Breast Reconstruction after Mastectomy

Abstract

Summary T iming of breast reconstruction after mastectomy involves many factors that are important in choosing between three options: immediate, delayed, or “delayed-immediate” reconstruction. Immediate reconstruction is performed at the time of initial breast cancer surgery and allows for joint planning of incisions between the oncologic and plastic surgery teams. This produces the optimal aesthetic result since it allows for preservation of the breast skin envelope and sometimes for nipple preservation, and is oncologically safe for patients treated for cure of their cancers. Delayed reconstruction involves initially performing a mastectomy and then determining the need for postmastectomy radiation, which cannot be assessed until review of permanent sections on pathology. Reconstruction is then performed after chemotherapy, radiation therapy, or both (if needed) are completed. Delayed-immediate reconstruction involves placing a tissue expander at the time of skin-sparing mastectomy to preserve the breast skin envelope. Currently, the majority of breast reconstructions are performed as immediate reconstructions at the time ofmastectomy. Immediate reconstruction is a routine consideration for patients suspected to have stage 0, I, or IIA breast cancers. These patients with early-stage cancer represent more than 70% of women who undergo mastectomy. Less-extensive resection of the breast skin by oncologic surgeons and the development of reconstructive options by plastic surgeons have improved quality of life for breast cancer patients. Nipple-sparing mastectomy in selected patients is associated with high levels of patient satisfaction, improved aesthetic outcomes, and oncologic safety in the setting of early-stage tumors with no skin involvement. In a patient who will require radiation, autologous reconstruction (using the patient’s own tissue) is preferable to tissue expander and implant reconstruction. Indications for radiation after mastectomy include tumor invasion of the chest wall, invasive cancers larger than 5 centimeters, and, in some cases, positive lymph nodes. Patients who undergo radiation of an autologous flap often have some shrinkage of the flap volume. Dense scar formation, capsular contraction, and implant extrusion may occur with radiation of implants, leading to a poor cosmetic outcome. Implant reconstructions that fail for these reasons are best corrected by autologous means. Concerning the psychological determinant of breast reconstruction; some studies .have criticized immediate reconstruction, speculating that it does not afford women an opportunity to appreciate the reconstruction, while in other studies about 94% of the immediate reconstruction groups were moderately or very satisfied and this was significantly higher than in the delayed reconstruction group. Immediate breast reconstruction confers a psychological benefit to thepatient. Patients who undergo immediate reconstruction have less psychological distress when recalling the surgery, accept their body appearance more. Furthermore, and women who have immediate breast reconstruction are likely to accept the new breast as an integral part of their body. Immediate breast reconstruction has significant financial advantages over delayed reconstruction, especially in institutions with high case loads. Immediate reconstruction requires less total operating time than a two-stage delayed reconstruction; it also leads to a shorter total hospital stay, so the cost is also reduced, the costs for delayed reconstruction can be as much, as 62% more than those for immediate reconstruction. Standard cost calculations from the hospital's point of view indicated that about 1/3 of direct and indirect hospital costs couldbe saved through mastectomy in combination with immediate reconstruction in comparison with the delayed procedure. The initial cost savings can only increase since fewer revisional and contra-lateral procedures are necessary with immediate reconstruction. This information can only reinforce the growing consensus that immediate breast reconstruction is cost effective in comparison with delayed reconstruction. Selecting a procedure merely on costs would be wrong, immediate reconstruction, however, yields the greatest patients benefit. The economic evaluation should, therefore, encourage the trend towards moxejmrnediate reconstructions. Patients will continue to demand breast reconstruction. It is probable that flap techniques will continue to be refined and perforator techniques take over all these donor sites. On the other hand, expander, implant techniques and devices continue to improve and economic factors continue to weigh OKI us. This allows the surgeon to perform the operation within, acceptable time intervals,. Economic factors cannot be overemphasized in assessing the future for breast reconstruction. 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.