Breast reconstruction with expanders and implants: Choosing between the 1-stage and 2-stage techniques

Maurice Nahabedian, MD, FACS
Director: Center for reconstructive and aesthetic surgery of the breast
Johns Hopkins Hospital

Many women following mastectomy for cancer choose to have breast reconstruction using implants. This method of reconstruction has now been practiced for nearly 40 years and provided many women with an excellent quality of life. Over that time, significant improvements and modifications have occurred both with the implants and with the technique of reconstruction. Currently, there are a variety of implants from which to choose and a variety of techniques that can be used for the reconstruction. One of the debated topics among plastic surgeons today is whether implant reconstruction should be performed in 1-stage or 2-stages. There are many factors that the surgeon and the woman undergoing mastectomy must consider when making this decision. The purpose of this article is to discuss some of the various factors related to this decision that include choice of implant, patient selection, and technique of 1-stage and 2-stage implant reconstruction.

There are a variety of implants that the plastic surgeon has to choose from that relate to the shape, texture, and filler material of the implant. The shape of the implants can be round or contour profiled. The texture of the implant surface can be smooth or textured. The filler materials within the implant can be saline, silicone gel, or a combination of saline and silicone gel that are contained within separate compartments. In addition, the implants can be intraoperatively adjustable, postoperatively adjustable, or fixed volume. The decision as to what implant to choose is based upon the woman's expectations regarding projection, ptosis, size, and feel of the breast as well as the judgement and experience of the surgeon.

The techniques by which these implants are inserted are variable and based on location of implant placement, need for skin expansion, and number of stages for the reconstruction. The specific technique used depends on various factors that include but are not limited to preoperative breast size, degree of breast ptosis, thickness of the mastectomy skin flaps, amount of breast skin excised, and need to obtain breast symmetry. Most implants are placed under the pectoralis major muscle. This helps to minimize capsular contracture and provides additional padding on top of the implant. Whether a traditional mastectomy or skin-sparing mastectomy is performed, the remaining breast skin will require expansion to a certain degree. The decision to perform a 1-stage or 2-stage breast reconstruction should incorporate these elements in order to optimize the outcome. Some women are candidates for the 1-stage technique while others are candidates for the 2-stage technique. With each technique, the majority of the expansion is performed in the office, not in the operating room. The important details of each technique will be described.

2-Stage Implant Reconstruction
Candidates for 2-stage reconstruction include women any size breast and women with moderate breast ptosis. The primary reason that a 2-stage reconstruction is performed is that during the first stage the pectoralis major muscle and the skin envelope of the breast are expanded using a temporary tissue expander. It is not uncommon following the first stage to have a high-riding implant that can be firm and distorted in shape and contour. However, once the muscle and skin are adequately expanded, these abnormalities are corrected during the second stage. During the second stage, the tissue expander is removed, the scar tissue surrounding the implant that is causing the distortion is incised or excised, the inframammary fold is positioned to match the opposite side, and a new permanent implant is inserted. This procedure results in a well-shaped breast that is softer and closely approximates the opposite side. The 2-stage reconstruction will allow for the use of any implant that can include round, contour profile, smooth surface, textured surface saline, silicone gel, and prefilled implants. A postoperatively adjustable permanent implant can be used during the second stage to fine-tune the reconstruction.

1-Stage Implant Reconstruction
Ideal candidates for 1-stage implant reconstruction in my practice include women who have small breasts with minimal to no ptosis and for women having subcutaneous mastectomy with preservation of the nipple areolar complex. The primary reason that women with small breasts do not benefit from a 2-stage procedure is because creating a breast with ptosis is usually not necessary. In addition, most companies that make tissue expanders for breast reconstruction do not make expanders less that 350 cc in volume. A 1-stage procedure is indicated following subcutaneous mastectomy because the skin envelope of the breast is intact and does not require expansion. Only the pectoralis major muscle is expanded. It must be remembered however, that the first stage of any implant reconstruction frequently results in an implant that is positioned higher on the chest wall than the opposite breast. This is due to the action of the initial positioning of the implant, the action of the pectoralis major muscle and the formation of scar tissue. Although an implant exchange is not performed with the 1-stage reconstruction, a revision of the reconstruction is usually necessary to shape and position the breast to more closely match the opposite side. A surgical limitation of this technique is that only postoperatively adjustable implants can be used.

In conclusion, both the 1-stage and 2-stage techniques are appropriate methods of breast reconstruction in properly selected women. The 2-stage technique requires a second operation in which the implant is exchanged and the breast is shaped. The 1-stage technique does not require an implant exchange but frequently requires a revision in order to obtain a symmetric and well-shaped breast. Both techniques can result in a well-shaped and contoured breast.

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