How Tissue Expanders are Used in Conjunction with DIEP Flap Breast Reconstruction.

By: Dr. Minas Chrysopoulo

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Tissue expanders are most commonly used in patients seeking implant reconstruction. However, in select situations, tissue expanders can be placed prior to DIEP flap breast reconstruction.  

Most situations involve the potential for radiation. 

Radiation therapy can impact breast reconstruction in several ways depending on the type of reconstruction, and whether radiation is performed before or after the reconstruction. The reconstructed breast can shrink and become more firm and tight which can lead to deformity, discomfort and worsening breast asymmetry. Skin color changes are also common.

Despite the use of protocols, not all radiation oncologists deliver treatment the same way and experience with radiating breast reconstruction patients varies tremendously. This means results with radiation after a flap reconstruction can be quite variable and unpredictable, despite studies that show this is a safe approach in select patients and centers. The impact of the patient’s individual biological response to the radiation also cannot be understated - everyone responds differently. 

For these reasons, most plastic surgeons still favor delaying flap reconstruction until the patient has had their mastectomy and is at least six months out from completing radiation. This allows the chest tissues to heal fully and soften as much as possible. However, delayed reconstruction is associated with more scarring and cosmetic results aren’t as nice as with immediate reconstruction.

Women seeking immediate flap reconstruction, despite anticipated radiation therapy, must do their homework and find a radiation oncologist who is experienced in radiating breast reconstruction patients to minimize the risk of complications as much as possible.

Another option for patients who ultimately want a flap reconstruction but may be getting radiation is for a tissue expander to be placed at the time of the mastectomy. In this situation, the expander is used to preserve the breast skin envelope as much as possible until the radiation therapy has been completed. The expander is then replaced by the flap once the patient has recovered from the radiation. This "delayed-immediate" approach preserves as much of the breast skin and shape as possible and therefore maximizes the final cosmetic results, without exposing the flap to the potentially damaging effects of radiation.

Expanders can also sometimes be used when radiation isn’t planned...

For women who want DIEP flap reconstruction but will have to travel for the surgery, an expander can be placed at the time of the mastectomy to preserve the breast envelope and overall shape until they can have their definitive reconstruction. This prevents the tissues from contracting and scarring down which negatively impacts the final cosmetic result. In this situation, the expander essentially allows for the cosmetic benefits of an “immediate” reconstruction (nicer breast shape, less scarring).

Expanders have also been used in select situations to help “pre-shape” the breast prior to DIEP flap reconstruction. However, in our experience, this is rarely needed. 

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