Overview of breast reconstruction

INTRODUCTION — Breast reconstruction is an option for patients following a unilateral or bilateral mastectomy, or after breast conservation therapy that has had a less-than-ideal cosmetic result. Breast reconstruction provides psychological, social, emotional, and functional improvements, including improved psychological health, self-esteem [1], sexuality, and body image [2,3]. Patients who choose breast reconstruction are presented with complex decisions, including the type and timing of reconstruction.

An overview of breast reconstruction following mastectomy for breast cancer is reviewed. Techniques for breast reconstruction using autologous tissue and prosthetic implants, and complications of breast reconstruction, are reviewed in detail separately. (See "Implant-based breast reconstruction and augmentation" and "Options for autologous flap-based breast reconstruction" and "Complications of reconstructive and aesthetic breast surgery".)

UNDERUTILIZATION OF BREAST RECONSTRUCTION — Outcomes research on quality-of-life improvements and psychosocial benefits associated with breast reconstruction served as the driving force for the 1998 Women's Health and Cancer Rights Act, which mandated health care payer coverage for breast and nipple reconstruction, contralateral procedures to achieve symmetry, and treatment for the sequelae of mastectomy [4]. This was followed in 2001 by additional legislation imposing penalties on noncompliant insurers. Despite such legislation in the United States, breast reconstruction still remains an underutilized option. The underlying reasons seem to be multifactorial and related to socioeconomic factors, including access to care, insurance coverage, education, and race/ethnicity, as well as geographic location, age, and personal choice [5-9].

Although the overall rate of breast reconstruction is increasing in the United States, the number of women who undergo reconstruction after mastectomy remains low [10]. Based upon a claims and encounters database of 20,560 patients (1998 to 2007), approximately 56 percent of patients who had a mastectomy in the United States underwent breast reconstruction [11]. A survey of attending general surgeons from a population-based sample of 1844 women diagnosed with breast cancer in 2002 showed that only 24 percent of surgeons referred more than 75 percent of their mastectomy patients to plastic surgeons prior to surgery [12]. In a review of the Surveillance, Epidemiology, and End Results (SEER) database, factors that were significantly associated for choosing no reconstruction included lower educational level, increased age, major comorbidity, and chemotherapy [5]. Patient-reported reasons for not having reconstruction included the desire to avoid additional surgery (48.5 percent), the belief that breast reconstruction was not important (33.8 percent), and fear of implants (36.3 percent). [6]In a survey of 84 women treated with mastectomy, participants were able to correctly respond to only 38 percent of questions about reconstruction options [13].

With the advent of genetic testing, many women are choosing to undergo prophylactic mastectomy, either of the contralateral breast or bilaterally. Some surgeons feel that aesthetic outcomes are typically improved following bilateral mastectomy and reconstruction because of the ability to achieve better symmetry. A symmetry procedure can be performed on the reconstructed breast or on the natural breast [14]. On the contralateral breast, symmetry is usually achieved by performing a reduction mammaplasty or mastopexy; however, in some cases an implant is needed. On the reconstructed breast, symmetry procedures may include soft tissue contouring, autologous fat grafting, implant repositioning, and in the case of autologous reconstruction, placement of a small implant. Plastic surgeons are able to optimize aesthetic outcomes because of our wide range of reconstructive options that include improved prosthetic devices and the use of patients' own body tissues with minimal morbidity. (See 'Adjunctive procedures' below.)

The issue of contralateral prophylactic mastectomy (CPM) for patients who do not have a genetic mutation increasing risk is controversial. Although occult malignancy can be found in some cases, it is rare [15]. In addition, the majority of patients seeking CPM are younger patients who choose to have immediate reconstruction. Interestingly, complications occur with greater frequency in the breast with cancer when compared with the breast without cancer (20.6 versus 4.4 percent respectively) [16].

OPTIONS FOR BREAST RECONSTRUCTION — Breast reconstruction following total mastectomy can be performed using a breast expander/implant, or using autologous tissues, or a combination of expander/implant and autologous reconstruction (eg, latissimus dorsi musculocutaneous flap with an implant). When using a combination of autologous flaps and implants, a simultaneous approach compared with a staged approach is associated with an increased rate of complications (32 versus 18 percent) [17]. Breast reconstruction following partial mastectomy is typically performed using oncoplastic techniques that include reduction mammaplasty, mastopexy, adjacent tissue rearrangement, autologous tissue from adjacent or remote sites of the body, as well as prosthetic devices [18].

Implant-based reconstruction — Implant-based (ie, prosthetic) reconstruction can be performed in one or two stages. With one-stage reconstruction, a permanent implant is inserted at the time of mastectomy. With two-stage reconstruction, a tissue expander is placed following the mastectomy and gradually filled to the desired volume. A permanent implant is used to replace the tissue expander at a later date. Prosthetic devices can be placed under (subpectoral) or above (prepectoral) the pectoralis major muscle. Studies have demonstrated several advantages to prepectoral placement of implants and tissue expanders; however, proper patient selection is important for prepectoral prosthetic breast reconstruction [19-23]. (See "Implant-based breast reconstruction and augmentation".)

Flap-based reconstruction — Flap-based (ie, autologous) breast reconstruction can take two forms. One type uses remote tissues from different parts of the body such as the abdomen (figure 1 and figure 2 and figure 3), posterior chest (figure 4), medial thighs (figure 5), buttock (figure 6), posterior thigh, or lumbar region. Flaps can be moved to the breast as a free tissue transfer where the artery and vein supplying the flap is attached to an artery and vein (microsurgery) at the mastectomy site (free flap) or on a vascular pedicle (pedicle flap) where attaching the blood vessels is not necessary. (See "Options for autologous flap-based breast reconstruction".)

The most common flaps for breast reconstruction are the deep inferior epigastric artery perforator (DIEP) flap and the free transverse rectus abdominis musculocutaneous (TRAM) flap. These are based from the abdominal area. Other flaps include the gluteal musculocutaneous and perforator flaps (SGAP and IGAP) as well as the thigh-based flaps such as the transverse gracilis (TUG) and profunda artery perforator (PAP) flaps. Another novel flap is the lumbar artery perforator (LAP) flap. The latissimus dorsi flap uses skin, fat, and muscle from the back, whereas the thoracodorsal artery perforator flap (TDAP) uses skin and fat only. These flaps can be performed immediately following the mastectomy or on a delayed basis. Some of these smaller-volume flaps such as the latissimus dorsi flap are often combined with an implant, when needed, to achieve optimal volume and contour symmetry. The latissimus dorsi flaps are also commonly used for salvage procedures following failed implant reconstruction.

Oncoplastic reconstruction — Another type of autologous reconstruction uses breast tissue adjacent a partial mastectomy defect to fill the tumor resection related breast defect. This is also known as oncoplastic surgery. Oncoplastic surgery is used to prevent or minimize the occurrence of a contour abnormality or significant asymmetry [24,25]. Oncoplastic resection increases the margin of excision, decreases reexcision rates, and decreases the need for completion mastectomy [26]. Techniques for oncoplastic surgery, which include either volume displacement or volume replacement procedures, are reviewed separately. (See "Oncoplastic breast surgery".)

●Volume displacement procedures involve rearrangement of the adjacent tissue, mastopexy, or reduction mammaplasty [25]. These are usually considered in women with moderate-to-large breasts. A partial mastectomy is performed first and typically involves resection of a specimen that weighs between 100 and 200 grams. Following that, a common approach is to perform a reduction mammaplasty; the contralateral breast is reduced at the same time. (See "Overview of breast reduction".)

●Volume replacement procedures involve advancement or rotation of local pedicle flaps or free tissue transfer to obliterate the defect following breast resection [25]. These techniques are usually recommended for women with small-to-moderate breasts who do not have enough breast tissue to safely and aesthetically perform a reduction mammaplasty [27]. An innovation for women with small breast volume is a biplanar technique in which adjacent tissue rearrangement is performed above the pectoralis major muscle, and a small implant is placed under the pectoralis major muscle [28].

Total breast reconstruction with autologous fat — For patients who undergo a total mastectomy who are either not candidates or do not desire standard autologous reconstruction with a flap or standard prosthetic-based reconstruction, total breast reconstruction with autologous fat grafting (AFG) is a possibility. With this technique, fat is liposuctioned from one or more remote sites and then injected into the breast area. Typically, the fat is taken from the lower extremities, flank, abdomen, or buttock and transplanted to the breast. The process is often long and cumbersome and may require multiple sessions and may take one to two years to complete. The procedure is facilitated using an external skin expansion device that uses negative pressure. These external expansion devices are not available for use in the United States. Complications of AFG for total breast reconstruction can include (but are not limited to) fat resorption, fat necrosis, lumpy breasts, infection, suboptimal cosmetic outcome, and donor site abnormalities. It should be noted that this technique is not widely performed or offered in all geographic areas. Patients should consult with their physicians to determine if they are a candidate for this procedure.

The BREAST trial randomized 191 patients to AFG with external expansion or implant-based reconstruction (IBR) for total breast reconstruction in a setting of external skin expansion [29]. Eighteen of those allocated to IBR did not receive the implant, and 12 of those in the AFG group discontinued intervention. The primary outcome, which used the Breast-Q questionnaire, was analyzed for 64 in the AFG group and 68 in the IBR group. The AFG group had significantly high scores in three of the five domains scored at 12 months postoperatively, including satisfaction with breasts, physical well-being, and satisfaction with outcome. No significant difference was seen for psychosocial or sexual well-being. The mean breast volume achieved was significantly lower for AFG compare with IBR (300 versus 384 mL). Serious adverse events, which included oncologic events, were similar between the groups. Based on the outcomes of this trial, AFG appears to provide a reasonable alternative for total breast reconstruction with good patient satisfaction. However, larger trials with complete and longer follow-up, comparison of AFG with other types of total breast reconstruction, and more widespread availability of the skin expansion device are needed.

Adjunctive procedures — Following implant-based or flap-based breast reconstruction, adjunctive secondary procedures are often necessary to improve symmetry, reconstruct the nipple, or correct contour abnormalities [14,30]. In the United States, these are usually covered by insurance. In a review of 271 direct-to-implant reconstructions performed in the prepectoral (n = 143) or subpectoral (n = 128) position, there was a trend toward more secondary procedures in the subpectoral cohort (36.5 versus 19 percent) [31]. The most common procedures were pocket revision (11.7 versus 3.5 percent) and implant exchange (11.7 versus 4.2 percent). The need for adjunctive fat grafting was similar between the subpectoral (46 percent) and prepectoral (40.5 percent) cohorts.

Obtaining symmetry — Once reconstruction of the affected breast has begun, the challenge of creating symmetry with the contralateral breast is undertaken [32]. Mastopexy, breast reduction, breast augmentation, or a combination of procedures can be used to improve symmetry and aesthetics (picture 1). As an example, in a woman with very large breasts who undergoes a mastectomy with reconstruction, a contralateral breast reduction will decrease the size discrepancy, resulting in improved patient comfort and increased symmetry. Contralateral breast surgery can be performed at the time of the initial reconstruction or at a second stage [33,34]. It is important for surgeons to understand patient expectations and for surgeons and patients to have a detailed discussion about breast symmetry following reconstruction [35]. (See "Implant-based breast reconstruction and augmentation" and "Overview of breast reduction".)

Nipple reconstruction — Following completion of the breast reconstruction, women are given the option of nipple-areolar reconstruction. This is typically performed during the second stage of breast reconstruction but can also be performed in an office setting. The goal of nipple and areolar reconstruction is to achieve symmetry of position of the nipple-areolar complex in the contralateral breast with comparable appearance and color [36,37]. There are multiple techniques by which a nipple and areola can be created. Surgical methods involve local tissue rearrangement procedures or skin grafts, while others use donor sites that are closed primarily. Nipple projection varies among the different techniques, but adequate results can be achieved with most. Although nipple projection may be adequate immediately following the procedure, flattening of the reconstructed nipple over time may limit its efficacy. Symmetry of position on the breast mound is the most important goal of nipple reconstruction, as even small discrepancies are obvious. Once the projecting papilla has been created, the appearance of the entire nipple-areolar complex can be enhanced by the use of tattooing (picture 2). An alternative to surgical reconstruction of a nipple is a three-dimensional tattoo. Most of these three-dimensional tattoos are performed in a nonmedical facility since many large centers do not have dedicated practitioners in their clinics. The tattooing of a surgically created nipple not only includes tattooing of the nipple but also creation of a new areola with pigmentation. The results with nipple tattooing have been excellent, and patient satisfaction has been high.

Handling contour abnormalities — Contour abnormalities of the breast can occur following breast reconstruction with implants, autologous tissue, or oncoplasty.

Approximately 20 to 40 percent of women undergoing breast-conserving surgery will develop a contour abnormality [38-43]. The adverse change in contour can be particularly challenging to correct if the patient also received radiation therapy to the breast. The initial assessment includes a thorough evaluation of the skin and parenchymal quality, as well as an assessment of the degree of postradiation skin damage. The cutaneous and glandular elements often become fibrotic and scarred after radiation treatments.

AFG is the most common reconstructive procedure used to restore breast contour following breast conservation or oncoplastic surgery. Prospective studies have shown that fat grafting is an effective approach to correct these deformities [43]. Other surgical approaches include mastopexy and reduction mammaplasty. While these procedures can effectively restore the breast contour for patients after breast-conserving surgery, complications, including delayed healing, infection, and fat necrosis, are more common for women who have also been treated with radiation therapy [44]. In a study comparing secondary procedures following breast-conserving surgery, ipsilateral breast reduction/mastopexy was performed in 41 percent, augmentation or implant exchange was performed in 18 percent, myocutaneous flaps were performed in 17 percent, local procedures such as fat grafting were performed in 14 percent, and contralateral reduction mammaplasty was performed in 10 percent [45]. (See "Options for autologous flap-based breast reconstruction".)

Contour abnormalities can also occur following autologous or prosthetic reconstruction and may be corrected using a variety of techniques. Fat grafting has been especially useful for correcting upper pole deformities as well as rippling in the setting of prosthetic reconstruction and can be used for volume discrepancies following autologous reconstruction [34].

CLINICAL EVALUATION — Optimal management of women who have undergone mastectomy for breast cancer requires a collaborative effort between oncologic and reconstructive surgeons, radiologists, and pathologists, as well as medical and radiation oncologists [46,47]. This multimodality approach allows providers to coordinate cancer and reconstructive procedures with the need for radiation therapy and chemotherapy. (See "Clinical features, diagnosis, and staging of newly diagnosed breast cancer".)

A productive, caring relationship is crucial to patient satisfaction with the reconstructive process and must be established early [48]. The patient with newly diagnosed breast cancer may have feelings of grief and anger as well as unrealistic expectations that may be directed toward her health care team. If possible, the patient's family or other health care advocates should be included in the consultation.

At the initial consultation, educational literature, including preoperative and postoperative photographs of patients who have undergone reconstruction, is helpful for the patient to aid the decision-making process. Peer-reviewed internet sites (eg, National Cancer Institute, American Cancer Society) are a useful resource for information on breast reconstruction [49]. The opportunity to speak with other women who have undergone breast reconstruction may also be worthwhile.

History — A thorough medical history should focus on the following factors:

●Stage of disease

●Treatment plan (including likelihood for postmastectomy radiotherapy)

●Past surgical history

●Comorbidities

●Volume and shape of the contralateral breast

●Body habitus

●Smoking history

●Potential donor sites for autologous reconstruction

●Patient expectations

A past medical history of radiation therapy or current disease extent for which radiation therapy is mandated may impact the patient's reconstructive options. (See 'Integrating radiation therapy and breast reconstruction' below.)

Comorbidities such as obesity, insulin-dependent diabetes mellitus, chronic obstructive pulmonary disease, smoking, thrombophilia, and connective tissue disease may also influence reconstructive options [50,51]. When poorly controlled, these comorbidities may increase the risk for complications such as impaired wound healing, reduced tissue perfusion, and infection. (See "Complications of reconstructive and aesthetic breast surgery".)

Likewise, past surgical histories that include open cholecystectomy, abdominoplasty, or coronary artery bypass grafting (with use of internal mammary vessels) may limit reconstructive choices because of their adverse effects on the blood supply to autologous tissues at potential donor sites. For patients with abdominal scars due to prior operations, preoperative computed tomographic angiography will facilitate the decision-making process by documenting the vascular anatomy of the anterior abdominal wall as well as in the gluteal and thigh regions.

Physical examination — The physical examination is a critical component in order to adequately set patient expectations following reconstructive breast surgery. (See 'Patient counseling' below.)

The physical examination of the breasts includes an evaluation for volume, ptosis, asymmetry, and scars, and the axilla is examined for palpably abnormal lymph nodes. If radiation therapy has been administered previously, the quality of the breast and chest wall soft tissues must be assessed. The abdomen, back, and buttocks are evaluated as possible donor sites, taking note of scars, overall fat content, skin laxity, and abdominal wall strength. Potential asymmetry between the native contralateral breast and the newly reconstructed breast must be addressed. The contralateral breast may require a reconstructive procedure, such as mastopexy, reduction, or even augmentation (breast implant placement), in order to obtain symmetry. The patient's personal distribution of excess skin and fat is also considered because it dictates whether a given reconstructive choice can provide enough tissue volume to recreate a breast. Finally, the patient's wishes regarding scar location, tissue sacrifice, postoperative recovery, and aesthetic outcome are also important in guiding the reconstructive surgeon. (See 'Adjunctive procedures' above.)

Patient counseling — The counseling consultation for breast reconstruction is comprehensive and involves a major time commitment from both the surgeon and patient. The complexities can be difficult to comprehend during a time when many patients with newly diagnosed breast cancer have stress and anxiety. Psychologic support should be offered to all women diagnosed with breast cancer, regardless of type of surgical procedure (breast conserving or mastectomy) or reconstruction being undertaken.

During this time, a rapport is established between the reconstructive team and the patient. Following the initial history and physical examination, patient-specific recommendations are made for breast reconstruction that may include prosthetic reconstruction, autologous reconstruction, and/or oncoplastic reconstruction.

An in-depth discussion regarding appropriate timing for reconstruction is essential to optimize outcomes and minimize the potential for postoperative complications [52]. Although patient satisfaction with postmastectomy reconstruction remains high in obese patients, these patients should be counseled preoperatively regarding their higher complication rates [53,54]. (See "Complications of reconstructive and aesthetic breast surgery", section on 'Obesity'.)

Following the surgeon's initial discussion with the patient regarding the options for breast reconstruction, it is generally considered good practice to have a nurse or midlevel provider review the information discussed and assist in answering any additional questions. This approach can be less intimidating for many patients and is often very effective in alleviating the patient's fears and anxiety. It also can be useful to show patients drawings, videos, and preoperative and postoperative photographs of the results of the specific reconstructive procedures. One important aspect of the initial consultation for the surgeon is to understand what the patient's expectations are and whether or not they are realistic, and to address them with the patient. This is arguably one of the most important components of the initial consultation.

Tobacco users are at a significantly greater risk for developing surgical complications, particularly related to autologous (natural) tissue reconstructions [55,56]. For these reasons, avoidance of tobacco products and nicotine products, including electronic cigarettes, is recommended for at least four weeks prior to surgery and two weeks following prosthetic or autologous breast reconstruction [57-59]. Former smokers do not appear to be at increased risk of morbidity provided they are in otherwise good physical health. (See "Complications of reconstructive and aesthetic breast surgery", section on 'Smoking'.)

Many patients ask about "resensation" of the breast and nipple areolar complex following mastectomy and reconstruction. Resensation involves coapting two adjacent nerve endings with the goal being to provide sensation when there is at least 50 percent permanent loss. This is usually performed using an allogenic nerve graft that extends from the chest wall to either the nipple areolar complex or by using an autologous flap. In a systematic review, nerve coaptation was performed in 536 breasts and included direct coaptation (65.1 percent of flaps), coaptation with nerve conduit (26.3 percent), and coaptation with nerve allograft (8.6 percent) [60]. Innervated breasts achieved earlier and superior sensory recovery that was more uniformly distributed throughout the flap compared with noninnervated breasts. Studies are ongoing to determine the feasibility of this technique because not all patients may be candidates for this technique.

Other important point of discussion with the patient is explaining that prosthetic breast implants do not last forever and that a secondary procedure is likely. In addition, the patient should be made aware that the US Food and Drug Administration (FDA) has placed a boxed warning on breast implants for three reasons [61]. (See "Implant-based breast reconstruction and augmentation", section on 'Concerns over breast implants'.)

●Breast implants will not last a lifetime and generally need replacement in 10 to 15 years.

●Textured surface devices have been linked to anaplastic large cell lymphoma.

●A small percentage of patients may develop an entity known as breast implant illness that may represent an allergic-type reaction to the implant materials.

The FDA has also issued a safety warning regarding the use of acellular dermal matrices (ADM) that are often used in conjunction with prosthetic devices. Complications may be increased when ADM is used compared with when it is not [62]. The use of any mesh material is considered "off label" when used in the breast. However, mesh products can be used when deemed necessary. Patients should be informed about the use of mesh.

Special considerations during the COVID-19 pandemic — The coronavirus disease 2019 (COVID-19) pandemic increased the complexity of cancer care. Important issues have included balancing the risk from delaying cancer treatment versus harm from COVID-19, minimizing the number of clinic and hospital visits to reduce exposure whenever possible, mitigating the negative impacts of social distancing on delivery of care, and appropriately and fairly allocating limited health care resources. Specific guidance for decision-making for cancer surgery on a disease-by-disease basis during the pandemic was made available from the American College of Surgeons, American Society of Breast Surgeons, the Society of Surgical Oncology, and from others. (See "COVID-19: Considerations in patients with cancer".)

The COVID-19 pandemic had a significant impact on the rates of breast reconstruction. In a review from 2017 to 2020, 175,949 patients had either partial or total mastectomy [63]. Between 2019 and 2020, patient volume declined by 10.7 percent, the unilateral mastectomy rate increased slightly from 70.5 to 71.9 percent, and the rate of contralateral prophylactic mastectomy decreased. Although the overall rate of breast reconstruction was unchanged, tissue expander reconstruction increased from 64.0 to 68.4 percent (p<0.001), whereas direct-to-implant and autologous reconstruction rates decreased. Finally, the rate of outpatient alloplastic reconstruction increased from 65.7 to 73.8 percent, whereas in-patient hospitalization rates decreased for all reconstruction patients.

CHOICE OF RECONSTRUCTION — For women undergoing mastectomy, breast reconstruction offers quality-of-life benefits and is a vital option to enhance breast cancer recovery. With the variety of reconstructive techniques available, choosing the "right" option can sometimes be a daunting task, even for highly educated consumers.

The selection of a reconstructive procedure depends on a variety of clinical factors, but patient preference plays a major role in determining the procedure that is ultimately performed. Considerations include body habitus and prior surgical procedures. Age alone should not discourage breast reconstruction. Older women who undergo breast reconstruction following mastectomy have similar outcomes and may have better breast-related quality-of-life outcomes compared with those who do not [64,65]. In a retrospective of 309 patients aged 60 years or greater, 26.7 percent of patients had at least one complication requiring reoperation, and 6.9 percent of patients had a failed reconstruction [66]. Complications were not related to age greater than 60 years but were related to prior radiation therapy following breast conservation therapy (BCT) and adjuvant chemotherapy. When analyzing patients having tissue-expander reconstruction, complications were significantly associated with body mass index (BMI) >35 kg/m², prior BCT, and adjuvant chemotherapy.

Based on clinical factors — Most women will be considered a reasonable candidate for either implant-based or flap-based breast reconstruction. Some women are clearly a better candidate for one approach over another, based upon individual body habitus, previous breast-related surgery or radiation, or personal choice. The ideal patient characteristics for flap-based breast reconstruction include:

●Ample tissue at the desired donor site (eg, at the abdomen, posterior thorax, gluteal region, or thigh) – The most commonly considered donor site is the abdomen. The benefits of using abdominal tissue are the ability to form and shape the tissues to recreate the breast, as well as contouring the abdomen for an abdominoplasty-type effect. The other donor sites listed are usually secondary sites and associated with a lesser amount of tissue, and these are sometimes used in conjunction with an implant. For patients who desire autologous reconstruction but who have a paucity of donor site tissue, stacked flaps can be considered, where two flaps are used to create one breast [67,68].

●Personal history of previous radiation to the breast – Because of the local tissue effects of radiation therapy, autologous tissue options are preferred over implant-based techniques in previously irradiated patients. Although radiation is effective at killing cancer cells, it can also cause soft tissue fibrosis and limit skin elasticity and the ability to expand. When considering microvascular autologous reconstruction following radiation therapy, it is recommended to wait 6 to 12 months following radiation to perform a microvascular anastomosis , when considering reconstruction using the abdominal, gluteal, or thigh donor sites [69].

●Multiple scars on the breast – The scarred breast may pose challenges when considering mastectomy and reconstruction. Poorly placed biopsy scars may compromise prosthetic reconstruction because of the risk of skin necrosis. When planning a breast biopsy, it is important to place scars along aesthetic units that include the periareolar region and radially when along the periphery of the breast [70,71]. With autologous reconstruction, the scarred skin can be excised and replaced with skin from the donor flap.

●Bilateral mastectomies and any of the above characteristics.

The ideal patient characteristics for implant-based reconstruction include:

●BMI <30 kg/m² – Although less desirable, some patients with a BMI over 30 kg/m² may still be candidates for prosthetic reconstruction. This will depend on assessment of tissue perfusion, general health, and absence of tobacco use. Patients with a BMI exceeding 40 kg/m² have traditionally been considered more prone to complications following immediate reconstruction, however, this dogma has been challenged. In a series of immediate prepectoral prosthetic breast reconstructions in 45 patients (85 breasts) with a BMI >40 kg/m², postoperative complications occurred in 11 breasts (12.9 percent) and included major skin necrosis (3.5 percent), seroma (4.7 percent), wound dehiscence (5.9 percent), and reconstructive failure (1.2 percent). This rate of complication is similar with the general rate of complications seen in patients without obesity using a prepectoral approach.

●Active lifestyle with a desire for a shorter recovery time.

Based on outcomes — Outcomes data on surgical complications, physical function, quality of life, and patient satisfaction provide the surgeon and patient with useful information when choosing the most appropriate reconstructive technique and timing. The following sections emphasize data on postreconstruction outcomes that are relevant to psychosocial issues, patient satisfaction, and physical functioning.

Patient satisfaction — Clinicians and researchers evaluate health care not just by assessing objective outcomes (complication rates and length of hospitalization, for example) but also from the consumer's point of view in terms of patient satisfaction.

It is well established that breast reconstruction is associated with high levels of patient satisfaction [72-75]. The type of reconstructive procedure appears to affect postoperative patient satisfaction. This was illustrated in the Mastectomy Outcomes Reconstruction Consortium (MROC) project, which measured patient satisfaction with regard to aesthetic result (softness, symmetry) and general satisfaction with the process and outcome of care [75,76]. At one year following surgery, women with pedicled transverse rectus abdominis musculocutaneous (TRAM) flaps, free TRAM flaps, and expander/implants had similar levels of general satisfaction [76], but autologous tissue reconstructions (TRAM procedures) were associated with greater aesthetic satisfaction than expander/implant techniques. At year 2, these procedural differences had diminished, but patients continued to be more aesthetically satisfied with autologous tissue compared with expander/implant reconstructions [75]. At postoperative year 2, the percentages of patients aesthetically satisfied in the expander/implant, pedicled TRAM, and free TRAM groups were 43, 69, and 70 percent, respectively. With regard to general satisfaction, the percentages of patients who were satisfied with their procedure were 64, 79, and 78 percent, respectively.

While more extensive reconstructive procedures are associated with increased surgical risk and longer recovery times, the choice of reconstruction has had a limited impact on most measures at one and two years of observation [76,77]. One randomized trial of 75 women treated with delayed reconstruction (ie, lateral thoracodorsal flap, the latissimus dorsi flap, or the pedicled TRAM flap) found a high level of satisfaction in the majority of women regarding the cosmetic result of each procedure [4]. All three reconstructive procedures were associated with improvements in patient-defined problem areas of life, quality of life, and social functioning at six months and one year after reconstruction. The latissimus dorsi and TRAM flap cohorts scored higher on quality-of-life questionnaires in terms of breast symmetry and reduced problems in social situations compared with patients undergoing the thoracodorsal flap. In a later review of 459 patients, women who underwent deep inferior epigastric artery perforator (DIEP) flap had higher satisfaction scores with breast and overall outcomes compared with those who had a latissimus dorsi flap, lateral thoracodorsal flap, or expanders with secondary implant [78].

To examine return of sensation following breast reconstruction, one study used the BREAST-Q sensation module to determine whether differences existed for autologous versus prosthetic reconstruction [79]. Of 933 respondents, 620 (66.5 percent) underwent alloplastic reconstruction and 313 (33.5 percent) underwent autologous reconstruction. Patients who had autologous reconstruction scored an average of 6.1 and 5.3 points higher, respectively, on the Breast Symptoms and Quality of Life Impact scales compared with patients who had prosthetic reconstruction. However, there was no difference on the Breast Sensation Scale. Radiation therapy had a negative impact on both Breast Symptoms and Quality of Life Impact scales scores.

Even after controlling for possible confounding factors, such as preoperative physical function and timing of surgery, patients with TRAM flaps (both free and pedicle) had higher levels of aesthetic satisfaction at year 2 as compared with expander/implant patients (odds ratio [OR] 2.8, p <0.01). There were no significant differences in aesthetic satisfaction between women with free and pedicle TRAM flaps, a finding that has been noted by other investigators [80,81].

A retrospective cohort study that included 325 patients was designed to determine if there were factors that were predictive of a favorable surgical outcome [82]. Included were 133 patients that had DIEP flap reconstruction and 192 had implant-based reconstruction. At two years from the last surgical procedure, no significant differences were seen between patients who underwent radiotherapy, chemotherapy, or hormone therapy compared with those who did not. Age and BMI had no influence on patient satisfaction. Only the type of mastectomy and the type of reconstruction performed had any influence. Patients undergoing nipple-sparing mastectomy and DIEP flap reconstruction were the most satisfied, regardless of age, BMI, or type of cancer therapies performed.

Overall satisfaction and patient aesthetic satisfaction are not significantly different in patients who undergo implant/expander reconstruction following radiation compared with patients who did not receive radiation therapy [83]. However, radiation therapy may have more of a negative effect on health-related quality of life and satisfaction with implant breast reconstruction. Based upon a multicenter cross-sectional BREAST-Q survey of women with implant reconstruction (n = 633), women undergoing radiation therapy (n = 219) were less likely to be satisfied with the results compared with women without radiation treatments (66.8 versus 71.4 percent) [84]. In addition, women undergoing radiation treatment also scored lower for psychosocial well-being (66.7 versus 70.9 percent), sexual well-being (47.0 versus 52.3 percent), and physical well-being (71.8 versus 75.1 percent). The impact of the diagnosis or clinical setting that required the addition of radiation therapy, rather than the results of the radiation treatments on the reconstructed breast, needs to be further evaluated.

However, in a separate study, radiation therapy did not affect patient satisfaction scores but was associated with an increased rate of breast implant removal [85]. A cohort study comparing outcomes among 40 women who had reconstruction with an implant in the setting of radiation therapy with 40 others who were not irradiated showed that capsular contraction rates among the women who did and did not receive radiation therapy were 33 and 0 percent, respectively [86]. Nineteen of the 40 irradiated breasts ultimately needed the addition of, or replacement by, autologous tissue to salvage the reconstruction. Similar rates have been found in other studies [87]. A later matched cohort study compared outcomes in patients who underwent two-stage prosthetic reconstruction who were not exposed to radiation (423 breasts) with those who were (69 breasts) [88]. Of the radiated breasts, 28 were prepectoral and 41 were subpectoral. There were no differences in clinical outcomes between the cohorts at 24-month follow-up. Prepectoral reconstruction was deemed safe in the setting of radiation therapy without a significant difference in the rates of capsular contracture.

Not all studies associate poor cosmetic/aesthetic outcomes with women who undergo immediate implant reconstruction followed by radiation therapy [89-92]. A cohort study that included 725 women (754 reconstructed breasts) undergoing breast cancer reconstruction with implants found that the five-year implant failure rate was 10.4 percent for nonradiated implants (n = 386), 28.2 percent for implants placed after prior radiation (n = 64), and 25.2 percent for implants placed prior to radiation (n = 304) [92]. The majority of women with none (86.2 percent), previous (68.6 percent), and postoperative (77.7 percent) radiation would encourage implant reconstruction for other women. Newer strategies for implant placement (ie, prepectoral placement) have demonstrated that radiation-related complications may be reduced when compared with subpectoral placement [93]. The reasons for this are that the effects of radiation on the pectoralis major muscle are more deleterious and will cause foreshortening of the muscle that will in turn result in radiation-related device malposition.

Physical functioning — The variability in the degree of muscle that is sacrificed, denervated, or injured in creating abdominal wall flaps for breast reconstruction makes the comparison of abdominal wall function after abdominal flap reconstruction challenging. Several studies have evaluated abdominal function using basic physical functioning tests such as getting out of bed and the ability to perform sit-ups, although more sensitive testing of muscle function, such as isokinetic dynamometry, which measures the maximum strength a muscle can reach, may be necessary for accurate comparison [94-96].

Many patients are concerned about potential abdominal wall morbidity with TRAM procedures. Physical functioning following free or pedicled TRAM flap reconstructive surgery depends upon whether the reconstruction was unilateral or bilateral, whether the motor innervation to the rectus abdominis muscles was sacrificed or preserved, and the degree of postoperative fibrosis occurring within the remaining muscle. In general, for most women who require unilateral reconstruction, breast reconstruction with a pedicle TRAM flap will not make a significant impact on the activities of daily living. However, for women who need bilateral reconstruction, perforator or muscle-sparing flaps may confer an advantage in physical function. In a review of 20 studies of abdominal wall function following breast reconstruction, bilateral reconstruction was associated with the greatest difficulty in performing some daily activities [97]. However, unilateral reconstruction did not affect the performance of activities of daily living.

Functional outcomes studies have shown mixed results, with between 6 and 23 percent of patients demonstrating deficits in trunk function (eg, torque and range of motion) following TRAM reconstruction [98,99]. However, these are largely single-center studies without long-term follow-up. Physical function outcomes data are especially important as more technically complex procedures, such as perforator flaps, are being increasingly performed to limit the surgical "insult" to the abdominal wall. In the Michigan Breast Reconstruction Outcomes Study, data on trunk peak torque and range of motion were collected preoperatively and at postoperative years 1 and 2 in the expander/implant, free TRAM, and pedicled TRAM groups [100]. At two years postoperatively, procedure type, timing, and laterality (unilateral versus bilateral) did not significantly affect the range of motion for trunk flexion or extension. Peak torque for trunk flexion at year 2 was significantly lower (by 11 to 18 percent) in patients with TRAM flaps compared with those undergoing expander/implant reconstructions. However, no significant difference in flexion peak torque was found between patients who had free and pedicle TRAM reconstructions. These data are consistent with other contemporary breast reconstruction functional outcomes studies [101-103].

The available outcomes data on perforator flaps are limited to retrospective reviews [104-107]. One study evaluated the ability of patients to do sit-ups at three and six months following perforator flap reconstruction [106]. At three months, 95 percent of women were able to return to their preoperative sit-up activity; this was 100 percent by six months postoperatively. Another retrospective series evaluated abdominal wall function in 18 patients with DIEP flaps compared with free TRAM reconstructions [107]. The TRAM group appeared to have significantly lower trunk flexion torque compared with the DIEP group.

Psychosocial function and quality of life — It is challenging to accurately compare the psychosocial impact of the various surgical procedures, as some women who are candidates for breast-conserving surgery opt for mastectomy, and some who are candidates for reconstruction opt for none. A breast cancer diagnosis affects psychologic function, regardless of the surgical procedure (ie, mastectomy, mastectomy with reconstruction, or breast-conserving surgery) [108]. In addition, some women are not candidates for either breast conservation or immediate reconstruction because of advanced stage of disease or comorbid illnesses.

A few studies have attempted to measure the impact of the type of reconstruction on psychosocial function and quality of life. A prospective study of 90 women found that psychologic distress was evident regardless of reconstruction (performed or not) or timing of reconstruction (delayed or immediate) at one year after the procedure [109]. Nevertheless, quality of life at one year following reconstruction after mastectomy was equivalent to age-matched controls of women never diagnosed with breast cancer [65].

TIMING OF BREAST RECONSTRUCTION — Breast reconstruction can be carried out at the time of the mastectomy (immediate) or during a subsequent operation (delayed). Immediate reconstruction may be considered in most patients who are undergoing mastectomy. This includes patients having prophylactic mastectomy as well as mastectomy for invasive or in situ carcinoma. Delayed reconstruction is considered in patients with inflammatory breast cancer or in patients at increased risk for adverse outcomes due to comorbidities as well as patient or surgeon preference. Staged-immediate reconstruction is sometimes considered in patients with suboptimal perfusion of the mastectomy skin flaps as a method of reducing the incidence of delayed healing and reconstructive failure. Patients in this category are usually able to resume reconstruction two to four weeks later once the healing is complete [110]. In a meta-analysis of 30 studies reviewing 14,034 patients, the risk of surgical complications was higher among those who had immediate breast reconstruction [111]. The consequences of postmastectomy radiation therapy did not increase complications based on whether the reconstruction was immediate or delayed.

Immediate — Opinion within the surgical community regarding immediate breast reconstruction has evolved over time [112,113]. Delayed procedures had been favored because it was assumed that the time between mastectomy and reconstruction provided women with the opportunity to "psychologically adjust" to the loss of a breast, therefore allowing for a greater appreciation for their reconstruction. This assumption was found to be faulty when several studies revealed that women undergoing immediate reconstruction experienced significant psychosocial benefits. It is our belief that immediate reconstruction provides at least some "buffer" from the psychological and body image disturbances associated with a breast cancer diagnosis and mastectomy. In a study from Toronto, Canada, immediate breast reconstruction appeared to protect breast cancer patients from a period of psychosocial distress, poor body image, and diminished sexual well-being compared with women waiting for delayed breast reconstruction [114].

Immediate reconstruction may be considered for most patients who are undergoing mastectomy. Contraindications to immediate reconstruction include inflammatory breast cancer and those patients with multiple medical conditions that are poorly controlled. The types of immediate reconstruction that can be performed include prosthetic, autologous, and oncoplastic. The indications for the various options are highly variable and depend upon body habitus, likelihood of postoperative radiation, prior breast radiation, patient desire, and surgeon recommendation.

The advantages of immediate reconstruction include:

●The surgical process is streamlined since removal of the breast cancer and reconstruction are done in one operative setting. As a result, the overall cost of the reconstructive process is decreased [115].

●There are increasing data that support the view that immediate breast reconstruction provides substantial psychosocial benefits over delayed reconstruction and preserves normal perceptions of body image in women undergoing mastectomy [76,116-122].

●With all immediate reconstruction, the preoperative markings are performed for either skin-sparing or nipple-sparing mastectomy [123-125]. (See "Mastectomy".)

The disadvantages of immediate reconstruction include:

●Immediate reconstruction prolongs operative time, adding one hour or more for prosthetic reconstruction and several hours for autologous reconstruction. Although this is not harmful for most patients, those with multiple comorbidities may be at increased risk for adverse events.

●Necrosis of the mastectomy skin flaps can adversely affect the aesthetic result of the reconstruction. (See "Mastectomy", section on 'Skin flap necrosis'.)

●Large tumor size, direct skin involvement, or documented lymph node involvement will often necessitate postoperative radiation therapy, which can adversely affect the reconstruction [126]. (See 'Integrating radiation therapy and breast reconstruction' below.)

●Postoperative radiation therapy can compromise the quality of the reconstruction. Implants can become firm (capsular contracture) and autologous flaps can shrink or atrophy. Most surgeons prefer to radiate implants because the implant can be replaced with a flap if necessary, whereas a radiated flap is less able to be replaced. The topic of breast reconstruction and radiation therapy is very important and should be thoroughly reviewed during the discussion of reconstructive options, risks, and benefits.

Relative contraindications to immediate reconstruction:

●Advanced disease (stage III or higher) (see "Tumor, node, metastasis (TNM) staging classification for breast cancer")

●Need for postmastectomy radiation therapy (see 'Integrating radiation therapy and breast reconstruction' below)

●Significant medical comorbidities such as active smoking, obesity, or cardiopulmonary disease

Immediate autologous reconstruction — Immediate autologous reconstruction can be performed using flaps from all donor sites that include the abdomen, back, buttock, and thigh. When no radiation therapy is planned postoperatively, immediate autologous breast reconstruction can be safely performed in patients who are otherwise good candidates.

If the need for radiation therapy is uncertain, one approach is to perform a sentinel lymph node (SLN) biopsy prior to mastectomy [127,128]. If the SLNs are tumor free, then the likelihood that postmastectomy radiation therapy will be needed is low (but not zero) in patients who have tumors <5 cm, and immediate reconstruction can be considered.

An alternative approach is the "staged-immediate" reconstruction approach [129]. The first stage consists of a skin-sparing mastectomy with subpectoral or prepectoral insertion of a filled tissue expander to preserve the shape and dimensions of the breast envelope. After a review of the permanent histologic sections, patients who do not need postmastectomy radiation therapy then undergo reconstruction within two weeks of mastectomy.

However, when postoperative radiation therapy is planned, whether to perform immediate autologous reconstruction is based on the surgeon's experience along with a detailed discussion with the patient regarding potential risks. (See 'Integrating radiation therapy and breast reconstruction' below.)

●Some surgeons believe that if radiation therapy is planned postoperatively, then immediate autologous reconstruction should not be performed to avoid radiating the flap because of the untoward effects of the radiation on the flap such as shrinkage, induration, and distortion [130,131].

●Others believe that the effects of radiation are minimal on well-vascularized autologous flaps and that immediate reconstruction can be safely performed [132,133].

Immediate implant-based reconstruction — Immediate implant-based reconstruction is a common choice following mastectomy. This can be performed using the two-stage technique that includes placement of a tissue expander followed by a permanent implant, or alternatively, using the one-stage technique (ie, direct-to-implant reconstruction) in which a permanent implant is placed immediately following the mastectomy. Most women who select implant-based reconstruction following mastectomy do so because the operation requires less time, the recovery period is shorter, and the aesthetic results usually lead to high patient satisfaction. This is especially true in the setting of nipple-sparing mastectomy. Direct-to-implant reconstruction is increasing in popularity and incidence because it usually can be performed in a single setting; however, it is important to ensure that the mastectomy skin flaps have adequate blood supply. Otherwise, the incidence of adverse events may be increased [134,135].

Implant-based reconstruction also does not usually interfere with radiation therapy. In the setting of postmastectomy radiation, more surgeons prefer a tissue expander or implant because although radiation can cause soft tissue fibrosis, capsular contracture, and reconstructive failure, secondary procedures following implant-based reconstruction are relatively more easily performed [136]. However, it should be noted that the soft tissue consequences of radiation are permanent. For less severe cases, revisions can include capsulectomy or autologous fat grafting. In severe cases, many patients may opt to have their implants removed and replaced with a flap.

Implant-based reconstruction is performed using a variety of specific techniques; however, the use of acellular dermal matrix (ADM) in addition to the implant(s) has been a major advancement. ADM is cadaveric skin that is used to provide tissue support following the mastectomy. Although ADM is not specifically approved by the US Food and Drug Administration for breast reconstruction, the benefits of ADM in this setting have been established in a variety of publications. The use of ADM has facilitated both the two-stage and the one-stage techniques by compartmentalizing the implant to minimize migration, reducing the incidence of capsular contracture, and improving surgical outcomes [137]. ADM can be used when implants are placed under the pectoralis major muscle (dual plane technique) and above the pectoralis major muscle (prepectoral technique) [138,139]. (See "Implant-based breast reconstruction and augmentation", section on 'Acellular dermal matrix'.)

Delayed — Delayed reconstruction is indicated when there is impaired perfusion of the skin flaps after mastectomy, and sometimes when postmastectomy radiation will be needed [110,140]. Other considerations for delayed reconstruction include patients with comorbidities (eg, obesity, poorly controlled diabetes mellitus) or tobacco use that place them at high risk for complications. Women with inflammatory breast cancer are usually advised to delay reconstruction because of their higher risk of local recurrence and need for postoperative radiation therapy. In addition, the presence of dermal lymphatic invasion often mandates taking skin, so immediate reconstruction is less appropriate.

The longer the period of delay, the more fibrotic and contracted the mastectomy skin will become. If the period of delay is short (<1 month), the skin will still have its elasticity and can be manipulated for prosthetic or autologous reconstruction. However, if the period of delay is long (>2 months) or following radiation, the skin will lose some of its elasticity and will be more difficult to manipulate.

The advantages of delayed reconstruction include:

●Assurance of clear margins prior to definitive reconstruction

●Minimization of the effect of poorly perfused mastectomy skin flaps on the quality of the reconstruction

●Allows completion of all adjuvant treatment

The disadvantages of delayed reconstruction include:

●Need for subsequent surgery

●Limited reconstructive options following radiation therapy (see 'Integrating radiation therapy and breast reconstruction' below)

●Lesser aesthetic quality compared with immediate reconstruction

Delayed autologous reconstruction — Delayed autologous reconstruction is commonly performed following pre-or postmastectomy radiation therapy. (See 'Integrating radiation therapy and breast reconstruction' below.)

In the setting of prior radiation and delayed reconstruction, autologous tissue is preferred because the soft tissue fibrosis following radiation usually precludes effective tissue expansion or placement of implants. However, for patients who have not received prior radiation, either implant-based or autologous reconstruction can be considered. Ultimately, the decision between autologous and implant-based reconstruction will depend on the quality of the skin and fat over the mastectomy site.

With delayed autologous reconstruction, the radiated soft tissues can be excised (if need be) and replaced with well-vascularized autologous tissue. Donor sites for delayed reconstruction are similar to those of immediate reconstruction. Some patients undergoing immediate reconstruction with a prosthetic device with subsequent postoperative radiation therapy may have the radiation changes that can be severe and associated with capsular contracture and pain. In this setting, delayed autologous reconstruction can be considered to remove the radiated device and replace it with a flap. Patient outcomes following delayed autologous reconstruction have been favorable [141].

Delayed implant reconstruction — Delayed implant reconstruction is considered in patients who have had mastectomy without reconstruction or who have had prior failure with an autologous flap. Patients having delayed reconstruction are usually reconstructed with tissue expanders to stretch the skin followed by removal of the tissue expander and placement of a permanent implant. Permanent implants can be silicone or saline filled, round or anatomic shaped, and placed above or below the pectoralis major muscle.

Delayed reconstruction with breast implants is facilitated in patients who have not had prior radiation therapy to the breast or chest wall; however, prior radiation therapy is not a contraindication to delayed implant reconstruction. In a review comparing immediate versus delayed tissue expander reconstruction in the setting of radiation therapy, delayed tissue expander reconstruction had a lower rate of mastectomy flap necrosis and complications compared with immediate tissue expander reconstruction [142]. Postmastectomy radiation significantly increased operative complications and explantation, resulting in a decrease in overall, two-stage success rate in patients having immediate reconstruction. (See 'Integrating radiation therapy and breast reconstruction' below.)

INTEGRATING RADIATION THERAPY AND BREAST RECONSTRUCTION — Women who require postmastectomy radiation therapy present a reconstructive challenge. Radiation therapy leads to fibrosis, which compromises the quality of the skin and underlying tissue, results in a higher incidence of complications from the reconstructive procedure and may produce a less aesthetically pleasing result [143,144]. The timing of breast reconstruction and complications of radiation therapy in the setting of breast reconstruction are discussed below.

Timing of reconstruction — The optimal timing of integrating radiation therapy with any method of reconstruction is controversial [145]. The need for postmastectomy radiation therapy often cannot be determined definitively until the final pathologic evaluation is complete (typically three to five days following mastectomy). For women who will need postmastectomy radiation, the possibilities include radiation of the unreconstructed chest wall, radiation with a tissue expander or implant in place, or radiation of a flap reconstruction. Most, but not all, plastic surgeons would not advocate for waiting until radiation therapy is completed before initiating breast reconstruction.

For women desiring to have autologous reconstruction, the National Comprehensive Cancer Network (NCCN) as well as most plastic surgeons advocate against radiating tissue flaps because of subsequent potential complications such as flap fibrosis and shrinkage and distortion [146].

As such, the protocol advocated by most plastic surgeons is delayed-immediate reconstruction in which a tissue expander is placed following the mastectomy and radiation therapy initiated about one month later. Sometimes, it will be advised to have the tissue expander deflated on the chest wall to optimize treatment delivery; however, this is not universally performed. In either case, radiation is delivered to the soft tissues surrounding the tissue expander [126]. Early results with this approach have been promising, but radiation therapy-related tissue expander complications may still require interruption of postmastectomy radiation therapy, with the associated risk of compromising oncologic outcomes.

Following radiation therapy, the options are to remove the expander and perform autologous reconstruction or to remove the expander and place a permanent implant. For patients who will undergo implant-based reconstruction, radiation therapy after the permanent implant is placed is another option. In a multicenter review, no significant differences in complication rates were seen among those who had postmastectomy radiation after tissue expander placement compared with postmastectomy radiation after exchange for a permanent implant [147].

Some have suggested a prepectoral placement of prosthetic devices in the setting of known future radiation therapy [19,93]. Early outcomes demonstrated less likelihood of superior displacement of prepectoral tissue expanders following radiation therapy compared with subpectoral tissue expanders. However, in a later study that compared postmastectomy radiation in the setting of prepectoral and partial subpectoral tissue expander placement, there was no significant difference in complication rates between the two reconstructive cohorts, including rates of explantation (15.4 versus 19.3 percent) [148]. More research on breast reconstruction in irradiated patients is needed to determine optimal management in this setting. (See 'Delayed' above.)

Oncoplastic reconstruction, which can be performed immediately following partial mastectomy or be delayed (staged), is completed before the onset of radiation therapy that is typically required. Most surgeons agree that the aesthetic results are superior if performed immediately. It is often very difficult to have significant improvements if oncoplastic reconstruction is performed in a delayed fashion, particularly if patients have already received radiotherapy. The risks of immediate oncoplastic surgery include a positive tumor margin on final pathologic evaluation that often requires a reexcision or, in some cases, a mastectomy. The options for oncoplastic reconstruction include volume displacement and volume replacement procedures and are reviewed separately. (See "Oncoplastic breast surgery".)

Radiation-related complications — Radiation-related complication rates are highest among women undergoing expander/implant reconstruction, regardless of when radiation therapy is given relative to surgery [149,150]. The end results of the complex tissue changes induced by radiation include scar formation at the implant/tissue interface, capsular contracture, and impaired skin healing. Other complications associated with implant reconstruction include implant rupture or extrusion and implant malpositioning.

In cases of autologous reconstruction, radiation may result in flap shrinkage and fibrosis. Although autologous tissue reconstructions may be better able to withstand radiation-induced tissue damage [89,151-155], they are still subject to radiation-related fat necrosis, fibrosis, atrophy, and flap contracture. Delayed autologous flap reconstruction usually provides improved cosmetic results with the fewest complications (picture 3) [156]. However, this concept has been challenged in several studies that contend that patient-reported outcomes are no different when comparing radiation therapy before or after flap reconstruction [157].

The incidence of late complications (fat necrosis, flap volume loss, flap contracture) is significantly higher in immediate reconstructions that have undergone radiation therapy [124,130,158,159]. In a retrospective study of 113 women who underwent postmastectomy radiotherapy and breast reconstruction, the complication rate was 32 percent for patients who had radiation first and 44 percent for patients who had breast reconstruction first [87]. Early complications were seen more frequently in patients having radiation first while late complications were more common in patients who had breast reconstruction first. In another study comparing outcomes of 32 patients who underwent immediate transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction followed by radiation therapy compared with 70 women who underwent radiation therapy and subsequent delayed flap reconstruction, the incidence of late complications was significantly higher in the immediate compared with the delayed reconstruction group (88 versus 9 percent) [158]. Nine patients (28 percent) in the immediate reconstruction group required an additional flap to correct contour deformities resulting from flap shrinkage and contracture.

Transferring nonirradiated tissue to the mastectomy site may avoid some of the radiation-associated wound healing complications. Tissues severely damaged by radiation therapy can be resected and discarded at the time of the reconstruction, and the skin "paddle" of the designed flap can be tailored to replace the missing breast surface skin. In general, prior radiation therapy increases the amount of tissue required for breast reconstruction, and this may limit flap selection. In some patients, volume and skin requirements may exceed those of a single flap; therefore, the use of stacked flaps or two flaps for one breast may be considered. The use of stacked (ie, combined) flaps provides a solution to increase the amount of skin available for autologous reconstruction.

POSTOPERATIVE CARE AND FOLLOW-UP — The postoperative care of a patient following prosthetic, autologous, and oncoplastic reconstruction is important. Early ambulation is recommended to reduce the risk of deep vein thrombosis (DVT) and to improve pulmonary function. It is common for patients to experience incisional pain and muscle spasm, which can be alleviated with narcotics and muscle-relaxing medications. With the increasing awareness of the opioid crisis, many institutions and surgeons are now using enhanced recovery after surgery (ERAS) protocols to reduce the risk of narcotic use and to further reduce pain and increase comfort [160]. In a review of 16 studies of patients who underwent autologous flap reconstruction, the use of ERAS protocols reduced the severity of pain and also reduced the hospital length of stay [161]. Postoperative oral antibiotics may be prescribed based on need, although many surgeons have reduced antibiotic administration based on the Surgical Care Improvement Project (SCIP) guidelines [162]. Patients are instructed to refrain from strenuous activity for four to six weeks to allow for optimal wound healing and to reduce the risk of a seroma or contour abnormality at the donor site.

●Following prosthetic reconstruction, a drain is typically placed in the prosthetic space and will remain for several days. Most patients are allowed to shower on postoperative day 2 or 3. When a tissue expander is placed, patients typically are expanded in the office or clinic at one- to two-week intervals until complete.

●Following autologous reconstruction, most patients are typically admitted for three to four days in the hospital. Surgical drains may be placed in the reconstructed breast and the donor site. The duration of drainage is variable. Abdominal and gluteal drains are usually removed in one week, whereas latissimus dorsi drains are removed at two to three weeks because of the risk for seroma. Patients are instructed to shower on postoperative day 3 and to follow up with the surgeon a few days following discharge from the hospital.

Surveillance of the reconstructed breast — Following mastectomy, there remains a risk for locoregional recurrence and, less often, a second primary breast cancer, regardless of whether the breast was reconstructed or not.

The vast majority of locoregional recurrences are palpable; thus, physical examination remains the cornerstone of detection of recurrent breast cancer after reconstruction. Patient counseling should emphasize the importance of breast self-examination [163]. In a retrospective review of 390 patients who underwent immediate transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction following mastectomy for cancer, 18 (4.6 percent) locoregional recurrences occurred at a mean interval of 35 months following the mastectomy [164]. All recurrences (nine subcutaneous, nine nodal) were detected by physical examination. Recurrent cancers can occur either just below the skin in the subcutaneous tissue or just over the pectoralis muscle. Given that most surgeons remove the pectoralis fascia with the mastectomy specimen, recurrence on the chest wall is less common than subcutaneous tissue recurrence [165]. To clarify any physical findings, imaging (eg, magnetic resonance imaging [MRI], ultrasound, mammography) can be used as an adjunct [166]. If there is a high index of suspicion for a chest wall recurrence in the setting of reconstruction, a breast MRI may be helpful; however, a biopsy is required to make the diagnosis. If a skin lesion is present, a punch biopsy can be performed. Detection rates of locoregional recurrence using imaging and outcomes are not significantly affected by the reconstruction [166,167]. As an example, the mammography (image 1) shows features consistent with a recurrence warranting a biopsy in a patient who developed a palpable mass following TRAM flap breast reconstruction.

Guidelines from expert groups for the follow-up of breast cancer patients recommend annual mammography, but these recommendations generally do not apply to women who have undergone mastectomy with or without breast reconstruction, regardless of whether the reconstruction was autologous or implant based [146,168]. It is generally accepted that routine mammography following autologous breast reconstruction is not necessary [167,169]. The bulk of the reconstructed breast is composed of abdominal adipose tissue, which is not at risk, but even after the most aggressive mastectomy, some small amount of normal residual breast tissue remains, which may be at risk for developing a subsequent new primary breast cancer. While mammography is technically feasible following autologous myocutaneous flap reconstruction, particularly following TRAM or perforator flap reconstruction, fat necrosis can appear radiographically as calcifications in reconstructed breast tissue, leading to unnecessary biopsy procedures. Studies illustrating the use of mammography following autologous breast reconstruction are given below. Additional studies will be needed to determine the usefulness of mammographic surveillance following mastectomy and reconstruction for breast cancer.

●In a retrospective review of 615 patients who had autologous reconstruction for cancer, 27 patients (5 percent) demonstrated a locoregional recurrence [170]. Mammography was performed in 397 patients, resulting in 25 biopsies in 25 patients, of which 2 were malignant (8 percent). Routine clinical examination was performed in 537 patients, resulting in 77 biopsies in 66 patients, of which 30 were malignant (39 percent). Locoregional recurrence was detected on clinical exam in 24 of 27 patients (88.9 percent), whereas mammography detected two recurrences that were palpable on follow-up examination.

●In a retrospective review of 515 women who underwent mastectomy with autologous reconstruction for cancer (78.5 percent) or prophylaxis (21.5 percent), locoregional recurrence occurred in 21 women (4.1 percent) with a median time between reconstruction and first recurrence of 4.4 years (range 0.8 to 16.2 years) [167]. After prophylactic mastectomy, there were no breast cancers within the flap, skin, or chest wall; the two malignant ipsilateral events included one lymphoma and one contralateral nodal metastasis. Among 24 malignancies in the 21 women, 15 (62 percent) were symptomatic (visible or palpable) and 9 (39 percent) were occult. For women undergoing routine mammography, the cancer detection rate per flap reconstruction was 1.5 per 1000 mammograms, which was comparable to that of an age-matched woman.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Breast surgery".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Flap surgery (The Basics)")

SUMMARY AND RECOMMENDATIONS

●There are three general types of reconstructive procedures: prosthetic devices (eg, tissue expanders, saline implants, silicone implants), oncoplastic reconstruction using volume displacement or replacement techniques, and autologous tissue reconstruction, which involves the transfer of a flap of tissue from a donor site to the anterior chest wall. The choice of the reconstructive option depends upon a variety of factors, including body habitus, associated comorbidity (eg, obesity, history of diabetes, smoking), the size and configuration of the contralateral breast, prior surgical procedures, the quality of the chest wall skin, and patient choice. (See 'Clinical evaluation' above.)

●Breast reconstruction is often performed immediately after mastectomy. The advantages of immediate reconstruction include streamlined care, reduced cost, superior cosmetic results, and psychosocial benefits. Immediate reconstruction may be considered for most patients undergoing mastectomy (with the exception of inflammatory breast cancer). (See 'Timing of breast reconstruction' above.)

●For women who are likely to need postmastectomy radiation therapy, the majority of plastic surgeons prefer to place an implant or tissue expander. If autologous reconstruction is ultimately desired, this can be performed 6 to 12 months later. Most surgeons prefer not to radiate a flap reconstruction due to the long-term effects of the radiation on the flap. In patients who have had prior radiation therapy and now need reconstruction, most surgeons will use autologous reconstruction because of the decreased incidence of complications and the increased likelihood of long-term success. (See 'Integrating radiation therapy and breast reconstruction' above.)