Breast Reconstruction Q&A with Scott Sullivan, M.D., F.A.C.S.: Implant Reconstruction

By on June 11th, 2015 Categories: Treatment & Side Effects

Welcome to our breast reconstruction Q&A blog series with Scott Sullivan, M.D., F.A.C.S. of the Center for Restorative Breast Surgery in New Orleans, LA. In this installment of our series, Dr. Sullivan answers your questions about reconstruction using implants. Stay tuned for future blogs in which Dr. Sullivan answers questions about flap reconstruction (using your own tissue to recreate the breast).

Update: Read the Q&A with Dr. Sullivan on flap reconstruction.

 

Q: Do all women who have breast implants feel the pectoral muscle tightening over the implant? Does that sensation ever go away?

A: All patients I have come into contact with who’ve had implant reconstruction admit to some amount of tightness. It might be a little bit of a “nuisance” tightness they feel around their chest. Others describe it as more extreme tightness, almost like someone wrapped a thick rope around their chest and is continuously tightening it.

A lot of the tightening comes from capsule formation. Remember that the implant is placed under the pectoralis muscle, and scar tissue forms and creates a capsule wall around the implant. The body forms a capsule like this around any object it recognizes as foreign. The capsule is stuck to the chest wall, it surrounds the implant, and it also adheres to the underside of the pectoralis muscle. Muscles like to move, but now you have a muscle that is trapped. It can’t really move like before. The breasts may have some weird movement to them when you flex your pectoralis.

Again, the degree of tightness differs from person to person. Sometimes the capsule is very thin, pliable, and soft, so it allows the muscle a little bit more movement. In other women it becomes much more dense and firm, to the point where the muscle is really stuck down and the breast hardly moves. Think of a mouse stuck on a glue trap, trying to move but being totally stuck. The same thing can happen with the muscle. This is what we refer to as capsular contracture.

Now, does it go away? For the milder cases, I think the patients learn to live with the tightness and block it out, and for the most part it goes away. For those that have a little denser capsule formation and more tightness, it can be harder to overcome. There are things we can try, like medications and physical therapy. If it becomes unbearable, we can consider surgery.

 

Q: Is it possible to correct or improve mild-to-moderate capsular contracture in a radiated implant?

A: Well, it can be difficult to correct because we can’t control the changes that the radiation has caused to the tissue. The “capsule” of tissue around the implant can basically harden as a result of radiation damage.

When I talk to patients with this issue, I first try to figure out if it’s something that bothers them a great deal or that they might be able to overcome. The breast with an implant that received radiation is always going to feel “thicker” and “firmer” than the non-radiated side. We can start by trying some non-invasive therapies, such as anti-inflammatory medicines, vitamin E, and even the allergy medicine Singulair. Some women get improvement with ultrasound massage and others by working with a physical therapist on range of motion exercises. I can’t say with certainty that these approaches will help most women; often it’s a matter of trying one thing, seeing if it helps, and then trying something else. These won’t eliminate the capsular contracture, but they may help enough so that a woman tolerates it better and ultimately finds she can live with it. It becomes kind of a mild discomfort or a nuisance.

If the capsular contracture causes immense pain and difficulty with range of motion, and it compromises a patient’s daily routine and she cannot live with it, that’s a different story. Then it would need to be surgically corrected. I feel the best solution is to take the implant out and replace it with flap reconstruction, which uses your own tissue to recreate the breast. You won’t develop a capsule around your own tissue. However, many patients don’t want to do this because it is a bigger operation.

So another option is to get in there and take out the capsule or release the capsule by surgically breaking it up or crosshatching it. Then you put in a new implant. Often I’ll try a different type of implant — maybe one with a textured surface if the previous one was not textured, for example. We might place steroid medication in the pocket to try to prevent scarring. Postsurgically we can try some of the medications I mentioned earlier, such as anti-inflammatories, vitamin E, and Singulair. There is no guarantee that contracture won’t become a problem again, but these are all things we can try.

 

Q: If you develop capsular contracture with an implant, will you always be at high risk for it or can it be avoided during subsequent surgeries?

A: Just because you had capsular contracture does not mean you will have it again with a new implant. The primary risk factor is radiation to the implant, or placing an implant in an area that has already been radiated. So if you had radiation therapy, there will always be some risk. If you’re placing the new implant in an area that was not radiated, there is a better chance the capsular contracture will not come back.

There are other factors that play a role in capsular contracture. Smoking increases risk. Trauma to the area, whether because of the surgery itself or a later injury, can be a factor. If you developed a hematoma or seroma [buildup of blood or fluid] after reconstruction surgery, that can increase risk. There is some research suggesting that bacteria can colonize the implant pocket and create an inflammatory process that thickens the capsule and leads to capsular contracture. So any of those may have been the cause in the past, and if they can be avoided in future surgery, the risk is lower. It is reasonable to let a surgeon go in and take the hardened capsule out, put a new implant in, and see if it comes back.

 

Q: Given a history of radiation, then mastectomy and reconstruction years later, how common is symmastia? What are the methods of correcting it?

A: Symmastia occurs when two breast implants come together. The skin that is attached to the sternum [breastbone] detaches and the two pockets that the implants were in now come together to form one pocket and the implants “kiss.”

Symmastia is more common in radiated tissue because the tissues are already stiff and inelastic, and this puts more tension on the skin holding the implants in place. It’s also more common when a patient has fairly large breast implants. The larger the implant is, the larger the volume and the bigger the pocket has to be, and the more tension there is on the part of the skin that has to adhere to the sternum and hold the implant. Sometimes a plastic surgeon is overly aggressive in releasing the tissue to create the pocket to fit the implants, which can also contribute to symmastia. The implants are placed below the pectoralis muscle, and if you release too much of the muscle, then the only things separating one breast implant from the other are some skin attachments to the sternum, which are not very tough. If the skin can’t really handle the volume of the implants, the unintended consequence is that things can detach and the two implants come together. The risk of symmastia is substantially less when implants are smaller and the surgeon releases the tissue properly to create the pocket.

It can be difficult to correct symmastia. This requires surgery to remove the implants, downsize them, and then reattach the skin that has detached from the sternum. Often we’ll use non-dissolving sutures [permanent stitches] to hold the tissue in place. We may put in some mesh or acellular dermis [soft tissue replacement] to reinforce the pocket that holds the implant. Then we have the patient wear a special bra that is almost like a figure-8, with a rigid underwire that helps apply pressure to where the sternal reattachment was.

I have seen women who have a successful reattachment later ask for bigger implants again, but this just causes another disruption that can lead to symmastia again. So it’s not a good idea.

 

Q:  I understand that the “gummy bear” anatomical implants require a snug fit, and that it is common practice to use an implant that is larger than the volume to which a woman has been expanded using tissue expanders. In a woman of average dimensions, how much larger should the implant be? 20%? 40%? Would radiation to the expanded breast affect that decision?

A: In my practice, I have found that any implants — whether the regular round ones or the newer anatomically-shaped ones — look better when there is a snugger fit within the skin envelope. So we do tend to add a bit more volume over and above the size of the expander so that the skin will drape more tightly around the implant.

For the anatomical implants, if a patient wants to stay the same size as before, I generally need to make the implant 10 to 15% bigger than the volume of the expansion. I might start with 10, see how it looks, go up to 15 or maybe 20% — 40 would be rare. With round implants, I find I can stay a little closer to the expansion volume. I think it simply has to do with the fact that the anatomical implants are teardrop-shaped and the volume is distributed differently than in the rounds — larger on bottom, smaller on top. There’s no set percentage to go by, but yes, I would put in more volume than I took out.

It also depends on the individual patient as well. If a woman had nice breast shape before and a good quality of skin, you could put in about the same size implant or just a touch more than the expansion and get a great-looking result. If a woman has more sagging or “deflation” and poorer-quality skin, you might need to go bigger to get a better fill of the skin envelope and a better shape.

As far as radiation goes, radiated skin does contract down and compresses the volume of the expanded breast, making it look smaller. So often we do put an even larger implant on the radiated side versus the non-radiated breast. Let’s say that a woman is having bilateral mastectomy and reconstruction. The breasts were the same size going in, but perhaps only one is going to get radiated. You are going to end up getting a larger implant in the radiated side because that skin has contracted. You need to do that so the two breasts appear to have the same volume.

 

Q:  I had bilateral implants placed before radiation and now, two years later, I have moderate encapsulation, severe axillary cording, significant discomfort, and loss of symmetry. My surgeon has suggested latissimus dorsi flap surgery [reconstruction using the latissimus dorsi muscle on the back], but I am concerned about further impact on my active lifestyle. Are there other solutions? Is it possible to consider a smaller implant and fat grafting to introduce some healthy tissue to the area? And could the axillary cording be cut during surgery to relieve pain?

A: Smaller implants and fat grafting aren’t likely to provide significant improvement in this situation. She would get much better relief by taking the implants and capsules out and replacing them with free flap reconstruction using tissue from the abdomen, hips, buttocks, or thighs, instead of the latissimus dorsi flap. Putting her own soft tissue in there will be the best solution. This will help most with the pain and tightness. It would be possible during that surgery to cut the axillary cords [hard, fibrous bands of tissue running along the inner arm]. Typically, cording is treated with external massage or ultrasound to gradually break them up, but if you’re in there doing an operation, you can cut the cords.

 

Q: I had bilateral implants placed three years ago. One of my breasts has been bothering me lately — there is achiness between the collarbone and above the breast, especially when touched. There is also aching and some numbness under the armpit. Is this normal or should I be concerned?

A: This should be checked out, but it’s not likely to be a recurrence of disease. When patients start to develop these symptoms, usually it’s due to worsening capsular contracture. Often you can see that the breast is tighter and firmer and this is in keeping with the onset of new symptoms such as tightness and achiness. Women may even have a posture change, holding one shoulder up higher on the side of the capsular formation. It’s a gradual thing, and since women are looking at themselves every day, they don’t notice it as much. But when you see them after 6 months, or you compare their appearance to photos taken some time ago, you can notice it.

Sometimes symptoms like these can be related to a ruptured implant. It blows out and some of the material can go toward the axilla (armpit area). This can account for the numbness. Numbness can be associated with recurrent disease there, but often you can feel the disease before any numbness occurs.

In these cases it is good to do an exam and also get an MRI, which shows you some of the internal architecture.

 

Q:  How do you counsel patients choosing between the newer anatomically shaped implants and round implants? My plastic surgeon said he has had many patients get anatomicals but then switch them out for round implants. What are your thoughts on this?

A: Anatomicals have been used in Europe for about 10 to 12 years, but only 3 to 4 here in the U.S. I tend to lean toward the anatomicals or “shaped” implants in most cases.

Before reconstructing, you have to evaluate the shape of the breasts: their width, height, and how they relate to the size of the patient and the height of her torso. Sometimes you can get good fill and projection with the round implant. If a woman is petite with a shorter torso, round implants can work well. But sometimes you want more upper pole fullness, and for that you can get a better outcome with the anatomicals, which have a teardrop shape and are wider at the bottom.

The so-called “gummy bear implants” are exceptionally good quality implants. They have a highly cohesive gel, more cohesive than the other round implants. Overall, the gel implants produced today are far, far better than the ones that they had more than a decade ago that came off the market, and better than the first-generation ones that later came back on the market. Since they have an asymmetric shape, though, you have to make sure they are positioned properly on each side so that they mirror each other. There is a chance the implants can rotate, in which case they would need to be replaced and repositioned. They also can flip. Some people may have more of a problem with this, which may lead them to switch to rounds. With a round implant, you don’t worry about rotation because it’s round — the same shape all over.

Anatomicals do come in a textured version that has a fine granular finish, and this can help them stay in place and diminish the chance of rotating. They also tend to drop less and the risk of capsular contracture is lower versus a smooth implant.

The anatomically shaped implants are firmer than the round implants, and some people don’t like the firmness. That may be why they switch them out as well.

But again, I favor anatomicals because the breast itself is kind of a teardrop shape, and that is how the anatomicals are shaped — wider at the bottom to give more natural-looking fullness in the upper breast. With round implants, often there is a deficiency in fill in the upper pole of the breasts.

Kris Conner, MA, Contributing Writer--Kris has been writing about cancer and other medical conditions since 1998. Her first assignment involved creating content for the National Cancer Institute's patient-focused web site on clinical trials--and she was hooked. Since then, she has worked on projects for several cancer centers, educational web sites, and advocacy and professional groups, and she co-authored Ovarian Cancer: Your Guide to Taking Control (O'Reilly, 2003). Kris also works on marketing and development projects for hospitals and health systems, schools and universities, and nonprofit clients.

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