When I first heard that I would need to have a double mastectomy, I already knew I wanted breast reconstruction. There are two main options for reconstruction – implants made of silicone or saline, and breasts reconstructed from tissue from other parts of your body. Here, I will be addressing strictly implant reconstruction.

Because nothing about having breast cancer is simple, neither is the reconstruction process. I thought I’d have my mastectomy, the cosmetic surgeon would be there and put in my implants right after, and that would be that. And while that is the case for a small percentage of women, the majority require a two-step process utilizing tissue expanders.

Depending on where you are in your breast cancer journey, you may have already met with a cosmetic surgeon who hopefully explained the reconstruction process and options to you. If not, you may be meeting with different plastic surgeons, or may not have even started that phase yet. You may have already heard the word “expander,” but I had never heard it before meeting with surgeons. I didn’t know what was in store; I had no idea the process could take months and ended in one more surgery.

Here is what you need to know about breast reconstruction after a mastectomy. 

Tissue Expanders

A tissue expander is like an empty breast implant used to stretch the breast skin (and chest wall muscles for under-the-muscle implant placement) over several months so that breast implants can fit properly, and in the correct position; this is especially important for those who are going any size bigger than their natural breasts. 

Your skin is very weak and fragile after your mastectomy, and tissue expanders allow for the breast skin to be gradually stretched. Additionally, at the time of mastectomy, your natural breast borders, including the inframammary fold, are obliterated, making it difficult to directly place an implant in that large pocket. Therefore, the tissue expander is placed to both define a pocket and redefine these borders for future breast reconstruction.

Almost a balloon-like device, it has a silicone outer shell and either an internal or external valve through which it is filled with saline. Expanders are not intended to be permanent and are usually placed by your cosmetic surgeon during the mastectomy surgery. This adds approximately an hour per breast to the total surgery time.

Over or Under the Muscle

Your cosmetic surgeon will either put the implant over the muscle or under the muscle, which is a whole other discussion and process, laid out in its own article here. If you and your surgeon decide the implant is going to be under the muscle then the surgeon will create a pocket under the large pectoralis muscle and put your expander there. 

If it’s going to be over the muscle, then the expander will be placed over the large pectoralis muscle in your chest. With both, a mesh dermal matrix around it may be used to support the expander while your skin heals. While typically the expander is filled with saline, it is sometimes filled with air during surgery for over-the-muscle placement because it puts less pressure on the skin. Then, it’s filled with saline around two weeks post-surgery.

The Expansion Process

Based on incision healing, between 10 days and four weeks after your mastectomy and expander placement surgery, you’ll go to your cosmetic surgeon’s office for your first “fill,” in which saline is injected through the expander’s port. This will be a weekly or biweekly visit, with the expander gradually filled, stretching the skin and chest muscle to make space for a permanent breast implant, until reaching the size chosen by you and your surgeon. 

Depending on how much stretching is needed, this process can take from two to seven months.

Some people experience discomfort or pressure during the fill itself and for a few days after, and you may feel pain as your chest muscles stretch, but it should gradually subside. Check with your doctor to see if you can take on OTC pain medicine if needed. 

Personally, I don’t remember the fill itself hurting, but I experienced discomfort due to the weight of the saline-filled expanders. However, permanent implants are much lighter— thank goodness.

It’s worth a mention that a newer form of expansion fills with carbon dioxide instead of saline; just something to ask your surgeon about to see if this is an option for you and what the pros and cons might be.

During the expansion process, you may still be recovering from your mastectomy, so already following protocols that promote healing. But to stay as comfortable as possible, it’s recommended to avoid strenuous exercise which may cause your breasts to bounce or that use your chest muscles. Wearing wire-free, supportive, soft bras (we’ve got really great options) and loose-fitting tops (we've got those too!) is also encouraged.

Exchange Surgery

Once you and your surgeon are happy with your breast size, the filled expander will stay in for at least another three weeks and then you will go for outpatient surgery where your expanders will be swapped for a permanent implant. The material (silicone or saline), size, shape, and silhouette of the implant will already have been discussed with your surgeon, and hopefully, he or she will have shown you what the implant looks like. 

I had no idea there were so many options! Mine showed me quite a few, and then what he thought would look and fit best on me, given my frame and preferences. 

The outpatient surgery usually occurs three to six weeks after your last fill and takes about one hour per breast. Once you’ve recovered from anesthesia and the healthcare team feels it’s safe, you will be sent home that day with instructions and begin healing one more stage of your breast cancer journey. 

Radiation and Exchange Surgery

It is recommended to keep the expanders in place and postpone exchange surgery until radiation is finished for a few reasons. One is to make sure the skin is healed and strong enough post-radiation to endure the surgery. 

Also, having a breast implant may make it more difficult to deliver the radiation effectively, and radiation can shrink the skin, causing a reconstructed breast to become firmer, sit higher (asymmetry), and the skin over it to become tighter and denser; because of this, it is common for the breast that is going to be radiated to be over-filled in anticipation of it shrinking. 

There can additionally be complications from capsular contracture, in which the fibrous scar tissue that has formed around the implant becomes hard and firmer around it. 

One strategy to lower your risk of capsular contracture is to take Vitamin E and a medication called Pentoxyfilline (which is a blood thinner) daily for a full year after treatment. Ask your physician if this is right for you. Finally, waiting can be beneficial so that any scar tissue caused by the radiation can be removed before placing the final implant.

Takeaway: if you are going to have radiation, it is imperative that your surgeon knows, so you can discuss what’s best for you and your overall timeline.

Direct-to-Implant

Instead of expanders being placed after your breast surgeon is finished with your mastectomy, the permanent implant will be directly placed. This is what I told my cosmetic surgeon I wanted. I did not want to go through another surgery — after my mastectomy, I wanted to start to move on and heal!

However, I wanted my reconstructed breasts to look as much like my real ones as possible, and because my real breasts were big for my small frame (D cup, at 5’3”), my surgeon was honest in saying that while he could do direct-to-implant if that’s what I really wanted, he didn’t think it would yield the best results. 

He said he would have the implants there and ready at the surgery, but if it was not going to look good, he would put in expanders. I trusted him and felt comfortable leaving it up in the air like this.

When I woke up from the surgery and looked down to see teeny breasts, I realized there were no implants. And while I would have liked it to have been “one and done,” I appreciate that he did what would make for the best aesthetic. After all, what’re a few more months of expansion compared to a lifetime of weird-looking implants!?

 Final thoughts:

• You don’t need to decide right away about reconstruction. Take the time to meet with surgeons, learn about all your options, and discuss with your care team.

• No matter how adamant or cavalier your surgeon seems, remember that he or she works for you. I met with one surgeon who wouldn’t even listen to my concerns or desires, or answer my questions; she told me, “This is the way I do it, and it’s the only way.” I met with a few until I found a doctor who spent the first 10 minutes talking to me about my lifestyle, fitness routines, and general picture of my day-to-day, and how I wanted my breasts to look. From there, we discussed what reconstruction would best support those things.  

• I was told that the metal valve on the tissue expanders might make the metal detector go off at the airport, and I had this whole image of myself as one of those fembots from the Austin Powers movie whose nipples were actually metal guns that shot bullets out of them. But, alas, I went through airport security without issue. (After your exchange surgery, you’ll be given an identification card of the types of implants you have. If you are flying, be prepared just in case by either having that card with you or getting a medical note.)

• Expanders can feel extremely heavy and firm; compared to an implant, they are hard as a rock! They also may have ripples or edges which you can feel and appear lumpy through clothes, but permanent implants are lighter and much smoother, so remember that it is only temporary. 

Usually, the implant reconstruction takes place as soon as your breast surgeon is finished removing the breast tissue during a mastectomy. As such, your breast surgeon and cosmetic surgeon should collaborate closely to develop the best strategy and options for you.

For more information on breast reconstruction options, visit the other articles in this series:

For more information on breast reconstruction, visit the other articles in this series:

Breast Reconstruction: Implants Under vs. Over the Muscle

Keeping Your Nipples with a Mastectomy

Nipple Reconstruction After Mastectomy Yes, it’s a thing!