Breast reconstruction with implants was first described in the 1960s. It was initially a single staged placement of implant alone. It has now evolved into tissue expansion over several weeks to months with ultimately an exchange of the tissue expander for the permanent implant. They are common options for patients undergoing mastectomy because of the uncomplicated nature of the procedure which adds little extra time to the initial mastectomy. Patients can choose to have the expanders placed during the initial mastectomy or have the procedure as a delayed repair.
Pertinent anatomy for the reconstruction is similar to that of the breast surgery itself. The position of the inferior mammary fold (IMF) is of critical importance to the reconstructive surgeon as it is a reliable landmark for how far to extend the envelope. Over dissection medially in the area of the sternum can cause symmastia.
Most patients are candidates for expanders and implants. The ideal candidate is a thin female undergoing bilateral mastectomy or a thin female undergoing unilateral mastectomy with little to no ptosis on the remaining breast. This is simply for the benefit of symmetry. Obese patients and patients with very large contralateral breasts may complicate the results of the expander and implant. The expansion process may fail to obtain symmetry of the new breast pocket. The patient can undergo the procedure immediately following the mastectomy or in a delayed setting. The benefit of the immediate expansion is that the patient is undergoing two procedures but only one anesthesia administration. Also during immediate reconstruction, the plastic surgeon and breast surgeon can decide on the best technique to save as much of a skin envelope as possible. 
With the increased use of radiation, careful patient selection for reconstruction needs to be undertaken. Placement of a tissue expander in patients who are undergoing concurrent radiation may fail to expand, have poor wound healing and have poor projection. Complication rates can be as high as 60% for tissue expanders are radiation.
Patients who are active smokers are at high risk of infection and poor wound healing. These patients need to undergo counseling for smoking cessation.
Many surgeons will have multiple shapes and sizes of implants available while performing the surgery. The final decision as to which implant to use may be based on the pocket that is achieved during the dissection. Lighted retractors may add a benefit during dissection of tight post-pectoral pockets.
The surgeon may benefit from assistance during the procedure, but this is up to the discretion of the surgeon.
Patients should be educated on all their reconstructive options during their initial consultations. Many patients may even need to directed to survivorship group therapies prior to their procedure to gain insight on what to expect postoperatively.
Antibiotics should be given during the immediate preoperative period to decrease the risk of contamination of the skin flora into the wound.
The technique to create the submuscular pocket for expansion is similar regardless if the procedure is primary or delayed. If performed during the initial mastectomy, the skin flaps are used to access the inferior-lateral border of the pectoralis major. Taking care to keep the inferior mammary fold intact, the surgeon dissects the pectoralis major muscle away from the chest wall maintaining its attachments to the lateral sternal border. Many surgeons will augment the subpectoral pocket with the use of an acellular dermal matrix such as Alloderm. This may aid in the speed of expansion and decreased pain, but this is based on anecdotal information. A tissue expander is then placed into this subpectoral space, and the defect is closed. These expanders have a port on the anterior side which is easily accessed in the clinic. A drain is then placed in the mastectomy pocket, and the skin closed. Tissue expansion occurs over weeks to months after the initial procedure with the intention to over-expand an envelope of tissue that will comfortably accommodate an implant. In the clinic setting, a magnetic marker is used to identify the subcutaneous port. Under sterile conditions, the tissue is expanded with saline. The patient is usually instructed to take over the counter NSAIDs to treat the pain associated with the expansion. Expansion may concurrently occur while the patient is undergoing chemotherapy; however, the patient should wait until their white blood cell count has normalized to undergo their exchange to a permanent implant. Once tissue expansion is complete, the tissue expander is planned to be exchanged for a permanent implant. A thorough discussion with the patient is imperative to discuss their different options regarding what type of implant is best for them. 
Many different implants are available through the market. The implants are either smooth or textured, silicone gel or saline, and round or anatomically shaped. The benefits and risks of each should be discussed before proceeding. This portion of the procedure is straightforward; the previous incision is used to access the tissue expander, which is removed. If capsular contractures are present, a capsulectomy or capsulotomy can be performed at this time in order to achieve optimal symmetry. A disposable sizer may be used in order to identify the correct implant and achieve optimal base height, projection, and size. The implant of choice is carefully inserted into the pocket at this time taking care not contaminate it, and the pocket is closed. Further detailing such as moving the inferior mammary fold, fat grafting, or even contralateral mastopexy/mammoplasty can be performed at this time to obtain symmetry between the breasts.
Implants do not increase the incidence of breast cancer. They are radiopaque which can cause difficulty on mammogram, therefore, additional views are necessary. It may be necessary to follow the patient with other studies such as sonography and MRI.
Postoperative instructions and care are a vital resource to the patient. Patients should be instructed to avoid wearing bras with an underwire. Many surgeons will use surgical bras postoperatively to hold dressings in place and may augment this with a binding implant stabilizer to aid the position of the implant. Oral antibiotics are used at the discretion of the surgeon.
Complications of tissue expanders and implants are similar to those of cosmetic implants. Care must be taken intraoperatively to achieve hemostasis. Hematomas have high rates of infections and can increase the chance of capsular contractures. Prompt removal of hematomas must be done once noted. Tissue expander and implant infection can lead to multiple procedures. Bleeding and infection are reported to occur at an incidence of 1% to 2%. Skin flap necrosis can be devastating to patients and care must be taken to ensure adequate blood flow and not to be excessive when performing tissue expansion. Other complications can occur later down the line. Local complications are the most frequently encountered complications. These include skin rippling, capsular contracture, infection, and implant rupture. Follow up with these patients should be planned to monitor the implants.
Capsular contractures are a fibrotic scar that forms around the implant as a foreign body reaction. It causes tightening of the implant, may displace its location, make the breast feel firmer and can be painful. Contractures are graded based on the Baker grading scale. Baker Grade I is a normal, soft breast that appears to be in natural shape and size and therefore no discernable capsule is noted. Baker II is a slightly firm feeling implant with a normal appearance. Baker III is where the contracture causes the breast to firm and appears abnormal. In Baker IV, the breast is hard, distorted and painful. Surgical intervention should be considered for grade III and IV. It is difficult to maintain a Grade II to a Grade I; therefore, special consideration should be given to these patients. 
Recently, there has been a link with implants to T-cell Anaplastic Large Cell Lymphoma. Although most studies have been anecdotal, there seems to be linked to the textured implants because of the "salt-loss" technique causing chronic inflammation, bacterial biofilm or other causes which are unknown. This is a special area of interest at this time because fewer than 100 cases worldwide have been identified. 
Breast cancer patients are a specialized population, and the reconstructive surgeon has a wide variety of options to help the patients regain a sense of normalcy after their disfiguring surgery. Tissue expanders and breast implants play a key role in this. They are an easy option for many patients, and their use has been widely studied and described.
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