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What is tissue expansion?
Tissue expansion is a means to reconstruct the breast using a breast implant without a flap, where enough healthy skin and soft tissue necessary to cover an implant is not present. It involves the placement of an implant that is not completely filled, or of a tissue expander (a silicone shell balloon-like device) at the breast mound. Through gradual filling of the implant or expander over many weeks, enough healthy tissue is produced to cover a breast implant.
Tissue expansion and placement of a breast implant is appropriate in most cases of unilateral (one side) or bilateral (both sides) breast reconstruction. However, women who have had prior radiation to the chest, or certain skin conditions or scarring may not be able to safely expand enough viable tissue to cover a breast implant. Because of changes in the skin that can result from radiation therapy, it is often not advised to undergo tissue expansion concurrently with radiation therapy. In addition, if you smoke, you may not be a good candidate for reconstruction of any kind and will likely be advised to quit smoking before any reconstructive procedure and for many weeks following surgery. To quit smoking for life is in the best interests of your health.
Tissue expansion begins with placement of a medicalgrade, silicone shell balloon or a breast implant shell that over time is filled with sterile fluid through an internal, one-way valve. The implant shell may have a silicone outer form and a hollow inner cavity that allows tissue expansion, or it may be an unfilled saline breast implant. Tissue expansion can begin an immediate reconstruction at the time of mastectomy, or be used in delayed reconstruction. In most cases, the procedure is performed under general anesthesia. Following tissue expansion at the time of ablative breast surgery, you will likely remain in the hospital for two or more days depending on the type of expander used and the degree of your ablative breast surgery. In some cases of delayed reconstruction, placement of the expander may be performed on an outpatient basis.
Once your surgery is completed, you will likely be somewhat sore and experience discomfort in the chest area; this can be controlled with medication. In addition, you may notice a valve, or port from the implant under your skin. This is where the implant will be filled with sterile fluid over time to achieve its final size. Initial discomfort should lessen significantly in the first three to four days following surgery. You should be ready for light, normal activity within three to four days following surgery. Over the next few months or more, you will make several visits to your cosmetic surgeon’s office to add fluid to the expander or implant. As the shell is filled and increases in size, it stretches the overlying skin and tissue. The goal of tissue expansion is to create enough healthy tissue to support a breast implant or to expand the implant to its final size. The process of tissue expansion is not one without discomfort. Each time more fluid is added, you will likely feel tightness in the chest region, and you may feel sore. It is important to discuss any discomfort with your cosmetic surgeon; prescription or over-the-counter medications will help make the tissue expansion a more comfortable process. Once the process of tissue expansion is completed, the existing expander may be replaced with a final breast implant. Those expanders designed to serve as the final implant will be sealed, and any valve near the skin may be removed in a simple in-office procedure.
All of the complications and risks associated with breast surgery and with surgery in general are possible. Tissue expansion does require the use of a breast implant for your reconstruction and, therefore, all of the risks associated with the use of breast implants are possible. Tissue expansion can result in areas of skin that are thinner or weaker, so the risk of implant extrusion is somewhat higher. The best means to avoid this is to take all the time necessary for tissue expansion to achieve desired results, and avoid factors that can impair wound healing such as smoking.
Tissue expansion will not affect your daily routine; however, it may limit some of your exercise options. During the process of expansion, your figure will slowly evolve. Therefore, you may prefer to wear loose-fitting tops or padded bras to camouflage your evolving figure, or to softly pad a bra in order to lessen any asymmetry.
Does the use of a breast implant always require a flap or tissue expansion?
In most cases of mastectomy, there is not enough soft tissue remaining to cover an implant without significant risk of contracture, implant extrusion (breaking through the skin), or for a good result. However, some cases of skin-sparing mastectomy may retain enough skin and underlying soft tissue to allow for reconstruction with an implant and no additional procedures. Where lumpectomy or a partial mastectomy has significantly reduced breast size, the use of an implant without subsequent procedures may also be possible. However, if breast shape has been severely disfigured, a flap procedure and more advanced reconstruction may offer better outcomes. In 2004, the American Society for Cosmetic Surgery (ASPS) reported over 16,424 breast implants used in breast reconstruction were surgically removed, of which 73% were replaced.