Updated: November 2004

Reconstruction mammoplasty in properly selected patients following mastectomy for cancer does not adversely affect the prognosis or the physician's ability to follow the patient for metastatic disease. The procedure can be of great psychological benefit and can be discussed with the patient prior to or following mastectomy.

The reconstruction may include the breast mound alone or also the nipple-areolar complex. The plastic surgeon performing the reconstruction should be in close contact with the surgeon who performed the original mastectomy for details of the patient's previous treatment and prognosis.

The timing of the reconstruction is important. Experience with immediate reconstruction is increasing and a draft policy statement on immediate reconstruction follows. Discussion should be directed to the B.C. Reconstruction Program at VGH: (http://www.vch.ca/breastreconstruction//)

A Statement Re: Immediate Breast Reconstruction

A review of literature to date does not identify any detrimental effects associated with immediate breast reconstruction. The advantages to the patient in terms of body image and emotional state are well documented. There is no documented increase in local or regional recurrence associated with immediate reconstruction. No delay in recognition of local or regional recurrence, when it does develop, can be documented. Furthermore, no survival difference can be identified in patients who have undergone immediate reconstruction. Hence, in terms of tumour control, there are no patients in whom the procedure is specifically contraindicated.

Post-operative radiotherapy, when indicated, may be given in the usual way. There may be some adverse effects in terms of capsular fibrosis around implants. Tissue flaps should not be adversely affected. There are no problems in flaps utilized in head and neck reconstruction which are subsequently irradiated.

There may be some concern about delay of post-operative adjuvant chemotherapy. It is possible that post-operative complications may be increased if extensive tissue transfer is carried out. Again, review of the literature does not suggest that this is a significant problem in centres where this type of procedure is done frequently. The complication rate does not appear to be higher than that for mastectomy alone.

As a general principal, there does not appear to be any contraindication to immediate reconstruction for any patient who wishes it. There is, however, a significant resource issue to consider. The operating time for extensive tissue transfer is obviously significantly longer than that currently utilized in breast surgery. If the numbers done increase, then it may be necessary to select patients according to a priority list. It is understood that patients with known metastasis would not be candidates for reconstruction. A proposed patient grouping follows:

Before delayed reconstruction the following assessments are mandatory to assess the status of potential metastatic disease and the remaining breast tissue:

• Careful history and physical examination     
•  A chest X-ray     
• Mammogram of the contralateral breast     
• Liver function studies and CEA
• Bone scan

There are many patients who have no interest in breast reconstruction, but it is reasonable to discuss its availability with all women. Any patient contemplating reconstruction should recognize that the goal of reconstruction is for a good body image while fully clothed.

Reduction mammoplasty of the contralateral breast may be considered to retain symmetry. The remaining breast is at increased risk for malignancy with the risk probably greatest for patients who have lobular carcinoma or a significant family history. Some patients may be candidates for contralateral total mastectomy with bilateral implantation rather than simple reduction on the contralateral side.