PURPOSE Breast reconstruction is usually a staged procedure.  Most patients electing to undergo breast reconstruction want an aesthetically pleasing breast with as few procedures as possible.  This expedites their return to normal life and allows the oncologist to proceed with adjuvant therapies.  Recent advances in breast reconstruction, like the use of allograft in conjunction with expanders/implants, have led to faster and more favorable results.  With these advances has come renewed interest in one stage breast reconstruction.  We review our experience and provide a framework for selecting the appropriate procedure in patients who are candidates for single stage breast reconstruction.

METHOD We present our experience with single stage breast reconstruction in 32 patients with an average 2-year follow up.  There were 48 breast reconstructions performed (16 bilateral and 16 unilateral), all by a single attending surgeon in one hospital setting.  Various procedures were used to achieve a single stage breast reconstruction- including reconstruction with allograft and a saline or silicone implant (n=30); reconstruction with a latissimus muscle or musculocutaneous flap, allograft, and a saline or silicone implant (n=14); reconstruction with an intercostal artery perforator flap, allograft, and implant (n=1); and free TRAM flap reconstruction (n=3).  In some patients who had a saline implant used for reconstruction, a saline expander/implant was used.  A nipple reconstruction was performed at the time of surgery, if safe.  Nipple reconstruction was delayed in patients who would later undergo a symmetry procedure on the contralateral breast.

RESULTS Major complications included partial flap necrosis is 6 patients, seroma requiring reoperation in 1 patient, and infection in 1 patient.  All 48 breasts had a satisfactory aesthetic result.

CONCLUSION Single stage breast reconstruction is possible, but both the patient and the procedure must be chosen very carefully.  In our series, complications occurred mostly in smokers and those with a history of chest wall radiation.  Relative contraindications include obesity, smoking, and history of chest wall radiation.  In our practice, autologous tissue reconstruction is preferred in patients with a history of chest wall radiation.  If single stage implant reconstruction is planned, use of a latissimus dorsi muscle or musculocutaneous flap to cover the implant is advisable in thin patients, patients with a paucity of skin, or patients with a history of chest wall radiation; additionally, the skin paddle of the latissimus dorsi musculocutaneous flap has the advantage of being well-vascularized and suitable for immediate nipple reconstruction.  We have also found that the use of an expander/implant is preferable to use of a nonadjustable saline or silicone implant in the case of single stage implant reconstruction; having the ability to adjust the implant volume is important as postoperative skin tension can lead to pressure necrosis.  Lastly, we recommend that nipple reconstruction be delayed if a symmetry procedure is planned.  Complications can be minimized by appropriate patient and procedure selection and meticulous surgical technique.  Nevertheless, the surgeon should always be prepared to convert to a staged procedure.