After Bilateral Mastectomy, my Expanders Are Excruciating

Although your symptoms may be entirely normal, I would need more information to advise about your specific case. For example, the traditional approach using the "total submuscular" technique is typically quite painful, and the expansions can be difficult as well. The trend now is to use Alloderm to support the bottom and sides around the expander. This avoids having to dissect up the muscles that are the most tight and painful, while also giving a lot of control over the shape. Hopefully this was done in your case, and things will settle down. Either way it is early and it will get better.

Breast reconstruction with tissue expanders is a very painful operation. I doubt that there is any way that your body is too small to accommodate the smallest expanders. I don’t think that this is the problem. Creating the pockets for the expanders is what hurts, and now that this has been done, you have been through the worst part. You are probably still experiencing the normal pain expected after surgery. It seems that it is somewhat more severe in your case. I would encourage you not to end the reconstruction. Things should get better soon. Filling the expanders can wait until you are feeling better. In fact, removing some of the fluid placed in the expanders at the initial surgery may relieve some of your discomfort. Another option is to ask your surgeon for a referral to a pain management specialist. There may be some more effective pain medications for you to take. Topical anesthetics or even intercostal nerve blocks may also be of help in getting you through this difficult but temporary phase.

After mastectomy, breasts can be reconstructed using a variety of methods. In general, techniques use autologous tissue (from your own body), implants, or a combination of the 2.

You and your surgeon chose to go with tissue expanders and from the preoperative size of your breasts, it sounds like you needed additional volume and stretching of your skin.

You are having pain after surgery. You are frustrated and are thinking about ending the reconstruction. Try to stick with it and see if you can make some adjustments. This is the most difficult time and things will become easier.

A few questions to consider…Did your surgeon fill the tissue expander intra-operatively? Are they submuscular? If yes, then ask your surgeon to deflate the tissue expander and see if that helps. If you are still having pain, then there should be some consideration to changing your tissue expander to a subglandular (above the muscle) location. That should do the trick, but remember, putting the TE above the muscle increases other issues with your implant. Ask your surgeon. Hope this helps, good luck.

If you have skin available, you do not need expanders. Ido almost all my reconstructions in a single stage ,and immediate . I understand your mastectomy already happened. If you have extra skin, you can avoid the expanders with the use of a collagen graft to expand your muscle and place a small memory gel permanent implant. If no skin was saved, and the expanders are painful, the graft can expand the muscle and reduce the skin expansion pain. The other option is a flap reconstruction.Good luck.

The pain you are experiencing is probably due to the pectoralis muscle that is being stretched by the tissue expander. The newer technique of placement of the tissue expander and coverage with acellular dermal matrix may be possible to treat this issue. The tissue expanders potentially could be placed above the muscle and expanded to accommodate your desired breast size. 

The smallest tissue expanders are 350 cc, and I have reconstructed breasts where the total volume removed from each breast was 80-90 cc. Thus, I can understand completely if even the smallest completely unexpanded tissue expander under your muscle causes pain in a small-breasted woman. In these cases, you have a few options. First, you should know that the smallest size implant is 100 cc, so when you exchange your tissue expander for the permanent implant, you can have a smaller implant. That said, a 100 cc implant may have a narrow base width that makes it look like you have a small bean bag under your skin. Another option is to forego implant-based breast reconstruction altogether. If you undergo autologous tissue breast reconstruction (with your own tissue), you can have a natural and normal-looking breast that is closer to your original size. If you don't have enough tissue in your abdominal area, you can go to other donor sites such as the upper inner thighs (PAP flap) or buttock (GAP flap). With autologous tissue breast reconstruction, you can have a natural appearing breast reconstruction that is over your muscle, so that you don't have the discomfort of stretching out your pectoralis muscle. 

I am assuming that you underwent a bilateral mastectomy and bilateral immediate reconstruction with tissue expanders. It is not unusual to have pain 3 weeks after the surgery.  You may be also experiencing some muscle spasms from the stretching of the pectoralis muscle.  Make sure you have adequate pain pills and maybe add a muscle relaxant.

If the pain is so severe that it can not be controlled with oral medication, then you might consider removing the expanders.  BUT, there is no guarantee that the expanders are causing the pain, it may be just normal post op pain from the mastectomies.  Removing the expanders would require another anesthetic and reopening your incisions again, maybe even replacing the drain tubes.  It would not be a picnic.

I would recommend holding off on any surgery for now and see if you can get a better handle on the pain control.

Unfortunately, some pain with the tissue expansion process is normal, however, it sounds like your pain is more than is typically expected. You may want to visit with your surgeon to double check that everything is OK and that the pain is not the sign of a problem like a hematoma (which hopefully it is not).

In the event that the pain is not  the result of a problem, and just your body's response to the tissue expansion, you may want to consider alternate methods of reconstruction. Some natural tissue methods of reconstruction such as perforator flaps or fat grafting can be much less painful than tissue expansion. Perforator flas such as the DIEP and the SGAP flaps are generally very well tolerated, and almost every woman has a donor site available that can provide enough tissue for breast reconstruction in proportion to her body (even though this may not be possible from the abdominal tissue).

Best of luck, and I hope you are able to achieve a sucessful reconstruction with a minimum of further discomfort.

I am sorry to hear of your pain after tissue expander placement.   I can understand your frustration in consideration of ending your reconstruction.   I ask that you consider a few points on the subject:

1.  You are only 3 weeks out, your pain is going to improve with time 

2.  Have your surgeon evaluate you frequently to ensure that you do not have an early infection or a retained fluid collection (r your drains still in?)

3.  Discuss with your surgeon the option of a muscle relaxer or anti-inflammatory agent to help ease your pain.

4.  Consider physical therapy to help with range of motion exercises and deep tissue massage.   the combination of these will help subside any pain due to scar tissue formation

I wish you a safe recovery and hope you are able to undergo your reconstruction.  All the best.

 

Paul S. Gill, M.D.

GIll Plastic Surgery

Houston Double Board Certified Plastic Surgeon

I would  give it a little more time yet for your pectoralis muscle in the chest to relax after being stretched.  This will likely improve in a couple more weeks then you can begin expansion in small increments.