Options and considerations in the timing of breast reconstruction after mastectomy
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.
DELAYED-IMMEDIATE RECONSTRUCTION
The goal of delayed-immediate reconstruction is to optimize reconstruction in patients who are at risk of needing postmastectomy radiation therapy, since it is not known until after review of permanent sections, several days following mastectomy, whether these patients will require radiation.
The rationale
If immediate reconstruction is performed and the patient is found to have pathologic lymph node involvement, postoperative radiation therapy may compromise aesthetic results. Additionally, the reconstructed breast may pose technical difficulties in terms of delivery of radiation to the internal mammary nodes. At the same time, if breast reconstruction is delayed and final pathology review shows that radiation is not indicated, the mastectomy skin and shape of the breast skin envelope will be lost (and the aesthetic outcome compromised) unless measures are taken to preserve them.7
The protocol at a glance
Those measures to preserve the breast skin envelope consist of placement of a tissue expander at the time of mastectomy, pending final pathology results. If no radiation therapy is needed, the optimal reconstructive procedure can be chosen and performed within the next 1 to 2 weeks. If radiation is necessary, the expander can be deflated in the clinic before initiation of radiation therapy, to optimize radiation delivery to the internal mammary nodes. The expander can then be serially expanded after radiation, and delayed reconstruction with an autologous flap can be performed at a later date. Delayed-immediate reconstruction also offers the opportunity to revise the inframammary crease and debride any nonviable mastectomy skin.
Insurance coverage is federally mandated
Patients should be aware that the Women’s Health and Cancer Rights Act of 1998 (see article by Djohan et al earlier in this supplement) applies to delayed and delayed-immediate reconstruction as well as to immediate reconstruction, requiring that medical insurers that cover mastectomy cover these procedures as well.
CONCLUSIONS
The timing of breast reconstruction is determined primarily by patient factors and the necessity for postmastectomy radiation therapy. If the risk of needing postmastectomy radiation is low, then immediate reconstruction produces the optimal aesthetic outcome. The main advantage of immediate reconstruction is the availability of relatively supple nonscarred tissue that can be recruited for reconstruction. If the risk of needing postmastectomy radiation is high, then delayed reconstruction is preferable to optimize both radiation delivery and aesthetic outcome. Delayed reconstruction is somewhat more challenging, as it involves well-healed scar tissue that is already retracted and adherent to the chest. Nevertheless, reconstruction remains possible at this point and options depend on tissue quality and the plastic surgeon’s expertise. For patients with an increased risk of needing postmastectomy radiation, delayed-immediate reconstruction represents a viable approach that optimizes oncologic as well as aesthetic outcomes regardless of whether the patient ultimately does or does not need radiation therapy.
