Delayed Tissue Expansion

Hana Farhang Khoee

Edward C. Ray

Joseph J. Disa

ANATOMY

Diagram of the chest wall (sagittal) showing tissue planes of the breast (FIG 1). From superficial to deep, layers include the skin, subcutaneous tissue, breast parenchyma, and pectoralis major muscle.
The dissection involves creating a pocket deep to the pectoralis major muscle but above the pectoralis minor muscle.

PATIENT HISTORY AND PHYSICAL FINDINGS

History Taking

Cancer history
Previous adjuvant therapy, including radiation and chemotherapy
Define the goals and expectations of the patient
Psychosocial
Overall fitness for surgery

Physical Exam

Breast dimension: base width, height, projection, position, and symmetry of inframammary fold (IMF)
Skin integrity
Changes in skin due to prior irradiation
Scars
Contralateral breast
Presence of a functioning ipsilateral latissimus dorsi muscle

IMAGING

Imaging usually not necessary
May consider ultrasound to assess thickness of skin flap

SURGICAL MANAGEMENT

Delayed tissue expansion

Preoperative Planning

Tissue expander (TE) selection
- Size is determined by breast width of patient.
- Most TE are anatomical and textured with integrated valves.
Assessment of skin integrity and suitability for expansion
- Irradiated skin or poor skin quality may suggest the need for latissimus dorsi myocutaneous flap.
Markings
- Should be done with patient in standing position prior to the operation
- The most important is to identify the IMF.
  - Achieve symmetry with contralateral breast or, if bilateral, create a natural-appearing fold that is not too high.
- Mark breast footprint.
  - Superior, medial (2 cm from midline), IMF, and anterior axillary fold (AAF)

Positioning

Supine with arms either extended on arm boards (preferred) or tucked
Ensure body and shoulders are centered on the table.

Approach

One standard approach for delayed tissue expanders

FIG 1 • Relevant anatomy of the chest wall: Sagittal cross section: Note skin, subcutaneous tissue, breast parenchyma, pectoralis major, and minor muscle on diagram.

TECHNIQUES

▪ Creation of Submuscular Tissue Expander Pocket (TECH FIG 1)