Breast Cancer : Simple Implant Placement, Latissimus Dorsi, Rectus Abdominus

by Food and Drug Administration (FDA)

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"Simple" Implant Placement

This operation takes one to two hours. It is usually done under general anesthesia, but local anesthesia is sometimes used and it can be done as outpatient surgery. A small incision is made along the lower portion of the breast near the mastectomy scar, and the implant is inserted in the pocket created under the chest muscle. A drain may be inserted temporarily to remove excess fluid. If the surgeon is able to make the reconstruction incision in the original mastectomy scar, there will be no additional scarring. In fact, the appearance of the mastectomy scar can be improved, but not eliminated, during this operation.

Silicone breast implants have been in use since the 1960s. As of 1989, about 2 million women have had them implanted — about one-fourth for reconstruction after mastectomy. (The rest have been for cosmetic surgery to augment or change the shape of the woman's natural breast.)

Many women have been highly satisfied with the appearance, size, and softness of their reconstructed breasts and have reported a number of psychological benefits. Some women, however, have had problems with the implants, prompting concern about their safety.

The most common problem associated with breast implants is capsular contracture. This occurs when scar tissue shrinks around the implant, making it feel hard and sometimes misshaping it. Other known health risks include false mammography results, infection, silicone leakage and migration to other parts of the body, and implant rupture. There have also been questions raised about the possibility of long-term risks that may include some immune reactions and carcinogenicity (ability to cause cancer). Experts are divided on these questions.

Silicone gel implants have been marketed under a "grandfather" clause in the Medical Device Amendments of 1976, which exempted them from standard pre-market approval. Because of the safety issues, FDA in June 1988 classified the implants into Class III — giving the agency authority to request safety and effectiveness data after 30 months. In April 1991, FDA published a final regulation requiring submission of the data.

The agency has received 1,200 comments about the benefits and risks of the devices and, although the comments varied, a significant number of women proposed that the implants remain available as long as consumers are fully informed of the potential risks.

Women who are considering breast reconstruction with silicone gel implants should discuss any concerns they may have with their plastic surgeons and possibly other health professionals, consumer groups, and women who have had the surgery. They can also ask the plastic surgeon for the printed information that comes in the implant package.

Latissimus Dorsi

"Latissimus dorsi" reconstruction gets its name from the broad flat back muscle that the surgeon moves to the chest to take the place of muscles that have been removed during the mastectomy. The surgeon also transfers skin and other tissue from the patient's back to the mastectomy site. An implant is then placed under the new muscle, and drains may be inserted temporarily. This operation takes longer and requires longer hospitalization than simple reconstruction. It leaves a scar on the back in addition to the mastectomy scar on the chest.

Rectus Abdominus

In this procedure, the surgeon transfers one of the two rectus abdominus muscles (the parallel vertical abdominal muscles) to the breast area, along with skin and fat from the abdomen. The surgeon shapes this flap of muscle, skin and fat into the contour of a breast. If there is enough abdominal tissue available, no implant is needed. One of the "side effects" of this procedure, which some might consider a benefit, is a tightening of the stomach, colloquially called a "tummy tuck." This procedure leaves a horizontal scar across the lower abdomen in addition to the mastectomy scar.

Nipple and Areola Construction

Breast reconstruction fashions the shape of the breast but does not always include a reconstructed nipple and areola (the dark skin around the nipple). Some women, who wish primarily to improve their appearance in clothing, choose not to have the additional one- to two-hour operation to reconstruct the nipple and areola. During this operation, the areola is most commonly fabricated from skin on the upper thigh or from behind the ear, and the nipple is created either from tissue from the newly created breast mound or from the other nipple. Skin from the vaginal lips can also be used to reconstruct the nipple and areola. If the reconstructed areola is not dark enough, ultraviolet light can be use to darken the skin.

Although breast reconstruction offers a more normal appearance both in and out of clothes, women should be aware that if there are scars from these operations they are permanent and that reconstruction does not restore lost sensation.

About the Author

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FDA is A United States government body that oversees medical devices, including contact lenses, intraocular lenses, excimer lasers and eyedrops. In the US, these products must be approved by the FDA before they can be marketed.