Breast Reconstruction Options

What are the benefits of having breast reconstruction at the same time as mastectomy, and in which situations would it be recommended to postpone reconstruction?

Doctor Answers 32

Immediate Breast Reconstruction with fat

When possible, it is better to perform the first stage of breast reconstruction with
fat graft at the time of the mastectomy. Grafting at the time of the mastectomy
presents a uniquely privileged situation where three main constraints of large-volume
fat grafting are no longer restrictive.
1. The graft-to-recipient interface is preserved. We now have the opportunity to graft
the fat under direct vision and this will ensure optimal distribution of the micrografts.
The usual breast grafting procedure is in many ways a blind procedure. The tip of the
injection cannula is under the skin as the fat is being delivered. We do not see it. We
assume that with our micro grafting technique the fat droplets are adequately distributed,
but we cannot tell with certainty that the graft-to-recipient interface is preserved
and that there aren’t any areas of localized collections. However, when we
start the reconstruction (regeneration) at the time of the mastectomy, the chest muscle
we are grafting is exposed, and it’s no longer a blind procedure. We see the graft
being delivered by the cannula so we can make sure the graft is well distributed with
good contact with the muscle and that there aren’t any collections.

2. There is not an issue with internal pressure build up. The muscle we are grafting had
its restrictive envelope removed as part of the mastectomy so we can graft it without
being limited by the tightness developing inside. This allows us to make it swell with
very large volumes of fat delivered as ribbon rows in between the exposed muscle
fibers. We routinely graft well over 350 mL per breast at the time of the mastectomy.
We cannot achieve this amount when the graft is placed in a closed situation after a
mastectomy, where the recipient site has a restrictive envelope and will get rapidly
tight, even after BRAVA expansion.

3. The only reasons not to start the breast reconstruction at the time of the mastectomy
are usually the need for post mastectomy radiation, or the unavailability of an experienced team of plastic and cancer surgeons who can work together during that first operation. In this case, the reconstruction would follow.

We allow 3 to 4 weeks to pass to assure the adherence of the mastectomy skin
flaps to the chest wall and then we begin BRAVA expansion. Grafting would follow.  The ultimate outcome would be the same, but we would have missed
an opportunity to do the first graft and the patient would need an additional grafting
session to make this up. The immediate reconstruction opportunity would be lost
along with the satisfaction of instantly having a “social breast.”

The main advantage of immediate regeneration is that the patient is spared waking up
from the mastectomy with a concave chest defect. She actually wakes up with a breast,
albeit a small one. With the fat graft done concurrent with the mastectomy, she can preserve her cleavage and a “social breast”.

If a woman is at risk for hereditary breast cancer and has tested positive for the BRCA1
or BRCA2 Gene, the BRAVA + AFT (Autologous Fat Transfer) procedure is the least invasive method to regenerate a breast and produces the most natural results. Our technique, following a prophylactic mastectomy, will help the patient reclaim her breasts.

Immediate vs. Delayed Reconstruction

Immediate reconstruction generally facilitates a more elegant cosmetic result.  But to determine if you are a candidate for immediate reconstruction will depend on your tumor biology, the need for radiation, and your overall health status.  Delayed reconstruction is always an option (delaying your reconstruction until all your cancer care is complete).  For patients who are not sure if they will need radiation, a newer modality is also available called the delayed-immediate approach.  This means that at the time of mastectomy,  a temporary spacer implant is placed.  Once your pathology has been finalized and the need for radiation has been determined, then your definitive reconstruction is completed at a later date.  

Immediate Reconstruction vs. Delayed Reconstruction

Most patients are candidates for immediate breast  reconstruction. If you definitely need radiation treatment, you should consider delaying your breast reconstruction until after your treatment is complete. 

For most other patients, immediate breast reconstruction have several advantages including:

1. Few surgeries and anesthetics

2. Improved Cosmetic Outcome

3. Smaller Scars

4. Psychologic Benefit / Impact

To learn more about the difference between immediate and delayed breast reconstruction in Jacksonville, visit our site below.

Ankit Desai, MD
Jacksonville Plastic Surgeon
5.0 out of 5 stars 19 reviews

You and your surgeon will have to decide

Immediate breast reconstruction (at the time of mastectomy) has several advantages; it saves a surgery, the aesthetic results are better, there are psychologic advantages as well. Some complications, wound healing and infection rates are slightly higher with immediate reconstruction.

There are times when immediate reconstruction is not feasible and delayed would be better. Not everyone is a candidate for this. You and your surgeon will decide this.

Michael S. Beckenstein, MD
Birmingham Plastic Surgeon
5.0 out of 5 stars 18 reviews

Either approach can work well


This is a great question, and I imagine you will see lots of different answers to it. Some plastic surgeons will only perform a delayed reconstruction (postponed until after all of your breast cancer treatments are complete) while others offer immediate reconstruction to their patients.

In my practice, I will offer an immediate procedure to women who desire an immediate reconstruction, who are in overall good health and don't smoke, and who do not have advanced disease which would likely require radiation therapy. I think the advanatges to an immediate reconstruction in this case are one less surgery for the patient, less time between mastectomy and final reconstruction, and less time, if any, without a breast mound. There are some disadvantages, however, including the risk of delayed wound healing, infection, and if radiation is required, possibly a less than ideal cosmetic result or even complete loss of the reconstruction.

This is something that you need to sit down and carefully discuss with your surgeon in detail so that the two of you can put a plan together that works well for you. Remember, the first goal is to get you cancer-free-- everything else takes a back seat.

Best of luck,

Dr. S

Shahram Salemy, MD, FACS
Seattle Plastic Surgeon
5.0 out of 5 stars 134 reviews

Breast reconstruction options

I think it is better to have reconstruction at the same time if possible. This is because you can compare what you have removed to what you are adding, and also can perform the reconstruciton with more supple tissue that is not scarred down. I would postpone it if the patient has a very large tumor, metastatic disease ( not just in the axillary nodes), and those that require radiation.

Steven Wallach, MD
New York Plastic Surgeon
4.0 out of 5 stars 23 reviews

Immediate breast reconstruction preserves the skin of the breast!

Three basic forms of breast reconstruction exist. You can use your own tissue, implants or a combination of the previous two techniques. Your own tissue can be used in the form of the DIEP flap, PAP flap, SGAP flap or fat grafting. Implants can be done in one stage or two stage. Two stage reconstructions are started by placing expanders at the time of mastectomy. Once they expanders are placed they are able to be inflated as determined by wound healing. The final time consists of combining any of the above techniques..

Please find an experienced Board Certified Plastic Surgeon and member of the Aesthetic Society using the Smart Beauty Guide. These Plastic Surgeons can guide you on all aspects of facial surgery, breast augmentation and body procedures including tummy tucks or mommy makeovers!

Breast reconstruction immediately following mastectomy

When the first stage of the reconstruction is done at the time of the mastectomy, it eliminates the need for an additional surgical procedure. Another benefit is psychological; it sometimes is easier for people to accept the loss of a breast if they immediately begin the process of reconstruction. Some surgeons believe that the aesthetic results are also better with immediate reconstruction.

This method is not recommended, however, if radiation treatment is anticipated or for patients who smoke or have dietary issues or other health problems. Also, reconstruction should be delayed if a patient is unsure whether she wants to proceed with reconstruction. This way, she will have more time to consider her options, which can be excellent whether the procedure is immediate or delayed.

Wandra K. Miles, MD
Seattle Plastic Surgeon
5.0 out of 5 stars 2 reviews

Immediate versus Delayed Reconstruction

Immediate reconstruction after skin sparing mastectomy is by far the best way to get the most natural result possible.  The only time I recommend waiting is if the patient requires postoperative radiation therapy and even then it is not a hard and fast rule.  You will always get a better result with immediate reconstruction.

Choosing breast reconstruction - details to consider

If you choose reconstruction, there are several details to consider. Reconstruction can be performed at the same time as your mastectomy (immediate reconstruction), or it can be performed at any time in the future following your mastectomy (delayed reconstruction). After any type of breast reconstruction, plans may be made to reconstruct a nipple and areola complex in the future. This may be performed at any time after a few months from your final reconstructive procedure. The breast reconstruction procedures that are offered today include both implant-based and autologous (your own tissue) flap reconstructions, including DIEP, SIEA, TAP, and other free-tissue transfer breast reconstructive procedures. Be aware of all of your options, and again, become involved in the decision of which reconstructive procedure will be the best fit for you.

Women may choose not to undergo surgical reconstruction. For medical or psychological reasons, some women choose to delay their reconstruction. If you choose not to undergo immediate reconstruction, this does not preclude you from undergoing reconstruction at a later date. Some women have had breast reconstruction surgery months to years after their mastectomy. Often times, the same reconstructive options are available to you, and your surgeon will help to determine this for you when you feel ready to proceed with your reconstruction.

During this time, you may consider wearing an external breast prosthesis garment fit to match your remaining breast, or wear prostheses for both breasts. However, a reconstructed breast offers several advantages over breast prostheses. You will not be limited in your clothing options or the activities in which you participate. Psychologically, women reiterate the fact that they feel more confident, attractive, and feminine with a reconstructed breast than without one. The fear of the prosthesis becoming visible or displaced is gone. There is no constant reminder of the previous surgery on your breast or the cancer when placing the prosthesis on and taking it off. Lastly, there is a wholeness that is achieved, as the reconstructed breast becomes part of your own body.

Overall, every woman should be informed of her breast reconstruction options following breast surgery at the time of her diagnosis. Taking into account your cancer type, tumor size, nodal involvement, the need for pre/postoperative chemotherapy or radiation therapy, your overall medical health and comorbidities, along with your own personal preferences, should lead to a meaningful discussion about which reconstructive procedure, if any, you should have.  Just as stated in other posts, immediate reconstruction is preferred for its increased aesthetic results, psychologic advantages, and "single operative & anesthetic" procedure.  Although recent studies have shown excellent results with immediate reconstruction in the face of post-mastectomy radiation therapy, the traditional mode is to perform the reconstruction several months after completion of the radiation therapy.  There are several reconstructive options to consider, and not one procedure is right for each person. However, your breast surgeon should discuss the breast reconstruction option and your plastic & reconstructive surgeon should inform you about the pros and cons of every procedure available and assist you in deciding which procedure is most suitable for you.

Lewis Albert Andres, MD
Scottsdale Plastic Surgeon
5.0 out of 5 stars 17 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.