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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Breast Reconstruction With Tummy Tissue (Abdominal Flaps)

DIEP flap? TRAM flap? SIEA flap? With so many breast reconstruction options available these days it's difficult to understand what these terms really mean and what the differences are between all these "tummy flap" procedures.

It is important for women considering these reconstructive options to realize that not all tummy tissue options are created equal. For example, a DIEP flap is not the same as a TRAM flap just because both provide the benefit of a tummy tuck.

Many women are now rejecting breast implants preferring to use their own abdominal tissue for reconstruction after mastectomy. A breast that has been reconstructed with the patient's own tissue typically looks and feels more natural than an implant reconstruction, will last longer without the long-term complications that can be associated with implants, and will also age like a natural breast. Women wanting to use their abdominal tissue have 3 reconstructive options: TRAM flap, DIEP flap, or SIEA flap.

The TRAM flap is a very common breast reconstruction technique that requires the sacrifice of at least a portion of the rectus abdominus (sit-up) muscle. There are 3 different types of TRAM flap ("pedicle", "free", and "muscle-sparing free"): the exact type is defined by the amount of abdominal muscle removed. Unfortunately, TRAM surgery can be associated with significant post-operative pain, prolonged recovery and a host of abdominal complications such as loss of abdominal muscle strength (up to 20% or more), bulging (or "pooching"), and even abdominal hernia.

The DIEP flap procedure is similar to the TRAM flap except that it spares the rectus abdominus muscle completely. Only skin and fat are removed from the abdomen. This tissue is disconnected from the body completely, transplanted to the chest and re-connected using microsurgery to create the new breast. As the sit-up muscle is saved completely and left behind in its natural place, the risk of abdominal complications is much less than with a TRAM. There also tends to be less pain and a quicker recovery time because the abdominal muscles are preserved and left in place.

Like the DIEP flap, the SIEA (Superficial Inferior Epigastric Artery) flap completely preserves the abdominal muscles. The main difference between these two procedures is the artery used to supply blood flow to the newly reconstructed breast. The “SIEA” blood vessels are generally found in the fatty tissue just below skin whereas the “DIEP” blood vessels run below and within the abdominal muscle (making the DIEP more technically challenging). Recovery from the SIEA flap is even easier than the DIEP since the abdominal muscles are not disturbed at all during the surgery.

Despite the similarities between these two surgeries the SIEA flap is used much less frequently than the DIEP flap because less than 20% of patients have the appropriate anatomy. Unfortunately, there are no pre-operative tests to reliably show which patients have the appropriate anatomy and the decision as to which procedure to perform is made intra-operatively by the plastic surgeon based on the anatomy found at the time of surgery.

Since the TRAM, DIEP and SIEA procedures all use the patient's lower abdominal skin and fat, all these abdominal flap options provide the added benefit of a tummy tuck at the same time as the breast reconstruction.

There are many plastic surgeons in the US offering TRAM flap reconstruction. Unfortunately, very few centers in the US routinely perform the advanced microsurgical procedures like the DIEP and SIEA flap. Many patients will therefore have to travel for these procedures.

When considering a reconstructive surgeon, ensure he/she is a plastic surgeon certified by the American Board of Plastic Surgery that has extensive experience with this specific type of surgery. Also ask about the success rate in their hands - most specialists boast a flap survival rate of 97% to 99%+.

The 2 websites below list surgeons that offer DIEP and SIEA flap reconstruction and serve as a good starting point when researching surgeons:

www.diepbreastreconstruction.org and www.breastrecon.com

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Dr Chrysopoulo is a board certified plastic surgeon at PRMA Plastic Surgery. PRMA specializes in microsurgical breast reconstruction including the DIEP flap procedure. PRMA has performed thousands of DIEP flaps and is In-Network for most US insurance plans. On Facebook?.... Connect with other breast cancer patients in our FB Breast Cancer Reconstruction Community.

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Breast Reconstruction: New Video Discusses Latest Breast Reconstruction Options

Breast reconstruction surgery restores something that nature has provided but cancer has taken away.

Unfortunately, most American women with breast cancer do not even realize they have the option of breast reconstruction after mastectomy or lumpectomy.

Breast reconstruction is not a cosmetic procedure.... it is every woman's right: it restores something that nature has provided but cancer has taken away. It is also covered by insurance thanks to a Federal Mandate passed in 1998.

Despite this mandate, studies alarmingly show that only 30% of women facing mastectomy are even offered the option of breast reconstruction.

Women have many reconstructive options after mastectomy or lumpectomy. These range from breast implants to "autologous" techniques which use the patient's own tissue to recreate a more "natural", warm, soft breast. The nipple and areola (the darker area surrounding the nipple) can also be recreated.

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 With Tissue Much Safer Than Implants When Radiation Planned After Mastectomy

A study published in the November issue of the International Journal of Radiation Oncology*Biology*Physics examined the effect of radiation therapy on different methods of immediate breast reconstruction surgery. For breast cancer patients who receive radiation therapy after a mastectomy and immediate breast reconstruction, autologous tissue reconstruction (ie reconstruction using their own tissue) provides fewer long-term complications and superior cosmetic results than breast reconstruction with a tissue expander and subsequent breast implant.

Many women choose to undergo breast reconstruction surgery at the same time as their mastectomy procedure (under the same anesthetic). This avoids many of the psycho-social issues women face when dealing with a flat chest after mastectomy alone. However, frequently radiation can negatively affect the outcome of reconstruction and increase the risk of long-term complications.

Radiation therapy is increasingly becoming the standard of care for high-risk breast cancer patients after mastectomy in an attempt to decrease local cancer recurrence. However, this can cause a problem for both patients and their radiation oncologists.

Researchers at the Department of Radiation Oncology at Long Island Radiation Therapy in Garden City, N.Y., the Department of Surgery at Long Island Jewish Hospital in New Hyde Park, N.Y., the Department of Surgery at North Shore University Hospital in Manhasset, N.Y., and the Department of Surgery at Winthrop University Hospital in Mineola, N.Y., looked at whether the type of reconstruction performed in women receiving radiation after a mastectomy had an impact on their long-term outcomes.

Two general types of breast reconstruction are available for patients facing mastectomy for breast cancer: autologous tissue reconstruction utilizing the patient's own tissue (eg DIEP flap, GAP flap, TRAM flap, or latissimus flap) transferred to the chest to recreate the breast(s); and tissue expander/implant reconstruction which involves placement of an inflatable tissue expander (temporary saline implant) and exchange for a permanent implant (saline or silicone) at a separate procedure later on.

This study involved the largest reported series of patients who sequentially underwent mastectomy, immediate reconstruction and postmastectomy radiation therapy. Ninety-two patients were observed for a period of 38 months following breast reconstruction and radiation therapy.

Researchers found that autologous breast reconstruction is better tolerated by breast cancer patients because it is associated with fewer long-term complications and better cosmetic results than tissue expander/implant reconstruction.

None of the 23 patients reconstructed with their own tissue required further surgery while 33% of tissue expander/implant patients needed surgery to correct a problem with their reconstruction. Eighty-three percent of autologous reconstruction patients reported acceptable cosmetic results, as opposed to only 54% of implant patients.

"This study is useful for patients who are candidates for either [method of reconstruction] and are making a decision with regards to reconstruction technique," Jigna Jhaveri, M.D., lead author of the study and a radiation oncologist at Advanced Radiation Centers of New York in Hauppauge, N.Y., said. "Our study provides evidence that patients who undergo autologous tissue reconstruction and radiation therapy have fewer long term complications and better cosmetic outcomes than those who undergo tissue expander/implant reconstruction and radiation therapy."

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Here's my take....

While some plastic surgeons will disagree with this statement I strongly believe that breast implants and radiation therapy do not get along (at all). I feel the complication rate in implant-reconstructed women receiving radiation therapy is very high, particularly long-term. The handful of women that "do fine" in the short-term will very frequently end up with hard, uncomfortable breasts as the irradiated tissue firms-up over time and squeezes down on the implant. In my opinion the re-operation rate is too high for tissue expander/implant reconstruction to be offered as a routine option when radiation is on the table. This study confirms that breast reconstruction using the patient's own tissue is far safer than tissue expander/implant reconstruction in women facing radiation therapy after mastectomy.

Dr C

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Dr Chrysopoulo is a board certified plastic surgeon specializing in breast reconstruction surgery after mastectomy, particularly advanced perforator flap techniques such as the DIEP flap procedure. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest breast reconstruction news by following The Breast Cancer Reconstruction Blog.

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FDA Approves Silicone Breast Implants

The American Society for Aesthetic Plastic Surgery and The American Society of Plastic Surgeons, the two largest plastic surgery membership organizations, applaud the FDA’s decision today to approve Allergan Corp. and Mentor Corp.'s silicone breast implants and return these devices to the U.S. market. This decision comes 14 years after the FDA restricted access to the silicone implants because of safety concerns.

“This is a great day for American women and the plastic surgeons who care for them,” said Roxanne Guy, MD, ASPS president. “Silicone breast implants have been scrutinized more than any medical device, and we applaud the FDA for making its well thought-out decision and allowing American women to make informed choices about their health care.”

Today’s FDA decision follows a lengthy process in which the agency sent “approvable with conditions” letters to the two silicone breast implant manufacturers in the second half of 2005. The approvable letter stipulated a number of conditions that the manufacturers needed to satisfy in order to receive FDA final approval to market and sell silicone breast implants in the United States. These letters came after an FDA advisory panel hearing in April 2005, in which the panel heard more than 20 hours of data presentations from the manufacturers and public comment.

Approximately 300,000 women chose breast augmentation in 2005, according to ASAPS and ASPS statistics. Nearly 58,000 women had breast reconstruction in 2005, according to ASPS. Both breast augmentation and reconstruction have been proven in numerous studies to have psychological and physical benefits for women who choose these procedures.

The ASPS and ASAPS will continue to offer their assistance to the manufacturers for the conditions set forth by the FDA related to physician and patient education. One comprehensive example of this assistance is a joint Web site, breastimplantsafety.org, which offers objective and science based information regarding saline and silicone breast implants.

The American Society for Aesthetic Plastic Surgery (ASAPS) is the leading organization of board-certified plastic surgeons specializing in cosmetic plastic surgery. ASAPS active-member plastic surgeons are certified by the American Board of Plastic Surgery or the Royal College of Physicians and Surgeons of Canada. www.surgery.org.

The American Society of Plastic Surgeons is the largest organization of board-certified plastic surgeons in the world. With more than 6,000 members, the society is recognized as a leading authority and information source on cosmetic and reconstructive plastic surgery. ASPS comprises 94 percent of all board-certified plastic surgeons in the United States. Founded in 1931, the society represents physicians certified by The American Board of Plastic Surgery or The Royal College of Physicians and Surgeons of Canada.

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Minas T Chrysopoulo, MD
Board certified plastic surgeon specializing in microsurgical breast reconstruction after mastectomy including the DIEP flap operation.
Plastic, Reconstructive & Microsurgical Associates (PRMA) of South Texas,
San Antonio, TX
(210) 692-1181, Toll Free (800) 692-5565
www.prma-enhance.com
www.look-your-best.yourmd.com

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Breast Implants Do Not Cause Breast Cancer Recurrence In Mastectomy Patients

Early Detection and Treatment Not Hindered, Says Study Presented at American Society of Plastic Surgeons Annual Meeting

Women interested in immediate breast reconstruction after mastectomy should not worry that their implants could cause, hinder detection of, or affect treatment of cancer recurrence, according to a study presented today at the American Society of Plastic Surgeons (ASPS) Plastic Surgery 2005 conference in Chicago.

“For women contemplating immediate breast reconstruction, there is a lot of information being presented to them. As plastic surgeons, we want to help our patients feel better about their bodies without risking their safety and long-term health,” said Andrea Pusic, MD, ASPS Member Surgeon and co-author of the study. “It is important for us to provide them with hard facts that show an implant does not increase the chance that their cancer could recur, delay the diagnosis of a recurrence or affect the outcome.”

In the study, 309 women who had immediate breast reconstruction with an implant were compared, on the basis of age and stage of disease, to a group of 309 women who had mastectomy without reconstruction. The incidence of local breast cancer recurrence in reconstructed patients (6.8 percent) was not significantly different from non-reconstructed patients (8.1 percent). In addition, the implants did not hinder early detection of recurrence. Ninety-five percent of recurrences were initially detected by physical examination of the breast during regular check-ups with their plastic surgeon or oncologist. Five percent of recurrences were detected through a computer-assisted tomography (CT) or bone scan.

The treatment for recurrence was not affected by the implants and did not generally require removal of the implants. In the study, only three of the 21 patients who experienced a recurrence had their implants removed after treatment, and two of those patients specifically requested their implants be removed for personal reasons.

“We are pleased to report that treating breast cancer recurrence rarely requires the removal of patients’ implants,” said Dr. Pusic. “This is reassuring information for women who choose to have implant-based breast reconstruction.”

In 2004, almost 63,000 women had breast reconstruction after mastectomy, according to ASPS statistics. The American Cancer Society estimates 211,240 new cases of invasive breast cancer will occur in 2005 among women in the United States and more than 40,000 women will die from the disease.

The American Society of Plastic Surgeons is the largest organization of board-certified plastic surgeons in the world. With more than 5,800 Member Surgeons, the society is recognized as a leading authority and information source on cosmetic and reconstructive plastic surgery. ASPS comprises 94 percent of all board-certified plastic surgeons in the United States. Founded in 1931, the society represents physicians certified by The American Board of Plastic Surgery or The Royal College of Physicians and Surgeons of Canada.

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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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