Surgical decision-making in immediate breast reconstruction

Immediate breast reconstruction has been accepted as safe and practical after mastectomy for breast cancer; factors limiting its use are patient comorbidities and potential complications caused by adjuvant therapies (particularly radiotherapy). The aim of this study was to identify factors considered by surgeons when deciding whether to offer immediate breast reconstruction, to determine the surgeon's accuracy when predicting postmastectomy radiotherapy, and to assess the impact of premastectomy investigations on decision-making.

Four oncoplastic breast surgeons completed a survey for every mastectomy performed over an 11-month period. On the survey form they indicated reason for mastectomy, investigations available premastectomy, if they offered immediate reconstruction, and if not offered, why they did not offer it. Data on adjuvant therapies employed was also collected.

A total of 157 women underwent mastectomy during the study period. Seventy-six (48.4%) were offered immediate reconstruction and 36 (22.9%) accepted. The most common reason for not offering immediate reconstruction was the predicted need for postmastectomy radiotherapy (56.8%). Of the 76 patients offered immediate reconstruction, 9 went onto be offered postmastectomy radiotherapy (11.8%). Decision-making was no more accurate in those women who had MRI, axillary staging, or excisional pathology available premastectomy.

The most common reason for not offering immediate breast reconstruction is the need for postmastectomy radiotherapy and surgeons are able to predict this accurately. The addition of invasive and expensive staging investigations premastectomy does not appear to assist this decision-making process. Despite careful patient selection, a high rate of immediate reconstruction may be maintained.