Now or later: When should you have breast reconstruction surgery?

Breast reconstruction
Should you have breast reconstruction surgery, and if so, is it better to do it right away, or should you wait?

Patients typically feel overwhelmed with a cancer diagnosis, not just with processing the news, but with decisions they have to make, typically sooner than later.

Should I seek a second opinion?

Which treatment is right for me?

Which treatment may provide the best chance for a positive outcome?

For breast cancer patients who have made the choice to get a mastectomy or lumpectomy, an additional, highly personal decision must also be considered:

Should I have breast reconstruction surgery, and if so, is it better to do it right away, or should I wait?

One in eight American women develop some form of invasive breast cancer in her lifetime, so these questions around whether and when to get reconstructive breast surgery are asked with regularity, says Frederick L. Durden Jr., MD, Plastic and Reconstructive Surgeon & Microsurgical Reconstructive Surgeon at Cancer Treatment Centers of America® (CTCA), Atlanta. But, he says, the answers are not always black and white. A variety of breast reconstruction options may be available and each patient must weigh the pros and cons before choosing the best fit for her breast cancer type and lifestyle. Some patients may not be candidates for reconstruction, while others may choose not to do it at all.

“Breast reconstruction can have a significant impact on a woman’s post-operative life,” says Dr. Durden. “For some women, it can greatly improve their ability to interact socially, to enjoy life, and it may reduce the stress caused by seeing surgical scars as a daily reminder of their cancer, so it may have a clear benefit. Choosing whether to do immediate or delayed reconstruction varies greatly based on a number of factors.”

The number of women opting for breast reconstruction after a mastectomy or lumpectomy has been rising steadily, though the data varies slightly by study. The U.S. Department of Health and Human Services’ Agency for Healthcare Research & Quality (AHRQ) reported that as of 2016, more than 40 percent of American women who underwent a mastectomy chose to have breast reconstruction, a jump from 27 percent nine years earlier.

Experts believe the increase may be attributed to psychosocial benefits, surgical advances and the Women's Health and Cancer Rights Act of 1998 (WHCRA), a federal law requiring health insurers to cover breast reconstruction for those who opt for it following a mastectomy.

In this guide, we’ll cover the factors that typically are considered in deciding when to undergo breast reconstruction surgery, including:

Other considerations include the patient’s overall health, the stage of the cancer, and whether the patient will need radiation therapy.

If you’re interested in learning about breast reconstruction options at CTCA, or if you or a loved one is interested in getting a second opinion for a breast cancer diagnosis and treatment plan, call us or chat online with a member of our team.

Types of breast reconstruction

Generally speaking, there are two main options on when reconstructive surgery is performed:

Immediate reconstruction is done at the same time as the mastectomy or lumpectomy. It may be performed using breast implants or by taking tissue from another part of the body—usually the abdomen—to form a breast, or sometimes, a combination of the two. Immediate reconstruction is typically only an option for patients with early-stage disease.

Delayed reconstruction is performed in a different surgical procedure, weeks, months or even years after the mastectomy. One reason the oncologist and patient may opt for delayed reconstruction is to allow for time for the patient to complete chemotherapy and/or radiation therapy. This allows the patient to take more time to decide when, or if, to have reconstructive surgery.

In addition to these two options, there’s a third option that many women choose instead: a combination of the two, known as immediate-delayed breast reconstruction. In this procedure, the surgeon inserts a tissue expander to maintain the form of a breast at the time of the mastectomy or lumpectomy. The patient may undergo additional treatment, if needed, then undergo reconstruction later.

The tissue expander acts as a placeholder for the new breast. It gradually stretches the skin and muscle, creating a pocket in the skin and tissue of the chest wall to make sufficient room for the implant or reconstructed breast. Tissue expanders may be uncomfortable, and it may take months for the tissue to expand enough to allow for reconstruction.

Another option, of course, is to forego breast reconstruction altogether. “There’s an entire spectrum of women who do not have additional surgeries after their lumpectomy or mastectomy,” says Dr. Durden.

The advantages and disadvantages of immediate reconstruction

With an immediate reconstruction, the patient only has to undergo a single operation, meaning just one time under general anesthesia, and she doesn’t have to live without a breast, which may help some women with the psychological aspect of healing. “A mastectomy is body-changing surgery, and to come out of surgery with no breast may be very traumatic for many women,” Dr. Durden says. “We can talk about it, but actually seeing it is a different thing.”

Immediate surgery typically leaves fewer scars on the reconstructed breast, and in many cases, the nipple may be spared.

However, immediate reconstruction means a longer surgery, which requires taking the patient’s overall health into account. Smokers, or those who have co-morbidity conditions, such as diabetes or obesity, may be at an increased risk for complications.

Whether the patient needs radiation therapy also is a major consideration when it comes to the timing of breast reconstruction. According to breastcancer.org, some research indicates that a reconstructed breast may prevent some of the radiation dose from reaching the cancer.

Other risks for undergoing immediate breast reconstruction before radiation therapy include:

  • Increased risk of developing complications
  • Thinning of the skin
  • Breast asymmetry
  • A radiated breast that looks different than the other breast
  • An infection that delays radiation therapy, which is typically done four to six weeks following a mastectomy
  • Skin that has shrunken after radiation therapy, resulting in the reconstructed breast hardening and sitting higher on the chest

The advantages and disadvantages of delayed reconstruction

For patients who are uncertain about whether they want a breast implant or a new breast made from their own tissue, or they haven’t yet decided whether they want reconstruction, delaying the procedure is typically the preferred option. Some patients want time to recover from the cancer surgery before deciding about next steps for cosmetic purposes.

If radiation therapy is part of the treatment plan, delayed reconstruction is usually recommended for the reasons mentioned above.

Other advantages of delaying reconstruction include:

  • The surgical site has had time to heal.
  • If the patient required radiation therapy, the radiated skin has also had time to heal.
  • The patient’s care team, which may include an oncologist, radiation therapist and breast reconstruction surgeon, have had time to confer about the recommended course of action.
  • The reconstructive surgeon may have more time and information to better advise the patient about her individual options.

Should you choose implants or tissue transfer?

The vast majority of women choose breast implants (81 percent) over an autologous surgery (19 percent). In the latter procedure, also called tissue or fat transfer, the plastic surgeon constructs the breast out of the patient’s own tissue taken from somewhere else on their body.  

There are advantages and disadvantages to any of these types of procedures, and a number of considerations must be weighed prior to deciding, Dr. Durden says.

“The patient’s overall health is part of the decision,” he says. “Is she healthy enough for a longer operation, or does she need a shorter one? There’s also a limitation to the size of breast implants. Larger women may need a tissue transfer because implants are not available that match the size of the other breast. Obesity, diabetes and other health conditions factor into choosing which type of surgery is best for that patient. There’s an increased risk of infection with diabetes that needs to be part of the discussion about implants. Medical conditions factor heavily into the decision. And we always try to optimize patient health before any surgery.”

The advantages and disadvantages of implants

Breast implants are popular among those getting them solely for cosmetic purposes. Perhaps for this reason, among others, most breast reconstruction patients choose breast implants over using their own tissue. It’s important for women to know ahead of time that breast implants are not lifetime medical devices, and the longer they’re in place, the greater the risk of complications.

Advantages of breast implants for breast reconstruction include:

  • Shorter and less technical procedure required than transferring tissue
  • Potentially easier recovery
  • Ability to choose a desired size, shape and texture for the implant
  • No tissue needed for harvesting from another part of the body, which translates into a lower risk of complications, such as poor wound healing and infection

Implants also come with these risks, including:

  • Scarring
  • Infection
  • Leaking, rupture or displacement of the implant
  • Breast implant illness, a term used to describe a variety of symptoms that may manifest as joint pain, autoimmune and connective tissue disorders, brain fog, fatigue and memory problems
  • Breast implant-associated large cell lymphoma (BIA-ALCL), a rare form of non-Hodgkin lymphoma linked to certain textured implants and tissue expanders

The advantages and disadvantages of tissue transfer

There are a number of advantages to a new breast that’s formed from the patient’s own tissue.

“In terms of the technical aspect of the operation, without a doubt, using tissue is more complicated,” Dr. Durden says. “But it feels more like a breast, it doesn’t involve a foreign body, and it’s permanent, whereas an implant may need to be revised during the patient’s lifetime. Tissue surgery also requires a secondary surgical site, where we harvest skin.”

The tissue is usually taken from the abdomen, though the upper and lower buttock and inner thigh may also be options. Dr. Durden says a number of women prefer to use their own tissue because “they just don’t wish to have an implant in their body.”

Advantages of tissue transfer include:

  • A more natural look
  • No need to worry about the body rejecting the tissue since it’s taken from the patient’s own body
  • Better breast symmetry
  • No chance of complications like leakage or rupture
  • No need for future implant-replacement surgery

Disadvantages of tissue transfer include:

  • Longer, more complicated procedure that requires a plastic surgeon trained in autologous breast reconstruction
  • Reduction in breast sensation
  • Complications at harvesting site

Because of the risk for delayed healing and/or infection, tissue-transfer procedures are not recommended for smokers, diabetics and those with certain other health conditions.

Reconstructive surgery at CTCA

When seeking treatment for your breast cancer and/or breast reconstruction, Dr, Durden recommends going to a specialist who focuses on breast cancer.

“At CTCA Atlanta, our patients have a team of experts dedicated to their care,” he says. “There are breast surgeons whose job is only to advise and treat the patient for breast cancer surgery. I am a breast reconstruction surgeon specializing is reconstructing breasts. The medical oncologist specializes in just medical oncology for breast cancer, and the radiation oncologist specializes in just radiation for the breast. Our job is to make our patients aware of the safest way to get them the outcome they want.”

The most important takeaway, according to Dr. Durden, is that each patient understands that her case is unique and she has options.

“Part of our responsibility to our patients is to make sure they are educated on the options available to them,” he says.

If you’re interested in learning about breast reconstruction options at CTCA, or if you or a loved one is interested in getting a second opinion for a breast cancer diagnosis and treatment plan, call us or chat online with a member of our team.