Implant-Based Breast Reconstruction

Implant-based reconstruction is the most common method for rebuilding the breast after a mastectomy. It is typically a shorter surgical procedure than autologous (flap) reconstruction and often involves two main stages to achieve the final result.

The Two-Stage Reconstruction Process

The majority of implant reconstructions are performed in two stages, allowing the chest tissue to adapt and heal gradually.

Stage 1: Tissue Expander Placement

Immediately following the mastectomy, a tissue expander—a temporary, balloon-like device—is placed under the chest muscle (Pectoralis Major) or beneath the skin and a special synthetic mesh (acellular dermal matrix, or ADM).

Placement: The expander is positioned to create the space needed for the final implant.
Expansion: Over the next few weeks or months, the expander is slowly filled with sterile saline solution through a small, self-sealing port (accessed with a thin needle in the clinic). This process gradually stretches the overlying skin and muscle to the desired size and shape.
Duration: The expansion phase continues until the skin envelope has been stretched sufficiently to accommodate the size of the planned final implant.

Stage 2: Permanent Implant Exchange

Once the expansion is complete and the tissue has settled, the patient undergoes a second, smaller surgery.

Removal: The tissue expander is removed.
Insertion: A permanent silicone or saline breast implant is placed into the newly created pocket.
Refinement: This stage also allows Dr. Khout to perform final adjustments to symmetry, including possible fat grafting (lipofilling) to smooth contours or correct minor defects.

Direct-to-Implant (One-Stage) Reconstruction

In select patients, the final permanent implant can be placed immediately during the mastectomy (known as Direct-to-Implant or DTI).

Eligibility: DTI is typically suitable for patients with smaller or pendulous breasts, excellent skin quality, and no requirement for post-operative radiation therapy, as radiation can severely impact implant success.
Advantage: Eliminates the need for the second surgery and the weekly expansion visits.

Comparison: Two-Stage vs. Direct-to-Implant

Feature	Two-Stage (Expander to Implant)	Direct-to-Implant (DTI)
Duration	Requires two surgeries and several months of expansion.	One surgery. Faster overall time to final result.
Flexibility	Allows for fine-tuning of size and shape during expansion.	Less flexibility; size and placement determined at the time of mastectomy.
Radiation	Generally safer for patients requiring post-operative radiation.	Usually contraindicated if post-operative radiation is needed.
Contour	Often uses ADM/mesh to support the expander, potentially improving lower pole contour.	Requires excellent native tissue coverage for a good result.

Important Long-Term Considerations

Implants are not considered lifetime devices. They may require future maintenance surgeries due to complications (like capsular contracture or rupture) or simply wear and tear, usually 10-15 years after the initial placement.