Breast reconstruction is not a cookie-cutter procedure. Typically, reconstruction is done in stages for optimal cosmetic outcomes. What happens during each phase can look very different from one individual to another.
Are Tissue Expanders Required Before DIEP Flap Breast Reconstruction?
A question we receive often is, “Are tissue expanders necessary before DIEP flap breast reconstruction?”
This is an excellent question, but it’s not always an easy “yes” or “no” answer. The need for tissue expanders depends on several factors, including the timing of reconstruction, the condition of the chest wall and skin after mastectomy, and the patient’s overall treatment plan. For example, immediate reconstruction performed at the same time as mastectomy may not require expanders, while delayed reconstruction after radiation or healing may benefit from them.
In addition, every patient’s anatomy, healing response, and surgical goals play a role in determining whether a temporary expander is needed to prepare the area for the DIEP flap. Because of these variables, the decision is highly personalized and should be made in close consultation with your reconstructive surgeon.
When Might Tissue Expanders Be Used Before DIEP Surgery?
Tissue expanders can be used for a few different reasons. Here are some situations where tissue expanders may be recommended:
Preserving Breast Shape After Mastectomy
Tissue expanders may be placed at the time of a mastectomy (or any time after a mastectomy) to maintain or stretch the breast skin envelope. This process involves “fill appointments” in the office, which take place over the course of a few months until the optimal breast size and/or shape is achieved. Following completion of the expansion process, the expanders are removed and replaced with either a permanent implant or the patient’s own tissue.
Delaying Reconstruction
Patients can also have a tissue expander placed if they are delaying their definitive reconstruction. Reasons for delay could include life events, advanced disease, uncertainty about a procedure type, the need to travel for reconstruction, etc.
Even when reconstruction is delayed after a mastectomy, a tissue expander is not always needed. DIEP flap reconstruction can be performed at any time after a mastectomy and allows additional skin to be added to the breast to recreate the new breast shape and silhouette.
Undergoing Radiation Therapy
Expanders may also be placed as a temporary implant while a patient undergoes radiation. Because radiation can cause the skin to shrink, the expander can help preserve the breast envelope and overall shape until radiation is completed.
When Are Tissue Expanders Not Needed for DIEP Flap?
Tissue expanders may not be needed in the following cases:
Immediate DIEP Reconstruction
If you’re having a DIEP flap procedure at the same time as your mastectomy, tissue expanders are typically not needed. In these cases, the reconstructive surgeon can perform the mastectomy and immediately use your own abdominal tissue to create a new breast. Because the DIEP flap includes both skin and fat, there’s no need to “stretch” the remaining chest skin in advance. This approach can help patients wake up from surgery with a natural breast shape already in place and may reduce the number of procedures needed.
Sufficient Skin After Mastectomy
Some patients have enough healthy skin left on the chest after mastectomy to allow for direct DIEP flap reconstruction without using an expander. This may occur when the mastectomy spares a larger portion of skin, such as in a skin-sparing or nipple-sparing mastectomy. When there’s enough skin to accommodate the new tissue immediately, the surgeon can shape the reconstructed breast without first stretching the area. This simplifies the process and allows for a more seamless reconstruction experience.
Pros and Cons of Using Tissue Expanders Before DIEP Flap Surgery
For patients needing radiation treatment, tissue expanders can help maintain the breast skin envelope during treatment. Patients who must delay their reconstruction may also benefit from placing a tissue expander at the time of mastectomy. Because tissue expanders preserve the breast envelope’s integrity, there is typically less scarring visible in the final results.
Patients opting to have a tissue expander placed should be aware of the risks associated with the procedure. The risk of infection is always elevated any time a foreign object is placed in the body. This risk is even higher if the patient has had/will have radiation. If an infection does occur, additional surgery is often needed to remove the expanders. This can delay the reconstruction timeline and, more importantly, delay additional breast cancer treatments for some patients.
Patients often complain that tissue expanders are uncomfortable, especially when they are placed under the chest muscle. Although they are only meant to stay in place for a short time, the discomfort can be frustrating and can impact quality of life.
Ultimately, the option to use an expander should be thoroughly discussed with your surgeon to fully understand the benefits and risks.
Pros | Cons |
Prepares the chest for reconstruction by stretching the skin and muscle to make space for the new breast. | Adds another procedure since the expander must be placed and later removed. |
Improves symmetry planning by giving the surgeon more control over breast size and shape. | Extends the timeline because expansion happens over several weeks or months. |
Helpful after radiation therapy to improve skin quality and flexibility. | Can cause discomfort such as tightness, soreness, or limited movement. |
Gives healing time between surgeries if chemotherapy or radiation is needed after mastectomy. | Carries some risk of complications like infection, fluid buildup, or implant exposure. |
Is DIEP Flap Possible Without Expanders After Mastectomy?
Yes, many patients can have DIEP flap reconstruction without tissue expanders. Whether it’s possible depends on the condition of the chest skin, the type of mastectomy performed, and any previous treatments such as radiation. In some cases, there’s enough healthy skin remaining to move directly to DIEP flap reconstruction, even if the surgery is delayed. Your surgeon will carefully assess your anatomy, healing, and overall treatment plan to determine the safest and most effective approach for you. The goal is always to achieve natural-looking results with the fewest number of procedures necessary.
Personalized Reconstruction Plans at PRMA in San Antonio
At PRMA Plastic Surgery in San Antonio, every breast reconstruction plan is tailored to the individual. Our breast surgeons take time to understand your medical history, personal goals, and lifestyle to recommend the best path forward, whether that includes tissue expanders or not.
With one of the most experienced microsurgical teams in the world, PRMA is dedicated to restoring confidence and quality of life through advanced, compassionate care. If you’re considering DIEP flap reconstruction, our team is here to help you explore all your options and make an informed decision about what’s right for you.
