A breast can be reconstructed at three distinct times related to the mastectomy surgery:

• Immediate Reconstruction: If a breast is reconstructed at the same operation as the mastectomy, it is known as an immediate breast reconstruction. Immediate breast reconstruction has been shown to be safe. It does not increase the risk of the cancer coming back and it does not prevent the detection of a cancer if it does come back. Immediate breast reconstruction has certain significant advantages:

• Psychological benefit: in that you wake up with a breast and never experience a mastectomy defect. The psychological benefits are obvious.
• Fewer operations: because the two operations are done together
• Cosmetic: the skin of the breast can be kept, meaning that there is less scarring, a better breast shape and a better overall cosmetic outcome

However, immediate breast reconstruction also has some definite disadvantages:

• Less time to make decision: usually an immediate reconstruction is done following a diagnosis of breast cancer. In this case there is an urgent need to proceed with cancer removal. This leaves very little time to decide on breast reconstruction.
• More complications: because a combination of mastectomy and breast reconstruction together carries more chance of complications than a mastectomy alone. Also, there is less time to optimise patient health (eg stop smoking, lose weight, control other medical problems) which increases the risk of complications too.
• Possible delay in chemotherapy: depending upon the type of breast cancer, some patients will require chemotherapy after their mastectomy. This chemotherapy is most effective if it is given within 6 weeks of the mastectomy. However, chemotherapy can only be given once the surgical wounds have fully healed. Wound healing complications are more likely after immediate breast reconstruction.
• Postoperative radiotherapy may damage the reconstruction: Depending upon the type of breast cancer, some patients will require radiotherapy after their mastectomy. This radiotherapy will quite likely damage the breast reconstruction.

• Delayed Reconstruction: If the breast is removed first (mastectomy) and the breast is reconstructed after a period of months or even years, this is known as a delayed breast reconstruction. Delayed reconstruction can sometimes be the better option. It would be recommended for women:

• Who have certain cancer types: there are some types of breast cancer where it is not wise to do an immediate breast reconstruction because of the high risk of the cancer coming back. In these cases it is usually better to proceed with a mastectomy, and then complete post-mastectomy chemotherapy and radiotherapy before considering a delayed breast reconstruction. Your breast cancer surgeon will advise you on this.
• Who are more likely to experience complications: for example heavy smokers, the significantly obese, or those with other medical problems which increases the risk of complications too.
• Who do not wish to risk possible delay in chemotherapy: depending upon the type of breast cancer, some patients will require chemotherapy after their mastectomy. This chemotherapy is most effective if it is given within 6 weeks of the mastectomy. However, chemotherapy can only be given once the surgical wounds have fully healed. Wound healing complications are more likely after immediate breast reconstruction.
• Who will definitely require postoperative radiotherapy: because this radiotherapy will quite likely damage the breast reconstruction, it may be better to proceed with a simple mastectomy, then receive radiotherapy and then, six months after the radiotherapy has been completed, a delayed breast reconstruction can be performed.

Being advised against an immediate breast reconstruction can sometimes be disappointing, but in all cases the cancer treatment must take priority over the cosmetic outcome. None of the above recommendations are absolute and you should discuss your wishes and motivations with your surgical team.

• Delayed-Immediate Reconstruction: This is a newer, less commonly used procedure. It is useful for fit, healthy, younger women with a high cosmetic demand who have been advised to proceed with a mastectomy alone and are planning a delayed breast reconstruction. The quality of the cosmetic outcome depends upon the breast skin. If the breast skin can be preserved, then the cosmetic outcome is usually better because it avoids the ‘patch’ of skin that is seen with the delayed reconstruction. It is not possible to remove the breast tissue and simply leave the breast skin because the empty skin will scar up, shrink and develop deep wrinkles. It is not possible to eradicate these wrinkles later. However, the breast skin can be ‘banked’ by inserting a tissue expander into it to stop it from shrinking and wrinkling up. Then later, the tissue expander can be removed and the breast can be reconstructed using living tissue from another part of your body. This preserves the breast skin, minimises scarring and therefore has the same cosmetic advantage as an immediate reconstruction.

There is however a disadvantage to this approach. Having a tissue expander under the skin increases the risk of the breast skin breaking down after the mastectomy. If this happens, any planned chemotherapy would be delayed, which reduces the effect of the chemotherapy.