Definition & Overview
Breast reconstruction with a tissue expander is the process of reconstructing the breast following a mastectomy. The process involves placing a temporary tissue expander in the gap or space left by the removed tissue in preparation of placing a more permanent breast implant. With the advent of tissue-sparing mastectomy, breast cancer patients do not need to face the prospect of living the rest of their lives with a missing part of their physical anatomy. However, the removal of cancer cells and healthy margin of tissue around the tumour create the need for tissue replacement to make the affected breast still appear as natural as possible. To address this need, surgeons insert tissue expanders into the breast to expand the underlying muscles and breast skin in preparation for the placement of breast implants. A tissue expander is made up of an inflatable expander and an injection dome, both made up of silicone elastomer. The injection dome is connected to the expander via a tube composed of the same material. The injection site is also fitted with stainless steel needle guards.
Who Should Undergo and Expected Results
Breast cancer patients who are undergoing partial or skin-sparing mastectomy are suitable candidates for breast reconstruction with tissue expander, which can be immediately performed after mastectomy. This procedure is also offered for mastectomy patients who are not suitable for breast reconstruction using free-tissue transfer. These include those who have inadequate donor tissue and are unable to tolerate lengthy surgery. Other suitable candidates are patients who do not need to undergo radiation therapy after mastectomy and some breast cancer patients who wish to avoid additional scarring in any other parts of their bodies, which could result from harvesting autologous surgical flaps. Meanwhile, breast reconstruction with a tissue expander is not suitable for patients who have insufficient skin or tissue to cover the prosthesis. It is also not suitable for those whose other breast has undergone significant ptosis since the prosthesis would be unable to match its appearance and the patient would end up having asymmetrical or lopsided breasts. The procedure is considered safe and highly successful when it comes to reconstructing breasts that underwent a mastectomy. The resulting shape and form of the breast after the final stage of reconstruction proved to be highly satisfactory to patients. This helps reduce the psychological impacts of dealing with breast cancer and the prospect of removing a vital body part.
A few weeks after the insertion, the patient would need to have the expander inflated with saline solution. The tissue expander should also be removed within six months of its implantation. As such, patients need to schedule another surgical session to have it replaced with permanent implants.
How is the Procedure Performed?
Prior to surgery, the surgeon evaluates the patient by asking her to stand or sit in an upright position. The general shape and volume of the healthy breast are then evaluated so the appropriate size of breast expander can be determined. During the process, the prospect of over inflation is factored in so it is easier to make adjustments later on, if needed. The incision line is marked at this point. The patient is placed under general anaesthesia and made to lie in a supine position. The surgeon commences to perform mastectomy, making one or more incisions on the breast. Once the tumour and a healthy margin of healthy tissue around it are excised or removed, the expander is inserted into the breast, just underneath the pectoralis major muscle. The expander has a port that is connected to the tubing. The other end of the tube is left outside the chest wall. It is connected to a syringe when it’s time to inflate the expander. In some cases, the surgeon may opt to fill the expander up to 10 percent of its capacity with saline solution. Recent advancements also make use of a surgical mesh or a dermal matrix product to cover the tissue expander. The mesh or the dermal matrix product provides additional support to the expander. This way, the expander can take in more volume of saline solution before the surgical site is closed. The more saline solution injected into the expander, the fewer sessions would be needed after surgery to fill the expander. Once the surgeon is satisfied with the placement of the tissue expander, drainage tubes will be placed in the surgical site before it is closed with sutures and dressings are applied. In the following weeks, the patient is asked to return to the physician’s clinic to have the tissue expander filled in stages. This way, the skin and muscles over the expander can slowly stretch to make space for the more permanent implant. During the expansion, a sterile saline solution is slowly injected until the overlying tissue of the expander is raised slightly. This process is repeated after a few days until the desired volume is achieved.
Possible Risks and Complications
As in any major surgical procedure, the patient faces the risk of infection and excessive bleeding. All patients who have tissue expanders implanted in their breast experience the formation of fibrous tissue capsule around the foreign body. In most cases, this does not pose any significant health risks to the patient. However, there are instances in which the contracture of the fibrous capsule may occur. The thickening tissue can contract and cause pain and discomfort. A second surgical session may be needed to free the tension caused by this fibrous tissue.
There is also a small chance of the expander leaking and deflating over time. If this happens, the patient needs to have the expander replaced.
The skin overlying the expander will be prone to necrosis and sloughing, possibly due to inadequate blood supply. Hematoma can also occur at the surgical site as well as fluid accumulation.
References: * Gui GP, Kadayaprath G, Tan SM, Faliakou EC, Choy C, Ward A, et al. Long-term quality-of-life assessment following one-stage immediate breast reconstruction using biodimensional expander implants: the patient's perspective. Plast Reconstr Surg. 2008 Jan. 121(1):17-24. * Spear SL, Murphy DK, Slicton A, Walker PS. Inamed silicone breast implant core study results at 6 years. Plast Reconstr Surg. 2007 Dec. 120(7 Suppl 1):8S-16S; discussion 17S-18S.