I am undergoing a nipple sparing bilateral mastectomy in 11 days. Are tissue expanders a must?

I have been diagnosed with DCIS and am undergoing a nipple sparing bilateral mastectomy in 11 days. I have been told I can go directly to silicone implants up to 500 cc which is what I would like. My plastic surgeon prefers to do expanders first because they can be adjusted if the nipple starts to die. He says though that there's not a greater chance of them dying going one way or the other. If my skin can accommodate the implant and I am certain what size I want, why not go directly to implant?

Doctor Answers 7

Are tissue expanders a must

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Hi and thanks for your question.  Each plastic surgeon has their own preference on how to do an implant based reconstruction.  For your doctor he is worried about compromising the nipples.  I would go back and talked to him more thoroughly about the procedure and why you cannot have implants directly.  You want to go into this procedure with all your questions answered without any doubts.  Best of luck.

El Paso Plastic Surgeon
4.9 out of 5 stars 41 reviews

Breast Reconstruction: Are tissue expanders a must?

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That's a good question and it all depends on the skin tension.  I prefer not to put any undue tension on the skin as it is significantly compromised after the mastectomy. I only perform the direct-to-implant approach in specific situations. For most patients, I am doing fat grafting to the skin flaps to give it a more natural look. That requires a second operation anyway. Since we are going back to the operating room, it is safer to use the expander in the initial stage which gives me more options.  I'm also able to position and secure the expander using tabs which are not feasible with the direct-to-implant approach.  Your surgeon can possibly be prepared to do either the expander or the final implant depending on the quality and the thickness of your skin flaps after the breast surgeon completes the mastectomy. 

Best Regards,
Dr. Bidros

Rafi S. Bidros, MD, FACS
Houston Plastic Surgeon
5.0 out of 5 stars 25 reviews

Breast reconstruction revision with Silicone Gel Implants

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This decision is one that is made in the operating room.  We also use the SPY Elite to for assessment of perfusion of the breast skin during the case.
Three basic forms of breast reconstruction exist. You can use your own tissue, implants or a combination of the previous two techniques. Your own tissue can be used in the form of the DIEP flap, PAP flap, SGAP flap or fat grafting. Implants can be done in one stage or two stage. Two stage reconstructions are started by placing expanders at the time of mastectomy. Once they expanders are placed they are able to be inflated as determined by wound healing. The final time consists of combining any of the above techniques.

If you are interested in being seen in Austin please give us a call. I know this is a difficult time for you. The majority of my practice is devoted to reconstruction for women with breast cancer or who are BRCA+

Nipple Sparing Mastectomy and Expanders

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The decision of whether to proceed with direct to implant reconstruction or tissue expanders is a function of the condition of the post mastectomy skin flaps. Post mastectomy the tissue is traumatized and relatively devascularized. With this in mind, the goal is to minimize any further undue stress on the tissue. Depending upon the condition of the flaps (thickness, color etc.), a surgeon may opt to forego implants for expanders (which can be placed relatively empty) and fill at a later date so as to allow the tissue to recover.

Typically, candidates for direct to implant reconstruction are smaller and non-ptotic and have post mastectomy skin flaps of adequate thickness. Placing a permanent implant deep to these flaps, a surgeon must be confident they will heal. Implant exposure is a serious complication which can compromise the entire reconstruction.

As always, discuss your concerns with your board certified plastic surgeon.  

Donovan Rosas, MD
Kissimmee Plastic Surgeon
5.0 out of 5 stars 12 reviews

Tissue expanders are the traditional method of implant reconstruction

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Tissue expanders are the traditional method of implant reconstruction.  Although it is possible to go directly to an implant, acellular dermal matrix (such as alloderm) is usually required to help cover the implants.  I would speak to your surgeon to clarify the treatment plan.

Martin Jugenburg, MD
Toronto Plastic Surgeon
4.9 out of 5 stars 508 reviews

Breast Reconstruction - tissue expanders

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No not a must be certainly more consistent of a route!  Direct to implant reconstruction works well in only a few surgeon's hands that I have seen.  Staged with initial expanders seems to work well with most surgeons.  Best Wishes!!

I am undergoing a nipple sparing bilateral mastectomy in 11 days. Are tissue expanders a must?

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If you choose reconstruction, there are several details to consider. Reconstruction can be performed at the same time as your mastectomy (immediate reconstruction), or it can be performed at any time in the future following your mastectomy (delayed reconstruction). After any type of breast reconstruction, plans may be made to reconstruct a nipple and areola complex in the future. This may be performed at any time after a few months from your final reconstructive procedure. The breast reconstruction procedures that are offered today include both implant-based and autologous (your own tissue) flap reconstructions, including DIEP, SIEA, TAP, and other free-tissue transfer breast reconstructive procedures. Be aware of all of your options, and again, become involved in the decision of which reconstructive procedure will be the best fit for you.
Women may choose not to undergo surgical reconstruction. For medical or psychological reasons, some women choose to delay their reconstruction. If you choose not to undergo immediate reconstruction, this does not preclude you from undergoing reconstruction at a later date. Some women have had breast reconstruction surgery months to years after their mastectomy. Often times, the same reconstructive options are available to you, and your surgeon will help to determine this for you when you feel ready to proceed with your reconstruction.

For implant-based breast reconstruction, both tissue expanders or direct-to-implant reconstruction are viable options. You and your surgeon will have to decide which is the wiser option, given all of the risks and benefits. Your thoughts are reasonable, and a discussion should be done with your surgeon. 

During this time, you may consider wearing an external breast prosthesis garment fit to match your remaining breast, or wear prostheses for both breasts. However, a reconstructed breast offers several advantages over breast prostheses. You will not be limited in your clothing options or the activities in which you participate. Psychologically, women reiterate the fact that they feel more confident, attractive, and feminine with a reconstructed breast than without one. The fear of the prosthesis becoming visible or displaced is gone. There is no constant reminder of the previous surgery on your breast or the cancer when placing the prosthesis on and taking it off. Lastly, there is a wholeness that is achieved, as the reconstructed breast becomes part of your own body.
Overall, every woman should be informed of her breast reconstruction options following breast surgery at the time of her diagnosis. Taking into account your cancer type, tumor size, nodal involvement, the need for pre/postoperative chemotherapy or radiation therapy, your overall medical health and comorbidities, along with your own personal preferences, should lead to a meaningful discussion about which reconstructive procedure, if any, you should have. Just as stated in other posts, immediate reconstruction is preferred for its increased aesthetic results, psychologic advantages, and "single operative & anesthetic" procedure. Although recent studies have shown excellent results with immediate reconstruction in the face of post-mastectomy radiation therapy, the traditional mode is to perform the reconstruction several months after completion of the radiation therapy. There are several reconstructive options to consider, and not one procedure is right for each person. However, your breast surgeon should discuss the breast reconstruction option and your plastic & reconstructive surgeon should inform you about the pros and cons of every procedure available and assist you in deciding which procedure is most suitable for you.

Lewis Albert Andres, MD
Scottsdale Plastic Surgeon
5.0 out of 5 stars 28 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.