Immediate Versus Delayed Breast Reconstruction: Evolving Concepts and Evidence Base

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Key points

  • Immediate breast reconstruction is oncologically safe with good results, but patient selection must be done properly.

  • 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.

  • Neoadjuvant radiochemotherapy in combination with the IDEAL concept is a promising treatment protocol to achieve optimal oncologic and aesthetic results.

Indications for immediate versus delayed breast reconstruction

  • 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.

  • 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.

  • 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

  • Aesthetic outcome and functionality of the reconstructed breast might not be significantly influenced by postoperative radiotherapy.

  • IBR is oncologically safe and the complication rate is not significantly elevated.

  • 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

  • IBR is an oncologically safe procedure with good results, if patient selection is done properly.32, 34, 44, 52, 53

  • 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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References (59)

  • F.J. DellaCroce et al.

    Breast reconstruction

    Surg Clin North Am

    (2013)
  • P. Zhang et al.

    Comparison of immediate breast reconstruction after mastectomy and mastectomy alone for breast cancer: a meta-analysis

    Eur J Surg Oncol

    (2017)
  • L.R. Henry et al.

    The impact of immediate breast reconstruction after mastectomy on time to first adjuvant treatment in women with breast cancer in a community setting

    Am J Surg

    (2017)
  • S.M. Bentzen et al.

    Patient-to-patient variability in the expression of radiation-induced normal tissue injury

    Semin Radiat Oncol

    (1994)
  • J.A. Nelson et al.

    Delayed autologous breast reconstruction: factors which influence patient decision making

    J Plast Reconstr Aesthet Surg

    (2013)
  • M.V. Schaverien et al.

    Is immediate autologous breast reconstruction with postoperative radiotherapy good practice?: a systematic review of the literature

    J Plast Reconstr Aesthet Surg

    (2013)
  • J.J. Disa

    Delayed-immediate breast reconstruction: technical and timing considerations

    Breast Dis

    (2010)
  • P.G. Cordeiro

    Breast reconstruction after surgery for breast cancer

    N Engl J Med

    (2008)
  • M.C. King et al.

    Breast and ovarian cancer risks due to inherited mutations in BRCA1 and BRCA2

    Science

    (2003)
  • S.M. Domchek et al.

    Association of risk-reducing surgery in BRCA1 or BRCA2 mutation carriers with cancer risk and mortality

    JAMA

    (2010)
  • T.R. Rebbeck et al.

    Bilateral prophylactic mastectomy reduces breast cancer risk in BRCA1 and BRCA2 mutation carriers: the PROSE study group

    J Clin Oncol

    (2004)
  • C.R. Albornoz et al.

    Bilateral mastectomy versus breast-conserving surgery for early-stage breast cancer: the role of breast reconstruction

    Plast Reconstr Surg

    (2015)
  • D.J. Lucas et al.

    Doing more: trends in breast cancer surgery, 2005 to 2011

    Am Surg

    (2015)
  • S.N. Razdan et al.

    Quality of life among patients after bilateral prophylactic mastectomy: a systematic review of patient-reported outcomes

    Qual Life Res

    (2015)
  • M.S. Neto et al.

    Sexuality after breast reconstruction post mastectomy

    Aesthetic Plast Surg

    (2013)
  • Y. Cemal et al.

    A paradigm shift in U.S. breast reconstruction: part 2. The influence of changing mastectomy patterns on reconstructive rate and method

    Plast Reconstr Surg

    (2013)
  • C.R. Albornoz et al.

    A paradigm shift in U.S. breast reconstruction: increasing implant rates

    Plast Reconstr Surg

    (2013)
  • A. Roberts et al.

    Contralateral prophylactic mastectomy rate stable at major Canadian breast cancer center

    World J Clin Oncol

    (2016)
  • S.E. Gabriel et al.

    Complications leading to surgery after breast implantation

    N Engl J Med

    (1997)
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