Synthetic implants are usually teardrop-shaped pouches that are placed under a layer of chest muscle to create the shape of a breast. The outside of the implant is made of silicone and it is filled with silicone gel or saline. Saline is another word for salt water. Silicone is an artificial material that feels like natural breast tissue.

The process of breast reconstruction using implants may involve one or two stages, often depending on the individual patient's breast size. For smaller breasted women, a single stage reconstruction may be possible. With this approach, the plastic surgeon places the silicone gel or saline implant in a pocket beneath the skin and muscle layers, at the location of the new breast. This surgery is usually performed through the old mastectomy scar.

Most commonly, implant breast reconstruction is carried out in two stages. The first stage consists of placement of a device called a " tissue expander." An expander is a silicone-walled pouch that resembles an empty balloon with a small valve in its front wall. This valve allows the surgeon to fill the implant with saline in the weeks following this initial operation. During the second stage, the tissue expander is replaced with an implant.

During the first surgery, the tissue expander is placed in a pocket beneath a chest muscle (the pectoralis major) and the overlying skin. The tissue expander must be used to enlarge the implant pocket to accommodate the size of the implant needed to match the opposite breast. This initial surgery takes approximately one to two hours.

At the end of the surgery, the side of the chest undergoing reconstruction will still be flat. Depending on your doctor's recommendations, this procedure can be performed on an outpatient basis or may require a hospital stay of one to two days.

Approximately 10 to 21 days following placement of the tissue expander, the process of tissue expansion will begin. Every one to two weeks, you will visit your plastic surgeon. During these 20- to 30-minute visits, approximately two to four ounces of saline (salt water) will be injected through the overlying skin into the valve located on the front wall of the tissue expander.

With each visit, the tissue expander is gradually inflated. The growing tissue expander enlarges the pocket, inducing growth of the overlying skin. In essence, this tissue expander grows the skin for the new breast. While the expansion process causes slight soreness or discomfort in some women, others report simply a feeling of "tightness" for several days following each expansion.

Approximately one to three months after the tissue expander has reached the correct size, you will undergo a second operation. During this surgery, the expander is removed and an implant is inserted in its place. The surgery lasts about one to two hours and is followed by a hospital stay of four to 24 hours.

This is done in a single operation that takes about one to two hours. Since a small implant is used, the surgeon may be able to insert it without additional operations to stretch the skin and muscles of the chest wall. The implant is placed under a layer of muscle, rather than directly under the skin, to ensure the most natural shape and feel of the reconstructed breast. This also helps to reduce formation of scar tissue around the implant.

In some smaller-breasted women, an implant may be placed in a space directly under a layer of chest muscle.

MY IMPLANT: ONE WOMAN'S STORY

"I had the implant. Every week I went in and they inserted more saline. Then once it got up to size, then I had the surgery to have the implant put in. But they had to custom make the implant. They did not have one on the shelf that was, it only went up to like a B+, and I'm a D. I had the choice of having that done or having the other breast augmented. And I chose not to do that; there was nothing wrong with the other one, it was clean, and I just didn't want to mess with it. I chose to have an implant because I have adhesive sensitivity. I broke out in blisters from the adhesive [from the temporary prosthesis] when I was first going through the [mastectomy]. So I did not want to attempt it. And because of being large-breasted, I was having problems with my shoulder coming in, because there was nothing there to support. So my husband and I discussed it and I said I wanted to go through the reconstruction. [I decided I did not want to have a TRAM because] I had been through a biopsy, lumpectomy, then two weeks later a mastectomy, and so I had had like two months of nothing but getting over surgery. [A TRAM is] like two major surgeries at once and it was going to be almost a week in the hospital and everything, and I had been through so many surgeries already that I just didn't want to do that. So I went for the implant. And then I also had the nipple reconstruction.

It was worth going through the little bit of pain that I had. Going through the tissue expansion was not as bad as what I thought. And once the [implant] was in, I had about a week of discomfort, and I found that I could not lay flat on my back for a couple of nights, because of the weight would push to one side or the other, and I would be in a lot of pain. Having the expander in there was not like having the actual [implant]. You knew exactly where the fill valve was, and in me, it moved around. So it sometimes was at one side or the other. And it could get uncomfortable if it got in the wrong position. But I was able to manipulate it so that I would be comfortable again.

It came out very good. For having an [implant] in there, it not being a TRAM flap, and [for] the size that I am, I really got very good results. [If I had it to do over again], I might have them make it just a little smaller. Because the one thing that you have to think about is that if somewhere down the line you lose weight, one place that you lose weight is your breasts. I lose weight in the other one, but I don't lose weight in that one. It doesn't change. Somewhere down the line if I lost more weight, then I would have to pad the other side to match. [What's my advice to other women considering breast reconstruction?] Investigate it, and be sure that you get an experienced surgeon, one that has done a lot of breast reconstructions. Don't just go to any plastic surgeon.

I would have reconstruction again. It's more comfortable. I have a cleavage. When I bend over, it looks very normal, you can't tell anything. When I had to wear a prosthesis in there, I never wore anything that had a V-neck or a round neck, that if I did happen to bend over, and somebody happened to look, they would see my prosthesis. I always wore very high-necked type things. I wear looser clothes now. I don't wear anything really tight, because if I did, then yes, it would be noticeable, because it is flatter than what a normal breast is, even with the nipple reconstruction. But otherwise, I would have it done again, no question.

People that meet me today would have no idea that I have ever had breast cancer or reconstruction. The only ones that see the scar are me and my husband, and the doctor. It's under your clothes. And the scars do lighten over time. So I have been very satisfied with it. It's just much more natural. And I don't have to worry about fitting the prosthesis in and adjusting it and everything. It's there, it's part of me now."