Two-stage Tissue Expander and Permanent Implant Breast Reconstruction

View Photos of Before and After
Two-stage tissue expander and permanent implant breast reconstruction is a breast reconstruction procedure that is commonly performed in Los Angeles. During this procedure, a tissue expander is inserted into the breast in the initial stage. The tissue expander is a specialized type of implant that has a port located inside of it that allows fluid to be injected so that the size of the expander can slowly increase over time. This creates space so that eventually, it is possible to put a larger implant into the breast to complete the reconstruction. In a second stage at a later date, the tissue expander is removed and a permanent implant is placed into the breast.

During the tissue expander stage of the procedure, Dr. Hirsch will create a pocket under your pectoralis muscle and insert a tissue expander into the breast. Because this space is tight, there is a limited amount of volume that can be placed under the pectoralis muscle in the first stage of the procedure. Occasionally, he may use a special type of material such as Alloderm or FlexHD in order to create more space under the pectoralis muscle. During the permanent implant stage of the procedure, Dr. Hirsch will either open the previous mastectomy incision or make a new incision in the breast, through which he will remove the tissue expander. At this time, Dr. Hirsch will make surgical adjustments to the breast pocket so that symmetry and softness are improved, and then he will insert the permanent implant into the breast.

If the tissue expander is placed at the same time as the mastectomy, patients will often stay for one night in the hospital although they will occasionally go home the same day of surgery. If the tissue expander breast reconstruction is done at a later date than the mastectomy, patients will usually be able to go home the same day of surgery. In general, patients do not say that this procedure is very painful and usually say that it feels like they have done a lot of chest exercises, and this feeling can last for 1-2 weeks. The exchange for the permanent implant typically takes place in an outpatient setting. Patients usually will be able to go home the same day, and should not experience very much discomfort from this stage of breast reconstruction.

For existing patients, click here to download tissue expander reconstruction post-operative instructions.

In the following video, Dr. Hirsch performs an immediate tissue expander breast reconstruction for a Los Angeles patient with breast cancer.

Immediate tissue expander breast reconstruction

Frequently asked questions about two-stage tissue expander and permanent implant breast reconstruction:

I'm not sure what type of breast reconstruction that I want. If I start with a tissue expander, do I have to get a permanent implant or can I change to a different type of reconstruction?

The best way to think of the tissue expander is as a temporary filler of the breast. It will maintain the shape of the breast skin and will create the illusion of a breast when you are wearing clothes, although it is not as soft and comfortable as a permanent implant. If you start with the tissue expander, all options remain open to you- you can proceed with a permanent implant, a latissimus flap with an implant, or even an abdominal flap breast reconstruction. Depending on the condition of your breast skin, you may not be a candidate for certain types of breast reconstruction procedures. Dr. Hirsch will help you decide which type of breast reconstruction procedure is best for you at the time of your consultation.

What is the recovery like after each stage of breast reconstruction?

Once the incision is adequately healed and the drains have been removed (usually 1-2 weeks after the tissue expander is inserted), Dr. Hirsch and his team will begin expansion by injecting saline into the expander every 1-2 weeks. These injections are performed in Dr. Hirsch's offices in Burbank or Encino.  Although the injections themselves do not hurt, the volume injected can cause feelings of tightness or discomfort in the breast. The tightness usually only lasts for 1-2 days after the expansion, and is relieved with Tylenol or Ibuprofen. Usually, between 3-7 expansions are necessary to reach the desired breast volume.

Once the new size is reached, you will be able to exchange the new expander for a permanent implant. This entire process usually takes around 3 months if you are not treated with chemotherapy or radiation therapy. If you are undergoing chemotherapy, it is necessary to wait until you have recovered from your chemotherapy before having your permanent implant placed. If you are undergoing radiation therapy, then you will have to wait until your skin has recovered from radiation therapy before removing the tissue expander and placing the permanent implant. Occasionally, patients who have undergone radiation therapy will have tight, uncomfortable skin surrounding their implant. These patients may not be candidates for a permanent implant breast reconstruction and may need to consider a different type of breast reconstruction.

When the tissue expander has reached its final volume, many patients feel that it is tight and uncomfortable. It is important to understand that this is NOT how your breasts will feel forever. Once the permanent implant has been placed, the breasts become significantly softer and more comfortable.

Will I have drains after each stage of breast reconstruction?

Yes, you will have one or two drains placed in your breast at the time of the tissue expander placement.  Although drains are not needed when the tissue expander is exchanged for the permanent implant.

My oncologist would like me to undergo an MRI. Is this possible with the tissue expander in place?

Because there is a metallic port in the tissue expander, you should NOT undergo an MRI while the tissue expander is in place although you may undergo an MRI when the permanent implant has replaced the tissue expander. This metallic port may interfere with metal detectors, such as in airport security. Dr. Hirsch can provide documentation as necessary in order to avoid any unnecessary problems with airport security.

When can I start exercising again after each stage of tissue expander breast reconstruction?

If you breast reconstruction is combined with a mastectomy, you might need to wait a few weeks before you begin exercising again.  Although you can begin walking immediately after surgery, you will probably need to wait 4-6 weeks before beginning more strenuous exercises.