Tall Height Expanders
for Breast Reconstruction
Gregory J. Mackay, MD
Successful breast reconstruction with tissue expanders and implants can be a challenging task for even the most experienced plastic surgeon. There are many decisions to be made along the path to reconstructing a soft, natural-appearing breast. The type of expander to select, the placement and position of the expander, the type of implant to use, whether the reconstruction should be immediate or delayed, and the possible need for autogenous tissue are all important factors when considering breast reconstruction with tissue expanders. I have had a number of successful as well as unsuccessful breast reconstructions using tissue expanders. This article presents my personal experience and the knowledge and perspective of many other experienced plastic surgeons who have performed breast reconstruction using tissue expanders and implants.
TISSUE EXPANDERS
The use of tissue expanders for breast reconstruction was first introduced by Radovan1 in 1982. Since the initial introduction of skin expansion for breast reconstruction, there have been a number of changes in the type and shape of expanders. The newest and most popular generation of tissue expanders is the textured, anatomically shaped expander, which has self-contained ports. These expanders are designed to stretch out the lower pole of the breast as they are inflated and hence should not require a lot of overexpansion to develop the submuscular breast pocket. The development of the textured surface has reduced the incidence of capsular contracture and seroma formation during the expansion period.2 The various shapes of expanders, including the low height, medium height, and tall height devices, have allowed the development of a skin-muscle envelope to be reconstructed and custom designed in the shape of the patient’s premastectomy breast (Fig. 1). These tissue expanders are unquestionably the best type currently available for breast reconstruction.
FIG. 1 Siltex® Contour Profile® breast tissue expanders. A, Low height expanders. B, Medium height expanders. C, Tall height expanders. (Courtesy Mentor Corporation, Santa Barbara, CA.)
PATIENT SELECTION
Good judgment, meticulous surgical technique, and proper patient selection are paramount to achieving successful breast reconstruction with tissue expanders. Patients who are heavy smokers, patients with unrealistic expectations, or those who are obese, have an infection, or are unwilling to tolerate the 2- to 4-month period involving multiple office visits and two to three surgeries should be excluded from consideration for tissue expander reconstruction. The patient’s body habitus, breast size, degree of ptosis, unilateral or bilateral reconstruction, and the possible need for postoperative radiation therapy must all be considered. A close working relationship with the oncologic surgeon is helpful so that a coordinated team approach can be used to plan the necessary surgical incisions for both the mastectomy and the reconstruction.
In patients with moderate to severe ptosis who are undergoing a unilateral reconstruction, a contralateral breast reduction or mastopexy is often indicated. This is discussed with the patient at the time of the initial consultation for breast reconstruction. At this time, I also explain the limitations of expansion in creating a ptotic breast mound and emphasize that I usually perform the mastopexy or reduction on the opposite breast at the second surgery when the breast tissue expander is removed and the final implant is placed. This allows shaping of the contrala