Breast reconstruction can be done at different times, depending on what works best for your situation:
At the same time as mastectomy surgery. This is called immediate reconstruction. As soon as the breast is removed by the breast cancer surgeon, the plastic surgeon reconstructs the breast either with tissue from another location on your body or with an implant (and sometimes both). Nearly all the work is done during one operation and you wake up with a rebuilt breast. This approach requires coordination of both the breast cancer surgery and plastic surgery teams.
After mastectomy surgery, as well as after radiation therapy, chemotherapy, or targeted therapies that are given. This is called delayed reconstruction. Treatments such as radiation therapy and sometimes chemotherapy given after surgery can cause the reconstructed breast to lose volume and change color, texture, and appearance. Radiation therapy in particular is known to cause undesirable changes to a reconstructed breast. Cancers that are larger than 5 centimeters and that have spread to the lymph nodes are more likely to need radiation therapy after surgery. Research also has shown that a reconstructed breast may interfere with radiation therapy reaching the area affected by cancer. Many surgeons advise patients to wait until after radiation and chemotherapy are finished before having reconstruction. This means reconstruction might be done 6 to 12 months after mastectomy or lumpectomy.
As a two-step approach, involving some reconstructive surgery during mastectomy or lumpectomy and more reconstructive surgery after any additional treatments. This is called delayed-immediate reconstruction. This relatively new, two-stage approach has been pioneered at the University of Texas M.D. Anderson Cancer Center. In delayed-immediate reconstruction, a tissue expander is inserted under the chest muscle after the breast is removed. A tissue expander is a balloon-type device that keeps space available for the reconstructed breast under the skin.
In some cases, doctors aren't sure if a woman would benefit from radiation and chemotherapy until after the cancer and some lymph nodes are removed and analyzed. It can take up to a week for this analysis to be done. If radiation is necessary, the tissue expander remains in place until after radiation is completed. The expander has a port (a metal or plastic plug, valve, or coil) that allows the surgeon to add or remove liquid (a salt water solution) over time. Some doctors choose to deflate the expander during radiation therapy to allow the radiation oncologist to precisely target the breast area affected by the cancer. In this case, about 2 weeks after radiation is done, the tissue expander is gradually reinflated to its earlier size. As the expander is reinflated, you might feel some pain or pressure for a few hours after more liquid is added. This usually goes away by the next day. The breast reconstruction is usually completed about 4 to 6 months after radiation.
The timing of breast reconstruction is one of the most discussed topics in reconstruction research. It's important that your entire team of doctors -- breast surgeon, plastic surgeon, radiation oncologist, medical oncologist, and other caregivers -- meet as a group and discuss your unique situation. Ideally, this group should meet before you make your decision about mastectomy or lumpectomy because the type of breast surgery you have can affect the reconstruction outcome. For example, some women may opt to have mastectomy instead of lumpectomy because the plastic surgeon advises that reconstruction after mastectomy offers better cosmetic results. Because each breast cancer is unique, each reconstruction surgery and its timing are unique. Together, you and your team can decide on an approach that is best for you.
A number of factors influence the timing of your reconstruction:
Cancer stage: In general, women diagnosed with stage I or some stage II breast cancers who choose mastectomy based on a biopsy are less likely to need radiation or other treatments after mastectomy and are probably good candidates for immediate reconstruction. Still, after the cancer and lymph nodes are removed and analyzed, radiation may be recommended for some women.
According to Steven Kronowitz, M.D., F.A.C.S. of the M.D. Anderson Cancer Center, deciding on reconstruction timing for women diagnosed with stage I or stage II breast cancer is the most difficult.
"As a surgeon, you don't know if radiation is going to be necessary or not until after the cancer and the lymph nodes are analyzed," he said. "In my practice, all women diagnosed with stage I or stage II cancers are evaluated by a multidisciplinary breast cancer team that includes a radiation oncologist. If it's determined that the patient probably needs radiation therapy, we recommend delayed-immediate reconstruction rather than immediate reconstruction."
Women diagnosed with stage III or stage IV cancers almost always need radiation therapy or other treatments after mastectomy because of the size of the cancer or the number of lymph nodes involved. In this case, most doctors recommend delaying reconstruction until all other breast cancer treatments are completed for several reasons:
- reconstruction may require extra healing time that could delay radiation and chemotherapy
- the risk of the cancer coming back (recurrence) is higher with stage III or stage IV cancers; reconstruction can make it harder to detect recurrence
If you're unsure which breast cancer stage applies to your situation, ask your doctor. You also may want to visit the Stages of Breast Cancer page.
The facilities available in your area: If you want immediate reconstruction using your own tissue (autologous reconstruction), you'll need two surgeons with credentials and operating privileges in the same hospital who can work together: a breast cancer surgeon to do the mastectomy and a plastic surgeon who is experienced in breast reconstruction using microsurgery.
Also, because the delayed-immediate approach is relatively new and somewhat more involved than either immediate or delayed reconstruction timing, this option isn't available everywhere yet. Cancer centers in large cities and cancer centers affiliated with universities are more likely to have surgeons experienced with this approach. If you feel strongly about a certain timing approach, you may need to advocate for yourself and talk to several breast surgeons. Talk to your oncologist about the best timing options for your unique situation and the surgeons available in your area.
Your decision-making style: Getting a breast cancer diagnosis can be a frightening, stressful experience. Making decisions about mastectomy or lumpectomy and other treatments can leave you emotionally drained. The thought of making even more decisions about the type of reconstruction to have and when to have it might be more than you want to do. In most cases, it's perfectly fine to wait until after breast cancer surgery to make your reconstruction choices. Tell your doctor why you'd like to wait and ask if there are any reasons why you shouldn't.
Your overall health: If you have diabetes, circulatory problems, or a bleeding disorder, your doctor may want you to completely recover from mastectomy before you have reconstruction, so you may need more time between mastectomy and reconstruction. Heavy smoking can affect your ability to heal and your doctor may require that you quit smoking 2 or more months before reconstruction surgery so that your body has a better ablity to heal.