Why tissue expanders?

Just got back from the first appt with the PS and so far we're quite happy with her. I had originally wanted to do direct to implant reconstruction but she explained the increased risk of infection, of difficulty with blood supply from the skin being stretched so complications with direct to implant would be 20% versus 5%. Another plus that she mentioned was the opportunity to tweak things after things have healed to get better symmetry and outcome, both of which I'm definitely in favor of. The plan is to meet with the BS on Friday and then another meeting with the PS for a "show and tell", get to see the tissue expanders, implants, etc a couple weeks later. I'm not a huge fan of having another surgery but if blood flow/sensation/symmetry, etc could be better with the TE vs direct implant that's definitely a good thing.

I don't mean to argue with a ps, but in one step recon, your skin is not being stretched because you are having a skin sparing mx. That is why one steps are usually done for those who wish to stay the same size. You might be able to go a smidgen bigger, but not much. As for tweaking things, if you need it after one step, it can be done, but if you're satisfied then no need. Sensation, by the way, will never likely return. A mx removes all underlying tissue and nerves. You are left with an empty skin sack, essentially. You may regain some surface skin sensation. IMO, many docs steer patients away from one step because a) limitations on size b) they don't do many and are not as familiar with the procedure.

With the right patient and the right ps, it is a very viable option with not greater risk of infection and no skin stretching

Ipsy

You are right, there is no one right way, and I am certainly not doubting the credentials of your ps. However, the reasons for not doing one step ie: skin stetching, high infections rates are not true. The skin is not stretched and infection rates are roughly the same. I think the most important decision a ps can make is if the patient is a suitable candidate. The criteria for one step suitability is rather narrow.

I'll try to get the links, it may take a coupe of days since it's summer and I have 2 kids. I guess I am just getting fed up that we are at the mercy of the plastic surgeons and which surgery they prefer depending on their experience. I'm sorry if I came off the wrong way, I just wish everyone could get the type of surgery they prefer we all are individuals and have different needs and desires.

Reconstruction IS dependent on surgeons skill and experience, it does not matter what credentials the surgeon has if they simply don't do enough of a certain type of surgery. Surgeons skill level also explains why women are flocking to NOLA for their reconstruction. A woman on my chemo board had to travel to get her direct to implant surgery.

This article suggests that it took surgeons 1 year to cut their complication rate by half.

Three Hundred Thirty-one Consecutive Immediate Single Stage Breast Implant Reconstructions with Acellular Dermal Matrix in 211 Patients: Indications, Complications, Trends, and Patient Satisfaction

"A higher total complication rate occurred in the surgeons' combined first year performing single stage implant reconstruction 21.4% compared to subsequent years 10.9% (p<0.02) suggesting a learning curve with the technique"

Direct-to-implant breast reconstruction

"Although there are a number of reports associating ADM with an increased risk of infections and complications, there are also numerous studies showing no increase in complication rates, including our own paper (1,3-12). The reason for the discrepancy may reflect the learning curve in using a new product and technique. It is very important to drain the spaces adequately to prevent seroma and to limit excessive stress on the skin envelope to help prevent skin necrosis."

I have to say I am horrible at finding the articles again if I don't book mark them. But I believe it was Salzberg that offered direct to implant reconstruction to all women wanting implant based reconstruction, so selection criteria is not all that tight and if a surgeon tells someone they are not a good candidate for direct to implant they need to state the reasons. And it must have been one of the BRCA articles that stated that direct to implant is a good fit to anyone wishing to stay the same size and most women qualify for that surgery.

And the link you posted stated that infection rate is the same for direct to implant as with TE. So some of the reasons that surgeons give women why DTI is not a good choice are bologna. It comes down to surgeons skill and experience. But it is unfortunate that all types of reconstruction may require revisions. I myself have ripples in the prophylactic breast and lets not even talk about my radiated side. Is it obvious that I am tired of surgeries???? I do not want my sister to endure all this when she does not even have cancer, I wish she could have one simple surgery and be done with it.

And I totally agree all types of reconstruction can be successful and give good result. It is up to the patient at what cost are they willing to get those results (flap surgeries have great results but long hospital stay and donor site incision). My baby was 18m when I got diagnosed, I did not need the trips to get fills every 2 weeks while I was in chemo. I put off the exchange to implants for a long time since it would interrupt my life.And I did not even have any complications. It was doable but had I been offered DTI I would have done it in a heartbeat.

Thanks for the info inks. I do agree (and not dissing those ps's with a slew of credentials) that experience, lots of experience, seems to bode well for successful one steps. Need for revisions can be done, if needed, with either type of implant recon. My ps had the following criteria for one steps:

- mx must be skin sparing and preferably nipple sparing

- in general, patient should want to stay the same size and he felt best cosmetic results were best if patient stayed C cup or less. He felt that larger than C was harder on the pectoral muscles.

- Most important, initial examination of breast tissue, medically allows for it (one step)

- My ps also told me that he would bring TE's into the OR and if he felt the one steps did not yield the desired look, he would go with TE's. I greatly appreciated his perfectionism and his honesty.

-My ps did a lot of one steps. Within the group of plastic surgeons at my facility, if someone was interested in this route, they were referred to him. I believe his experience is what contributed to my aesthetically excellent and complication free recon.

Sandy, ISpy - just catching up on this thread. When I first heard about direct to implants - I thought, How Wonderful! Why wasn't i offered that option! Sounds wonderful - go to sleep, get the cancer cut out, wake up with boobs - rest, one and done! By PS is very very conservative.

On first appt, I had researched and decided on DIEP. I thought, I'm still going to be mostly me, my nipples (skin/nipple sparing) my fat (from my tummy - already have C-section scars which my research led me to believe that is the same place the insision for the fat would be) - and getting a tummy tuck at the same time - perfect - well as far as BC goes.

But, my PS, 1st meeting, said NOPE, I don't do those unless it's a last resort The surgery it too long, too invasive, and too many unneccary risks. And, that was that. No discussition. Period. Did I mention that he's a real, real, cocky, full of himself, kid?...He's good - has the best reputation in my neck of the woods, and, he KNOWS it. "I use silicone implants, TEs first - and we'll go from there." No real choice about size, shape, brands. He took a bunch of measurements of my chest/breast area - while I was in different positions - had his assistant to write it all down (like you were getting measured for a dress, or slacks). Then he gave me some reading material - asked if I had any questions (of course I'm in shock - just starring) and he says, well call my assistant later if you have any questions. And, I'lll see you May 6th before the surgery!

Well, I'm still recovering from the dx - so to heck with it - he's supposed to be good - so, I'll follow his lead. Skip to after the surgery and I'm getting the path results. BS is shocked that what was supposed to be a little bitty stage 1 tumor - was 5cm - with at least 1 lymph node with cancer. BS mumbles under his breath - this isn't good - this isnt good at all. I'm going to set you up for a auxillary lymph node discetion, and put a port in at the same time - (He didn't have to explain that he was sure the onc was going to schedule chemo and Rads)- And of course, I'm in shock - trying to absorb how quickly my almost one and done surgery was turning in to something way different! BS starts mumbling that Steve, the PS, may want to post pone all recon - and if the Rads are too tough on my skin, I might loose the efforts of the nipple sparring procedure - but if Steve doesn't want to do implants because of Rads - he can always do a DIEP as a last resort, and I can look at 3D tats down the road. He was able to get Steve on the phone while I was there - Steve still want's to avoid DIEP (and yes, has done them, DIEPs, many times) - but says he will just do the TE refills through out Chemo - but not do the exchange for at least 6 months after Rads. And my next PS appt - he explained all the risks, infections, lack of artistic out come - if the rad treatent has to occur with the implants ( the real fake boobs) are already "implanted" inside. He prefers to give the skin a long rest after rad treatments, like at least 6 months (which means I'll have TEs for about a year before exchange, so he can see/feel/measure what size/shape choice is going to set in my rad treated chest/skin AFTER the rads. He is very persistant about this - but of course I'm free to find another, less consertive PS - so that's what I'm doing. But I've left aout the important thing -

Before the BMx, I was a 36 C (and in his 1st appt. notes he did mention something about age related sagging....hummm), 55 yrs old, 5'4", 120 lbs - and 3 weeks out from the BMx and only 2 fills - my breasts are BEAUTIFUL (although I will never tell him that - he already can't get his head through the door...LOL) Sure, you can tell where the TEs are, a little dis-color where the 4 drains were, but you can hardly see the scars at all, tucked nicely, and flat, where the underwire of a bra would land. If things in the recon keep going as well, 6 months after the exchange - my boobs will be more attractive than they've ever been. So, based on what my PS has done so far - I'm willing to trust his instincts about doing TEs first - just in case there are problelms down the road - like in my situaiton where I may acutally end up a stage 4 patient (YIKES) - and then I found all kinds of researach on the web - both pro and con - mostly I found what is refleced in this quote below:

"If radiation theropy is a part of your treatment plan, most surgeons prefer that the radiation happen while you still have the tissue expander. This approach offers a better cosmetic result becauses it offers the opportunity to remove any radiatioin scar tissue before placing the final implant. In many cases, the radiated skin isn't the best environment for implants. So talk to your surgeon to see what his/her experience has been. " (Note - couldn't get the copy/paste to work, so I retyped the quote - typos/spelling mistakes on me!)

Anyway, I'm still a newbie having only been dxed early Feb. with ILC, that jumped from "nothing" to a really big "something" in just a few weeks. So, yes, I can see why direct to implants would be extremely attractive - I certainly didn't choose to have TEs for over a year:) but I can see how the risks of not waiting for the implants until you are 99% sure the treatment is complete, is worth taking a second look at. (And yes, I know that NONE of us have a gaureentee that our treatment is over.) And yes, I do see where my tablet changed to font to a bold face, and no, I don't know why. LOL - I've enjoyed this thread very much and I am learning so much! Thanks to all the ladies here!

Blessings, Prayers, Hugs, and Lots of Laughter!

Vol4Life