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Staged breast reconstruction begins with a tissue expander at the time of mastectomy, followed by placement of the final implant at a second stage. This two-stage approach is currently the most common method of implant breast reconstruction. The alternative is immediate placement of the implant at the time of mastectomy, a single-stage procedure that can only be done for patients that meet specific criteria. If you require mastectomy and are considering implant-based reconstruction, our plastic surgeons can help you decide which of these approaches is best for you. To arrange a consultation, please contact us today.

Placement and Adjustment of the Tissue Expander

Tissue expander implant breast reconstruction requires a staged approach. To begin the process, the tissue expander is first placed on the chest wall in a pocket created deep to the pectoralis muscle. This first stage can be performed immediately after mastectomy or at a later point in time as a delayed procedure.

The tissue expander itself is essentially a pouch that can be expanded by the injection of saline through a self-sealing fill port. When initially placed, the expander is partially filled with saline, potentially providing an immediate breast contour. At intervals that usually range from one to three weeks, the expander is then slowly filled through additional saline injections. For the purpose of expansion, the fill port on the front of the expander can be accessed through the skin during a simple office procedure. If needed, expansion sessions can be coordinated with chemotherapy treatment. At a typical expansion, a volume of 50 cubic centimeters of saline (approximately 10 teaspoons) is injected through the port to fill the tissue expander. Because of the incremental nature of the expansion process, most patients have minimal pain or only mild discomfort associated with the expansion procedure.

The number of expansions required depends on how much fluid was placed at the time of expander placement as well as on the quality of the surrounding soft tissue. Through the use of AlloDerm® as part of the breast reconstruction, our surgeons can frequently place a larger volume of saline during the initial expander placement. This in turn may affect the total duration of treatment, as the less the expander needs to be adjusted, the less time may be required to reach the fully expanded volume. Once the desired volume is achieved, the second stage of reconstruction can be planned. The second stage of expander-implant breast reconstruction is an outpatient procedure, which involves replacement of the tissue expander with a breast implant.

Choosing and Placing the Breast Implant

There are two types of breast implants: saline and silicone. Both types consist of a silicone outer shell, but saline implants are filled with a salt-water solution while silicone implants are filled with a gel material. Both saline and silicone breast implants are approved by the FDA and have been in common use for decades. The newest generation of silicone implants received approval in 2006.

Both saline and silicone implants come in various sizes and shapes, and are available with either a smooth or textured shell. Once the expansion process is complete, the proper implant can be chosen, taking into consideration factors such as patient preference, chest wall measurements and the quality of healed soft tissue at the mastectomy site. The exchange can then take place as an ambulatory surgical procedure. Patients often report feeling immediately more comfortable upon removal of the expander and placement of the final implant. The breast implant should fit nicely within the pocket that has been formed, and any tightness or discomfort should continue to decrease as the implant settles and the scars heal. After a period of two or three months, the third stage of the breast reconstruction can then be completed allowing reconstruction of the nipple areola, and if needed, any other revision procedures.