Immediate or primary reconstruction is the removal of part or all of the breast gland, with immediate breast reconstruction. Since the patient does not wake up without her breast, it is associated with much lower psychological morbidity than delayed reconstruction. Combining these two major procedures results in only one surgery and a shorter overall hospital stay. This makes immediate breast reconstruction more tolerable for the patient and significantly less expensive. Several recent studies have also indicated that there is no risk of delaying subsequent adjuvant therapy.
Primary breast reconstruction has become the standard of care over the last decades. Some debate still exists on whether primary reconstruction should be offered to patients for whom postoperative radiotherapy is scheduled. It is our preference not to perform immediate autologous reconstruction when post-mastectomy radiation is definitely required. In these patients, temporary implants (baby-sit implants) are inserted that simply restore the shape and volume of the resected gland. If the breast skin envelope is large, there will inevitably be some post-operative skin shrinkage or one can perform a skin reduction at the time of the mastectomy. However, if the skin envelope is naturally small or skin has been resected, tissue expanders can be inserted. Some radiotherapy centers also prefer the expander to be deflated during irradiation. Delayed primary reconstruction is then performed six months after finishing the last radiotherapy session.
If it is unclear whether postoperative radiotherapy is required, an immediate autologous breast reconstruction can still be performed but the reconstructed breast is made 15-20% larger than the final desired size. Post-radiotherapy fibrosis and sclerosis are often associated with approximately a 10% volume loss. In addition, having some surplus tissue provides flexibility in refining the shape of the breast at a second procedure.
Benefits of primary reconstruction include:
- Lower psychological impact for women: the fear of living without a breast(s) is removed. There is no loss of self-confidence, as body image is maintained.
- A single surgical procedure: only one set of surgical and anesthetic complications and one recovery period.
- The hospital stay after ablative (tumor removal) surgery combined with reconstruction is no longer than ablative surgery alone.
- Primary reconstruction is significantly less expensive than delayed reconstruction.
- Adjuvant therapy (chemotherapy, radiotherapy, hormone therapy) is not delayed.
The disadvantages of primary breast reconstruction are:
- It is more difficult to plan and schedule these procedures because two teams are required - an oncological surgeon (gynaecologist or general surgeon) and a plastic surgeon.
- The operation takes longer than ablative surgery alone.
- There is little or no time for a patient to adapt to the loss of her breast(s). This may lead to unrealistic expectations about the aesthetic result that can be achieved by immediate reconstruction.
It can be stressful for the patient, making multiple, often difficult decisions, on whether to proceed with breast reconstruction, in addition to all the mixed emotions of a recent cancer diagnosis. Some people need or prefer more time to process the information they have received.