Expander-to-implant reconstruction

Dr Johan van Heerden explains the advantages of the two-stage expander-to-implant reconstruction.

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History

In 1963, two plastic surgeons from the United States, Thomas Dillon Cronin and Frank Judson Gerow, developed the first silicone gel-filled breast implant. In 1976, Chedomir Radovan used the first tissue expander for breast reconstruction, and this was the start of an era for breast reconstruction with tissue expanders.

Current technique

Plastic and reconstructive surgeon, Peter Cordeiro, is credited for establishing the standard two-stage expander-to-implant reconstruction technique. This is where an expander is inserted immediately after a mastectomy operation and then at a delayed second stage, exchanged with a permanent silicone implant. 

The two-stage expander-to-implant technique remains the preferred choice, even today for most plastic surgeons. The breast tissue expander is secured onto the chest wall, and therefore helps in stabilising the pocket after mastectomy, avoiding the need for capsulorrhaphy procedures or use of mesh-devices. The expander can be used for expansion of remaining skin, where more skin is needed, or it can be used as a temporary spacer.

What are the advantages of the two-stage technique?

This technique has the advantages of the breast cancer patient waking up with volume in the breast and not being flat-chested. The expander can also be deflated during radiation therapy, if needed, and the adjustable volume helps the patient decide which volume suits her best, enabling more accurate implant size selection.  

Planning and being prepared for a two-stage breast reconstruction certainly also helps patients to be prepared for revision surgery, which is often part of the reconstructive journey.

Using an expander in the first stage also gives the patient the option of having an autologous reconstruction (skin, fat, and sometimes muscle taken from another part of the body) to reconstruct the breast in the second stage, if a permanent silicone implant is not preferred.

Step-by-step process

During the initial consultation, the important risks need to be discussed with the patient. It can’t be over-emphasised that mastectomies need to be done for the right reasons. 

Loss of skin and nipple sensation, expander loss (due to rupture or other complications), and capsular contracture (tissue capsule surrounding the implant tightens and hardens, leading to breast distortion and pain) are some of the most common complications. Seroma (collection of clear, straw-coloured fluid develops under the skin after surgery) formation occurs commonly as a normal sequela from mastectomy.  

Expanders tend to be more uncomfortable than implants due to the presence of the port and tabs that are sutured onto the chest wall. The sensation of the moving saline inside the expander is also not pleasant.

Regular follow-up consultations will be part of the reconstruction method to complete the expansion process until the desired volume has been reached. 

It’s advised to wait at least six months after radiotherapy is completed, before the second-stage with the implant can be completed. When radiotherapy is not indicated, the final stage can be performed from three months after the initial stage.

In summary

The use of the two-stage expander-to-implant technique is well-established and reliable. Even though there is increasing evidence for the use of the one-stage implant technique, the two-stage technique remains with numerous advantages and will continue to have its place in the armamentarium of plastic surgeons. 

A true one-stage mastectomy and immediate reconstruction with perfect results and no need for revisions remains a very rare occurrence and all patients should be aware of this fact.