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Immediate Breast Reconstruction
A mastectomy is the surgical removal of breast tissue to treat or prevent breast cancer, performed by a breast or general surgeon. Breast reconstruction, performed by a plastic surgeon, rebuilds the breast(s) after mastectomy. Breast reconstruction can be done in a separate surgical procedure from the mastectomy, but it can also be performed at the same time as the mastectomy. This depends on the recommendations of the breast or general surgeon and/or the plastic surgeon. There are many procedure options that a plastic surgeon can use to re-create the volume of the breast, and some can take months to complete. Patients of the New York Group for Plastic Surgery can have breast reconstruction done immediately following the mastectomy, within the same surgery.
Direct to Implant, or “One Step” Breast Reconstruction
Dr. C. Andrew Salzberg pioneered the direct to implant, or “one step,” breast reconstruction procedure using a special support material called acellular dermal matrix (ADM). He performed the first ever direct to implant reconstruction in December 2001, and has since reconstructed more than 900 breasts (more than 500 patients) with this procedure as part of breast cancer treatment, or prevention for women at high risk due to BRCA mutations or family history.
How does Direct to Implant Differ from Traditional Breast Reconstruction?
Direct to implant breast reconstruction is completed in one surgical procedure at the same time as mastectomy. With a traditionally performed breast reconstruction using prosthesis, the plastic surgeon inserts an empty, balloon-like device called a tissue expander into the breast immediately after the breast tissue is removed. Then over 3 - 6 months, the tissue expanders are filled with saline to stretch the skin and pectoralis major (chest) muscle to create a pocket for an eventual permanent implant. Once the breast skin and muscle are fully expanded, a second surgery is performed to exchange the tissue expander for a permanent silicone or saline breast implant.
With direct to implant breast reconstruction, however, we insert the permanent implant into the breast immediately following breast tissue removal. This procedure avoids the need for our patients to have tissue expanders. We are able to bypass the expansion process by using a specially prepared skin tissue called acellular dermal matrix (ADM). The ADM is attached to the lower border of the pectoralis major muscle and then to the inframammary (lower) fold of the breast, essentially creating a pocket sufficient to place a permanent implant underneath. Thus, the combination of ADM and the pectoralis muscle eliminates the need to stretch the muscle with devices such as a tissue expander.
What are the Advantages of New York Direct to Implant Breast Reconstruction Procedures?
There are many advantages for a woman who chooses a direct to implant, or one step, breast reconstruction:
- One surgery is needed for the mastectomy and breast reconstruction to be completed.
- Avoidance of tissue expanders and the stretching process, which can be uncomfortable and takes three to six months.
- Breast are in place right after mastectomy, which may help lessen emotional stress and preserve a positive body image.
How Do You Perform Direct to Implant Breast Reconstruction?
We perform direct to implant breast reconstruction surgery within the same surgery as the mastectomy. The breast or general surgeon we are operating with will remove the breast tissue in a way that preserves the breast skin properly. Then, we immediately begin the breast reconstruction portion of the surgery.
First, we lift the pectoralis major muscle, which is the main muscle underneath the breast. Next, we attach a strip of specially prepared skin tissue (acellular dermal matrix, or ADM) to the now elevated lower border of the pectoralis muscle. This skin tissue acts like an “extension” of the pectoralis muscle.
We then place the silicone or saline implant beneath the pectoralis major and the ADM, which together cover the implant in its entirety. The lower border of the ADM is then secured to the lower pole of the breast, also known as the inframammary fold.
Drains are then placed that lead from your breasts to a tube outside of your body, in order to get rid of excess fluids that collect post-surgery. Lastly, the skin is closed using dissolvable sutures (stitches).
Of note, acellular dermal matrix, or ADM, is donor tissue but it contains no human cells or DNA. This means there is no rejection of the product for the patient using the material. It will incorporate into your tissues and contain your DNA and blood vessels within 6 weeks.
Am I a Candidate for Mastectomy with Direct to Implant Breast Reconstruction?
Many women in need of mastectomy come to the New York Group for Plastic Surgery for direct to implant, or one step, breast reconstruction. Their goal in seeking our care is to avoid a months-long tissue expander process and a second surgery for permanent implants, and to achieve great aesthetic results. The direct to implant breast reconstruction technique is often performed with nipple sparing mastectomy when possible, so that a woman can keep her own nipple area (nipple areola complex, or NAC) for more natural appearing breasts.
Direct to implant breast reconstruction is usually an option for a woman whose breast skin is healthy and able to accommodate the implant. Very obese patients are generally not good candidates for implant reconstruction overall and usually do better with other reconstruction options that may involve fat and/or muscle transfer to reconstruct the breasts.
Can I Have Direct to Implant Breast Reconstruction if I have Large and/or Sagging Breasts (Ptosis)?
You can have direct to implant breast reconstruction with mastectomy even with large (cup size of D - DD or larger) or ptotic breasts, which is when the nipples face downward or are positioned lower than the inframammary (bottom of breast) fold.
If you are not having nipple sparing mastectomy surgery, we can remove excess skin during the mastectomy/reconstruction surgery to create a smaller, lifted breasted and do a direct to implant procedure. If you want a nipple sparing mastectomy, we take a different approach and use a two-stage procedure. The first stage is a breast reduction and/or lift, called mastopexy. The mastopexy makes the breast shapelier and slightly smaller, fixes the ptosis and places the nipples into the correct, forward-facing position.
Six months to a year later — once the nipples have recovered and re-established an adequate blood supply to keep them viable—we perform the nipple-sparing mastectomy with direct to implant reconstruction. Dr. Salzberg has performed more of the direct to implant procedures after reduction than any surgeon in the U.S. to date.
Can I Have Direct to Implant Breast Reconstruction if I’ve had Radiation Treatment for Breast Cancer?
If your breast skin was only mildly affected or changed from radiation therapy, you may be a candidate for direct to implant breast reconstruction, and in fact have a good chance for a successful outcome. However, you are at a slightly increased risk for complications such as capsular contracture (firmness to the implant and breast) and/or infection. If radiation has injured your breast skin to where it can’t be properly expanded, you’re likely not a good candidate for implants and should explore other types of breast reconstruction.
What is the Skin Tissue Used in Direct to Implant Breast Reconstruction?
We use an FDA-approved piece of skin tissue known as acellular dermal matrix or ADM, in direct to implant, or one step, breast reconstruction. The ADM, made from human cadaver or porcine skin, is completely sterilized and all the skin cells are removed (by the company which produces it) so that only the collagen remains. Your body will incorporate the material into your own tissue, i.e., it will contain your cells and DNA. ADM is needed to create a pocket, or space, for the implant to be placed into right after the breast tissue is removed. (With traditional breast reconstruction, this pocket is created using tissue expanders that are filled over 3 - 6 months to stretch the breast muscle and skin.)
What is the Surgical and Cosmetic Recovery Following Direct to Implant Breast Reconstruction?
As with any type of mastectomy and breast reconstruction, there can be moderate pain and discomfort, especially in the first couple of days after surgery. You should rest as much as you can for the first 4 days. Limit upper body activity to range of motion only — that is, no lifting, but gently raising your arms to do your hair or get a glass out of the cabinet, for example, is fine. It’s actually beneficial to use your arms in a full range of motion after a week. But you should not lift, push, or pull anything more than five pounds for 2 weeks. You can start exercising 2 weeks after surgery, but start slowly and work your way up little by little. Do not do exercises that directly strain the pectoralis muscle, such as push-ups or yoga positions that require upper body strength.
As for appearance, expect that your breasts may look bruised and swollen the first week or 2 after surgery — this will change a lot! Your breasts may also seem high and feel firm. Over the next weeks and months, the bruises on your breasts will fade and disappear, and your breasts settle into a more natural shape and position. The firmness softens and the breasts will feel more soft and mobile. A supportive bra is typically worn all day for 8 - 12 weeks to help properly shape the breasts.
Is It Possible I’ll Need Revisions to My Direct to Implant Breast Reconstruction?
Most women do not require revisions after New York direct to implant breast reconstruction surgical procedures. However, some of the new techniques used in revisions have really become successful in putting the “finishing touches” on the aesthetic appearance of the breast, and women are opting to pursue these revisions in order to make their results just that much better!
One of these new techniques is referred to as fat transfer. This outpatient procedure involves taking a small amount of fat using liposuction techniques and transferring it into the breast using very small cannulas so that the grafted fat is layered carefully just underneath the skin and above the muscle. The result is a more natural breast as there is more tissue camouflaging the implant, i.e., the breast is rounder and softer.
As the breast settles with time, there can be contour (shape) irregularities or a small loss of the upper pole, or portion, of the breast. This is also a scenario that is dramatically improved with fat transfer. Some women may have revision surgery for other reasons that include the desire for a larger implant size, the presence of an infection, or skin necrosis.
Let's Get Started
Would you like to learn more about New York Direct to Implant Breast Reconstruction? Request your consultation online, or give us a call at 800-433-7410 (New York City) or 914-366-6139 (Tarrytown), or 845-294-2018 (Goshen) or 914-293-8700 (Cortlandt Manor). At the New York Group for Plastic Surgery, we serve patients in the entire Hudson River Valley, Northern New Jersey, Eastern Pennsylvania and Western Connecticut.