What To Know About One-Stage Breast Reconstruction

Since 1985, October has served as Breast Cancer Awareness (BCA) Month — a period devoted to educating the public on the disease that, according to the Centers for Disease Control and Prevention (CDC), is the second most common form of cancer in women, regardless of race or ethnicity. Men can also be diagnosed with breast cancer (albeit at a much lower rate), and The AEDITION is devoting much of its coverage this month to BCA, from expert guides to mastectomies and reconstructive breast surgery to powerful patient perspectives and roundups of products that give back.

The physical and emotional toll a breast cancer diagnosis takes is considerable. In addition to the fear and confusion often associated with various treatment options, breast cancer patients must also consider the breast reconstruction process and how that might impact their overall health and sense of identity. Fortunately, breast reconstruction techniques have come a long way in recent years, and one such example is the rising popularity of one-stage breast reconstruction. Here, we’re breaking down everything you need to know about the singular surgery — from who’s a candidate to what’s involved — with one its pioneers.

What Is One-Stage Breast Reconstruction?

Also known as direct-to-implant (DTI) breast reconstruction, one-stage breast reconstruction refers to when a plastic surgeon places implants at the time of a mastectomy. “This is in contrast to tissue expander reconstruction, which is more commonly performed, where a special expansion device is put in the breast at the time of mastectomy,” explains Lisa Cassileth, MD, a board certified plastic and reconstructive surgeon and founder of Cassileth Plastic Surgery in Beverly Hills.

For women who are interested in breast implants after a mastectomy, the standard has long been to schedule a delayed breast reconstruction. Instead of putting the implants in during the mastectomy surgery, the patient would have tissue expanders sutured into the breast pocket. In the weeks and months that follow, the expanders are gradually inflated in a plastic surgeon’s office using air or saline. Once they reach the appropriate size, the expanders are swapped out for implants.

The expansion process can be painful, but some surgeons believe it is a necessary evil. Dr. Cassileth and her team, however, have been refining what they consider to be a more desirable alternative. Back in 2012, Dr. Cassileth’s original research on one-stage reconstructive surgery was published in the Annals of Plastic Surgery. The study found the procedure to have lower risks compared to traditional two-stage tissue expander reconstruction and highly satisfactory outcomes. The technique has only improved from there.

Ideal Candidates for One-Stage Breast Reconstruction

For many years, it was thought that only women with smaller, non-droopy breasts could be candidates for DTI, but that is no longer the case. “DTI is good for women who qualify for nipple-sparing mastectomy, since no skin will be cut away during the mastectomy and the lost volume of the breast can immediately be replaced without worrying about skin tension,” Dr. Cassileth says. With that said, patients with cancers that grow into the skin and must have skin removed may not qualify.

How One-Stage Breast Reconstruction Works

At Cassileth Plastic Surgery, DTI is performed over the muscle for the most natural-looking results. “This is in contrast to the under-the-muscle procedure, which was pretty standard years ago and now is more rarely performed because it cuts the pectoralis muscle,” Dr. Cassileth notes. When the breast implant is placed above the pectoralis major muscle, you avoid the so-called ‘pec flex’ deformity some sub-pectoral implant patients see and also experience a less painful recovery because the muscle remains intact.

Rather than simply wrap the implant in an acellular dermal matrix and place it in the mastectomy flap, Dr. Cassileth creates an internal bra structure to support it. By using a dermal matrix to bridge the gap between the implant and the chest wall, she prevents drooping at the bottom of the breast pocket, softens the contour of the implant, and decreases the need for fat grafting. Additionally, Dr. Cassileth performs a nerve graft at the same time as the reconstruction to restore sensation to the breast. Sensation improves as you heal.

It is important to note that the success and safety of a DTI breast reconstruction is not just in the hands of the plastic surgeon. One-stage reconstruction should only be performed when a mastectomy surgeon has a low rate of flap necrosis. Dr. Cassileth says that the rate should be less than one percent or else it is not safe to go direct-to-implant because the breast skin may not survive.

Following a mastectomy and one-stage breast reconstruction, patients stay in aftercare for two to three days. Drains are typically removed one to two weeks after surgery. “They can have normal day-to-day activities, like driving, after two weeks, and are allowed to lift heavy objects and exercise after one month,” Dr. Cassileth says.

A Non-Implant Alternative...

For women who do not wish to have implants or are not a candidate for them, there is another innovative option to consider. Developed by Dr. Cassileth and mastectomy surgeon Heather Richardson, MD, of the Bedford Breast Center in Beverly Hills, SWIM breast reconstruction combines a nipple-sparing mastectomy with a breast reduction (SWIM stands for skin-sparing wise-pattern internal mammary perforator).

In this procedure, the mammary tissue is removed during the mastectomy portion of the surgery, but the skin and subcutaneous fat are preserved. During reconstruction, the extra fat is folded and placed to create the breast shape. Unlike traditional TRAM and DIEP flap surgeries, no muscle is sacrificed and no abdominal, back, or buttocks tissue is transferred. This provides an alternative for women who want to avoid the extensive surgery, incisions, and long recovery period involved with other flap procedures.