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Options and considerations in the timing of breast reconstruction after mastectomy

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ABSTRACT

Timing of breast reconstruction after mastectomy is determined primarily by patient factors and the need for postmastectomy radiation therapy. If the risk of needing postmastectomy radiation is low, then immediate reconstruction produces the optimal aesthetic result. If the risk of needing postmastectomy radiation is high, then delayed reconstruction is preferable to optimize both radiation delivery and aesthetic outcome. For patients with an increased risk of needing postmastectomy radiation, "delayed-immediate" reconstruction, which involves placing a tissue expander at the time of mastectomy and awaiting pathology results to determine the need for radiation and guide reconstruction scheduling, is a viable approach. Thorough and informed physician counseling about the pros and cons of these options is critical for all women undergoing mastectomy.


 

References

Timing of breast reconstruction after mastectomy involves many factors that are important in choosing between three options—immediate, delayed, or “delayed-immediate” reconstruction.

Immediate reconstruction is performed at the time of initial breast cancer surgery and allows for joint planning of incisions between the oncologic and plastic surgery teams. This produces the optimal aesthetic result since it allows for preservation of the breast skin envelope and sometimes for nipple preservation, and is oncologically safe for patients treated for cure of their cancers.

Delayed reconstruction involves initially performing a mastectomy and then determining the need for postmastectomy radiation, which cannot be assessed until review of permanent sections on pathology. Reconstruction is then performed after chemotherapy, radiation therapy, or both (if needed) are completed.

Delayed-immediate reconstruction involves placing a tissue expander at the time of skin-sparing mastectomy to preserve the breast skin envelope. After the final pathology is reviewed following mastectomy, immediate reconstruction is performed if the patient does not require postmastectomy radiation therapy. If radiation therapy is required, then the patient undergoes standard delayed reconstruction after the radiation therapy is completed. This allows for skin conservation, thereby improving aesthetic outcome, while still allowing final reconstructive decisions to be made after it is determined whether radiation will be required.

IMMEDIATE RECONSTRUCTION: WHEN INDICATED, THE OPTION WITH THE BEST AESTHETIC RESULTS

Currently, the majority of breast reconstructions are performed as immediate reconstructions at the time of mastectomy. Immediate reconstruction is a routine consideration for patients suspected to have stage 0, I, or IIA breast cancers (see table in the article on staging and surgical treatment by Hammer et al). These patients with early-stage cancer represent more than 70% of women who undergo mastectomy. Less-extensive resection of the breast skin by oncologic surgeons and the development of reconstructive options by plastic surgeons have improved quality of life for breast cancer patients.1 Nipple-sparing mastectomy in selected patients is associated with high levels of patient satisfaction, improved aesthetic outcomes, and oncologic safety in the setting of early-stage tumors with no skin involvement.2

Oncologic safety is established

Numerous factors affect patient decision-making regarding reconstruction. The primary reason patients elect not to undergo immediate reconstruction is fear that reconstruction will hamper the ability to detect a cancer recurrence. In addition, patients as well as many physicians may have the unfounded fear that cancer cells can remain viable in the mastectomy bed and therefore that immediate reconstruction is ill-advised.

Multiple studies have shown that immediate reconstruction is oncologically safe after mastectomy, even in patients with locally advanced breast cancer.

In a study of 540 patients who underwent immediate reconstruction following mastectomy, Newman et al identified 50 patients with locally advanced breast cancer; all of these patients received postoperative chemotherapy, and 40% received postoperative radiation therapy as determined by tumor characteristics.3 At median follow-up of 58.5 months, there were no differences in either local or distant recurrence between these 50 patients and 72 matched patients with locally advanced breast cancer who did not undergo immediate reconstruction but received standard chemotherapy and radiation therapy for locally advanced disease.3

Similarly, a study by Langstein et al demonstrated that immediate reconstruction does not delay detection of cancer recurrence in the chest wall, in that the time to diagnosis of recurrence was similar whether patients underwent immediate reconstruction or not.4 No differences in local recurrence rates were noted based on the type of reconstruction performed (autologous flaps or implants). In addition, most cases of chest wall recurrence were associated with distant metastatic disease.4

Importance of physician input, other factors

Physician input is of vital importance to the patient considering mastectomy with immediate reconstruction. Traditionally, many patients have been advised by their health care providers to wait until mastectomy and chemotherapy or radiation therapy are complete before considering reconstruction. After undergoing such physically and emotionally exhausting treatments, however, patients are often spent and have no interest in undergoing another surgical procedure. Proper counseling by physicians—including the explanation that immediate reconstruction is associated with no difference in recurrence or survival outcomes compared with delayed reconstruction or no reconstruction at all—is essential to allay the fear of recurrence or death that often guides patients’ decision-making.

Indeed, a recent questionnaire-based study of factors influencing mastectomy patients’ choices regarding reconstruction found that patients regarded their surgeon’s advice as the most important factor.1 Moreover, women in the study who chose to undergo reconstruction were more likely than women who chose mastectomy alone to identify their surgeon’s advice as the most important influencing factor. These women who chose reconstruction also were more likely than those not choosing reconstruction to have discussed their decision with their partner and to express interest in meeting other women who had undergone mastectomy. The study’s quality-of-life assessment demonstrated that women who chose reconstruction were in better physical health, placed more importance on body image and sexuality, and were less afraid of surgery compared with those not choosing reconstruction.1

The type of cancerous lesion also contributes to patient decision-making regarding immediate reconstruction. Patients with ductal carcinoma in situ are twice as likely to choose immediate reconstruction as those with invasive cancer.5 Age plays an important role as well. Younger patients are more likely to elect to undergo reconstruction, with patients younger than age 50 having a 4.3-fold greater likelihood of choosing reconstruction than their older counterparts.5

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