One-Step Breast Reconstruction with Implants and Alloderm

Implant breast reconstruction is the most common method of breast reconstruction currently performed in the US. There are two main approaches: the "Alloderm one-step" (also referred to as "single stage" or "direct to implant" reconstruction), and the two-stage reconstruction with tissue expanders. To easier explain the ins-and-outs of the one-step procedure, I first need to summarize the more traditional two-stage approach...

Tissue expanders essentially act as "spacers". They can either be placed at the same time as the mastectomy or some time later. They are inflated with saline injections to recreate the desired breast size. This expansion process can take several weeks depending on the amount of expansion required to reach the optimal cup size. Once the expansion process is completed, the tissue expanders are removed and the final implants are placed. Reconstruction with breast implants is therefore usually performed as a multiple-step process and can take several months.

Alloderm One-Step / Single Stage / Direct to Implant Reconstruction

Some patients are candidates for a "One-Step" procedure whereby the permanent implant is inserted at the time of the mastectomy. A cadaveric implant known as Alloderm is also used to provide extra implant coverage and support. By going direct to the final implant in a single stage, the patient has only one procedure and avoids the use of a tissue expander (and the whole expansion process) altogether. The scar can also be placed in the inframammary fold (at the breast crease) which makes it much easier to hide. The One-Step procedure is also referred to as "direct to implant" or "single stage" reconstruction.

This procedure is obviously very appealing to many women, including those that may not be candidates for perforator flaps. The down time in terms of recovery is also much shorter than most of the alternatives (2-4 weeks).

There are some caveats though.... I used to offer this procedure to most patients. Some One-Step surgeons still do. Personally, I don't anymore - "the perfect candidate" for the procedure has evolved in my eyes. Experience (and grey hair) has a tendency of doing that.

So who is the "ideal candidate"?

1) Patients that do not have a current breast cancer diagnosis

2) Patients that are having prophylactic mastectomy only, e.g. for BRCA1 or BRCA2

3) Patients that are having nipple-sparing mastectomy

4) Patients that do not need a significant breast lift

5) Patients that have not had previous breast/chest radiation


By limiting the procedure to women who fulfill these strict criteria the surgical results are far more predictable and very cosmetic. The risk of further revision or "touch up" procedures is also very low.

PRMA patient Mrs Michelle Coben kindly shares her experience with the One-Step procedure in the video below. You can also see before and after pictures here.

I hope this info helps.

Dr C

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Dr Chrysopoulo specializes in advanced breast reconstruction techniques including perforator flaps, Alloderm One-Step and fat grafting. He is In-Network for most US insurance plans. Patients are routinely welcomed from across the USA. Please call (800) 692-5565 or email patientadvocate@PRMAplasticsurgery.com to learn more about your breast reconstruction options. Connect with other breast cancer patients at facebook.com/PRMAplasticsurgery.

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Alloderm Breast Reconstruction

Alloderm is now being used routinely in breast reconstruction. Here's what you need to know...

First off, what is it? AlloDerm is derived from donated (cadaveric) human skin. It is FDA approved and is used in many different types of reconstructive surgery including breast reconstruction. Before being packaged for use, the Alloderm undergoes a multi-step process that removes all the cells that can lead to tissue rejection: even though it comes from another person, your body does not reject Alloderm because the immune cells are removed. Alloderm essentially acts as a scaffold and over time, the patient's own cells grow into it.

Since it is a human (cadaveric) product, the U.S. Tissue Bank rigorously screens all tissue donors' medical records. All donors must be negative for Syphilis, Hepatitis B and C, and HIV 1 and 2. AlloDerm grafts are also examined under the microscope before and after processing to rule out contamination.

Alloderm is frequently used in implant-based breast reconstruction (and has been for years). The tissue expander or implant is placed under the pectoralis (chest) muscle. The more tissue coverage over the implant, the better the results. Unfortunately, the pec muscle cannot cover the entire implant. The Alloderm is used to cover the lower part of the implant that is not covered by muscle.

Advantages:
- Stabilizes the implant in position.
- Allows for complete implant coverage.
- Can allow the creation of a full-sized breast when the tissue expander/implant reconstruction is performed at the same time as the mastectomy.
- No risk of rejection.
- Once incorporated by the body, resists infection as well as the patient's "natural" tissue.

Disadvantages:
- Like anything that is implanted in the body, there is an initial (low) risk of infection (until it becomes incorporated).
- Can cause temporary redness in the skin over the Alloderm.
- Costly but usually covered by insurance.

Many plastic surgeons, including myself, use Alloderm routinely when performing breast reconstruction with tissue expanders and implants.

Dr C

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PRMA Plastic Surgery specializes in advanced breast reconstruction including DIEP flap, SIEA flap, GAP flap, TUG flap and Alloderm One-Step. In-Network for most US insurance plans. Patients routinely welcomed from across the USA. Please call (800) 692-5565 or email patientadvocate@PRMAplasticsurgery.com to learn more about your breast reconstruction options. Connect with other breast cancer reconstruction patients at www.facebook.com/PRMAplasticsurgery.

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Breast Reconstruction Surgery Options After Mastectomy

Every woman has a right to breast reconstruction surgery after breast cancer. This has been a federal mandate for some time and insurance companies have to pay for breast reconstruction surgery by law. There is no age limitation for breast reconstruction and there are many different options available.

"Immediate" breast reconstruction is performed at the same time as the mastectomy. Advantages include: preserving most of the patient's breast skin, a shorter/less obvious mastectomy scar and waking up with the new breast already in place (and avoiding the experience of a flat chest). It also generally provides the best cosmetic results particularly when combined with nipple-sparing or skin-sparing mastectomy.



"Delayed" reconstruction generally takes place after the mastectomy has healed. Many times patients required to undergo radiation following their mastectomies are advised to delay reconstructive surgery in order to achieve the best results. It is common to wait several months after the last radiation therapy session before proceeding with reconstruction to allow the soft tissues to recover completely from the radiotherapy.

Tissue expander reconstruction is the most common method of breast reconstruction in the United States. Most plastic surgeons perform this as a two-stage procedure. The expander is used to stretch the skin envelope and create the size of breast the patient and plastic surgeon desire. The expander is replaced by a permanent breast implant (saline or silicone) at a separate procedure some time later.

Some patients are candidates for one-step implant reconstruction (without expanders): a permanent breast implant is inserted immediately without going through the whole expansion process. In the one-step implant reconstruction the implant is completely covered by the pectoralis muscle and an acellular dermal graft (like Alloderm or FlexHD). These grafts are tissue implants that provide support and increase the amount of padding over the implant.

Implant reconstruction can be the best option for some patients. However, reconstruction with expanders and breast implants are associated with more complications than cosmetic breast augmentation. Complications following radiation therapy are also higher with implants compared to reconstructions using the patient’s own tissue.

The Latissimus procedure uses muscle (latissimus dorsi), fat and skin from the back (below the shoulder blade) that is brought around to the chest to create a new breast. Many patients also need an expander to obtain a satisfactory result. The expander is replaced by a permanent implant at a second procedure down the line. Patients typically a scar on their back that can be seen with some low-cut clothing. Women who are very active in sports may notice some strength loss with activities like golf, climbing, or tennis.

TRAM flap surgery is a common procedure that uses skin, fat and varying amounts of the sit-up muscle (rectus abdominus) from the lower abdomen. The tissue (or flap) is then relocated to the chest to create the new breast. This procedure also results in a tightening of the lower abdomen, or a "tummy tuck." Unfortunately, sacrifice of all or part of the abdominal muscle can result in bulging (or “pooching”) of the abdomen and even a hernia. Up until a few years ago, this was the gold standard in breast reconstruction.



DIEP flap breast reconstruction has replaced the TRAM flap as today's gold standard in breast reconstruction. The DIEP flap uses only skin and fat. This is disconnected from the lower abdomen and reconnected to the chest area using microsurgery to create a new breast. Since all the abdominal muscles are saved, patients do not have to sacrifice their abdominal strength. They also experience less pain and have a quicker recovery than TRAM patients. The risk of abdominal bulging and hernia is also very small. The SIEA flap is a variation of the DIEP flap. It is associated with an even easier recovery and a 0% hernia risk but requires specific anatomy which not all patients have. Like the TRAM, the DIEP and SIEA procedures also provide a simultaneous tummy tuck.

Women who do not have enough abdominal tissue for reconstruction may be eligible for the GAP (buttock) or TUG (upper inner thigh) flap procedures. The resulting scars are generally easily hidden by most underwear.

Like the DIEP flap, the GAP and TUG flap procedures are unfortunately not offered by most plastic surgeons as they require advanced training in microsurgery and reimbursement is very low. Only about 40 surgeons in the US perform these advanced procedures routinely.

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Dr Chrysopoulo is a board certified plastic surgeon specializing in breast reconstruction including advanced techniques like the DIEP flap procedure. Keep up to date with the latest news in breast cancer reconstruction at The Breast Cancer Reconstruction Blog, on Facebook and on Twitter!

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Breast Reconstruction Surgery - Part I - Tissue Expanders, Breast Implants and Alloderm

This posting is the first of a 3-part series on breast reconstructive surgery discussing the reconstructive options available to women facing mastectomy for breast cancer.

Every woman has a right to breast reconstruction. This has now actually become a federal mandate and insurance companies are required to pay for all types of breast reconstruction by law. Having said that it is also important to remember that it’s not up to the health insuranc carrier to decide which reconstruction a patient receives. That’s determined by the patient and her surgeons.

Breast reconstruction is not a form of cosmetic surgery – it restores something that nature has provided but cancer has taken away. There is also no age limit – as long as there are no medical conditions that render the surgery unsafe and the breast cancer is diagnosed at an early enough stage, most women are candidates.

Breast reconstruction can be performed as an “immediate” or “delayed” procedure. As the term implies, immediate reconstruction is performed immediately after the mastectomy while the patient is still under anesthesia. Once the general surgeon has completed the mastectomy the plastic surgeon begins creating the new breast. Advantages of this approach include the option of preserving most of the breast skin (“skin-sparing mastectomy”) and a shorter scar. The patient also wakes up “complete” and avoids the experience of a flat chest. Immediate reconstruction generally provides far superior cosmetic results.

Delayed reconstruction generally takes place several months following mastectomy. Patients required to undergo radiation after mastectomy may be advised to delay reconstruction in order to achieve the best results. This delay may last several months in order to allow the tissues to recover as much as possible from the radiotherapy.

There are several reconstructive options for women to choose from, ranging from breast implants to “autologous” techniques using the patient's own tissue to recreate a more “natural”, warm, soft breast. The nipple and areola can also be recreated.

Tissue Expanders and Breast Implant Reconstruction

This is the most common method of reconstructive breast surgery currently being used in the United States. Most surgeons perform this is a two-stage procedure. The tissue expander is essentially a temporary breast implant which can be placed either at the same time as the mastectomy or after the mastectomy has healed. The expander is used to stretch the skin envelope and recreate the size of breast the patient wants. The expander is ultimately replaced by a permanent implant (saline or silicone) at a separate procedure several months later.

Some patients undergoing immediate breast reconstruction are candidates for one-step breast implant reconstruction whereby a permanent implant is inserted at the time of the mastectomy and the patient avoids going through the whole expansion process. In the one-step implant reconstruction the implant is completely covered by the pectoralis muscle and Alloderm (a cadaveric acellular dermal graft). This is specially treated skin from a cadaver that is used to provide a sling and coverage of the lower part of the implant.

Two types of implants are available to patients: saline and silicone. There are many opinions regarding both types of implants and it is advised that you speak with your surgeon as to which implant would be best for you. Patients who undergo implant reconstruction should be aware that their breast implants may need to be replaced at a future date.

Implant reconstruction can be the best option for some patients. However, tissue expanders and implants can be fraught with complications long-term, particularly if the patient has had or is going to have radiation therapy as part of her cancer treatments. For these reasons, many surgeons and patients prefer autologous reconstruction, i.e. reconstruction using the patient's own tissue taken from another part of the body. These will be discussed in upcoming posts.

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Dr Chrysopoulo is a board certified plastic surgeon specializing in reconstructive breast surgery after mastectomy. Techniques offered include Alloderm one-step reconstruction and DIEP flap reconstruction. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest news in breast reconstruction surgery and research at The Breast Cancer Reconstruction Blog.

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Breast Reconstruction Surgery - Part II - Muscle Flap Reconstruction

Women interested in breast reconstruction after mastectomy have several reconstruction options to choose from. In Part I of this series we discussed tissue expanders, breast implants and Alloderm.

Though implant reconstruction remains the most common method of breast reconstruction in the US, many women are now steering away from this option, opting instead to use their own tissue for more “natural” results. Muscle flaps have, until fairly recently, been the only choice available for these tissue reconstructions. The most commonly offered muscle flaps are the latissimus and TRAM flap procedures.

Latissimus Dorsi Flap:

The latissimus procedure uses muscle from the back of the shoulder blade which is brought around to the breast mound to help create a new breast. During the procedure a section of skin, fat and muscle is detached from the back and brought to the breast area.

Many patients also need a tissue expander placed under the muscle flap in order to obtain a satisfactory result. The expander is replaced by a permanent implant at a second procedure down the line.

Patients will have a scar on their back shoulder region that can sometimes be seen through a tank top, swimsuit or sundress. The upper back can be numb or sore for a few following this procedure until the nerves grow back and the incisions are completely healed.

Women who are very active in sports should know that this procedure can reduce ability to participate in activities like golf, climbing, swimming, or tennis.

TRAM (Transverse Rectus Abdominis Myocutaneous) Flap:

The TRAM flap was the first procedure to describe use of one of the rectus abdominis muscles (sit-up muscles) for breast reconstruction. This procedure begins with an incision from hip to hip rather like a “tummy-tuck”.

A "flap" of skin, fat and one of the patient's abdominal muscles is typically tunneled under the skin to the chest to create a new breast. This is known as a pedicled TRAM flap. Recovery from the TRAM flap procedure can be difficult and painful and there is a risk of abdominal bulging (or “pooching”) and even hernia. Long-term, the patient has to adapt to the loss of some abdominal strength (up to 20%) which most active patients will notice.

In cases where both breasts are being reconstructed, both abdominal muscles are sacrificed and transferred to the chest (one for each breast). The loss of abdominal strength in these situations is far greater and very significant.

Over the years and with the introduction of microsurgery, the procedure has evolved several times with each modification preserving more and more abdominal muscle. This has made postoperative recovery a little easier and has decreased the potential for abdominal complications somewhat.

The latest evolution in breast reconstruction is  “perforator flap surgery”. These techniques use skin and fat from various parts of the body. Since no muscle is sacrificed recovery is much easier and muscle strength and function are preserved long-term. These techniques will be discussed in Part III of this breast reconstruction series.

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Dr Chrysopoulo is a board certified plastic surgeon specializing in breast reconstruction after mastectomy including the DIEP flap and Alloderm one-step procedures. In-network for most US insurance plans. Toll Free (800) 692-5565. Latest news in breast reconstruction surgery and research available at The Breast Cancer Reconstruction Blog.

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Breast Reconstruction Advances Fix Distortions Left by Lumpectomy

ASPS Report Examines Reconstruction Innovations for Breast Cancer Patients Including Partial and Full Mastectomies

For Immediate Release: April 2008
ARLINGTON HEIGHTS, Ill. – Lumpectomy or breast conservation surgery is the most common type of breast cancer surgery currently performed. A benefit of the surgery is that only part of the breast is removed, but a drawback can be the resulting physical appearance of the breast, which may be disfigured, dented or uneven. A report in April’s Plastic and Reconstructive Surgery® , the official medical journal of the American Society of Plastic Surgeons (ASPS), examines advances plastic surgeons have made in breast reconstruction to repair the damage left when cancer is removed.

“Although breast conversation therapies are a huge advance in the treatment of breast cancer, women are still concerned about how their breast will look after surgery,” said Sumner Slavin, MD, ASPS Member and report co-author. “Breast conservation surgery or lumpectomy can mean many things; a biopsy, partial mastectomy, wedge resection, or having a quarter of the breast taken. Women are often left with portions of their breasts removed and there are currently no implants that can address this unique cosmetic issue.”

After lumpectomy or breast conservation surgery, plastic surgeons are now approaching the challenge of misshapen breasts by immediately remodeling the breast with remaining breast tissue or tissue taken from another area of the body. The result is a more natural looking breast that is more symmetrical with the unaffected breast.

Three additional advances the report examines are nipple-sparing mastectomy, deep inferior epigastric perforator (DIEP) flaps and acellular dermis graft slings. These are options for women who require a full mastectomy and young women who opt for preventative mastectomy due to a strong family history of breast cancer.

In nipple-sparing surgery, cancerous tissue and the duct system of the breast are removed, but a pocket of skin, the nipple and areola are saved. Plastic surgeons insert either an implant or the patient’s own tissue into the pocket to recreate the breast. The result looks very similar to the patient’s original breast because the original nipple and areola are used. Nipple-sparing surgery is still somewhat controversial, but if the origin of the tumor is away from the nipple and areola, it is considered safe, according to the report.

DIEP flap surgery involves using skin and fat from the lower abdomen to recreate the breast. The muscle is left intact, eliminating potential muscle weakness in the donor area, according to the report.

For patients undergoing a mastectomy, the DIEP flap procedure may allow them to better resume normal activities since they have not loss muscle function in their abdomen.

Finally, the use of acellular dermis (connective tissue layer of the skin) derived from cadaver tissue (such as "Alloderm") allows plastic surgeons to create a new breast pocket, in patients undergoing a mastectomy, without using a tissue expander. A breast implant may then be inserted, creating an aesthetically pleasing breast. This one-stage method of breast reconstruction is often referred to as "Alloderm one-step breast reconstruction".

“Many women don’t know the full scope of their reconstructive options or are intimidated to ask,” said Dr. Slavin. “For breast cancer patients, even though they are living through the anguish of cancer, there are reconstructive procedures that will improve their quality of life and reduce the negative long-term impact of the disease and its treatment.”

In the United States today, there are nearly 2.5 million breast cancer survivors – the largest group of cancer survivors in the country, according to Susan G. Komen for the Cure. More than 56,000 breast reconstructions were performed in 2007, according to the ASPS.

Learn more about your breast reconstruction options here.

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Dr Chrysopoulo is board certified in Plastic and Reconstructive Surgery and specializes in breast reconstruction surgery after mastectomy for breast cancer. He and his partners perform hundreds of microsurgical breast reconstructions with perforator flaps each year including DIEP flap reconstruction. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest breast reconstruction news by following Dr Chrysopoulo's Breast Reconstruction Blog.

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