How Tissue Expanders Are Used in Breast Reconstruction

About half of breast reconstructions are done using permanent breast implants, but unlike breast augmentation, breast reconstruction is a multi-step process.

Breast implants are the option for reconstruction that requires the least surgery. Unlike a tissue flap, no tissue is transplanted, and unlike a TRAM or Lat Flap, no muscle is relocated.

Some women choose immediate breast reconstruction with implants; others may choose to delay it and opt for breast prostheses that fit inside post-mastectomy bras for a while.

Breast implants can be used for reconstruction after a single or a double mastectomy.

Before you choose reconstruction with implants, consider the pros and cons of this method over one of the other methods that use transplanted tissue:

Pros:

• less extensive surgery, anesthesia, and pain than with other reconstruction methods
• no relocation of tissue or muscle
• faster recovery from surgery than with tissue transplantation
• breasts reconstructed with implants do not sag as you age
• uses the mastectomy incision for the procedure, so doesn’t create new scars
• sometimes can be completed in one step
• gaining or losing weight won't change the size of the reconstructed breasts

Cons

• leaking and shifting is possible
• results are not cosmetically perfect
• overall reconstruction process can take longer (multiple steps, multiple office visits to receive tissue expander injections)
• less likely to feel, look, or move like a natural breast
• subject to future problems such as rupture, deflation, capsular contracture
• opposite healthy breast often needs surgery to match the implant
• generally not a good option if skin has undergone radiation
• implant won’t last a lifetime

Getting a tissue expander is the first step for breast reconstruction with an implant.

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—usually for two to six months..

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. These balloon-like devices have smooth or textured surfaces.

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

After a mastectomy, a tissue expander is inserted beneath the muscle in the chest wall muscles, where it is positioned within a pocket of tissue.

Because your expander and your implant are surrounded by muscle, instead of being on top of muscle or only partly under muscle, the weight of the device will be well-supported. This muscular support prevents "bottoming out." When an implant is not supported by muscle, it can eventually slide 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.

Once your incision has healed, saline will gradually be injected into your tissue expander to stretch the surrounding tissues and create space for a permanent breast implant. This may 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 will through a needle that is inserted through your skin to the port. For expanders with external ports, saline goes directly into the port. You will feel some stretching and perhaps discomfort during fills. Discomfort should quickly fade. Some women experience pain during saline fills and for a day or so after an expansion treatment. But if pain persists, contact your surgeon for help.

Once your chest tissue has reached the desired size, the expander and the valve will be removed and replaced with a permanent implant. This surgery is usually done as an outpatient procedure.

Implants can contain either saline or silicone. These are available in several shapes, sizes, and textures. When you consult with your surgeon about implants, ask if you can see and hold a variety of sample implants.

Saline implants are the most common implants used and are filled with a salt water solution. Saline implants tend to feel firmer than silicone implants. There is also more wrinkling under the skin that can be felt with this type of implant.

Silicone gel implants are filled with liquid or firm silicone gel. They tend to feel softer than saline implants; some women think the texture is more like natural breast tissue.

All implants have a slight risk of rupturing; if this happens, surgery would be required to replace the implant.

Silicone implants are considered safe, but if you’re concerned, saline implants may be a more reassuring alternative.

Some things to be aware of while you have tissue expanders in place:

• Airport security scanners and metal detectors can sometimes detect the metal valves of tissue expanders. Prepare before your flight by getting a doctor's note explaining that you have an implanted metal object.
• 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.
• An implant with an external port has a small risk of becoming infected, so it's important to keep it clean. If necessary, an infection can be treated with antibiotics.
• Tissue expanders may ripple and their edges may show through or be easily felt. Permanent implants should feel more comfortable.
• In some cases, a tissue expander will rupture, leak or break. Saline solution that leaks out won't harm you, but you will need another procedure to fix and replace the expander.

If radiation therapy is part of your treatment plan, most surgeons prefer that you receive this 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.