Types of Tissue Expander and Implants Used in Breast Reconstruction
By: Dr. Minas Chrysopoulo
The most common method of breast reconstruction performed uses tissue expanders and breast implants. In most cases, the reconstruction is performed in stages starting with a tissue expander which is later exchanged for the final implant. Here is an overview of the types of tissue expanders and implants used in breast reconstruction today. Some of these products may not be available in all countries.
Saline expanders are by far the most common type of expander currently used. They can be placed at the same time as the mastectomy or any time later. When placed at the same time as the mastectomy, they are usually partially filled at the time of surgery. Further expansion is performed by the surgeon during several office visits once the patient has healed from surgery. The saline is injected into the expander fill-port through the skin using a syringe.
The AeroForm Tissue Expander uses carbon dioxide which is released in controlled, small amounts from a cartridge inside the expander. The expansion process is controlled by a hand held remote and can be performed at home by the patient by pressing a single-touch button. This expander has just been approved for use in the US by the FDA.
BRAVA External Expander
BRAVA is an external bra-like suction device. The device works by applying negative external pressure to expand the underlying tissue, creating more space for subsequent fat grafting. Recommended use can vary significantly between surgeons but the device is typically worn for 12 hours daily for several weeks before the first session, again between fat grafting procedures and sometimes also after the last fat grafting session. The BRAVA/fat grafting technique avoids the use of implants and tissue flaps but requires multiple procedures to achieve a satisfactory final breast volume in most patients.
Saline Breast Implants
A saline breast implant consists of a silicone shell filled with sterile saline solution (salt water). The implant is inserted into the breast and filled to the desired size during the surgery.
Saline implants can be associated with rippling (waves in the implant shell) which can be visible through the skin. To decrease the appearance of rippling, many surgeons will overfill saline implants, which also makes them more firm to the touch.
If a saline implant leaks, the implant will collapse and the breast will “deflate”. The saline is simply absorbed by the body. Ruptured implants cannot be repaired and need to be replaced.
Silicone Breast Implants
A silicone breast implant consists of a silicone shell pre-filled with silicone gel. Silicone implants typically feel softer and more like natural breast tissue compared to saline implants.
The consistency of the gel inside the implants varies. Traditional silicone implants use a soft gel. Soft gel implants feel more like typical breast tissue but have more rippling. More cohesive (thicker) silicone implants feel more firm but ripple less. Since breast reconstruction patients typically have little soft tissue “padding” to camouflage the implant after a mastectomy, implant rippling is a more frequent problem in reconstructive patients than in cosmetic augmentation patients who still have their breast tissue. Many breast reconstruction surgeons therefore prefer to use highly cohesive implants to minimize the risk of visible rippling as much as possible. Highly cohesive implants are also known as “form-stable” or “gummy bear” implants.
If a silicone implant ruptures, the gel may remain within the implant shell, or may escape into the breast implant pocket. Form-stable implants maintain their shape even when the shell is broken. A leaking silicone implant will not usually collapse like a leaking saline implant so some ruptures will initially go unnoticed. Routine screening with ultrasound or MRI is therefore recommended for patients with silicone implants to monitor implant integrity. It is important to discuss this with your plastic surgeon.
Adjustable Breast Implants
Adjustable breast implants are just that - adjustable. Saline can be added to these implants post-operatively by the surgeon to adjust the size. This can provide more control over the final size. Most types of adjustable implants are filled with saline only, others have two lumens (compartments) containing silicone gel in the outer lumen, and saline in the inner lumen.
Round Breast Implants
Round breast implants are just that—round. Because of their uniform shape, there is little worry about the implant rotating out of place and causing an abnormal “shifted” appearance. Round implants can have either smooth or textured surfaces and are available in various projections or profiles. The profile of an implant is the distance an implant projects (sticks out) from the chest. Low profile implants are flatter and wider and project the least. Higher profile implants are more spherical and narrower and project the most.
Teardrop (“Anatomic”) Breast Implants
Teardrop breast implants are more anatomically correct. The implant projection is greater at the bottom and tapered at the top to mirror the natural breast shape. These implants are filled with highly cohesive silicone which helps them maintain their shape. Anatomic implants can sometimes shift position and create an obvious breast deformity. All anatomic implants therefore have textured surfaces to encourage soft scar tissue formation and make them less likely to rotate out of position.
Smooth Breast Implants
Smooth breast implants have a smooth outer shell allowing the implant to move more naturally within the implant pocket.
Textured Breast Implants
Textured breast implants have a coarse, rough outer lining. Textured surfaces act a little like “Velcro” and decrease implant movement within the breast by encouraging soft scar tissue formation around the implant shell. Texturing also decreases the risk of a tight scar capsule forming around the implant (known as “capsular contracture”).
Your surgeon’s personal preferences and experience with each type of implant will also factor into the best decision for you. Experienced surgeons know what can be achieved “in their hands” and often this will include a specific style of implant. This should always be part of an honest discussion to ensure appropriate expectations are met. Full discussion of the associated risks is also crucial, as with any procedure.