When Should You Have Breast Reconstruction?

By Marshalee George, Kimlin Tam Ashing

Breast reconstruction can be done at the same time as the breast cancer surgery (called immediate reconstruction). It can also be done in a two-stage process where tissue expander (a temporary placeholder) is placed at the time of breast cancer surgery. For the final breast reconstruction, a synthetic implant or tissue from another part of your body is used to complete the procedure at a later date. You can also have breast reconstruction after breast cancer surgery, called delayed reconstruction.

Your breast plastic surgeon will consider the following before making a recommendation for your breast reconstruction surgery.

  • Type and stage of your breast cancer
  • Additional treatments that you might need for your breast cancer
  • Your body shape
  • Your feelings
  • Your personal preferences and lifestyle

When you meet with your breast plastic surgeon, she will discuss your reconstructive options, including the risks, benefits, and options available for each procedure. You’ll also discuss the expected cosmetic outcomes from the reconstruction.

Immediate breast reconstruction

An immediate reconstruction is typically recommended when you have no known breast cancer in the breast, and it gives you a new breast straight away. For example, when women have pre-cancerous lesions removed or when women with positive BRCA mutation who have not yet developed cancer have their breast removed (called a prophylactic mastectomy), they may have immediate reconstructive surgery reconstruction. Even though the breast is not identical to the one that was removed, most women find that immediate reconstruction helps them cope better with the loss of a breast.

When you do have breast cancer, you will have delayed reconstruction because it gives time for the final surgery pathology to determine whether you have clear margins (that is, no cancer cells are seen at the outer edge of the tissue that was removed). If you are found to have positive margins, or cancer cells are seen at the outer edge of the tissue, then an additional surgery may be indicated to remove the cancer cells. Having had immediate reconstruction would interfere with the surgery in this case.

Advantages

  • You will have your newly reconstructed breast after waking up from your lumpectomy or mastectomy. Immediate breast reconstruction may also have a psychological benefit, as you won’t have a period of time with “no breasts.”
  • You will have fewer surgeries and fewer anesthetics.
  • Your reconstructed breasts may form better because the plastic surgeon can use the extra skin that’s already there, leading to improved cosmetic outcome.
  • You may have less scarring on the reconstructed breast itself.
  • It involves lower healthcare costs.

Disadvantages

  • You may not have as much time to decide on the type of breast reconstruction that you want.
  • If you’re having radiation therapy after surgery, it may cause injury to the reconstructed breast.
  • Difficulty in detecting mastectomy skin problems.
  • Your doctor may advise you not to have implant reconstruction if you’re having radiation therapy afterwards. However, you may have a temporary implant during radiation with another breast reconstruction surgery after radiation has completed.
  • You will have longer hospitalization and recovery times than if you had mastectomy alone.
  • Complications from breast reconstruction surgery may delay chemotherapy that you need. Chemotherapy stops the body from being able to heal well, so if you have any problems with wound healing after your breast reconstruction, you won’t be able to start chemotherapy until the problems have been resolved. If you were given chemotherapy at this time, it would stop the wound healing and cause a serious infection.

Research has shown that the most benefit received from chemotherapy is when it is given within six weeks of breast cancer surgery. And if your breast reconstruction surgery causes delayed wound healing, then chemotherapy could be delayed beyond those six weeks.

Immediate breast reconstruction requires a lot of coordination between the breast surgeon and plastic surgeon operating room (OR) schedules, because they both will have to be in the OR at the same time, along with other members of the team to ensure the success of the procedure.

Immediate breast reconstruction may be a good option if you have the following:

  • Smaller tumor size (less than 2 cm)
  • Low chance of needing radiation therapy after surgery
  • Diagnosis of a non invasive cancer or pre-cancer (such as ADH or DCIS)
  • Auxiliary lymph nodes under your armpit don’t have cancer
  • Clear margins from surgery
  • You’re healthy to undergo general anesthetic
  • Prophylactic (preventive) mastectomy due to having a genetic mutation (such as BRCA 1 or 2)

Delayed breast reconstruction

Some women prefer to get over the mastectomy and breast cancer treatment first, before they think about reconstruction. Delayed reconstruction is typically done after the mastectomy site has healed. Healing can take six months or even several years after the mastectomy.

Advantages

  • You have more time to look at all types of reconstruction options and discuss them with your plastic surgeon.
  • If you’re having additional cancer treatment after mastectomy (such as radiation), it won’t cause problems at the reconstruction site.
  • You schedule the surgery at your leisure or at the time you elected.

Disadvantages

  • You have a period after the mastectomy during which you have no breast tissue, but you can choose to wear a false breast.
  • You will have a mastectomy scar on the chest wall, which is a larger scar on the reconstructed breast than after immediate reconstruction.
  • Delayed reconstruction requires additional surgery and recovery time.
  • The breast is sometimes difficult to reconstruct after scarring occurs.

Delayed reconstruction may be a good option if you have the following:

  • Larger breast tumor (over 2 cm)
  • Tumor-free from breast cancer (all cancer was successfully removed in your first surgery) and have completed chemotherapy/radiation therapy
  • Healthy to undergo general anesthesia
  • Radiation therapy completed at least six months prior to surgery