Residency · Residency · Plastic Surgery

Implant-Based Breast Reconstruction

Introduction

Most common form of breast reconstruction in North America (~70-80% of all reconstructions). Options include two-stage tissue expander/implant (TE/I) and single-stage direct-to-implant (DTI). Can be performed immediately at the time of mastectomy or delayed. Requires adequate soft tissue coverage (muscle, fascia, or acellular dermal matrix). Radiation significantly increases complication rates and may favor autologous reconstruction.

Implant Types

Saline Implants

Silicone shell filled with sterile saline intraoperatively. Adjustable volume; can be overfilled or underfilled within manufacturer guidelines. Palpable rippling more common (especially in thin patients). Rupture easily detected clinically (deflation). Lower cost.

Silicone Gel Implants

Cohesive silicone gel fill. More natural feel and less rippling. "Silent rupture" possible; MRI recommended for screening (FDA guideline). Form-stable ("gummy bear") implants: highly cohesive gel that maintains shape.

Anatomic (teardrop) or round profiles available. Shaped implants require textured surface to prevent rotation (but textured implants associated with BIA-ALCL).

Surface Textures

Smooth: lower BIA-ALCL risk; higher malposition risk; standard for subpectoral placement. Textured: designed to reduce capsular contracture and prevent rotation of shaped implants; associated with BIA-ALCL (see topic 40). Microtextured/nanotextured: intermediate texturing; theoretical reduction in BIA-ALCL risk (insufficient long-term data). Many surgeons have moved away from macro-textured implants due to BIA-ALCL concerns.

Implant Dimensions

Base width: should match the breast base width (most important measurement). Profile: low, moderate, moderate-plus, high — determines projection for a given base width. Volume: selected to match the contralateral breast or desired outcome.

Tissue Expander/Implant (Two-Stage) Reconstruction

Stage 1: Tissue Expander Placement

Tissue expander placed at the time of mastectomy (or delayed). Creates a soft tissue pocket and gradually stretches the skin envelope. Expander has an integrated or remote port for saline injection. Expansion begins 2-3 weeks postoperatively; 50-100 cc per visit every 1-2 weeks. Overexpansion by 10-20% beyond target volume creates more natural ptosis.

Coverage Options

Total submuscular (subpectoral): pectoralis major covers the superior and medial aspect; serratus anterior covers the lateral aspect. Advantages: complete muscle coverage, lower exposure rate. Disadvantages: animation deformity, lateral malposition, limited expansion. Dual-plane with ADM: pectoralis major covers the superior pole; acellular dermal matrix (ADM) covers the inferior and lateral poles.

Most common current approach. Advantages: better control of the IMF, less muscle dissection, more natural lower pole. Disadvantages: ADM cost, potential for seroma, infection risk.

Stage 2: Expander-Implant Exchange

Performed 3-6 months after completion of expansion (or after radiation if applicable). Expander removed; permanent implant placed. Capsulotomy or capsulectomy if needed for pocket modification. Fat grafting may be performed simultaneously for contour refinement. Nipple reconstruction can be performed at this stage or later.

Direct-to-Implant (DTI) Reconstruction

Indications

Skin-sparing or nipple-sparing mastectomy with adequate skin envelope. Small to moderate breast size. Adequate soft tissue coverage. No planned radiation (relative contraindication). Good mastectomy skin flap perfusion (confirmed intraoperatively with ICG angiography).

Technique

Permanent implant placed at the time of mastectomy. ADM or mesh used to create a defined pocket. Prepectoral or subpectoral placement. ICG angiography to assess skin flap viability before implant selection.

Advantages

Single surgery (no expansion phase). Faster recovery. Avoids second anesthesia.

Limitations

Less control over final shape. Higher revision rate than TE/I in some series. Requires ideal operative conditions.

Prepectoral Versus Subpectoral Placement

Subpectoral (Traditional)

Implant placed deep to the pectoralis major muscle. Superior muscle coverage with ADM inferolaterally (dual-plane). Advantages: additional soft tissue coverage reduces rippling and exposure risk. Disadvantages: animation deformity (breast moves with pectoral contraction), muscle spasm, pain, distortion during exercise.

Prepectoral (Above the Muscle)

Implant placed directly on top of the pectoralis major, wrapped in ADM (anterior and posterior coverage). Advantages: eliminates animation deformity, less pain, faster recovery, more natural breast dynamics. Disadvantages: higher visibility of implant edges in thin patients, rippling, relies heavily on ADM integrity. Patient selection: adequate mastectomy flap thickness (>1 cm), adequate soft tissue coverage, confirmed flap perfusion by ICG angiography. Rapidly growing in popularity; now represents a significant proportion of implant reconstructions.

<image>Cross-sectional anatomical illustration comparing subpectoral and prepectoral implant placement in breast reconstruction. The left panel shows subpectoral (dual-plane) placement with the implant beneath the pectoralis major muscle superiorly and covered by acellular dermal matrix (ADM) inferolaterally, forming a sling. The muscle, ADM, implant, chest wall (ribs), and mastectomy skin flap are labeled. The right panel shows prepectoral placement with the implant sitting on top of the intact pectoralis major muscle, completely wrapped in ADM anteriorly and posteriorly. Both panels show the relationship of the implant to the skin, subcutaneous tissue, muscle, and ribs. Arrows indicate the direction of animation deformity in the subpectoral case and the absence of animation in the prepectoral case.</image>

Acellular Dermal Matrix (ADM)

Types

Human-derived: AlloDerm (most widely used), FlexHD, DermaMatrix. Porcine-derived: Strattice, Permacol. Bovine-derived: SurgiMend.

Functions in Breast Reconstruction

Provides inferior and lateral pole support. Defines the inframammary fold. Controls the implant pocket. Provides additional soft tissue coverage (particularly in prepectoral placement). May reduce capsular contracture rates (controversial).

Complications

Seroma (most common ADM-specific complication). Infection (higher than non-ADM implant cases in some series). Red breast syndrome (sterile inflammation). Cost (significant addition to operative expense).

Complications

Early

Hematoma (1-3%): return to OR for evacuation. Infection (2-8%): may require implant/expander removal; IV antibiotics. Skin flap necrosis: mastectomy flap ischemia; manage conservatively or with debridement. Seroma: aspiration, drain management. Expander/implant exposure: may require salvage with flap coverage or removal.

Late

Capsular contracture (Baker classification):

Rippling: visible implant edge undulations (more common with saline, prepectoral, thin tissue). Animation deformity: breast movement with pectoral contraction (subpectoral placement). Implant rupture: saline (deflation), silicone (silent rupture — MRI screening).

Radiation and Implant Reconstruction

Impact of Radiation

Significantly increases capsular contracture (30-50%). Higher rates of infection, skin necrosis, expander/implant loss. Compromised aesthetic outcomes. Reconstruction failure rate approximately 2-3x higher.

Strategies

TE placement → radiation → implant exchange: most common sequencing. Maintain TE partially deflated during radiation; re-expand after completion. Autologous reconstruction preferred for irradiated patients (lower complication rates). Delayed reconstruction: wait for radiation effects to stabilize (6-12 months). Fat grafting as adjunct to improve irradiated tissue quality.

Nipple-Areolar Complex Reconstruction

Typically performed 3-6 months after final reconstruction. Nipple: local flaps (C-V flap, skate flap, star flap) or nipple sharing from contralateral breast. Areola: intradermal tattoo (3D tattooing increasingly popular). Tattooing alone (without nipple reconstruction) is an acceptable option for many patients. Nipple-sparing mastectomy eliminates the need for NAC reconstruction.

Clinical Pearls

ICG angiography (SPY) intraoperatively is invaluable for assessing mastectomy flap perfusion; areas of poor perfusion should be excised to prevent necrosis and implant exposure. The inframammary fold must be precisely recreated and fixed (often with ADM suturing to the chest wall); malposition of the IMF is the most common cause of poor aesthetic results. Animation deformity is the most common reason for patient dissatisfaction with subpectoral reconstruction; prepectoral placement with ADM eliminates this but requires adequate soft tissue.

Capsular contracture is the Achilles' heel of implant reconstruction, especially after radiation; have a low threshold for conversion to autologous reconstruction in irradiated patients with recurrent contracture. Textured implants reduce capsular contracture but carry BIA-ALCL risk; the current trend favors smooth round implants with careful pocket management. Fat grafting is an excellent adjunct to implant reconstruction for contour refinement, rippling correction, and improving irradiated tissue quality.

References

• Sbitany H, Piper M, Lentz R. Prepectoral breast reconstruction: a safe alternative to submuscular prosthetic reconstruction following nipple-sparing mastectomy. Plast Reconstr Surg. 2017;140(3):432-443.
• Nahabedian MY, Jacobson SR. Two-stage prepectoral breast reconstruction. Gland Surg. 2019;8(Suppl 4):S43-S52.
• Salzberg CA, Ashikari AY, Koch RM, Chabner-Thompson E. An 8-year experience of direct-to-implant immediate breast reconstruction using human acellular dermal matrix (AlloDerm). Plast Reconstr Surg. 2011;127(2):514-524.
• Ho G, Nguyen TJ, Shahabi A, et al. A systematic review and meta-analysis of complications associated with acellular dermal matrix-assisted breast reconstruction. Ann Plast Surg. 2012;68(4):346-356.
• Cordeiro PG, Albornoz CR, McCormick B, et al. What is the optimum timing of postmastectomy radiotherapy in two-stage prosthetic reconstruction: radiation to the tissue expander or permanent implant? Plast Reconstr Surg. 2015;135(6):1509-1517.

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