How does one decide between immediate and delayed breast reconstruction?

Stuart A. Linder, MD
Plastic Surgery
The decision between immediate and delayed breast reconstruction depends on multiple factors. First, and foremost, is the vascularity of the remaining tissue of the breast mound after the mastectomy. Patients that undergo radiation therapy after the mastectomy should undergo delayed autologous reconstruction. In general, prosthetic devices in an irradiated tissue bed do poorly. The blood supply is often reduced and there is an increased propensity for capsular contracture or scar tissue formation. Immediate breast reconstruction with tissue expanders, permanent implants, or autologous flap reconstruction may be safer options for those with DCIS, or patients not requiring radiation and chemotherapy. The psychological impact of waking up without a breast may also make immediate reconstruction an excellent decision.
Part of the decision depends upon the goals/desires of the patient and part depends upon the treatment needs for the cancer. In my experience, reconstruction that is initiated at the time of mastectomy has potential to preserve as much of the natural breast skin as possible. Doing so may result in a more realistic, satisfying reconstruction. However there are some women who feel overwhelmed with the decisions regarding their cancer treatment and do not wish to initiate reconstruction at the time of mastectomy. This is a very individual decision. Many of those women will return later and say, "OK, I'm a survivor. I can't stand this defect and I would love to do something about it." Such a reconstruction is possible. 

There may be some women who wish to have reconstruction with their own tissues, such as a DIEP flap, however they have been recommended for radiation of the chest wall after the mastectomy. While having the reconstructed breast mound will not usually interfere with radiation treatments, the risk of a hard, fibrotic, displaced flap from radiation is not worth it in my opinion. In such situations, I favor delaying the definitive reconstruction until after such treatments are accomplished. However, a temporary measure, such as a tissue expander, may be performed at the time of mastectomy as a "place holder" until radiation is complete. The expander is then replaced by the definitive flap reconstruction.

Again, the decision will be based upon a combination of the personality/goals/desires of the patient and the treatment algorithm of her physician/surgeon.
Tara Whitworth
Immediate breast reconstruction is when breast reconstruction is done at the same time as the mastectomy. Delayed reconstruction is done some time after mastectomy. Whether you choose immediate or delayed breast reconstruction depends on your preferences as well as if you need any additional treatment. Your physician can help you decide which option is best for you.

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