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Breast Reconstruction Using Tissue Expander

Tissue Expanders and Direct to Implant (DTI)

Tissue Expander / Implant / Acellular Dermal Matrix

Breast reconstruction can also be accomplished by using prosthetics, implanted devices. With this method, the final reconstruction consists of a permanent breast implant, either silicone or saline, positioned under the skin and pectoralis muscle. Generally speaking, implant-based reconstruction can be done in multiple stages or as a single step.

Staged expander-implant

In the staged method, a device known as a tissue expander is placed at the initial operation. This can be placed at the same time as the mastectomy or at a later date, in a delayed fashion. Two to three weeks after surgery, the tissue expander is gradually inflated by adding saline to the device. This is done in the outpatient setting and continued until the expander is filled to the desired size. The main goal of this first stage is to expand the skin and create a pocket where the permanent implant will ultimately reside.

The second stage involves the removal of the tissue expander and placement of the permanent implant. This is usually an outpatient procedure and involves less recovery time than the initial operation.

Single-stage or Direct-to-Implant

A traditional mastectomy procedure removes the breast tissue and skin, leaving a relatively flat surface on the chest. In such cases, the staged approach with initial tissue expansion is necessary to expand the skin and create a space for the permanent implant. Other mastectomy techniques, such as the skin-sparing and nipple-sparing procedures, remove mainly the breast tissue while leaving much of the skin of breast and chest intact. If an adequate amount of skin is spared, it is sometimes possible to avoid the initial expander stage and place the permanent implant at the time of mastectomy, this approach is also known as a Direct to Implant breast reconstruction.  The ideal candidate for such an approach is typically a smaller cup size patient with excellent skin quality that can be evaluated at the time of physical examination. The Direct-to-implant reconstruction is only possible immediately after the mastectomy and not an option for patients seeking a Breast Reconstruction Timing.

Acellular Dermal Matrix

The tissue expander and implant method may, in some cases, require the use of a biologic implant known as the acellular dermal matrix. This material is derived from the skin of either animals or cadavers and is treated to contain no living cells. Instead, it serves as a biologic scaffold, or sheet, that can be used to facilitate the reconstruction. There are several different products available such as AlloDerm (Lifecell), AlloMax (Bard), and Flex HD (Ethicon) to only name a few.


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In both the staged and Direct-to-implant methods, the prosthesis is placed under the pectoralis muscle. In its natural, uninterrupted state, the pectoralis muscle sits closely on the chest wall and there is very little space between these two structures. Additionally, the lower attachments of the pectoralis muscle to the chest wall are generally higher than the natural position of the breast crease (inframammary fold). Therefore, dividing these lower attachments can allow for improved positioning of the tissue expander or implant and more space under the muscle making it possible to accommodate a larger volume in the device. However, when it is cut, the lower part of the muscle retracts upwards and creates a gap between the muscle and the chest wall. This is where the acellular dermal matrix is placed, essentially forming a bridge or sling between the lower, cut edge of the muscle and the chest wall. Once placed, the biologic material is gradually replaced by ingrowth of one’s own cells and tissue and does not need to be removed at a later date.

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*The information available on this page was created to educate our patients. It is not an alternative for a formal consultation with a board-certified plastic and reconstructive surgeon. Individual results vary per patient. For more information, we strongly recommend scheduling a consultation with our doctors.