Breast Implants: Part 1, Getting Ready

Patient Expert

When you're having a mastectomy, one of the decisions you'll be asked to make is whether or not you want reconstruction. Many women choose reconstruction, rather than an external prosthesis (or nothing at all). And, for a variety of reasons, most women choose implant surgery - rather than the more complicated autologous (body tissue) reconstruction.

Once you decide to have reconstruction with implants, be prepared to make some decisions: there are two types of implants, and two ways of going about the process.

Implants: Saline vs. Silicone
Despite scares about safety (and a 14-year FDA ban of silicone implants, ending in 2006), there's been no reliable research showing that implants - silicone, or saline - cause immune system disease, or significantly increase cancer risk.

One recent study found that there's a very slight risk of anaplastic large cell lymphoma, an extremely rare cancer that attacks lymph nodes and skin, in women with implants - either saline, or silicone. But the number of cases have been so few, researchers are unable to establish with certainty that implants are the cause. Data will continue to be gathered; and women with implants are urged to contact their doctor if they experience pain or feel a lump around their implant.

So, which implant is best for you - saline, or silicone?

The advantage of a saline implant is that it's completely natural. If you're at all worried about having a "foreign substance" (silicone) in your body - for instance, if you have an autoimmune condition - saline might be your better choice.

In addition, a saline implant is more easily adjustable; it can be filled a bit or drained a bit to change the size/shape of your breast. With silicone, once the implant is inserted, its size can't be changed without removal/replacement surgery.

The advantage of silicone implants over saline is that they're softer, hang more naturally, and assume a more natural shape than saline.

The newest type of silicone implant, made of form-stable cohesive gel (a.k.a. "gummy bear implants") gained FDA approval in 2013. Made of a thicker, more solid silicone gel (thus the "gummy bear" comparison), these implants won't leak if ruptured. They also hold their shape better over time, and are less likely to sag, ripple, or shrink.

Surgery: direct vs. expander
There are two basic paths to reconstruction surgery:
-Direct to implant, which places the implant directly into the space left by your mastectomy; or
-Tissue expander, which places an expander behind your chest wall, which is filled over the course of several months to desired size; the expander is then removed and the implant put in place.

Direct to implant (or "one-step") surgery is a new procedure that bypasses the traditional use of expanders to create a pocket for the implant. Instead, the surgeon uses artificial skin (common names are AlloDerm ® or Stratticeâ„¢) to create the pocket.

This procedure is appropriate for women who haven't had radiation; and are of a reasonable breast/body size. Women with a body mass index over 30 aren't candidates for this surgery. In addition, women choosing this surgery should understand that they may need further surgery to improve the cosmetic result.

Right now, there aren't as many plastic surgeons able to perform this surgery as there are those qualified to perform the more traditional implant surgery; so you may not be able to find one near enough to your home to make the procedure worthwhile.

The tissue expander, a temporary device, is a flexible sac partially filled with saline solution and positioned under the chest muscle at the time of mastectomy. Once the mastectomy incisions have healed, the expander is gradually filled, over the course of several months, with saline solution, stretching the patient's skin to provide space for the final implant to rest comfortably. This process may take up to 6 months, depending on how much the patient's skin needs to be stretched to accommodate the size implant she'll receive.

As with direct to implant surgery, this procedure isn't recommended for women who've had radiation in the past; or those with a BMI greater than 30. In addition, it's not a good choice for women with advanced cancer.

Insurance coverage
One more thing you'll want to examine, before you start the process, is insurance coverage for reconstruction. While federal law is clear on insurance coverage of breast reconstruction after a mastectomy, it won't hurt to check with your particular insurance company, just to be sure.

The federal Women's Health and Cancer Rights Act of 1998 states "Under WHCRA, group health plans, insurance companies and health maintenance organizations (HMOs) offering mastectomy coverage must also provide coverage for reconstructive surgery in a manner determined in consultation with the attending physician and the patient.   Coverage includes reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, and prostheses and treatment of physical complications at all stages of the mastectomy, including lymphedemas."

Note that this law doesn't apply to Medicare or Medicaid. While implant surgery may be covered by these federal programs, it's not a given. So, whatever your insurance program - verify coverage before you start.

Next: Surgery

(This information was last updated on March. 31, 2014.)