How Tissue Expanders Are Used in Breast Reconstruction

Tissue expanders have silicone outer shells and either an internal valve or external port to allow for saline fluid injections that stretch the skin over time.

Your tissue expander should match the shape of the permanent breast implant that you are going to use. Both devices come in round, oval, and anatomical shapes, and can have smooth or textured surfaces.

Tissue expanders are not intended to be permanent. They will be removed in a second surgery and replaced with permanent implants.

Once you've consulted with your surgeon and decided to have reconstruction with implants, you will either opt to have the tissue expanders inserted during your mastectomy surgery or after you have healed. The most common scenario is for the two procedures to happen simultaneously.

Either way, you should arrange in advance for someone to pick you up and drive you home from the hospital.

If you are having expanders put in at the same time as a mastectomy, you will remain under general anesthesia; if you're having expanders placed at a later date, local anesthesia combined with a sedative may be used.

The tissue expander is inserted beneath the muscle in the chest wall muscles, where it is positioned within a pocket of tissue. The support of the muscle around it prevents the expander (and later, the implant) from "bottoming out"—i.e., sliding down as gravity takes effect and tissues relax with age.

A valve through which saline will be injected is placed, either within the breast or externally.

The placement procedure takes one to two hours. It will take twice as long if you are having expanders placed in both breasts.

Once you have recovered from your mastectomy and your incision has healed, around four weeks after the surgery, saline will gradually be injected into your tissue expander to stretch the surrounding tissues and create space for a permanent breast implant.

This will be done over a series of appointments and usually takes two to six months.

If your expander has an internal valve, your surgeon will locate the port and add saline through a needle inserted through your skin. Saline goes directly into the external ports. You will feel some pain due to the muscles being stretched, but this usually subsides in a day or two. If pain persists or worsens, contact your surgeon.

A newer form of expansion fills the expanders with carbon dioxide instead of saline, and a remote-controlled expander releases the gas from an internal reservoir. Your doctor can let you know if this is an option for you and what the pros and cons might be.

Here are some things you can do to be as comfortable as possible between tissue expansions:

• Avoid strenuous exercise or activities such as jogging, jumping, and running, which may cause your breasts to bounce.
• Avoid strength-training exercises that will tighten or bulk your chest muscles.
• Wear soft, supportive bras without underwires. You may want to use a breast form or padding to maintain a balanced appearance until the expansion is complete.
• Wear loose blouses, tops, and sweaters that won't rub against your breasts.

Once your chest tissue has been stretched enough, the expander and the valve will be removed and replaced with a permanent implant. This surgery will be done four to six weeks after the last saline fill.

However, if radiation therapy is part of your breast cancer treatment plan, most surgeons prefer that you receive it while you still have the tissue expander so that any scar tissue caused by the radiation can be removed before placing the final implant. In some cases, radiated skin isn’t the best environment for an implant. Your cosmetic surgeon can advise you on what's best in your situation and how/if this may impact your overall timeline.

Removal of tissue expanders is usually done as an outpatient procedure; it takes about one hour for each side. You will be able to go home once you have recovered from the anesthesia.

In addition to the usual risks inherent in having surgery, specific risks and potential complications of tissue expanders include:

• Infection: An expander with an external port poses a small risk of infection, so it's important to keep the port clean. If necessary, an infection can be treated with antibiotics. In some cases, the expander may need to be removed for several months until the infection clears. A new expander can then be inserted.
• A rupture, leak, or break in the expander: Saline solution that leaks out won't harm you and will be absorbed into your body, but you will need another procedure to fix and replace the expander.

While not health risks, you should also be aware of some realities of tissue expanders that will have an impact on how your breast looks:

• Lumpiness: Tissue expanders may ripple and their edges may show through or be easily felt. Permanent implants should not create these problems.
• Asymmetry: Tissue expanders will be overfilled so your skin can stretch and drape when your permanent breast implant is placed. If you have only one expander, your breasts will be asymmetrical until you receive your implant.