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 of the work is done during one operation, and you wake up with a rebuilt breast (or breasts). This approach requires coordination of both the breast cancer surgery and plastic surgery teams. Immediate reconstruction may not always be possible if you need additional treatments such as chemotherapy or radiation therapy. In some cases, a surgeon will recommend waiting until after these treatments are finished before starting reconstruction. Or, depending on your situation, a surgeon may recommend doing part of the reconstruction immediately and then finishing the reconstruction after chemotherapy and/or radiation therapy are done. You and your surgeon can discuss your particular situation and needs. If you’re having prophylactic mastectomy — mastectomy to reduce a high risk of breast cancer — then reconstruction is always done immediately.
After mastectomy or lumpectomy 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 an implant reconstruction. 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 suggests that a reconstructed breast may interfere with radiation therapy reaching the area affected by cancer, although this can vary on a case-by-case basis. Some 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.
Reconstruction also can be done years later if desired. Some women aren’t ready to have the surgery sooner, or they change their minds about their initial decision to “go flat” or wear a prosthesis.
As a staged approach, involving some reconstructive surgery during mastectomy or lumpectomy and more reconstructive surgery after any additional treatments. This is also called delayed-immediate reconstruction. The newer staged approach has been pioneered at the University of Texas M.D. Anderson Cancer Center. In delayed-immediate reconstruction, a tissue expander or ordinary breast implant is inserted under the chest muscle and preserved breast skin after the breast is removed. Temporarily placing an expander or implant will preserve the shape of the breast and breast skin during the upcoming radiation treatments and allow for the final benefit of a skin-sparing mastectomy technique. A tissue expander is a balloon-type device that stretches the skin to create a “pocket” for the reconstructed breast under the skin. Once radiation is complete and tissues have recovered (4-6 months), the expander/implant that was used to maintain the shape of the breast is removed and replaced with a flap from the proper donor site as decided upon in consultation with your surgeon.
Often, doctors aren't sure if a woman will benefit from radiation and chemotherapy until 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 or implant 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 often good candidates for immediate reconstruction. This is their best option because it combines the mastectomy and reconstruction into one surgical procedure. However, if there’s a good chance that radiation will be needed, the staged approach may be used instead. Your surgeon will help you choose the timing that is right for you.
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, some doctors recommend delaying reconstruction until all other breast cancer treatments are completed. Reconstruction may require extra healing time that could delay radiation and chemotherapy.
In some cases, though, immediate reconstruction may be appropriate. For example, if you have chemotherapy as your first treatment to shrink the breast cancer, this may allow for a downstaging of your tumor. You may then be eligible for skin-sparing mastectomy, which preserves as much of the breast skin as possible. While radiation may still be necessary, your doctor may be comfortable with its potential effects on an immediate flap reconstruction. Or, your doctor may suggest the staged reconstruction with a tissue expander or saline implant to maintain a breast pocket throughout your treatments. You and your doctor can discuss what makes the most sense for you.
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 and expertise available in your area: If you want immediate reconstruction using your own tissue (autologous reconstruction) or an implant, 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 the type of reconstruction you wish to have. Some of the newer approaches to flap reconstruction require expertise in microsurgery, which involves attaching the tiny blood vessels in the tissue flap to the vessels in the chest area, so the flap can get the blood supply it needs in its new “home.” Not all plastic surgeons have this skill set. Often, microsurgery requires two plastic surgeons in addition to the breast surgeon.
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. However, try to remember that mastectomy is not usually emergency surgery, even though it might feel like it. You have time to pause and think. Take some time to clear your head, do your own research, and consider multiple opinions. Try to make a decision that is geared toward the long-term, instead of reacting to present circumstances. If you decide not to have reconstruction right now, ask your doctor about the differences between immediate and delayed reconstruction with regard to near-term recovery and longer-term outcomes.
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. However, you may still be eligible for immediate reconstruction; this decision has to be made on a case-by-case basis. Heavy smoking can affect your ability to heal and your doctor may require that you quit for a period of time before reconstruction surgery so that your body has a better ability to heal.
“Immediate reconstruction at the time of mastectomy is preferable whenever possible. The great majority of patients are candidates for immediate reconstruction and should take time to research their options and seek reconstructive consultation before mastectomy. Even if the recommendation received is to wait until later, a pre-mastectomy consultation with a plastic surgeon can allow collaborative planning between the mastectomy surgeon and the reconstructive team regarding timing and approach to maximize the eventual outcome.”
— Frank J. DellaCroce, M.D., FACS, Center For Restorative Breast Surgery, New Orleans, LA
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