Tissue Expander to Saline/Silicone Implant

Tissue expanders are saline-filled medical devices that are designed with an "access port" on the superficial surface of the device. This "access port" can be used to add saline to the device by inserting a needle into your skin and into the device. This procedure is called "tissue expansion" and is performed in the office on a weekly basis post-operatively.

Tissue expanders are commonly placed beneath the pectoralis major muscle flap (Stage 1 Breast Reconstruction). More recent surgical techniques employ the use of Alloderm™ in addition to the pectoralis major muscle flap to form an internal bra to prevent malposition of the tissue expander with time. Some plastic surgeons speculate that Alloderm™ may reduce the risk of capsular contracture associated with the use of breast reconstruction implants. If you have concerns regarding the use of Alloderm™, please share them with Dr. Marga such that your reconstructive plan can be adjusted to fit your particular needs.

Stage 1 of this breast reconstructive technique (placement of a tissue expander +/- Alloderm™) can be done at the time of your mastectomy (immediate breast reconstruction) or at a later date (delayed breast reconstruction). This procedure can be accomplished in less than 2 hours. Patients typically remain in the hospital for 1-2 nights and do receive pain medications intravenously with a conversion to pain pills and muscle relaxants on the morning following surgery. Two surgical drains are placed in each reconstructive site and may remain in place for up to 14 days. You should be on antibiotics for as long as a reconstructive drain is in place.

Tissue expansion is a technique where needed skin is recruited on the chest wall for use in your final reconstruction. Women who may require tissue expansion include those who choose breast implants for their final reconstructive approach:

a. If skin is removed in the setting of your mastectomy;

and/or

b. If you request a breast reconstruction larger than your native breast(s);

Patients who elect tissue expansion, visit with us weekly to have saline injected into their tissue expander starting 1 week after your final reconstructive site drain is removed. Tissue expansion does not require anesthesia. However, you may experience some chest wall tightness and discomfort for several days after expansion (similar to having your wire changed on braces in orthodotic procedures….). Tissue expansion has been associated with the bowing-in or depression of the rib cage. Dr. Marga is well aware of this potential side effect and will monitor your progress and keep you informed should this happen to you.

After your tissue expansion process is complete (typically 3 months), you return to the operating room for a second operation (Stage 2) to have your permanent breast implants placed. You may choose saline-filled or silicone-filled implants at this time.

Please review all of the information provided to you regarding the safety of silicone breast implants prior to your Stage 2 surgical procedure. Specifically you need to understand:

a. Silicone breast implants should be only offered to you by board-certified Plastic Surgeons with experience in the use of silicone breast implants;

b. You should be provided with patient education materials regarding the safety of silicone breast implants at least 2 weeks preceeding any implant surgery. Please refer to the following web-based information at www.natrelle.com, and at www.mentorcorp.com). Please let Dr. Marga know if the web review is not an option for you and we will provide this information to you on paper at the time of your consultation.

c. "Implant device tracking" is an elective service provided to you by implant manufactures that you may or may not choose to pursue – it is entirely elective but we encourage you to participate; please review and return the appropriate paperwork to your implant company after the completion of your implant surgery. Your participation adds to our ongoing clinical outcomes research effort.

d. Silicone breast implants are NOT life-long devices and you will likely require additional surgical procedures to the breast if you elect to have a silicone breast implant placed in your body – the national unplanned re-operation rate at 7 years for implants used in breast reconstruction approaches 50% for non-irradiated patients and may be higher for patients requiring irradiation in the treatment of their cancer.

e. The FDA has recommended that you undergo MRI screening of your silicone breast implants 3 years after implantation and every 2 years following that to screen you for asymptomatic implant rupture (device failure) - this is a recommendation from the FDA and not a restriction for their use.

f. Implant companies have warranties on their products that may be subject to change over time. You can find out more information regarding implant warranties on the world wide web (www.natrelle.com, www.mentorcorp.com). We encourage you take advantage of implant warranties as you likely will require additional breast implant surgery in your lifetime.

Your final implant placement surgery is designed to provide you with more "cleavage" than that which your tissue expanders typically promote. Scar tissue associated with your tissue expanders is removed during this procedure, if required, and called a capsulectomy. Stage 2 breast implant surgeries do require a general anesthetic (typically 2 hours in duration) but can be completed as an outpatient. The placement of surgical drains during this procedure is uncommon. Dr. Marga will want to follow you post-operatively to look for signs of bleeding or infection and to teach you methods of breast implant massage. Breast implant massage is an important daily requirement that you will need to master in order to promote a mobile and soft reconstructive result.

Nipple reconstruction is completed as a Stage 3 outpatient procedure without the need for general anesthesia. Nipple reconstruction is typically scheduled 2-3 months after your implant placement. Nipples are reconstructed using local flaps of tissue from your reconstruction site ("fishtail flap" or "bow-and-arrow flap"). Historic procedures using tissues from the groin and labia are not routinely utilized unless requested. Some patients elect for simultaneous labial reductions and tissue transfer for nipple reconstructions on a limited basis upon request. We additionally offer "nipple sharing" from the contra-lateral breast.

Specialized nipple protectors ("Xena Warrior Princess Nipple Guards") will be provided for your use in the post-operative period when you are wearing a bra. Please do not remove the adhesive paper to expose the underlying adhesive. Tape and "sticky" things are bad for the skin and may cause allergic rashes. Your bra will hold the nipple protector in place. And, you do not need a nipple protector if you are not wearing a bra. Most nipple reconstructions flatten with time. Use of the nipple protectors will maximize your final nipple projection.

Clear sutures on the outside of your skin will fall out on their own at about 3 weeks post-operatively. Some reconstructive methods employ the placement of a "yellow bolster" which is sewn to the skin. "Yellow bolsters" are commonly removed on post-operative day #7. You should refrain from submerging such a bolstered wound in the shower/bathtub/whirlpool/river/lake/ocean for 14 additional days after the bolster is removed.

Dr. Marga will instruct you when it is safe to resume your implant massage protocol. Please call Dr. Marga directly on her cell phone if she neglected to discuss this with you.

Areolar reconstruction is completed as a Stage 4 office procedure. Local anesthesia is administered along with epinephrine in order to reduce bleeding. The areola is reconstructed using a tattoo technique. Dr. Marga prefers the Sof-Tapp® over a more mechanical technique. However, she does employ Permark® pigments (permanent cosmetics) that are distributed in individual-use packaging to prevent cross contamination and infection. Post-tattoo care includes the use of petroleum jelly to the areolar tattoo site 2-3 times daily followed by a telfa™ pad. It is important not to use ointments with antibiotics within them as they may leach out the color of the tattoo. You are encouraged to use a quantity of petrolum jelly that keeps the wound moist enough to avoid scabbing of the wound. Dry areas of the country, i.e. Utah, may make it necessary for you to apply petroleum jelly to your wound more often. Please do not submerge the tattoo site in the bathtub/whirlpool/swimming pool/river/lake/ocean for 21 days after the procedure. It is safe to shower remembering to place your petroleum jelly on the wound soon thereafter. Dr. Marga does her own areolar reconstructions and does not employ a nurse or aesthetician to perform this very important component of your reconstruction.

We would like to see you in our office on a routine basis after you complete your reconstruction. We recommend an appointment every 6 months if you elect breast implant reconstruction as you may develop capsular contracture and asymmetries. We would like to follow your progress and offer care options to you before you have a major problem. It is important to remember that you likely will require additional reconstructive procedures in your lifetime related to the imperfections of breast implant reconstruction. Dr. Marga would like to support you should this happen to you.

If you are a patient of Dr. Marga and are having problems with your breast implants, please contact us toll-fee at 866-446-0962. Dr. Marga would like to help you with any concern you may have.

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