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Media Resources

Direct-to-Implant or “One-Step” Breast Reconstruction Fact Sheet

Mastectomy is the surgical removal of breast tissue to treat or prevent breast cancer, and breast reconstruction is the surgical procedure to restore the breast’s shape, size and appearance. Mastectomy with breast reconstruction is an option for women being treated for breast cancer, or women at high genetic risk or strong family history of breast cancer. 

Breast reconstruction can be accomplished using different surgical methods and with various “fill” material. Most commonly, the breast is reconstructed with silicone or saline implants, or using tissue (fat, muscle and blood vessels) taken from the patient’s own body (abdomen, buttocks). 

Dr. C. Andrew Salzberg, a board certified plastic and reconstructive surgeon specializing in breast and cosmetic surgery, was the first to utilize acellular dermal matrix (ADM) in the breast to pioneer the Direct-to-Implant, or “One-Step,” breast reconstruction. He performed the first Direct-to-Implant reconstruction in December 2001, and has since reconstructed more than 900 breasts with this procedure as part of breast cancer treatment or prevention. 

Dr. Salzberg answers frequently asked questions about Direct-to-Implant breast reconstruction: 

What is Direct-to-Implant, or One-Step, breast reconstruction and how does it differ from more traditional breast reconstruction? 

A key difference between these breast reconstruction procedures is the amount of time each takes to achieve final cosmetic results. 

Traditionally, post-mastectomy breast reconstruction requires the plastic surgeon to put a tissue expander in the breast immediately after the breast tissue is removed. Over three to six months, the surgeon fills the patient’s expander with saline to stretch the skin and muscle in preparation for implants; expansion can be painful for some women. The surgeon replaces the expander with a permanent implant in a second surgical procedure. 

The newer Direct-to-Implant, or One-Step, breast reconstruction provides an immediate breast reconstruction within one surgical procedure. The surgeon places a permanent implant in the breast following breast tissue removal, avoiding the need for tissue expanders and the fill process. One-Step reconstruction uses a specially prepared skin tissue placed over the implant to accomplish the role of the tissue expanders and fills. 

What are the advantages of a One-Step breast reconstruction? 

There are many advantages for a woman having a Direct-to-Implant, or One-Step, breast reconstruction as part of her mastectomy procedure: 

  • One surgery is required to insert the permanent implant and the majority of women can avoid a second reconstructive surgery 
  • Tissue expanders, which can be uncomfortable or painful and typically take three to six months to be expanded, are avoided 
  • A woman wakes from her mastectomy with breast implants in place, helping reduce emotional stress and preserve a positive body image 
  • May reduce the overall cost in health care dollars by avoiding a second anesthesia and hospital procedure 
  • Reduces complications associated with implants - such as skin necrosis, or breakdown, and capsular contracture, or tightening and distortion of skin around the implant - compared to the tissue expander process1
Who is a candidate for mastectomy with One-Step breast reconstruction? 

The Direct-to-Implant, or One-Step, breast reconstruction has become more popular with mastectomy patients seeking to avoid a months-long tissue expander process and a second surgery for permanent implants. The One-Step breast reconstruction is often done with nipple-sparing mastectomy for a breast that retains a more natural appearance. 

One-Step breast reconstruction is usually an option for a woman whose breast skin is healthy and able to accommodate the implant, and without excessive ptosis (sagging.) Very obese patients are generally not good candidates for implant reconstruction overall and are usually better served by other reconstruction options that may involve fat and/or muscle transfer. 

How is a One-Step breast reconstruction performed? 

The breast surgeon removes the breast tissue (mastectomy) in a way that preserves the breast skin properly for the implant. The plastic surgeon immediately places the silicone or saline implant beneath the pectoralis major, the main muscle underlying the breast; the muscle covers the upper half of the implant. 

The surgeon places a strip of specially prepared skin tissue (“acellular dermal matrix” or ADM) over the exposed bottom part of the implant to serve as an “extension” of the muscle, then closes the breast skin with sutures (stitches.) 

What is the skin tissue used in One-Step breast reconstruction? 

The specially prepared skin tissue that covers and supports the implant in a One-Step breast reconstruction is known as “acellular dermal matrix (ADM).” ADM is prepared from either human cadaver or porcine skin. ADM is thoroughly sterilized and all skin cells removed, leaving only the collagen for surgery. The ADM eventually interconnects with and becomes part of the breast tissue and blood vessels. ADM has been safely used for decades for many types of reconstructive surgery, including skin burn and scar tissue repair, and is also used for cosmetic procedures like rhinoplasty and lip augmentation. 

What is the surgical and cosmetic recovery following One-Step breast reconstruction? 

Mastectomy and reconstruction of any type, including the Direct-to-Implant or One-Step procedure, may cause moderate pain and discomfort, particularly in the first few days. Activities must be minimal for the first four days after surgery. Arms shouldn’t be raised above the shoulders for two to three days; after one week, full range of motion is allowed and encouraged. However, lifting, pushing, or pulling is restricted to five pounds or less for two weeks. Exercise can begin at a gradual pace two weeks post-surgery, except for those that directly strain the pectoralis muscle. 

Cosmetically, the breasts may appear bruised and swollen the first week after surgery. A supportive bra is typically worn all day for six to 12 weeks to help properly shape the breasts. With each passing week, the reconstructed breasts will heal and settle into a more symmetrical, natural shape. 

Some women may have revision surgery for reasons that include desire for a larger implant size, infection, or skin necrosis. 

Can a woman who had radiation treatment for breast cancer have One-Step breast reconstruction? 

Women who have mild breast skin changes after post-mastectomy radiation therapy are candidates for One-Step breast reconstruction, with an excellent chance for a successful outcome. However, if a woman’s radiated breast skin changes are severe and the skin cannot be expanded well, she is typically not a good candidate for implants and should probably seek other types of reconstruction.2

What are possible complications with One-Step Breast Reconstruction? 

As with all surgical procedures, there are potential complications with One-Step breast reconstruction. Recent peer-reviewed data from 439 procedures (790 breast reconstructions) I performed over a 10-year period in 439 patients show low complication rates at an incidence of less then two percent; these include implant loss (1.6 percent), skin necrosis requiring reoperation (1.3 percent), infection (1.1 percent), hematoma (0.6 percent), seroma (0.5 percent) and capsular contracture (0.5 percent).2

Overall, Direct-to-Implant, or One-Step, breast reconstruction following mastectomy to treat or prevent breast cancer is effective, safe and provides aesthetic benefits when performed on appropriate patients.2

Dr. Salzberg, a board certified plastic and reconstructive surgeon, is Associate Professor at NY Medical College and Chief of Plastic Surgery at Westchester Medical Center and St. John's Riverside Hospital at Dobbs Ferry Pavilion. He also operates at the Institute for Aesthetic and Reconstructive Surgery within the Hudson Valley Hospital Center and at The Mt. Sinai Hospital Center in New York City. He is a partner with the New York Group for Plastic Surgery: http://www.nygplasticsurgery.com


1  Salzberg, CA, Ashikari AY,  Koch RM, Chabner-Thompson E. An 8-Year Experience of Direct-to-Implant Immediate Breast Reconstruction Using Human Acellular Dermal Matrix (Alloderm). Plastic and Reconstructive Surgery, 2011.

2  Salzberg CA. Focus on Technique: One-Stage Implant-Based Breast Reconstruction.Plastic and Reconstructive Surgery, November Featured Supplement, 2012.

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