Pros and Cons of immediate versus delayed post-mastectomy breast reconstruction

A new breast cancer diagnosis is emotionally challenging, and it becomes even more difficult when women must also make decisions about treatment during a stressful time. In the case of a woman who will have a mastectomy, the difficulty can be even more overwhelming due to the variety of options available and the choices she must make about if, when and how to have breast reconstruction.

According to Constance M. Chen a board-certified plastic surgeon and breast reconstruction specialist, “there are two types of breast reconstruction, breast implants and natural tissue breast reconstruction that uses the body’s own tissue, also known as autologous tissue breast reconstruction.” And with each scenario, there are multiple options. One time-sensitive consideration is whether to have the reconstruction performed immediately in the same surgery as the mastectomy, or delayed by months or even years after the mastectomy. Dr. Chen details the considerations of immediate versus delayed post-mastectomy reconstruction.

Immediate Reconstruction

One of the primary advantages of immediate reconstruction is blunting the emotional suffering from losing one or both breasts. “For many women, waking up from a mastectomy and seeing that she still has breasts is very positive”. Immediate reconstruction that conserves the nipple, areola, and skin is the highest standard in breast reconstruction. Nipple-sparing mastectomy preserves the entire skin envelope, which makes it possible to preserve the breast shape. Thus, regardless of the type of reconstruction, whether implants or natural tissue, the resulting breast shape will always be best after nipple-sparing mastectomy. When performed with natural tissue, the reconstructed breast has the added benefit of being soft, warm and alive, and it is also possible to reconnect nerves to restore feeling.

One drawback of immediate reconstruction is that the hospitalization and recovery time may be longer than with a mastectomy alone with breast reconstruction. Moreover, for women with advanced disease who need immediate chemotherapy, immediate reconstruction may delay treatment until after healing is complete.

Delayed Reconstruction

Delaying reconstruction sometimes shortens the recovery time after a mastectomy. If a patient has a high-grade tumor or advanced disease, she may elect to delay reconstruction so that she can start her chemotherapy or radiation therapy sooner. With both implants or with the woman’s own tissue – breast reconstruction can be performed after healing from the mastectomy is complete and after chemotherapy and radiation therapies, if those are required.

The biggest drawback to delaying reconstruction is the need for another surgery at a later date, and the potential for an inferior aesthetic result. This is particularly true if the patient has not undergone nipple-sparing mastectomy, and/or if the patient needed radiation therapy. Without nipple-sparing mastectomy, a significant amount of breast skin may have been removed, which permanently deforms the breast by changing the shape and flattening it. Radiation therapy also alters the remaining breast skin and tissue so that it does not stretch and heal normally. Without nipple-sparing mastectomy, the skin will need to be stretched with a tissue expander if using breast implants. With natural tissue breast reconstruction, skin from the patient’s donor site can make up for the lost skin, but it may appear as a patch. In these cases, there will likely be a need for additional follow-up procedures to improve the overall cosmetic result.

One of the biggest considerations driving the timing of reconstruction is whether the woman will need radiation therapy after her mastectomy. “Radiation therapy always automatically unfavorably affects the aesthetics of any breast reconstruction,” says Dr. Chen. “But if a woman wants autologous tissue reconstruction, she may be advised to postpone placing the natural tissue until her radiation is completed.” In these cases, the patient can undergo a delayed immediate reconstruction, in which a tissue expander is placed at the time of mastectomy to save the breast skin, and then the natural tissue reconstruction is performed after the radiation is completed.

The Takeaway

According to Dr. Chen, “women have the best aesthetic result and the most sustained level of satisfaction with nipple-sparing mastectomy and natural tissue breast reconstruction. Autologous tissue reconstruction produces a soft, natural breast that looks and feels like the breast lost to mastectomy. Most breast surgeons are reluctant to perform nipple-sparing mastectomy without immediate breast reconstruction, because of the deflated appearance of the breast skin. Whether immediate or delayed, however, preservation of the nipple-areola complex and all of the breast skin sets the foundation for the best possible breast reconstruction”.

“There are pros and cons to immediate and delayed reconstruction, and each woman must consider personal and medical reasons for choosing the best course of action for them. Breast reconstruction is an integral piece of managing breast cancer,” says Dr. Chen. “We’ve made amazing developments in our ability to reconstruct a breast that closely resembles the breast lost to mastectomy. Today more than ever we can offer women a wide range of options to fit their medical needs and personal preferences, including the choice of when to have reconstruction. Each breast cancer patient has unique needs and we can help her get the best care that is ideal for her”.

About Dr. Constance M. Chen

Constance M. Chen, MD, is a board-certified plastic surgeon in New York City with special expertise in the use of innovative natural techniques to optimize medical and cosmetic outcomes for women undergoing breast reconstruction. She is Clinical Assistant Professor of Surgery (Plastic Surgery) at Weill Cornell Medical College and Clinical Assistant Professor of Surgery (Plastic Surgery) at Tulane University School of Medicine.

Dr. Chen is frequently invited to lecture nationally and internationally on new advancements in breast reconstruction and the surgical treatment of lymphedema. She is the author of three books, five book chapters, and fifty journal articles. She has also won numerous awards for her work in plastic and reconstructive surgery at the local, regional, and national levels.

Dr. Chen has developed a reputation in the community for the personalized attention that she devotes to her patients. She is committed to aesthetic restoration of the breast and body, and enjoys helping her patients achieve overall well-being. At the end of the day, there is nothing more important to her than the joy she hopes to bring to her patients’ lives. Come into the beautiful world of Dr. Constance M. Chen.

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