Dr. Karen Horton has either authored or reviewed and approved this content.
Traditional implant reconstruction involves two stages in which shapeless skin remaining after a mastectomy is slowly expanded over many months using a tissue expander placed beneath the pectoralis major muscle. Tissue expansion is a lengthy, painful process where small amounts of sterile salt water (saline) are injected into the tissue expander to slowly inflate the expander and gradually stretch out the muscle (not fun at all!). Later, a permanent silicone gel breast implant is placed in a second operation, and the nipple and areola reconstruction are performed in a third or fourth procedure. This process is associated with a great deal of physical discomfort from stretching the flat muscle out over an implant and multiple inflation steps using a needle in the office.
However, our office offers a state-of-the-art technique that is not really new, but has been getting a lot of press in the scientific literature. Subcutaneous implant reconstruction (under the breast skin and subcutaneous fat but on top of the muscle) has been rebranded “prepectoral reconstruction”. We have been performing this technique in our office since 2006 and have performed well over 300 cases.
Single-stage prepectoral implant reconstruction does not require placement of tissue expanders under the muscle as a preliminary step, it spares the nipple and areola in 99% of cases, it provides the most natural looking results and enables immediate reconstruction often in a single operation.
Single-stage prepectoral implant reconstruction involves placing a permanent but postoperatively adjustable breast implant to replace the breast tissue during the same operation as the mastectomy. The implant is placed right where the breast tissue was previously located, on top of the pectoralis major muscle. The implant reconstructs the breast form and can be tailored as needed after surgery to suit a woman’s body, her curves, lifestyle and individual aesthetic goals.
Reconstruction is usually done immediately (at the time of the mastectomy) but can also be done in a “delayed” fashion (from months to many years after the cancer surgery). An implant can also be used for reconstruction following a large “lumpectomy” (removal of a large lump from the breast) to balance out the breast if there is a defect or contour deformity following cancer treatment.
Good candidates for immediate breast implant reconstruction in the subcutaneous or prepectoral position include women who have small tumors, those with non-invasive cancer that is not directly beneath the nipple and areola, and women who are considering “prophylactic” (preventative) mastectomy if they carry the BRCA gene or a strong family history of breast or ovarian cancer. Most women have nipple-sparing mastectomy unless there is a specific cancer-related indication to remove the nipple and areola.
You may not be an appropriate candidate for prepectoral immediate single-stage implant reconstruction if you are a smoker, if you have poorly-controlled diabetes or an inadequately treated major medical problem. Immediate single-stage implant reconstruction in the prepectoral location may also not be appropriate for women with advanced or rapidly growing tumors where surgical margins may be involved, those with multiple serious medical problems, and those who are psychologically unprepared for reconstruction.
Your past medical history and current medical status will be evaluated at your consultation. You may be asked to see your Primary Care Physician for a full physical examination and appropriate laboratory tests prior to being medically cleared for surgery.
Nipple sparing mastectomy (NSM) is a state-of-the-art technique for mastectomy that preserves all of the breast skin in addition to the nipple and areolar complex. NSM removes the entire contents of the breast through an incision in the inframammary fold (the natural crease beneath the breast). Preservation of the nipple and areola obviates the need for a second reconstructive procedure to create a new nipple-areolar complex.
We developed our NSM technique jointly with our Breast Surgeons (who do the mastectomy), incorporating Plastic Surgery principles, gentle tissue-handling technique and preservation of blood supply to the nipple. Nipple-sparing mastectomy has become the standard of care in our practice.
During the NSM procedure, the nipple is cored out from the inside and a separate specimen is sent by the Breast Surgeon to “Pathology” for analysis under the microscope. If there is any concern about abnormal cells extending into the nipple, the nipple can be removed in the office but the remainder of the breast skin is preserved (in less than 1% of cases).
NSM is safe and “oncologically sound” (safe from a cancer point-of-view) in selected patients such as those seeking prophylactic mastectomy (prevention because of a strong family history or carriers of the BRCA gene), in women with DCIS (non-invasive cancer), or small tumors that do not lie directly beneath the nipple. Breasts are relatively small to medium-sized (A cups to C cups) without significant excess skin or droop. Combining a nipple sparing mastectomy with a prepectoral breast reconstruction provides the very best aesthetic results, similar to a natural breast or a subtly augmented result – depending on what our patient is going for!
The most common incision used for NSM is in the inframammary fold (IMF), the natural fold beneath the breast. This incision preserves the entire breast “envelope” and is generally invisible unless the breasts are lifted. The IMF scar lies in a natural crease and does not tend to stretch or become raised, as can happen in other areas. See our Before and After Photo Gallery for images of NSM incisions.
Inframammary scars are hidden when viewing the breasts from above or from the front, are concealed in bras and even triangle-top string bikinis, and are generally only visible on careful inspection up close when the breasts are lifted. Most other incisions used for breast reconstruction are a “one-time option” only, with an IMF incision required in the future.
Following breast implant reconstruction, there is the potential that another surgery may be required at some point during your lifetime. The inframammary incision is most commonly used for future breast surgery procedures such as implant exchange or breast revision, if required.
Women with very large breasts (D cups or larger) or very pendulous (droopy) breasts who wish to have a prepectoral breast implant reconstruction can still have preservation of the nipple and areola. As long as a slightly smaller and perkier breast reconstruction is planned, rather than keeping the nipple and areola attached to the skin envelope, the nipple and areola is removed as a “free graft”. The mastectomy is done by way of incisions used commonly for a breast reconstruction by reduction or lift, sometimes known as the “Wise pattern”.
Planning is essential before surgery by your Plastic Surgeon and Breast Surgeon. After the breast tissue is removed, the implant is placed and the skin is “reduced” or redraped around the prepectoral implant. The nipple and areola graft is then placed in the appropriate position on the reconstruction. Preserving the nipple-areolar complex by way of a free graft eliminates any concern about blood supply to the nipple and facilitates the most reliable healing. Please see our Before and After Photo Gallery for pictures of immediate breast reconstruction with free nipple-areolar graft and a reduction/lift.
Advantages of immediate prepectoral implant-based breast reconstruction include a shorter operation time (1-2 hours including the mastectomy) compared to flap reconstruction (3-5 hours), a somewhat slightly shorter recovery time (approximately 4 weeks), and usually a single scar under the breast that lies in the natural breast fold. Placing the implant on top of the muscle is much less painful, with most patients going home from surgery on plain Tylenol only.
Regardless of whether the implant is placed on top of or below the muscle, breast reconstruction operations require two surgeons: the Breast Surgeon (who performs the mastectomy) and the Plastic Surgeon (who performs the reconstruction). Usually, your Plastic Surgeon will assist with the mastectomy and she will be there for your entire procedure.
The type of reconstruction you select should ultimately take into account your body type, the details of your cancer and its treatments, your lifestyle, profession, family situation and your personal goals for reconstruction. For women who wish to take the least amount of time off work or to have the shortest recovery, implants may be a reasonable option.
One additional advantage of implants is that they are technically “reversible”: that is, if a woman’s situation changes, or should implant complications occur, the implants can be changed, altered or removed or the type of reconstruction converted to a flap in the future, if desired. Having a prepectoral breast implant reconstruction does not take away the potential to have flap breast reconstruction in the future. In contrast, whereas once a flap is done, the effect is permanent.
Breast implants are not infallible, and like all medical devices, have some potential disadvantages. Because an implant is a foreign body, it can become infected, excess scar tissue can form around it and create hardening of the reconstruction (“capsular contracture”), or the device can fail (leak). These risks may be increased if radiation is involved. Studies have shown that the complication rate is equal between prepectoral reconstructions and those for implants under the muscle.
In our experience, submuscular reconstructions have increased complications such as animation deformity, chronic pain or tightness and a displeasing aesthetic result. It is possible to convert a submuscular implant to a prepectoral reconstruction even after radiation therapy or years after the mastectomy. Please see our sections on Breast Implants, Special Considerations for Breast Surgery and Postoperative Instructions for Breast Surgery for additional information and further education about breast implants.
A permanent, postoperatively adjustable breast implant is precisely matched to the dimensions of your breast, your chest and your aesthetic goals in immediate single-stage prepectoral breast reconstruction. All breast implants contain a shell that is made of silicone. Because the implant is adjustable, by definition it contains saline (sterile salt water) that can be added or subtracted as needed to adjust implant size after surgery. In contrast, silicone gel implants contain a full-sized, fixed volume that cannot be adjusted. Silicone implants therefore are not normally used immediately at the time of mastectomy. Please see our section that discusses breast implants further for additional information about the science and safety of all implants.
Please see our Preparing for Surgery section to learn about what actually happens in the operating room on the day of surgery.
After the mastectomy is complete, your reconstruction will be performed right away as part of the procedure. Measurements are taken and your breast tissue is weighed as a reference point for your reconstruction.
The permanent, postoperatively adjustable implant is placed in the space where the breast tissue was, on top of the pectoralis major muscle, in the prepectoral position. There are many advantages to having the implant on top of the muscle as opposed to beneath the pectoralis major muscle, including less postoperative pain and less discomfort than traditional techniques, no animation deformity (wrinkling and contraction of the skin with chest muscle flexion) and a much more natural-looking and symmetric outcome.
The implant is inflated with sterile saline (salt water) approximately 60% to 80% of the way full while you are still asleep. This partially fills out the breast space but avoids any tension on the breast skin, facilitating smooth healing without complications.
The implant is connected to a “port”, an injection dome that enables additional filling of the implant as desired after the surgery in the office. The port is placed beneath the skin under the breast fold. More saline can be added to the implant after surgery to suit your aesthetic goals. Usually only one or two inflations are all that are needed until your reconstruction is complete.
Please print out and read the comprehensive Preparing for Breast Reconstruction Surgery handout. Written by Nurses and Doctors at the hospital, this pamphlet describes in detail how to prepare for breast reconstruction surgery, educates you what to expect in the hospital and explains postoperative recommendations specific to your type of breast reconstruction.
You will spend approximately two nights in the hospital after a mastectomy and immediate implant reconstruction. We will see you back in the office a few days after you go home and weekly thereafter for approximately the first month.
It is recommended that you do not exercise, lift more than 5 pounds, or do any activities that raise your heart rate and blood pressure for approximately 4 weeks after surgery. At 4-6 weeks after surgery you can return to your usual activities, without restriction. However, “listen to your body” is the general rule, and if it feels like you are straining even after you are allowed to resume exercise, please continue to avoid activities or movements that still create discomfort. Remember that is takes many months up to a full year for your body to fully recover after any type of surgery. Prepectoral breast reconstruction is no exception.
At one to two weeks after surgery, when healing is underway and swelling has decreased, additional saline is added to the implant though injections into the port. The implant is fully inflated within a few weeks. The port will remain in place for approximately three months after surgery to enable fine-tuning of your reconstruction. The port can be later removed under local anesthesia in the office, or in the operating room if combined with other surgical steps (such as implant exchange to silicone). The permanent saline implant remains in place, and the reconstruction is complete in a single stage.
The implant port enables saline to be added or removed from the implant to carefully “titrate” (adjust) the volume to your precise goals during your recovery. Some women find that they are pleased with a slightly fuller volume than the one they had before their mastectomy – particularly Moms who may have some post-partum breast deflation. You will not know what it feels like to have a different breast size until you experience it and get used to your reconstruction.
We usually recommend waiting a period of three months before the port is removed to allow for swelling to go away and to ensure you are satisfied with the size (volume) of your reconstruction before the implants are no longer adjustable. During this time, you will resume all your normal activities without any restrictions. You will continue to be seen in the office for regular follow up visits throughout your recovery. Adjustment of implant volume is possible at any time until the ports are removed. Some women use this period to “test out” a new size of their breasts before committing to a final volume. Remember, breast reconstruction is supposed to be fun!
Once your implant has been fully inflated and your reconstruction is complete, you have the option of keeping your permanent saline implant (and having the implant “ports” removed as an outpatient procedure) or switching out the saline implant to a silicone gel implant. By this time, the exact volume and dimensions that suit your preference are determined. Please see our section on silicone gel breast implants to learn more about silicone implants.
Breast implants can be placed either on top of the pectoralis major muscle or beneath the pectoralis major muscle (the “submuscular position”). In the medical literature, sometimes a partial submuscular position is described (the “subpectoral” or “dual plane”). There are proponents for each technique, based on opinion, surgical training and professional experience.
In most instances, breast implant reconstructions are placed on top of the pectoralis muscle in our practice, known recently as prepectoral reconstruction. The reason for this is multifactorial, and is based on the belief that a breast reconstruction should never interfere with muscle motion or function, and should create a natural result that remains constant in the long term and with changes in age and in the body over time.
Implants placed on top of the muscle move as expected with changes in body position, without the “motion deformity” or “animation deformity” of submuscular implants (described below), creating a more natural breast shape that is consistent over time, without affecting long-term pectoralis muscle function.
During reconstruction of the breast, it makes the most sense to replace volume to the breast where it is missing: in the breast space, rather than under a flat muscle! The pectoralis major (“pec”) muscle is activated and engaged in nearly all activities of the upper body and the “core” (the trunk). It has a straight vector of pull upwards and outwards, and it was certainly not designed to be stretched out over a breast implant! Contraction of this muscle causes displacement of the implants upwards and outwards, along the vector of muscle flexion. This deformity is known as the animation deformity of submuscular implants, and is a common reason why women seek revision surgery after breast reconstruction or cosmetic augmentation.
For some women, chronic contraction of the pectoralis muscle around the implant can create strain, tension or physical discomfort in the neck, upper back or shoulder area. In addition, because part of the pectoralis muscle is permanently detached from the sternum and ribs in submuscular procedures, implants in this location can sometimes negatively affect muscle strength and function. Implants placed on top of the muscle do not flex or become distorted with pectoralis major motion.
For all these reasons, women who are athletic, who become fully educated about their options for implant reconstruction and who wish to maintain full function of their pectoralis muscles choose the prepectoral reconstruction technique. As women surgeons, we only recommend to our patients what we would do to our own bodies and what makes most sense functionally, aesthetically and when using common sense.
The most appropriate size for breast implant reconstruction is individualized to each woman on a case-by-case personalized basis. The precise implant choice suits a woman’s height, weight and lifestyle, and fits her frame, remaining proportional to her body curvature.
Breast implant reconstruction is a dynamic process that involves individualized planning and multiple discussions with your surgeon. Your Plastic Surgeon has an aesthetic eye for what “looks right” in your body and fits your frame and will exercise sound judgment in the operating room.
When we use a permanent, postoperatively adjustable implant, You choose the final size of your reconstruction. The implant volume can be modified (increased or decreased) after surgery as your swelling decreases, allowing you actively participate and to “test out” different sizes in your own body! At a stressful time when you may feel like you have little control over your cancer situation, we give you Control over your final reconstructive outcome.
Please visit our Breast Augmentation section for ideas on how women choose their breast implant size for cosmetic augmentations; some of these ideas may be of interest to you while you are planning your breast reconstruction surgery.
Implant reconstructions tend to create a fuller but potentially slightly less natural breast shape (as in when wearing a push-up bra) when compared to a completely natural, flat or droopy breast. For this reason, we often suggest a performing balancing augmentation of the other breast for symmetry at the time of reconstruction. Any “balancing” procedure to the other breast is considered part of the reconstruction and is also covered by insurance. Your surgeon will discuss this option with you at your breast reconstruction consultation.
Implant reconstruction can also occur after a lumpectomy (with or without radiation) if the treated breast is smaller or misshapen when compared to the other breast. An implant will help to fill out missing volume, normalize the breast shape and achieve better symmetry of the breasts.
Either a permanent, postoperatively adjustable implant (saline-filled) or a silicone gel implant can be used for reconstruction after lumpectomy. The details of the cancer treatment, radiation dosage and reconstructive goals are all taken into account. Prior radiation slightly increases the risk of complications related to the implant such as infection and capsular contracture.
Like reconstruction after mastectomy, if an implant is used for reconstruction after lumpectomy and radiation, a balancing breast augmentation is usually recommended for the non-cancer side to achieve the best possible symmetry. Both breasts are normally operated on at the same time.
Breast reconstruction with implants certainly IS possible after radiation, with good results! This woman had implants placed on top of the muscle (prepectoral reconstruction) without any ADM. She is soft and natural, despite radiation on the left side!
After mastectomy and breast implant reconstruction, you will have drains in place for approximately 10-14 days. Drains are vital to remove wound fluid from around the implant while you are healing and to decrease the risk of complications. We urge you to read Dr. Horton’s blog post on surgical drains and watch all of the accompanying videos so that you are well prepared to care for your drains after surgery.
Please click here to see before and after NSM and implant reconstruction results!
A delayed breast implant reconstruction is still possible as long the skin does not have significant radiation damage, even in the prepectoral position. For non-radiated patients, the adjustable implant may require a few more inflations than for an immediate reconstruction until the implant is full size. It can take some time for the contracted breast skin to fill out and assume its final shape when compared to an immediate implant reconstruction. See our Before and After Photo Gallery for examples of delayed breast reconstruction using implants.
During your lifetime, you may require at least one additional procedure related to your implants. This may consist of implant removal, replacement, or adjustment of size, based on changes in your wants, needs or personal situation. However, breast implants are not like tires and do not need to be changed “every 10,000 miles”!
Your surgeon will follow up with you in the long term and ensure that you are still looking good and feeling good many years after your surgery. There is no reason to undergo any additional surgery unless you are experiencing a problem or you wish to have another procedure in the future.
At your initial breast reconstruction consultation, a complete medical history will be taken. Your surgeon will spend a great deal of time getting to know you personally. She will explore your goals for breast reconstruction and examine you. A great deal of time will be taken going over all the available options for breast reconstruction, including implants. If you are an appropriate candidate for prepectoral single-stage breast implant reconstruction, this option will be described to you in detail.
Dr. Karen Horton has either authored or reviewed and approved this content.
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*Please note: Cosmetic surgical and non-surgical procedures are not covered by insurance. Dr. Horton accepts limited insurance plans for breast reconstruction and breast reduction. Please contact our office to inquire about insurance coverage for reconstructive surgery.