In many patients mastectomy is still indicated. Factors influencing this decision are the size of the primary tumor, unfavorable localization of the tumor, multifocality or multicentricity of the cancer and finally recurrence after previous breast conserving surgery. Fortunately we have moved away from the conventional radical mastectomy and in most cases a modified radical mastectomy or skin sparing mastectomy is offered. Depending on the wishes of the patient and the size and shape of the breast, skin-sparing mastectomies can be combined with either reduction of the skin envelope or breast lift.
Replacement of the breast volume and regaining the shape of a natural breast may be achieved by using either implants or transferring autologous (body-own) tissue from the abdomen, buttocks, thighs or back.
When a primary reconstruction is envisioned the inframammary crease, the pectoral muscle and the overlying skin should all be preserved during the mastectomy procedure. In case of shortage of breast skin the envelope needs to be replaced either by skin from the free flap or by a period of preoperative expansion in case of implant reconstruction.
When confronted with a secondary or tertiary breast reconstruction, the degree of surgical post-ablative damage and radiotherapy damage to the different anatomical structures of the breast needs to be assessed. More aggressive ablative surgery, higher doses of radiotherapy (or higher sensitivity to radiotherapy), the number and type of previous reconstructive attempts and the absence of the nipple-areolar complex will all make the reconstructive procedure more complex and negatively influence the final result.