Why the "One and Done" Approach to Breast Reconstruction Can Be Misleading
By: Dr. Minas Chrysopoulo and Courtney Floyd
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 offer direct-to-implant 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 truly 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 quality of the tissue covering the implant (ie the mastectomy flaps). After a mastectomy, the tissues over the implant can be quite thin and don't camouflage the implant completely, even if the implant is under the pec muscle. Patients often experience visible implant "rippling" because of this and more surgery is required (usually fat grafting) to camouflage the implant and address any other contour irregularities. 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 certainly be performed, but consistently superior cosmetic results are achieved with a staged approach which allows the opportunity for "fine-tuning". Procedures such as the DIEP flap are performed at the same time as the mastectomy whenever possible ("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 performed a few months later that often includes further breast shaping, fat grafting, scar revision, and nipple reconstruction (if the patient did not have a nipple-sparing mastectomy).
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.