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Immediate breast reconstruction is oncologically safe with good results, but patient selection must be done properly.
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If postmastectomy radiotherapy is indicated or cannot securely be excluded, an immediate-delayed autologous breast reconstruction should be considered, and an implant is temporarily placed in an epipectoral plane.
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Neoadjuvant radiochemotherapy in combination with the IDEAL concept is a promising treatment protocol to achieve optimal oncologic and aesthetic results.
Immediate Versus Delayed Breast Reconstruction: Evolving Concepts and Evidence Base
Section snippets
Key points
Indications for immediate versus delayed breast reconstruction
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Risk of postmastectomy radiotherapy (PMRT)
Patients with uncertain diagnostic results, which may need a postoperative irradiation of the breast, should not receive an immediate autologous breast reconstruction.
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Oncologic safe removal not 100% possible
If during mastectomy it is found that the tumor may not have been safely removed, an immediate delayed reconstruction should be considered.
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Breast with ptosis and skin excess
Women with severe ptotic breasts may have an excess of the skin envelope,
Controversies for immediate versus delayed breast reconstruction
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Aesthetic outcome and functionality of the reconstructed breast might not be significantly influenced by postoperative radiotherapy.
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IBR is oncologically safe and the complication rate is not significantly elevated.
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Skin envelope can be corrected at the same time mastectomy and IBR is performed.
Evidence base for immediate versus delayed breast reconstruction
Radiation after implant-based IBR has certain disadvantages as described above. However, what happens after irradiation of autologous transplanted tissue? A retrospective analysis of 370 reconstructed breasts with lower abdominal flaps revealed that postoperative radiation leads to a significantly higher occurrence and extent of fat necrosis. Flap shrinkage or flap contracture has also been found to be significantly increased, when breasts were irradiated. Overall, these complications resulted
The authors’ personal approach for immediate versus delayed breast reconstruction
The authors’ department specializes in reconstructive breast surgery with more than 2000 free autologous breast reconstructions over the last 12 years. They work in an interdisciplinary breast center with a separate department for breast surgery for oncologic treatment. They maintain close cooperation between the departments, especially in patients with necessity of either a prophylactic or a therapeutic mastectomy.
Recently, the author group developed an Immediate DElayed AutoLogous breast
Discussion
The aim of this article is to elaborate different arguments for the correct timing of breast reconstruction and to present the authors’ personal approach on this topic. The most important aspect to keep in mind with any form and timing of breast reconstruction is oncologic safety.
If a patient has the desire to have a breast reconstruction after mastectomy, a delayed procedure is presumably only chosen for individual reasons of the patient. Because of psychological or social burden within the
Current status of evidence for immediate versus delayed breast reconstruction
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IBR is an oncologically safe procedure with good results, if patient selection is done properly.32, 34, 44, 52, 53
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The influence of PMRT on IBR is controversially discussed in the current literature. A meta-analysis of available studies concluded satisfactory outcomes and a similar incidence of complications for IBR with autologous tissue and PMRT when compared with no radiotherapy or delayed reconstruction following radiotherapy. However, the rate of revision surgery was higher in IBR than in
Future direction to improve clinical practice for immediate versus delayed breast reconstruction
As mentioned above, the evidence of existing studies on this topic can still be improved, but RCTs are difficult to find.
A relatively new approach is to replace the adjuvant radiation therapy before the mastectomy, resulting in a neoadjuvant radiotherapy. It seems that neoadjuvant radiochemotherapy is a safe and reliable method in patients with breast cancer. In patients with local advanced breast cancer (LABC), there is evidence that this treatment protocol has a better outcome concerning
Summary
IBR is oncologically safe with good results, but patient selection must be done properly. If PMRT is indicated or cannot securely be excluded, an immediate-delayed autologous breast reconstruction should be considered, and an implant is temporary placed in an epipectoral plane. Neoadjuvant radiochemotherapy in combination with the IDEAL concept is a promising treatment protocol to achieve optimal oncologic and aesthetic results (Fig. 1).
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The significance of timing in breast reconstruction after mastectomy: An ACS-NSQIP analysis
2024, Journal of Plastic, Reconstructive and Aesthetic SurgeryImpact of ERAS in breast reconstruction with a latissimus dorsi flap, compared to conventional management
2023, Journal of Plastic, Reconstructive and Aesthetic SurgerySalvage of infected implant-based breast reconstructions in morbidly obese patients with explantation and replacement with an autologous muscle-sparing latissimus dorsi flap
2022, JPRAS OpenCitation Excerpt :In the past, these patients had their implants removed and were placed on antibiotics with plans for delayed reconstruction after the acute infection and inflammation resolved. Delayed reconstruction usually requires tissue expansion followed by additional surgery for implant placement while autologous reconstruction often requires skin replacement with significant challenge to obtain symmetry.2 This approach leaves women without a breast for several months, decreasing patient satisfaction with many abandoning reconstruction altogether.3
Staging computerized tomography before delayed breast reconstruction could alter the management plan
2021, Journal of Plastic, Reconstructive and Aesthetic SurgeryCitation Excerpt :Despite the popularity of immediate breast reconstruction (IBR), it is unavailable to every patient for reasons such as oncological factors, comorbidities, time constraints, and patient and doctor's preference1,2,3–6.
Rising age-specific rates of immediate breast reconstruction after mastectomy: Report from an Italian Breast Unit
2023, Journal of Surgical OncologyThe Language of Implant-based Breast Reconstruction: Can We Do Better?
2022, Plastic and Reconstructive Surgery - Global Open
The authors have nothing to disclose.