Every year approximately 15,000 women in Australia are diagnosed with breast cancer according to the Breast Cancer Network Australia. Many of them are likely to undergo a mastectomy or breast removal surgery. Often only one breast is removed. As is common with most other nations, a large number of women undergoing single or double mastectomy do not have breast reconstruction.

A few women opt to have immediate breast reconstructive surgery, which combines the breast removal and reconstruction into a single procedure. The rest—a majority of reconstructive patients—opt for a delayed breast reconstruction procedure, which essentially involves two operations. If a woman wants to preserve the skin of her removed breast (or breasts) intact, for a later, more natural looking breast reconstruction this is where tissue expanders come in useful.

Tissue expansion is a technique used by plastic and restorative surgeons to help the body grow additional, skin, bone and other tissues. Tissue expansion is achieved by implanting a tissue expander under the healthy skin, which is inflated gradually over time with saline injections to achieve the desired enhanced volume. Tissue expansion works by taking advantage of the natural elasticity of the skin. This technique is useful in breast reconstruction as well as in reconstructive procedures on the lips and the eyelids. Tissue expanders can also be used in other situations, such as repairing damaged skin caused by birth defects, accidents or previous surgery.

What is a tissue expander?

“A breast tissue expander is an inflatable breast implant designed to stretch the skin and muscle to make room for a future, more permanent implant,” says the Johns Hopkins Medicine Breast Center web.

Once implanted underneath the skin and the pectoral muscle, the tissue expander is gradually inflated over time with saline injections, made via a small valve in the expander. This occurs over a period of several weeks—with an average of around three months—until the expander has reached the desired size or volume.

Reasons for using tissue expanders in breast reconstruction

Tissue expansion is a common technique used in breast reconstruction. Here’s why it is popular among both patients and surgeons alike:

• Breast reconstruction with tissue expansion is a simpler, faster, relatively less expensive surgical procedure compared to other breast reconstruction options, including using a persons own tissue in the reconstruction process (autologous reconstruction).
• The tissue expansion technique is suitable for any woman including very slim women. Compared with autologous reconstruction, no donor site—such as tummy muscles or tissue as in TRAM or DIEP flap procedures—is necessary. Autologous reconstruction requires the woman to have an adequate amount of tissue, fat and muscle to be used as a donor site. In fact, TRAM, DIEP, LAT-Dorsi Flap—these names that you come across as you research breast reconstruction techniques—are all referring to the muscles or tissue that will be used in the reconstruction process.
• A breast reconstruction using natural skin draped over the reconstructed breast looks more natural. This is why preserving the natural skin envelope after a mastectomy is important.
• Since skin of the breast does not have to be moved from one area of the body to another, it leads to less scarring. The resulting scars are also likely to be less visible.
• This technique enables a woman to get back to normal life a lot more quickly compared to alternatives.
• Because the skin of the breast remains connected to the body’s blood and nerve supply, there is less risk that the skin will die causing surgical complications.
• Compared to tissue expansion reconstruction, autologous breast reconstruction involves many hours of surgery, typically between 8 and 12 hours. This includes the time spent on microsurgical reconstruction to ensure a ready blood supply to nerves at the reconstructed site. Autologous methods of reconstruction can be very expensive for the patient because in addition to surgery time, these methods also involve a longer hospital stay during recovery.

Your surgeon will also look at, among other factors, the quality of the overlying skin of the breast, the condition of the pectoral and serratus muscles, in determining whether you are a good candidate for the issue expansion technique.

Using tissue expanders and preserving the natural skin towards reconstruction with a breast implant is ideal for women who want to have more natural looking breasts following a mastectomy.

What to expect: stages of breast reconstruction with tissue expanders

Breast reconstruction with tissue expansion is achieved in three stages:

Implanting the tissue expander

This is the first stage and is required to take place immediately after mastectomy. To make this possible, the tissue expansion procedure should be planned prior to the breast removal surgery date.

Immediately after the mastectomy operation removes the breast tissue in its entirety, the tissue expander is placed under the pectoral muscle. Sometimes, the tissue expander may be expanded with saline at the time of insertion.

It is always better to consult with a surgeon before a mastectomy so that all options can be explored, explained and understood. When other supporting therapies such as chemotherapy and radiotherapy are necessary, it becomes even more important to plan the reconstruction before the mastectomy.

For those patients who need to undergo radiotherapy it is important to have the expander placed at the time of mastectomy to preserve the skin. Undergoing radiotherapy without placing an expander can lead to skin and tissue damage during the therapy. Such damage rules out any possibility of future tissue expansions, making that person only eligible for an autologous-flap reconstruction.

If the patient does not require radiotherapy as part of her cancer treatment the placement of the tissue expander may be delayed.

If your surgical oncologist following the mastectomy has recommended chemotherapy or radiation, this will essentially mean a delay of the tissue expansion process by around four to eight weeks.

Expansion stage

During the expansion stage, you will need to visit your surgeon’s office at regular intervals for expansion of the tissue expander with saline. Your surgeon will measure and monitor the amount of saline that is injected into the expander. Doing so ensures that when the appropriate size is reached, it becomes possible to make a direct swap with a similar sized silicone implant.

Expansion rates and volumes are dependent on each patient’s level of comfort and the progress of wound healing, among other factors.

Your surgeon will monitor your progress carefully at each post operational visit. It may take up to 6 months for full expansion and settling time before the expander is ready for replacement.

Replacing an implant for the expander is considered the second stage of breast reconstruction using a tissue expander. In Australia, surgeons usually replace the expander with an anatomical or tear drop shaped permanent silicone breast implant.

Completing the reconstruction

The third and final stage of the breast reconstruction process involves reconstructing the nipple and tattooing of the areola. Usually this is done under local anaesthesia in a surgeon’s office.

Things to consider once you’ve decided to have tissue expanders

Tissue expanders are a breast reconstructive option for women who have undergone a surgical breast removal (mastectomy). As with any other procedure, breast reconstruction with tissue expansion and implants have their limitations.

• What they can do: They can provide you with good breast contour and improved symmetry so that your breasts look natural and similar under clothing or a bathing costume. They also help you avoid having to wear an external prosthesis.
• What they may do: Although there are no guarantees, breast reconstruction may help improve your body image and self-esteem, at least partially erasing physical reminders of breast cancer.
• What they won’t do: It is essential to have a breast reconstruction using any method with realistic expectations. It is unlikely that breast reconstruction will make you look exactly as you did before your mastectomy operation. Reconstructed breasts will not provide the same sensations as your normal breasts.
• Additional surgery: Those who undergo breast reconstruction surgery with tissue expansion may need additional surgery to correct reconstructive problems.
• Asymmetry: If an expander is only inserted in one breast, you need to be prepared for asymmetrical breasts until corrective surgery is completed on the other breast. It’s important to understand that during the first few sessions of expansion, your breast will not have the same size or shape as the opposing breast. The breast will not take its absolute form until the expanders have grown to their full-expected size, settled and the implant is placed inside. Until then, you will have to deal with asymmetry.
• The other breast: If the mastectomy and reconstruction is only on one breast (unilateral), it is likely that the other breast may require surgery to produce better symmetry and contour. Depending on patient needs and requirements, this procedure may be a breast lift (mastopexy), breast reduction (reduction mammoplasty) or a breast augmentation (augmentation mammoplasty). The links given here will provide you with details about each procedure.
• Other considerations: Be aware that airport security scanners or metal detectors can detect the metal valves used in tissue expanders. It’s a good idea to have a doctor’s certificate stating that you have a metal object implanted in your body.

Before and after surgery

If you decide to have a breast reconstruction with tissue expanders immediately following a breast removal you’ll see your surgeon for your first post-op visit about two weeks following the removal. This first visit is the best time to ask all your questions about the procedure.

On your next visit, saline will be added to the expander. Your surgeon will also examine the incision to make sure your breast is healing properly. If the sutures are not the dissolvable kind, your surgeon will decide when to take them out.

Every week, for one to two months, you will have to return to your surgeon’s office to insert more saline solution inserted into the tissue expanders. Prior to each expansion, your surgeon will examine the incision line and breast mound. This process takes anywhere from 20 to 30 minutes. During the procedure and immediately afterwards, you may feel tightness in the area of your breast. You may also develop a slight soreness in your back and shoulders. The discomfort usually subsides after a day or two.

If pain or discomfort does not subside after three days, contact your surgeon immediately.

After each expansion you can continue regular activities. You may also return to work and perform light-duty housekeeping a couple of hours after your expansion. Once you regain a full range of motion in your shoulder and have stopped taking pain medications, you can resume driving a car.

Your surgeon may show you a few stretching exercises to perform after every expansion. Expect your surgeon to ask about your progress with these exercises when you have check-up appointments.

Once your expansion is nearly complete, you may notice that your new breast mound looks significantly larger than your natural breast. This is completely normal. Loose tops or sweaters can help to camouflage this imbalance.

If your job involves lifting 5 or more kilograms, you may need to discuss temporary light-duty options with your employer.

As the advice goes, be careful around kids, men and pets, especially dogs.

If you have any questions, your surgeon should be happy to answer them.

Possible risks and complications

There are potential risks and complications in any medical and cosmetic procedure. Tissue expansion and breast reconstruction is not an exception to this rule.

The possible risks and complications vary according to the type of tissue expanders used. It can also vary by individual.

• Breaks, leaks and ruptures. Tissue expanders, like other medical devices, can fail. They are susceptible to breaks or leaks like other types of breast implants. Rupture can occur from an injury, during a mammogram and even during expansion. However, when saline-filled tissue expanders rupture, the saline water leaks into the body and the body absorbs it. Although the ruptured implant may not be hazardous to your health, it will need to be removed.
• Capsular contracture occurs when internal scar tissue forms around the tissue expander. It can make the breast tighten, causing the expander to be round, firm and quite painful.
• Tissue death (necrosis) is possible when a patient uses steroids after chemotherapy or radiation therapy. It can also be caused by smoking, excessive hot or cold therapy and microwave diathermy. Diathermy is a form of physical therapy that involves generating local heat in body tissues using high-frequency electromagnetic currents.
• Implant extrusion occurs when the tissue expander becomes exposed through the skin. This can happen in cases where there is insufficient tissue coverage or as the result of an infection.
• Skin irregularities in the chest wall are common side effects associated with most types of breast implants. A ‘dog-ear’ effect can form at the end of the incisions when there is an excess of skin. These can improve with time or may need to be surgically removed.
• Implant displacement, by way of rotation or migration of the tissue expander may occur. It is often accompanied by discomfort and distortion in the shape of the breast and visible rippling of the skin. Additional surgery may be required to rectify this problem.

Rough costs involved

Surgeon, anaesthetist and hospital costs will vary. Since tissue expanders are considered to be part of reconstructive surgery (as opposed to cosmetic surgery), Medicare and private health insurance usually cover their expense as well as hospital costs. Patients with private health insurance will also be eligible for a rebate for the expander/implant and surgical fee.

You should expect the costs to be higher if you are having combined procedures at the same time.

This information is correct as of 2019.