Immediate breast reconstruction is a reconstruction that is begun at the time of mastectomy. It may involve tissue moved from the abdomen or the back, but more frequently is performed with a tissue expander which is partially filled and then held in place with the assistance of a material called acellular dermis which acts like a demi cup bra. There are advantages and disadvantages to this approach and certain patients a good versus poor candidates.
Advantages of immediate reconstruction include potentially having one fewer operation, having immediate volume on the chest was so the appearance is not so devastating post mastectomy, and maximal preservation of tissue for maximal size. Nipple sparing mastectomies almost always require an immediate approach. Disadvantages of immediate reconstruction are primarily secondary to healing problems from mastectomy skin flap with poor thickness and blood supply, so an experienced general surgeon is a crucial part of the team. The general surgeon has a very difficult job – the flaps must be thin enough to remove the breast tissue, but thick enough to have a good blood supply. Healing problems include scarring and infection which can lead to expander removal, backing up the process considerably. Radiation, if it turns out to be necessary, can severely effect the skin as well. Delayed reconstruction (starting about 6 weeks post mastectomy) usually avoids the skin flap healing problems, but of course, gives up the advantages of the immediate approach. A delayed result can usually be just as good as an immediate one.
What is the best way to go then? I and others believe it is to select good candidates (ones with few risk factors) for immediate reconstruction and make sure they are appropriately counseled to the risks, benefits, and alternatives. Studies have proven risk factors for immediate reconstruction problems include C cup breast or larger, expander diameter greater than 13 cm, BMI outside of normal range, age greater than 50, nicotine use (smoking, vaping, chewing, patches), medical problems, chemotherapy possible or known, radiation therapy possible or known, and inexperienced general surgeon. Having some of these factors does not mean you cannot have an immediate reconstruction, but it does mean that you will be at higher risk for problems.
In the Treasure Valley, the decision whether immediate reconstruction is offered is usually made by the general surgeon with the agreement of the patient and plastic surgeon, as well as the rest of the breast cancer team.