Synopsis
Assess when implant reconstruction can provide a suitable breast mound, distinguish direct and staged approaches, and recognise the tissue, radiotherapy and device issues that alter the plan.
- Implant reconstruction requires adequate, viable soft-tissue cover. A direct-to-implant operation places the intended implant at mastectomy; an expander pathway creates or adjusts the envelope in stages before the definitive result is established.
- Prepectoral implants lie above pectoralis major; subpectoral approaches use muscle cover. Acellular dermal matrices or other support may assist selected techniques, but they do not supply a new blood circulation to ischaemic mastectomy skin.
- Increasing pain, spreading erythema, wound separation, threatened skin or an exposed implant requires prompt surgical assessment. Systemic illness demands emergency care; changing expansion volume or giving reassurance cannot replace assessment of infection and tissue viability.
Key red flags
Review pain, redness, warmth, swelling, wound discharge, separation and skin discolouration with observations and the person's general condition. These findings can reflect infection, a collection, bleeding or threatened tissue. Early contact with the operating service is important because worsening cover can endanger the implant as well as the overlying skin.
Investigation priorities
Match the proposed implant volume and cover to skin quality, mastectomy requirements and the patient's goals.
Management branches
A patient chooses implant reconstruction, but the surgeon considers the desired final volume unsuitable for immediate placement within the available, viable mastectomy envelope.
- Before surgery, she compares an expander pathway with a smaller immediate result and autologous alternatives. She prefers to avoid a distant donor site and accepts repeat visits and possible exchange surgery. The team documents the permitted change in technique if the skin assessment is less favourable than expected.
- The mastectomy skin is assessed as viable, and an expander is placed at a volume appropriate to the tissues in this illustrative operation. The wound is closed without attempting the full desired breast volume. The patient receives clear contact instructions for worsening pain, swelling, redness or skin breakdown.