the implants surgically, and what happens when a replacement is needed.
What types of implants are available?
Breast implants are generally filled with one of two different substances: either saline water or silicone gel. There are advantages and disadvantages with both of these substances.
Saline implants are simply saline water encased in a silicone capsule. Some women feel more comfortable with the use of saline water in their implants, as it is a natural substance found in abundance within the human body ordinarily. Should the implant develop a leak, the saline water can be absorbed naturally. The saline implants are generally implanted empty and the surgeon slowly inflates them through injections of salt water. That allows the woman a fair bit of control, as well as trial and error, as she and her surgeon find just the right size for her. Lastly, saline implants involve the least amount of scarring, as a much smaller incision will suffice for inserting the implants. This can be useful for women who have undergone skin sparing mastectomies.
On the other hand, if there is a leak or rupture, the deflation in the implant will be immediately visible. While this can be useful in terms of prompting the woman to seek medical attention, it may also cause the woman awkwardness or embarrassment, while she waits for an appointment with the plastic surgeon. Moreover, saline implants generally feel less natural. They are usually harder and rounder (some women describe them as looking like a firm water balloon, rather than breast-shaped). Additionally, wrinkling or rippling of the breast implants are more common in saline implants than silicone implants, which hold their shape a little better.
The primary advantage of silicone implants are their natural feeling. They are softer and more malleable like a woman’s natural breast tissue. For smaller women, the difference between saline and silicone implants will be more pronounced, as saline implants are unfortunately sometimes visible in these women and the round shape of a saline implant (instead of a teardrop shape) frequently looks more strikingly out-of-place in women with a smaller BMI. With silicone implants, the breast shape can be chosen in advance to match the woman’s natural or desired shape, and the silicone gel, once implanted, will generally hold that shape well.
The disadvantage of silicone implants is what happens in the case of a leak or rupture. Because the gel holds its shape better than saline, it may take the woman longer to realize that the implant has begun to leak. Though there have been no findings of leaked silicone gel associated with medical problems, some women remain uncomfortable with the thought of this possibility. Another problem is that when leaks or ruptures occur, there is a greater incidence of capsular contraction, which creates firm scarring around the implant, making the breast feel hard.
“Gummy Bear” Implants
If you can imagine an implant that is made out of a type of silicone more resembling the material of a gummy bear than liquid gel, that would pretty well describe the Cohesive Gel Implants (frequently referred to as “gummy bear” implants). These are a newer type of silicone implants in the U.S., though they’ve been used by women for years in Europe. These implants offer several advantages over both saline and traditional silicone implants:
- Cohesive gel implants maintain the breast shape best of all implant types. Whatever distinct shape is chosen will be maintained (again, think of “gummy bears” which maintain the small features of bears indefinitely).
- Because they maintain their shape well, implants do not develop rippling or wrinkling, nor do they collapse from a rupture.
- There is very little leakage in cohesive gel implants. Whether or not the shell breaks (which appears to also happen less frequently in gummy bear implants), the implant stays together. While some degree of microscopic silicone diffusion will occur, the amount of leakage is significantly less than in traditional silicone implants.
- Based on European experiences, the hard scarring that can occur around implants (capsular contraction), particularly traditional silicone implants, seems to be less common in cohesive gel implants.
On the other hand, there are a few disadvantages. While the cohesive gel implants may still be softer than the saline implants, they tend to be slightly firmer than the traditional silicone implants. Also if only one breast receives the implant, the natural breast may change and sag over time, while the reconstructed implant with the “gummy bear” silicone will maintain its shape creating asymmetry. These implants may therefore be best suited for women who intend to undergo reconstruction in both breasts.
What types of reconstruction are used with implants?
There are two main areas where you and your medical team will have to make decisions regarding your reconstruction if you choose implants. Those choices are whether to have Immediate or Delayed Reconstruction and whether to have a One Stage or Two Stage Reconstruction. These decisions will be informed by the treatment your medical team recommends for you.
Immediate reconstruction means that the reconstruction process begins at the same time as the mastectomy. This surgery is usually coordinated between your breast surgeon and your plastic surgeon. At this time, depending on the type of implants, the size of your breasts, and the amount of remaining tissue you have following the mastectomy, the plastic surgeon might either insert a tissue expander to create space for permanent implants or immediately insert your final implant. Final implants often cannot be placed if the woman will be undergoing radiation, as radiation will change the final look of the implants.
In the case of delayed reconstruction, the reconstruction process begins at a later date. This date might be simply after radiation and/or chemotherapy to allow the woman to heal and/or grieve her original breasts, or it could be years later as the woman’s feelings about her post-mastectomy body change. The longer it has been since a woman’s original mastectomy, the more likely it is that she will need a tissue expander before her final implants.
One Stage Reconstruction
Just as it sounds, in one-stage reconstruction, the patient undergoes a single surgery to place the final implants. This surgery is usually done at the same time as the in an immediate reconstruction (though not necessarily) and is usually reserved for patients who will not need radiation post-mastectomy. In patients with less remaining tissue surrounding the chest, additional tissue, either from the woman’s own body or using a matrix such as Alloderm, may have to be implanted simultaneously.
Two Stage Reconstruction
In two-stage reconstruction, the final implants are not placed immediately. Either at the time of the mastectomy or at a later date (sometimes years later), the woman will undergo surgery to have a tissue expander placed. A tissue expander works a bit like a balloon which is placed in its deflated stage. Then in the following weeks and months, the expander is slowly inflated to create a space in the chest wall for the future permanent implant. A second procedure is required to replace the tissue expander with the final implants.
Will I have to replace my implants at some point?
The short answer to this question resides between “maybe” and “probably,” depending on all the details of your surgery and type of implants. According to the American Cancer Society, “up to half of implants used for breast reconstruction have to be removed, modified, or replaced in the first 10 years.” The number is even higher when we look at 20 years later. While modification may be considered simply a normal part of the breast reconstruction process (you have a right to try to get it “just right” when talking about the long-term appearance of your breasts), the need for removal or replacements is unique to implants. Reasons for replacing your implants could be aesthetic, such as if an implant is wrinkling or no longer looks symmetrical, or medical in the case of a rupture or infection. If you notice any signs of infection or rupture, develop pain, or are otherwise concerned about your implants, you will need to see your physician immediately. These could be signs of a problem with your implants, or they could indicate the possibility of cancer recurrence. In either case, you will need to seek medical attention. The good news is that if your implants require replacement, whether for aesthetic or medical reasons, the law requires that any insurance which also covers mastectomies cover your additional surgeries and replacement. This may take the edge off of many of the financial worries when a woman chooses her reconstruction route.
There are many choices to make, even once you decide between breast implants or autologous reconstruction. However, there is no need to become overwhelmed. Write down any options that interest you and discuss these with your plastic surgeon.