Why the "One and Done" Approach to Breast Reconstruction Can Be Misleading
Recently, a news article circulated with information regarding a new “one and
done” approach to breast reconstruction being available and providing promising
results. Sounds great right? While the procedure can be a great option for some
women, calling it "one and done" can be misleading as over 30% of women will
need further surgery. For this reason, many surgeons refer to the procedure as
"direct-to-implant" instead.
At PRMA we do perform "One-Step" breast reconstruction using implants and Alloderm.
However, we try to limit this procedure to patients who are seeking immediate
reconstruction after prophylactic nipple-sparing mastectomy (eg for BRCA+) since
this group of women have the best chance of needing only one surgery.
For patients undergoing a mastectomy due to cancer, there are some things to
consider before choosing the “one and done” surgery. The final cosmetic results
after implant breast reconstruction depend heavily on the thickness of tissue
covering the implant. Often after mastectomy, the tissues over the implant
aren't thick enough to camouflage the implant completely, even if the implant is
under the pec muscle. Many patients experience visible implant "rippling"
because of this and more surgery is required (usually fat grafting) to add more
tissue over the implant(s) to decrease the visible rippling. This is the most
common reason for needing further surgery after a "one and done" procedure.
The possibility of post-mastectomy radiation also needs to be considered.
Radiation certainly doesn't preclude breast reconstruction, but it does increase
the risk of complications and can impact the final cosmetic results. Radiation
and implants often do not get along very well and patients undergoing radiation
therapy after breast reconstruction often need more surgery for the best
results.
One more factor to consider is the impact of nipple-sparing mastectomy (NSM). Preserving the nipple-areola
significantly improves the cosmetic results after breast reconstruction,
particularly reconstruction with implants. Patients who aren't candidates for
NSM, or prefer not to preserve the nipple-areola, often have results that aren't
as cosmetically appealing after implant-based reconstruction as those who have
NSM.
For patients seeking flap-based reconstruction a single-step approach can be
performed, but consistently superior results are achieved with a staged
approach. Procedures such as the DIEP flap are often performed at the same time as the mastectomy ("immediate reconstruction")
allowing patients to wake up with breasts and avoiding the trauma of a missing
breast. However, the newly reconstructed breast is not considered a finished
product. A second surgery—or revision surgery— is typically needed a
few months later to "fine tune" the reconstructed breast(s) for the best
cosmetic results. This outpatient surgery often includes further breast shaping,
fat grafting, scar revision, and nipple reconstruction.
Although the idea of having everything taken care of in one surgery sounds
great, unfortunately this will not always be in your best interests. Please
discuss your expectations thoroughly with your surgeon prior to proceeding with
"one and done" breast reconstruction to make sure it is the best choice for you.
For more information, including a list of ASPS plastic surgeons in your
community, please use our Find a Surgeon
tool.
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