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. A question we receive often is, “Are tissue expanders necessary before DIEP flap breast reconstruction?”
This is an excellent question, but is not always an easy “yes” or “no” answer.
Tissue expanders can be used for a few different reasons. They 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 includes “fill appointments” in the office that 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.
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.
Patients can also have a tissue expander placed if they are delaying their definitive reconstruction. Reasons for delay could be life events, advanced disease, undecided on a procedure type, needing to travel for reconstruction, etc.
In most cases, DIEP flap can be performed at the same time as the mastectomy. This is called “immediate reconstruction.” When immediate reconstruction is planned and the patient has either a nipple-sparing or skin-sparing mastectomy, a tissue expander is rarely needed unless there is a true need to expand the skin to optimize the final breast shape.
Even in the setting of delayed reconstruction (meaning the reconstruction takes place sometime after a mastectomy), a tissue expander is not necessarily 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.
So, what are the pros and cons of using a tissue expander before DIEP?
For patients needing radiation treatment, tissue expanders can help maintain the breast skin envelope during treatment. Patients who must delay their reconstruction for a variety of other reasons 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 overall reconstruction timeline and more importantly, other breast cancer treatment in some cases.
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 and tailored to your specific situation, and the benefits and risk fully understood.
Author: Dr. Minas Chrysopoulo and Courtney Floyd
Regardless of whether a tissue expander is placed before reconstruction or not, DIEP flap breast reconstruction can still be performed with optimal results. The decision to use an expander should be thoroughly discussed with your surgeon, and the benefits and risked understood.
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