review - wordpress.com … · reconstruction have been shown to be those of a younger age, married,...

IntroductionMastectomy is frequently used in the treatment and pro-

phylaxis of malignant breast disease, and thus breast recon-struction has become a significant part of the management of breast cancer. The removal of a breast has implications for the psychologic, social, and sexual well-being of the patient, establishing the need for discussion of postmastectomy breast reconstruction in suitable patients. Advances in reconstructive options have created a diversity of procedures that are becom-ing increasingly utilized, ranging from implantation to autolo-gous reconstruction, with the abdominal wall donor site flaps becoming increasingly established as a preferred method.

Despite improvements in cosmetic outcome and the tech-niques for reconstruction, operative morbidity is not insignifi-cant, and so too the oncologic safety of breast reconstruction has been contentious. This review discusses the interplay between the psychosocial need for breast reconstruction in patients after mastectomy and the issues surrounding onco-logic safety. Oncologic safety is affected not only by the timing of breast reconstruction, but also by the need for adjuvant chemotherapy and/or radiation therapy (RT).

The Need for ReconstructionRemoval of a breast has long been known to have a signifi-

cant psychosocial effect on the patient (Table 1).1-19 This can include changes in body image and sexuality, with patients hav-ing undergone mastectomy more likely to have low self-esteem, low self-image, and a loss of feelings of attractiveness and femininity. A recent review of the literature on the psychologic effect of mastectomy demonstrated precisely these findings, in showing that half of all women undergoing a mastectomy suf-fer negative effects on body image and changes in sexuality.2 These findings have been further emphasized compared with

Submitted: Sep 6, 2007; Revised: Dec 12, 2007; Accepted: Jan 10, 2008

Jack Brockhoff Reconstructive Plastic Surgery Research Unit, Department of Anatomy and Cell Biology, The University of Melbourne, Parkville, Victoria, Australia

Address for correspondence: Warren Rozen, MBBS, Jack Brockhoff Reconstructive Plastic Surgery Research Unit, Room E533, Department of Anatomy and Cell Biology, University of Melbourne, Grattan St, Parkville 3050, Victoria, AustraliaFax: 613-9523-6155; e-mail: [email protected]

Defining the Role for Autologous Breast Reconstruction After Mastectomy: Social and Oncologic Implications

Breast reconstruction plays a significant role in the management of breast cancer. The removal of a breast has implications for the psychologic, social, and sexual well-being of the patient, establishing the need for discussion of postmastectomy breast reconstruction with suitable patients. However, operative morbidity and the potential for diminished oncologic safety are ongoing issues of contention. A Medline literature review was performed to evaluate the interplay between the psychosocial need for breast reconstruction in patients after mastectomy and the issues surrounding its oncologic safety. Immediate breast reconstruction does not impair the oncologic safety of breast cancer management, with no increase in local recurrence rates, and no delays in the initiation of adjuvant chemotherapy or radiation therapy (RT). Immediate breast reconstruction in the setting of chemotherapy is not associated with greater complication rates; however, there is some evi-dence for increased complications in the setting of adjuvant RT. Breast reconstruction has a positive effect on the psychosocial outcomes of mastectomy and is oncologically safe in the immediate and delayed settings. Ultimately, the decision-making process of whether to reconstruct, how to reconstruct, and when to recon-struct requires a multidisciplinary approach, with the patient, plastic surgeon, oncologic surgeon, medical oncologist, and radiation oncologist all contributing.

Clinical Breast Cancer, Vol. 8, No. 2, 134-142, 2008Key words: Chemotherapy, Fat necrosis, Flap loss, Predictive factors, Radiation therapy

Abstract

reviewcomprehensive

Warren Matthew Rozen, Mark W. Ashton, G. Ian Taylor

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134 • Clinical Breast Cancer April 2008

Clinical Breast Cancer April 2008 • 135

women undergoing partial mastectomy, suggesting that this response is greater than would be expected from dealing with the diagnosis and treatment of breast cancer alone.3,6,10,11

The need for reconstructive options has been considered since the 1890s, when reconstructive surgery of the breast came to clinical practice.20 Breast reconstruction in the pres-ent day is undertaken variably by 10%-30% of women after mastectomy.21,22 The women more likely to undertake breast reconstruction have been shown to be those of a younger age, married, employed full-time, and those with sufficient informa-tion about breast reconstruction (Table 2).7,8,18,19,22-28 Other factors that might predict women more likely to undertake breast reconstruction have been variably shown to be those placing a higher significance on appearance,25-27 those more likely to discuss important issues with their doctor and partner,25 those who are required to undertake mastectomy as the only surgical treatment option rather than those selecting it as a treatment option,28 and those requiring adjuvant chemotherapy and/or RT.8 Psychologic traits that have been described as potential associations with predicting patients likely to select reconstruction include depression and anxiety, and with poorer association, factors such as neuroticism, extroversion, and psychoticism have also been suggested.7,8,18,19 The surgical practice in a particular hos-pital has also been shown to affect decision making.7 Tumor size and other facets of tumor biology have not been shown to influence decision making.19,23

An awareness of these factors by treating surgeons is important when giving advice to all mastectomy patients; however, individual advice need also be tailored. In addi-

tion, the positive effect of reconstruction on many of these responses to mastectomy should be recognized. The pub-lished literature attests to the positive psychologic and social responses to breast reconstruction, with many large stud-ies displaying this benefit in the setting of immediate and delayed reconstruction.11-17 However, many of these studies demonstrate a greater psychosocial benefit from immediate reconstruction, with many of the negative effects of mastec-tomy prevented by avoiding a delay between mastectomy and reconstruction.

In addition to making the decision of whether to recon-struct the breast, the decision-making process further

Psychologic Responses to Mastectomy1-8,10-19Table 1

Depression

Anxiety

Poor body image

Poor self-esteem

Poor self image

Impaired emotional function

Impaired social function

Impaired sexual function

Patient Factors Predictive of the Choice to Undergo Breast Reconstruction7,8,18,19,22-28

Table 2

Younger age

Married

Employed full-time

Adjuvant chemotherapy

Adjuvant radiation therapy

Well-informed

Higher significance on appearance

More depressed

Local Recurrence Rate Postmastectomy and Immediate Breast Reconstruction for Breast Cancer

Table 3

Brown et al36

Carlson et al37

Carlson et al38

Downes et al64

Foster et al39

Foster et al61

Hidalgo et al40

Howard et al65

Huang et al62

Johnson et al41

Knottenbelt et al42

Kroll et al44

Kroll et al43

Kuske et al45

Langstein et al46

Medina-Franco et al47

Mustonen et al35

Noone et al49

Noone et al48

Petit et al50

Ringberg et al51

Rivadeneira et al52

Salhab et al53

Sandelin et al54

Sandelin et al55

Simmons et al56

Slavin et al30

Slavin et al57

Snoj et al58

Toth et al59

Vandeweyer et al60

Woerdeman et al63

Study

151

187

539

38

26

35

28

419

82

118

58

104

154

66

1694

173

66

185

306

146

79

198

20

100

203

231

161

25

156

50

49

85

No. ofPatients

48

38

65

53

49

48

27

59

40

28

60

67

72

48

80

73

46

26

77

156

43

49

14

36

60

60

65

45

66

57

72

73

MedianFollow-up(Months)

3 of 151 (2)

9 of 187 (4.8)

31 of 539 (5.8)

1 of 38 (2.6)

1 of 26 (3.8)

1 of 35 (2.9)

0

16 of 419 (3.8)

3 of 82 (3.7)

7 of 118 (5.9)

1 of 58 (1.7)

7 of 104 (6.7)

11 of 154 (7.1)

5 of 66 (7.6)

39 of 1694 (2.3)

7 of 173 (4)

5 of 66 (7.6)

10 of 185 (5.4)

16 of 306 (5.2)

13 of 146 (8.9)

4 of 79 (5)

9 of 198 (4.5)

0

8 of 100 (8)

13 of 203 (6.4)

8 of 231 (3.5)

17 of 161 (10.6)

1 of 25 (4)

1 of 156 (0.6)

0

2 of 49 (4.1)

2 of 85 (2.4)

LocalRecurrence

Rate (%)

encompasses the issues of when to reconstruct the breast and how to reconstruct the breast. This further complicates the decision-making process by the mastectomy patient, and emphasizes the need for consideration of all factors affecting decision making by the patient and surgeon.22 The advances in anatomic knowledge, surgical techniques, and prostheses have resulted in marked changes in the options available for reconstruction. These options have provided improvements

in cosmetic outcome, operative recovery, and operative mor-bidity, and with these advances, so too have patient expecta-tions similarly advanced.

The Timing of ReconstructionBreast reconstruction can be undertaken at the time

of mastectomy or delayed for a variable period thereafter. Although the decision to reconstruct the breast should ultimately be made by a well-informed patient, the timing of reconstruction requires the combined input of the plastic surgeon, oncologic surgeon, medical oncologist, and radia-tion oncologist. An understanding of the individual need for further investigation, further surgery, and/or adjuvant therapies will influence this decision process. However, where oncologically and logistically possible, the psycho-social benefits of immediate reconstruction, as previously described, have become increasingly apparent.

The influence of ongoing cancer management on the timing of reconstruction is the main concern when contem-plating immediate breast reconstruction. The detection of locoregional cancer recurrence has been discussed widely in the literature as being affected by immediate breast recon-struction. Similarly, adjuvant therapy has been discussed in this context, with breast reconstruction potentially delaying the administration of chemotherapy or RT, or conversely the adjuvant therapy affecting the operative outcome of breast reconstruction.

With changing techniques for reconstruction, there is a trend toward fewer staged procedures, and a trend toward increasingly refined operations to minimize operative com-plications. However, with these changing techniques have come changing spectra of complications. This requires con-sideration when reviewing the complications arising from the use of adjuvant therapies.

The Detection of RecurrenceThe need for ongoing screening for cancer recurrence is an

important part of the management of patients with breast cancer postmastectomy, and the impact of breast reconstruc-tion is worth consideration. The concern that autologous reconstruction might mask local recurrence, particularly chest wall recurrences, has been discussed widely in the literature. However, of note is that most local recurrences occur at the anterior chest skin and not on the chest wall,

Autologous Breast Reconstruction: Social and Oncologic Implications


Delay in Chemotherapy After Mastectomy and ImmediateBreast Reconstruction for Breast Cancer

Table 4

Agarwal et al80

Allweis et al81

Elliott et al78

Gouy et al74

Knottenbelt et al42

Mortenson et al75

Newman et al77

Salhab et al53

Schusterman et al76

Taylor et al72

Wilson et al71

Yeh et al79

Study

152

31

36

48

58

81

35

8

28

37

95

15

No. ofPatients

–

None, 12 days earlier thannonreconstructed

1 Patient delayed (no period given)because of wound complications

–

–

–

14-Day delay

–

7 Patients delayed (no period given)because of wound complications

5-Day delay

No significant delay (5 patientsdelayed > 40 days because of

operative recovery/complication)

–

Chemotherapy Delay

Morbidity Related to Chemotherapy After Mastectomy and Immediate Breast Reconstruction for Breast Cancer

Table 5

Agarwal et al80

Allweis et al81

Elliott et al78

Gouy et al74

Knottenbelt et al42

Mortenson et al75

Newman et al77

Salhab et al53

Sandelin et al55

Schusterman et al76

Taylor et al72

Wilson et al71

Yeh et al79

Study

152

31

36

48

58

81

35

8

203

28

44

95

15

No. ofPatients

–

–

Nonsignificant increase inwound complications

–

–

–

16% Early wound complications:infection, necrosis

–

–

Greater wound complications(no numbers given)

Greater impaired wound healing(no numbers given)

–

–

Morbidity

Delays in RT After Mastectomy and Immediate Autologous Breast Reconstruction for Breast Cancer

Table 6

Downes et al64

Foster et al39

Gouy et al74

Hultman et al89

Salhab et al53

Study

34

26

48

5

2

No. of Patients

–

–

–

–

–

RT Delay

Warren Matthew Rozen et al

and can therefore be detected easily on clinical examina-tion.29-33 An interplay is certainly present between the need to remove a maximal amount of breast tissue from the skin flap and the risk of skin necrosis. Whereas residual breast tissue in the skin can lead to a greater incidence of local recurrence, skin necrosis and its treatment can similarly lead to a delay in oncologic adjuvant treatment.

To assess this issue, many studies have attempted to com-pare local recurrence rates after mastectomy and reconstruc-tion to reported rates of recurrence after mastectomy alone. The local recurrence rate after mastectomy alone has been reported variably as 2%-7%.30-32,34,35 As shown in Table 3, there have been many studies assessing the local recurrence rate after mastectomy with reconstruction.30,35-65 These studies have variable patient numbers and follow-up peri-ods, and demonstrate local recurrence rates of 0-11%, with a noticeable trend in more recent studies to significantly lower rates, certainly comparable with the recurrence figures for mastectomy without reconstruction. Several studies have performed comparative analyses of local recurrence between reconstructed and nonreconstructed mastectomy patients. These have not shown any increase in local recurrence rates, nor any increase in recurrence-free survival or any increase in overall survival (OS).66-68

Adjuvant and Neoadjuvant Chemotherapy

Immediate breast reconstruction after mastectomy for breast cancer might influence the administration of adjuvant chemotherapy. Operative recovery and potentially operative complications might prolong the onset of initiating chemother-apy and thus can undermine oncologic safety. However, there


Skin and Flap Contracture in a Deep Inferior Epigastric Artery Perforator Flap

Figure 1

Postoperative RT was administered to the superomedial pole of the breast. Marked skin changes, asymmetry, and nipple displacement are evident.

Skin and Scar Retraction in the Setting of Adjuvant Radiation Therapy After Partial Mastectomy

Figure 2

Skin and Nipple Retraction in the Setting of AdjuvantRadiation Therapy After Partial Mastectomy

Figure 3

is no clear evidence for the optimal timing of initiating chemo-therapy, with most guidelines suggesting that chemotherapy can be safely started within 4 weeks of mastectomy.68-71

Although most clinicians would not routinely delay the administration of chemotherapy after breast reconstruction, there are studies in the literature suggesting this possibility. In addition to the need for operative recovery, there has been apprehension at the influence of chemotherapy on wound healing and other operative complications. Chemotherapeutic agents have myelosuppressive and cytotoxic effects, which can last several weeks, and the effects of anemia and immu-nosuppression on wound healing, tissue necrosis, and infec-tion rates generate concern for operative recovery.29,72,73

As such, the potential for delayed initiation of chemo-therapy after immediate breast reconstruction has been looked at in the literature, in multiple nonrandomized stud-ies (Table 4).42,53,71,72,74-81 The majority of these studies, and in particular the studies with greater numbers, show no delay in the initiation of chemotherapy. The studies that did describe delays in starting chemotherapy listed opera-tive complications, particularly wound complications, as the causative factors.

In addition to the effect of operative complications on the initiation of adjuvant chemotherapy, the effect of the chemo-therapy itself on operative outcomes and operative compli-cations from breast reconstruction has also been assessed. There have only been limited studies, with few controlled or with comparative groups, but all the larger studies in this

setting have shown no significant increase in complication rates in those receiving adjuvant chemotherapy after breast reconstruction (Table 5).42,53,55,71,72,74-81 Neoadjuvant che-motherapy has also been looked at, with only 3 studies describing operative outcomes after neoadjuvant treat-ment.74,82,83 These were small studies, which weren’t con-trol matched: 2 showed no increase in operative complica-tions, whereas 1 study showed a 55% complication rate from breast reconstruction after neoadjuvant chemotherapy.

With limited studies from which to base clinical practice, the current data suggest that immediate breast reconstruc-tion does not affect the initiation of chemotherapy and is not fraught with an increase in complications before adju-vant chemotherapy, and there is no evidence to suggest any increase in complications after neoadjuvant chemotherapy.

Previous Irradiation and Adjuvant Radiation Therapy

Just as with chemotherapy, the issue of adjuvant RT is simi-larly contentious. Radiation therapy is an increasingly used adjuvant therapy in the treatment of breast cancer, with the use of adjuvant RT widely shown to reduce local recurrence after both partial and total mastectomy and shown to pro-long both disease-free and OS with nodal disease.84-88 In the setting of breast reconstruction, the effects of RT are poten-tially 2-fold, with consideration required of the effect of breast reconstruction on the administration of and the initiation of RT and the effects of RT on operative complications and cos-



Operative Complications After Autologous Breast Reconstruction with Previous Radiation TherapyTable 7

Chang et al112

Chawla et al117

Disa et al113

Hartrampf et al107

Hultman et al89

Jacobsen et al108

Kroll et al105

Kroll et al106

Kuske et al45

Moran et al114

Salmon et al109

Schuster et al118

Spear et al116

Temple et al115

Tran et al110

Watterson et al111

Williams et al104

Study

17

14

11

52

5

47

65

82

8

14

40

8

42

100

70

91

108

No. of Patients

Flap loss (partial), 6 patients (35.3%)

No increase in overall or individual complications, no effect on cosmetic outcome

Flap loss (partial), 1 patient (9.1%)

Flap loss (partial or complete), 6 patients (11.5%)

Flap loss (partial), 3 patients (60%)

No increase in complications: fat necrosis, 4 patients (8.5%); flap loss (partial or complete), 3 patients (6.4%)

Significantly poorer cosmetic outcome (aesthetic score)

Total complications significantly higher, 32 patients (39%); cosmetic outcome significantly poorer;flap loss (partial or complete), 28 patients (34.1%)

Significant increase in complications: overall complications, 5 patients (62.5%)

No increase in complications: fat necrosis, 1 patient (7%); flap loss (partial), 1 patient (7.1%)

Fat/skin necrosis, 2 patients (5%)

Significant increase in complications: overall complications, 5 patients (62.5%)

Fat necrosis, 10 patients (23.8%); flap loss (partial), 4 patients (9.5%); flap loss (complete), 1 patient (2.4%);overall flap complications, 24 patients (57.1%)

Fat necrosis, 16 patients (16%); flap loss (partial), 7 patients (7%); flap loss (complete), 2 patients (2%)

Fat necrosis, 6 patients (8.6%); flap loss (partial), 5 patients (7.1%); flap loss (complete), 1 patient (1.4%)

Total complications significantly higher, 34 patients (37.4%)

Fat necrosis, 19 patients (17.6%); flap loss (partial), 3 patients (2.8%)

Complication

metic outcome after rates of immediate breast reconstruction. These have been somewhat explored in the literature.

The effect of breast reconstruction on delaying the admin-istration of RT has only been explored in a handful of recent studies (Table 6).39,53,64,74,89 This is surprising considering the importance of the issue, with several significant stud-ies demonstrating poorer oncologic outcomes with delays in RT.90-93 The studies which have addressed the issue have all been relatively low in numbers and were all single institution-al. All studies showed no delay in the initiation of adjuvant RT in patients undergoing immediate breast reconstruction.

Autologous breast reconstruction can also affect the deliv-ery of RT by distorting the chest wall anatomy and thus altering the design of the RT fields. The randomized control trials discussed previously, all demonstrate the advantages of RT in the setting of radiation fields that include the chest wall, internal mammary lymph nodes, supraclavicular lymph nodes, and the apex of the axilla. Distorting the anat-omy with a reconstructive flap might diminish the radiation administered to these regions, or more commonly, might dictate the need for a wider radiation field.94-96

Radiation therapy involves the use of ionizing radiation, delivered by external-beam radiation to the chest wall and/or the surrounding lymph nodes. The mechanism for its effect is 2-fold: direct disruption of protein and DNA molecules and the formation of free radicals and electrons that cause molecular damage.93 However, in addition to direct toxicity to malignant cells, radiation also damages healthy tissue (Figures 1-3). Direct tissue cellular damage with chromosomal alteration, microvascular occlusion with ischemia, and inhibition of fibro-blast action have all been implicated as mechanisms for tissue damage.97-100 Structural changes to the skin include epidermal and dermal keratinocyte and melanocyte changes, damage to skin appendages, skin thinning, and fibrosis.97,99,100

On this background of tissue damage, the incidence of operative complications would be expected to be higher,

particularly those associated with healing. In the setting of implant reconstruction, adjuvant RT has been shown to have an unacceptably high complication rate, particularly the com-plications of capsular contracture, and rupture of the implant envelope or fibrous capsule.68,101 If there is any possibility of postoperative RT, implant reconstruction has been well docu-mented as an ill-advised option.101-103 The same conclusion for autologous reconstruction is certainly less rigid.

The effect of RT on operative outcome has been explored to a large extent, but not in any randomized control trials. For autologous reconstruction, there is conflicting data, with the timing of RT of importance. The complications that occur after autologous reconstruction in the previously irradiated chest are similar to those occurring in the setting of no radiation. However, for the reasons previously described, the tissues have been afflicted with radiation damage, and thus wound complications can be increased. Nevertheless, autolo-gous reconstruction allows removal of some of the damaged tissue and the introduction of donor-healthy tissue.

The outcome of autologous reconstruction in the setting of previous RT has been described in studies spanning a period of > 15 years (Table 7).45,89,104-118 These studies range from small, noncontrolled studies to large studies with > 100 cases that have been matched to an unirradiated group. This diversity is echoed in their findings, with some of the larger studies demonstrating no significant difference in outcome and some showing significant increases in com-plication rates. The largest study was that of Williams et al, in which 108 patients with trans-rectus abdominis muscle flap reconstruction after previous RT were compared with 572 patients without previous RT, with this study showing an increase in fat necrosis in patients with previous RT, but no increase in overall complications.104 Of the larger studies that assessed cosmetic outcome in the setting of previous RT, there were significantly poorer cosmetic scores.105,106 However, the overall incidence of these complications were



Operative Complications from Autologous Breast Reconstruction with Subsequent Adjuvant Radiation TherapyTable 8

Chawla et al117

Halyard et al125

Hanks et al127

Huang et al62

Hunt et al128

Mehta et al126

Rogers et al121

Spear et al116

Tran et al122

Tran et al110

Williams et al123

Zimmerman et al124

Study

16

15

25

82

19

22

30

38

41

32

19

20

No. of Patients

No increase in overall or individual complications, no effect on cosmetic outcome

Fat necrosis, 2 patients (13.3%); flap loss, 1 patient (6.7%); good cosmetic result, 13 patients (86.7%)

No flap loss

Fat necrosis, 7 patients (8.5%); no flap loss

Fat necrosis, 2 patients (10.5%); no flap loss, good cosmetic result, 16 patients (84.2%)

No flap loss (partial or complete)

Fat necrosis, 7 patients (23.3%); flap contracture, 5 patients (16.7%)

Fat necrosis, no flap loss, 9 patients (23.7%); overall flap complications, 19 patients (50%)

Significant increase in fat necrosis, 14 patients (34.1%); flap contracture, 10 patients (24.4%);flap fibrosis, 17 patients (41.5%)

Fat necrosis, 14 patients (43.8%); no flap loss (partial or complete)

Fat necrosis, 3 patients (15.8%); flap fibrosis, 6 patients (32%)

No flap complications, good cosmetic result, 18 of 20 (90%)

Complication

not high and, as such, autologous reconstruction is still considered safe after neoadjuvant RT. An additional con-sideration of preoperative RT is that it might reduce the incidence of locoregional recurrence and increase disease-free survival, thus reducing the incidence of local recurrence after reconstruction.119,120

The outcomes after autologous reconstruction with subse-quent adjuvant RT has been explored widely, with variable results (Table 8).62,110,116,117,121-128 Although most studies described extremely low flap loss rates, the incidence of tissue complications was generally greater than comparative groups, particularly that of fat necrosis. Several studies documented fat necrosis rates of > 20%.110,116,121,122 However, the largest study by Huang et al, did not demonstrate high complication rates, with no flap loss and an 8.5% incidence rate of fat necro-sis, a figure comparable with those without adjuvant RT.62 Despite this, if RT is expected, delaying the reconstruction is the preferred mode of management.

Because of these findings, the studies described herein var-ied in their conclusions. Several conclude that delayed recon-struction results in fewer complications and better outcomes, and others suggest that immediate reconstruction is safe and has no adverse consequences over delaying reconstruction. A compromise, the “delayed-immediate” reconstruction has also been described herein, in which a 2-stage approach comprises a tissue-expander in the first stage, and autologous recon-struction ensuing if radiation is subsequently not required.129 The group at greatest risk for requiring adjuvant RT, those with locally advanced disease and/or nodal metastases, cer-tainly warrant greater consideration of a delayed reconstruc-tion. However, this group is not always easily determined as, although preoperative ultrasonography can predict nodal status, there is a low sensitivity for small macrometasta-ses and indeed micrometastases.130 Similarly, both axillary node frozen section and imprint cytology have significant false-negative rates, and thus it is only postoperatively that a complete management plan can be formulated.131,132 As such, a significant number of patients not expected to require adjuvant RT will ultimately be found to require it, warranting consideration of delayed reconstruction.

ConclusionBreast reconstruction plays a highly important role in the

management of patients with breast cancer. The social and psychologic benefits of reconstruction are further enhanced in the setting of immediate breast reconstruction after mas-tectomy. Immediate breast reconstruction does not impair the oncologic safety of breast cancer management, with no increase in local recurrence rates and no delays in the ini-tiation of adjuvant chemotherapy or RT. Immediate breast reconstruction in the setting of neoadjuvant or adjuvant che-motherapy is not associated with greater complication rates. Both neoadjuvant and adjuvant RT can increase the incidence of postoperative complications, which are greater after adju-vant RT. Although this is not high-level evidence, if adjuvant RT is planned or in patients at high risk, a delayed reconstruc-

tion should be considered. Ultimately, the decision-making process of whether to reconstruct, how to reconstruct, and when to reconstruct requires a multidisciplinary approach, with the patient, plastic surgeon, oncology surgeon, medical oncologist, and radiation oncologist all contributing.

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