Direct to Implant (“One-Step”) Breast Reconstruction
Post Mastectomy Reconstruction
Post mastectomy reconstruction with a direct to implant, or “one-step” approach allows for a single-stage reconstruction of the breast mound in select patients. This approach is best suited for patients with good preservation of the breast skin after mastectomy. A permanent implant is inserted immediately following the mastectomy, forgoing the initial placement of a tissue expander and subsequent expansion process.
Placing the Implant
At the time of the initial post mastectomy reconstruction operation, the implant is positioned on the chest wall behind the pectoralis major muscle. Today, with the use of a dermal matrix (such as AlloDerm®), the surgeon can frequently use a permanent implant of the desired definitive volume during the initial surgery, provided the amount and quality of the breast skin remaining after mastectomy can accommodate the volume. The patient will have the definitive breast volume and approximate shape after the first operation.
Depending on the quality of the result after allowing the initial reconstruction to settle and heal for a few months, a second stage reconstruction creating a more refined breast shape may still be desirable. This is an outpatient procedure that involves minor refinements in contour and symmetry potentially without exchanging the implant. The initial implant placement, and possible second stage, each take about one hour in the operating room.
Direct to implant and Dermal Matrix Breast Reconstruction
Click Image to Enlarge
Choosing Your Implant
Together with your surgeon, you will decide which implant best suits your individual needs. There are two general categories for implants: saline-filled, and the new generation of silicone cohesive gel-filled implants. Saline implants have historically been more commonly used in breast reconstruction, and between 1992 and 2006 they were the only fully-approved devices in the United States. Silicone gel implants prior to 1992 were often well received by patients, but were sometimes associated with microscopic gel-bleed or leakage. This led to their removal from the marketplace in 1992. However, due to certain advantages over saline implants, product development continued worldwide. FDA studies in silicone safety led to FDA approval of the latest generation of silicone implants in 2006. The advantages of gel implants are that they tend to be softer; with a feel that is more like natural breast tissue. Also, gel implants can have less rippling and visibility as compared to saline implants. Both types of implants come in numerous shapes, sizes, and profiles. There are smooth and textured designs (some surgeons use textured implants to reduce the risk of capsular contracture). Most importantly, the choice of implant style should be determined by the patient’s body shape.
In two to three months, the next stage of surgery will be performed to reconstruct the nipple areola. If desired, additional contouring procedures, such as fat injections, can be performed to adjust breast shape at this third stage. In some patients, further contouring and shaping procedures may be needed. For patients with a unilateral breast reconstruction, it is very common to require an adjustment procedure on the opposite breast (such as an augmentation, reduction, or lift), in order to achieve better symmetry. For patients undergoing bilateral reconstruction, symmetry using implants is easier to achieve.
You are an ideal candidate for direct to implant post mastectomy reconstruction if you:
have no available flap options
do not desire a flap operation have sufficient breast skin and do not have compromised tissue after the mastectomy site
have no history of previous radiation to the breast or chest wall
are having prophylactic mastectomies
want bilateral reconstruction
are of a reasonable size and body weight
agree to have an operation on the opposite breast to help improve symmetry
You are not an ideal candidate for expander implant post mastectomy reconstruction if you have:
- compromised tissue at the mastectomy site (numerous surgeries or infection)
- been previously radiated (refer to effects of radiation)
- advanced disease
- autoimmune disease (may be a contraindication for gel-filled implants)
- a Body Mass Index greater than 30
The above mentioned characteristics are considered relative contra-indications for the use of direct to implant reconstruction because each is associated with a higher risk of complications. This does not rule out the use of implants in all patients with these conditions.
You may refer to the Post-Operative Expander Implant section to learn about care after direct to implant reconstruction.