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Tissue Expansion, Staged Breast Reconstruction

Tissue expansion is a process whereby existing tissue overlying the breast is slowly stretched by a balloon type devise to create sufficient tissue with which one can create a breast.

A temporary breast tissue expander is placed in the chest. The tissue expander can be placed at the time of breast cancer surgery (mastectomy) or at a later stage. Over a period of weeks the reconstructive surgeon gradually fills the expander with saline solution. During this process, your skin will gradually stretch and grow to make room for a new breast as it expands. Your body will slowly adjust to the growth of the implant in the same manner a women’s body adjusts to the gradual growth of her abdomen when she is pregnant.

Eventually when the desired size have been achieved the newly created space can be filled with an appropriate reconstruction. The second stage reconstruction is done at approximately three to six months after the desired expanded size have been achieved. The delay allows the tissue to soften and permanently acquire the expanded shape.

Thus one procedure in theatre to place the expander and a drain. One week later the drain is removed. Wait one month before commencing expansion allowing the scar to mature and not rupture, open up when stretched. Expansion can be done daily, weekly, biweekly or whenever you feel up to it. The expansion process continues until the desired size is reached. Once the desired size is reached we wait 3 months before removing the expander and performing the definitive reconstruction at a second surgical procedure.

The reconstructive options range from prosthetic or implant reconstruction to any type of flap reconstruction. Often we place a silicone implant alone or in combination with a latissimus dorsi flap from the back to provide additional coverage over the implant. The latissimus dorsi flap lends itself well to gradual expansion and allows for added coverage. Free flap reconstruction with your own tissue could also be used to fill the cavity so created for the breast.

This type of reconstruction requires a minimum of two operations. Should you develop complications, wish to delay your nipple and areola reconstruction or wish to have alteration in the shape of your breasts, you would need additional surgery.

The initial procedure involves the placement of the expander. Gradually the desired size will be reached during the expansion process. The seconds or definitive reconstruction will depend on the type of reconstruction decided upon. Please see appropriate informative note. The nipple and areola may be reconstructed at the second stage or at a delayed third stage. Delaying the nipple areola reconstruction allows the breast to settle in the correct shape and allow for a more correct positioning of the nipple areola.

You will receive a general anaesthetic. The reconstructive surgeon draws the appropriate access incisions on your breast either before or during the procedure.

The mastectomy may have been done previously or at the time of tissue expander placement. A tissue expander should only be placed 12 months after completion of radiation. Premature placement will result in expansion failure.

The expander is placed under the existing chest tissue and muscle. If the existing soft tissue and muscle is inadequate to provide sufficient coverage the reconstructive surgeon may decide to cover the expander with a latissimus dorsi flap.

A drain is placed at the surgical site. These drain will remain until the drainage is less than 30 ml in 2 consecutive days. The wound is closed in layers and appropriate dressings applied.

You would have to stay in hospital for a period of 1 to 2 days during the healing process. You will be taught to empty the surgical drain and to keep record of the drainage. Antibiotics and pain tables will be given to take home. The drains will be removed once it drains less than 30 ml in two consecutive days. The recovery time following expander placement is faster as the initial procedure is a relative small and simple procedure. You need to follow up with both the reconstructive as well as the oncological surgeon on the dates given at discharge.

Pain, bruising and swelling will gradually disappear over the next few weeks. The first expansion will occur in the surgeon’s room approximately 1 month after the initial expander placement. The patient and surgeon will proceed with weekly expansion until the desired size is reach and as the patient tolerate the expansion.

Should any complications arise the surgeon may attempt salvage of the expander but in the case of infection the expander would have to be removed and the reconstruction delayed for a period of 6 to 12 months.

Below follows a list of some of the more frequent complications associated with tissue expansion. Please note that the complications below have an increased incidence in patients who have previously received radiation therapy or smokers.

Local compilations i.e. around the breast……

  • Haematoma formation
  • Seroma formation
  • Delayed wound healing
  • Wound sepsis
  • Wound breakdown
  • Sensory changes in the breast
  • Pain

Expander Complications

  • Expander deflation
  • Expander rupture
  • Expander extrusion
  • Capsular contracture (hardening of the expander)

Systemic complication…. your body

  • Fluid and electrolyte abnormalities
  • Deep vein thrombosis
  • Post operative lung complications

Long term and cosmetic complications… the way it looks

  • Reconstruction malposition
  • Breast Asymmetries
  • Poor scarring
  • Secondary procedures to improve the appearance eg. fat fills

 

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