My name is Dr. Brian Pinsky. I’m a board-certified plastic and reconstructive surgeon. I’m originally from Akron, Ohio and I’ve been in practice with the Long Island Plastic Surgical Group since 2012.
Breast reconstruction has been part of my practice, really, since the beginning. It was something that we focused on heavily in my residency training and I’ve chosen to continue that in my practice since starting.
When patients come in for a consultation for breast reconstruction, they really have two basic choices to make in the beginning. The first choice is whether they want to pursue autologous reconstruction, or breast reconstruction with their own tissue, or breast reconstruction using implants and tissue expanders are part of the implant reconstructive process. At the time of the mastectomy, during the cancer surgery, or at a later date depending on the situation, essentially, a tissue expander is placed into the chest pocket that’s created from the mastectomy.
Tissue expanders, this is a pretty classic example of a tissue expander, this one has a textured surface. Nowadays, we use a lot with a smooth surface, but the actual composition of the expander is the same. It has an integrated port, which sits below the skin. So through the skin, place a magnet on the patient’s chest, which helps us locate the position of the port. And then sometimes we’ll even put place a small amount of local anesthetic into the skin, oftentimes that’s not even needed after the mastectomy. The skin is a bit denervated from the surgery so the patients don’t really feel it. And the needle goes in, directly into the port. The saline gets filled to how much we decide to do in any given visit and the needle comes out and that’s it. And they come back the next time and we repeat the process until the expander is fully expanded to the point that we’re happy.
There’s really two different ways that a tissue expander can be placed. It can either be placed above or below the chest muscle. In this photograph here, the pectoralis or chest muscle is elevated and the muscle’s extended with a cellular dermal matrix, or basically cadaver skin, to cover the lower portion of the implant. And it’s placed into the chest under the muscle. And then there’s also a relatively newer technique which we use, which is pre-pectoral placement, where the implant is placed above the muscle. Essentially they’re placed in the same position in the chest pocket. It’s just how we’ve chosen to place it relative to the chest muscle for coverage of the implant.
Placing the implants above the muscle, so doing a prepectoral reconstruction, has shown to have significantly less pain for the patients. You’re really just stretching the skin and not stretching the muscle. There are times when an implant under the muscle is better, given the situation, either depending on the skin quality or blood supply to the skin at the time of the mastectomy. And those patients, I typically will give some sort of muscle relaxing medication because muscle spasms can be the most difficult part of that process. But in general, it’s very tolerable for the patient.
The initial step of the tissue expansion process is the actual placement of the tissue expander at the time of surgery. So once the general surgeon and the breast surgeon completes their portion of the surgery, I’ll come in and I’ll place a tissue expander. So it initially comes out of the package with nothing in it except a little bit of air. And then at the time of surgery, we’ll choose to put in either more air or a little bit of saline to partially fill it. Over time, the skin will contract down around the implant so we want to take advantage of that laxity and expand it as rapidly as possible, but you don’t want to expand it too quickly so as to either cause the patient unnecessary discomfort or to cause issues with the wound healing.
So typically I’ll wait two to three weeks after the initial surgery to begin the expansion process and that’s to make sure the drains are removed, to make sure that the skin is healing properly and we’re not having any wound issues. And that’s usually around the three week mark, and then we’ll start the expansion process because I’d like to take advantage of the skin elasticity that’s present from the initial surgery. And we want to fill as rapidly as we can and so I’ll begin the expansion process then. And the patients will come back weekly or every other week, depending on their schedule, and we’ll add more until we’ve reached the desired end point.
The expansion visits are quick, they usually take just a few minutes. So the patients are typically in and out so it doesn’t take up a significant amount of their time in a given day. I try to minimize that knowing that there is a certain amount of inconvenience with having to come back to the office multiple times. And there’s two sort of end points, you can either reach the end point of the maximum fill volume of the expander, or you can reach the point where the patient is satisfied with the volume. So sometimes some patients say, “You know what? I like this volume. This is where I want to be,” but we may xfhave another 200 CCS to go in the expander. I may fill a little bit more just to get a little extra skin stretch, but I don’t feel the need to overdo it or to reach maximum volume if the patient is satisfied.
I wouldn’t say that the expansion process is very painful for the patients. Most patients complain of a tight feeling, and that really depends on how much saline we choose to put in in each visit. So patients with a tighter skin envelope may experience more of that tight feeling, in which case we may expand a little slower to accommodate that. So maybe I’ll put in 50 CCS instead of 100 at each visit, or even less, depending on how the patient feels. I don’t want it to be overly uncomfortable for the patients, but we do want to achieve the end goal as soon as we can, so there is a balance.
The risks for expansion are really similar to any other breast implant surgery. There’s the risks of anesthesia with the initial surgery, which are really unavoidable. The primary risks are infection, implant related complications like fluid collections around the implant, exposure of the implant if the wound breaks down, the need to take the implant out if there is a significant infection in the short-term. And the long-term risks are things like capsular contracture, where you have thickened scar forming around the implant, which may impact the cosmetic results or can cause discomfort for the patient, and that may be increased with postoperative radiation or other types of treatments for the breast cancer.
The typical patient has the expander placed at the time of surgery, the time of the initial mastectomy. I’ll see the patient for one or two weeks afterwards until the drains are out and to be sure that the wounds are healing well, and we’ll begin the expansion process and that’ll take about two to three months. Once the expansion process is complete, the expander is filled, it gets removed and it gets replaced with a permanent implant.
There are other options for reconstruction that are not simply silicone implants. There are saline implants, which have a similar outer shell, but it’s filled with saline inside. So it has a little more of a feel of a water balloon and less of a soft, more natural feeling breast, but some patients do prefer it. And then nowadays, there’s a more modern, multi-chambered saline implant, which is sort of a hybrid in-between, which has more of the feel of a silicone implant, but some of the safety profile factors of a saline implant. So again, there are multiple options in terms of implants that we discuss during the consultation and the visits. Again, the patient can choose what’s best for them.