WHEN IS THE BEST TIME TO RECONSTRUCT THE BREAST?

Reconstruction can be done in the same procedure, immediately following breast removal. For some patients, immediate reconstruction is not recommended or available. Therefore a delayed reconstruction is performed in a second procedure, anytime later on.

There is also a third option called delayed-immediate reconstruction which balances the benefits and constraints of both immediate and delayed reconstruction. It provides an improved aesthetic and psychological outcome, compared with delayed reconstruction but does not impede radiation delivery, if indicated postoperatively.

DELAYed-immediate breast reconstruction

At the time of mastectomy, a tissue expander is inserted under skin and chest muscle to maintain the overlying skin envelope. After a couple of months, it is replaced by either a flap or an implant.

If staging and pathology assessment of cancer within the removed breast tissue indicate no need for additional radiation therapy, patients proceed to the second stage. During the second stage, they undergo definitive breast reconstruction, either with a flap or silicone implant. In cases where additional radiation therapy is needed, the tissue expander preserves the skin envelope during treatment. Patients are monitored during radiation, in cases where the overlying skin becomes too thin, the tissue expander can be temporarily deflated. Partial deflation reduces the stress exerted on the overlying skin. After radiation therapy is concluded and tissues healed, a second stage, during which expander is replaced, most commonly with a flap, is performed.

Advantages:

• This provides the best option to apply the optimal radiation dosage, while minimising the consequential tissue injury caused by radiation, resulting  in the optimal aesthetic outcome
•  It reduces possible unpleasant cosmetic outcomes (contracture, distortions)
• It enables the possibility of a revision of the inframammary fold position and possible removal of skin injured during radiation

Disadvantages:

• Additional surgical procedure and recovery process due to a two-staged procedure
• Risk of tissue expander infection
• Possibly increased risk of social or emotional difficulties during tissue expander phase
• Prolonged time to the final result
  
  

IMMEDIATE (PRIMARY) Breast reconstruction

The main shape of the breast or the breast mound is reconstructed in the same operation as the mastectomy. It is done either with a flap, implant or combination of both. One of the options in this category is also a single-stage reconstruction. This is the only technique that alleviates the need for additional procedures, as nipple-sparing mastectomy (nipple and areola are preserved) following immediate reconstruction with an implant is performed.

Advantages:

• Single procedure and recovery process
• Possibly a better aesthetic result
• Body image is maintained all throughout, as the patient wakes up with the newly reconstructed breast

Disadvantages:

• Inferior aesthetic results in cases of additional radiation therapy (due to fat necrosis and fibrosis)T
• The operation and recovery takes longer than ablative surgery alone
• There is little or no time for the patient to adapt to the loss of her breast(s).  This may lead to unrealistic expectations about the aesthetic result that can be achieved with immediate reconstruction.
• It can be stressful for the patient, making multiple, often difficult decisions, on whether to proceed with breast reconstruction, in addition to all the mixed emotions of a recent cancer diagnosis. Some people need or prefer more time to process the information they have received.
• Possible delay in additional cancer treatment due to recovery phase after reconstruction
  
  

DELAYED (SECONDAry) reconstruction

Delayed reconstruction is done in cases where the patient has had no breast reconstruction after previously failed breast reconstruction or is dissatisfied with her current breast reconstruction result.

Secondary or delayed reconstruction is done using the same techniques as primary but without the possibility of immediate implant placement. This is not possible due to insufficient soft tissue quantity in the breast area.

Advantages:

• No delay in cancer treatment
• Possible removal of skin and tissues injured due to previous radiation therapy
• It enables the patient a sufficient amount of time to think about the options, wishes, and the preferred reconstruction option
• The recovery process is faster than during immediate reconstruction

Disadvantages:

• The patient spends a period without one or both of her breasts, causing possible social or emotional difficulties
• Additional surgical procedure and recovery process following mastectomy
• Possibly inferior aesthetic result with longer scars, a larger skin island in flap reconstructions
  
  

The decision about the timing of reconstruction is complex, and we approach it in a multidisciplinary fashion. It is essential for the doctors to consider the patient’s wishes, the need for postoperative radiotherapy, the extent of the disease as well as other medical conditions when deciding about the optimal treatment plan.