Why the “One and Done” Approach to Breast Reconstruction Can Be Misleading

Recently, a news article circulated with information regarding a new “one and done” approach to breast reconstruction being available and providing promising results. Sounds great right? While the procedure can be a great option for some women, calling it “one and done” can be misleading as over 30% of women will need further surgery. For this reason, many surgeons refer to the procedure as “direct-to-implant” instead.

At PRMA we do perform “One-Step” breast reconstruction using implants and Alloderm. However, we try to limit this procedure to patients who are seeking immediate reconstruction after prophylactic nipple-sparing mastectomy (eg for BRCA+) since this group of women have the best chance of needing only one surgery.

For patients undergoing a mastectomy due to cancer, there are some things to consider before choosing the “one and done” surgery. The final cosmetic results after implant breast reconstruction depend heavily on the thickness of tissue covering the implant. Often after mastectomy, the tissues over the implant aren’t thick enough to camouflage the implant completely, even if the implant is under the pec muscle. Many patients experience visible implant “rippling” because of this and more surgery is required (usually fat grafting) to add more tissue over the implant(s) to decrease the visible rippling. This is the most common reason for needing further surgery after a “one and done” procedure.

The possibility of post-mastectomy radiation also needs to be considered. Radiation certainly doesn’t preclude breast reconstruction, but it does increase the risk of complications and can impact the final cosmetic results. Radiation and implants often do not get along very well and patients undergoing radiation therapy after breast reconstruction often need more surgery for the best results.

One more factor to consider is the impact of nipple-sparing mastectomy (NSM). Preserving the nipple-areola significantly improves the cosmetic results after breast reconstruction, particularly reconstruction with implants. Patients who aren’t candidates for NSM, or prefer not to preserve the nipple-areola, often have results that aren’t as cosmetically appealing after implant-based reconstruction as those who have NSM.

For patients seeking flap-based reconstruction a single-step approach can be performed, but consistently superior results are achieved with a staged approach. Procedures such as the DIEP flap are often performed at the same time as the mastectomy (“immediate reconstruction”) allowing patients to wake up with breasts and avoiding the trauma of a missing breast. However, the newly reconstructed breast is not considered a finished product. A second surgery—or revision surgery— is typically needed a few months later to “fine tune” the reconstructed breast(s) for the best cosmetic results. This outpatient surgery often includes further breast shaping, fat grafting, scar revision, and nipple reconstruction.

Although the idea of having everything taken care of in one surgery sounds great, unfortunately this will not always be in your best interests. Please discuss your expectations thoroughly with your surgeon prior to proceeding with “one and done” breast reconstruction to make sure it is the best choice for you.

For more information, including a list of ASPS plastic surgeons in your community, please use our Find a Surgeon tool.

*Originally publushed on PRMA’s blog

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