In immediate prosthetic breast reconstruction, during the same surgery as the mastectomy, plastic surgeon Dr. John Kim places a tissue expander within the breast pocket. Over the next several weeks or months, the expander is gradually inflated with salt water, which allows the skin to stretch over time. Once the expander is filled to the patient’s desired or necessitated volume, it is exchanged with the permanent implant. Check out this training video of one of Dr. John Kim’s surgeries in which he prepares his patient’s breast envelope for submuscular tissue expander placement:
The process of placing the tissue expander adds about 1 hour to the mastectomy surgery. Once the breast surgeon has finished the mastectomy, Dr. Kim starts the expander placement portion of the surgery. Dr. John Kim works with several breast surgeon colleagues at Prentice Women’s Hospital on these combined cases. Depending on the volume of the patient’s breast envelope and the quality of the mastectomy flap skin after the mastectomy, Dr. Kim may or may not add the first fill of saline to the expander at the time of surgery. About 2 weeks after surgery, the expansion process begins, and patients come to the plastic surgery clinic in Galter Pavilion on the Northwestern campus in downtown Chicago every 1-2 weeks on average to have their expander(s) gradually filled. Each expansion typically adds 30-60 cc of salt water. Once the patient’s desirable size is attained (and she has completed chemotherapy, if required) her expander will be removed and replaced with the permanent saline or silicone implant. This surgery is done on an outpatient basis, so patients typically return home that same day.
After a patient has healed from the mastectomy and exchange surgeries, she may choose to undergo nipple reconstruction. Dr. Kim also performs this procedure on an outpatient basis. A nipple is created from a small flap of the reconstructed breast skin. Once the new nipple has completely healed, patients have the option to have an areola (the colored portion surrounding the nipple) tattooed on by our experienced medical aesthetician.
Although prosthetic breast reconstruction, or tissue expander/implant reconstruction, involves at least two distinct surgeries (plus a third for the nipple and any subsequent revision surgeries) it is in fact the least invasive breast reconstruction procedure and also the most popular. Approximately two-thirds to three-fourths of all breast reconstructions are of the prosthetic variety. Prosthetic reconstruction results in the fewest scars, as Dr. Kim does not take any tissue from the abdomen or back, in contrast to autologous flap procedures. It is important to note that smokers or obese patients are more likely to have complications than non-smokers and patients with normal body weights for not only expander/implant reconstructions, but for all modalities. For another look at tissue expander breast reconstruction surgery (this time with the addition of acellular dermal matrix, a sling-like supportive material) check out this training video from Chicago reconstructive surgeon Dr. John Kim:
Advantages of tissue expander/implant reconstruction
- No additional scars: Dr. John Kim places the implant through the pre-existing mastectomy scar
- Only one additional hour of surgery after the mastectomy
- Patients are in the hospital for the same length of time as if they had the mastectomy alone
- There are minimal additional risks to adding in a tissue expander beyond the risk already present for mastectomy
- Tissue expansion leaves you with choices: you can change to a flap-based procedure prior to the exchange surgery
Disadvantages of tissue expander/implant reconstruction
- If you have one reconstructed breast and one natural breast, the reconstructed breast will not be symmetrical with the native breast. A tissue expander is not your own tissue and is not a true breast, so it will appear different.
- Expanders put you at risk of infection, which may result in expander removal. In an ideal candidate, the risk of expander failure is 1 in 20 to 1 in 25. If your reconstruction fails, you can still undergo a second attempt at reconstruction several months after infection/failure resolution.
- Tissue expansion requires several visits to our clinic in Galter Pavilion in downtown Chicago over several weeks.
- Tissue expander reconstruction requires at least 2 surgeries.
Risks of Tissue Expander/Implant Reconstruction
- Dr. John Kim always informs his patients that there is a 5-10% risk that your expander will have to be removed, which is considered a reconstructive failure.
- For patients who have had radiation, the risk of explantation can be as high as 30-40%.
- You may experience expander malposition. Dr. Kim can fix this during the second surgery, when your expander is replaced with the permanent implant.
- Patients are sometimes unhappy with the final appearance of their prosthetic reconstruction. Perhaps the patient had unreal expectations, or there may have been a medical/surgical difficulty during the procedure. Dr. Kim feels it is crucial to have open and honest conversation with his patients starting at the first consultation visit.
- The integrity of the expander itself, in rare cases, may be compromised, as with a puncture. In this case, the expander will not be able to perform its job of expanding the skin, and a replacement expander will have to be put in place in the operating room.
- The incisions may not heal in an ideal manner. The incisions can become overly scabbed, or scar healing may be poor. Sometimes, Dr. Kim needs to revise the edges of the incision as an in-office procedure. Patient who smoke or have larger breasts are more susceptible to this issue.
- Like any surgery, patients are at risk of excessive bleeding.
- Patients may experience seromas, or fluid collections underneath the skin. The reason drains from inside the breast leading to the outside are placed at the time of surgery is to prevent seroma formation. If you have a seroma, Dr. Kim will drain the excess fluid with a needle.
- Many mastectomy patients develop an uncomfortable feeling in their armpit skin and sometimes down their arm. This is due to pressure or injury on the nerves that leave the breast and feed into these regions. This is a mastectomy-related issue and not specifically caused by the expander.
- As with any surgery, patients may develop a blood clot in the leg, which is a serious complication, as these clots can move from the leg into the lungs, causing breathing issues. The risk is low at 1 in 500, but it is still very important to note and look out for. Blood thinners are used to treat blood clots.
- There is a chance of death with any operation, and prosthetic reconstruction is not an exception. In an otherwise healthy patient, the risk of death is 1 in 10,000.
For further information on tissue expander/implant breast reconstruction and its associated advantages, disadvantages, and risks, please contact Chicago plastic surgeon Dr. John Kim to set up a personalized consultation today.