Breast Reconstruction: Tissue Expanders

A tissue expander is a flat balloon placed underneath the skin and underneath the throwing muscle (the pectoralis muscle) of the chest. Patients wake up fairly flat on the surgery side after the mastectomy. About two weeks after surgery, the tissue expander will be "blown up" by injecting salt water into the implant, and this process takes 2-3 months of weekly visits. Then, after the expander has reached a symmetric size with the opposite breast and after any additional cancer treatments are over, the expander is removed in the operating room and a permanent implant is placed. The nipple is created in the operating room as a third step. The tattoo for the brown of the nipple occurs in the office about 1 month later to complete the four step process.

Ideal Candidates for Tissue Expander Breast Reconstructions

Tissue expanders and implants are round in appearance. They work best for slender patients with A or B cup breasts. The opposite breast is round, and with the nipple in the center of the breast mound. If the opposite side is not round but rather more of a triangle shape, patients request a surgical manipulation of the opposite non-affected breast to help achieve symmetry. Patients who select tissue expander breast reconstruction would say they want more symmetry in clothes, rather than out of clothes. They want to avoid extra risks, and to avoid any additional scars on the abdomen or the back. They have the time and ability to come to the office for multiple easy office visits. They don't mind the idea of a second outpatient surgery to take out the expander and to put in a permanent implant. This second surgery takes about 1 hour and is done as an outpatient. Most patients only miss 4-7 days of work for this second surgery if they work out of the home.

Patients who are not "ideal" candidates for tissue expander breast reconstruction are heavier with C and D cup breasts, or with the opposite breast with the nipple pointing downward. Patients who want symmetry out of clothes are not ideal candidates for this procedure. Patients with difficulty coming to the office also find this means of reconstruction difficult. Smokers and obese patients have more complications than non-smokers and ideal body weight patients for all of the 3 types of breast reconstruction. Patients who have had radiation therapy already prior to the mastectomy are typically advised not to undergo this procedure.

Advantages to Breast Reconstruction with a Tissue Expander

• No new or extra scars. The scar of the mastectomy is used for placement of the implant.
• One hour of extra surgery after the mastectomy.
• No extra time in the hospital. Most women go home the day after the mastectomy and reconstruction.
• Minimal extra risk to your body.
• Tissue expansion leaves all of your options open. After the expansion and before the implant exchange, you can still undergo the back operation or the TRAM flap for the final reconstruction step.

Disadvantages to Breast Reconstruction with a Tissue Expander

• The goal of a tissue expander is to fill out your bra. Women select this option if their goal is symmetry in clothes, rather than symmetry out of clothes. An expander is not a breast. The major risk to this procedure is an infection of the expander, and the need to remove the expander to resolve the infection. In an ideal candidate for tissue expander breast reconstruction, the risk is 1 in 20 to 1 in 25 of a failure of the reconstruction. If this were to occur, you would still be able to undergo a reconstruction many months after the infection resolved.
• Multiple steps and multiple office visits.
• This method of reconstruction is relatively static. While the non-affected breast ages over the years, the reconstructed breast with an implant does not change. Over the years, patients often ask for adjustments of the implant size, and lifts/reductions of the non-affected breast.

Risks of Tissue Expansion

• Loss of the expander and a total failure of the reconstruction. In an ideal candidate, this is on the order of 1 in 20 to 1 in 25.
• Malposition of the expander. Adjustments of the final position of the implant are made at the time of the expander removal and final implant placement (the second procedure).
• Unhappiness with the final appearance of the expander/implant reconstruction. This is due to unrealistic expectations of the patient, or due to some difficulty with surgery. Patient counseling by the surgeon and a clear understanding of the goals of the reconstruction by the patient will keep this risk to a minimum.
• Rarely, there will be a problem or puncture of the expander, causing the expander not to stretch the tissues well. This would necessitate placement of a new expander in the operating room.
• This procedure can have scabby wound healing of the incision. Approximately 1 in 8 times, the surgeon will need to revise the incision edges in the office. This happens more in patients who smoke, and in large breasted patients.
• Any operation can be associated with bleeding.
• Any operation can be associated with seromas, which are fluid collections under the skin. Drains are left at the time of surgery, and are removed about one week after surgery. The drains are placed to decrease the chances of a seroma. If a seroma is noted by your surgeon, a needle can be placed through the skin to drain the fluid collection.
• Most patients who undergo mastectomies develop a bad feeling in the skin of the armpit and sometimes down the arm. This is due to stretching or injury of nerves that exit the breast and go to these areas. It is a common complaint, and not really caused by the placement of the expander.
• Patients who undergo mastectomies will need to be monitored to regain the motion of the shoulder. Some patients will need to go to a physical therapist to help this motion. This is not specifically caused by the expander.
• Any operation can be associated with the serious complication of a blood clot in the leg. Blood clots in the leg can dislodge and go to the lungs, making breathing painful or difficult. The approximate risk of this is 1 in 500. Blood thinners can be used to treat this complication.
• Any operation can be associated with the chance of death. The risk of death in an otherwise healthy patient is on the order of 1 in 10,000 cases.