Focus on technique: one-stage implant-based breast reconstruction.

Abstract

Direct-to-implant reconstruction with acellular dermal matrix has expanded the surgeon's repertoire and given the patient an opportunity to have a one-stage option after skin- or nipple-sparing mastectomy. The technique produces total implant coverage without the need for expansion, repeated operations, and delayed return of normal body image. In patients with adequate, good-quality mastectomy skin, a subpectoral pocket is created after mastectomy. The inferomedial pectoralis major muscle is elevated for implant placement. The acellular dermal matrix is sutured to the released inferior pole of the pectoralis muscle along its entire lower course and to the lateral mammary fold. The implant is introduced beneath the muscle-matrix layer, and the matrix is sutured to the inframammary fold at its desired position. Two suction drains are placed, one subpectorally and the other subcutaneously, through separate stab incisions, followed by skin closure. Over a 10-year period, the author has performed this technique in 439 patients (790 breasts). Consistently low complication rates and good aesthetic outcomes have been obtained. Major complications, including implant loss (1.6 percent), skin necrosis requiring reoperation (1.3 percent), infection (1.1 percent), hematoma (0.6 percent), seroma (0.5 percent), and capsular contracture (0.5 percent), have remained at an incidence of less than 2 percent. The author's 10-year results using acellular dermal matrix in direct-to-implant breast reconstructions demonstrate the effectiveness of the procedure, as well as its long-term safety and aesthetic benefits. Its success, however, relies on appropriate patient selection and specific intraoperative technique principles.