5 Reasons for ONE Surgery Breast Reconstruction in 2019

A little about the author...

Dr. William Albright is a Board Certified Plastic Surgeon specializing in breast and body cosmetic and reconstructive plastic surgery.

Why does breast reconstruction technique matter?

Recreating a breast at the same time the breast is removed (during a mastectomy) is called an immediate breast reconstruction.  Immediate reconstruction continues to grow in utilization from an estimated 27% of mastectomy patients in 2005 to 43% by 2014.  Approximately 101,657 reconstructions were performed by ASPS members in the United States in 2018.  

And most of these reconstructions involve implants in some form.  In fact, back in 2002, implant-based breast reconstruction (IBBR) surpassed autologous (flap) reconstruction and accounted for a majority of all reconstructions in the US.  This gap continues to widen today.  So implant-based breast reconstruction is worth discussing in more detail…

What is the most common breast reconstruction technique used today?

Most common sequence for breast reconstruction involves at least two surgeries.

Still today, the most common sequence for reconstruction involves at least two surgeries.  A “two stage” reconstruction places an expander under the pectoralis muscle when the breast tissue is removed.  An expander is a temporary, adjustable but NOT permanent implant. Usually, a few months after the first surgery to place the expander, the patient will need a second surgery to remove the expander and replace it with a permanent breast implant.

Autologous or flap-based reconstruction borrows and relocates tissue from some other part of the body.  This tissue is moved to the chest to act as the new breast. This surgery is challenging for patients and surgeons.  Patients will not only have to recover from the chest surgery but will also have to recover from the site where the tissue was borrowed.  You can have complications at either site (chest and belly).

So it's no surprise that the rate of total complications from free flap surgery is double the rate of implant-based surgery, as published in 2018 from the Mastectomy Reconstruction Outcomes Consortium (MROC) study (47% of flap patients had a complication versus 25% of implant patients within the first year after surgery). In this same article, flap patients also had nearly twice as many reoperations (29.2% versus 15.5% of implant patients needed to be operated on again), and "major" complications (29.3% versus 18% of implant patients had a "major" complication). Just this month in 2019, Klement et al published their experience which showed 52.8% of obese patients had a complication at the abdomen (NOT even counting the complications that involved the breasts)!

Also, unique to flap based reconstructions, are complications that can occur where the tissue is donated (the donor site, which is most commonly the belly). Depending on what types of tissues are removed or violated (muscle, fascia, etc), patients can have additional short and long-term problems, like weakness of their abdomen. 5-15% of patients may get an abdominal bulge (5% reported by MROC). 5-7.5% developed either a bulge or a hernia according to Klement et al. Commonly referenced rates of hernia typically fall in the 2-4% range, although some articles report lower rates. MROC further showed 2.5% of patients needed a hernia repair surgery after their belly-based reconstruction... Yikes.

• In general it is difficult to compare complication rates between different studies and different techniques. This is because there are so many potential variables that may affect outcomes, like the patient population / surgeons' experience or techniques / statistical analyses / defining complications (what is classified as minor or major complication) / sensitivity in detecting said complication (abdominal weakness or implant seroma) / length of follow up ..... The list can go on. Therefore, complication rates are usually best thought of as general ranges.

What is Direct To Permanent Implant reconstruction?

Direct to Permanent Implant reconstruction means that a permanent breast implant is placed at the time of the mastectomy, instead of an expander or a flap.  

What is prepectoral breast reconstruction

Prepectoral breast reconstruction is one of the most modern type of breast reconstruction.

Prepectoral reconstruction is one of the most modern types of breast reconstruction and has many benefits over traditional below-the-muscle techniques. When the saline or silicone gel implant is placed below the pectoralis muscle, the muscle must stretch across the implant. Not only will this produce more pain, it will also limit how much volume of implant can be placed to reconstruct the breast and is the main rationale for using an expander. Since an expander is not a good permanent implant device, it will eventually need to be removed and replaced with a permanent breast implant in a second surgery which may be several months after the first surgery.

5 Reasons for ONE Surgery Breast Reconstruction

1. For over 85% of my patients, it is just ONE Surgery!

• And this is where most of the benefits are derived.  Avoid the stress and worry of having another planned surgery (expander exchanged for permanent implant) during any post mastectomy cancer treatments like chemo, hormonal or radiation therapy. Avoiding an UNPLANNED reoperation after your mastectomy is also critically important. My immediate implant surgery reoperation rate is 2% of breasts. Avoiding complications at the initial reconstruction helps avoid unnecessary delays in breast cancer treatments, and is why complication rates matter. Fewer surgeries means fewer chances to have a surgical and/or anesthesia complication.
• By having only one surgery, you also have only one recovery.  This means less overall downtime for you. My direct to implant patients recover more quickly than my flap surgery patients.
• With fewer surgeries there are fewer doctor visits to schedule.  Compared to expander reconstruction, there is no need for expansion visits.  Expansion is where a needle is placed through the skin into the expander to slowly fill it up.  This filling then stretches the overlying soft tissue. You only need to read online stories from patients to hear about how annoying and occasionally painful this can be.  
• My revision rate with immediate direct to implant surgery is 14.3% of patients (8% of breasts).  Meaning only 1 out of 7 of my patients undergoes a second (revision) surgery within 1 year of the mastectomy. The majority of these revision patients simply desire fine-tuning the cosmetic appearance of the reconstruction, usually with fat graft alone, and do not need any functional problems addressed. Fat grafting is a straightforward, outpatient surgery that can wait until some distant time point when surgery is more convenient for you.

2. No distortion of the pectoralis muscle!

• Avoiding muscle stretching and distortion has many benefits. A huge advantage is less pain from surgery!  With less pain, patients get out of the hospital faster and can return to regular life and work sooner.  After evolving my breast reconstruction techniques, patients started telling me how they would go to survivor group meetings and feel “guilty” about having so little pain after their reconstruction compared to other women in the group.  Seriously.
• With less muscle stretching, patients report less long-term discomfort.  As opposed to cosmetic breast implants, recon implants tend to be larger because they must replace the missing breast tissue volume.  Some patients do not tolerate the sensation of muscle contracting over a large implant.  In fact, my patients routinely wanted or needed physical therapy to adapt to an implant under the muscle.  And now, almost none of my patients request physical therapy.
• Finally, when the implant is above the muscle, there is no implant displacement due to muscle contraction.  Instead, just like other techniques, the only force that will move the implant overtime is gravity.

3. It looks better!

Granted this is subjective, there are still a couple of improvements that my patients and I routinely see.  For one, having the implant above the muscle allows the implant to create a slight overhang. This creates a more natural lower breast fold which is difficult to achieve with sub-muscular implants.  Secondly, there is no animation deformity with muscle contraction.  Animation deformity is distortion of the breast shape (implant shape) caused by muscle tightening (which creates and applies pressure) over the implant.  It can be quite distressing to patients. But now my patients don’t have to worry about this.

4. Want bigger breasts after mastectomy, well this can STILL happen even with a permanent implant!

For prophylactic nipple-sparing mastectomies, patients may prefer to wake up from surgery with slightly larger, fuller breasts that look more like an augmentation.  Obviously, this will depend on the just how much bigger the patient would like to be but, for most skin-sparing mastectomy patients, it is achievable.  In fact, I’ve had several patients who look and feel like they had a cosmetic augmentation rather than a disfiguring reconstructive procedure.

5. Potentially lower costs!

This is a subject that will continue to increase in importance as the delivery and payment of healthcare continues to change.  So let's talk about it.

• Patients can see fewer overall costs when there are fewer surgeries. This makes sense, but why is it so?  Compared to two stage expander reconstructions, Fewer surgeries = fewer anesthesia/facility/surgeon’s costs.  With expander surgery, the second exchange surgery usually happens several months after the first surgery and this may fall in a new calendar year when the deductible has reset.  Even if it is not in a new calendar year, patients may have to cover their coinsurance cost for secondary procedures.
• Patients should also consider the initial surgery itself.  If you are in the hospital for many days after a surgery, or if you require ICU care (as many free flap patients do), this adds tremendous cost.  With my newer technique, my patients have had shorter overall hospital stays and NO ICU stays compared to free flap reconstruction.  Also, as previously mentioned, less postoperative downtime and fewer doctors’ visits (plastic surgeon and physical therapy), patients get back to work faster and miss fewer work days.  Missing work and losing that income is often under appreciated by physicians. And no one gets hurt more by lost income than my single mom patients.  
• Yeah, but what if Dr. Albright is Out-of-Network for my insurance?  Won’t this cost me more? - For most patients, the answer may surprise you.  The reality is many patients will either (a) have already met their out-of-pocket maximums before the mastectomy surgery (lab tests, genetic tests, diagnostic imaging, biopsies, doctor consults, and/or adjuvant chemotherapy), or (b) will meet their out of pocket maximums at the time of the mastectomy surgery.  Therefore, most patients will not personally see the increased cost of going with an out of network plastic surgeon; their insurer will cover the additional costs.
• Finally, there is a very sensitive topic to discuss.  The elephant in the room.  Having “in network” coverage on paper does NOT mean that you have access to high quality innovative breast reconstruction in the real world. One of the first phone calls we received at Alamo Plastic Surgery, (before we had even opened our doors!) was a patient trying to find a plastic surgeon who would be willing to do her breast reconstruction.  She told us that her in-network provider would not do a reconstruction, unless the patient combined it with a cosmetic, out of pocket cash-pay procedure!!!!  I truly hope this is an outlier, but I fear that it is a taste of things to come.  Unsustainable low insurance payments for different breast reconstruction techniques is altering the types of reconstruction offered to patients. For example, healthcare providers guiding patients toward types of breast reconstructions (flap vs implant) that may not be in the patient’s best interest, but instead, offer better physician compensation or hospital remuneration.  Limiting your options, before you may even be aware of the bias. Completely shameful?  Yes. But it happens.

Who are good candidates and who are not ideal candidates for prepectoral direct to permanent implant breast reconstruction?

The short answer is MOST patients are good candidates.

The short answer is MOST patients are good candidates just like other forms of reconstruction!  Since so many patients are good candidates, it’s easier to identify people who are not ideal candidates. Non-deal candidates for direct to implant reconstruction also tend to be poor candidates for other types of reconstruction because non-ideal patients tend to have higher risks for complications independent of the technique used.  These factors include:

• Uncontrolled diabetes
• Active smokers
• Poorly compliant patients
• Previous or planned post-mastectomy radiation therapy
• Obesity (somewhat controversial)
• Advanced age (also controversial)

Perceived drawbacks of prepectoral direct to implant surgery

Whether from one stage or two stage surgery, implants have some inherent drawbacks compared to using one’s own tissue.  I recommend patients read more on our website about these issues.  But I will say that, although there are likely more lifetime surgeries for implants over flap surgery, implant revision surgeries tend to occur years after the reconstruction when the patient has fully recovered and has overcome their cancer diagnosis and treatments. For most patients, these future surgeries are relatively straight forward surgeries with an acceptably low complication rate.  The major exception to this is the radiated breast.

Radiated Breasts:

• The reality is: NO reconstruction tolerates radiation perfectly, whether implant or flap based.  Every reconstruction technique has a higher complication rate with previous or subsequent radiation, including reconstruction failure.  It’s really a matter of degree.  I readily grant that implants have a higher failure rate than flaps after radiation.  However, if an initial implant reconstruction fails (which is not a 100% guarantee), then a flap-based reconstruction is the fall back plan. If a flap is used first and fails, then the fall back plan is a different, less favorable alternative flap. Presumably the first flap selected had been the best option, so other flaps are inherently less ideal for you.
• I discuss these risks with you at your consultation to see what your goals are and what your comfort level is with the risks and downsides of each reconstructive approach.  And, I assure you, ALL reconstructive techniques have downsides when it comes to radiation.

Ready to try the ONE Surgery Breast Reconstruction?

True, this technique is a newer innovation, and NEW does not always EQUAL BETTER. But my complication rates compare favorably to published large case series.  Furthermore, I have been performing this technique in the vast majority of my reconstruction patients for the last 3 years with excellent results and patient feedback.

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