Today we are going to talk specifically about the tissue expander process. Many patients ask me about the expansion process at their first postoperative visit after the mastectomy surgery. Some questions patients ask: When does the expansion process begin? How is the expansion process done? How many expansions will I need? How many expansions is a “C” cup? Or any cup size? Does the expansion hurt? What is an overexpansion? How long does the expansion process take? How long before my surgery do I have to do the last expansion?
The expansion process will begin around 2-3 weeks after your initial surgery once the drains have been removed and the skin appears healed. The expansions are done in the office and can be done weekly until we achieve your desired size. If you require additional therapies, the expansions can be done throughout chemotherapy, but not during radiation therapy. Future surgeries take place after chemo and radiation therapies are complete.
Once you begin expansions, you can continue weekly until you reach your desired size. Many times there is fluid placed into the expanders at the time of surgery. Depending on this amount and how large you desire to be, will determine the number of expansions necessary. At each expansion, 50-60ml of fluid is placed into the expander. The fluid is placed into the expander through the port located on the upper middle portion of the expander. This port is located using a magnet and is accessed through the skin. Most commonly, the area is numb and you will not feel the needle stick. You may feel a pulling or pressure sensation during and even after the expansion is complete. This typically only lasts a few days. If you have continued discomfort from the expansion, over the counter medication such as Ibuprofen or Tylenol can be used. Generally, expansions take 10-15 minutes a session and around 2 months to complete. In some cases, limitations due to skin may dictate your ability to continue with expansion, and we will discuss that as the process proceeds.
The most common question I am asked, during the expansion process, is about bra cup size. Patients want to know how many expansions they will need to achieve a certain cup size. I, in return, ask what cup size they were before reconstruction. Most patients usually tell me a couple of different sizes depending on where they are shopping. I then reply to them, “Exactly!” What I mean by this is that we don’t measure in bra cup sizes, but rather in milliliters of volume. The reason we don’t go by bra cup sizes is because that is really dependent on the manufacturer. There isn’t a universal bra cup mold that exists that all manufacturers have to adhere to. What doesn’t change anywhere you go is: volume. We keep a record of how much fluid is being placed in the expander at each visit and will order your permanent implant based on that volume. My advice to patients is to choose a bra they like in a cup size that they desire to be. As we fill the expanders each week, I have them go home and try the bra on to see the progress we have made. With each fill, you will fill in the bra better until you achieve the look you want. This is the best way to determine when you have achieved your desired bra cup size.
Once you have achieved your desired size, we will do an additional expansion that is called the overexpansion. This additional expansion gives the surgeon a little extra skin to work with at your exchange surgery, to make any adjustments necessary, to create the best result possible. We like for that overexpansion to be done about 3 weeks prior to your exchange surgery. At the exchange surgery, the expanders are removed and a permanent implant of equal volume is placed. This permanent implant can be either silicone or saline. The exchange surgery is an outpatient surgery that is done under sedation and doesn’t require the use of drains. The initial mastectomy incision is used for the exchange surgery unless you have been radiated. On the radiated breast, a new incision at the bottom of the breast will be used. Most patients would only need around 2-3 days for recovery with your first postoperative visit in the office occurring within the first two weeks.
If you have an adjustable saline implant instead of an expander, exchange surgery may not be necessary. If you are content with the initial cosmetic result; instead of exchange, the port can simply be removed either in the office or the operating room. Once the exchange surgery is complete, many patients will proceed to the next stage in the reconstruction process: nipple reconstruction. Stay tuned for future blogs discussing the nipple reconstruction process.