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Implant-Based
Breast Reconstruction

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Approach
Expander→Implant
Most Common
~80% of Recon
Second Stage
3–6 Months
Insurance
WHCRA Covered

Breast Reconstruction

Restoring Breast Form After Mastectomy with Implants

Implant-based breast reconstruction is the most widely performed method of restoring breast shape after mastectomy. Rather than borrowing tissue from the back, abdomen, or thigh — as in flap-based reconstruction — implant reconstruction uses a silicone or saline implant to recreate breast volume. It is often chosen for its shorter operative time, faster initial recovery, and the fact that it does not create a donor-site scar elsewhere on the body.

Under the Women's Health and Cancer Rights Act of 1998 (WHCRA), all health insurance plans that cover mastectomy are required to cover breast reconstruction — including implants, the opposite breast for symmetry, and prostheses and treatment for complications. This is a federal law, not a benefit that can be excluded.

Immediate vs. Delayed Reconstruction

Immediate Reconstruction

Reconstruction begins at the time of mastectomy

  • Tissue expander or implant placed during mastectomy surgery
  • Patient wakes with a breast mound already in place
  • Preserves skin envelope and, often, the nipple
  • Fewer total surgeries and anesthesia events
  • May not be suitable if radiation therapy is planned post-mastectomy
  • Most common approach when radiation is not needed

Delayed Reconstruction

Reconstruction begins months to years after mastectomy

  • Mastectomy heals completely before reconstruction begins
  • Preferred when post-mastectomy radiation is planned
  • Radiation damages skin and blood supply — reconstruction after radiation requires careful planning
  • Allows time for cancer treatment to be completed
  • May require more tissue expansion due to tighter, radiated skin
  • Can still achieve excellent results — even years later

"The decision between immediate and delayed reconstruction is made together with your oncologist. Radiation timing is the most important factor — and it must be part of the conversation before surgery."

— Dr. Farhad Rafizadeh MD FACS

The Two-Stage Expander-to-Implant Process

The most common implant reconstruction approach involves two stages, separated by 3–6 months:

1

Stage 1: Tissue Expander Placement

A tissue expander — a temporary, adjustable implant — is placed behind the chest muscle (or in a prepectoral position, above the muscle) at the time of mastectomy or in a separate procedure. The expander is partially filled at surgery, then gradually expanded over 2–4 months through a port under the skin, using saline solution added at office visits every 1–2 weeks.

2

Expansion Phase (Outpatient Office Visits)

Each fill takes approximately 10–15 minutes and adds 50–100cc of saline. You may feel tightness or pressure for 1–2 days after each fill. Expansion continues until the desired volume is reached — typically 10–15% larger than the final implant, to allow the tissue to be fully stretched.

3

Stage 2: Implant Exchange Surgery

Three to six months after completing expansion (allowing the expanded tissue to soften and settle), the expander is exchanged for the permanent implant in a 1–2 hour outpatient procedure. This is typically performed under general anesthesia with recovery of 1–2 weeks. Fat grafting, nipple reconstruction, and symmetry procedures on the opposite breast can be performed at this stage or shortly after.

→ Schedule a ConsultationMeet with Dr. Rafizadeh personally to discuss your goals and a personalized plan. Call (973) 267-0928 or request a consultation online.

Direct-to-Implant (DTI) — Skipping the Expander

In selected patients — typically those with smaller breasts and good skin quality who do not require radiation — a direct-to-implant (DTI) approach places the permanent implant at the time of mastectomy, eliminating the expansion phase entirely.

Direct-to-Implant (DTI)

One Surgery, Faster Completion

  • Permanent implant placed at mastectomy — no expansion visits
  • Fewer total surgeries and anesthesia events
  • Best for smaller breast volume and good skin quality
  • Requires nipple-sparing mastectomy or preserved skin flap
  • Not suitable if radiation is planned
Tissue Expander (TE)

Gradual, Controlled Expansion

  • More control over final size and shape
  • Accommodates larger breasts and variable skin quality
  • Allows time for radiation to be completed before implant exchange
  • Safer option when skin viability at mastectomy is uncertain
  • Two-stage process — requires second surgery for exchange

Implant Placement: Submuscular vs. Prepectoral

The implant or expander can be positioned behind the pectoralis muscle (submuscular/subpectoral) or in front of it (prepectoral). Each has advantages depending on patient anatomy and radiation history.

Subpectoral (Under Muscle)

Traditional approach. Muscle provides additional coverage over the implant, which can reduce visible rippling. Slightly longer initial recovery as the muscle is elevated. Animation deformity (implant movement with arm use) can occur.

Prepectoral (Over Muscle)

Newer approach gaining favor. Implant sits above the pectoralis, preserving the muscle. No animation deformity. Requires good skin flap thickness and often an acellular dermal matrix (ADM) for additional coverage. Excellent option for thinner patients with good skin.

ADM (Acellular Dermal Matrix)

A biological mesh (e.g., AlloDerm) used to support the implant pocket, particularly in prepectoral reconstruction. It integrates with the patient's tissue over time and provides a physical barrier between the implant and skin.

Insurance Coverage: The Women's Health and Cancer Rights Act

Federal law requires that all health insurance plans covering mastectomy must also cover:

  • All stages of breast reconstruction on the mastectomy side
  • Surgery and reconstruction on the opposite (contralateral) breast to achieve symmetry
  • Prostheses (external breast forms) if reconstruction is declined
  • Treatment for physical complications of mastectomy, including lymphedema

This coverage applies to both immediate and delayed reconstruction, and there is no time limit on when reconstruction must begin. Contact your insurer for specific in-network benefit details, but denial of coverage for reconstruction after mastectomy is legally prohibited under the WHCRA.

Dr. Rafizadeh performs implant-based breast reconstruction at his accredited surgical facility in Morristown, NJ, serving women throughout Morris County, Essex County, Bergen County, and Union County. Patients from Parsippany, Short Hills, Summit, Chatham, Livingston, Madison, Montclair, and across North Jersey choose his practice for post-mastectomy reconstruction coordinated closely with their oncology team. Patients from New York City also travel to his Morristown office for board-certified reconstructive care.

Implant Reconstruction — Common Questions

Yes, but timing matters significantly. Radiation damages the skin and underlying tissue, which can increase complication rates for implant reconstruction — including capsular contracture (scar tissue hardening around the implant), infection, and implant loss. The recommended approach for patients who need radiation is typically to delay implant exchange until after radiation is complete, allowing the tissue to partially recover. In some cases, a tissue-based flap reconstruction (such as a DIEP flap) is preferred after radiation because it brings in new, unirradiated tissue. Dr. Rafizadeh works in close coordination with your oncologist and radiation oncologist to sequence reconstruction properly.

Reconstruction implants are the same devices used in cosmetic augmentation — silicone gel implants from Motiva, Allergan, or Mentor. They are not designed to last forever; most manufacturers quote a useful life of 10–20+ years, but they can last longer. The most common reasons for implant replacement in reconstruction patients are capsular contracture (scar tissue that distorts or hardens the implant), implant rupture (rare with modern devices), and changes in body weight or symmetry over time. Your reconstruction is not a one-time, permanent result — it requires ongoing follow-up and may involve revision procedures over the years.

Mastectomy severs the cutaneous nerves that provide skin sensation to the breast. Implant-based reconstruction does not restore those nerve connections, so the reconstructed breast skin typically has reduced or absent sensation — a consequence of the mastectomy, not the reconstruction. Sensation may partially return over months to years as small cutaneous nerve branches regenerate. Nerve grafting at the time of reconstruction (a technique under active investigation) may improve sensation outcomes in selected patients. This is an important conversation to have preoperatively so that expectations are realistic.

For immediate reconstruction, yes — the plastic surgeon joins the breast surgeon in the operating room during the mastectomy, so both surgeries are performed consecutively at the same facility. Dr. Rafizadeh coordinates directly with your breast surgeon to plan the combined operative session. The second stage (implant exchange) is typically performed as an outpatient procedure at our accredited surgical facility in Morristown. If you had your mastectomy elsewhere and are now seeking delayed reconstruction, Dr. Rafizadeh can begin the reconstruction process from wherever you are in your recovery.

Reconstruction

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