Is it better to have my reconstruction with implants in one or two stages?
With increasing numbers of women having mastectomies either due to cancer or due to gene mutations such as BRCA, more implant reconstructions are being done by plastic surgeons. We are seeing increases numbers of bilateral (both breasts) mastectomies as the other side is frequently done preventatively and to increase the symmetry and cosmetic result. I get frequently asked about having a one – stage reconstruction by women who have had this procedure recommended.
When breast reconstructions were first done after mastectomy, an implant was placed since there was no such thing as a tissue expander. The implant was placed below the muscle on the chest and the results were quite poor as the implant often looked flat and capsular contractors, or tightening of the scar around the implant, occurred frequently. With the advent of mesh, or acellular dermis, and tissue expanders, breast reconstruction was revolutionized. We could now but the expander below the muscle on the chest and place the mesh on the lower half of the expander, much like an “internal bra” and this allowed the lower half of the breast to make a much nicer shape. Since the nipple and areola were always removed, an expander was placed to make sure the skin healed and to then stretch out the skin to accommodate a larger implant.
With the increase in nipple sparing mastectomy and preventative surgeries, we have been able to offer increasing numbers of one stage implant reconstruction. Because essentially no skin is removed, the skin “envelope” is able to be filled maximally. The use of large pieces of mesh has allowed us to completely “cover” the implant with material and separate it from the overlying skin. This allows less rotation or displacement of the implant which would occur if it were “floating” in the pocket. The only concern became whether the skin would have enough blood flow to survive and this is the main limiting factor for most women. There are now devices that assist in determining this intraoperatively. If an expander is placed and there are blood flow issues, the expander can be deflated to relieve the pressure and increase flow whereas in implant cannot and can lead to deleterious effects.
Women who are good candidates for one – stage implant reconstruction include those who are healthy, young (<65 or so), do not smoke, are not obese (BMI 30 or less) and those who are having nipple sparing mastectomy, not too large breasted (“C” cup or less) without too much droopiness.
Women who are poor candidates for one – stage implant reconstruction are unhealthy, obese, smokers, very droopy breasts, large breasted (“D” cup or greater) and will be undergoing skin – sparing mastectomy which removes the nipple and areola. These women should have a two – stage implant reconstruction or a delayed reconstruction.
Finally, the other thing to consider is that most women really do need two surgeries for optimal results. Int the second surgery, the implants can be moved closer together, fat can be injected around the implant to camouflage or blend in the surrounding tissues which are now thin and any asymmetries between the breasts can be corrected by shifting the implants or doing a left or augmentation on the other side. The other issue involves knowing what size implant a woman might want before surgery. Since this is not an augmentation and the volume is not being “added” to the existing breast, it can be confusing. Many women who initially believe they may want to be a “B” or “C” cup choose to go larger. This would obviously necessitate a second surgery if you had an implant placed at the time of mastectomy and some insurance companies may not cover this whereas the second stage of an expander – implant reconstruction is always covered. Furthermore, radiation may cause asymmetries to occur and a revision of one or both sides may be needed.