Timing of Breast Reconstruction Following Mastectomy: Immediate Versus Delayed

Maurice Nahabedian, MD, FACS
Director: Center for Reconstructive and Aesthetic Surgery of the Breast
Johns Hopkins Hospital

The timing of breast reconstruction following mastectomy continues to generate discussion. For the majority of the 20th century, delayed reconstruction was the rule. Immediate reconstruction was not advocated because of issues related to breast cancer recurrence and postoperative surveillance. However, over the past 20 years, numerous studies have increased our understanding of tumor biology and breast cancer recurrence that has optimized the management of breast cancer. As a result of these advancements, women diagnosed with early breast cancer (stage I or II) who are candidates for mastectomy, can now choose between immediate and delayed breast reconstruction without the fear of compromising their care.

The advantages of immediate reconstruction include improved aesthetic outcome, fewer operations, reduced costs, and psychosocial benefits. Immediate reconstruction can be performed using autologous tissue or implants. Both methods are capable of providing excellent aesthetic results. Immediate reconstruction following lumpectomy is not usually necessary, however, it is an option following mastectomy. With the increasing popularity of skin sparing mastectomy, many women are choosing to have immediate reconstruction using their own tissue (TRAM flap). The advantages of immediate reconstruction in this setting are that the breast shape and contour are preserved and scars are minimized. Skin sparing mastectomy also can be useful for immediate reconstruction using implants by creating less scar deformity. Oncologic concerns related to skin sparing mastectomy and immediate reconstruction have been alleviated by the fact that local recurrence, distant metastases, disease free survival, and tumor related mortality are not significantly altered when compared to women having conventional mastectomy without reconstruction. Another advantage of immediate reconstruction is that fewer operations are necessary that serves to minimize the anesthesia time and reduce the overall cost of the reconstruction. Perhaps the most important benefits of immediate reconstruction are those related to psychosocial factors. Women choosing immediate breast reconstruction with the TRAM flap are told, "You go to sleep with two breasts and you wake up with two breasts. All that is gone is the cancer." Restoration of body image for many women is an important element towards improving their overall well-being and self esteem.

Despite the benefits of immediate breast reconstruction, delayed reconstruction is occasionally recommended. This is especially true for women with advanced disease (Stage III or IV) who are at high risk for recurrence. In general, once adjuvant therapy has been completed and there has been no evidence of tumor recurrence after 1 to 2 years, delayed reconstruction of the breast can be considered. Delayed reconstruction can be performed using implants or autologous tissue (TRAM flap, DIEP flap, latissimus dorsi flap, and SGAP flap). Implants are generally not recommended following radiation therapy because of the soft tissue fibrosis that impairs adequate expansion. Autologous tissue reconstruction is recommended in this situation to replace the fibrosed tissue with soft and health tissue. For women who did not initially desire breast reconstruction following their mastectomy, delayed reconstruction can be performed at any time and at any age as long as good health is maintained.

In conclusion, breast reconstruction can be performed immediately or on a delayed basis following mastectomy. Results are excellent using either implants or autologous tissue. Immediate reconstruction does not mask tumor recurrence or impede surveillanc

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