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Breast Implant Reconstruction

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After a mastectomy, one of the ways that a breast can be reconstructed is with an implant. A breast implant is a round, flexible silicone shell filled with either saline (salt water) or silicone gel. Breast implants can either be placed over the chest muscle (pectoralis) or underneath part or all of the chest muscle. The implant replaces the breast tissue that is removed during the mastectomy, restoring the shape and volume of the breast.

Reconstruction with implants is the most common type of breast reconstruction. Of the more than 107,000 breast reconstruction procedures performed in the United States in 2019, about 80% of them used implants.1

The other main type of breast reconstruction — autologous or “flap” surgery — uses tissue transplanted from another place on your body, such as your belly, thighs, or buttocks, to form a breast shape. More plastic surgeons have experience with breast implant surgery than with flap reconstruction.

Breast reconstruction can give you a good cosmetic result, but reconstructed breasts may not have the same look or feel as your original breasts. It’s also important to know that most women lose sensation in their breast area after mastectomy.

Implant reconstruction may be a good option for you if:

  • after the mastectomy, you have enough healthy skin and tissue to cover and support a breast implant
  • you’d like to avoid the incisions and scars on other parts of your body that happen with flap reconstruction
  • you can’t or don’t want to have the longer surgery and recovery time needed for flap reconstruction
  • you do not need radiation therapy (there is a high chance of developing problems with implant reconstruction after radiation)

If you’re having a mastectomy and implant reconstruction on only one breast, your breasts may not be symmetrical after surgery. If you'd like, you can choose to surgically alter your healthy breast so it will better match the reconstructed breast in size and shape. Read about Altering the Opposite Breast.

Before a mastectomy, it’s smart to meet with more than one board-certified plastic surgeon who specializes in breast reconstruction. Individual plastic surgeons may have different levels of skill and experience, perform different types of procedures, and prefer different techniques. Make sure that the surgeon you choose has experience with the types of reconstruction you are considering and can discuss the advantages and disadvantages of your options. It’s also important to make sure that you’re comfortable with how your surgeon communicates with you.

If radiation therapy is part of your breast cancer treatment plan, you should try to meet with a plastic surgeon who specializes in flap reconstruction, because radiation can lead to complications with implants.

If you’re having immediate breast reconstruction at the same time as the mastectomy surgery, you’ll need to choose a plastic surgeon who does surgery at the same hospital as your breast surgeon so they can work together as a team.

On this page you can learn about the types of breast implants, breast implant surgery, the risks of breast implants, the differences between breast implant reconstruction and autologous (flap) reconstruction, and more.

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Different types of breast implants

Breast implants vary in:

  • size
  • shape
  • projection or “profile” (how much the implant projects forward from the chest wall)
  • filling type
  • surface texture

Your plastic surgeon will work with you to determine the best implant for your body type and preferences.

All breast implants have an outer shell made of silicone, a flexible, rubber-like material. You will need to choose the type of filling (saline or silicone gel) you’d prefer.

Saline-filled implants are filled with salt water. They are empty when the surgeon inserts them and are then filled to the desired size once they're in place. Saline implants tend to feel firmer than silicone implants.

An advantage of having saline implants is that you don’t need to get routine MRI screenings to check for “silent rupture” (implant rupture that doesn’t cause any noticeable symptoms). If a saline implant gets a tear in its shell or its valve fails, it’s usually obvious because the saline leaks out quickly and the breast appears deflated. The saline is harmless and absorbed by the body.

Silicone-filled implants are pre-filled with firm silicone gel. They usually look and feel softer, and more like natural breast tissue, than saline implants do.

If a silicone-filled implant ruptures, it’s harder to recognize because the implant will often maintain its shape.

If the silicone gel comes out of the implant, it can stay in the body and may spread to nearby tissues or to other parts of the body such as the lymph nodes or the lungs.

Signs that your silicone-filled implant has ruptured can include changes in breast shape and size and increasing pain, firmness, and swelling over several weeks. Rupture of a silicone-filled implant can also cause capsular contracture (tightening of the scar tissue capsule around the implant).

The FDA recommends that people with silicone-filled implants should have routine imaging with ultrasound or MRI to screen for silent rupture. This screening should start 5 to 6 years after the implant is placed and then be repeated every 2 to 3 years.2 Getting health insurance to cover imaging tests to screen for breast implant rupture can be challenging. Your plastic surgeon may be able to help you work with your insurance company to get coverage approved for this screening in advance.

If a breast implant ruptures, it is usually surgically removed as long as you are healthy enough for surgery. If you have a health condition that makes surgery unsafe, it is generally OK to leave a ruptured saline-filled implant in place. Ruptured silicone-filled implants have greater health risks and should be removed if possible. If silicone gel has leaked past the scar tissue capsule around the ruptured implant, your plastic surgeon will try to remove as much of it as they can.

Breast implant surface type: Smooth or textured

The silicone shell of a breast implant can be either smooth or textured. It’s important to know that women who have implants with a textured surface have a very small increased risk of developing breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), a rare type of T-cell lymphoma (cancer of the immune system). Textured tissue expanders — temporary implants that gradually stretch the skin and muscle in preparation for breast implants or flap surgery — may also carry a very small risk of BIA-ALCL.

In July 2019, Allergan announced a global recall of its Biocell textured breast implants and tissue expanders. The FDA requested the recall after finding the risk of BIA-ALCL was 6 times higher with Allergan Biocell textured implants vs. other textured implants sold in the United States.3

There may be other risks of using textured breast implants besides BIA-ALCL. A small South Korean study published in 2020 found a slight increase in the risk of the breast cancer coming back (recurrence) in women who had reconstruction with textured implants.

Some textured implants and tissue expanders are still being sold in the United States and in other countries. Textured implants can be round or teardrop-shaped (in fact, all teardrop-shaped implants are textured) and can be filled with either silicone gel or saline. Many, but not all, plastic surgeons have stopped using textured implants and tissue expanders in recent years. If you’re concerned about the risks linked to textured implants and tissue expanders, talk to your surgeon about your preference for smooth-surfaced expanders and implants.

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Breast implant placement: Over-the-muscle or under-the-muscle

Breast implants can be placed either on top of the chest muscle (pectoralis) or underneath part of all of the chest muscle. Talk with your surgical team about which would be best in your particular situation.

Keep in mind that sometimes the plan you’ve discussed with your surgical team for where the implants will be placed may have to change depending on what happens during the mastectomy. For example, over-the-muscle (prepectoral) placement may not be possible if the remaining breast skin is not thick and healthy enough after some tissue has been removed. Under-the-muscle (subpectoral) placement may not be possible if some of the chest muscle or a lot of the layer of tissue on top of the chest muscle was removed during the mastectomy.

Here’s what you need to know about each implant placement option:

Subpectoral (also called under-the-muscle or submuscular) implant placement means the breast implant is placed underneath part or all of the chest muscle. Part of the chest muscle is usually cut or divided so the implant can be placed under it. The surgeon may sew a material called acellular dermal matrix (a soft tissue substitute made from human or animal skin) to the tissue at the bottom of the breast to create a pocket that helps hold the lower half of the implant in place.

Advantages of subpectoral implant placement include:

  • lower risk of implant rippling or wrinkling; the chest muscle on top of the implant can help prevent the outlines of the implant from being visible through the skin
  • capsular contracture may be less likely to occur
  • the skin is better protected while it’s healing

Disadvantages of subpectoral implant placement include:

  • possibly more discomfort during recovery from the surgery and, in some cases, chronic pain, tightness, and weakness (because the chest muscle was cut and/or divided during the procedure)
  • higher risk of dynamic distortion (or animation deformity), which makes the breasts move in unnatural looking ways when you flex your chest muscle

Prepectoral (also called over-the-muscle) implant placement means the breast implant is placed directly under the skin, on top of the chest muscle. The implant isn’t covered by as much soft tissue as it would be if placed under the chest muscle. The surgeon may wrap the implants in acellular dermal matrix material and sew the material to the surrounding tissue. This helps provide support for the implants, helps keep them in place, and makes them less visible through the skin.

Your surgeon can determine if prepectoral implant placement is an option for you based on certain factors, including the amount and condition of the breast tissue that remains after mastectomy. More plastic surgeons have experience with subpectoral implant placement, so it may be challenging to find a surgeon who can do prepectoral placement.

Advantages of prepectoral implant placement include:

  • less pain, tightness, and weakness during and after recovery
  • lower risk of animation deformity or dynamic distortion

Disadvantages of prepectoral implant placement include:

  • a potential risk of implant rippling and wrinkling showing through the skin if the implant is not covered by enough soft tissue
  • a slightly higher risk of developing an infection around the implant compared to subpectoral placement
  • a possible risk that the implant shifts out of the correct position over time, if your breast skin is thin

Your surgeon may recommend one to three fat-grafting treatments sometime after implant reconstruction surgery to help thicken the soft tissue layer over the implant and prevent wrinkling and rippling. This involves removing fat from another part of your body — usually your thighs, belly, or buttocks — by liposuction. The fat is then processed and injected in small amounts into the breast area.

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Breast implant risks and maintenance

Before you decide whether to get breast implant reconstruction, make sure you understand the risks and benefits and how to care for breast implants over time. Here are some things to keep in mind:

  • You shouldn’t expect your breast implants to last a lifetime. Women who have implant reconstruction usually have one or more surgeries at some point because of a complication or to improve how their breasts look and feel. The longer you have implants, the greater the chance that they will develop a complication.
  • About once a year, you’ll need to schedule an appointment with a healthcare professional (such as a breast surgeon or plastic surgeon) who can check your implants for rupture and other problems.
  • The FDA recommends that women with silicone-filled implants should have regular exams using magnetic resonance imaging (MRI) or ultrasound to screen for “silent” implant rupture (meaning rupture that causes no symptoms). This screening should begin 5 to 6 years after the implant is placed and then be repeated every 2 to 3 years.2 These imaging tests may not be covered by your insurance — ask your surgeon if they can help you work with your insurance company to get them covered in advance.
  • If you notice any abnormal changes in your breasts or implants, you will need to see a healthcare provider right away.

Possible complications that can occur after implant reconstruction include:

  • Capsular contracture: tightening of the scar tissue capsule around an implant, which can cause pain and distort the shape of the breast.
  • Implant rupture: a tear or hole in the shell of an implant that allows the silicone gel or saline to leak out.
  • Implant displacement: movement of the implants that causes them to shift or become incorrectly positioned in the breast.
  • Breast implant illness (BII): a range of symptoms (such as joint and muscle pain, chronic fatigue, memory and concentration problems, rashes, headaches, hair loss, and gastrointestinal problems) that can develop after implant reconstruction. BII is not well understood, but some doctors who have treated many patients with BII say it is more likely to occur in people who have a personal or family history of autoimmune conditions, allergies, and conditions such as irritable bowel syndrome, migraines, chronic fatigue, or fibromyalgia. Still, some women who develop BII don’t have any of these risk factors.
  • Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL): a very rare type of immune system cancer that can develop in the scar tissue capsule and fluid surrounding an implant. BIA-ALCL seems to mainly occur in people who have had implants with a textured surface.

Read more about Breast Implant Reconstruction Risks and Complications.

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Radiation and breast implants

If radiation therapy is part of your breast cancer treatment plan or if you’ve had radiation to the breast or chest in the past, some doctors may recommend that you should not have breast reconstruction with implants. Radiation often causes the skin over an implant to become tighter, tougher, and more rigid, and it can raise your risk of complications including infection around the implant, capsular contracture, extrusion of the implant, and asymmetry.

You may be able to get a tissue expander at the time of the mastectomy, and then months later, you and your plastic surgeon can decide if you’ll get implant or autologous (flap) reconstruction using your own tissue. This approach will allow you to complete other treatments, including radiation and chemotherapy if needed, and then make the decision about reconstruction based on the condition of the skin after those treatments. In some cases, flap reconstruction that is performed after you’ve completed radiation treatments turns out to be the best option. So if radiation therapy is part of your breast cancer treatment plan, it’s smart to meet with a plastic surgeon who is experienced with flap reconstruction.

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Timing of breast implant reconstruction surgeries

Reconstruction with breast implants can be done at the same time as the mastectomy or at a later date. Some plastic surgeons think you can get better cosmetic results when implant reconstruction is done at the same time as the mastectomy. Talk with your medical team about what’s best for your situation.

Immediate reconstruction is done at the same time as the mastectomy. After the breast surgeon removes the breast tissue, the plastic surgeon inserts the breast implants or tissue expanders.

Some women have breast implants placed immediately after the mastectomy (called direct-to-implant reconstruction). Other women have tissue expanders placed first and the breast implants placed at a later time. Tissue expanders are temporary, empty implants that are gradually inflated with saline over time. This stretches the skin (and muscle if the expander is placed under the muscle) to make room for the breast implants. Tissue expanders can also be used to prepare the skin for flap reconstruction or as a first step while you decide what type of reconstruction to have.

Even if you plan to have direct-to-implant reconstruction, your surgeon may find out during the surgery that a tissue expander is needed instead. This can happen if the skin needs more time to heal before the implant is placed.

Tissue expanders can have a smooth or a textured surface. Since having textured tissue expanders could very slightly increase your risk of developing BIA-ALCL, you may want to ask your plastic surgeon about using smooth-surfaced tissue expanders.

You will need to make appointments every 1 to 2 weeks for several months to have your expanders inflated. Each expander has a tiny valve that is located under your skin. The surgeon or nurse will inject saline into the valve, filling the expander in stages.

You’re likely to experience some discomfort, pain, or pressure as the expanders inflate. It usually takes 2 to 6 months for the skin to be expanded enough. Then you’ll have another surgery to replace the expanders with breast implants. Depending on your treatment plan and what your doctors recommend, you may wind up having chemotherapy and/or radiation while you have the tissue expanders.

If you’re considering immediate reconstruction with tissue expanders or breast implants, you’ll need to choose a plastic surgeon who does surgery at the same hospital as your breast surgeon so they can work together as a team.

Delayed reconstruction is done months or years after the mastectomy and other breast cancer treatments are completed. This approach may be used if:

  • your skin is too tight to close over a tissue expander or implant
  • the breast skin doesn’t have a good enough blood supply after the mastectomy
  • you’d like to take more time to decide about whether to get reconstruction or which type to get

If you’ll be receiving radiation therapy after the mastectomy, your doctors may recommend delaying reconstruction until after you’ve finished radiation treatment. Your doctors may also recommend delaying reconstruction if you have health problems that make it riskier to have a longer surgery — for example, uncontrolled diabetes, heart disease, or lung disease.

If you decide to get delayed reconstruction with implants, you’ll probably need to get tissue expanders to stretch your skin and then have a follow-up surgery to replace the expanders with breast implants.

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What to expect with breast implant reconstruction surgery

Breast implant reconstruction often involves two or more surgical procedures over 6 months to a year or more.

Before each surgery, you’ll need to follow your medical team’s specific instructions, such as adjusting your current medications, when to stop eating and drinking, and showering with a special antibacterial skin cleanser.

After each surgery, your medical team will give you instructions to follow for your recovery. For detailed information on the special exercises you should do to minimize stiffness and scar tissue build-up after immediate breast reconstruction (done at the same time as the mastectomy) and how to care for the dressings, stitches, staples, and surgical drains, visit the Mastectomy: What to Expect page.

It can take about 6 to 8 weeks to recover from implant reconstruction surgery done at the same time as the mastectomy. It's important to take the time you need to heal. It's also important to continue doing your arm exercises each day and follow any other routines your doctor or physical therapist prescribes for you.

If you have tissue expanders placed during your initial surgery, you will have another surgery to swap the expanders for breast implants, usually 2 to 6 months later. This follow-up surgery is usually done as an outpatient procedure, which means you don't stay overnight in the hospital. You'll still be given general anesthesia, so you'll need to have someone come with you to the hospital or clinic to drive you home. This surgery takes about an hour. Recovery usually takes about 2 to 4 weeks.

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Comparing breast implant vs. flap reconstruction

If you’re trying to decide whether to have breast reconstruction with implants or with tissue transplanted from another part of your body (called autologous or “flap” reconstruction), here are some key things to consider:

Potential advantages of implant reconstruction compared to flap reconstruction

  • shorter, less complex surgery; shorter hospital stay; and quicker recovery time
  • can use the mastectomy incision for the procedure and doesn’t create new scars
  • no additional surgical incisions (and potential complications) on other parts of the body
  • gaining or losing weight won't change the size of the reconstructed breasts
  • it may be easier to find qualified surgeons
  • it may be easier to attain a larger breast size than you had before, if that’s what you’d prefer

Potential disadvantages of implant reconstruction compared to flap reconstruction

  • the overall reconstruction process can take longer (multiple steps, multiple office visits to receive tissue expander injections)
  • implants are less likely to feel, look, or move like natural breasts
  • implants may make the reconstructed breast(s) feel cool to the touch
  • implants can have future problems such as rupture, capsular contracture, displacement, and others
  • asymmetry between breasts can occur if you’re only having implant reconstruction on one breast (it’s easier to match the size and shape of the natural breast with flap reconstruction)
  • implants are generally not a good option if radiation therapy is part of your breast cancer treatment plan or you had radiation to the breast or chest in the past
  • implants probably won’t last a lifetime

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Hybrid reconstruction using an implant and a flap

It may be an option to have your breast(s) reconstructed with a flap of your own tissue and a small breast implant behind it. This is known as hybrid breast reconstruction. The main reasons to choose hybrid reconstruction are:

  • you prefer the more natural look and feel of flap reconstruction, but you don’t have enough tissue to transplant from other parts of your body to get the volume you want
  • you want to disguise the appearance of the implant through the skin — minimizing rippling and dynamic distortion

The types of flaps that are most commonly used in combination with implants are DIEP flaps and latissimus dorsi flaps. Depending on your individual situation, you may want to have the flap surgery first, evaluate the results, and then decide if you want to add implants.

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Follow-up procedures after breast implant reconstruction

Once your reconstructed breasts have healed and settled into a final position — about 4 to 6 months after your final implant reconstruction surgery — you might decide to have other procedures to improve the results. For example:

  • nipple reconstruction and/or nipple tattooing
  • a procedure to address asymmetry if you only had one breast reconstructed
  • fat grafting, which can be used to fill in imperfections or add volume to the reconstructed breast, soften and improve skin affected by radiation therapy, and thicken the layer of tissue between an implant and the skin
  • scar revision surgery, which can make the scars from breast surgeries less visible
  • corrective surgery to fix a complication that occurred during or after breast reconstruction

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Read more about:

Written by: Jen Uscher, contributing writer

This page was developed with contributions from the following experts:

Sophie Bartsich, M.D., FACS, plastic surgeon in private practice in New York, NY, assistant clinical professor of surgery at New York-Presbyterian/Weill Cornell Medical Center

Constance M. Chen, M.D., MPH, FACS, plastic and reconstructive surgeon in private practice in New York, NY, assistant clinical professor of surgery at New York-Presbyterian/Weill Cornell Medical College

Minas Chrysopoulo, M.D., FACS, plastic surgeon, president of PRMA Plastic Surgery, Center for Advanced Breast Reconstruction in San Antonio, TX, and creator of the Breast Advocate App

Frank J. DellaCroce, M.D., FACS, plastic surgeon, founding partner of the Center for Restorative Breast Surgery and the St. Charles Surgical Hospital in New Orleans, LA

Ron Israeli, M.D., FACS, plastic surgeon, founding partner of New York Breast Reconstruction and Aesthetic Plastic Surgery in Great Neck, NY, clinical assistant professor at the Zucker School of Medicine at Hofstra/Northwell

Elisabeth Potter, M.D., plastic surgeon in private practice in Austin, TX, affiliate faculty member in the department of surgery and perioperative care at the University of Texas at Austin Dell Medical School

Smita Ramanadham, M.D., FACS, board-certified plastic surgeon at SR Plastic Surgery in East Brunswick, NJ

William L. Scarlett, DO, FACS, FACOS, FAACS, plastic surgeon, chief of surgery and director of surgical services at Holy Redeemer Hospital in Bensalem, PA

Dhivya Srinivasa, M.D., plastic and reconstructive surgeon, breast microsurgeon, and academic faculty member at Cedars-Sinai in Los Angeles, CA

References

  1. American Society of Plastic Surgeons. 2019 Plastic Surgery Statistics. Available at https://www.plasticsurgery.org/documents/News/Statistics/2019/plastic-surgery-statistics-full-report-2019.pdf (PDF)
  2. U.S. Food and Drug Administration. Breast Implant Labeling Recommendations. September 29, 2020. Available at https://www.fda.gov/media/131885/download (PDF)
  3. U.S. Food and Drug Administration. Allergan Recalls Natrelle Biocell Textured Breast Implants Due to Risk of BIA-ALCL Cancer. September 12, 2019. Available at https://www.fda.gov/medical-devices/medical-device-recalls/allergan-recalls-natrelle-biocell-textured-breast-implants-due-risk-bia-alcl-cancer

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