Two-Stage Implant-Based Breast Reconstruction: An Evolution of the Conceptual and Technical Approach over a Two-Decade Period

Background: Over a two-decade period, the senior author (P.G.C.) has had extensive experience with two-stage implant-based breast reconstruction with total musculofascial coverage. During this period, the approach has evolved substantially. The evolution has been based on changes in breast cancer treatment, available technology and, most importantly, yearly evaluation of surgical outcomes. Methods: This article describes changes in the conceptual approach to breast reconstruction, and the resulting evolution of surgical techniques. Evolving concepts and current techniques are described as they relate to each consecutive stage of implant-based breast reconstruction. Results: For the first stage of breast reconstruction (i.e., placement of the tissue expander), key concepts and techniques described are the vertical mastectomy defect, the point of maximal expansion, the musculofascial pocket, and the inferior fasciotomy. For the second stage of breast reconstruction (i.e., the exchange procedure), key concepts and techniques described are implant selection, setting the inframammary fold, defining the inferolateral shape of the breast, and circumferential capsulotomy. Conclusion: The purpose of this article is to relay the lessons learned from this long experience and to provide a conceptual and technical framework to twostage implant-based breast reconstruction.