Volume 9 Supplement 1

VII Madrid Breast Cancer Conference: Changes in the treatment of breast cancer

Open Access

Immediate versus delayed breast reconstruction

  • GL Robb1
Breast Cancer Research20079(Suppl 1):S9

https://doi.org/10.1186/bcr1692

Received: 23 May 2007

Published: 19 June 2007

With numerous advances in the field of plastic surgery, breast reconstruction is available today to almost any woman undergoing surgery for breast cancer. Several methods can be used for restoration of the breast either at the same time as breast cancer surgery (immediate reconstruction) or months or even years later, at the patient's discretion (delayed reconstruction). The skin sparing approach to mastectomy, originated in the early 1990s, has especially facilitated immediate reconstruction of the breast and resulted in a high standard of cosmetic outcomes. In general, the reconstructive options include using autologous soft tissues from the patient's donor areas, such as the abdomen, hips, back, or buttock, or using a prosthetic implant to create a new breast mound. For well over a decade now, skin-sparing mastectomy and immediate reconstruction has offered the compelling advantages of both superior cosmetic appearance of the reconstructed breast as well as favorable psychological and economic benefits [1].

For many years in the past there was the misconception that breast reconstruction must be delayed for several years after mastectomy because reconstruction might prevent or delay detection of local recurrence. Hence, a large population of women has sought and presently still seeks to undergo delayed postmastectomy reconstruction months to years later. The outcomes of these reconstructions are good to excellent but the cosmetic outcome is always somewhat inferior to the results obtainable by immediate reconstruction because of the loss of the breast skin envelope after mastectomy and the need to replace so much of the chest wall skin. In regard to the all-important question of local recurrence, several longer term follow-up studies at the MD Anderson Cancer Center actually indicate a lower incidence of local recurrence after immediate reconstruction.

Current comparative statistics for the numbers of patients undergoing immediate as well as delayed reconstruction from 2002–2006 are presented in Table 1. Since 2002, the MD Anderson Plastic Surgery Department has seen a progressively increasing demand of early breast cancer patients for implant-based reconstructions performed on an immediate basis. The opposite trend of a preference of autologous tissue reconstructions is apparent for delayed reconstructions.
Table 1

Immediate versus delayed breast reconstruction, 2002–2006, MD Anderson Cancer Center

 

Number of immediate reconstructions

Number of delayed reconstructions

  

Year

Implant

Patient's own tissue

Implant

Patient's own tissue

Total number of reconstructions

Number of mastectomies

2002

167

153

43

55

418

418

2003

186

176

53

68

483

482

2004

256

158

45

84

543

541

2005

239

164

48

75

526

523

2006

313

234

39

98

684

683

The controversy today is that we continue to undergo an important evolution in our approach to breast reconstruction because of the identified advantage of the addition of postmastectomy radiation therapy to mastectomy and chemotherapy. The inability to determine which patients will require postmastectomy radiation therapy, especially which patients with early-stage breast cancer, has increased the complexity of planning for immediate breast reconstruction. There are two potential problems with performing an immediate breast reconstruction in a patient who will require postmastectomy radiation therapy. One problem is that postmastectomy radiation therapy can adversely affect the aesthetic outcome of an immediate breast reconstruction [13]. The other potential problem is that an immediate breast reconstruction can interfere with the delivery of postmastectomy radiation therapy. Because radiation therapy is one of the most important considerations affecting the timing and technique of breast reconstruction, plastic surgeons and radiation oncologists must work together to maintain an appropriate balance between minimizing the risk of recurrence and providing the best possible aesthetic outcome. Our experience at the MD Anderson Cancer Center and many of the other experiences reported in the literature indicate that breast reconstruction should probably be delayed in patients who are known preoperatively to require postmastectomy radiation therapy [2, 4].

Considering, then, our evolving approach for early breast cancer patients who want immediate breast reconstruction but are at higher risk for postmastectomy radiation therapy and likely delayed reconstruction, our updated 'delayed-immediate' [5] reconstruction experience between May 2002 and November 2006 includes 42 patients who were considered preoperatively to be at an increased risk of requiring postmastectomy radiation therapy (PMRT) and underwent delayed-immediate breast reconstruction at the MD Anderson Cancer Center. After review of the permanent pathology, 62% (26 of 42 patients) of patients did not require PMRT and, because of the preserved breast envelope, could go ahead with essentially an immediate reconstruction. The remaining 38% (16 of 42 patients) did require PMRT, but selected patients are being managed on a similar IRB reconstruction protocol that will allow a 'skin-preserving' delayed reconstruction following completion of the PMRT. Fifteen of these 16 patients (94%) were evaluated as having uncompromised radiation delivery. Cosmetic results of this approach are very promising and compare favorably with immediate reconstruction in the short-term follow-up to date. Complication rates with delayed-immediate reconstruction are considered quite acceptable and included: stage I (three of 42 patients, 7%), stage II (four of 26 patients, 15%), skin-preserving delayed reconstruction (one of 13 patients, 7%), and expander loss (surgery-related, 2%; PMRT-related, 6%). Only 2% (one of 42 patients) of the patients developed a recurrence of breast cancer after an average follow-up of 24 months.

Breast reconstruction plays an important role in the multidisciplinary, comprehensive care of the breast cancer patient. Advances in techniques have allowed immediate reconstruction to minimize incisional scars on the breast and improve overall breast contour, shape, and appearance. The improved aesthetic outcomes over delayed reconstruction, achieved also by the skin-preserving 'delayed-immediate' approach for early breast cancer patients at risk for radiation therapy and similarly for selected patients actually undergoing PMRT, has convinced many breast cancer patients to view mastectomy with reconstruction as a viable and positive treatment choice. Those patients who are candidates for and who will undergo delayed reconstruction, either because of the planned need for adjuvant radiotherapy or because of poorly controlled comorbidities that must be stabilized before a reconstruction can be undertaken, can still anticipate an excellent cosmetic outcome with a record of high patient satisfaction.

Authors’ Affiliations

(1)
Division of Plastic Surgery, Department of Surgery, The University of Texas MD Anderson Cancer Center

References

  1. Robb GL: Reconstructive surgery. Breast Cancer. MD Anderson Cancer Care Series. Edited by: Hunt KK, Strom EA, Ueno NT. 2001, New York: Springer-Verlag, Inc, 223-253.Google Scholar
  2. Tran NV, Evans GRD, Kroll SS, Baldwin BJ, Miller MJ, Reece GP, Robb GL: Postoperative adjuvant irradiation: effects on transverse rectus abdominis muscle flap breast reconstruction. Plast Reconstr Surg. 2000, 106: 313-317. 10.1097/00006534-200008000-00011.View ArticlePubMedGoogle Scholar
  3. Kronowitz SJ, Robb GL: Breast reconstruction and radiation therapy. dvanced Therapy of Breast Disease. Edited by: Singletary SE, Robb GL, Hortobagyi GN. 2003, London: BC Decker, Inc, 427-438. 2Google Scholar
  4. Kronowitz SJ, Robb GL: Breast reconstruction with postmastectomy radiation therapy: current issues. Plast Reconstr Surg. 2004, 114: 950-960. 10.1097/01.PRS.0000133200.99826.7F.View ArticlePubMedGoogle Scholar
  5. Kronowitz SJ, Hunt KK, Kuerer HM, Babiera G, McNeese MD, Buchholz TA, Strom EA, Robb GL: Delayed-immediate breast reconstruction. Plast Reconstr Surg. 2004, 113: 1617-1628. 10.1097/01.PRS.0000117192.54945.88.View ArticlePubMedGoogle Scholar

Copyright

© BioMed Central Ltd 2007

Advertisement