State of the art in breast reconstruction

In patients undergoing breast reconstruction after partial and total mastectomy, selecting the appropriate timing as well as the best method of reconstruction are essential to optimize the outcome. At M.D. Anderson Cancer Center, the timing of oncoplastic repair after partial mastectomy defects and breast reconstruction after mastectomy tends to dictate the technique for reconstruction. In patients undergoing repair of a partial mastectomy defect, immediate or delayed repair before radiation therapy allows for the use of the remaining breast tissue to perform the repair. Delayed repair after radiation therapy is usually performed with autologous fat grafting or a flap. Immediate breast reconstruction after mastectomy is preferable for patients with a low risk of requiring postmastectomy radiation therapy (XRT) (stage I breast cancer, some stage II). In patients who are deemed preoperatively to be at an increased risk of requiring XRT (stage II breast cancer), delayedimmediate breast reconstruction may provide an additional option. Delayed-delayed reconstruction may be a consideration in patients known preoperatively to require XRT (stage III breast cancer), to allow for a skin-preserving delayed reconstruction after XRT. Newer techniques for breast reconstruction after mastectomy include one-stage implant, implant-based reconstruction plus acellular dermal matrix, autologous fat grafting after negative suction applied to chest wall, and perforator-based autologous tissue flaps. Often, the decision to perform a partial or total mastectomy depends upon reconstructive issues, not oncology-related considerations. Whether to repair a partial mastectomy defect or perform a total breast reconstruction after mastectomy is one of the most critical decisions in breast reconstruction.