The reconstructive technique will be largely dependent on the amount of tissue left behind after the mastectomy. If there is sufficient skin, subcutaneous tissue, and the nipple areolar complex is intact, it may be possible to place a silicone gel implant in the pocket, often times above the muscle; however, placement beneath the muscle is necessary. In these instances, the muscle has to be released in order to create a larger submuscular space. After releasing the muscle the space can be filled in with acellular dermal graft, or more recently we have been using a synthetic mesh with equally good results.
It is usually advantageous to place an adjustable implant immediately after the mastectomy as the circulation to the skin flaps are often compromised. By placing the implant underfilled, tension on the incision and pressure on the compromised skin flaps is avoided. The implant can be filled a few days later once circulation is re-established, by injecting saline into the detachable injection dome. The expansion process usually takes a few weeks and once the satisfactory size and shape has been reached the injection dome is removed. Sometimes the adjustable implant is over expanded in order to stretch the tissues and create an improved shape. The injection port is then removed under local anesthetic.
If the nipple areolar complex was saved at the time of the subcutaneous mastectomy, no further surgery is usually necessary. If the nipple has been removed, the nipple is reconstructed by using the saved areolar skin. The saved areolar skin is fashioned into the shape of the nipple and the areola is reconstructed with a tattoo. If the nipple areolar complex has been totally removed, then the nipple areolar complex is reconstructed by tattooing the areola and then using either a local flap or a skin graft to create projection for the nipple. Fat injections may also be used to increase the projection in this area.
In patients who have large breasts or sagging breasts, the subcutaneous mastectomy may be combined with a breast reduction type procedure or a breast lift procedure. In these cases, there will be a scar around the areola known as a circumareolar lift or a vertical scar known as a vertical lift. Occasionally a free nipple graft will be performed and a scar is usually then made in the breast fold and the nipple graft sutured back into position.