Two Stage Reconstruction with Tissue Expander and Implant

This is the most common type of breast reconstruction performed. A tissue expander is a temporary “spacer”, similar to a balloon, which allows the plastic surgeon to preserve the volume and shape of the breast. It is shaped like a breast and has a “tear drop” appearance when viewed from the side. The outer shell of the tissue expander is made of silicone. There are different sizes of tissue expanders, so it can be individualized to fit your body and reconstructive goals. Unlike a breast implant, a tissue expander has a port that is used to fill the cavity. A tissue expander is used as a temporary device to help create a nice pocket to hold the final implant while also expanding or stretching the breast skin to create the desired post-operative size and shape. You can see an example of a tissue expander during your consultation with Dr. Elswick.

The decision for where to place the incision is based upon the type of mastectomy you are having (i.e. whether or not the nipple is being saved), the location of the cancer, and the size and shape of your breast. Common incisions include in the crease along the bottom of the breast, across the center of the breast (for a skin-sparing mastectomy when the nipple is sacrificed), around the areola (the pigmented portion of the breast) sometimes extending laterally towards the chest wall under the arm, or an inverted T or an anchor pattern (for patients having Golidlocks reconstruction). You may also require additional incisions for lymph node procedures in the armpit. The breast surgeon and plastic surgeon will work together to decide what incision is most appropriate for your situation.

Once the decision has been made that is safe to proceed with reconstruction, the next step is to decide where to place the tissue expander. There are two different locations where the tissue expander can be placed: subpectoral (under the muscle) or prepectoral (on top of the muscle). The traditional approach was to place the tissue expander under the muscle to provide additional layers of protection. Placing the tissue expander under the muscle may also provide more fullness in the upper portion of the breast, leading to improved cleavage while also camouflaging the implant by creating a smoother transition between the chest wall and the implant and hiding rippling from the implant. Risks for this approach includes skin wrinkles when the peck muscles contract (animation deformity) and chronic pain due to placement.

Prepectoral breast reconstruction has become popular in the last five years. This has been made possible by newer generation breast implants that are more cohesive or form-stable (hold their shape better), newer surgical techniques such as fat grafting, and the use of acellular dermal matrix (or ADM). ADM is a donated skin graft, The ADM is used as an internal bra, which provides an additional layer of protection and support to the implant. In contrast to subpectoral reconstruction, prepectoral implant placement is not typically associated with animation deformity or chronic pain. Expansions (described below) are quicker and easier to perform since the muscle does not need to be stretched. Risks include implant rippling or visibility since the implant is right under the skin, although fat grafting and proper implant selection can minimize this. The implants may have a tendency to drop lower since they are not supported by muscle, this is a theoretical risk that has not yet been proven. The preference as to where the place the tissue expander will be a mutual decision between you and Dr. Elswick that is discussed pre-operatively. Rarely, the planned location of the tissue expander may change based on factors that are discovered intra-operatively.

After the mastectomy is complete, the ADM is placed around the tissue expander, which is inserted into the breast. The tissue expander is filled with air to the desired level. Using air (rather than fluid or saline) to fill the expander limits the weight of the expander, which is gentler on the mastectomy skin and incisions and subsequently facilitates healing. By using air to fill the expander, Dr. Elswick is able to take advantage of the remaining breast skin and most patients wake up with a breast that is similar in size to what they had pre operatively if so desired. One to two drains are placed on each side of the mastectomy, depending on whether or not you have a lymph node dissection.The tissue expander surgery usually takes 1-1.5 hours depending on whether you are having single or double mastectomies. This time is in addition to the time it takes to complete the mastectomy. Patients are usually hospitalized for one night after a mastectomy with tissue expander reconstruction.

The patient is usually seen 10-14 days post-operatively (when the drains are ready to be removed). As long as everything is healing appropriately, the air in the tissue expander is removed and replaced with saline (salt water). The patient then returns to the office every 1-2 weeks depending on their schedule, goals, and need for any additional cancer treatment such as chemotherapy or radiation. Tissue expansion (“fills” with additional saline solution) are continued until the desired breast size is reached. The number of expansions that a patient requires depends on the pre-operative breast size, the desired post-operative breast size, and the amount of volume that is able to be injected during each expansion. However, most women generally require anywhere from one to three expansions. The breast skin is usually fairly numb post-operatively so most women tolerate the expansions with little to no pain. An expansion takes about five to ten minutes to complete. One of the major advantages of tissue expansion is that the patient is able to “try on” their breast size.

Once the tissue expander fills are complete (generally in the first month after surgery barring any major complications), you can begin the discussion on when to complete the second stage of reconstruction, which entails removing the tissue expander and placing a permanent implant. Dr. Elswick will discuss the various options for implants, focusing on the preferred size and projection (how much the implant sticks out from the chest wall). Almost all patients utilize silicone implants (rather than saline implants) for breast reconstruction. Usually a form stable or “gummy bear” implant is chosen. Usually the incision is placed in the scar from the previous mastectomy and tissue expander surgery. Usually no drains are required at the second stage surgery. Additional procedures are frequently combined with the implant exchange. The most common additional procedure is fat grafting (see additional information on fat grafting below). Other simultaneous procedures include mastopexy (breast lift), scar revisions, and symmetry procedures for the other breast (breast augmentation, breast lift, or breast reduction). The duration of the implant exchange surgery is variable depending on what other procedures are being at that time, but usually takes 1-2.5 hours. Patients usually do not require hospitalization for the second stage reconstruction and leave the hospital a few hours after their surgery is complete.

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