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Expander Implant Exchange and Revisions

The second stage of expander implant reconstruction involves the removal of the tissue expander, followed by placement of the implant, and creation of the final breast shape. This is an outpatient procedure, performed by opening the mastectomy scar (no new incisions are made) and removing the expander. Before placing the final implant, changes that need to be made to the implant pocket are addressed. These can include repositioning the implant on the chest wall, improving the inframammary fold, using AlloDerm® or Strattice® to address areas of thin skin, and revising or removing the capsule as needed. The final implant is then placed in the pocket, and the incision is closed. Drains are usually not needed. Placement of the implant will result in a softer, more natural breast as compared to the tissue expander.

Healing of the final breast implant is necessary before proceeding to any additional stages of reconstruction. These may include, procedures on the opposite breast, creating the nipple areola, and revisions in the implant reconstruction. Areas of concern that can be addressed in revising an implant reconstruction include thin skin with rippling, capsular contracture, contour abnormalities, and problems with the inframammary fold.

Revisions in Implant Reconstruction

A common concern with implant reconstruction is thin skin that allows irregularities of the implant to show through. This can result in skin rippling, a problem, that is more likely with saline implants. In order to help correct skin rippling, a saline implant can be exchanged for silicone gel, or a higher volume device. Also, AlloDerm® or Strattice® can be used to camouflage skin rippling.

Capsular contracture complicating implant reconstruction may also require revisionary surgery. The capsule is the internal layer of scar that forms around an implant as a natural reaction to the presence of a foreign device. The capsule can contract (shrink), thereby causing a feeling of tightness. In the most severe cases, the tightness may be visible and associated with pain. Surgical treatment may require a capsulectomy to remove a portion, or all, of the capsule to soften the pocket. Capsular contracture is extremely common in patients who have had prior radiation.

Contour abnormalities following implant reconstruction can be treated with a number of approaches. If needed, the skin envelope around the implant can be reshaped. In areas with thin, soft tissue, contour may be improved with fat injections. In this procedure, fat is removed from other parts of the body with liposuction, and is then prepared for injection into the skin of the reconstructed breast. It is not always predictable as to how much fat will “take” or be accepted by the body. It is not unusual to need more than one procedure to get the desired final outcome. The fat that does survive should last forever.

Breast implant malposition and asymmetry, or a poorly defined inframammary fold, can frequently be corrected by placing stitches to alter the shape of the implant pocket. The inframammary fold position can be revised in this way, or by cutting the skin below the breast to help create a fold.

Once the areas of revision have been addressed, and the breasts have completely healed, the nipple areola reconstruction can be done. Refer to the Nipple Areola Reconstruction section.

Photos and Doctor Commentary

Expander asymmetry with right capsular contracture

After expander implant exchange and revision

Expander Impnat Exchange

Click Image to Enlarge

This patient underwent bilateral prophylactic mastectomies and tissue expander AlloDerm® reconstruction. She developed capsular contracture of the tissue expander on the right side, resulting in asymmetry. At the time of her expander implant exchange, markings were made to outline the correction required for repositioning of the right inframammary fold. After the expander implant exchange and revision, she has a symmetrical reconstruction.