Delayed-Immediate Breast Reconstruction

Abstract

In patients with early-stage breast cancer who are scheduled to undergo mastectomy and desire breast reconstruction, the optimal timing of reconstruction depends on whether postmastectomy radiation therapy will be needed. Immediate reconstruction offers the best aesthetic outcomes if postmastectomy radiation therapy is not needed, but if postmastectomy radiation therapy is required, delayed reconstruction is preferable to avoid potential aesthetic and radiation-delivery problems. Unfortunately, the need for postmastectomy radiation therapy cannot be reliably determined until review of the permanent tissue sections. The authors recently implemented a two-stage approach, delayed-immediate breast reconstruction, to optimize reconstruction in patients at risk for requiring postmastectomy radiation therapy when the need for postmastectomy radiation therapy is not known at the time of mastectomy. Stage 1 consists of skin-sparing mastectomy with insertion of a completely filled textured saline tissue expander. After review of permanent sections, patients who did not require post-mastectomy radiation therapy underwent immediate reconstruction (stage 2) and patients who required postmastectomy radiation therapy completed postmastectomy radiation therapy and then underwent standard delayed reconstruction. In this study, the feasibility and outcomes of this approach were reviewed. Fourteen patients were treated with delayed-immediate reconstruction between May of 2002 and June of 2003. Twelve patients had unilateral reconstruction and two patients had bilateral reconstruction, for a total of 16 treated breasts. All patients completed stage 1. Tissue expanders were inserted subpectorally in 15 breasts and subcutaneously in one breast. The mean intraoperative expander fill volume was 475 cc (range, 250 to 750 cc). Three patients required postmastectomy radiation therapy and underwent delayed reconstruction. Eleven patients did not require postmastectomy radiation therapy. Nine patients had 11 breast reconstructions (stage 2), six with free transverse rectus abdominis musculocutaneous (TRAM) flaps, one with a superior gluteal artery perforator flap, and four with a latissimus dorsi flap plus an implant. The median interval between stages was 13 days (range, 11 to 22 days). Two patients who did not require postmastectomy radiation therapy have not yet had stage 2 reconstruction, one because she wished to delay reconstruction and the other because she required additional tissue expansion before permanent implant placement. Six complications occurred. The stage 1 complications involved two cases of mastectomy skin necrosis in patients who required post-mastectomy radiation therapy; one patient required removal of the subcutaneously placed expander before postmastectomy radiation therapy and the other patient had a subpectorally placed expander that only required local wound care. The stage 2 complications were a recipient-site seroma in a patient with a latissimus dorsi flap, a recipient-site hematoma in the patient with the supe...

Radiotherapy and breast reconstruction: a meta-analysis

“…Autologous reconstructions have a more predictable response than implants to radiotherapy however the exact sequencing of this therapy is contentious. Kronowitz et al, suggested the concept of the delayed-immediate breast reconstruction as a potential solution [34]. This involves placing a tissue expander at the time of a skin-sparing mastectomy and waiting for the final pathological results of the specimen.…”

Advances and surgical decision‐making for breast reconstruction

“…However, because lymph node metastases may not be detected until mastectomy 5 and because micrometastases may not be detected until the final pathology review, [6][7][8][9] it is often not known until several days after mastectomy whether PMRT will be required. If breast reconstruction is performed at the time of mastectomy and it is determined postoperatively that the patient has lymph node involvement, then PMRT may affect the aesthetic outcome adversely, 1,[10][11][12] and the reconstructed breast may cause technical difficulties with radiation delivery to the internal mammary lymph nodes, resulting in either increased lung dose or inadequate radiation doses to these lymph nodes. 13,14 Conversely, if breast reconstruction is delayed because physicians suspect that the patient may require PMRT, but the review of permanent sections reveals that PMRT is not needed, then the mastectomy skin and the shape of the breast skin envelope will be lost along with the chance of the best possible aesthetic outcome.…”

“…Patients who are deemed to be at increased risk for conditions that necessitate PMRT and who want breast reconstruction are considered candidates for delayed-immediate breast reconstruction 11 ( Fig. 2).…”

“…10,11 It is essential that these patients have a careful preoperative evaluation for risk factors for occult axillary lymph node involvement (age < 50 years, lymphovascular invasion in the initial biopsy specimen, and T2 tumor). 1 In patients who have any of these risk factors, it may be preferable to avoid the use of breast implants, to perform delayed reconstruction, or to use a delayed-immediate approach.…”

“…11 Delayed reconstruction after radiotherapy usually requires resection of the retained inferior breast skin (between the mastectomy scar and the inframammary fold) to reconstruct a natural, ptoticappearing breast. Therefore, delayed reconstruction with a TRAM flap after PMRT often requires the use of 75% of the lower abdominal ellipse of the TRAM flap, including tissue across the midline of the lower abdominal wall.…”