When to have breast reconstruction?

One of the first choices you’ll have is whether to undergo immediate or delayed reconstruction. Because each breast cancer is unique, the timing of reconstruction is also unique.

Several factors will affect 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. In fact, deciding on reconstruction timing for women diagnosed with stage I or stage II breast cancer is the most difficult since the surgeon doesn’t know if radiation is going to be necessary until after the cancer and the lymph nodes are analyzed.

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 since reconstruction may require extra healing time that could delay radiation and chemotherapy.

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.

Your Preference

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 decide. Tell your doctor why you’d like to wait and ask if there are any reasons why you shouldn’t.

IMMEDIATE BREAST RECONSTRUCTION

A lot of organization is needed to perform this procedure at the same time as a mastectomy. Consequently, only a limited number of breast centers are able to offer this service.

Immediate reconstruction is suitable in the following cases:

Low chance of needing radiotherapy after surgery

Smaller tumor size (less than 2 cm)

Diagnosis of a non-invasive cancer or pre-cancer

Lymph nodes in your armpit are cancer-free

Likely to obtain clear margins

Preventive mastectomy

If you decide to have immediate reconstruction, your breast surgeon will perform a skin-sparing mastectomy, removing as much breast tissue as possible while leaving an envelope of breast skin intact. Once this is completed and while you’re still under anesthesia, the reconstructive surgeon then refills the breast envelope with a temporary expandable implant, a full-sized implant, or a transferred flap of your own tissue, depending on the reconstructive technique you’ve chosen. Nearly all the work is done during one operation and you wake up with a rebuilt breast. This approach requires coordinating both the breast cancer surgery and plastic surgery teams.

Advantages

You’ll have your new reconstructed breast when you wake up after your mastectomy or breast conserving surgery

Fewer operations and fewer anesthetics

Your finished breast may look better because the surgeon is usually able to use the breast skin already there

Less scarring on the reconstructed breast itself (usually you have a small patch of skin where your nipple was, with a scar around it)

Psychologically, mastectomy patients who have immediate breast reconstruction also experience less post-mastectomy depression, because their positive body image is retained. They also have the opportunity to balance the diagnosis of breast cancer against information about the positive aspects of breast reconstruction. Mastectomy patients who begin immediate reconstruction, however, sometimes have unrealistically high expectations about the results because they cannot see what the post-mastectomy results would be without reconstruction.

Disadvantages

You may not have as much time to decide on the type of reconstruction you want

If you are having radiotherapy after surgery for breast cancer, it may damage the reconstruction

Harder to detect mastectomy skin problems

Longer hospitalization and recovery times than if you had mastectomy alone

More scarring than mastectomy alone

If you have complications of surgery, it may delay any chemotherapy you need

The last point is an important one. Chemotherapy stops the body from being able to heal itself well. So if you have any problems with wound healing after your reconstruction, you won’t be able to start chemotherapy until the problems have cleared up.

DELAYED RECONSTRUCTION

Delayed reconstruction is performed after the mastectomy has healed and can take place months or even years later.

In general, reconstruction should begin after all cancer treatments such as radiation and chemotherapy are completed. Once your cancer treatment is done, you can have reconstruction at anytime with no time limit (although if you have radiation treatment you may have to wait 6 to 12 months until the skin has recovered).

Some women choose to have their reconstruction many years after a mastectomy for personal reasons. For example, some women prefer to put their cancer fully behind them first.

Advantages

Breast reconstruction is always available, even years after your original surgery

Having your surgery in stages means a shorter recovery after each procedure.

There’s no risk of reconstructive surgery causing delays to cancer treatments.

You have time to think over whether reconstruction is right for you.

You can deal with your cancer treatment first, and then think about reconstruction surgery.

Additional cancer therapy after mastectomy (such as radiation) does not cause problems at the reconstruction site

Disadvantages

Mastectomy scar on chest wall

Additional surgery and recovery time

Sometimes difficult to reconstruct after scarring occurs

You’ll be without a breast shape for a period of time

The result may not be as good as with an immediate reconstruction

You’ll need at least one additional operation and anesthetic.

DELAYED-IMMEDIATE RECONSTRUCTION.

This relatively new, two-stage approach involves some reconstructive surgery during mastectomy or lumpectomy, with more reconstructive surgery after any additional treatments. Delayed-immediate reconstruction is recommended when your doctor can’t be sure if you’ll need radiation or chemotherapy until after the cancer and some lymph nodes have been removed and analyzed, which can take up to a week.

In delayed-immediate reconstruction, a tissue expander (a balloon-type device that keeps space available for the reconstructed breast under the skin) is inserted under the chest muscle during the mastectomy after the breast is removed. If you’ll need radiation or chemotherapy, the tissue expander remains in place until after your treatment is completed.

Once your treatment is finished, your reconstruction will continue. The breast reconstruction is usually completed about 4 to 6 months after radiation.