With immediate reconstruction, the surgical process is smooth because both procedures can be associated in one operative setting. In addition, because there is no scar tissue, breast reshaping is easier, and the cosmetic results are improved (3,5,6,7,9). Some studies advocate that the ideal treatment should be preventive by performing immediate reconstruction before radiotherapy (3,4,5,6,7,9,18,19). Papp et al. (19) observed that the aesthetic results showed a higher success rate in the immediate group when compared with delayed reconstruction patients. Similarly, Kronowitz et al. (6) observed that immediate repair is preferable to delayed repair because of a decreased incidence of complications (Fig. 11.1).

In terms of oncologic advantages, immediate reconstruction can be beneficial. Some studies have observed that patients with macromastia present more radiation-related complications than patients with normal-volume breasts (16,20,21). In addition, some authors suggested that there is an increased fat content in large breasts, and the fatty tissue results in more fibrosis after radiotherapy than glandular tissue (22) (Fig. 11.2).

Gray et al. (21), in a series of 257 patients, found that there was more retraction and asymmetry in the large-breasted versus the small-breasted group. Thus, breast reduction can increase the eligibility of large-breasted patients for BCS since it can reduce the difficulty of providing radiation therapy (7,9,16,20,21).

Another aspect is the possibility of accomplishing negative resection margin. In fact, the immediate reconstruction allows for wider local tumor excision, potentially reducing the incidence of margin involvement (3,7,23). Kaur et al. (23) compared patients submitted to oncoplastic procedures and to BCS. The oncoplastic approaches permitted larger resections, with a superior mean volume of the specimen and negative margins.

Another positive aspect is the opportunity of examining the opposite breast. Despite the low incidence of occult malignancy observed in aesthetic breast reductions, the risk undoubtedly increases in patients with previous breast cancer (3,7,8,12,24). In our previous study (24), 4.3% of the patients submitted to opposite mammaplasty were diagnosed with breast cancer.

Despite the benefits, the immediate reconstruction presents limitations. The surgical time can be lengthened, and potential complications can unfavorably affect the aesthetic outcome. It can be time consuming, technically demanding, and require specialist training to learn and properly apply these procedures (2,3,7). Despite these limitations, the immediate approach can reduce deformities, favor the oncologic treatment, and optimize the aesthetic outcome in most early-stage cancer patients.

Some patients are so distressed by their cancer diagnosis that they are not capable of significantly participating in reconstructive considerations, and delayed reconstruction defers decisions about it. Another important point is related to postoperative radiation, which may adversely affect the aesthetic outcome of an immediate BCS reconstruction. One might



surmise that the final contour of the breast cannot be predicted at the time of the BCS. It is well accepted that radiation usually involves some degree of fibrosis and shrinkage. Some authors observed that although the aesthetic outcome can be satisfactory, the appearance of the radiated breast is occasionally less pleasing than that of the nonradiated one (3,4,5,6,9,12,15,25). Thus, in delayed reconstruction the plastic surgeon waits until the postoperative changes in the deformed breast stabilize (9) (Fig. 11.3).

Concerning the delayed reconstruction management, Clough et al. (4) proposed a classification based on response to the type of reconstruction. Patients with a type I breast defect have a normal breast with no deformity. However, there is asymmetry between the contralateral breasts. These patients were reconstructed with contralateral breast surgery (see Fig. 11.3). Type II patients have clearly deformed breasts, and the defect is repaired with ipsilateral breast surgery or flap reconstruction. Type III patients have major deformity and were treated with mastectomy and reconstruction (Fig. 11.4).

Another controversy is related to the postoperative recovery. In theory, some complications of the immediate reconstructions can unfavorably defer the adjuvant therapy. With the delayed approach, operative time is shortened and the surgical process is less extensive than in the immediate approach. However, our previous experience (8,10,11,12,13,24) and that of others (5,26) has shown that immediate reconstruction does not compromise the start of radiotherapy and chemotherapy in the overall treatment of breast cancer.

By definition, two-stage procedures can be delayed-immediate, with initial wide local excision and then oncoplastic reconstruction with appropriate technique at that time when the histologic margin assessment has been performed (7,9,27,28). In this approach, it is possible to postpone reconstruction until after the review of the final pathology report and the definitive surgical margins (Fig. 11.5). If partial breast reconstruction is done at the time of BCS and the patient is found postoperatively to have surgical margin involvement, reexploration can be troublesome. Therefore, the advantage of two-stage procedures relate to the possibility of accurate location of the original tumor site in the cases where positive margins are observed in the permanent pathology (27). However, the delayed-immediate approach can present some limitations. There are some technical difficulties in operating on a previously treated breast, for example, recent scar tissue and fibrosis. The procedure can be time consuming and demands additional costs, which may have additional resource implications for community hospitals (27).