This is the most common type of breast reconstruction performed. A tissue expander is a temporary “spacer”, similar to a balloon, which allows the plastic surgeon to preserve the volume and shape of the breast. It is shaped like a breast and has a “tear drop” appearance when viewed from the side. The outer shell of the tissue expander is made of silicone. There are different sizes of tissue expanders, so it can be individualized to fit your body and reconstructive goals. Unlike a breast implant, a tissue expander has a port that is used to fill the cavity. A tissue expander is used as a temporary device to help create a nice pocket to hold the final implant while also expanding or stretching the breast skin to create the desired post-operative size and shape. You can see an example of a tissue expander during your consultation with Dr. Elswick.

The decision for where to place the incision is based upon the type of mastectomy you are having (i.e. whether or not the nipple is being saved), the location of the cancer, and the size and shape of your breast. Common incisions include in the crease along the bottom of the breast, across the center of the breast (for a skin-sparing mastectomy when the nipple is sacrificed), around the areola (the pigmented portion of the breast) sometimes extending laterally towards the chest wall under the arm, or an inverted T or an anchor pattern (for patients having Golidlocks reconstruction). You may also require additional incisions for lymph node procedures in the armpit. The breast surgeon and plastic surgeon will work together to decide what incision is most appropriate for your situation.

Once the decision has been made that is safe to proceed with reconstruction, the next step is to decide where to place the tissue expander. There are two different locations where the tissue expander can be placed: subpectoral (under the muscle) or prepectoral (on top of the muscle). The traditional approach was to place the tissue expander under the muscle to provide additional layers of protection. Placing the tissue expander under the muscle may also provide more fullness in the upper portion of the breast, leading to improved cleavage while also camouflaging the implant by creating a smoother transition between the chest wall and the implant and hiding rippling from the implant. Risks for this approach includes skin wrinkles when the peck muscles contract (animation deformity) and chronic pain due to placement.

Prepectoral breast reconstruction has become popular in the last five years. This has been made possible by newer generation breast implants that are more cohesive or form-stable (hold their shape better), newer surgical techniques such as fat grafting, and the use of acellular dermal matrix (or ADM). ADM is a donated skin graft, The ADM is used as an internal bra, which provides an additional layer of protection and support to the implant. In contrast to subpectoral reconstruction, prepectoral implant placement is not typically associated with animation deformity or chronic pain. Expansions (described below) are quicker and easier to perform since the muscle does not need to be stretched. Risks include implant rippling or visibility since the implant is right under the skin, although fat grafting and proper implant selection can minimize this. The implants may have a tendency to drop lower since they are not supported by muscle, this is a theoretical risk that has not yet been proven. The preference as to where the place the tissue expander will be a mutual decision between you and Dr. Elswick that is discussed pre-operatively. Rarely, the planned location of the tissue expander may change based on factors that are discovered intra-operatively.

After the mastectomy is complete, the ADM is placed around the tissue expander, which is inserted into the breast. The tissue expander is filled with air to the desired level. Using air (rather than fluid or saline) to fill the expander limits the weight of the expander, which is gentler on the mastectomy skin and incisions and subsequently facilitates healing. By using air to fill the expander, Dr. Elswick is able to take advantage of the remaining breast skin and most patients wake up with a breast that is similar in size to what they had pre operatively if so desired. One to two drains are placed on each side of the mastectomy, depending on whether or not you have a lymph node dissection.The tissue expander surgery usually takes 1-1.5 hours depending on whether you are having single or double mastectomies. This time is in addition to the time it takes to complete the mastectomy. Patients are usually hospitalized for one night after a mastectomy with tissue expander reconstruction.

The patient is usually seen 10-14 days post-operatively (when the drains are ready to be removed). As long as everything is healing appropriately, the air in the tissue expander is removed and replaced with saline (salt water). The patient then returns to the office every 1-2 weeks depending on their schedule, goals, and need for any additional cancer treatment such as chemotherapy or radiation. Tissue expansion (“fills” with additional saline solution) are continued until the desired breast size is reached. The number of expansions that a patient requires depends on the pre-operative breast size, the desired post-operative breast size, and the amount of volume that is able to be injected during each expansion. However, most women generally require anywhere from one to three expansions. The breast skin is usually fairly numb post-operatively so most women tolerate the expansions with little to no pain. An expansion takes about five to ten minutes to complete. One of the major advantages of tissue expansion is that the patient is able to “try on” their breast size.

Once the tissue expander fills are complete (generally in the first month after surgery barring any major complications), you can begin the discussion on when to complete the second stage of reconstruction, which entails removing the tissue expander and placing a permanent implant. Dr. Elswick will discuss the various options for implants, focusing on the preferred size and projection (how much the implant sticks out from the chest wall). Almost all patients utilize silicone implants (rather than saline implants) for breast reconstruction. Usually a form stable or “gummy bear” implant is chosen. Usually the incision is placed in the scar from the previous mastectomy and tissue expander surgery. Usually no drains are required at the second stage surgery. Additional procedures are frequently combined with the implant exchange. The most common additional procedure is fat grafting (see additional information on fat grafting below). Other simultaneous procedures include mastopexy (breast lift), scar revisions, and symmetry procedures for the other breast (breast augmentation, breast lift, or breast reduction). The duration of the implant exchange surgery is variable depending on what other procedures are being at that time, but usually takes 1-2.5 hours. Patients usually do not require hospitalization for the second stage reconstruction and leave the hospital a few hours after their surgery is complete.

Direct to implant reconstruction has frequently been called “single stage” breast reconstruction. A permanent implant is placed at the time of mastectomy, avoiding the need for a tissue expander. However, many women still require a revisional surgery to optimize breast shape, scars, or symmetry. Once the mastectomy is complete, the patient is evaluated to ensure they are an appropriate candidate for immediate reconstruction. The criteria to undergo immediate reconstruction include complete removal of the cancer, an adequate amount of skin to perform the reconstruction, and healthy mastectomy skin with a good blood supply.

Candidates for direct to implant reconstruction include women with small to moderate size breasts that want to have the same breast size or smaller breast size post-operatively. Large implants can cause strain on the breast skin after the mastectomy which may lead to implant failure. In addition, patients who want to have the possibility of one surgery are also good candidates, although a small revision surgery may still be required.

There are many similarities between the two stage reconstruction described above and the direct to implant reconstruction except the implant is placed at the time of the mastectomy rather than the tissue expander. Acellular dermal matrix (ADM) is placed around the implant, which is inserted into the breast. The ADM is used as an internal bra that provides an additional layer of protection and support to the implant. The implant can be placed under the muscle or above it. One or two drains are placed on each side of the mastectomy, depending on whether or not you have a lymph node dissection.

The surgery usually takes 1-1.5 hours depending on whether you are having single or double mastectomies. This time is in addition to the time it takes to complete the mastectomy. Patients are usually hospitalized for one night after a mastectomy with direct to single stage reconstruction.

Traditionally Goldilocks Reconstruction was used to describe a type of reconstruction where the skin and fat left after a mastectomy was rearranged in such a way to create a breast. The tissue from the lateral breast and chest wall can also be recruited to provide additional volume. This technique works well in women with large breasts who want smaller breasts postoperatively and fits the adage of “not too big, not too small, but just right” from the Goldilocks and Three Bears story. Now, there are multiple applications of Goldilocks Reconstruction:

• The reconstruction can be performed in the traditional aspect, rearranging the patient’s own tissues to create a new, smaller breast. If desired, the patient can undergo one or more episodes of fat grafting to enhance the size or shape of the breast.
• The reconstruction can be performed in combination with a tissue expander and/or implant for women with large, droopy breasts desiring better breast shape with a more youthful and “perky” appearance.
• The reconstruction can be performed in patients who do not want reconstruction but want to limit or prevent the concavity that can be caused by a mastectomy.

If you are a candidate for a nipple-sparing mastectomy, there is a chance that the nipple areola complex can be salvaged with Goldilocks Reconstruction. The ability to preserve the nipple is unpredictable; the nipple receives much of the blood supply from feeding blood vessels that travel through the breast tissue which is removed during the mastectomy. Hence, the nipple is only receiving a fraction of the blood supply it once did. The ability to save the nipple is an intra-operative decision and the various options on how to proceed if it is not able to be saved can be discussed with Dr. Elswick pre-operatively.

The incision is in the form of an upside down “T” with a horizontal scar in the fold under the breast. If your nipple-areola complex is preserved, there will also be a scar around the areola.

Once the mastectomy is complete, Dr. Elswick will rearrange the remaining tissue to create the best shape possible. Some of the extra skin and fat on the lower part of the breast gets buried under the upper skin and fat. This is done through a process called de-epitheliazation where the most superficial part of the skin is removed so it can be buried in the breast cavity. One to two drains are placed on each side of the mastectomy, depending on whether or not you have a lymph node dissection.

The surgery usually takes 1.5-2 hours depending on whether you are having single or double mastectomies. This time is in addition to the time it takes to complete the mastectomy. Patients are usually hospitalized for one night after a mastectomy with Goldilocks Reconstruction.

A “flap” refers to the transfer of tissue from one part of the body to another. There are two main types of flaps in breast reconstruction, pedicled flaps and free flaps. A pedicled flap remains attached to its native blood supply whereas a free flap is disconnected from its original blood supply and transferred to another part of the body where the blood vessels are connected to a new blood supply.

There are two main types of pedicled flaps that are used for breast reconstruction, the latissmus dorsi flap (LD flap) and tranverse rectus abdominis muscle flap (TRAM flap). Both of these flaps utilize the muscle and overlying fat and skin to create the new breast.

In the LD flap, the latissismus dorsi muscle is utilized which is located in the mid/lower back. It is the muscle utilized in “pull downs.” Most women will not notice any long term weakness with using this muscle for breast reconstruction because there are other muscles in the shoulder that are able to compensate, but people who perform activities such as swimming or cross country skiing may want to consider alternative methods of reconstruction. The scar from the LD flap can be placed in a horizontal line (hiding it in the bra strap line) or obliquely across the mid back.

In the TRAM flap, the rectus abdominis muscle (the six pack muscle on the abdomen) is utilized. It is possible to have some weakness with activities that require use of these muscles. Additionally, bulging of the abdominal wall or hernias are a potential complication. Sometimes a piece of mesh is placed to help prevent abdominal bulging or hernias. The scar lies transversely in the lower abdomen where it is usually easily hidden by underwear.

Tissue expanders or implants can also be placed in conjunction with pedicled flaps to give a patient additional volume. Pedicled flaps are usually utilized as a salvage procedure when there are complications from an earlier reconstruction or when a large amount of skin has to be resected during the mastectomy. Sometimes they are used when patients would like a reconstruction using only their own tissue but do not wish to undergo a free flap.

The surgery for an LD or TRAM flap usually takes about 3 hours to perform. Usually patients are in the hospital for 1-2 nights after an LD or TRAM flap.

Oncoplastic reconstruction utilizes techniques to mold the breast tissue that is left after a lumpectomy to give the breast a more natural, rounded appearance. This can limit the divet or concavity that can be left after a lumpectomy.

Performing a breast reduction during a lumpectomy is a type of oncoplastic reconstruction. It is possible to perform a breast reduction at the same time as a lumpectomy. If you are interested in having a breast reduction on both sides, there are advantages and disadvantages to consider with regards to doing the breast reduction on the non-cancer side at the same time as the lumpectomy or at a later date. Almost all patients undergoing a lumpectomy will require radiation after surgery. Radiation tends to shrink the remaining tissue and make it firmer, although the degree to which this occurs is unpredictable. Hence, if you wish to have both breasts reduced in one surgery, Dr. Elswick will try to predict the amount of tissue that needs to be excised to make you a similar shape after radiation (the radiated breast would be left slightly larger than the non radiated breast). Alternatively, you could have a breast reduction on the non- radiated side at a later date, generally at least six months after radiation, so Dr. Elswick can assess how the radiation has impacted the other breast. Despite this, radiation changes continue to occur throughout your life and the radiated breast tends to stay firmer and perkier over time when compared to the non-radiated breast.