Is One-stage Breast Reconstruction Better Than Two-stage Reconstruction?
- Asked by Eva S in Seattle, WA
- 4 years ago
Can the same results be expected with a single breast reconstruction surgery as with a two-stage procedure over time?
Single vs. Two Stages
This is complex question without an easy answer. My practice is 80% breast, a majority of that being breast reconstruction (both primary and revision). I perform both procedures and I believe that unless it is a prophylactic mastectomy in a small breasted women, the safe option is to stage. There are several reasons for this approach:
- if there is cancer and the patient needs radiation, then the implant is not taking the brunt of the radiation
- if there is a problem with healing, then it is the expander that is seeing the bacteria (potentially) and not the implant. One of the best theories we have for capsular contracture is bacterial colonization of the implant/pocket. I would rather have an expander exposed to bacteria (know it's coming out) than the permanent implant.
- Even with total lower pole coverage with Alloderm, placing the expander allows the internal bra (capsule) to form which provides support for the implant. Additionally, it can be manipulated, if need be, to make sure the implant is best possible position.
-some breast surgeons are overly aggressive with the mastectomy and this can lead to thinner tissues that wont support an implant as well as healing difficulties (see above).
A one stage approach can yield a great result, in the carefully selected patient. It depends on the plastic surgeon AND the breast surgeon. Don't let the desire to skip an operation compromise your results. If you're healthy enough to undergo reconstruction, you're healthy enough to undergo a second stage...especially for better results.
Single stage vs. two in breast reconstruction.
It is tough to say which is a "better" reconstruction as there is no such qualitative measure as to which one is a "better" one as I assume your main goal is the final aesthetic outcome of the breast reconstruction. What is better for you may not be for someone else as everybody has different skin qualities, breast shapes, volume, size (even differences - more the norm than the exception) as no two breasts are exactly the mirror image or in perfect symmetry. The advantage of a single stage breast reconstruction however, is that it is one surgery for both the mastectomy and the breast reconstruction. Whether you qualify for that technique however is a decision made between you, your surgeons (oncologic and plastic) and your medical team, that is whether your breast skin and nipple areolar complex is safe to preserve given the stage of the cancer, the size of it, how far away is it from the nipple and other "personality" characteristics of the cancer that is biopsied that can be different in each individual as are the breasts. It is important to remember, that in either scenario, breast reconstruction at time of mastectomy whether implants are used as single stage or staged with tissue expanders or with your own tissue as from they tummy or back, all of these may require revisions in the future. There is always room for aesthetic perfection and improvement of results as the years go by and our bodies age and elasticity changes, weight gain / loss etc.... The short answer, is yes it is less times in the operating room and down-time from personal and professional life when same time implants are placed at time of mastectomy (again not every woman may qualify for this as it depends on the stage and other things mentioned above). The best candidates for same time implant single stage breast reconstruction are as in the case of Ms. Angelina Jolie, where she did not have active cancer, but had tested positive for the BRCA1 mutation therefore, she tremendously lowered her risk by deciding to remove both breasts and reconstruct at same time, but in her case her surgeon had decided to stage it with tissue expander first as some surgeons feel they can better control the final aesthetic outcome. Alternatively, some women may want slightly larger breast volume post reconstruction than their original breast size, and therefore, tissue expanders may be temporarily used for a short time to stretch the muscle and skin to minimize the risks of vascular problems to the skin envelope if a larger implant was used in the first stage, to protect the skin and the final aesthetic reconstruciton. Therefore, it is an individual choice, multifactorial in nature, but remember that you will be living with the reconstruction and that needs to be in the best possible aesthetic result and it is not always the best in one stage. Even with staged reconstruction, revisions are the rule than the exception, the trusted rapport that you have and the aesthetic sensibility and skill that your plastic surgeon has is key in making your reconstructive journey a satisfactory and rewarding experience for all involved. I hope this helped in answering some of your questions :-)
One stage breast reconstruction will be the standard of care
Fully 50% of my business is breast reconstruction, and I perform one stage breast reconstruction routinely. Of course, the patient must be healthy, the breasts are best if smaller than a D, although I have performed it with larger implants (>600cc) without increase in complication rates. Most importantly, performing it in one stage takes practice and time. In surgery, the patient must be brought up into a seated position to check if the breasts are even, and any asymmetries fixed on the spot. I use Alloderm, and this must be positioned just right to make an "internal bra" to allow the implant to sit correctly, it it needs to be a "cup" shape and not just slapped on to the lower half of the breast. This technique is especially advantageous with nipple sparing procedures and skin sparing procedures, as there is no need for a tissue expander as the breast skin is completely preserved. Make sure you choose your surgical team wisely, however, as the general surgeon and the plastic surgeon need to be comfortable with the technique to acheive a good result - never push a surgeon to do a procedure that he/she does not do routinely, go with what gives the surgeon good results in their hands.
Recent Breast Reconstruction Reviews
Breast Reconstruction Photos
One vs Two Stage Breast Reconstruction: Multifactorial
Options that I consider in determining if a patient is more suitable for a one vs. two stage breast reconstruction:
1. Stage of Cancer: if there is a potential for radiation, I always recommend delayed reconstruction or 2 stages with a tissue expander.
2. Type of mastectomy: if there is limited potential for skin involvement with cancer and your plastic surgeon trusts the ability of your breast surgeon to perform a good skin sparing mastectomy, I will recommend a single stage implant reconstruction. Otherwise, I advocate for 2 stages to implant procedure.
3. Patient goals: If the patient desires a symmetry procedure to the opposite breast or nipple reconstruction, I always advocate for 2 stages. A breast will change shape to some degree over the first 2 months as swelling decreases and tissues relax. Therefore, much better symmetry will be obtained in a staged fashion. However, if a patient tells me that I simply want to fill out my bra and look normal in clothes, then I discuss the option of a single stage reconstruction.
Don't try to hit a home run.
It really depends on your surgeon. In my opinion I prefer two stage reconstruction. Simply stated it gives me two attempts to make the best reconstructed breast possible.
One Stage vs Two Stage, the jury is still out
It would be nice to say that one technique is better than the other, but that's just not the case. Some surgeons prefer one stage to two and others like myself prefer a rwo stage but will ocassionally do a one stage reconstruction. Much of this depends upon the type of mastectomy you are having (skin sparing, lumpectomy, modified radical), the type of reconstruction you are having( tissue adding like flaps or available tissue like expanders and implants) and your anatomy to begin with.
Speak to your plastic surgeon and discuss the options available to you. Be more concerned about the end result rather than one versus two stage becuase it's the end result that counts. Good luck with your surgery.
Steven Schuster MD FACS
One-stage vs two-stage breast reconstruction still debatable
This question is STILL hotly debated even among Plastic surgeons.
All things being equal, Breasts can be created in several ways begining at the time of the mastectomy (ie IMMEDIATE vs. Delayed) :
1. a tissue expander is placed in, the matectomy incision is closed. Over the next 3-4 months depending on the patient's circumstances the expander is slowly filled creating enough breast skin. Then, in a second stage the expander is taken out and a breast implant is placed in. A nipple/areola is created later in a third operation if the patient wishes it.
2. A better way (in MY opinion) - The mastectomy is completed with the plastic surgeon in the room making sure the general surgeons do not remove too much skin AND leave the breast fold intact. The plastic surgeon then builds a sling with either ALLODERM or STRATTICE which will hold the breast implant in place. NO NEED for an expander stage which may be complicated by infection etc. The mastectomy incision is closed. The patient saves herself another operation and can have a nipple areola reconstructed if she so desires (and the insurance company allows it) in the future.
Problem - Alloderm and strattice are not cheap and surgeons are paid much more for doing Operation 1 instead of 2. Not fair to the patient nor to the doctor.
3. After the mastectomy is completed, the plastic surgeons make a breast out of Tummy skin and fat (either based on its blood supply - TRAM flap or by using micrurgery to do a DIEP flap), or use the back muscle with an implant to build the breast. Here too, a nipple complex is built later.
If you were referring to operation 2 - Yes, many of us DO believe that "same results be expected with a single breast reconstruction surgery "
I hope this was helpful.
Breast reconstruction can be performed using autologous tissue( your own) versus non-autologous ( like a tissue expander and implant). The implant method will often require two stages. One to expand the chest skin and two to replace with an implant. A later stage is performed to reconstruct the nipple. For autologous reconstruction, this is usually a one stage procedure but sometimes secondary procedures are performed to adjust the shape and volume. But there are many variables that may change the number of surgeries.
These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.