The Breast 20 (2011) S3, S104–S107

Contents lists available at ScienceDirect

The Breast

journal homepage: www.elsevier .com/brst

Original Article

Immediate breast reconstruction after mastectomy

Paolo Veronesia,b, *, Francesca De Lorenzic, Bettina Ballardinia, Francesca Magnonia, Germana Lissidinia,Pietro Caldarellaa, Viviana Galimbertia

aDepartment of Breast Surgery, European Institute of Oncology, Milan, ItalybUniversity of Milan, School of Medicine, cDepartment of Plastic Surgery, European Institute of Oncology, Milan, Italy

a r t i c l e i n f o

Keywords:

Immediate reconstruction

Mastectomy

Invasive cancer

Elderly

s u m m a r y

Aims: There is a general agreement for immediate breast reconstruction in case of in situ tumors,

while the reconstruction is often still delayed in cases of invasive cancers or not performed in the

elderly cohort.

Aim of this review is to investigate the safety of immediate postmastectomy reconstruction for

invasive cancers and in the elderly population.

Methods and results: We reviewed our series and the recent literature on this topic. While there

is a general consensus that advanced age is not a contraindication to immediate reconstruction

and breast reconstruction can be successfully performed on well-selected elderly patients, many

oncologists in Europe do not prefer immediate reconstruction for invasive carcinoma, advocating

the risk of delay of the medical adjuvant treatment in case of complications due to the

reconstructive procedure. Our experience and a lot of studies suggest that immediate breast

reconstruction is a safe and reliable treatment option in case of invasive cancers. However, if

postmastectomy irradiation is necessary on the basis of the final pathological finding, this is

associated with a high rate of surgical complications and implant loss among patients who

underwent immediate reconstruction with prostheses. Moreover, current evidence suggests that

postmastectomy radiation therapy also adversely affects autologous tissue reconstruction.

Conclusions: Immediate breast reconstruction after mastectomy is an integral part of the complete

management of breast cancer. Determining the risk of postmastectomy irradiation prior to

definitive resection and reconstructive operations may reduce complications and improve aesthetic

outcomes by guiding surgical decision making.

© 2011 Elsevier Ltd. All rights reserved.

Introduction

Immediate breast reconstruction is actually an integral part of

breast cancer treatment with positive aesthetic and psychological

results. At present, the surgical options available involve either

the use of autologous tissue, alone and in combination with an

expander/implant, or the use of prosthetic implant only: the choice

is based on patients’ characteristics and preference, stage of disease,

adjuvant therapies and surgeons’ attitude. Autologous tissue

are definitely preferable to breast implant within an irradiated

operative filed, in example in case of mastectomy after conservative

treatment.1 Immediate reconstruction is considered more practical,

and it is technically and economically more advantageous than

a delayed procedure. In term of psychological impact, immediate

reconstruction gives a greater sense of self-esteem and freedom

to wear the kind of clothes they desire, although the perception

of altered body image remains for a long time.2,3 Furthermore,

immediate reconstruction has an impact on proper body posture.4

* Corresponding author. Prof Dr Paolo Veronesi. Department of Breast

Surgery, European Institute of Oncology, Via Ripamonti 435, 20141

Milan, Italy. Tel.: +390257489656; Fax: +390294379228.

E-mail address: paolo.veronesi@ieo.it (P. Veronesi).

Moreover, since the first introduction of the skin sparing

mastectomy in 1991,5 immediate breast reconstruction has resulted

in better aesthetic results, also thanks to the preservation of

the inframammary fold. Even in women with macromastia, for

which there tends to be a mismatch between the retained skin

envelope and the reconstructed mound, whether this is with an

implant or an autologous flap, the Wise pattern skin-reducing

mastectomy provides the best options for shape and symmetry.6–8

And more recently, nipple-sparing mastectomies provide more

options for immediate breast reconstruction.9–16 Conservation of the

skin envelope and nipple areola complex with its vascularisation17

has led to improved aesthetic results following both autologous and

implant based reconstruction.18,19

In this article, we explore the current controversies regarding

immediate breast reconstruction, especially in cases of invasive

cancers and in the elderly cohort.

Methods

The Authors reviewed their series and searched the MEDLINE

database for studies of immediate breast reconstruction after

0960-9776/ $ – see front matter © 2011 Elsevier Ltd. All rights reserved.

P. Veronesi et al. / The Breast 20 (2011) S104–S107 S105

mastectomy. Studies were included if published after the 1990s and

a mean follow-up period was more than 1 year.

Results

Indications for immediate reconstruction in case of invasive tumors:

consensus and controversies

Although breast reconstruction has been a part of cancer treatment

for more than 30 years, many oncologists recommend delaying

the reconstruction in cases of invasive cancer, while immediate

reconstruction is widely accepted in case of in-situ cancers. They

advocate the risk of delay of the medical adjuvant treatment in

case of complications due to the reconstructive procedure. In a

previous publication20 we showed the absence of delay of the

chemotherapy despite the risk of local complications in relation

with the reconstruction. Moreover, it has been demonstrated

that neither the inclusion of chemotherapy nor the timing

of its administration significantly affect the complication rate

after mastectomy and immediate reconstruction.21 Although a

number of recent publications underline the safety of immediate

postmastectomy breast reconstruction for invasive carcinoma,22–30

no long term follow up of immediate reconstruction and no clear

comparison with a control group has been described until our

series in 2008.31 To reach a consensus on the safety of immediate

reconstruction after mastectomy for invasive breast cancer we

compared a consecutive series of 518 patients who have undergone

immediate reconstruction with 159 patients with no reconstruction

over a prolonged period time (average 70 months). All patients

underwent total mastectomy and complete axillary dissection,

including all three Berg’s levels. The same protocol of medical

treatment was delivered to the two groups. We observed that

disease-free survival (calculated from date of surgery to any local,

regional or distant relapse or death from cancer or to last visit

date in case of no events) and overall survival (defined as the time

interval from date of surgery to death from any cause or to the

last date of follow-up) were very similar for patients treated by

mastectomy only or mastectomy with reconstruction. Hence, the

type of immediate reconstruction does not influence the clinical

outcome of the disease. Most local recurrences observed were

cutaneous or subcutaneous and easily clinically diagnosed.32 The

presence of an implant facilities the palpation of the superficial

recurrence, whereas the deepest ones are diagnosed thanks to

the ultrasound examination or MRI. This data are consistent with

those in the literature26,33 No increased risk of local relapse has

been observed in other series of patients receiving postmastectomy

immediate reconstruction.27,34

Indications for immediate reconstruction in the elderly: consensus

and controversies

Elderly patients are defined as those patients exceeding 65 year

of age. In this population immediate reconstruction is performed

less frequently than in younger women, probably due to patient

preference or biases of advising medical personnel.35,36 In fact, it

is possible that at a later stage of life fewer women consider

breast reconstruction important, however breast reconstruction

often has not been offered to the elderly due to the reluctance of

clinicians who concerned about attendant serious co-morbidities.

These patients are still considered unfit for reconstruction due

to an inaccurate estimation of the operative risk.37 In our series

of consecutive 63 elderly patients who underwent immediate

reconstruction38 with a mean follow-up of 43.1 months, implant-

based breast reconstruction has been demonstrated to be feasible

and safe, although it is well known that the risk of perioperative

complications is proportionately increased because of the number

of co-morbidities and the relative risk of severe complications and

death are significantly greater in the geriatric population than in

the younger cohort. Accurate patient selection is mandatory. It is

necessary to address the overall status of the elderly patient when

reconstructive options are being considered. Acute and chronic

medical conditions, nutritional status and level of activity need to

be taken into consideration. Optimization of pre-existing medical

conditions is necessary.

Similar encouraging data are reported by Lipa et al.39 with

regard to autologous reconstructions in the elderly. They observed

acceptable rate of complications although the longer operative

times required for autologous tissue reconstruction, with prolonged

anaesthesia and greater fluid shifts.

There is a general agreement that elderly patients are less likely

to complete the reconstruction with the creation of a nipple–areola

complex and tattoo for colour symmetry.38–40

Indications for postmastectomy radiation therapy: consensus and

controversies

Postmastectomy radiation therapy improves the outcomes of

breast cancer patients with T3 or T4 or four or more positive

axillary lymph nodes.41–43 There is a general agreement that

reconstruction should be delayed in patients who are known at

mastectomy to require postmastectomy radiation therapy. In fact,

even with the latest prosthetic and modern radiation delivery

techniques, the complication rate for immediate implant-based

breast reconstruction in patients undergoing postmastectomy

radiation therapy is greater than 40 percent,44 and the extrusion

rate is 15 percent.45 Postmastectomy irradiation independently

predicts the occurrence of a complication and implant loss among

patients who underwent immediate reconstruction.46 The two-

stage breast reconstruction, with placement of a permanent

breast implant after postmastectomy radiation therapy, consistently

results in high rate of capsular contracture and poor cosmetic

outcomes.47 Specifically, for women with implants, radiation can

promote significant capsular fibrosis. Capsular contracture not only

distorts the appearance of the breast but also causes chronic chest

wall pain and tightness that can be crippling. Modified sequencing

of two-stage implant reconstruction, such that the expander is

exchanged for the permanent implant before postmastectomy

radiation therapy,48 can decrease the occurrence of acute wound-

healing problems (i.e. wound dehiscence, infection and implant

exposure) but results in higher rates of capsular contracture.

Moreover, it has been observed colour change of silicone gel

implants with less formable gel after irradiation.49

Current evidence also suggests that postmastectomy radiation

therapy also adversely affects autologous tissue reconstruction.50,51

A further important question concerning immediate breast

reconstruction and postmastectomy irradiation is whether the re-

construction can impair the efficacy of postmastectomy irradiation

by interfering with the radiation targeted field. In fact, even with

modern radiation delivery techniques, immediate implant-based

or autologous tissue breast reconstruction can distort the chest

wall and limit the ability to treat the targeted tissue without

excessive exposure of the heart and lungs. Although some radiation

oncologist believe that the effect of a breast implant or inflated

expander or autologous reconstruction is negligible52 and recent

studies53,54 have found that the metallic port within a tissue

expander does not result in significant scatter, which could lead

to “hot” or “cold” spots that alter the homogeneous treatment

of the chest wall, there is an increasing evidence that such

reconstruction can interfere with the delivery of postmastectomy

radiation therapy. In fact, the sloping contour of a reconstructed

breast results in an imprecise geometric match of the medial and

lateral irradiation fields, which can lead to underdosing of the chest

S106 P. Veronesi et al. / The Breast 20 (2011) S104–S107

wall, especially centrally underneath the breast mound and near

the internal mammary nodes.55,56 On the contrary, other Authors57

confirm that in women undergoing immediate expander/implant

reconstruction, postmastectomy irradiation can achieve excellent

local control with acceptable heart and lung doses. These results

can be achieved even when the internal mammary nodes are being

treated, although doses to the heart and to the lungs will be

higher. However, the need to treat the internal mammary nodes

is controversial because irradiation of the internal mammary chain

has not been shown to confer a benefit in survival or rate of distant

metastases.58,59

Unfortunately, the need of post mastectomy irradiation is not

always known at the time of mastectomy. In fact, recommen-

dations regarding postmastectomy irradiation are often based

on pathological analysis of the mastectomy specimen and on

axillary involvement and it is hard to tell at the time of

mastectomy how many lymph nodes are positive. Until we can

reliably predict the need for postmastectomy radiation therapy, one

option is to always delay breast reconstruction until the need of

postmastectomy irradiation is known. However, this denies patients

who ultimately do not require postmastectomy radiotherapy the

aesthetic and psychological benefits of immediate reconstruction.

Many oncologists are increasingly using this approach.1

Second option is performing an immediate expander/implant

reconstruction and, in case of post mastectomy irradiation and

possible unfavourable cosmetic results, performing a second

stage autologous reconstruction, as a salvage procedure. This

approach gives the positive psychological impact of the immediate

reconstruction and allows preserving the breast skin flaps and

mound. At our institute, if postmastectomy irradiation appears

likely but not is required, patients are well informed about the

possibility of unfavourable events due to irradiation and aware

of these issues throughout the entire decision-making process

and contribute to decisions concerning the sequencing of breast

reconstruction and postmastectomy radiation.

Third option is the so called delayed-immediate reconstruction.60

In this approach a tissue expander is placed at the time of

mastectomy. If postmastectomy irradiation is required, the tissue

expander can be deflated before irradiation to create a flat chest

wall and facilitate irradiation itself. It can be reinflated after the

completion of irradiation and afterwards a second stage autologous

reconstruction is planned.

Conclusion

Immediate postmastectomy reconstruction is an integral part of

the complete management of breast cancer. It is reliable and

safe in elderly patients and in invasive cancers. Controversies

regarding immediate postmastectomy reconstruction and following

irradiation are still unanswered. In patients who will receive or

have already received post mastectomy radiation therapy, the

optimal approach is delayed autologous tissue reconstruction after

postmastectomy radiation therapy.

Conflict of interest statement

The authors have no conflict of interest to declare.

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