Breast Reconstruction: Is One-Step Reconstruction right for you?

Dr. Andrew Salzberg pioneered one of the latest techniques of breast reconstruction following breast cancer. Called immediate breast reconstruction, direct to implant or one-step reconstruction, the surgery allows an implant to be placed at the time that cancer is surgically excised by an oncologic surgeon. It can sometimes be used in place of the traditional implant reconstruction with expanders. Dr. Salzberg answers basic questions below about whether this sophisticated technique is right for you.

1. How do you tell if you have enough natural tissue left after a mastectomy to do one-step reconstruction?

Breast implants come in a variety of shapes and sizes, which can usually accommodate the majority of breast reconstruction patients. If more of the skin flap needs to be excised during the mastectomy due to viability issues and there is not a small enough implant available to accommodate the pocket, a tissue expander can be used in its place. This decision that would be made intraoperatively by your trusted surgeon.

2. I have heard that AlloDerm® Regenerative Tissue Matrix is used as part of the procedure. How does it work?

AlloDerm®, derived from donated human tissue, is the most studied and widely used acellular dermal matrix. AlloDerm® acts as an internal sling/bra to keep the implant in a desirable position as well as protects the delicate skin flap from the silicone implant. It undergoes extensive testing and processing in order to ensure it is completely stripped of any cellular material.

3. You mention that not all women are good candidates for direct-to-implant reconstruction. Who is a candidate for this procedure? Who is not?

Patients who have already had radiation treatment for breast cancer are not likely candidates for the direct to implant procedure. Radiated skin has been compromised meaning that the blood supply to the breast skin is not as healthy as it was before radiation. A radiated breast can have more trouble healing and is at increased risk for infection if an implant is placed immediately after mastectomy.

Other patients who may not be good candidates for the for the direct to implant procedure are patients who have very large, pendulous breasts.

With this being said, don’t worry just yet! We encourage all patients to come in and have a formal consultation where we perform a physical examination as well as review your medical history in detail. We will then be able to determine personalized breast reconstruction options for you.

4. It sounds like there is a lot of stretching of the skin involved compared to the tradition expander method. Should I be concerned?

Contrary to popular belief, there is no additional expansion or stretching of the skin when placing an implant versus a tissue expander. In order to prove this, we use an advanced imaging technique called the SPY machine while in the operating room. The SPY Elite allows the surgeon to evaluate the perfusion to the skin by using the fluorescent properties of indocyanine green dye (ICG), which is injected intravenously. Video images of blood flow are taken in the operating room, which the surgeon is able to see in real time.

4. What if not all of the tumor is removed at the time of surgery?

The breast surgeon is responsible for removing all of the breast tissue during the mastectomy. A MRI is done at one-year post-operative time to confirm that all breast tissue has been removed. Silicone and saline breast implants are MRI compatible; however, a tissue expander is not. A tissue expander contains a magnetic port and because of this, a MRI cannot be performed while the expander is in place as magnets are contraindicated in MRI machines.

6. It sounds like there are many pros to direct-to-implant reconstruction – less downtime, immediate reassurance that you’ll have breasts again, better results in terms of symmetry and scarring. But there are downsides to everything. Can you give a couple of things to consider?

The one thing that patients may see as a downside when considering the direct to-implant procedure is that, although we have nicknamed it the “one step,” revisions are often needed. As the implants settle and the surrounding breast skin flap heals into place, there are often some minor contour and symmetry irregularities that can be seen. These irregularities are easily correctable through an outpatient surgical procedure. Patients who are choosing the direct to implant to avoid having two separate surgical procedures as with the tissue expander reconstruction should keep in mind that the revision surgery is completely optional and not required. Revision surgeries are done in the ambulatory setting meaning that the patient can go home the same day and downtime is often minimal.