Implant reconstruction

Breast reconstruction using implants is an option during or after mastectomy. In this procedure, a plastic surgeon places a breast implant directly under the skin or under the muscle of the chest wall.

A breast implant is like a balloon, with silicone (like rubber or plastic) on the outside, and either silicone or saline on the inside.

Reconstruction using implants is a common way to rebuild a breast after mastectomy. Tissue reconstruction is another way.

Implants come in different shapes and sizes. Implant reconstruction may be a good option if you do not have very large breasts, or you cannot use tissue from other parts of your body to create a breast.

Types of implants

The two main types of breast implants are silicone-filled and saline-filled.

Silicone implants have a silicone shell and are filled with thick silicone gel. They feel like a natural breast in texture and shape.

Saline implants have a silicone shell and are filled with a saltwater solution called saline. Saline-filled breast implants can feel like a water balloon

Saline implants may feel less firm than silicone implants. Silicone implants can feel more natural than saline. In breast reconstruction, silicone implants are used more often than saline implants.

Breast implants can be round or shaped like a teardrop. A silicone implant called a highly cohesive gummy bear is available in a teardrop breast shape.

Breast implants have smooth or textured shells.

Talk with your doctor about your implant options to make the best choice for you.

How implant reconstruction works

Implant reconstruction can be done in one or two stages:

• Single-stage reconstruction (also called direct to Implant or DTI) can be completed at the same time as mastectomy.
• Two-stage reconstruction can begin at the time of mastectomy and be completed a few months later.
• Both techniques can also be done months or years after mastectomy (delayed reconstruction). Delayed reconstruction with implants is usually done in two stages to allow for stretching the skin, which tends to tighten over time.

Single-stage direct-to-implant reconstruction

With single-stage, direct-to-implant reconstruction, a plastic surgeon inserts an implant into the breast pocket created by the mastectomy.

Surgical mesh is often used to hold the implant in place.

• The mesh may be donor tissue known as acellular dermal matrix (ADM). ADM is a kind of regenerative tissue that supports the growth of new cells and tissues.
• Mesh can also be made of other materials, including synthetic materials.
• Ask your surgeon if mesh will be used, and if so, what kind and what to expect. Different types of mesh can have risks, such as infection or allergic reaction, so it’s important to discuss this with your doctor ahead of time.

Two-stage implant reconstruction

Two-stage implant reconstruction involves stretching the breast skin with a short-term, expandable implant (called a tissue expander) that is later replaced with a permanent implant.

First, the tissue expander is placed in the chest after mastectomy.

• The expander may go under or over the pectoralis (chest) muscle.
• In some cases, surgeons may use a dual plane approach in which a portion of the tissue expander is placed under the muscle and the remainder is placed under the skin.
• If the tissue expander is placed over the muscle or in a dual plane, regenerative tissue, such as ADM, is used to hold the expander in place.
• Using ADM can also help reduce the risk for capsular contracture (scar tissue that hardens around the implant and can cause pain).

Every few weeks, your surgeon will stretch the breast skin by injecting salt water (saline) or air into a port on the tissue expander. This process can be uncomfortable, but most people do not experience much pain. It requires regular office visits. Your surgeon may recommend that you take pain-reducing medicine after each visit if needed.

When the breast reaches the desired size, the expander is replaced with a permanent implant in a second surgery, often called exchange surgery.

How implants are placed

Whether you have direct-to-implant or two-stage surgery, implants can be placed over (prepectoral) or under (subpectoral) the pectoralis muscle.

Or, surgeons can create a pocket in the pectoral muscle so the top of the implant can go under the muscle and the lower part can sit on top of the muscle. This is called a dual-plane procedure.

These days, the most frequent implant placement is over the pectoralis muscle. Regenerative tissue, such as acellular dermal matrix (ADM), is placed around the implant to add support.

Prepectoral placement benefits:

• May have a more natural look than subpectoral placement
• Pectoral muscle function is not affected
• Recovery is faster than with subpectoral placement

Prepectoral placement risks:

• Rippling of the implant may be more visible through the skin and cause similar rippling of the skin, because there is not as much tissue between the implant and the skin
• Implant may shift position

Subpectoral placement benefits:

• Holds implant firmly in place
• Risk of rippling is lower

Subpectoral placement risks:

• Recovery takes longer than with prepectoral placement
• The implant may move when you flex your pectoral muscle (surgeons may call this “animation”)
• This placement may impact upper body athletic activity

Dual-plane placement benefits:

• Shorter time between tissue expander placement to permanent implant placement
• Less pain than subpectoral placement

Dual-plane placement risks:

• The implant may move (animation) when you flex your pec muscle

When ADM is used to support an implant, there are risks of:

• Seroma (a clear fluid-filled lump)
• Infection
• An allergic reaction to the matrix

Visit the regenerative tissue page to learn more.

Implant placement decisions depend on many factors, including your personal health history. Talk with your plastic surgeon about the best option for you.

Radiation therapy after breast implant reconstruction

If you need radiation therapy after mastectomy, your doctor will likely recommend having two-stage implant reconstruction so that a tissue expander can be placed at the time of mastectomy. This is because radiation therapy can tighten and shrink a reconstructed breast.

A tissue expander allows your surgeon to stretch the skin before radiation. When radiation therapy is finished, the tissue expander can be removed (along with any scar tissue from radiation) and the final implant placed.

Your surgeon will exchange the expander for an implant after a period of time that allows the skin and soft tissue to recover from the radiation. This may range from 6 months to a year.

If radiation therapy is part of your treatment plan and you are considering implant reconstruction, talk with your doctor about timing that will allow both effective cancer treatment and the best cosmetic outcome.

Paying for implant reconstruction and removal

In the U.S., federal law requires insurers to cover most of the procedures mentioned on this page if they are related to mastectomy and breast reconstruction. However, the cost of implant removal or replacement may not always be covered, even if you have complications.

If you need to have an implant removed (explant surgery), call your health insurance provider to find out whether the procedure will be covered. You can learn more about coverage on the Explant surgery page.

Visit Financial matters, health insurance, and work for more information about paying for care.