When to Have Breast Reconstruction After Mastectomy

Female healthcare worker holding breast implants
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Breast reconstruction is something on top of many women's minds when they know they must undergo a mastectomy. On top of dealing with the stress of a cancer diagnosis, women facing mastectomy struggle with the knowledge that their bodies will never be the same. They may worry about their attractiveness and sexuality after surgery, and look to breast reconstruction as a way to address those concerns.

The idea of breast reconstruction may be very appealing because it may seem like a way to look and feel "normal" again. It's even possible to begin reconstructive surgery while still under the anesthesia given for the mastectomy. But what if you need to undergo ​radiation and chemotherapy after your breast reconstruction? Will those treatments damage the results you hope to achieve?

Until just a few years ago, most experts warned against breast reconstruction before radiation. But recent studies, including one by Fox Chase Cancer Center in Philadelphia and another by University Hospital of Cleveland, conclude that there is no reason to put it off. Nonetheless, medical authorities still disagree as to whether patients should wait or proceed.

Any patient considering breast reconstruction should consult a breast reconstruction specialist (as well as her oncologist) as soon after the cancer diagnosis as possible to determine her course of action.

The Case for Going Ahead With Breast Reconstruction

There are many benefits to immediate breast reconstruction. Most breast reconstruction requires more than one surgery, and starting it while still under the mastectomy anesthesia means that the process is well underway before a patient even wakes up. A skin-sparing mastectomy, which leaves the breast "sac," is only advised if reconstruction will be imminent.

As a general rule, women with early-stage breast cancer (smaller tumors that have not spread to the lymph nodes or whose progression is confined to underarm nodes on the same side as the affected breast) can proceed with reconstruction. Unless it is obvious that a patient will need radiation after her mastectomy because of a very large cancer in the breast or obvious cancer in the armpit, Dr. Christy Russell, a breast oncologist at the University of Southern California, prefers that the reconstruction is done during the mastectomy.

However, it can be difficult to determine whether radiation will be needed for some patients before their mastectomies. According to Dr. Russell, many leading breast surgeons would prefer to have the patient undergo an immediate reconstruction, rather than delay it to avoid a second large surgery and more anesthesia.

Possible complications can be medical, cosmetic or both. They can include the formation of excess chest wall tissue, tissue tightening, infection or necrosis (death) of some fat tissue, which can cause lumps. If extensive, complications may require further surgery to undo or correct reconstruction.

Newer studies have concluded that when radiation follows breast reconstruction, there are no increases in minor or major complications. One study found that 75% of patients who had breast reconstruction before radiation described the cosmetic outcome as good to excellent, which is the same as or better than the satisfaction of patients who did not have radiation.

Reconstructive surgery during mastectomy is much more common in multidisciplinary medical centers which have oncologists and plastic surgeons working together in the same facility.

The Case for Waiting for Breast Reconstruction

The American Cancer Society notes that many doctors recommend delaying reconstruction for those who know they will have radiation, which is about half of all patients. In the long run, radiation can permanently affect the skin's pigment, texture, and elasticity, which could affect the appearance of reconstructed breasts.

Women who know that they have intermediate or advanced breast cancer (those whose tumors are greater than 5 centimeters with affected lymph nodes) are advised to wait six months to a year for surgery until treatments are completed. Those with locally advanced or inflammatory breast cancer are strongly cautioned against going ahead with immediate reconstruction.

When considering radiation and breast reconstruction, it is important to determine which type of surgery is best for you:

Autologous Tissue Breast Reconstruction

Autologous tissue reconstruction is the most common form of surgery, and there are several methods that can be used, all of which involve the use of tissue that comes from a part of the body other than the breast.

One is called the TRAM flap, named after the transverse rectus abdominis muscle (TRAM) that is used in the procedure. This works best in women who have excess fat on their stomachs or skin stretched out from pregnancy.

Newer types of autologous tissue reconstruction include superficial inferior epigastric artery flap (SIEA) and deep inferior epigastric artery perforator flap (DIEP), which also use abdominal skin and fat.​

As post-mastectomy radiation affects the blood supply to the skin and tissues of the chest, cosmetically, it is better to radiate first and then bring in a flap later than to try to radiate a flap from the abdomen or the back.

Artificial or Breast Implants

Artificial or breast implants are usually inserted after a tissue expander gradually increases the size of what's called the "breast mound." Breast implants are usually only recommended for women with small-to-average breasts or those who don't have enough abdominal tissue for a TRAM to be carried out. If considering radiation after the implant, make sure you receive an expander with a plastic port instead of a metal one.

While TRAM poses a higher risk of fat necrosis, it is the better choice for avoiding future corrective surgeries after radiation. It may also be the most desirable option for those who wait for reconstruction until after radiation because tissue taken from the abdomen, back or elsewhere on the body has not been radiated.​

Chemotherapy and Other Breast Reconstruction Considerations

Whether mastectomy patients should delay reconstruction until the end of chemotherapy is another point of debate. One study of women who underwent chemo after reconstruction showed a 25% jump in the number of follow-up surgeries for cosmetic reasons. And there is another issue: If chemo is administered too soon after reconstruction, it can stop the natural healing process, creating a greater risk of infection.

Patients who plan to have implants can have expanders inserted during mastectomy. Afterward, if necessary, they can undergo chemotherapy during the several months it takes for the expanders to stretch the skin (before implants are in place).

There is a flip side to the issue of whether treatments affect the results of reconstructive surgery: Does surgery affect subsequent treatments? Chemotherapy typically begins immediately after mastectomy. If chemo is delayed to avoid interfering with the healing process, its effectiveness may be decreased. Delaying radiation, which is commonly only given after chemotherapy, may more than double the local recurrence rate of breast cancer.

The Bottom Line

Currently, there are as many questions as answers when it comes to the timing of breast reconstruction and post-mastectomy treatments. If and when to have breast reconstruction are life-changing decisions for patients who are already making many other crucial choices. With conflicting information coming from many sources, researching the issues and talking with your doctors is of utmost importance before settling on a solution that's right for you.

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