What is the role of breast reconstruction in the surgical treatment of breast cancer?

Updated: Feb 13, 2019
  • Author: Mary Jo Wright, MD; Chief Editor: James Neal Long, MD, FACS  more...
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Answer

Answer

Breast reconstruction after mastectomy may be performed in the immediate or the delayed setting. Most patients undergoing mastectomy for prophylaxis or early stage breast cancer are candidates for reconstruction. [15]

Immediate reconstruction, when feasible, generally provides superior cosmetic results, because a skin-sparing total mastectomy (SSM) or nipple-sparing total mastectomy (NSM) may be offered to selected patients, resulting in preservation of the native skin envelope and inframammary crease. [16] However, when postmastectomy radiation is likely or a reconstructive surgeon is unavailable, delayed reconstruction following all adjuvant therapies may be recommended.

Reconstruction may be performed using implant-based methods, autologous tissue-based (termed flaps) methods, or a combination of the two. Implant-based approaches include tissue expanders and saline or silicone implants. Tissue-based approaches include the transverse rectus abdominis myocutaneous (TRAM) flap, latissimus dorsi flap, and the deep inferior epigastric perforator (DIEP) flap.

Although federal law protects the rights of patients to have reconstruction by mandating that insurance companies support the procedure, most patients undergoing mastectomy do not undergo breast reconstruction. Reasons for this include provider biases, patient preferences, and lack of available specialty services.

Patients and physicians should have realistic expectations for breast reconstruction. Although excellent results may be achieved, often multiple operations are required for revisions, symmetry procedures, and nipple reconstruction. Complications related to reconstruction include an infected prosthetic implant, implant rupture, capsular contracture, flap necrosis, flap loss, fat necrosis, asymmetry, and scarring.

Using multivariate analysis, a study by Ito et al of patients who underwent either SSM, NSM, or total mastectomy, followed by immediate breast reconstruction, determined that NSM and weight of breast resection (WBR) are significant risk factors for skin flap necrosis, while WBR is associated with nipple-areolar complex necrosis. [17]


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