Breast 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.
Stage One of Breast Reconstruction
At the time of the initial operation 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. 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 of Breast Reconstruction
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 Reconstruction and Areola Pigmentation being performed.
Stage Three of Breast Reconstruction
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. Areola pigmentation, also called nipple tattooing, 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 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.
Direct-to-Implant Breast Reconstruction
In some unique situations, the first stage of reconstruction can be skipped (Tissue Expansion) and a permanent breast 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, called direct-to-implant breast reconstruction, 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 Denver breast surgeons will be happy to assist you in determining whether you are a candidate for this technique.
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 Surgeries. 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.
Post-Operative and Home Care Instructions for Placement of Tissue Expanders
Diet: Start with clear liquids and toast or crackers. If those are well tolerated, progress to a regular diet.
Wound Care: You will have a 1 or 2 drains in each breast. A drain kit with instructions and teaching by the nursing staff will be provided at the hospital. Empty and record (in “cc” amounts) the drainage amount once or twice per day after discharge from the hospital and bring your drain record with you to each clinic appointment.
All of your sutures will be under the skin. You will either have a layer of skin glue that resembles clear nail polish or steri-strips, similar to tape, on all of your incisions. Please do not remove the steri-strips. Your surgeon will remove the dressings, if needed.
You may feel and see the expander under the skin most pronounced at the midline.
Pain & Swelling: While in the hospital, your pain will be monitored very carefully. Pain medication will be prescribed to you to use as needed postoperatively. Pain is best controlled with lower doses of multiple medications such as Tylenol, Celebrex and narcotics.
You can expect moderate swelling in the reconstructed breast, underarm and abdomen. You will have numbness in the reconstructed breast and abdomen for up to 12 months.
Garments: Do not wear a compressive bra for the first 3 weeks. You may wear a light camisole for gentle support.
Bathing: You may shower and wash your hair 48 hours after surgery. You may get your incisions wet, but do not direct the water spray at your incision site. Pat dressings dry. Do not submerge the incision in a bath or swimming pool or hot tub for the first 4 to 6 weeks. Support your drains in the shower around your neck or waist.
Medications: Take pain medication as needed for up to 4 weeks in moderation and at night if needed. While you are taking pain medicine, you are encouraged to follow a high fiber diet or take a stool softener such as Colace (available over the counter), as pain medications tend to cause constipation. Do not take Motrin/Ibuprofen or Aspirin products for 1 week after surgery. Ask your surgeon when you may resume your blood thinning medications. All other prescription medications may be resumed immediately, as discussed with your physician. Take your full course of antibiotics if prescribed by your surgeon.
Sleeping: During the first 2 weeks, place pillows under your head and knees. Sleeping in a recliner may be most comfortable to keep the upper body supported. After the first 2 weeks, sleeping on your side and back is permitted, but not on your stomach. After 4 weeks, resume normal and comfortable sleeping positions.
Activity: You may walk and climb stairs immediately following surgery. After 2 weeks you may resume moderate activity such as brisk walking. No sexual activity for 3 weeks. During the first 4 weeks, do not lift anything heavier than a gallon of milk (10 pounds). No heavy exercise for 4 weeks (tennis, yoga, pilates, jogging, aerobics, weights, etc.). After 6 weeks you may resume more strenuous aerobic work and lifting activities. No abdominal exercises for 8 (+) weeks.
Driving: No driving for 2 or 3 weeks after your procedure or while taking pain medicine.
Smoking, Alcohol, and Cannabis: Do not smoke for the first several weeks after surgery as it impedes wound healing and can lead to serious wound complications. Smoking, Alcohol, and Cannabis consumption is dangerous while taking pain medicine. It has a tendency to worsen bleeding. If you use Cannabis/Marijuana, please discuss with your physician.
Post-Operative Appointment: Your first follow-up visit will be approximately 1 week after surgery. Your surgeon will then see you at appropriate intervals after this to monitor your progress.
Physical Therapy: A prescription for physical therapy will be given to you at either your pre-operative appointment or your first post-operative appointment. Gentle range of motion exercises are encouraged during the first 2 weeks.
Work and Travel: Depending on your career and your rate of healing, you should be able to return to work within 4 to 6 weeks of surgery. If your job involves heavy lifting, please allow 8 to 12 weeks before returning to work. Your surgeon will be able to give you a better estimate depending on your physical and professional profile. Flying or traveling is permitted after the first week as tolerated.
Special Considerations: Call your surgeon immediately if you experience any of the following: excessive pain, rapidly expanding swelling under the skin, bleeding, redness at the incision site or pus drainage from incision, spreading bright pink discoloration, or fever over 101.5° F.
Call 911 if you are experiencing a life-threatening emergency. Such symptoms include severe shortage of breath, chest palpitations, sudden or sever chest pain, or other life-threatening concerns.
To learn more about breast reconstruction with tissue expanders and breast implants, call our board certified plastic surgeons at Park Meadows Cosmetic Surgery in Lone Tree serving Denver and all of Colorado: 303-706-1100. Schedule a consultation online to learn about our services and take a tour of our state-of-the-art facility