In this type of reconstruction the breast tissue is removed but the skin and nipple is kept (preserved). It is only suitable for women with fairly small breasts. An implant is put underneath the skin to replace the lost breast tissue.

This kind of reconstruction may be used for women who have had certain types of breast cancer. Rarely, it is used for women who have a high risk of developing breast cancer and want to have a prophylactic mastectomy (removal of a breast to try and prevent cancer from developing).

The scar from subcutaneous reconstruction may be on either side of the nipple and continue sideways around it, or run in the crease under the breast. The scar may extend to the side of the breast.

The advantage of this type of reconstruction is that it usually looks good from soon after the operation. However, some surgeons worry that if the operation is carried out for breast cancer, tiny areas of cancer cells may be left in the nipple and areola areas and may continue to develop.

Sometimes the implant is very easy to feel under the skin of the breast and so the breast does not have a natural, soft texture. The implants may also wrinkle, which can show through the skin of the breast. This is less likely with the newer solid-gel implants.

Breast implants put just under the skin are more likely to develop capsular contracture than other types of reconstruction using implants.

In this type of breast reconstruction the implant is put underneath the muscles covering the chest. This method of reconstruction is only suitable if you have fairly small breasts. It is not possible if you:

• have had a radical mastectomy, as the chest muscle has been taken away
• have large breasts, as it would be difficult to make this breast match the other breast
• have had radiotherapy, because your skin and muscles are unlikely to stretch enough to hold the implant.

The scar from this type of operation is usually side-to-side, or at an angle following the line of the original mastectomy scar.

The advantage of this method is that it is a simple procedure. It may not give a very good appearance compared to the other breast, as the new breast will not have its normal droop and can look higher. However, this sort of reconstruction may be helpful if both breasts are being removed (bilateral mastectomy and reconstruction). Another disadvantage is that the implant can change shape slightly when you move, as the overlying muscle contracts. It is not possible to give a normal breast shape using this method in older women.

Breast reconstruction involving tissue expansion can give very good results and avoids the need for the extensive surgery involved in using tissue flaps. However, it may take much longer to form a breast than other methods, and some women find this frustrating.

This type of reconstruction uses the ability of your skin and muscle to stretch. Skin is surprisingly elastic in most people.

How it is done

Two operations are carried out. In the first, an expandable implant (like an empty balloon) with a valve for filling it is put under the chest muscle. This is expanded over a few months by injecting  sterile salt water (saline) into the implant through a valve just under the skin of the armpit. This is done weekly or fortnightly at the outpatients clinic. You may feel a sensation of stretching and pressure in the breast area during this procedure, but most women find it is not too uncomfortable. The process continues until the size is slightly larger than your other breast.

After several months, the inflatable silicone bag is taken out during a second operation and replaced with a permanent implant. The implant matches the size of the other breast and the previous over-expansion allows it to lie on the chest wall with a more natural appearance.

Another type of reconstruction using tissue expansion, uses a silicone implant with an outer chamber of silicone gel, which has an inflatable inner chamber with an expansion valve. The inflatable inner chamber can be filled with salt water to allow the implant to be adjusted for size. The implant is inflated over several weeks and left over-inflated for several more weeks.  Some of the salt water is then removed through the valve so that its size matches the other breast. A small operation, often carried out under local anaesthetic as day surgery, is then done to remove the valve.

When the expander is being inflated, it can be uncomfortable, making the breast feel tight and hard. This usually lasts only a day or so after each inflation. If you find this very uncomfortable, let your doctor know. They may remove some of the fluid, and inflate the expander implant more slowly.

This type of reconstruction is suitable and acceptable for many women. However, if you have had radiotherapy, or you need to have it after mastectomy, your skin will probably have lost, or will lose, a lot of its elasticity. In this situation, tissue expansion is not usually possible and a flap reconstruction will be more appropriate. Tissue expansion may give a good appearance for some women, but sometimes is not as good as a reconstruction using flaps.