I had breast implants 25 years ago. I had breast cancer 2 years ago and had radio therapy which caused the implants to capsulate. My surgeon replaced them in October 2010 but the left one which had the radiation went wrong and the implant was far too high. He has recently done it again and used fat from my stomach at the bottom of the breast. However, this has gone rock hard, is uncomfortable and does not move at all. It also looks square and unnatural. Any advice?
I Have Had Reconstruction Using Implant and Fat, why is it now rock hard?
Doctor Answers 8
Having hard tissue may be a capsular contracture of even fat necrosis from the fat injections. An exam would be helpful and other reconstructive options can be offered to you. The radiation couls also have an impact eventhough it was done in the past. You may need to bring in healthier tissue to provide a better reconstruction.
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Breast cancer radiation treatment and implants - solutions
Developing capsular contracture with implants after radiation is unfortunately quite common and difficult to fix. Even if the scar capsule can be made soft, the breast overlying it is often hard and misshapen from the radiation. (This is one reason why many women actually do better with skin-sparing mastectomy and resonctruction with implants than with radiation.) One thing that helps avoid recurrent capsular contracture is the use of Alloderm grafts. I would encourage you to look in to this before having another revision.
Capsular contracture in reconstructed irradiated breast
Implants in irradiated breasts for breast cancer are associated with a very high rate of capsular contracture. That is exactly the hardness and distortions that you see and feel. This is caused by the damage that radiation therapy causes to the treated tissues.
Two reasonable options would include performing a capsulectomy of the affected side and placing an acellular dermal matrix such as AlloDerm around a new implant. This has been shown to reduce the incidence of this hardness developing - but still is no guarantee.
The other option would be to consider autogenous reconstruction which means using your own tissues for the affected side. This is a far more extensive procedure, riskier and potentially deforming of the donor site.
It may be wise to consider the first approach initially and if this fails, consider the second or even just removal of the implants.
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Hardness following fat grafting
Hardening following fat grafting is secondary to fat necrosis. Eventually, these fat cells will reabsorb (years), but you are feeling the calcification that is taking place in the compromised fat.
Hard Tissue after Implant Reconstruction
Unfortunately, there is a very high incidense of capsular contracture (in your case, it sounds like recurrent capsular contracture) when breast implants are used for breast reconstruction after radiation. Of course without knowing more about the details of your surgery and examing you, it would be difficult to say for certain, but it sounds like a recurrent capsule and scar tissue are making your reconstructed breast feel "hard".
When a woman has had radiation, many plastic surgeons (myself included) recommend using only natural tissue for breast reconstruction; in other words, a flap procedure. In my pracice, I favor perforator flaps such as the DIEP, SGAP or LAP flaps. . Natural-tissue (autologous) reconstruction has the benefit of bringing non-radiated, healthy, well-vascularized tissue to the mastectomy site, and this can actually aid in the healing process.
Implant rock hard after radiation
It is not clear whether you have had a mastectomy or just a wide excision of your breast cancer leaving the rest of your breast behind. I think that you have just had a wide local excision. If this is the case and the capsule is recurring very quickly, then the option would be to remove the implant and use your own tissue. This could either be in the form of more fat grafting, or, if you need a lot of volume to be replaced, the muscle of your back (latissimus dorsi) could be used to fill the space left by the implant. Because it is your own tissue, it will not go hard like an implant.
You could also consider having both implants removed to make it easier to gain symmetry, although then you may be looking at a breast lift.
It is difficult to give a complete answer without examining you.
Reconstruction After Radiation
It sounds as if you are experiencing scar tissue around your implant (likely due to your history of radiation therapy). I generally do not recommend placement of implants after radiation because of an increased risk of scar tissue formation around you implant (also known as capsular contracture).
In my breast reconstruction practice, following XRT, I usually recommend autologous (tissue) reconstruction with excess abdominal tissue (DIEP flap) or back tissue (latissimus flap). The reason why I recommend autoloogus reconstruction following radiation is that the new tissue that is brought to the radiated site, I believe, brings new non-radiated soft tissue, new blood supply, and perhaps new healing potential to a radiated chest wall. Furthermore, a tissue-only reconstruction (DIEP flap) may not require a foreign body implant. Hence this eliminates any risk for foreign body (implant) scar tissue (post radiation capsular contracture). I believe a tissue-only reconstruction breast following radiation therapy will give my patient the best long lasting result.
Capsular Contracture Post Radiation
It sounds as though you are having recurrent capsular contracture, an all too common problem in radiated patients. Although fat grafting can be used to improve the contour of an implant reconstruction, you will most likely benefit from a tissue (autologous) reconstruction. There are multiple options DIEP/TRAM (abdomen), SGAP/IGAP (buttock), TUG (inner thigh), or latissimus (back) tissues.
I wish you a safe and healthy recovery.