The management of breast cancer with immediate or delayed reconstruction

In patients with stage I and stage II disease who are candidates for a mastectomy, either immediate or delayed reconstruction can be accomplished with remarkably good cosmetic results. Age is not a specific contraindication to reconstruction, but, in my experience, the majority of women over 55 years of age are not interested. Mastectomy or modified radical mastectomy should be performed in these patients using a technique that facilitates delayed reconstruction. The patient may or may not elect to have the reconstruction eventually. Immediate or delayed reconstruction is appealing to a significant number of women under 55 years of age. They should see a plastic surgeon in consultation and the advantages and disadvantages of a subpectoral silicone implant vs. a myocutaneous flap (usually a transverse rectus abdominis musculocutaneous flap) should be discussed in detail. The patient's acceptance of the cosmetic result is better if she has an opportunity preoperatively to review photographs of reconstructed breasts and to discuss the results with women who have undergone a similar procedure. The timing of the reconstruction is a matter of clinical judgment; no prospective clinical trials have been performed. Immediate reconstruction is feasible if the skin flaps will accept the slight tension produced by either a subpectoral implant or a transposed muscle flap. A subpectoral silicone implant produces a satisfactory cosmetic result in the majority of patients, particularly if both breasts are supported by a properly fitting brassiere. In long-term follow-up, infection, contracture, and displacement requiring removal and reinsertion occur in approximately 15% of patients. Reconstruction by a myocutaneous flap is a technically more difficult operation. The operating time is prolonged significantly and blood loss is increased. In my opinion, a myocutaneous flap probably is not worth the risk of a heterologous transfusion. The long-term cosmetic results, however, are considerably better in comparison to a subpectoral silicone implant. The reconstructed breast is much more mobile, making it a more realistic replacement of the original breast. In most cases, it is better to perform this type of reconstruction with a myocutaneous flap as a delayed procedure. In experienced hands, however, immediate reconstruction, with the transverse rectus abdominis musculocutaneous flap harvested while the modified radical mastectomy is being performed, is perfectly feasible. Nipple/areolar reconstruction is available. However, the cosmetic results are only fair to good, and the patient should be aware of this before undergoing the procedure. The problem of symmetry between the breasts requires a good deal of judgment.(ABSTRACT TRUNCATED AT 400 WORDS)