Reconstructive Breast Surgery

Breast Implants: Insertion of Saline- or Silicone-Filled
Prosthesis

Description
Implants are normally inserted under general anesthesia, as adequate local anesthesia
is diffi cult to achieve. Implants are artifi cial devices for providing additional
breast volume and are of various types, shapes, sizes, and contents (saline, silicone,
emulsion, or other). They are used in three main areas of surgical practice.
Firstly, for cosmetic bilateral breast augmentation, secondly to achieve symmetry
in patients with congenital conditions leading to asymmetry or where breast
reconstruction has failed to achieve symmetry, and thirdly as an integral part of
immediate or delayed subpectoral reconstruction or with latissimus dorsi breast
reconstruction.

Anatomical Points
Breast implants are commonly inserted into one of three different sites, including
the subpectoral and submammary positions during breast augmentation and deep
to myocutaneous fl aps during breast reconstruction. It is important to ensure that
the space developed or constructed for the implant matches the base dimensions of
the native or reconstructed breast. Congenital abnormalities of pectoralis major are
usually associated with absence of the lower third of the muscle. Poland’s syndrome
is a rare congenital condition characterized by unilateral hypoplasia of the breast,
thorax, and pectoral muscles. Previous radical surgery, nerve division, and radiotherapy
may lead to muscle atrophy or muscle loss, which in turn may dictate the
anatomical position of the implant and risk of complications.
Perspective
Breast implants currently have a fi nite lifespan and will typically
need replacement within the 20 years after surgery. The complications of breast
implants are related to the type of implant, the context in which they are used,
and the length of follow-up. Implants have been used for breast augmentation and
reconstruction for more than 30 years, and outside the USA, silicone-gel implants
remain the most popular choice. Implants contain a fi ller, within a shell made from
polydimethylsiloxanes and amorphous silica, and include silicone gel, saline, and
polyvinylpyrrolidine. Most early complications are related to inappropriate case
selection and surgical technique, which can often be reduced by experience, careful
planning, and attention to operative detail. Patients require comprehensive information
and advice backed up by printed materials providing a realistic expectation of
outcomes. It needs to be explained that implants are long term and not permanent
devices, which require regular surveillance and replacement if the outer shell ruptures
or fatigues or other complications develop. The design of silicone-gel implants
has been modifi ed progressively since their introduction. The fi rst generation
implants had a smooth surface, and the second-generation devices had a textured
surface, while the current third generation implants have improved surface texture
with a fi ller of cohesive silicone-gel associated with lower levels of “silicone bleed”
into the surrounding tissues. Saline implants are used widely in the USA, but have
a less natural consistency and are more prone to leakage, defl ation, auto-infl ation,
visible surface rippling, and folding. Implant wrinkles and ripples are more obvious
in the reconstructed than in the augmented breast, as they lie closer to the surface
and are not usually able to be covered by breast parenchyma.
Major Complications
Major complications following the use of breast implants are uncommon and occur
either shortly after surgery or many months to years later. Early complications in the
fi rst 24 h include hemorrhage and implant displacement , which in turn are usually
related to surgical technique. Signifi cant hemorrhage requires re-exploration, as
conservative treatment of a peri-prosthetic hematoma is likely to lead to progressive
capsule formation . A clear-cut infection in a toxic patient should be managed
by implant removal and appropriate antibiotics. Infection is more common following
implant-based breast reconstruction, as this is a prolonged procedure which is
associated with more extensive dissection than breast augmentation. Tissue tension
and devascularization are key contributors to ischemia and consequent infection.
A sterile peri-prosthetic seroma can lead to mild reddening of the breast several
days or weeks after implantation, leading to diagnostic confusion. It can be managed
by careful ultrasound-guided aspiration and culture to reduce confusion with
pyogenic infection. Overzealous tissue expansion of relatively ischemic or irradiated
tissues can lead to overlying tissue necrosis and extrusion of the expander.
Implants may also extrude through recent incisions if they are closed under tension,
irradiated, become infected, or have been inadequately sutured. The most frequent
and frustrating late complication is adverse capsular contracture (ACC), which
may occur in up to 70 % of cases. The etiology is unknown, but possible causes
include a foreign body reaction, hematoma, infection, and radiotherapy. The use
of textured implants reduces this risk. ACC is more common after reconstruction,
when using larger implants and with longer follow-up. If ACC is symptomatic, it
is treated by open capsulotomy or capsulectomy and replacement of the implant
with a textured device, but recurrence is common. Prosthesis rupture is the second
most common late complication which may be symptomatic or asymptomatic. It is
detectable in up to 20 % of patients with silicone-gel implants who are followed up
for more than 10 years. Rupture can be detected by ultrasound or, more specifi cally,
MRI scanning and should be treated by removal and replacement of the implant.