Autogenous tissue reconstruction is generally thought to produce the most natural looking and feeling breast(s). Although the permanency of these results and lack of dependancy on a permanent prosthesis is also advantageous, the relative magnitude of these procedures is great. Many women will instead opt for a prosthetic reconstruction, choosing a less invasive operative procedure with a faster recovery and the capability of achieving excellent results. In fact, of the nearly 60,000 women in the United States who had postmastectomy reconstruction in 2007, the majority (approximately 70%) elected to pursue implant-based, postmastectomy reconstruction.1
Current options for implant-based reconstruction include the following: (1) single-stage implant reconstruction with either a standard or an adjustable, permanent prosthesis; (2) 2-stage tissue expander/implant reconstruction; and (3) combined implant/autogenous tissue reconstruction.
Immediate, single-stage breast reconstruction with a standard implant is best suited to the occasional patient who has a small, nonptotic breast and adequate skin at the mastectomy site, which will allow for immediate placement of a permanent implant. Selection criteria for single-stage, adjustable implant reconstruction is similar, yet it is the preferred technique when the ability to adjust the volume of the device postoperatively is desired. In small-breasted women where the skin deficiency is minimal, the implant can be partially filled at the time of reconstruction and gradually inflated to the desired volume postoperatively. In addition, disadvantages of this technique include the placement of a remote port and the need for its subsequent removal. Finally, many suggest that the aesthetic outcomes tend not be as good as 2-stage reconstruction and/or revisional procedures are often necessitated. Consequently, this approach is not used for a majority of implant-based reconstructions.1
Two-Stage Expander/Implant Reconstruction
Although satisfactory results can be obtained with single-stage reconstruction, in the vast majority of patients, a more reliable approach involves 2-stage expander/implant reconstruction.2 Tissue expansion is used when there is insufficient tissue after mastectomy to create the desired size and shape of a breast in a single stage. A tissue expander is placed in a submuscular pocket at the primary procedure. In the early postoperative period, the tissue expander is serially inflated with saline as a weekly office-based procedure. Once the expansions are completed (6-8 weeks), the tissues are allowed to relax and adjust to the new position for another 1 to 2 months (or until after adjuvant chemotherapy is completed). Exchange of the temporary expander for a permanent implant occurs at a subsequent operation. At the time of the secondary procedure, access to the implant pocket allows for release of capsular contracture, adjustment of the inframammary fold, and selection of the optimum-shaped and optimum-sized implant, which, in turn, maximizes the aesthetic result. Thus the 2-stage technique of tissue expander/implant reconstruction has become the most common approach to implant-based reconstruction.1,3,4
Combined Tissue/Autogenous Tissue Reconstruction