Ask the Doctor


After having a double skin sparing mastectomy where the expander failed in one breast due to infection. What are reconstruction options for the failed breast?

Unfortunately this is a common scenario. Capsular contracture and infection are two of the most common reasons for corrective breast surgery after reconstruction. For these women autologous tissue reconstruction is an excellent option. Using the patient’s own skin, fat, and tissue yields breasts that are more natural in feel and appearance. In addition, procedures like the DIEP flap are associated with fewer long-term complications than implants/expanders.

In patient cases similar to yours I have removed the expander and performed bilateral DIEP flap reconstruction. As a result, the breasts are symmetrical in shape and size, and the results are lifelong.


After having a DIEP flap surgery and during the healing process, is it okay to have caffeine? Or does that hinder healing?

There is no evidence that caffeine impairs wound healing. Nicotine on the other hand from first hand or second hand smoke is a known risk factor for wound healing problems.


I had a double mastectomy, and am having problems with expanders moving towards my arm pits, causing pain. What can I do?

My double mastectomy was the end of January. I am having the expanders exchanged for the final implants next Tuesday. Because I used to be an E and now I am a D, I’ve had problems with the expanders moving towards the arm pits, a bit, causing pain. Is it true that by tightening the “pockets” the implants will stay in place, like for ever? Or will this be a problem I will have to live with?

Unfortunately, this is a common problem with implant-based breast reconstruction. What you are experiencing is known as capsular contracture, and when this process sets in, it is almost impossible to reverse. Most patients with capsular contracture will undergo multiple procedures to release the capsule without any success.


Can I expect favorable results with two different breast reconstruction methods?

Patient has has an expander/implant on one side, and a TRAM flap reconstruction and small implant on other.)

Diagnosed with left breast invasive ductal carcinoma on 10/05/12, and had bilateral skin-sparing, total mastectomies on 12/12/12. I had a hematoma in the left breast at the hospital. I had to have some dying skin removed on the left breast on 01/05/13. Due to infection, I had to have the expander removed and replaced after flushing the breast on 02/26/13. I had to have the expander removed on 04/18/13 due to dying skin and opening of incision. Thin dying skin was removed and incision closed up. 04/21/13, incision opened up. Skin was too thin to close, so I have been nursing the open wound and it is slowly closing.

Due to all the problems with the left side, my surgeon has advised that we are more than likely going to have to do a TRAM flap breast reconstruction on the left side since the skin is so thin. That was the side with the cancer. My right side has had no issue with the expander, and it remains in me, but we have held off on adding any more saline since I am at a point where I can make a decent presentation with prostheses on both sides (my daughter’s wedding is in 13 days, and I am trying to look as normal as I can).

In cases where tissue expanders/implants are failing in breast reconstruction, they must be removed. In these cases, the body’s own tissue must be used to reconstruct both breasts. It is unlikely that perfect symmetry can be obtained with prosthetic (implant-based) reconstruction in one breast and natural tissue reconstruction in the other breast.

Also, TRAM flap reconstructive surgery can be associated with significant donor site morbidity, such as hernias, abdominal wall weakness, and bulges. For this reason, I neither recommend nor perform this operation. I believe that the best result for someone in your situation will be obtained with flap reconstruction for both breasts. Enough tissue usually can be obtained from the abdomen (using a DIEP flap reconstructive procedure) or with a combination of tissue from the abdomen, thighs, hips and/or buttocks (using a hybrid DIEP flap breast reconstruction) to obtain an adequate amount of tissue to reconstruct both breasts. The problem that you are experiencing is not uncommon, and can be easily treated by removing the cause of the problem (implants) and replacing the implants with your own tissue.


I had a double mastectomy, and am having problems with expanders moving towards my arm pits, causing pain. What can I do?

My double mastectomy took place at the end of January. I am having the expanders exchanged for the final implants next Tuesday. Because I used to be an E cup and now I am a D, I’ve had problems with the expanders moving towards the armpits a bit, causing pain. Is it true that by tightening the “pockets,” the implants will stay in place, potentially forever? Or will this be a problem that I will have to live with?

Unfortunately, this is a common problem with implant-based breast reconstruction. What you are experiencing is known as capsular contracture, and when this process sets in, it is almost impossible to reverse. Most patients with capsular contracture will undergo multiple procedures to release the capsule without any success. The result is that capsular contracture usually worsens over time. This problem is best alleviated by removal of the breast tissue expanders and their capsules, with immediate reconstruction using the body’s own tissue. Tissue can be obtained from the abdomen (in a DIEP flap breast reconstruction) or other parts of the body, such as the thighs or buttocks, to reconstruct the breasts.


I just had expanders exchanged for implants. How long until I can begin physical activity again?

I was receiving physical therapy, which included TENS unit for an ankle injury, prior to being diagnosed with cancer. At that time, my physical therapist terminated all massages and the TENS unit. Now I am post-double mastectomy, and the expander were exchanged for the final implants last week. Can I return to PT and pick up where I left off?

Once the incisions have healed (3 weeks without radiation, and 6 weeks with radiation) you should be able to begin physical activity.


How long after chemotherapy or radiation do I need to wait before I have breast reconstruction surgery?

You should wait 1-2 months following chemotherapy. This allows your body time to recover from the treatments before having an operation. You should wait at least 3 months or more following radiation therapy. This allows your chest skin to recover from the effects of radiation before your breast reconstruction.


What are the benefits of using my own tissue (, I believe thisit is called flap breastFLAP reconstruction), over implants?

Since autologous reconstruction uses your own body’s tissue to reconstruct the breast, the tissue is there for life. It will change in volume as your normal weight fluctuations occur throughout life, and it tends to improve in shape over time. The breast is reconstructed with fat, which is similar in density to breast tissue—thus, the “feel” is similar to that of a normal breast.

Implant breast reconstruction tends to require multiple operations over time. These additional procedures may include sequential expansion of breast skin, repositioning of the implant, correction of infra-mammary fold distortion, correction of shape deformity, correction of implant extrusion, correction of implant leakage, correction of capsular contracture, removal of implant due to infection, and replacement of temporary implant or expander with permanent implant.

If a patient has had radiation or is planning to have radiation, implant reconstruction is discouraged because of the unacceptably high complication rate. Breast implants often require replacement, as implant manufacturers do not consider them “lifetime devices”. Their life expectancy is around 10 years, per manufacturer documentation. Implant reconstructions often tend to remain firmer than a normal breast.


How do I know if I am a candidate for flapFLAP breast reconstruction?

You are a candidate for DIEP flap breast reconstruction if the amount of fat you have on your lower abdomen is sufficient to reconstruct one or both breasts to the desired volume. The tissue used is that which is often removed during tummy tucks.

Prior abdominal operations (i.e. hysterectomy, C-section, appendectomy, bowel resection, liposuction) do not exclude DIEP breast reconstruction from your surgical options. A prior tummy tuck does exclude the DIEP flap from being used. In cases where abdominal fat is inadequate, or prior surgery excludes the use of the DIEP flap, PAP flap reconstructive surgery (tissue from posterior thigh) is the procedure of choice.



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