Editing Breast reconstruction (section)

=== Implant-based reconstruction ===
This is the most common technique used worldwide.  Implant-based reconstruction is an option for patients who have sufficient skin after mastectomy to cover a prosthetic implant and allow for a natural shape.  For women undergoing bilateral mastectomies, implants provide the greatest opportunity for symmetrical shape and lift.  Additionally, these procedures are generally much faster than flap-based reconstruction since tissue does not have to be taken from another part of the patient's body.<ref name=":2">{{Cite book|title=Sabiston textbook of surgery : the biological basis of modern surgical practice| vauthors = Townsend Jr CM, Beauchamp RD, Evers BM, Mattox KL |year=2017|isbn=978-0-323-29987-9|edition=20th|location=Philadelphia, PA|pages=865–877|oclc=921338900}}</ref>

Implant-based reconstruction may be one- or two-staged.<ref>{{cite journal | vauthors = Lee KT, Mun GH | title = Comparison of one-stage vs two-stage prosthesis-based breast reconstruction: a systematic review and meta-analysis | journal = American Journal of Surgery | volume = 212 | issue = 2 | pages = 336–344 | date = August 2016 | pmid = 26499053 | doi = 10.1016/j.amjsurg.2015.07.015 }}</ref> In one-stage reconstruction, a permanent implant is inserted at the time of mastectomy. During two-stage reconstruction, the surgeon will insert a [[tissue expansion|tissue expander]] underneath the pectoralis major muscle of the chest wall at the time of mastectomy.<ref>{{cite journal | vauthors = Mannu GS, Navi A, Hussien M | title = Sentinel lymph node biopsy before mastectomy and immediate breast reconstruction does not significantly delay surgery in early breast cancer | journal = ANZ Journal of Surgery | volume = 85 | issue = 6 | pages = 438–443 | date = June 2015 | pmid = 24754896 | doi = 10.1111/ans.12603 | s2cid = 33670281 }}</ref><ref>{{cite journal | vauthors = Mannu GS, Navi A, Morgan A, Mirza SM, Down SK, Farooq N, Burger A, Hussien MI | display-authors = 6 | title = Sentinel lymph node biopsy before mastectomy and immediate breast reconstruction may predict post-mastectomy radiotherapy, reduce delayed complications and improve the choice of reconstruction | journal = International Journal of Surgery | volume = 10 | issue = 5 | pages = 259–264 | year = 2012 | pmid = 22525383 | doi = 10.1016/j.ijsu.2012.04.010 | doi-access = free }}</ref>  This temporary [[silastic]] implant is used to hold tension on the mastectomy flaps.  In doing so, the tissue expander prevents the breast tissue from contracting and allows for use of a larger implant later on compared to what would be safe at the time of the mastectomy.<ref name=":2" />  Following this initial procedure, the patient must return to the clinic on multiple occasions for saline to be injected into a tube inside the tissue expander.  By doing this slowly over the course of several weeks, the space beneath the pectoralis major muscle is safely expanded to an appropriate size without causing too much stress on the breast tissue.  A second procedure is then necessary to remove the tissue expander and replace it with the final, permanent prosthetic implant.<ref>{{Cite web|url=http://www.hopkinsmedicine.org/breast_center/treatments_services/reconstructive_breast_surgery/tissue_expanders.html|title=Tissue Expanders|website=hopkinsmedicine.org}}</ref>

[[File:Blausen 0139 BreastReconstruction Prosthesis.png|thumb|A permanent prosthetic implant eventually replaces the tissue expander.]]Although in the past, prosthetic implants were placed directly under the skin, this method has fallen out of favor because of the greater risk of complications, including visible rippling of the implant and capsular contracture.<ref name=":2" />  The sub-pectoral technique described above is now preferred because it provides an additional muscular layer between the skin and the implant, decreasing the risk of visible deformity.<ref name=":2" />  Oftentimes, however, the pectoralis major muscle is not sufficiently large enough to cover the inferior portion of the prosthetic implant.  If this is the case, one option is to use an acellular dermal matrix to cover the exposed portion of the prosthetic implant, improving both functional and aesthetic outcomes.<ref>{{cite journal | vauthors = Breuing KH, Warren SM | title = Immediate bilateral breast reconstruction with implants and inferolateral AlloDerm slings | journal = Annals of Plastic Surgery | volume = 55 | issue = 3 | pages = 232–239 | date = September 2005 | pmid = 16106158 | doi = 10.1097/01.sap.0000168527.52472.3c | s2cid = 45415084 }}</ref><ref>{{cite journal | vauthors = Salzberg CA | title = Nonexpansive immediate breast reconstruction using human acellular tissue matrix graft (AlloDerm) | journal = Annals of Plastic Surgery | volume = 57 | issue = 1 | pages = 1–5 | date = July 2006 | pmid = 16799299 | doi = 10.1097/01.sap.0000214873.13102.9f | s2cid = 23011518 }}</ref> This prepectoral space has recently, however, come back into practice, with comparable rates of post-operative complications and implant loss to submuscular placement.<ref>{{cite journal | vauthors = Li Y, Xu G, Yu N, Huang J, Long X | title = Prepectoral Versus Subpectoral Implant-Based Breast Reconstruction: A Meta-analysis | language = en-US | journal = Annals of Plastic Surgery | volume = 85 | issue = 4 | pages = 437–447 | date = October 2020 | pmid = 31913902 | doi = 10.1097/SAP.0000000000002190 | s2cid = 210121034 }}</ref><ref>{{cite journal | vauthors = Safran T, Al-Halabi B, Dionisopoulos T | title = Prepectoral Breast Reconstruction: A Growth Story | language = en-US | journal = Plastic and Reconstructive Surgery | volume = 144 | issue = 3 | pages = 525e–527e | date = September 2019 | pmid = 31461069 | doi = 10.1097/PRS.0000000000005924 | doi-access = free }}</ref> Both delayed and direct-to-implant reconstruction in this plane has been shown to be favourable.<ref>{{cite journal | vauthors = Safran T, Al-Halabi B, Viezel-Mathieu A, Boileau JF, Dionisopoulos T | title = Direct-to-Implant, Prepectoral Breast Reconstruction: A Single-Surgeon Experience with 201 Consecutive Patients | language = en-US | journal = Plastic and Reconstructive Surgery | volume = 145 | issue = 4 | pages = 686e–696e | date = April 2020 | pmid = 32221195 | doi = 10.1097/PRS.0000000000006654 | s2cid = 214695100 }}</ref>

Of note, a [[Cochrane review]] published in 2016 concluded that implants for use in breast reconstructive surgery have not been adequately studied in good quality clinical trials. "These days - even after a few million women have had breasts reconstructed – surgeons cannot inform women about the risks and complications of different implant-based breast reconstructive options on the basis of results derived from [[Randomized Controlled Trial]]s."<ref>{{cite journal | vauthors = Rocco N, Rispoli C, Moja L, Amato B, Iannone L, Testa S, Spano A, Catanuto G, Accurso A, Nava MB | display-authors = 6 | title = Different types of implants for reconstructive breast surgery | journal = The Cochrane Database of Systematic Reviews | volume = 2016 | issue = 5 | pages = CD010895 | date = May 2016 | pmid = 27182693 | pmc = 7433293 | doi = 10.1002/14651858.CD010895.pub2 | hdl-access = free | hdl = 2434/442804 }}</ref><ref>{{cite journal | vauthors = Potter S, Conroy EJ, Williamson PR, Thrush S, Whisker LJ, Skillman JM, Barnes NL, Cutress RI, Teasdale EM, Mills N, Mylvaganam S, Branford OA, McEvoy K, Jain A, Gardiner MD, Blazeby JM, Holcombe C | display-authors = 6 | title = The iBRA (implant breast reconstruction evaluation) study: protocol for a prospective multi-centre cohort study to inform the feasibility, design and conduct of a pragmatic randomised clinical trial comparing new techniques of implant-based breast reconstruction | journal = Pilot and Feasibility Studies | volume = 2 | pages = 41 | date = 2016-08-04 | pmid = 27965859 | pmc = 5154059 | doi = 10.1186/s40814-016-0085-8 | doi-access = free }}</ref>