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Implant Reconstruction: To Stage or Not to Stage?

| July 8, 2014 December 14, 2020 | |

implant reconstruction stage or not stageI like to tell my patients that there are two broad categories of breast reconstruction:

  1. Techniques which are based on implanted materials
  2. Natural reconstructions are based on one’s tissues.

Patients considering implant-based reconstruction often strong desire a path that will involve as few operations as possible.

The traditional method of implant reconstruction involves a staged approach, with the placement of devices known as tissue expanders at the initial operation (usually at the time of the mastectomy) and replacement of the expanders with permanent breast implants at a subsequent, separate surgery done at a later date. With this method, the tissue expanders stretch out the chest’s skin to recreate the breast mound on the chest wall.


photo credit Healthwise, Incorporated: Tissue Expander

In the past, the staged reconstruction method using tissue expanders was necessary because most of the mastectomy techniques did not leave much skin on the chest wall. These days, there has been a trend for mastectomies to be more skin-sparing, often taking only the nipple and areola and leaving most of the breast skin on the chest. In some cases, even the nipples are being preserved (known as nipple-sparing mastectomy). These skin-sparing operations have reduced the need for tissue expansion and driven the single stage’s evolution, or direct-to-implant reconstruction.

Just as the name states, the direct-to-implant method is completed in a single stage, with the permanent implant placement at the time of mastectomy. This method has potential benefits when compared to the more traditional staged method:

  • Fewer surgeries
  • Single recovery period
  • No need for multiple visits for filling/expansion
  • Smaller breast size for patients desiring a reduction in breast size

Things to Consider when Choosing Final Reconstructive Plan

While these advantages may be real in some cases, there are still many potential drawbacks that should be considered when choosing a final reconstructive plan:

Smaller breast size

Since the reconstruction is done using the skin left after mastectomy, the final reconstruction will usually be smaller than the original breast size with no additional expansion or stretching phase. For nipple-sparing mastectomies, where all of the outer breast skin and tissue is preserved, the final size can approach the breast-sized pre-mastectomy breast.

One final breast size

With the staged method, tissue expanders can give the patient the option to fill or stretch the reconstructed breasts to a size that they feel is optimal. This can often be smaller, the same, or even larger than their original breast size.

The direct-to-implant method places a permanent implant at the initial mastectomy operation. The implant is generally a fixed volume and cannot be changed after surgery.

A high rate of re-operation

In a very recent study published in the plastic surgery literature, nearly 1/3 of breasts reconstructed with the direct-to-implant method had to be fixed with additional surgery in the first six months after surgery.

To summarize, direct-to-implant reconstruction can undoubtedly be an excellent reconstructive option in certain cases. Just like any reconstructive technique, there are intrinsic advantages and disadvantages associated with the procedure. As I’ve noted throughout previous blogs and content on our webpage, the best reconstructive option for a given patient can depend on several factors. Arriving at a final decision regarding reconstruction requires careful consideration of these factors.

About the Author

Dr. Ergun Kocak, MD, is a board-certified plastic surgeon who specializes in plastic and reconstructive surgery of the breast using DIEP, SIEA GAP, TUG, PAP, and direct-to-implant, in Columbus and Cincinnati, OH.
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*Our blog entries are written in order to further educate our patients and raise awareness towards topics related to plastic surgery. Any solutions offered on this blog are intended to help possible patients develop educated decisions before undergoing a consultation with our doctors.

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