1 Avoidance and Management of Complications:

Tissue Expanders in Breast Surgery

Frank Elliot M.D, Hisham Seify M.D

Tissue expansion techniques have added a much needed dimension to breast

reconstruction techniques. During the 1970s, with the improvement of the silicone
gel implant and the addition of the latissimus myocutaneous flap, great strides were
appreciated in the results of breast reconstruction using an implant. However,
while this period was much improved over the previous one, surgeons still lacked
the ability, in many cases, to gain adequate soft tissue coverage that was not only
viable, but also supple, loose, and even ptotic. This was only possible with the
addition of significant amounts of extra skin, which the latissimus myocutaneous
flap generally could not provide, or through the recruitment of additional skin with
the use of the tissue expander.
As in any new technique, the introduction of the tissue expander for breast
reconstruction led to a whole host of ideas as to how best apply the technique.
These ideas led to a variety of tissue expander shapes, tissue expander surfaces,
types of injection ports, and various combinations of fillers. Each idea had its
proponents and, not surprisingly, each proponent could present beautiful results
with their own device, while others might report complications with the same
technique. This has led most of us to continue our search for the perfect tissue
expander for breast reconstruction, along with the perfect method for insertion,
expansion, removal and replacement.
Of course, the best method for management of complications is to avoid
them. While this cannot always be achieved, the tissue expander is the very device
that was introduced to reduce complications of breast reconstruction. However, a
tissue expander is not particularly similar to the breast tissue it intends to replace
and create. The tissue expander is generally a temporary device to transit the
patient from mastectomy to a soft, supple, natural-appearing reconstruction. If the
patient is evaluated correctly and the proper tissue expander is chosen and
expanded, the expander can be exchanged for a suitable permanent implant to
provide a good result for the patient and surgeon. Thus an excellent result should
be achieved in a high percentage of cases if the patient is chosen correctly and the
technique applied in a thoughtful unhurried manner.

Evaluation of Patient Preoperatively

Consideration should be given to the patient who is to have immediate or
delayed reconstruction. In either situation, discussion with the patient should
center on the option of using an expander/implant reconstruction or autogenous
tissue reconstruction. In either situation, intrinsic risk factors to the patient can
affect both preoperative planning and the final result. These factors include
smoking, previous radiation, obesity, thinness, diabetes, and a previous history of
autoimmune diseases. The presence of any of these risk factors should cause the
surgeon significant trepidation in planning the operation, no matter which
technique is chosen. Combinations of these risk factors are of particular concern
and may preclude the performance of breast reconstruction for the wise,
experienced surgeon. However, in the presence of one risk factor, the
reconstruction can generally be accomplished safely.
For instance, if the patient has a history of smoking, the patient should be
asked to quit. If the patient can stop smoking six weeks prior to surgery, the risk is
generally lowered to close to normal. If the patient has diabetes but is well
managed or managed with only dietary control, the risk appears to be relatively
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normal. On the other hand, a previous history of radiation would tend to lessen the
attractiveness of tissue expander/ implant reconstruction and increases our
tendency to perform breast reconstruction with autogenous tissue. Anticipated
post-operative radiation is generally dealt with by delaying the breast
reconstruction.
Generally, a full description of both techniques is explained to each patient
preoperatively. The thinner patient who has relatively scant abdominal tissue and
no previous abdominal scars would certainly be one for whom the surgeon should
strongly consider tissue expander/implant reconstruction. On the other hand, the
patient with adequate abdominal tissue and larger, perhaps somewhat ptotic breasts
who may have previous abdominal scarring may be an excellent choice for free
TRAM flap reconstruction. Many patients are astride the center of this continuum
and can have either technique. For this reason, I feel it is extremely important to
fairly present each operation, avoiding bias, until each technique has been
presented fully. Patients often find themselves inclined to want one technique or
the other due to previous information, friends who have undergone reconstruction,
or previous exposure to breast implants. For those of us doing breast
reconstruction, it seems appropriate that both techniques are made available and
offered to give the patient appropriate up-to-date choices for breast reconstruction.
Once a decision has been made to use tissue expander/implant for breast
reconstruction, consideration should be given as to whether the latissimus dorsi
muscle is needed. The latissimus muscle, either with or without a skin island, can
provide full muscle coverage for the expander and implant or, therefore, should be
considered for the very thin patient or for the patient in whom one is concerned
about overlying skin viability. (Fig ) Persons with risk factors as noted above may
fit into this category. The latissimus muscle can be harvested without a scar on the
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back at the time of immediate breast reconstruction and, therefore, is an excellent
option for full muscle coverage for the patient in whom one is concerned about
skin viability. This concern may be heightened in the patient who has a history of
smoking, previous or current, or in working with a surgeon who creates very thin
skin flaps that may be predicted to have problems with viability. Mastectomy skin
flaps viability could be assessed intra-operatively using the Fluorescein dye
injection test and examination with Wood’s lamp. The concept of tissue expansion
is, of course, meant to be done in gradual fashion. Nonetheless, if the scales can be
tipped toward safety and the price is low, safety should always be chosen. This
may be the case with the use of the latissimus, negating the use of a scar on the
back. Harvesting of the muscle and its rotation to be coupled with the pectoralis
major muscle leads to full muscle coverage and a relatively low chance of tissue
expander or implant extrusion should there be skin breakdown or if there is skin
thinness from previous operation. (Fig)
Another aspect of preoperative planning is coordination with the resecting
surgeon. Once one has an ongoing relationship with an oncologic surgeon, some
degree of predictability as to the residual flaps can be made. Some surgeons create
quite thin flaps, whereas others leave thicker flaps. There is also the handling of the
flaps by the surgeon during the performance of the operation. All these factors
lead to more or less risk with regard to primary healing of the mastectomy wound.

These factors should also be coupled with the choice of mastectomy incision. A
more limited incision, common today for skin-sparing mastectomy, generally leads
to better tissue viability, especially if only the circumareolar incision is used. On
the other hand, the use of the vertical incisions or inverted-T incisions for breast
lift at the time of mastectomy are certainly much more adventurous and necessarily
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put more stress on the primary healing of the skin. (Fig)
In summary, all the factors mentioned above should be considered as the
tissue expander reconstruction is planned. These include the risk factors of the
patient, previous history of the resecting surgeon, and the planned incision for the
mastectomy. Taken together, careful and safe planning of the operation can reduce
the chances of postoperative complications, hopefully avoid the incidence of
complications, and, therefore, obviate the need for management of postoperative
complications.
Current Operation
Assuming one has chosen the proper patient with low, or no, risk factors and
the oncologic surgeon is one whom leaves reliable flaps, the operation can be
contemplated to heal primarily and be safe for immediate tissue expander
reconstruction. The best choice in general for breast reconstruction is the low
height tissue expander. This expander gives direct, significant expansion to the
lower pole of the breast, where projection occurs most naturally. It avoids
projection in the upper pole of the breast, where projection is generally does not
naturally occur. Certainly, different breast shapes are desired by the patients, who
may favor upper pole fullness, but this is generally not the case. ( Fig)
Once the mastectomy has been performed, the pectoralis major muscle is
lifted off the chest wall and released inferomedially for the mid-pole of the breast
(Fig ). The tissue expander is chosen by both volume and transverse dimension.
Measurements from the midline to the lateral breast should be correlated with the
width of the tissue expander. A preoperative estimation of the desired size of the
patient’s breast should also be estimated. This can be simply a replacement of the
current breast size or enlargement to a desired size. It is always a good idea to use
an expander whose volume is slightly larger than the desired ultimate size. Of
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course, some patients may desire a reduction, but the point is to have an idea of the
ultimate volume goal using an expander that will expand beyond that goal.
Once the pectoralis muscle has been lifted up, the expander can be carefully
placed, with particular attention to the inframammary line. The expander should be
placed as close to the exact line as possible. With the textured surface of the low
height tissue expander, the implant should be expected to remain in position. A
drain is inserted in the dissected expander cavity. The pectoralis major muscle is
then draped over the expander and tacked to the subcutaneous tissue of the native
chest wall skin caudad to the line of skin closure (Fig). This can be done with
several interrupted absorbable sutures. This closure of the muscle caudad to the
ultimate skin closure line interposes muscle between the tissue expander and the
final skin closure in case there is wound breakdown. Prior to closure of the skin,
the tissue expander is inflated to the volume allowed by the overlying skin
envelope. We are careful to avoid any tension on the overlying skin with this
inflation. Depending on the laxity of the overlying skin, volumes range from the
insertion of 50-200cc at the time of the operation. (Fig)
If the latissimus muscle flap is used, dissection of the latissimus over
approximately 70% of its surface area is performed prior to insertion of the tissue
expander. Dissection of the latissimus muscle is done with the patient in a lateral
decubitus position so that approximately 70% of the muscle can be harvested and
the origin of the muscle from the humerus can be divided, facilitating its mobility
to the anterior inferior breast region. (Fig) A drain is placed in the donor site of the
latissimus and sutures are placed along the lateral chest wall between the latissimus
and the chest wall to prevent lateral migration of the tissue expander. The patient
is then turned to a supine position on the operating table and the tissue expander is
inserted, as noted above. The latissimus muscle is then carefully sewn to the
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pectoralis major muscle, creating total, complete muscle coverage.
Expansion proceeds in the office using the magnet to locate the injection
port and is generally done weekly utilizing 50cc increments. We like to over-
expand approximately 50-100cc beyond the patient’s desired size, waiting
approximately one month between the final expansion and subsequent implant
exchange. An important aspect of the final expansion is the projection of the breast
at the end of expansion. It is important to emphasize the projection to the patient,
as opposed to the size, which may be somewhat unusual, given the irregular shape
of the low height tissue expanders. Projection is the most important aspect of the
new breast since generally whatever projection the patient has with the expander in
place will be the projection the patient will have at the time of implant exchange.
At the time of implant exchange, capsulotomies, capsulectomies, and
capsulorrhaphies are performed to insure that the final implant is in the proper
position and stabilized there. Capsules at the end of expansion can range from
being very thick and palpable to being quite thin and relatively natural. The thick
capsules oftentimes need to be excised so that they are not palpated after final
implant placement.
The choice of implant is generally smooth, gel filled. Because a smooth
implant is used, the pocket for the implant must be secure and accurate, as the
implant will certainly move around in the pocket. A smooth implant is chosen
because it tends to be associated with less rippling of the overlying skin because it
is not adherent to the capsule. Gel is usually recommended because it has a
slightly more natural feel than saline implants. (Fig) However, there are some
patients who are set against gel implants, in which case saline implants are
relatively successful.
Nipple/areolar reconstruction can be done at the time of tissue expander
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removal and placement of the implant. It is not possible to do nipple/areolar
reconstruction; however, if the incision needs to be opened into the area of
reconstruction in order to do the implant or capsule work. In addition, if internal
capsule work is done underneath the site of the nipple/areolar complex, the
reconstruction should be postponed.

Complications and Management

Tissue expander or implant exposure or extrusion is probably the worst
complication associated with this type of reconstruction. Extrusion can be
associated with infection and, in fact, with any sign of infection, the tissue
expander or implant should be removed immediately. There have been instances
of implant or tissue expander salvage in the presence of infection, but these cases
almost always lead to very significant capsular contracture, for which subsequent
surgery is ultimately needed.(Fig) Therefore, tissue expander or implant removal
is the best idea, with secondary reconstruction using a tissue expander postponed
for several months later. Superficial skin infection without exposure is usually
treated by antibiotics and repeated clinical exam.
Shape and naturalness (feel) problems are second on the list of seriousness,
but first on the list in terms of incidence in terms of complications following tissue
expander reconstruction. The best choice is the use of existing tissue, if possible.
Oftentimes, the capsule can be used as an additional layer of tissue when folded
down or up, and, therefore, should not necessarily be discarded immediately. On
the other hand, if an expander or implant has migrated too far in any one direction,
generally the capsule should be resected and the two fresh edges sutured to each
other using permanent braided suture to re-establish the perimeter exactly where
the surgeon wants it to be.
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The use of human acellular dermal matrix (Alloderm) have been described in
several reports in dealing with skin rippling following implantation.
The profile of the final implant should be analyzed prior to choosing final
implant size and type. One can easily measure the projection of the tissue
expander at the termination of expansion and choose the implant that best
conforms to this achieve projection. While one does sacrifice width and height in
achieving greater projection, this characteristic may be quite desired by the patient
and certainly should be discussed in detail. (Fig)
There are times when implant reconstruction has not been successful in
terms of overt appearance or patient symptomatology. Despite previous maneuvers
in terms of implant exchange, capsule work, or even adjacent flaps, the patient may
remain unhappy with the implant result. In this situation, consideration for
exchange utilizing autogenous tissue should be made. A patient who has
previously rejected the TRAM operation as “too big” a surgery, may, after several
years of problems with expander/implant reconstruction, find herself a good
candidate for the TRAM operation. This is, indeed, one of the most successful
uses of the TRAM flap in terms of aesthetic results. The TRAM flap can simply be
placed into the pocket at the time the implants are removed, giving a natural, soft
result and rendering the patient absent of a foreign body. Obviously, this is a big
step for a patient and generally does not occur unless the patient has had a number
of unhappy results with the previous use of tissue expanders or implants.
In summary, much progress has been made in the use of implants for breast
reconstruction. Largely this progress is due to the continued improvements in
tissue expander design and use. We have, of course, learned a lot about patient’s
who are at high risk for any of these operations. These patients still account for a
considerable source of complications that ensue after tissue expander breast
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reconstruction. The converse is to say that good risk patients generally do well.
However, the improved design of tissue expanders and the use of muscle coverage
when necessary continues to place many of these patients in the good to excellent
category when judged postoperatively.
Radiation remains a serious contraindication to the use of implant expanders
for breast reconstruction. This is chiefly due to the associated high incidence of
capsular contracture. Adequate results can be achieved, but autogenous tissue is
generally preferred in this situation.
Tissue expander breast reconstruction has certainly improved in the past
decade and will continue to do so. Autogenous tissue breast reconstructions
remain a large operation for patients, along with the significant resultant scars
involved. Although autogenous tissue will always be a choice for breast
reconstruction, with the current recent progress in tissue expander reconstruction, it
seems likely that tissue expander and implants will be used increasingly for breast
reconstruction following mastectomy.

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