6 Delayed Breast Reconstruction
With regard to the indication of the specific procedures and the difficult task of differential indication, the reader is referred to the subsections “Indications” and “Patient Suitability” in order to avoid redundant text passages. It is only after one has an idea of all of the options available that it is possible to select the procedure best suited to the patient’s needs.
Although breast reconstruction following mastectomy is now taken for granted, it was a controversial idea for a long time. Those who were opposed to reconstructive measures tended to take the view that “the poor women should be left alone” and tried to obstruct the work of the procedure’s supporters by questioning the oncological safety of breast reconstruction.
However—as so often in the history of medicine—it was not possible for positive progress to be prevented. The psychological benefits for the mastectomy patient, in particular, were the key to helping reconstructive procedures gain acceptance. Simply knowing that reconstruction is possible provides hope for many women who have to undergo mastectomy. The chance of full rehabilitation, including restoration of their physical appearance, helps many women accept therapy with a confident attitude. This can be an important factor in successfully dealing with disease and the related psychological problems.
Since 1980, postmastectomy breast reconstruction has become an integral part of the treatment plan for breast cancer. Evidence of the oncological safety of the procedure, as well as developments and advances in various surgical techniques, have made it possible to reconstruct breast shape and size satisfactorily. A number of factors contributed to these dynamic developments—above all, the introduction of submuscular implant placement techniques for silicone implants; the development of expanders and textured implants; the introduction of myocutaneous and musculofascial flaps; and microsurgical techniques for free tissue transfer.
All of these methods are suitable for primary or secondary reconstruction. However, in the authors’ view, autologous tissue transfer is preferable to implant placement in delayed reconstruction, as it is clearly superior in relation to the aesthetic outcome and the lasting natural appearance of the breast.
Timing of Breast Reconstruction
In ideal circumstances, immediate reconstruction is preferable to secondary reconstruction. Immediate reconstruction spares the patient the trauma of breast amputation, and it also has greater potential for achieving good cosmetic results, since the breast skin and inframammary fold are preserved.
However, there are several factors nowadays that argue against immediate reconstruction. Mastectomy is often indicated for larger tumors. With tumor sizes of 3–5 cm or larger, or involvement of more than three axillary lymph nodes, follow-up radiotherapy of the chest wall is indicated. This is an important argument against reconstruction using either implants (given the risk of infection or capsular contracture, for example) or autologous tissue (given the risk of tissue fibrosis and radio-dermatitis, for example). Slow recovery due to abnormal wound healing can also delay adjuvant treatment such as chemotherapy.
If primary breast reconstruction is not possible, a secondary procedure should be performed after 6–12 months, by which time the tissue will have recovered from the surgical trauma. Adjuvant chemotherapy is usually completed by 6 months after the operation and thus does not prevent reconstruction. Patients who have received chemotherapy can be expected to have prolonged bone-marrow depression.
Tissue fibrosis is an important consideration in patients who have undergone follow-up radiotherapy. Fibrosis can preclude the use of simple methods of prosthesis implantation, which may require muscle flaps or other types of flap. The timing of reconstruction depends on the individual patient’s response to radiotherapy, hypoperfusion, and fibrosis, and reconstruction is generally performed after 1 year.