Immediate versus delayed breast reconstruction

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

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 [1–3]. 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.