Timing of sentinel lymph node biopsy and reconstruction for patients undergoing mastectomy

Options for immediate breast reconstruction after mastectomy are directly affected by nodal status. Historically, axillary dissection has been performed simultaneously with mastectomy. The advent of sentinel lymph node biopsy (SLNB) drastically changed the trends in breast cancer surgery. SLNB is often performed at the time of mastectomy and may negate the need for a formal axillary dissection. The algorithm presented here outlines an approach where SLNB is performed as a separate outpatient operation several days prior to mastectomy when immediate reconstruction is planned. While this approach requires a separate procedure, SLNB can be performed with minimal morbidity with monitored anesthesia care and local anesthesia. The significance of this algorithm is that it allows time for complete pathologic evaluation prior to definitive surgery, eliminating the dependency on frozen section diagnosis. This method also decreases the possibility of irradiating a fresh autologous flap if radiation therapy is deemed necessary after further pathology review of the sentinel node specimen. We endorse SLNB as a separate outpatient procedure prior to definitive surgery with reconstruction, particularly latissimus dorsi myocutaneous flap. This method involves a close team approach between the breast and plastic surgeons.