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Breast reconstruction plastic surgery
To get answers to the most frequent questions about breast reconstruction
plastic surgery and tissue expansion, please select one of the
What is tissue expansion?
In the early 1980's it was discovered that skin (and other tissues)
when subjected to a gradual stretching force will not only stretch
but will actually grow.
A good analogy is the way in which a woman's abdomen accommodates
to pregnancy — not only does the skin stretch but there
is actually more skin present as the delivery date nears. Moreover,
some increase in skin is permanent.
This discovery has led to a minor revolution in plastic surgery,
and consequently, various expansion devices are now available
to take advantage of the ability to stretch and manufacture tissues.
What is a tissue-expander?
A tissue-expander is a device, similar to a
water balloon, that is placed in the body so that tissue expansion
may be performed. Tissue expanders are made from a silicone compound
similar to that used in saline breast implants.
The exact size and shape of the expander is determined by the
size, shape and nature of the defect requiring reconstruction.
The most popular expanders used today for breast reconstruction
are the so-called "anatomical" tissue expanders. These
expanders are shaped as a tear-drop which simulates the natural
drape of the breast. They are designed to inflate more toward
their bottom thus providing greater "inferior pole expansion"
or greater amounts of tissue where needed toward the bottom of
the reconstructed breast.
A modern anatomical
integral filling port
How is tissue expansion performed?
The tissue-expander (or expander) is placed during a surgical
procedure in a deflated or largely deflated state.
After the surgical incision has adequately healed (ordinarily
about two to three weeks) the expander is gradually inflated in
your surgeon's office through weekly injections of saline solution
by way of a small needle placed through the skin. The injections
are usually performed on a weekly basis although this can be liberally
modified to fit the patient's schedule.
As the expander gradually inflates, the process of tissue expansion
occurs and the shortage of skin is compensated. (Tissue expanders
and tissue expansion are used throughout the body in plastic surgical
reconstruction of other defects and are not limited to breast
Early tissue expanders had what was known as a "remote filling
port", a small button-like device which was placed beneath
the skin adjacent to the expander and which was connected to the
expander by a small, soft tube. The saline solution was injected
into the remote filling port in the surgeon's office. Removal
of this remote filling port at the time of implant placement was
difficult and required an additional small incision.
Most expanders in use today for breast reconstruction utilize
an integral filling port that consists of a metal lined pocket
within the expander itself. One manufacturer utilizes a rare-earth
magnet within the filling port. The surgeon precisely locates
the filling port prior to each injection so that damage to the
expander does not occur.
Removal of these expanders is greatly simplified and no additional
incisions are needed to remove the filling port.
When is the expander placed?
Placement of the tissue expander is the most common first step
in breast reconstruction. The expander can be placed at the time
of mastectomy ("immediate breast reconstruction") or
can be placed at any time in the future.
Many plastic surgeons prefer to place the expander at the time
of mastectomy because it saves the patient a second anesthetic,
a second recovery period and a second trip to the hospital. Moreover,
because scar tissue has not yet formed, the procedure is easier
In addition, we prefer to close the mastectomy incision using
plastic surgical techniques in an attempt to optimize the appearance
of the scar and to determine the quality of the overlying skin
flaps. (This attention results in a more cosmetically acceptable
If an immediate reconstruction has not been performed the existing
mastectomy scar can be utilized for access during subsequent ("delayed")
placement of the expander. Many surgeons prefer this approach
because an additional scar is avoided and because the mastectomy
scar is revised during expander placement.
Will immediate reconstruction with a tissue
expander prolong my hospital stay?
Usually not. Expanders can even be placed on an outpatient basis
when reconstruction is delayed.
How long does tissue-expansion take?
In most breast reconstructions, depending upon the patient's
breast and chest wall size, a tissue expander in the range of
400 to 700 cc is used and usually can be filled at the time of
placement with about 120 to 300 cc.
If one begins expansion about two weeks following surgery and
inflates weekly with 100 cc, then seven weeks are required for
We feel it's important to expand slightly more than the anticipated
goal and to leave the expander fully expanded for a few weeks
to insure that adequate tissue is available for implant placement
as well as to achieve a softening of the tissues, which will give
the new breast a more natural look and feel. We also adjust the
expansion routine to accommodate our patient's work and social
Some patients also wish to proceed more slowly than 100 cc per
week, particularly toward the end of the expansion period. These
factors can all modify the length of time required for tissue
expansion, but the important point is that tissue expansion should
proceed at a rate and over a period of time that's comfortable
for the patient with minimal disruption to her daily schedule.
Is tissue-expansion painful?
There is some minor discomfort associated with the process, however
this is mostly during the 48 hours immediately following an injection
as the skin stretches. This is why smaller amounts of saline are
injected as the process nears completion. The discomfort is usually
well controlled with oral pain relievers.
How will I look when expansion is completed?
As the expander is filled a mound develops in the location of
the breast. The expander is usually filled to a volume that is
slightly larger than the implant used to replace it. The expander
usually feels significantly firmer than the subsequent implant
and many patients report some discomfort during the expansion
The final implant is usually quite comfortable and well tolerated.
Remember, the expander is really a "rough draft" of
your future breast. Sometimes the expander can extend farther
upward in the direction of the clavicle than desired, or an asymmetry
of the inframammary fold can occur. These imperfections can be
corrected at the time of implant placement.
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