Delayed-Immediate Breast Reconstruction: 4 Years Later
Introduction: In May 2002, we implemented a new two-stage approach to breast reconstruction, “delayed-immediate breast reconstruction,” for patients who are considered preoperatively to be at an increased risk of requiring postmastectomy radiation therapy (PMRT).
Purpose: The purpose of this study was to determine if this two-stage approach can achieve comparable outcomes with immediate reconstruction in patients who are determined not require PMRT and if it avoids the aesthetic and radiation delivery problems that can occur after an immediate breast reconstruction.
Methods: Between May 2002 and November 2006, 42 patients who were considered preoperatively to be at an increased risk of requiring PMRT underwent delayed-immediate breast reconstruction (Fig. 1) at M. D. Anderson Cancer Center.
Results: Preoperative indications for delayed-immediate breast reconstruction included: T2 tumor (8 patients); T1 or T2 tumor with associated extensive microcalcifications (6 patients); multicentric breast cancer (14 patients); T1 or T2 tumor with a biopsy-proven involved axillary lymph node (14 patients). After review of the permanent pathology, 62% (26 of 42 patients) of patients did not require PMRT and 38% (16 of 42 patients) did require PMRT. Only 6% (1 of 16 patients) of the patients who required PMRT had the radiation design fields scored (in terms of four basic objectives of PMRT, as follows; breadth of chest wall coverage, complete inclusion of the first three intercostal spaces of the ipsilateral internal mammary chain, minimization of lung irradiation, and avoidance of heart structures) as compromised, 94% (15 of 16 patients) were scored as uncompromised. Complications rates with delayed-immediate reconstruction included; stage I (3 of 42 patients, 7%), stage II (4 of 26 patients, 15%), skin-preserving delayed reconstruction (1 of 13 patients, 7%), and expander loss (surgery-related, 2%; PMRT-related, 6%). Mean aesthetic outcome scores (panel of 23 blinded judges) in patients who underwent delayed-immediate reconstruction but did not require PMRT [latissimus dorsi flap plus implant, (3.00); transverse rectus abdominis myocutaneous flap, (3.09)] were comparable with a matched-group of patients who underwent standard immediate reconstruction [latissimus dorsi flap plus implant, (2.94); transverse rectus abdominis myocutaneous flap, (2.95)]. Only 2% (1 of 42 patients) of the patients developed a recurrence of breast cancer after an average follow up of 24 months.
Conclusions: Delayed-immediate breast reconstruction may become the standard approach to managing patients who may require PMRT.
Figure 1