BREAST IMPLANT-BASED RECONSTRUCTION AFTER MASTECTOMY:
Please scroll to the bottom and find your tissue expander information and dimensions and/or breast implant information so that you can be well-informed about your optionsllll
PLEASE READ THE FOLLOWING INFORMATION IF YOU HAVE QUESTIONS REGARDING BREAST IMPLANTS.
It is very important and even crucial that you discuss all of your concerns, hopes, desires and plans for your breast reconstruction outcome with your doctor. You have every right and every reason to want to get it right the first time and to know what your options are in this regard. Please let your doctor know that you are very interested in being a partner in the decisions he or she will make regarding your breast reconstruction journey.
This thread is essentially an informational link for those who are preparing to undergo mastectomy [unilateral or bilateral] with immediate reconstruction with two-stage tissue expander placement or have already undergone reconstruction and you are in the tissue expander fill phase of this process.
1. TISSUE EXPANDER - OVERFILLING AND REASONS FOR DOING SO:
Overfill is sometimes performed and it can be done so for a myriad of reasons. It can be done because a PS always does it in his practice [which makes no sense to me]; it can be done for assurance of good implant coverage with the skin flap; expanding out the skin a bit more so that a larger implant can be used, or in order to achieve ptosis [droop], especially in unilateral recon. It is not necessary in all cases to overfill and some docs never overfill, some rarely ever and some always do. But for those who are small-breasted prior to MX, it often is necessary, so that there is good skin closure, if a larger volume of implant is needed or if symmetry with the contralateral breast is required for ptosis and symmetry.
2. SILICONE VS. SALINE?
Please note that the question of whether you should have silicone vs. saline implants at the time of exchange is one which you can research on your own, and you can find various threads discussing the differences on bc.org. However, the overwhelming number of women on these forums now have silicone breast implants
Breast Implant Shapes and Styles:
There are many styles and shapes of implants. There are silicone round implants, which typically have three profiles used in breast reconstruction. A moderate plus profile, a high profile and a ultra full profile implant.
Round implants - the moderate plus/midrange profile, high profile and ultra full profile are the ones used for breast reconstruction. The moderate profile is rarely, if ever, used for breast reconstruction.
There are anatomical implants, which come in a variety of styles in Canada and Europe, but only offer three styles in the U.S. There are shaped implants, which are different than anatomically shaped implants.
Anatomical implants look like this:
Shaped implants: Sientra
Round implant on the left and shaped Sientra on the right:
ALLERGAN 410 - "GUMMY BEAR" IMPLANTS:
There are numerous threads here on bc.org which discuss the merits of these implants versus the standard silicone rounds. [We are happy to help with sizing in this regard as well, although please note that breast reconstruction experts state that the tissue expander should be chosen specifically for expanding and creating the breast pocket for the corresponding cohesive gel/gummy bear implant. Therefore, it is probably more uniquely important that you discuss with your PS where he/she intends to go in terms of implant size/projection at the time of exchange.]
MENTOR CPG IMPLANTS:
UPDATE: October, 2014: Mentor has just received FDA approval for four other styles of CPG anatomical implants. No data regarding the styles or volumes and dimensions is yet available for the US market. You can find Canadian and UK links with sizing information, if you want to research further. I am not going to comment on sizing or styles until more data is available in this regard. It could take months before the new styles are available to plastic surgeons. However, those surgeons who had Mentor CPG implants in clinical trials, will likely have access already or sooner than those who have not been in clinical trials with the devices. Plastic surgeons may be provided with style and sizing information fo the new CPGs, long before they receive the actual implants, so if you are considering anatomicals, please discuss this with your plastic surgeon.
IMPORTANT INFORMATION RE: ANATOMICAL AND SHAPED IMPLANTS
There are a plethora of plastic surgeons who are trigger happy about the anatomicals, because they were so long in achieving FDA approval. There was such a hoopla about them....and they were touted as being the end-all-be-all of breast implants. But the plastic surgeons who are most experienced about using them in clinical trials, KNOW that they are not a one-size-fits-all implant. There is a criteria to follow when using the anatomical implants. Grant Stevens, MD and Steven Teitlebaum, MD are the two principal Allergan 410 clinical trial docs, and they BOTH say that the dimensions of the pocket MUST be created specifically to match the dimensions of the anatomical implant.
"Anatomically shaped implants such as the gummy bear implant project more on the bottom than on top, mimicking the shape of a natural breast. If an anatomical implant rotates because the pocket holding it is too loose, it causes a distorted appearance that does not occur with round implants."
Dr. Stevens also advises against using anatomical implants when the patient has previously had round implants.
"The shaped form-stable gummy bear implants, such as the 410 and the CPG, are not ideal implants for women who have had previous breast surgery and have already pockets for those previous implants. Those women have pockets which are generally too large to safely accommodate the shaped form-stable implants. However, the Sientra form-stable silicone gel breast implants, which are round, can be safely placed in these patients."
According to Florida plastic surgeon, David Bogue, MD:
"Shaped implants require a form-fitting pocket to allow for adhesion of the implant to the pocket to prevent rotation. In a single stage reconstruction with acellular dermal matrix, this can be achieved because the capsule will form around the shaped implant. However, concern exists when using a tissue expander prior to exchange to a shaped implant. The capsule has already formed and there is no guarantee that adherence to the new implant will occur. The implant space should also be fairly tight around the shaped implant to help prevent rotation."
This is from Robert Cohen, MD - Arizona plastic surgeon:
"The concerns about anatomical implants rotating in the pocket are mostly due to surgeons that did not adhere to precise pocket dissection techniques. If the breast pocket is designed to the size of a textured anatomical implant, the risk of rotation is minimal. In a recent large study by Sientra of their anatomical implants, the rotation rate was 0%."
Another plastic surgeon, who has used the Allergan 410 in clinical trials, and knows the principals of "precise pocket preparation, writes as follows:
"Shaped implants require precision in pocket dissection and placement. If a round implant spins, it is still round. No change in breast shape will result. This is not true for a shaped implant. If the implant turns, the breast will change shape. If the surgeon makes a pocket larger than the implant, and places a round implant, the implant may shift or spin within the pocket. Not a problem, the breast won't change shape. If the surgeon creates a pocket larger than the implant and places an Allergan 410 implant (or a tear drop saline implant for that matter), the implant may shift or turn, changing breast shape. That is not good. So here, precise pocket dissection within less than a centimeter tolerance is important. The implant must fit easily but precisely into the pocket. This is not hard to do, if you know how and are experienced at atraumatic pocket dissection. I have been using an atraumatic techique to create the pocket since 2004, and have extensive experience with shaped saline implants. Placement is also an issue. I believe that shaped implants should have a slight tilt to them to achieve optimum aesthetic results, and this is based upon my experience with them. This is true whether a saline or silicone gel shaped implant. As sometimes I also lower the inframammary (breast crease) fold, properly setting the crease level is essential with the Allergan 410. So for me, from my first Allergan 410 implant case forward, working with a teardrop-shaped implant is nothing new to me. The surgical technique, simply put, must be more refined, meticulous and precise.
"I urge caution for everyone interested in cohesive gel implants and would not recommend them to a majority of my own patients for several reasons, chief among them being that in most breasts, smooth (round) silicone implants will produce a more naturally looking, feeling and moving result" says board certified plastic surgeon Dr. William F. DeLuca of DeLuca Plastic Surgery. “I also think it's important to understand that today's (round) silicone implants are backed up by over 30 years of clinical research, testing, innovation and real-world use."
WHAT TO DO IF AN ANATOMICAL IMPLANT ROTATES:
Switch to a round implant...per Steven Teitlebaum, MD, Chief Allergan 410 clinical trials plastic surgeon.
"These implants only come in anatomical shapes, meaning that they project more on the bottom than they do on the top. One of the risks of such a design is that if the implant rotates in the body, it will create a distortion. Care is taken during pocket dissection and insertion in order to minimize this. It is a very rare, but very possible complication. The only way to fix it if it occurs is to remove them and replace them with a round implant. Rotation is at greater risk when the tissue is loose, for instance in a revision when a patient wants to go smaller. But even with the additional risk of rotation which is not present with round implants, the total rate of reoperations are lower with these implants than with standard round gel implants. For many patients, however, the thought of a rotation is very unsettling and they choose against gummy bear implants."
Article provided by Dr Steven Teitelbaum, board certified plastic surgeon in Santa Monica California.
3. IMPLANT SIZING INFORMATION:
If you are interested in discussing implant sizes, make sure you compile and provide us with the following information:
Height, weight, ribcage measurement [measuring the circumference of your ribcage under your tissue expander(s) or under your bra line]. Also, if you have TEs [tissue expanders] - we need to know about them. The style - Mentor or Allergan most likely - and whether they are short height, moderate height, full height if Mentor and style number if Allergan. We also need the recommended fill volume of the TEs - the number of cc's. (NOTE: If you have PMT Corporation tissue expanders or any other unlisted manufacturer, please see if your PS will provide you with the dimensions of such devices.]
4. "WHAT CUP SIZE WILL I BE?" OR "WHAT SIZE IMPLANT DO I NEED FOR A "C" CUP?"
I CANNOT PREDICT CUP SIZE. PLASTIC SURGEONS ADMIT THAT THEY CANNOT PREDICT CUP SIZE WITH ACCURACY!
It is very difficult to determine cup size with breast reconstruction patients, as volume does not easily translate to a specific bra size. There are so many factors which determine how implants will look on any one individual, e.g., your ribcage circumference, whether your chest wall is bony or if you have a fair amount of adipose tissue surrounding the chest wall.... if you have any ribcage deformities or other structural issues which might impact implant placement. We can sort of "project" where you might want to be...or estimate the implant volume which you could "aim" for - so that you can sort of look at the prize ahead of you. Most of us have found though, that it is better to continue with tissue expansion until you have reached a desired volume and appearance, and then compare these dimensions with the breast implant dimensions found on the links at the top of the Exchange City thread in the Breast Reconstruction forum.
5. BREAST IMPLANT SIZING IS SPECIFIC TO YOUR VITAL STATISTICS
Implants of a specific volume will look different on A 5'10" 176 pound woman with a 35 inch ribcage, than they will someone who is 5'3" tall, weighs 110 pounds and has a 29 inch ribcage. So height, weight, ribcage circumference, body habitus - all of these things come into play when determining what style and volume of implant will best fit someone's frame.
6. UNILATERAL MASTECTOMY/ SINGLE MASTECTOMY
If you are a unilateral MX, symmetry issues come into play and this determines the style and volume of implant selected. The focus is on attempting to match the appearance of the native breast. It is impossible to calculate the size of implant needed with a unilateral reconstruction, without knowing the SIZE of the native breast, whether that native breast is ptotic (droopy), whether it will undergo a lift and/or an augmentation. The key is for the PS to select a TE which will enable him/her to expand that MX side sufficiently to provide enough of a skin envelope to use an implant which will match, as closely as possible, the native breast. In this case, the physician may bring a number of implant sizes and styles into the OR at the time of exchange, in order to find the best fit possible to match that native breast.
QUESTIONS FOR YOUR PLASTIC SURGEON:
In the interim, here are very important questions to pose to your plastic surgeon. Ask your PS if he/she tends to place you in an implant with a volume larger than the TEs, or if he/she prefers to place you in an implant smaller than the TEs. If your PS likes to overexpand - overfill - ask about this. It is important to know what is in your PS' mind about where he intends to go with your reconstruction, because this will assist us in calculating to what extent you require expansion in order to exchange to the desired implant size and dimensions.
Based on everything I have read in my four years of researching breast reconstruction, the tissue expanders SHOULD be placed by the PS with the foreknowledge of the approximate size and style of implant he/she intends to use for you down the road. It should not be "let's just throw this tissue expander on her and see where it takes us." The WIDTH of the tissue expander is a very important consideration. Proper placement of the tissue expanders is a very important consideration. Please discuss these issues with your PS.
TE and Breast Implant Data: We should be given a little plastic credit card with information regarding our TEs and our breast implants after surgery. ASK FOR YOUR CARD! These are registered medical devices and the manufacturer intends that patients have access to this information. Make sure that you ask your physician's office for this information and retain it in your medical files.
It should be stated that a great deal of other criteria goes into implant selection. Also of importance: Your torso [short or long], any potential ribcage or chest wall deformities or issues [e.g. pectus excavatum, pectus carinatum], and how much tissue you have overlying the chest wall.
AFTER THE EXCHANGE:
Just remember that just after the exchange, the implants can look misshapen and flattened out and sometimes downright bizarre! You need to give it two weeks - sometimes much longer. DON'T OBSESS ABOUT THE SIZE OR SHAPE RIGHT AFTER THE EXCHANGE! STEP AWAY FROM THE MIRROR!
EMOTIONAL ISSUES AFTER THE EXCHANGE:
Many of us and I mean MANY of us go through a period of sadness and depression after the exchange. It is an emotional journey we have been on since diagnosis and we suddenly seem to start experiencing all of the emotions we have placed on hold throughout the mastectomy and TE expansion process. So just rest in knowing that we have been there and we know what you are going through right now. Try to avoid obsessing over the appearance of your new breasts. Feel free to ask any questions or voice your concerns, but it is quite normal as this point in your journey.
There are other women throughout the bc.org family who also have important information to share and we hope they add their thoughts to this thread so that your breast reconstruction journey is made easier and also so that you feel empowered about this aspect of your breast cancer recovery!
TISSUE EXPANDER AND BREAST IMPLANT CATALOGUE LINKS:
CATALOGUE FOR CANADIAN AND EUROPEAN PATIENTS
MENTOR - CLICK ON IMPLANTS OR TISSUE EXPANDERS
SSP - Specialty Surgical Products/DERMASPAN TES: (Dual chamber tissue expanders allowing the surgeon to control upper pole and lower pole expansion. A unique tool for expanding the lower pole, where projection naturally occurs in the native breast and an often difficult challenge for expansion after breast reconstruction.)
QUICK LINKS - IMPLANTS ONLY
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