Cancer Treatment and Research Communications 40 (2024) 100821

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Cancer Treatment and Research Communications

journal homepage: www.sciencedirect.com/journal/cancer-treatment-and-research-communications

Implant reconstruction after mastectomy–A review and summary of

current literature
Thomas Kidd *, Gerard Mccabe , Joanna Tait , Dhananjay Kulkarni
Breast Unit, Western General Hospital, Edinburgh, EH4 2XU, Scotland, UK

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: The landscape of breast reconstruction has changed significantly with a shift in focus to include the
Mastectomy restoration of a patient’s quality of life after cancer. Reconstructive options can be divided into alloplastic
Implant reconstruction (implant based) and autologous (tissue based). This paper aims to provide a current educational summary
Breast implants
regarding implant-based reconstruction after breast cancer surgery and review the current literature.
Method: A review of the literature was conducted utilising standard PRISMA flowchart. Databases searched
included Pubmed, EMBASE, and MEDLINE.
Results: Current practice is explored within the text, including types of implants, indications, and surgical ap­
proaches. Heterogenous cohorts, surgical technique variation, and selection bias can make comparison of the
literature challenging. The major evidence reviews of implant-based reconstruction topics are discussed
including, ADM use, radiotherapy, and complications. Despite the benefits of autologous reconstruction, implant-
based techniques still represent a significant proportion of reconstructive breast procedures. However, implant-
reconstruction is not without its risks and limitations and, with such variety in practice, there remains a lack of
high-quality evidence guiding practice. Most importantly, patients need to be counselled about the pros and cons
of each choice, particularly with the increasing utilisation of radiotherapy post-reconstruction. Ultimately, the
patient and surgeon should reach a decision in full knowledge of the risks and potential outcomes.
Conclusions: Further research is required into implant-based reconstructive therapy, which will allow a greater
consensus for management and a pathway for both surgeons and patients.

1. Introduction
Breast cancer is the most diagnosed cancer worldwide and the fifth
most common cause of cancer deaths in the world [1]. Within the United
Kingdom, 54,000 new cases are diagnosed each year and it represents
the second most common cause of cancer mortality with around 11,400
deaths every year [2]. Since the early 1990′s, the rates of invasive breast
cancer within the UK have increased by around a quarter (24 %)[2].
The outcomes of breast cancer over recent decades have significantly
improved both globally and within the UK [2]. There has been a decline
in overall mortality along with an improvement in cosmetic outcomes.
This can, in part, be attributed in the United Kingdom to mammogram
screening, increased public awareness, and the development of newer
treatment modalities as we continue to learn more about the spectrum of
disease [3].
The landscape of breast reconstruction has changed significantly
with the reconstructive armamentarium constantly expanding.
Innovations in surgical approaches mean there are more choices than
ever before and a shift of focus to include the restoration of a patient’s
quality of life after cancer. Broadly speaking, reconstructive options can
be divided into “alloplastic” (implant-based) and “autologous” (tissue-
based). The pros and cons of both techniques can be summarised in
Table 1 [4].
With the development of new oncoplastic techniques such as thera­
peutic mammoplasty, immediate lipofilling after wide excision of can­
cer, perforator flap reconstruction etc., the mastectomy indications and
rates have reduced slightly. But overall, there is a continued increased in
both the global and British rates of immediate breast reconstruction post
mastectomy. Some of this may be due to greater accessibility and the
rising incidence of contralateral prophylactic mastectomies, which are
often followed by immediate reconstruction [5]. 2018 NICE guidelines
state that all mastectomy patients should be offered immediate or
delayed breast reconstruction regardless of local availability, unless
significant co-morbidities rule it out [6]. Other reasons someone may

* Corresponding author.
E-mail address: thomaskidd@doctors.org.uk (T. Kidd).

https://doi.org/10.1016/j.ctarc.2024.100821

Available online 24 May 2024

2468-2942/© 2024 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
T. Kidd et al.
not undergo reconstruction include patient choice, age, accessibility
(globally), and a lack of patient information regarding options [7].
The options of post mastectomy reconstruction include autologous
(Latissimus dorsi flap or free flap reconstruction; mainly deep inferior
epigastric perforator flap) or implant-based reconstruction. Each option
of reconstruction has its own merits and shortcomings. Implant recon­
struction has the advantage of relatively short procedure, quicker re­
covery and no additional procedures and scars on back or abdomen. But
patients with previous history of radiotherapy, smoking, diabetes, pre­
vious scars/ procedures on the same breast are at significant risk of
complications and subsequently loss of implants. Patients are also likely
to require further procedures like fat grafting (for improving contours)
or contralateral reduction mammoplasty/ mastopexy for symmetry.
Also, if post mastectomy radiotherapy is required, then it can adversely
affect the reconstruction with capsular contracture.
Heterogenous cohorts, surgical technique variation, and selection
bias can make comparison of the literature challenging. This paper aims
to provide an educational summary regarding implant-based recon­
struction after breast cancer surgery and review the current literature.
Compared with autologous reconstruction, implants represent a mini­
mally invasive procedure with no donor-site related morbidity. How­
ever, they are still associated with short- and long-term complications
and the authors want to provide the reader with a review of key infor­
mation including implant selection, complications, and emerging
evidence.
2. Methods
Although this is not a systematic review, a comprehensive literature
search was conducted using Pubmed, Embase and clinicaltrials.gov. The
following search terms were used in relation to breast implantation and
breast reconstruction: ‘Surgical technique’, ‘Sub-muscular’, ‘Pre-pecto­
ral’, ‘Tissue expander’, ‘Direct to implant’, ‘Delayed’, ‘Immediate’,
‘ADM’, ‘Acellular dermal matrixes’, ‘Silicone’, ‘Saline’, ‘Textured’,
‘Smooth’, ‘Complications’, ‘Infection, ‘Rupture’, ‘Contracture’, ‘ALCL’,
‘Lymphoma’ and ‘Rippling’. Upon selection of the relevant papers the
reference lists were screened for additional relevant publications. Three
investigators individually screened and reviewed each article. Publica­
tions which did not include an English translation were excluded.
Table 1
Types of breast reconstruction – alloplastic versus autologous [4].
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Cancer Treatment and Research Communications 40 (2024) 100821
3. Results and discussion
3.1. History of implant reconstruction
Aesthetic operations of the breast have been performed for centuries.
One of the earliest published attempts of breast reconstruction was by
the German surgeon Czerny, who transferred a lipoma following tumour
removal in 1895 [8]. Following this, alternative attempts of several
prosthetics - including glass balls, ground rubber, ox cartilage, and wool
– were trialled with disastrous consequences [9]. The modern era of
breast reconstruction was fathered by Cronin and Gerow in 1960s with
the introduction of silicone implants. In 1976, Radovan began using
tissue-expander techniques in the reconstruction of post-mastectomy
defects. Shortly after, in 1984, Becker pioneered a dual-chambered
expander consisting of a silicone outer lumen and an inflatable inner
saline cavity [10]. Over the coming decades, there were continued im­
provements in implant technology and surgical techniques.
Following mastectomy, implant-based procedures are the most per­
formed reconstructive surgical option for breast cancer [11]. This is
either achieved with a single-stage fixed volume implant (direct to
implant) or by utilising the traditional technique of gradual tissue
expansion. For the latter, serial expansion is performed by progressive
saline injections into the inflatable device. This may then be followed by
replacement with a definitive implant upon completion, or removal of
the filling port in cases of permanent expanders [12].
Despite the advancements in technology and surgical techniques, the
complication rates associated with implant-based reconstruction ap­
proaches 40 % [13]. Additionally, nearly half of patients will require
further re-operative surgery at a later date [13].
3.2. Indication and contraindications for implant reconstruction
Non-autologous reconstruction is best suited to those with small to
moderate-sized breasts with minimal ptosis (up to C or maximum D cup
breasts), or when performing bilateral reconstruction. Additionally, it is
preferred for those seeking a shorter hospital stay, to evade donor site
morbidity, and generally those wishing to avoid or not suitable for
autologous techniques [12].
Implant reconstruction is less favourable in those with thin overlying
T. Kidd et al.
skin flaps or chest wall tissue. As mentioned below, radiotherapy
significantly increases the risks of complications and diminishes the
aesthetic results of both implant and expander reconstruction [12].
Patients with unilateral reconstruction should be aware of the potential
for future asymmetry due to the failure of the implant side to undergo
normal ptosis [12]. These patients are likely to need contralateral
reduction mammoplasty/ mastopexy for symmetry. The Association of
Breast Surgery (ABS) and the British Association of Plastic, Recon­
structive and Aesthetic Surgeons have produced both a Guideline for
Best Practice and a Patient Information Guide detailing pertinent con­
siderations of each technique [14,15]. Patients should be well informed,
particularly on the chances of complications and revisional procedures.
3.3. Method of implant reconstruction
3.3.1. Implant placement
In general, implants can either be submuscular (underneath pector­
alis major); dual-plane (under a combination of pectoralis major and
mastectomy flaps +/- Acellular dermal matrix: ADM); or pre-pectoral
(superficial to pectoralis major, often with a covering ADM) – see
Fig. 1. Although the submuscular plane offers substantial vascularised
soft-tissue coverage, it also involves a more invasive dissection of the
chest wall. It also causes late complications like animation, double-
bubble effect and twitching of the muscle.
Traditionally, pre-pectoral implants fell out of favour due to high
rates of implant extrusion, infection, and capsular contracture. Howev­
er, the advances in nipple-sparing mastectomy techniques have led to
greater skin flap viability and decreased complications, catalysing the
resurgence of pre-pectoral implants [16,17]. The improved quality of
ADMs and mesh technology has also helped in achieving better results. A
recent survey of 2535 members of the American Society of Plastic Sur­
geons, revealed that 48.4 % of surgeons utilised pre-pectoral recon­
struction in all or most of their cases, as opposed to 29.9 % who
performed few or none [17].
3.3.2. Direct to implant versus immediate expander
Direct to implant reconstruction at the same time as oncological
resection has the benefit of decreasing the total number of surgeries,
avoids expander period and weekly saline injections, and preserves
much of the natural shape of the breast envelope to achieve a better
aesthetic outcome[4]. However, it is technically more challenging and
may be more likely to compromise skin flap viability. It also does not
allow for adjustment of initial volume without correctional surgery,
which is particularly important in patients undergoing radiotherapy
[16]. Tissue expansion has traditionally been viewed as the safer option
with fewer complications, particularly regarding skin necrosis.
Fig. 1. Planes of Breast Reconstruction [59].
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Cancer Treatment and Research Communications 40 (2024) 100821
However, Srinivasa et al. identified no statistically significant difference
in complication rates or patient reported outcomes [18]. The consider­
ation to both approaches can be summarised in Table 2 [4].
Comparison within the literature is challenging due to patient het­
erogeneity, variation in surgical technique, and selection bias [19]. The
largest head-to-head meta-analysis to date by Basta et al., studied 5216
patients receiving either direct-to-implant reconstruction or two-stage
tissue expansion [19]. Their study demonstrated a significantly greater
risk of flap necrosis and implant failure with direct-to-implant recon­
struction. However, as was emphasised in this study, direct-to-implant
technique has been demonstrated to be a safe technique in appropri­
ately selected patients, in particular, those with good quality skin flaps.
Other studies have demonstrated similar outcomes between the two
techniques [20–22].
3.3.3. Acellular dermal matrices (ADMs)
The introduction of acellular dermal matrices (ADMs) represents a
significant advancement within breast reconstruction within the last
decade. There is a continuously increasing catalogue of available syn­
thetic, allo- and xenograft products with no clear consensus for one
product within the literature [12,23]. Up to 56 % of all implant-related
procedures in the US are now being performed using a biologic [24]. Its
popularity has arisen from putative benefits, which are summarised in
Table 3, but mainly relate to aesthetic outcome and a shorted timescale
to final aesthetic result [25].
Concerns have been raised over the increased risk of post-operative
complications, particularly infection and seroma [13,26] . Comparing
breast reconstruction with and without ADM is difficult due to the
variability of the studies and differing ADM products [27]. Despite its
widespread adoption and multiple systematic reviews, there is limited
high quality evidence supporting the proposed benefits. In the most
comprehensive systematic review and meta-analysis to date, there was
no definitive conclusion apart from that there remains a lack of
high-quality studies comparing the use of matrices in breast recon­
struction [28]. The certainty of evidence for overall complication rates
and implant loss was low. This conclusion was shared by Hallberg’s
meta-analysis studying ADM use in immediate breast reconstruction
[28]. The alternatives to ADMs such as titanium covered mesh pockets
are also popular.
The ABS (Association of Breast Surgeons, UK) and BAPRAS (British
Association of Plastic Reconstructive and Aesthetic Surgeons) produced
an additional joint guidance on the clinical indications, relative in­
dications, and cautions for those undergoing implant-based ADM
reconstruction [29]. Their Guide to Good Practice states patients should
be made aware of the complications of ADM-assisted implant recon­
struction, based upon the UK iBRA study of 2108 patients [30]. The
T. Kidd et al.
Table 2
Types of alloplastic (implant-based) reconstruction[4].
Table 3
Proposed benefits of ADM use [25].
- coverage of the lower pole without need for dissection of the upper portion of pectoralis major – so called ‘dual plane’ approach
- helping support the weight of the implant inferiorly, particularly where the skin is thin and vulnerable to additional pressure
- improved definition of the IMF
- providing additional soft tissue coverage for direct-to-implant pre-pectoral reconstruction
- facilitate the use of pre-pectoral tissue expanders (in addition to traditional sub-muscular approach)
- reduced operating time
- reduce post operative pain
- shorten time for tissue expansion
- treat complications of rippling
overall 3-month national complication rates were: readmission 18 %;
infection 25 %; reoperation 18 %; and implant loss 9 %. These were
higher than the National Quality Standard (<5 % for re-operation,
re-admission and implant loss, and <10 % for infection) [30]. Higher
complication rates were associated with smoking, increasing BMI,
longer operative time, and previous radiotherapy. However, other
smaller studies have demonstrated more favourable complication rates
with ADM (total complications of 14 %) when additional protective
measures are taken, such as strict selection criteria, implant selection,
and aggressive wound management [31].
The use of ADMs is widespread within current practice and therefore
better high-quality evidence is needed to evaluate their proposed ben­
efits. As was the conclusion in the Lancet’s iBRA study, further rando­
mised clinical trials are needed to establish the optimal approach to
breast reconstruction and an evidenced-based pathway for clinicians.
3.4. Types of implants
Breast implants have a silicone shell with either a saline or silicone
filling. The outer casing can be smooth or textured and the overall shape
anatomical or round. There are three key measurements to implants.
Firstly, the base width is the diameter of the bottom of the implant.
Secondly, the profile or projection of the implant. Thirdly, the volume of
the implant which is measured in cubic centilitres (cc). The choice of
implant will depend on a multitude of factors including patient expec­
tations, surgeon preference and individual body proportion measure­
ments. Modern breast implants do not have a specific lifespan and
4
Cancer Treatment and Research Communications 40 (2024) 100821
therefore do not need routinely replaced in the absence of concerns [25].
3.4.1. Silicone and saline implants
Several generations of silicone implants have been developed over
recent decades. They have the advantage of a natural weight and feel,
and typically more of a breast-like consistency than saline. When
compared to saline, silicone gel implants also have better resistance to
visible or palpable rippling in those with a thin tissue envelope. These
are the key reasons why silicone implants are commonly the preferred
material of choice [32]. The converse of this means that silicone im­
plants need a larger incision site due to being less malleable than saline.
Additionally, in the context of rupture, the saline is less toxic to the body
and therefore need less follow up and surveillance. Saline implants were
particularly popular during the silicone moratorium from 1992 to 2006
[33]. It is important to note that the US FDA deemed silicone safe
following the 14-year review.
3.4.2. Anatomical vs round implants, textured vs smooth
Anatomical implants – also known as ‘shaped’ or ‘teardrop’ implants
– have an increased projection of the lower pole. Due to the need to
retain this anatomical shape, their filling needs to be a more cohesive
silicone gel which maintains shape in the presence of physiological force
[34]. The choice should depend on a multitude of factors, including the
quality and quantity of native tissue. In general, shaped implants are a
good choice for women who have deficient upper pole soft tissue and
thin mastectomy flaps with relative low body index. Patients who desire
a more softer feeling breast with additional upper pole (‘cleavage’)
T. Kidd et al. Cancer Treatment and Research Communications 40 (2024) 100821

projection are good indications for using a round breast implant [35]. 3.6.1. Animation deformity
Smooth implants roll subtly within the breast pocket, whereas Animation deformity occurs after submuscular placement of the
textured implants adhere into the nearby tissue and keep the implant implant. It describes the distortion of the reconstructed breast during the
more rigidly in place. As such, anatomical implants tend to be textured contraction of pectoralis major. This can cause functional symptoms as
to reduce the chance of distortion, or ‘malrotation’, if it turns [25]. This well as producing an unfavourable aesthetic appearance. There is
can occur if the pocket containing the implant is too loose or loosens limited high-quality evidence focussing only on animation deformity
over time [36]. Round implants, however, can be textured or smooth. As outcomes within breast reconstruction. Additionally, variations in sur­
will be discussed in more detail, textured implants are now the preferred gical technique (e.g. muscle-splitting, dual-plane, triple-plane), surgical
implant choice worldwide since they also have been demonstrated to cohort (augmentation versus reconstruction), and differing grading
reduce the rate of capsular contracture, which continues to be the systems, make comparisons more challenging. However, animation
leading cause of re-operations [12]. deformity clearly represents a significant challenge with the sub­
muscular technique. Nigro et al. found that in 78 % of their 108 patients
undergoing submuscular implant reconstruction were aware of post-
3.5. Radiotherapy and implants
operative animation deformity. These findings were supported in a
study by Baker et al. and are significantly higher than those of sub­
The oncological benefit of radiotherapy is clear and has demon­
muscular implant-based primary breast augmentation [45,46]. Options
strated to decrease local tumour recurrence and increase overall survival
to treat animation deformity include conversion to a pre-pectoral plane,
in selected individuals [37]. Local variations may apply but NICE
muscle-splitting techniques, selective nerve muscle ablation, and Botox
guidelines advocate for radiotherapy after mastectomy in those at high
injections. The high incidence of animation deformity is perhaps why
risk of local recurrence (e.g. those with macro-metastases, involved
some surgeons are converting to pre-pectoral techniques entirely [47].
resection margins, or node-negative T3/T4 invasive disease) [38].
However, radiotherapy also compromises the healing capacity of the
3.6.2. Rupture
body, inducing soft-tissue fibrosis and inhibiting angiogenesis. Regard­
Implant rupture is most commonly due to capsular contracture but
less of the reconstructive approach, it is known to increase rates of
can be caused by iatrogenic injury or trauma [12]. In a meta-analysis by
re-operation, reconstructive failure, capsular contracture, infection, and
Han et al., shaped breast implants were associated with lower rates of
total complications in implant-based reconstructions [37,39]. The
rupture compared to round implant [35]. When comparing the inci­
shrinking of the skin can cause the reconstruction to sit differently on the
dence of rupture, the rate for respective round versus anatomical im­
chest and within the literature there is high-quality evidence associating
plants was 35% vs 12 % and 4% vs 2 % between different brands. This is
radiotherapy with poorer rates of cosmetic and satisfaction outcomes
perhaps attributable to the modern advances in silicone gel stability and
[40,41]. There also has been some concerns raised about the possibility
outer shell resilience with shaped implants. In cases of saline implant
of interference from the implant-expander devices resulting in imparted
rupture, the empty shell should be removed. The management of sili­
delivery to the internal mammary nodes, or the possibility of increased
cone implant rupture warrants closer attention. Silicone can leak into
tangential field radiation of nearby tissues. However, these theories are
the surrounding tissue and produce an inflammatory reaction or migrate
contested [42].
to axillary lymph node (typically a ‘snowstorm’ appearance on ultra­
Overall, autologous reconstruction remains the preferred recon­
sound). If the rupture is intra-capsular, the implant is removed, usually
struction technique if post-procedure radiotherapy is planned, although
alongside the capsule. If the rupture is extra-capsular, several surgeries
not all women are candidates (or may desire) this [21]. In a multi-centre
may be necessary to retrieve all the extravasated gel [48].
prospective study of over 2000 patients by Jagsi et al., major breast
complications occurred in 33 % of irradiated patients receiving
3.6.3. Wound infection
implant-based reconstruction, 17.6 % of irradiated patients receiving
Despite traditional thinking, the position of the implant pocket - pre-
autologous reconstruction, and 15 % of unirradiated patients receiving
pectoral versus sub-muscular - was not demonstrated to have a signifi­
implant-based reconstruction [43]. Another recent meta-analysis by Du
cant difference in the rate of infection in a meta-analysis of 10 studies
et al., looked at 6964 patients receiving implant-based reconstruction
containing 1628 patients [49]. This study also noted no difference be­
with or without post-operative radiotherapy. The rates of capsular
tween the rates of implant loss in these two groups and additional factors
contracture was 17 % in those irradiated versus 3 % in those who were
increasing the incidence of infection included radiotherapy and ADM
not. The overall rate of complications was 23 % versus 10 % in those
use. Other meta-analyses by Ostapenko et al., Abbate et al., and Li et al.,
respective groups. Tissue expanders and implants both caused similar
also demonstrated no difference in rates of infection and skin flap ne­
rates of capsular contracture and complications [44].
crosis between pre and sub pectoral groups [16,50,51]. Emerging evi­
The timing and choice of implant-reconstruction technique within
dence therefore supports the theory that pre-pectoral implant-based
patients expected to undergo post-operative radiotherapy is the subject
reconstruction does not increase the incidence of infection or compro­
of debate. Randomised trials of different approaches are not feasible and
mise skin viability in appropriately selected patients. As an additional
therefore individual institutions have adopted their own preferences
point, in keeping with previous data, the meta-analysis by Han et al., the
based upon their culture and experience of results [21]. ABS/BAPRAS
incidence of infection was similar between anatomical versus to round
guidance state that this sub-group patients should be counselled
implants [35].
pre-operatively and be made aware of the significant increased risks of
When studying ADM, Ho et al. demonstrated nearly a threefold in­
complications and re-operation that radiotherapy will cause. More
crease in the rate of infection in patients with ADM than those without,
research and consensus guidance are needed regarding the timing of
even after sensitivity adjustment for heterogeneity [24]. These results
radiotherapy and its effects on different implant-related breast recon­
are similar to those of the iBRA study described above. However, as
struction techniques [20].
mentioned before, the data quality is low and further evidence is
required to compare ADM outcomes in breast reconstruction [24,28].
3.6. Implant associated complications
3.6.4. Capsular contracture
Heterogenous cohorts, surgical technique, product variation, and Any foreign material within the body will induce a reactive response.
selection bias makes comparison of the literature challenging. The Moreover, scarring around an implant produces a capsule that may
following descriptions will draw together recent high-quality evidence contract over time [12]. Capsular contraction can cause pain, hardness,
within the literature on common complications. and change the shape of the breast. The Baker classification represents

5
T. Kidd et al.
the most popular grading system [52]. Treatment depends on the
severity of symptoms and patient preference but traditionally involves
removal of implant with a capsulotomy or capsulectomy with or without
re-augmentation [12].
A recently published meta-analyse demonstrated significantly lower
rates of capsular contracture in the pre-pectoral cohort when compared
to subpectoral cohort (4.2% vs 7.6 %)[16]. This supports conclusions
from previous studies and may be due to a thinner capsule wall,
ADM-use, and reduced mechanical stress over the implant [53]. Addi­
tionally, implants with textured surfaces have a lower incidence of
capsular contracture than smooth implants. The mechanism is not fully
understood but can perhaps be attributed to the way the texturing dis­
rupts the contractile forces around an implant [54]. Ho et al. demon­
strated a pooled capsular contracture rate of 0.6 % in those with ADM
implant reconstruction, compared with 3− 18 % reported in the litera­
ture for implant reconstruction without ADM. This reaffirmed existing
literature sighting that ADM has a potential protective effect against
peri‑prosthetic capsule formation [16,24].
3.6.5. Implant rippling
Implant rippling is the appearance of the implant edges beneath the
skin creating a wrinkling effect. Round, non-cohesive implants, are
particularly vulnerable to this due to their fluid nature [12]. Addition­
ally, it may be more apparent when there is a thin tissue envelope such
as with slim patients, those with ptosis, or where augmentation has
caused some degree of glandular atrophy [12]. In the meta-analysis by
Abbate, implant rippling was the most common complication in
pre-pectoral reconstruction [16]. This tends to affect the superior pole of
the breast and can be managed with fat grafting to increase the thickness
of the skin flaps. Rippling can also occur secondary to an implant being
underfilled. There is upper shell collapse, particularly evidence when
the patient is upright, with the filler following gravity [55]. Implant
rippling is less common in submuscular implant placement due to the
additional soft tissue coverage.
3.6.6. BIA-ALCL implant rippling
Breast implant associated anaplastic large cell lymphoma (BIA-
ALCL) is a rare type of primary effusion T-cell lymphoma arising around
breast implants and usually follows an indolent course. However, in a
small proportion of cases, it has caused disseminated and fatal disease,
bringing heightened attention and dedicated research [56]. There was
an estimated of 57 cases within the UK from 2011 to 2018 and a
worldwide risk of 1:50,000–300,000[57]. It characteristically presents
as a late seroma and the diagnosis confirmed via cytology of the aspi­
rated fluid [12]. There is a clear association between BIA-ALCL and
textured implants, however more data is required before this is absolute.
In a meta-analysis by Ramos-Gallardo, 21–35 % of the implants were
texturised, 0 % were smooth, and 65–75 % were unknown [58]. Similar
results were seen within Co’s meta-analysis, where implant texture was
not mentioned in 50 % if patients, with a potential of publication bias
[56]. Treatment includes implant removal, capsulectomy and complete
resection of any mass to negative margins. The outcomes are favourable
and completely removing the cancer often eliminates it for good [12].
4. Conclusion
Although not a systematic review, this article covers all aspects of
post mastectomy implant-based reconstruction. The heterogenous end
points that we are looking into, renders systematic review on this topic
extremely difficult.
Despite the benefits of autologous reconstruction, implant-based
techniques still represent a significant proportion of reconstructive
breast procedures. However, implant-reconstruction is not without its
risks and limitations and, with such variety in practice, there remains a
lack of high-quality evidence guiding practice. Most importantly, pa­
tients need to be counselled about the pros and cons of each choice,
6
Cancer Treatment and Research Communications 40 (2024) 100821
particularly with the increasing utilisation of radiotherapy post-
reconstruction. Ultimately, the patient and surgeon should reach a de­
cision in full knowledge of the risks and potential outcomes. Further
research is required into implant-based reconstructive therapy, which
will allow a greater consensus for management and a pathway for both
surgeons and patients.
CRediT authorship contribution statement
Thomas Kidd: Writing – original draft, Resources, Methodology,
Formal analysis, Data curation. Gerard Mccabe: Writing – original
draft, Methodology, Data curation. Joanna Tait: Writing – review &
editing. Dhananjay Kulkarni: Writing – review & editing, Supervision,
Conceptualization.
Declaration of competing interest
This is to confirm that all the four authors; Thomas Kidd, Gerard
McCabe, Joanna Tait, and Dhananjay Kulkarni have contributed to
writing the article ‘Implant Reconstruction after Mastectomy– A Review
and Summary of Current Literature’. We have no conflict of interest to
declare.
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