EXPANDER & IMPLANT RECONSTRUCTION

Expander & Implant Reconstruction

Implant and Tissue Expander methods of Breast Reconstruction are ideal for those women who do not have enough of their own tissue to use for reconstructing the breast or those who simply desire an Implant-Based Reconstruction.  One advantage of using an implant to reconstruct the breast is that the only incisions required are those used during the Mastectomy portion of the procedure.  For those patients who have already had a Mastectomy, the scars from the Mastectomy can be utilized to perform the implant Breast Reconstruction. 

Breast Reconstruction with a Tissue Expander and Implant usually involves at least three stages. The first stage involves the temporary placement of a Tissue Expander beneath the chest wall musculature in order to “stretch” the overlying skin and muscle, creating the pocket that will ultimately contain the permanent implant.  Tissue Expanders can be placed at the same time as the Mastectomy (Immediate Reconstruction) or months to years after a Mastectomy (Delayed Reconstruction).  Most women today are electing to have immediate Reconstruction (Reconstruction performed at the same time as the Mastectomy), but occasionally Immediate Reconstruction is not recommended due to factors that are related to the breast cancer itself.  In both Immediate and Delayed forms of Breast Reconstruction this first stage is termed Tissue Expansion.

In some unique situations, the first stage of Reconstruction can be skipped (Tissue Expansion) and a permanent implant can be placed immediately after the Mastectomy.  In general, this technique is best used in women with small breasts with good skin tone and the utilization of AlloDerm® is critical to provide complete coverage of the implant.  This technique has the advantage of skipping the weeks involved with Tissue Expansion and moving directly to the second stage (implant placement).  This technique does not usually result in fewer total surgeries as there are usually modifications made to the breast after the implant is placed and before the nipple and areola are reconstructed.  Because there is no Tissue Expansion, the ability to choose the exact implant size preoperatively is limited to what the tissues will permit.  Our surgeons will be happy to assist you in determining whether you are a candidate for this technique.

Stage One - At the time of the initial operation (either immediately after Mastectomy or delayed months to years after Mastectomy), a Tissue Expander is placed beneath the pectoralis major muscle.  The upper portion of the Tissue Expander is covered by pectoralis muscle, but the lower portion of the Tissue Expander is covered by AlloDerm®.  Traditionally, the pectoralis muscle covers the entire expander, but this creates more pain and slows the expansion process because the muscle has been stretched over the entire implant.  Today, AlloDerm® affords surgeons the ability to cover the lower portion of the expander without stretching the pectoralis muscle.  This allows more rapid expansion cutting the first stage of Tissue Expansion down from several months to several weeks.  Because the AlloDerm® creates a soft “hammock” covering the lower part of the expander, the lower part of the breast can be expanded in a more anatomic fashion creating much better breast contour and cosmesis.  AlloDerm® also permits more saline solution to be placed into the expander at the initial surgery, allowing a patient to be several months down the road in terms of expansion, which ultimately translates into fewer needed expansions.  Both Dr. Chris Williams and Dr. Jeremy Williams are uniquely trained in this state of the art form of Implant-Based Breast Reconstruction.

The expander has a port that is built into the front of the expander through which additional saline can be added to the expander.  There is usually a pain catheter and 2 drainage tubes placed into each breast.  The pain catheter infuses numbing medication into the pocket around the expander to assist with pain control, while the drainage tubes remove any additional fluid out of the pocket and into small collection bulbs.  These tubes will be removed by your doctor based on the amount of fluid that is collected over a 24-hour period.  Expansion will usually start within the first 7-10 days after surgery.  This process is performed in our Park Meadows office and involves only mild discomfort. Discomfort is usually limited to tightness and muscle soreness during expansion and this can usually be easily managed with over the counter pain medications.

Once the volume in the expander has reached a level that is satisfactory, and the patient has completed any additional medical or chemotherapy treatments, the second stage can be scheduled.  The volume in the expander will be similar to the volume in the permanent implant, but the firm, projecting shape of the expander will be exchange for a softened, more breast-like appearance with the permanent implant.  One advantage of Implant Reconstruction is that the patient can choose her ultimate breast size during expansion.  Fluid can be added to the expander until a volume is reached that the patient is pleased with.

Stage Two - This stage is an outpatient surgical procedure that usually only lasts 1-2 hours.  During this stage the expanders are removed from the pocket that has been created during Tissue Expansion.  Scar tissue is usually removed from the pocket to soften the overall appearance and feel of the new breast.  New implants are placed into the pocket and usually one small drainage tube is placed into each breast and removed the following week.

Choosing the type of implant is a decision that you and your surgeon will make together.  Understanding the choices is important and your surgeon will assist you in educating yourself regarding the options available.  There are essentially two types of implants available: saline-filled implant and silicone-filled implants.  Both implants are safe and FDA approved for use in Breast Reconstruction.  Saline implants tend to have more projection because they are more rigid and firm and the implant shell is manufactured differently than the shell of a silicone implant.  Saline implants will feel firmer, consistent with the viscosity of water.  The shell surrounding both saline and silicone implants is made of a silicone polymer.

Much of the public concern surrounding silicone implants has been based on misinformation and rumor.  Large studies have been completed and published in peer review journals establishing the safety of silicone gel implants.  Older silicone gel implants (like those used in the 1980’s) were constructed of a liquid silicone with very thin shells.  The current generation of silicone implants are made of cohesive gel, which does not leak or bleed through the silicone shell as previous silicone implants have.   When these implants are cut in half they appear much like a “gummy bear”, leading many people to erroneously refer to these implants as a Gummy Bear Implant.  The Gummy Bear Implant refers to an implant that is not yet FDA approved for use in the United States.  These new cohesive silicone implants have actually been around in markets in Europe and Latin America for nearly a decade and their safety and durability profiles are well established in the medical literature.  This extraordinary safety and durability profile is what led to the FDA approval of this latest generation of cohesive gel silicone implants in 2006.  Silicone implants tend to have less rippling or wrinkling than saline implants due to their greater viscosity.  They also tend to restore the feel of breast tissue better than saline due to their cohesive viscosity.

After the permanent implant has been placed you will immediately feel more comfortable than when the expander was in place.  The tightness will decrease quickly as the implant settles into the pocket.  The implant is usually allowed to settle for several months prior to the final stage of Nipple Areola Reconstruction being performed. 

Stage Three - Reconstruction of the nipple can be performed alone or can be combined with other contouring procedures such as fat grafting or scar revision.  Fat grafting can be used to soften implant edges and fill contour defects that may be present.  Nipple Reconstruction alone can be performed under a local anesthetic with virtually no discomfort as an in office procedure.  Pigmentation is usually placed around the nipple to reconstruct the areola 3-4 months after Nipple Reconstruction.

For some patients who undergo a unilateral (one-sided) Breast Reconstruction, adjustments on the opposite breast are often needed to match the reconstructed breast.  These adjustments can include Breast Lift, Breast reduction and Breast Augmentation in an effort to achieve better symmetry.  These symmetry procedures can be performed at the time of the second or third stages of Implant Breast Reconstruction. 

In ideal situations, where there is no chemotherapy or postoperative radiation therapy, Total Reconstruction can be completed in less than a calendar year (sometimes much less).  In other situations, where expansion and implant placement need to be separated by chemotherapy or radiation therapy, expansion may take slightly longer.  AlloDerm® significantly accelerates the entire process and enables most women who need to undergo adjuvant therapies such as chemotherapy to complete expansion entirely before starting chemotherapy.  This decreases infection, pain and discomfort during these additional treatments allowing women to direct their entire focus at the treatment of their breast cancer, knowing their Reconstruction is proceeding expeditiously.  As with any surgery complications can occur and though these complications are rare it is important to be aware these risks.

All Surgery Carries Some Uncertainty & Risk

All surgical procedures involve some possible risks, such as the effects of anesthesia, infection, swelling, redness, bleeding, and pain. There are also potential complications specific to breast implants and Tissue Expanders. These complications occur in a very small percent of women, but you need to be aware of the possible risks. After reading the discussion below, please contact your surgeon if you have questions.

Deflation and Rupture: You should be aware that breast implants may wear out over time and deflate or rupture. When breast implants deflate the saline solution leaks out of the silicone implant shell. It can occur rapidly over hours or slowly over a period of days. Deflation or rupture is recognized by loss of size or change in shape of your breast. Implants may deflate or rupture within the first few months or several years after surgery.  Today’s silicone implants do not deflate and the gel is usually retained within the capsule or implant pocket.  Causes include: damage by surgical instruments, overfilling or underfi1ling of the implant with saline solution, capsular contracture, trauma, intense physical manipulation, excessive compression during mammographic imaging, and other unknown reasons. Deflated implants require additional surgery to remove and to possibly replace the implant.

Capsular Contracture: Capsular contracture occurs when scar tissue (the capsule), that normally forms around the implant, tightens and squeezes the implant. At present, it is unclear whether capsular contracture is caused by infection or hypertrophic scar formation. Symptoms of capsular contraction range from mild firmness and discomfort to severe pain. Capsular contracture may cause pain because of nerve entrapment or interference with muscle motion. Breast distortion, palpability of the implant, and or movement of the implant may also be noted. To correct capsular contraction, surgical options range from removal of the capsule tissue to removal and possible replacement of the implant itself. Capsular contracture may reoccur in one or both breasts.

Pain: If you experience severe pain not relieved by pain medicine, notify your surgeon immediately. Some discomfort is expected after surgery and you will receive a prescription for pain medication. The intensity and duration of pain after Breast Reconstruction will vary among women.

Dissatisfaction With Cosmetic Results: We strive to attain the aesthetic results you desire. Some women are not entirely satisfied with their results due to mild wrinkling, asymmetry, implant displacement (shifting), incorrect size, unanticipated shape, implant palpability, scar deformity, hypertrophic (irregular, raised scar) scarring, or “sloshing”. Careful surgical planning and technique can minimize but not always prevent such results.

Infection: A small number of women develop an infection. This typically can occur several days to several weeks after the procedure. With implants present infection can be more difficult to treat than infection in normal body tissues.  If an infection does not respond to antibiotics, the implant may have to be removed, and another implant may be placed after the infection has resolved. In rare instances, toxic shock syndrome has been reported in women after Breast Implant Surgery. This life-threatening condition is characterized by symptoms such as sudden fever, vomiting, diarrhea, fainting, dizziness, and/or sunburn-­like rash. A doctor should be seen immediately for diagnosis and treatment for this condition.

Hematoma and Seroma: A hematoma is a collection of blood under the skin, and a seroma is a collection of the watery portion of the blood under the skin. Hematomas or seromas typically develop within the first few days after surgery. However, they may occur at any time after injury to the breast. The body can reabsorb small hematomas or seromas and often patients will be unaware or asymptomatic of these smaller fluid collections. Larger ones require the placement of surgical drains for proper healing. A small scar can develop at the surgical drain site. Implant deflation or rupture can occur if the implant shell is punctured when the drain is placed.

Breast Sensation: Feelings in the breast can decrease after Tissue Expander / implant placement. People report a range of feelings, from intense sensitivity to complete numbness in the breast. These changes are usually temporary, but can be permanent and may affect your sexual response or your ability to nurse a baby.  These changes vary widely between patients, but in general it can be expected that overall sensation to the breast region will be decreased after Mastectomy and Tissue Expander / implant placement

Delayed Wound Healing or Wound Dehiscence: In some instances, the incision site takes longer to heal than normal. Cigarette smoking, poor nutritional status and a compromised immune system can all cause delayed wound healing or wound separation.

Implant Extrusion: Extrusion is when the breast implant or Tissue Expander comes through the skin. If blood supply to the overlying tissue is compromised or if wound healing is interrupted extrusion may occur.

Possible Connective Tissue Disease: Concern has recently been raised over the association between breast implants and the development of autoimmune diseases, such as lupus, scleroderma, or rheumatoid arthritis. A review of several large epidemiological studies on women with and without implants indicates that these diseases are no more common in women with implants than those in women without implants.

Additional Surgeries: You should understand that you may require additional surgery in the future to replace or remove your implants. Situations such as deflation, capsular contracture, infection, shifting, and calcium deposits can require removal of the implants.