Tissue expanders questions

Hopeful07

Hi there,

After consulting three plastic surgeons, I have decided that I will go the expander/implant route as opposed to direct to implant option which was originally presented to me due to the fact that it seems to guarantee a more predictable outcome and less risks.

I am however, concerned about how uncomfortable the expanders are after reading many posts. I am small and "skinny" (97 lbs), does that mean I would find the expanders more uncomfortable? My dr told me I will have the exchange surgery three months after. Will I appear "normal" and do normal things after recovering from the mastectomy surgery (assuming around 4-6 weeks)? Do I have to wear a bra? If so, how do I deal with my changing breast size?

Thanks in advance.

SpecialK

hopeful - hard to say regarding the expander and discomfort - I did not have pain per se - rather a feeling of pressure. I am fairly petite - normally wear a size 2 or 4 jacket or top, but had no particularly painful experience with expanders, just mostly annoying. Your expanders may cause more discomfort initially as you are not only stretching the muscle, but simultaneously recovering from the breast tissue removal. I found that I felt much better by the end of the normal 6 week recovery period, and I had no problems being able to do all the things I prior to surgery. Expanders can press on nerves and skeletal frame, so this may be more problematic if you are thin, but I didn't find it to really be the case for me. I had small fills and did not need any pain meds or muscle relaxers while receiving fills, but others do, and if you are not comfortable you should certainly request those. "Low and slow" is my philosophy, meaning smaller fills - it is easier on the skin and muscle and sometimes you can proceed to exchange with less of a wait time since the process has been more gentle. Fills sometimes can actually alleviate discomfort as they "lift" the expander off of nerves or ribs since the fill adds forward projection. Your plastic surgeon will fit you with an expander that is tailored to your size - they come in differing manufacturers, with width, height and total fill volume that differs depending on which size is used. Depending on whether your PS is able to add some saline fill to your expander while you are in surgery will dictate what you expanders look like immediately afterward. While I looked a bit smaller than I had previously, I didn't augment with any prosthetics during the fill process - I wore stretchy bras like Coobie or Genie type so that I was comfortable - I had nipple sparing surgery so I felt I needed to wear something for modesty. I would not necessarily invest in bras along the way but rather purchase something with enough give to accommodate the changing size. Underwire bras are not always comfortable with expanders, as the expander can't be corralled into the cup, they just sit where they are - I found the stretchy bras provided enough coverage and structure for me. Wishing you the best!

Edited to add - you can currently get a discount on Coobie bras at their website, enter the code WANT3

Hopeful07

thank you so much for your detailed response, SpecialK!

JessieJake

Hi Hopeful07, I might be similar in build to you. My DH just said yesterday, "It's amazing how you feel everything in your body!" He was noting that I'm very thin if you look at me sideways. Not a lot of depth from front to back. Even before this I would always share how I could feel this or that which would sometimes lead me to worry about things that most people probably never notice.

My rib cage or band measurement is 28 inches. My PS at first thought she wouldn't be able to fit a regular round TE in me because of how tiny I am am there. During surgery, though, she did find she was able to fit the traditional round one that holds 300 cc (I just found that on the statement of charges we got from the hospital).

So, to answer your question, I do feel these TEs a lot, but I can't compare that to others. I think for most they are uncomfortable to some degree. I can only sleep on my back and foresee that being long term. Laying on my side pushes on the TE and feels like it would bruise. In the initial days, the left TE caused enough pain under my arm to wake me at night, but that has since disappeared as I think my body is getting used to it. I went above the muscle with my TEs. I don't think I could have tolerated the muscle stretching and my PS agreed. She mentioned there was not even much to attach the alloderm (artificial stuff added to support implant) to and she stitched it to my chest wall.

I've had moments when I'm busy that I have forgotten about them. Afterwards, when I realize it I'm always delighted to know that these moments are happening and I think it will happen more.

I should also share I'm only 3 weeks out from surgery. I have my first fill this week and that may change my "feels" again.

My PS likes to wait 6 months before exchange! Argh, that may require some patience I don't have!

Hope that is helpful to some degree.

Hopeful07

SpecialK - thanks for the code! I will check it out. Can you believe I have never heard of coobie bras until you mentioned it? Haha.

JessieJake- it does sound like your build is similar to mine. I wear 30 band size but only because I cannot find 28 usually! Thank you for your insight. Sounds like I may want to inquire my ps re: te over the muscle? I'd be curious how you feel after your firstfill!

SpecialK

You are welcome - my recon has been a bit of a protracted situation with much additional surgery that is ongoing, but I continued to wear the Coobie bras after exchange to silicone implants in '12. I have spent the last 18 months with the left implant out after an allograft repair caused some issues. I now have had a new TE that was placed in Dec. I will exchange again in May along with a right implant revision to downsize, right nipple removal and fat grafting - the Coobie bras have a pocket with a modesty liner that I was also able to slip a lightweight prosthetic in to balance both sides, and now that I am fully filled on the left and even with the right I wear them without the prosthetic. Love them!

JessieJake

first fill complete! Just to remind you of my situation - I have over the muscle TEs which were placed 3 weeks ago. At that time the PS put only 50cc of air in cuz I'm so small. I also have pretty small TEs. 300cc.

The port to add saline has a magnet in it so she first waved a magnet over me to locate that. It was near the top. They used what I thought was a very long needle to first extract the air and then filed with 50cc saline in each. My right side has some feeling so I felt the prick of the needle but the rest was painless. Despite it being the same amount, I can tell the difference, a little more filled rather than lumpy. They feel a little different, like not so smashed on my chest.

I go back next week for another small fill then every 2 weeks until I'm done.

Hopeful07 - you'll appreciate this. She told me we can't go too quickly cuz my skin is so tight. Lol, I said I'm pretty sure I'm already bigger today than I was before surgery. I don't think I'll be doing many fills. I'll hope that means my exchange to implants will come sooner. I'm still so happy I chose above the muscle. I think this will be quite doable

SpecialK

It is important to note that expanders have more forward projection than either silicone or saline implants. If you exchange to the same cc implant as you have filled to in an expander you will most likely appear smaller. Most need to go with a larger cc fill in the expander to maintain their desired size at exchange, some lose as much as half the projection and visual size.

JessieJake

ah, good to know! This will be interesting

littleblueflowers

Hi ladies! I'm considering doing delayed recon, and the thought of expanders scares me. When you got yours placed, how long before you were allowed to resume normal activity, if any of you would care to share? Thanks so much!

KellyAnne13

Hey littleblueflowers,

I have unique situation in that I had one expander placed during my bmx and, because of skin complications, had the other placed months later. It was not too bad at all. A little tight for the first week but I was quickly back to driving and most things right after that. I was skiing two weeks later too! Hope that helps

KellyAnne13

Hey littleblueflowers,

I have unique situation in that I had one expander placed during my bmx and, because of skin complications, had the other placed months later. It was not too bad at all. A little tight for the first week but I was quickly back to driving and most things right after that. I was skiing two weeks later too! Hope that helps

JessieJake

littleblueflowers, that's a good question!

I had mine placed when I had BMX and am restricted from regular activity for 4-5 weeks. I can walk, do light housework, etc.., just nothing heavy or repeated over my heavy.

But, as KellyAnne13 says, it sounds like it is much quicker if u get them later on their own.

Are you worried about being restricted or something else

Hopeful07

jessieJake - sounds like your first fill went well. I wonder why I wasn't told about an option to put the expanders above the muscle? Is that just a better option for petite people?

SpecialK - my understanding is that I don't have to worry at all about what type of implant until after the fills. Am I correct? I have no idea about moderate/high profile, etc etc. I assume all surgeons are aware that the expanders need to be exchanged with bigger cc implants?

Thanks again

SpecialK

hopeful - the vast majority of those doing implant recon have expanders under the muscle. Placing above the muscle may limit how much you may be able to expand because there is less holding the expander/implant up, and may be specifically requested by some for specific reasons, or may be appropriate only for specific patients. You don't really need to worry yet about what type of implant will be used. Speak with your PS about what you want for a final look and that will dictate final fill size, implant type, profile choice, etc. Not all surgeons automatically over-expand, or use a larger implant. There is a limit to how much larger an implant will fit into the expanded pocket and I have seen many here whose PS has said to let him/her know when you have reached a size you "like" and then they stop expanding. I have read many disappointed posts from members after exchange and they are smaller than they thought they would be. Also to all, note that every expander can be expanded beyond the max fill size - just because you have an expander with a certain cc size, that expander has been chosen to correspond with your frame and dimensions of your chest - not the eventual size you would like to be, and they can all be filled beyond the cc capacity.

Hopeful07

You're so knowledgeable about this stuff! Thank you. I get choked up just realizing how many of you are all out there, sharing what you have been through, and helping out a recently diagnosed like myself. It's really nice.

I just purchased a few coobie bras! Excited to try them.

This may be a strange question - but did you use any pics to show your ps what your preference is? I lost a lot of volume after breastfeeding the third until recently and both plastics surgeons seemed to have a hard time picturing me bigger because of my small frame

Hopeful07

and are we stuck with the size we get the first time or if something doesn't look right is that something we can reconsider as well in revisions

JessieJake

Hi again Hopeful07, I went into this kind of blind. I didn't research or do anything before meeting with my PS. We only grazed over the other options people chose like the various flap reconstruction options and talked only about implants after TEs. Of course, no option to go right to implants because I wouldn't have enough of my own skin to cover them! Again, all new to me in that moment of talking about it with her. Right away she mentioned both options - above or below the muscle with the various pros/cons. Until I did do some reading later I had no idea that above wasn't as common as below. From my limited amount of reading now it seems that there is various levels of buy-in on the over the muscle option with some not doing it at all while others do. So I did question her more on that on at a second meeting. As you may also be doing, I told her I didn't want to be very big, but certainly bigger than I was! My frame would look silly if I tried to go too big. They'd be like cylinders hanging off me 'cuz I don't have the width to accommodate big and round. LOL! I just want to look feminine and fill out a petite size bra (which I've never done except for when I was breastfeeding). I think based on that she was completely 50/50 on which choice I should make. She said for some she would certainly recommend one way or the other but one way wasn't sticking out as the best for me.

I had concerns about muscle spasms from under the muscle. I have a benign condition called costochondritis which causes breathing pain due to inflammation of cartilage around the sternum. I've had it all my life and I asked if below the muscle could aggravate that. She didn't think so because it's two different areas - sternum vs the muscle, but she said it's possible the muscle spasms would feel like that. That scared me as the costochondritis is a horrible feeling when it happens. Because I feel everything (and that simple little fill I had yesterday really lit up my chest!), I thought I'd just be asking for trouble. So, she still placed alloderm which will eventually hold whatever implant I end up with (she mentioned that anatomical is what she's thinking, "teardrop"). Did I mention she said she had others like me that she really liked the result of their over the muscle implant? It was this conversation and the video of the muscle contracting the implants that made me chose over.

Now that I'm doing fills, I see nurse practitioners. There are a lot of them! I feel badly that your PS might not be able envision you bigger. The NP I saw yesterday told me more than once about what a great result she thought I was going to have. My PS said that before suregery, too. She said she had a "vision" in her mind. Maybe when you go in they'll see you differently!

Yes, thank you SpecialK. Your knowledge is great! It gives me some questions to ask when I go in for my appointments.

SpecialK

hopeful - it is a bit trickier to revise based on just not liking the size rather than medical necessity, but I have seen others do it. Your PS can usually code the insurance claim in such a way that it is covered, but I will caution you to try to get it right the first time. This is best achieved by asking lots of questions and being very clear about what you want. I had skin integrity issues immediately after BMX which caused me to lose my TE. After a lot of additional surgery I finally got to implant exchange and everything was fine for two years. I had what should have been a simple repair surgery and again had skin issues that have now bought me six additional surgeries at a minimum, and being without that implant for 18 months. Every time you have another recon surgery you risk complications.

Jessie - all that surgery is why I have all that knowledge, lol! That said, I am glad I am here to help - it is a silver lining for me

Hopeful07

JessieJake - Sorry to hear about your condition, but it sounds like your fills are going well and you will have a good outcome!

SpecialK - I think sometimes I am choosing to focus more on the recon side to turn away from the things that I actually fear the most and that has made me weep. I guess I just wish I could walk away from this looking and feeling well and as if nothing horrible happened. Hearing everyone's story is humbling. At the end of the day, I want to heathy and be there for my kids for a very long time. So sorry to hear about your complications, and thanks again for your insight. I just keep having so many questions!

SpecialK

hopeful - it is possible to come out the other side of this experience looking and feeling well, try not to worry. I know many who have - I have just been an unlucky one recon-wise, but that is ok. Ask any questions you have, it is better to be prepared if you can!

kcat2013

Hopeful, I hover around 100lbs, quite petite. The initial few weeks after surgery were pretty painful to me, but I suspect that was not due only to my small size--although I my PS and several nurses commented on my small size/relatively physically fit body type probably contributing to more pain. I had 300cc's added to my expanders at surgery (which made my formally flat against the chest wall pecs very mad) and I had an outpatient mastectomy where I was released within 2 hours of coming out of surgery so never got good control of the pain to begin with. Anyway, once I got past about the 5-6 week point, the expanders weren't painful anymore. Uncomfortable and tight at times, but totally easy to deal with. My PS also had me go slow with the fills, adding only 20-30cc's at each fill. Which I found kinda funny since she filled so much during the surgery The small fills were the way to go though, I never dealt with any serious pain with them. My PS prefers to purposely overfill the expanders, so I filled to 430cc but was placed with a 400cc implant. I'm very happy with my recon at nearly 2 years out. My fake boobs are close in size to what the originals were, just a bit smaller--which I told my PS that I'd rather end up smaller than larger if there was a choice between implants during the exchange surgery.

JessieJake

kcat2013, I am simply stunned that you were able to go home so soon after surgery! I stayed overnight and even when I left the following evening I was barely mobile. I had ambled a short distance down a hallway with help from 2 people and kept thinking they were crazy to think I was able to go home. Even though it's now a memory I'm envious of your experience! I was still puking after I got home from the hospital and couldn't walk without help.

Oddly, something like up to 48 hours is considered outpatient by insurance definitions they told me. Weird. Anyway, a few nurses and a doc said I could stay but they transferred me to a new room after dinner because the wing I was in was closing!! I only saw one other person also transferring. I guess all the other ladies were well enough to leave as expected. In the end, I guess I preferred being home in my own bed!

I'm looking forward to these TEs settling in. My first fill aggravated everything again so my nerves are like WTF right now. The worst is where the sit under my arms a little bit. Thanks for your additional info, though, it help paint a better picture of what to expect!

kcat2013

Jessie, don't envy my experience! It was absolutely awful being sent home that quickly. I couldn't walk without blacking out, and my pain was excruciating at that point. Took me 30 minutes to get from the car to the house when we got home from the hospital!! I couldn't even go to the bathroom by myself, had to have a family member very very slowly walk me there, pull my pants down, help me sit on the toilet, then hand me toilet paper (I couldn't twist my body to reach the dispenser) and then help me pull my pants back up. It was just awful, I don't know how come the hospital and insurance companies can get away with discharging patients that quickly, especially when they are not ready to go home--my husband, my mother, and myself were begging them to let me stay at least a few more hours--but out I was kicked!

Can you tell I'm just a bit bitter about the whole thing? I'm sorry you were still puking that long after surgery! You may want to talk to the anesthesiologist before your exchange surgery and see if they can tweak things to maybe prevent that next time. I was nauseated but fortunately didn't puke.

My TEs sat under my arms quite a bit too and I felt like I could never comfortably cross my arms because they were up in my arm pits like rocks. But, thankfully, my implants are nothing like that and I mostly feel like they are part of my body now.

JessieJake

kcat2013, I'm with you on being bitter! I went to a very reputable place and it didn't occur to me to prep my DH to second guess anything they did, but I've already prepped him to be vigilant when I go in for my implant surgery (can't wait - although concerned about nausea again). Like, why on earth did they make me get off the gurney when I returned from recovery and WALK to my bed? I almost fell over more than once and was so sick. If I had half my brain alert at the time I would have said no! It sounds like you were feeling like I was but at home. Ugh. Glad those are memories now!

I was pretty naive on the anesthesia. I hadn't had it in many years and thought I'd be ok. LOL, anything but. I think the best thing is the scopolamine patch they placed behind my ear after I'd been in my room for a while. I'll get that earlier next time for sure. However, I think one of the biggest culprits was the nitro paste they used on my right nipple to increase blood blow. It was too much dosage for me and it gave me a headache I can only imagine is like a killer migraine all around my head. I couldn't even look at people (or anything) and that alone was making me puke. After narrowing it down to that, we wiped it off and viola! In less than an hour I was a new person. I am VERY bitter about that because I kept telling them in the hospital my head hurt and I got nothing. One nurse even asked if I was coffee drinker and since I hadn't had coffee that day....WTF? My PS said the nursing staff should have been well aware of this paste and that it causes headaches. PLEASE! They wanted me to use an inch (like toothpaste). After we figured out this was causing so much of my misery, my DH would apply about 1/16" and I could feel the effect within minutes - my temples would pulse, but at that amount we could keep the headache at bay. When we were using the greater amount which was maybe 1/2 inch (geez, my nipple just isn't that big! My whole breast area would have been coated with 1 inch!) I was getting heart palpitations, dizziness and of course the headache/nausea. I think an inch might have killed me which I told the NP on Tuesday. At first she kind of chuckled but when I told her the severity of my symptoms she looked pretty serious. Ok, that was my bitterness coming out big time!

Also, I can relate to the TEs in the armpits. That where my most discomfort is located. I keep reminding myself she isn't going to put implants there and obviously they'll be softer then these! Thanks for sharing! Gosh, it's helpful knowing others share similar experiences and we can commiserate.