Do You Need a Tissue Expander to Downsize During Breast Reconstruction?

I'll start by saying I do primarily direct-to-implant (DTI) breast reconstruction, so that's my perspective. If you're trying to downsize the size of your breast with a mastectomy and reconstruction — in my practice, no. I would just place a smaller implant. But it's important to understand the risks.

There is more risk to downsizing than there is to upsizing. In a paper I'm just about to get published with my partner, we actually found that our complication rates with upsizing were no different than staying the same size. But with downsizing, the complication rates are higher.

There are a few reasons for this:

• Larger patients have higher mastectomy complication rates — patients typically downsize because they're quite large, and mastectomies in those patients carry more risk
• Subdermal plexus perfusion — when the skin flap is rounded over an implant, it works better with improved blood flow. A smaller implant under a larger skin envelope doesn't support perfusion as well

No, I don't think you have to have a tissue expander. But the risk for mastectomy flap necrosis, seroma, and other complications is higher with downsizing. That's why many surgeons will elect to place an expander in that situation — it gives more control over the healing process.

If you're considering reconstruction and want to change your breast size, talk to your surgeon about whether DTI or a tissue expander is the better option for your anatomy.