Direct-to-implant, or single-stage, breast reconstruction refers to the insertion of a permanent implant immediately following the mastectomy, as opposed to initially placing a tissue expander, filling it over time, and then exchanging the filled expander for the permanent implant. Dr. John Kim of Northwestern Plastic Surgery performs his direct-to-implant single-stage breast reconstructions on a selective basis with very small breasted patients at Northwestern Memorial Hospital and Prentice Women’s Hospital in downtown Chicago.
Ideal patients for this type of surgery are undergoing bilateral prophylactic (preventative) mastectomies due to a BRCA1 or BRCA2 genetic mutation and/or have a strong family history of breast cancer. With these patients, Dr. Kim typically encounters good preservation of the breast skin after the mastectomy, since there is no cancerous portion to excise. If the post-mastectomy breast skin is fairly substantial in amount and quality, Dr. Kim may opt to place the implant in conjunction with a material called acellular dermal matrix (ADM), which acts as a sling to help support and cover the newly placed implant. The addition of ADM to the breast also commonly allows a patient to have larger implants placed than the size of her native breasts, if she so desires.
Qualities of an ideal candidate for single-stage, direct-to-implant breast reconstruction:
- You have a reasonable body weight and size
- You are having bilateral reconstruction or are agreeable to having surgery on the opposite breast to improve symmetry
- You are having prophylactic (preventive) mastectomies due to genetic mutation and/or strong family history
- You have not had breast radiation in the past
- Your mastectomy skin flaps are preserved and in good condition
- You are unwilling or unable to undergo flap-based reconstruction
- You are willing to have a final breast size equal to or smaller than your native breast size
Not an ideal candidate for single-stage, direct-to-implant breast reconstruction:
- You have a high BMI
- You have more advanced stage cancer
- You have undergone prior radiation treatment
- You have had prior breast surgery
- You have had prior breast complications, such as infection
- You are a smoker or have existing medical problems
Dr. Kim’s patients who undergo single-stage, direct-to-implant breast reconstruction at Northwestern have the same implant options as those who undergo tissue expander/implant breast reconstruction. Several manufacturers create many different types of implants with variations in shape, profile, size, fill, and surface texture. Breast reconstruction surgeon Dr. Kim will assist you in choosing the correct implant to meet your goals for your breast reconstruction results. He will explain how your personal anatomy and skin elasticity will impact your implant selection.
One of the main considerations when choosing your implants is whether you prefer saline or silicone. Saline implants are made from a silicone-based outer shell that is filled with sterile saline (saltwater) solution. The saline solution is typically added to the shell during surgery, but some saline implants come pre-filled. A major benefit to saline implants is that Dr. Kim is able to adjust the final size during your surgery if adjustments are needed, since he can remove or add saline according to his clinical judgment. Another benefit to using a saline implant is that if it were to rupture, the leaked saline solution will not harm your body. Our bodies naturally absorb saltwater and can excrete it easily. In this case, Dr. Kim will surgically remove the ruptured implant and replace it with a new one.
Silicone implants consist of a shell filled with thick, elastic gel. The gel moves and feels like natural breast tissue, so it is a popular choice among Dr. Kim’s Chicago breast reconstruction patients. In 2012, a new type of silicone gel implant technology was approved by the FDA. These new implants consist of a highly cohesive, high strength gel, and thus they are referred to as “cohesive gel”, “gummy bear”, and “form stable”. When this type of implant is cut or penetrated, it retains its shape (hence “gummy bear”). As with normal silicone gel implants, these too feel like natural breast tissue and are thought to reduce the undesirable side effects of liquid-filled implants, namely folding, wrinkling, over-filling, and rippling. When a silicone implant ruptures, it is less noticeable than when a saline implant breaks. The slow leaking of silicone gel to areas outside the breast may go unnoticed for a while. Our bodies do not naturally absorb silicone as they do saline, though, so it is important to see Dr. Kim right away if you suspect a rupture, as he will need to surgically remove the shell and silicone and replace the implant with a new one.
The main advantage to having direct-to-implant (single-stage) breast reconstruction is that you will have fewer surgeries and visits to Dr. Kim’s offices in Galter Pavilion in downtown Chicago than if you have a tissue expander placed then subsequently expanded and ultimately exchanged for a permanent implant in a separate surgery.
Here are some useful resources for your perusal as you explore your breast reconstruction options:
For more information on single-stage, direct-to-implant breast reconstruction, please contact board-certified reconstructive surgeon Dr. John Kim at his office at Northwestern Plastic Surgery.
Pre-pectoral Breast Reconstruction
When looking into a breast reconstruction procedure, an important consideration is which position you would like your implants to be placed: subpectoral or pre-pectoral. If you choose a pre-pectoral positioning, your implant will be placed above your pectoralis muscle while if you choose a subpectoral positioning, your implant will be placed below your pectoralis muscle. Dr. Kim will walk you through the pros and cons of each implant position during your initial consultation, but the decision ultimately comes down to what is best for each specific patient.
While the pre-pectoral implant placement has become increasingly popular over the past few years, the subpectoral implant position has been a more widely accepted technique for much longer. The placement under the pectoralis muscle can protect against rippling and hollowing of the breast due to thicker skin flaps and a larger volume of subcutaneous soft tissue. A downside of the subpectoral implant placement is implant movement within the breast pocket, termed “animation deformity.” Click here to see an article Dr. Kim has written on animation deformity.
Pre-pectoral implant placement can help prevent this implant movement within the breast. Animation deformity can be observed as a shift in the implant upon engagement and contraction of the chest muscle. The pre-pectoral placement is also believed to result in less post-operative pain, as well as high patient satisfaction. Placing the implant above the muscle helps avoid muscle function impairment leading to less pain and a potentially faster recovery.
Another important consideration is the thickness of the mastectomy flaps. This may or may not favor one type of breast reconstruction versus another. Dr. Kim can discuss these issues with you directly.