After radical mastectomy on left breast following cancer (but no chemo or radiation required), two plastic surgeons have recommended lat flap surgery followed by implant. One doctor suggested a "tear drop" (low profile) shaped tissue expander, while the other made no distinction of shape and would use what appears to be the typical round expander. Should I expect any difference in results following the implant?
Does Shape of Tissue Expander for Breast Reconstruction Matter?
Doctor Answers (15)
Radical Mastectomy Reconstruction
Radical Mastectomy involves removal of the pectoralis major muscle during the mastectomy. This is an extremely important barrier during implant reconstruction to protect the implant. If this is the case, I would recommend use of tissue from the back (LD) or abdomen (DIEP/TRAM) to help reconstruct the breast.
Speak with your cancer surgeon to ensure that you had a radical mastectomy. It is much more common to undergo a modified radical mastectomy or simple mastectomy and sentinel lymph node biopsy. Both of these procedures do not affect the pectoralis muscle and leave implant reconstruction a good option.
Why expander shape matters in breast reconstruction.
The goal of a tissue expander is to create a space for the permanent implant in the reconstructed breast. When you look at the natural shape of a breast, it has a tear-drop shape to it: More fullness in the lower pole of the breast than above. The expanders are shaped this way in order to either preserve that increased volume (as in a skin-sparing mastectomy) or the create more fullness inferiorly through expansion (as in a delayed or radical mastectomy). The implants themselves are usually round devices, however they will conform to the space created. This is why the expander shape is typically tear-drop shaped. The expanders themselves come in many sizes and heights to accommodate different size/shaped breasts.
Choice of tissue expander is guided by appearance of the opposite breast
Sorry to hear about your predicament. Given the history of a radical mastectomy, your reconstruction will require the "importation" of vascularized skin and muscle, hence the pedicled latissimus dorsi myocutaneous flap. In justifying the choice of tissue expander, I ask patients their opinion of their opposite breast. Is it too big and droopy, too small or just right? Since one of the goals of breast reconstruction is to produce symmetry, we need to be able to consider not only the mastectomy site, but also the opposite breast. Generally, I prefer the low height tissue expanders, because they preferentially "expand" or grow skin in the lower pole (area between the base of the reconstructed breast and future reconstructed nipple), which ultimately will provide a suitable skin envelope to match the opposite side, especially if the patient doesn't wish to surgically alter it. On the other hand, if a patient prefers to augment the noncancerous side, a medium height expander may be more appropriate to eventually accomodate a "high profile" implant. Good luck.
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Tissue Expander Shape- Does it Matter?
In general, the size and shape of the implant used for your reconstruction and the shape and size of the LD flap will influence the shape of the final reconstruction more than the shape of your tissue expander. If you are going to have an implant, I wonder, absent your history of radiation, why you need the LD flap? Furthermore, if you are going to go the route of a flap combined with an implant, you may want to explore the possibility of a reconstruction that uses only your own tissue (e.g., TDAP flaps, DIEP flaps, GAP flaps, TUG flaps, etc.). While these procedures may not be appealing to you, you may want to discuss them with your surgeon to be sure all options have been fully explored.
Best of luck with your surgery.
I used to use the low profile expanders. I should add that all will work, provided you get enough stretch at the bottom of the breast. I tend to use the round ones now for the simple reason that the patient gets a better idea of how the implant will look as we proceed with the expansion.
Tissue expander shape after mastectomy is important
One of the biggest advances in breast reconstruction has been the development of different profiles of tissue expanders. The reason for this is that the upper part of the breast area, where the pectoral muscle helps to cover the implant, expands much more easily than the lower half where the skin is adherent and there isn't good muscle coverage. So a round implant will overexpand the top and not round out the bottom enough. Shaped expanders focus on the lower part without overexpanding the top. Every case is a bit different but that is the typical pattern.
Another thing that has been very helpful is using Alloderm to give coverage and support to the lower part, where it functions like a muscle layer. That is the reason for the latissimus flap, but sometimes the alloderm can be used instead. If you are up for a third opinion, talk to someone who uses alloderm and they can also weigh in on expander shape.
Having had a radical mastectomy, if you are doing implant reconstruction, you do need muscle to cover your implant/expander. Question #1 would be, do you need tissue expansion at all or can you have a permanent implant placed at the time of latissimus flap? The answer to this question and ultimately your question about what type of expander to use depends on what you are trying to match on the other side. If your remaining breast has a lot of sagging, then your reconstruction might be better with tissue expansion using a lower profile expander. Further discussion with both plastic surgeons might shed better light on your situation. Good luck!
Tissue Expander shape in Breast Reconstruction
When doing an implant only breast reconstruction, the shape of the expander is very important. However, with a latissimus flap reconstruction, it probably matters little. The real question is, why the expander at all. Most frequently, when bringing in tissue, an expander is not necessary. Only an examination of your specific needs could decide exactly what will work best. Your particular situation may also be why a TRAM flap was not recommended. If possible, I prefer this (as one of its variations) since the donor site is symmetrical as opposed to the latissimus that leaves an asymmetrical back.
Shaped tissue expander for breast reconstruction
If you were going to get a reconstruction with a tissue expander followed by implant I would recommend using a shaped anatomical expander to stretch the lower part of the breast however if the reconstruction is with a flap then it does not make a difference if the expander is shaped or not because the flap position will help define the shape of the reconstructed breast. Good luck
Shape ot tissue expander in Lat. Dorsi Breast Reconstruction
This is a difficult question to answer in the absence of a photos and a physical exam. In general, the tissue expander and subsequent permanent implant usually serves to provide additional volume with the Lat. Dorsi flap. The use of a shaped or round tissue expander is probably of less importance.