DCIS right breast and looking at mastectomy with a tissue expander placement for delayed autologous (IGAP or TUG) 4 months after mastectomy. Is this common? Will it also be placed under the muscle? Won't that stretch out the muscle and create problems with the autologous reconstruction? Am VERY worried ... Oh, and adamantly opposed to implants.
Tissue Expanders As "Bookmarks" for Autologous Delayed Reconstruction?
Doctor Answers 9
Delayed-Immediate Breast Reconstruction
If you only have DCIS of the right breast, I would speak to your breast surgeon and plastic surgeon about the possibility of a simultaneous immediate breast reconstruction. Although recent studies show no clear indication to immediate testing of the sentinel lymph node for cancer, many surgeons utilize this as a green light to proceed with reconstruction. If the lymph nodes are negative and tumor size small, chances of radiation are very low.
With DCIS, I commonly recommend immediate tissue reconstruction if they desire this method and are a healthy candidate. This will save you a 2nd procedure and 2nd recovery. I wish you a safe and healthy recovery.
Using tissue expanders to hold the space prior to autologous reconstruction is done. Most commonly this is done when there is a high likelyhood of post operative radiation therapy. This would allow the autologous tissue to not be radiated. In a case of DCIS I wold usually plan for a definitive reconstruction at the time of the mastectomy
Delayed Immediate Reconstruction
You raise a good point about having the tissue expander placed under the muscle. The question is, when the free flap is done, do you put it in the pocket that has been created by the temporary expander, or do you create a new pocket and let the muscle drop back down? I think it is best to create a new pocket underneath the skin as I have had problems with contour irregularities putting the flap in to the pocket created by the implant, but this will be up to your surgeon. It is certainly a well described technique, although perhaps not desperately common. I have moved away from doing it myself and prefer to either do an immediate reconstruction with a flap or a delayed reconstruction.
You should go to your surgeon with these questions - he or she will give you the most accurate and relevant advice. Good luck.
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Tissue Expander as a "Bookmark" for a Free Flap
It sounds like what you are describing is known as "delayed-immediate" breast reconstruction. Placing a tissue expander as a place holder before a free flap is usually done when either a woman clearly needs radiation and is unwilling to be without a breast after reconstruction, or when a woman's breast management team cannot accurately determine, ahead of surgery, the possible need for radiation. It is not common to use a tissue expander as a "bookmark" in the setting of DCIS (but without knowing more about your history, I cannot be sure there is not a reason).
Most women with DCIS who want to undergo SGAP flap, IGAP flap, TUG flap or other free flap breast reconstruction AT THE TIME OF MASTECTOMY; this is known as immediate breast reconstruction. If you do not have any evidence of invasive carcinoma, it is unlikely that you will require radiation and therefore, the risk of a bookmark tissue expander is probably significantly outweighed by the benefits of immediate breast reconstruction.
If you wish, you can find more information about breast reconstruction and radiation as well as information about immediate and delayed breast reconstruction on my website.
Tissue expander and free flap
Without knowing the surgeon's plan I can only assume that he wants to keep the skin and perhaps stretch it out a bit for the perforator flap which is usually not placed under the muscle.
Tissue Expander as Spacer Implants before Delayed Autologous Reconstruction
One of the reasons to place a temporary tissue expander implant and delaying your definitive tissue only reconstruction is to see if after mastectomy, you will need radiation therapy or not. However, if you just have DCIS and a relatively small tumor, then if you are having a mastectomy, it is very unlikely you will need radiation. To eliminate this extra step of surgery, I would suggestion you explore IMMEDIATE autologous reconstruction with procedures such as a TRAM, DIEP, TUG, or GAP. In other words, if your breast surgeon is confident that with mastectomy, you will NOT require radiation therapy after surgery - then proceed with your mastectomy and reconstruction all in one surgery - all in one recovery. To learn more about your tissue only reconstructive options, please visit our breast reconstruction website below.
WHICH Mastectomy and Reconstruction would be best?
Regarding: "Tissue Expanders As "Bookmarks" for Autologous Delayed Reconstruction?
DCIS right breast and looking at mastectomy with a tissue expander placement for delayed autologous (IGAP or TUG) 4 months after mastectomy. Is this common? Will it also be placed under the muscle? Won't that stretch out the muscle and create problems with the autologous reconstruction? Am VERY worried ... Oh, and adamantly opposed to implants."
You have legitimate concerns but it sounds like you need to sit down with BOTH your breast surgeon and your Plastic surgeons to have them answered.
Depending on your breast surgeon's philosophy of how much breast skin needs to be removed at the time of a mastectomy for localized breast cancer (DCIS) you COULD have had an immediate reconstruction with EITHER an autologous tissue flap, a mixture flap and implant or breast implant.
I understand you have ruled out breast implants and will not question your reasons except to remind you that the use of breast tissue expanders has some of the same near term complications of breast implants.
WHY are you getting a delayed reconstruction and why are you not undergoing a breast conserving Mastectomy which would give you a more natural result should be the questions you need to ask your surgeons.
Dr. Peter Aldea
Tissue expanders then autologous reconstruction?
Firstly, tissue expanders are implants, so whatever your concerns are about implants that is worth knowing. The idea appears to be to prevent the skin envelope from shrinking until the flaps can be done to replace the volume. Your simplest sequence of events with the fastest recovery time is probably to go with implants, whether or not tissue expanders are done first. Autologous reconstruction involves major surgeries with much longer recovery and has its own set of risks. Implant reconstruction especially with the use of alloderm is an increasingly popular choice for that reason.
If the mastectomy is done as a SKIN SPARING MASTECTOMY, then no need for the expansion. Immediate reconstruction is the way to go, unless there are certain unknown ( to me) circumstances that requires staging the procedures.