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 Report: "I wanted to heal my way"

By Lisa Bernhard

I was 29 years old when my gray-haired surgeon looked at me from across his desk and said, "I'd recommend a mastectomy." My dad, seated to my left, exhaled hard. To my right, my mom sat in silence. Family history had repeated itself: My grandmother underwent a mastectomy at age 39. Now it would be me. But in the four days since my diagnosis, I had researched and stumbled upon a choice my grandmother never had.

"It's OK," I said to my dad. "They can rebuild me."

They did. In one nine-hour procedure, a cancer surgeon performed a skin-sparing mastectomy, removing the nipple and tissue inside my right breast but leaving most of the skin intact. Then a plastic surgeon performed a free-flap reconstruction, extracting a portion of my stomach skin and fat and microscopically reconnecting it to my chest. Later, he reconstructed the nipple. The result was a breast that looks and feels like...my breast.

In the 14 years since, my reconstructed chest has seen me through highs and lows: confident in an evening gown while reporting from the Oscars as a TV correspondent; sorrowful, at times, when standing naked under bright bathroom lights, the faint scars tracing my areola reminders of invading disease and scalpels. Yearly screenings send my heart pounding, but my surgery has helped me be hopeful about the future.

Of course, some women don't want any kind of reconstruction, sometimes due to health reasons or as a matter of preference. But women who do choose it report significant, lasting psychological benefits, in a way that transcends physical beauty, according to a study by Amy K. Alderman, M.D., assistant professor of plastic surgery at the University of Michigan Medical School in Ann Arbor. "Women tell me they feel whole again and more able to put cancer behind them," she explains.

Which is why I'm alarmed that many women don't know that options like the one I selected exist. Nearly 70 percent of women eligible for reconstruction aren't informed of their reconstructive options, according to a 2007 study by Dr. Alderman. Almost 65 percent of general surgeons said they believe patients lack interest in reconstruction, and less than one in four consistently refers breast cancer patients to plastic surgeons.

Meanwhile, plastic surgeons often limit the time they devote to cancer patients, because they tend to lose money treating them. Insurance reimbursements—which are roughly based on what Medicare pays—are paltry. In the case of free-flap surgery, plastic surgeons can charge $7,000 to $25,000 per breast; the average Medicare reimbursement in 2007 was $1,737. As a result, some doctors won't accept insurance for reconstructive surgeries, forcing patients to pay out of pocket. Others steer patients toward more profitable types of reconstruction, regardless of what's best medically, says Mark Sultan, M.D., my reconstructive surgeon and chief of the division of plastic surgery at St. Luke's-Roosevelt Hospital Center and Beth Israel Medical Center in New York City. Insurers reimburse implant reconstruction at roughly the same level as a flap, but surgery takes only about an hour. "Doctors may think, Why do a six-hour operation when I am paid the same amount for a one-hour implant?" Dr. Sultan says. "They may convince themselves, consciously or unconsciously, that the patient is a better candidate for an implant."



Comment by Dr C:

I completely agree with Dr Sultan and I strongly encourage all women considering breast reconstruction to research all their reconstructive options. Unfortunately, some patients will have to consider traveling for some of the more advanced procedures. A major consideration for most people is obviously cost. Patients must be aware of the practice of balance billing which can add thousands of dollars to the out-of-pocket expenses.


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