Timing and Type of Breast Reconstruction in Young Breast Cancer Patients

  • Rosa Di Micco
  • Oreste GentiliniEmail author


Breast reconstruction is a significant component in the final recovery of young breast cancer patients, who have a longer lifetime after breast cancer treatment, and aesthetic outcome is a main contributor to their quality of life. The appropriate timing and type of breast reconstruction are considerations in young as well as in older breast cancer patient. The choice of the best breast reconstruction is based on oncological needs, surgeon’s advice and patient’s desire and should always be discussed in a multidisciplinary setting. Breast reconstruction can be performed as an immediate procedure, at the time of mastectomy, or as a delayed procedure, after adjuvant chemotherapy and/or radiotherapy. The young breast cancer patient has usually a wider choice of breast reconstruction techniques and is often more demanding and well informed compared to her older counterparts. In general, there are two types of breast reconstruction: autologous reconstruction requiring that tissue coming from the same patient (i.e. free or pedicled flaps) is utilised to reconstruct the breast; implant-based reconstruction implying that a prosthesis (i.e. expander or implants with or without biologic and synthetic meshes) is used to rebuild the breast volume. Radiotherapy plays an important role in choosing the type and timing of breast reconstruction and should always be evaluated in the multidisciplinary meeting in order to discuss all the alternatives to offer the patient.


Immediate breast reconstruction Delayed breast reconstruction Autologous reconstruction Implant-based reconstruction Composite breast reconstruction Biologic meshes Synthetic meshes Post-mastectomy radiotherapy 


  1. 1.
    Blondeel PN, et al. Shaping the breast in aesthetic and reconstructive breast surgery: an easy three-step principle. Plast Reconstr Surg. 2009;123(2):455–62.PubMedCrossRefPubMedCentralGoogle Scholar
  2. 2.
    Blondeel PN, et al. Shaping the breast in aesthetic and reconstructive breast surgery: an easy three-step principle. Part II--breast reconstruction after total mastectomy. Plast Reconstr Surg. 2009;123(3):794–805.PubMedCrossRefPubMedCentralGoogle Scholar
  3. 3.
    Ellsworth WA, et al. Breast reconstruction in women under 30: a 10-year experience. Breast J. 2011;17(1):18–23.PubMedCrossRefPubMedCentralGoogle Scholar
  4. 4.
    Cordeiro PG, et al. Irradiation after immediate tissue expander/implant breast reconstruction: outcomes, complications, aesthetic results, and satisfaction among 156 patients. Plast Reconstr Surg. 2004;113(3):877–81.PubMedCrossRefPubMedCentralGoogle Scholar
  5. 5.
    Cowen D, et al. Immediate post-mastectomy breast reconstruction followed by radiotherapy: risk factors for complications. Breast Cancer Res Treat. 2010;121(3):627–34.PubMedCrossRefPubMedCentralGoogle Scholar
  6. 6.
    Brennan ME, Spillane AJ. Uptake and predictors of post-mastectomy reconstruction in women with breast malignancy--systematic review. Eur J Surg Oncol. 2013;39(6):527–41.PubMedCrossRefPubMedCentralGoogle Scholar
  7. 7.
    Barry M, Kell MR. Radiotherapy and breast reconstruction: a meta-analysis. Breast Cancer Res Treat. 2011;127(1):15–22.PubMedCrossRefPubMedCentralGoogle Scholar
  8. 8.
    Brennan ME, et al. Immediate expander/implant breast reconstruction followed by post-mastectomy radiotherapy for breast cancer: aesthetic, surgical, satisfaction and quality of life outcomes in women with high-risk breast cancer. Breast. 2016;30:59–65.PubMedCrossRefPubMedCentralGoogle Scholar
  9. 9.
    Clarke-Pearson EM, et al. Comparison of irradiated versus nonirradiated DIEP flaps in patients undergoing immediate bilateral DIEP reconstruction with unilateral postmastectomy radiation therapy (PMRT). Ann Plast Surg. 2013;71(3):250–4.PubMedCrossRefPubMedCentralGoogle Scholar
  10. 10.
    Costa SD, et al. Neoadjuvant chemotherapy shows similar response in patients with inflammatory or locally advanced breast cancer when compared with operable breast cancer: a secondary analysis of the GeparTrio trial data. J Clin Oncol. 2010;28(1):83–91.PubMedCrossRefPubMedCentralGoogle Scholar
  11. 11.
    Dawood S, et al. International expert panel on inflammatory breast cancer: consensus statement for standardized diagnosis and treatment. Ann Oncol. 2011;22(3):515–23.PubMedCrossRefPubMedCentralGoogle Scholar
  12. 12.
    Patel SA, et al. Immediate breast reconstruction for women having inflammatory breast cancer in the United States. Cancer Med. 2018;7:2887.PubMedCentralCrossRefGoogle Scholar
  13. 13.
    Simpson AB, et al. Immediate reconstruction in inflammatory breast cancer: challenging current care. Ann Surg Oncol. 2016;23(Suppl 5):642–8.PubMedCrossRefPubMedCentralGoogle Scholar
  14. 14.
    Chang DW, Barnea Y, Robb GL. Effects of an autologous flap combined with an implant for breast reconstruction: an evaluation of 1000 consecutive reconstructions of previously irradiated breasts. Plast Reconstr Surg. 2008;122(2):356–62.PubMedCrossRefPubMedCentralGoogle Scholar
  15. 15.
    Kronowitz SJ. Delayed-immediate breast reconstruction: technical and timing considerations. Plast Reconstr Surg. 2010;125(2):463–74.PubMedCrossRefPubMedCentralGoogle Scholar
  16. 16.
    Mennie JC, et al. National trends in immediate and delayed post-mastectomy reconstruction procedures in England: a seven-year population-based cohort study. Eur J Surg Oncol. 2017;43(1):52–61.PubMedCrossRefPubMedCentralGoogle Scholar
  17. 17.
    Albornoz CR, et al. A paradigm shift in U.S. breast reconstruction: increasing implant rates. Plast Reconstr Surg. 2013;131(1):15–23.PubMedCrossRefPubMedCentralGoogle Scholar
  18. 18.
    Cemal Y, et al. A paradigm shift in U.S. breast reconstruction: part 2. The influence of changing mastectomy patterns on reconstructive rate and method. Plast Reconstr Surg. 2013;131(3):320e–6e.PubMedCrossRefPubMedCentralGoogle Scholar
  19. 19.
    Salzberg CA, et al. An 8-year experience of direct-to-implant immediate breast reconstruction using human acellular dermal matrix (AlloDerm). Plast Reconstr Surg. 2011;127(2):514–24.PubMedCrossRefPubMedCentralGoogle Scholar
  20. 20.
    Colwell AS. Direct-to-implant breast reconstruction. Gland Surg. 2012;1(3):139–41.PubMedPubMedCentralGoogle Scholar
  21. 21.
    Colwell AS, et al. Breast reconstruction following nipple-sparing mastectomy: predictors of complications, reconstruction outcomes, and 5-year trends. Plast Reconstr Surg. 2014;133(3):496–506.PubMedCrossRefPubMedCentralGoogle Scholar
  22. 22.
    Pusic AL, Cordeiro PG. Breast reconstruction with tissue expanders and implants: a practical guide to immediate and delayed reconstruction. Semin Plast Surg. 2004;18(2):71–7.PubMedPubMedCentralCrossRefGoogle Scholar
  23. 23.
    Spear SL, et al. Two-stage prosthetic breast reconstruction using AlloDerm including outcomes of different timings of radiotherapy. Plast Reconstr Surg. 2012;130(1):1–9.PubMedCrossRefPubMedCentralGoogle Scholar
  24. 24.
    Reitsamer R, Peintinger F. Prepectoral implant placement and complete coverage with porcine acellular dermal matrix: a new technique for direct-to-implant breast reconstruction after nipple-sparing mastectomy. J Plast Reconstr Aesthet Surg. 2015;68(2):162–7.PubMedCrossRefPubMedCentralGoogle Scholar
  25. 25.
    Antony AK, et al. Acellular human dermis implantation in 153 immediate two-stage tissue expander breast reconstructions: determining the incidence and significant predictors of complications. Plast Reconstr Surg. 2010;125(6):1606–14.PubMedCrossRefPubMedCentralGoogle Scholar
  26. 26.
    Winters ZE, Colwell AS. Role of acellular dermal matrix-assisted implants in breast reconstruction. Br J Surg. 2014;101(5):444–5.PubMedCrossRefPubMedCentralGoogle Scholar
  27. 27.
    Becker H, Zhadan O. Filling the Spectrum expander with air-a new alternative. Plast Reconstr Surg Glob Open. 2017;5(10):e1541.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Kim JYS, Mlodinow AS. What’s new in acellular dermal matrix and soft-tissue support for prosthetic breast reconstruction. Plast Reconstr Surg. 2017;140(5S Advances in Breast Reconstruction):30S–43S.PubMedCrossRefPubMedCentralGoogle Scholar
  29. 29.
    Cheng A, Saint-Cyr M. Comparison of different ADM materials in breast surgery. Clin Plast Surg. 2012;39(2):167–75.PubMedCrossRefPubMedCentralGoogle Scholar
  30. 30.
    Hinchcliff KM, et al. Comparison of two cadaveric acellular dermal matrices for immediate breast reconstruction: a prospective randomized trial. J Plast Reconstr Aesthet Surg. 2017;70(5):568–76.PubMedCrossRefPubMedCentralGoogle Scholar
  31. 31.
    Gschwantler-Kaulich D, et al. Mesh versus acellular dermal matrix in immediate implant-based breast reconstruction – a prospective randomized trial. Eur J Surg Oncol. 2016;42(5):665–71.PubMedCrossRefPubMedCentralGoogle Scholar
  32. 32.
    Cabalag MS, et al. Alloplastic adjuncts in breast reconstruction. Gland Surg. 2016;5(2):158–73.PubMedPubMedCentralGoogle Scholar
  33. 33.
    Macadam SA, Lennox PA. Acellular dermal matrices: use in reconstructive and aesthetic breast surgery. Can J Plast Surg. 2012;20(2):75–89.PubMedPubMedCentralCrossRefGoogle Scholar
  34. 34.
    Jansen LA, Macadam SA. The use of AlloDerm in postmastectomy alloplastic breast reconstruction: part I. A systematic review. Plast Reconstr Surg. 2011;127(6):2232–44.PubMedCrossRefPubMedCentralGoogle Scholar
  35. 35.
    Kim JY, et al. A meta-analysis of human acellular dermis and submuscular tissue expander breast reconstruction. Plast Reconstr Surg. 2012;129(1):28–41.PubMedCrossRefPubMedCentralGoogle Scholar
  36. 36.
    Hoppe IC, et al. Complications following expander/implant breast reconstruction utilizing acellular dermal matrix: a systematic review and meta-analysis. Eplasty. 2011;11:e40.PubMedPubMedCentralGoogle Scholar
  37. 37.
    Sbitany H, Serletti JM. Acellular dermis-assisted prosthetic breast reconstruction: a systematic and critical review of efficacy and associated morbidity. Plast Reconstr Surg. 2011;128(6):1162–9.PubMedCrossRefPubMedCentralGoogle Scholar
  38. 38.
    Alamouti R, Hachach Haram N, Farhadi J. A novel grading system to assess donor site suitability in autologous breast reconstruction. J Plast Reconstr Aesthet Surg. 2015;68(6):e129–30.PubMedCrossRefPubMedCentralGoogle Scholar
  39. 39.
    Delay E, Guerid S. The role of fat grafting in breast reconstruction. Clin Plast Surg. 2015;42(3):315–23. viiPubMedCrossRefPubMedCentralGoogle Scholar
  40. 40.
    Hitier M, et al. Tolerance and efficacy of lipomodelling as an element of breast symmetry in breast reconstruction. Ann Chir Plast Esthet. 2014;59(5):311–9.PubMedCrossRefPubMedCentralGoogle Scholar
  41. 41.
    Delay E, Delaporte T, Sinna R. Breast implant alternatives. Ann Chir Plast Esthet. 2005;50(5):652–72.PubMedCrossRefPubMedCentralGoogle Scholar
  42. 42.
    Delay E, Meruta AC, Guerid S. Indications and controversies in total breast reconstruction with lipomodeling. Clin Plast Surg. 2018;45(1):111–7.PubMedCrossRefPubMedCentralGoogle Scholar
  43. 43.
    Khouri RK, et al. Aesthetic applications of Brava-assisted megavolume fat grafting to the breasts: a 9-year, 476-patient, multicenter experience. Plast Reconstr Surg. 2014;133(4):796–807. discussion 808–9PubMedCrossRefPubMedCentralGoogle Scholar
  44. 44.
    Kosowski TR, Rigotti G, Khouri RK. Tissue-engineered autologous breast regeneration with Brava®-assisted fat grafting. Clin Plast Surg. 2015;42(3):325–37. viiiPubMedCrossRefPubMedCentralGoogle Scholar
  45. 45.
    Rigotti G, et al. Autologous fat grafting in breast cancer patients. Breast. 2012;21(5):690.PubMedCrossRefPubMedCentralGoogle Scholar
  46. 46.
    Schneider WJ, Hill HL, Brown RG. Latissimus dorsi myocutaneous flap for breast reconstruction. Br J Plast Surg. 1977;30(4):277–81.PubMedCrossRefPubMedCentralGoogle Scholar
  47. 47.
    Clough KB, Kroll SS, Audretsch W. An approach to the repair of partial mastectomy defects. Plast Reconstr Surg. 1999;104(2):409–20.PubMedCrossRefPubMedCentralGoogle Scholar
  48. 48.
    Johns N, et al. Autologous breast reconstruction using the immediately lipofilled extended latissimus dorsi flap. J Plast Reconstr Aesthet Surg. 2018;71(2):201–8.PubMedCrossRefPubMedCentralGoogle Scholar
  49. 49.
    Mushin OP, Myers PL, Langstein HN. Indications and controversies for complete and implant-enhanced latissimus dorsi breast reconstructions. Clin Plast Surg. 2018;45(1):75–81.PubMedCrossRefPubMedCentralGoogle Scholar
  50. 50.
    Branford OA, et al. Subfascial harvest of the extended latissimus dorsi myocutaneous flap in breast reconstruction: a comparative analysis of two techniques. Plast Reconstr Surg. 2013;132(4):737–48.PubMedCrossRefPubMedCentralGoogle Scholar
  51. 51.
    Hammond DC. Latissimus dorsi flap breast reconstruction. Plast Reconstr Surg. 2009;124(4):1055–63.PubMedCrossRefPubMedCentralGoogle Scholar
  52. 52.
    Losken A, et al. Outcomes evaluation following bilateral breast reconstruction using latissimus dorsi myocutaneous flaps. Ann Plast Surg. 2010;65(1):17–22.PubMedCrossRefPubMedCentralGoogle Scholar
  53. 53.
    Colohan S, et al. The free descending branch muscle-sparing latissimus dorsi flap: vascular anatomy and clinical applications. Plast Reconstr Surg. 2012;130(6):776e–87e.PubMedCrossRefPubMedCentralGoogle Scholar
  54. 54.
    Bailey SH, et al. The low transverse extended latissimus dorsi flap based on fat compartments of the back for breast reconstruction: anatomical study and clinical results. Plast Reconstr Surg. 2011;128(5):382e–94e.PubMedCrossRefPubMedCentralGoogle Scholar
  55. 55.
    Rusby JE, et al. Immediate latissimus dorsi miniflap volume replacement for partial mastectomy: use of intra-operative frozen sections to confirm negative margins. Am J Surg. 2008;196(4):512–8.PubMedCrossRefPubMedCentralGoogle Scholar
  56. 56.
    Thomsen JB, Gunnarsson GL. The evolving breast reconstruction: from latissimus dorsi musculocutaneous flap to a propeller thoracodorsal fasciocutaneous flap. Gland Surg. 2014;3(3):151–4.PubMedPubMedCentralGoogle Scholar
  57. 57.
    Santanelli F, et al. Total breast reconstruction using the thoracodorsal artery perforator flap without implant. Plast Reconstr Surg. 2014;133(2):251–4.PubMedCrossRefPubMedCentralGoogle Scholar
  58. 58.
    McCulley SJ, et al. Lateral thoracic artery perforator (LTAP) flap in partial breast reconstruction. J Plast Reconstr Aesthet Surg. 2015;68(5):686–91.PubMedCrossRefPubMedCentralGoogle Scholar
  59. 59.
    Hamdi M, et al. The lateral intercostal artery perforators: anatomical study and clinical application in breast surgery. Plast Reconstr Surg. 2008;121(2):389–96.PubMedCrossRefPubMedCentralGoogle Scholar
  60. 60.
    Millard DR. Breast reconstruction after a radical mastectomy. Plast Reconstr Surg. 1976;58(3):283–91.PubMedCrossRefPubMedCentralGoogle Scholar
  61. 61.
    Knox AD, et al. Comparison of outcomes following autologous breast reconstruction using the DIEP and pedicled TRAM flaps: a 12-year clinical retrospective study and literature review. Plast Reconstr Surg. 2016;138(1):16–28.PubMedCrossRefPubMedCentralGoogle Scholar
  62. 62.
    Jones G. The Pedicled TRAM flap in breast reconstruction. In: Veronesi U, et al., editors. Breast cancer. New York: Springer; 2017. p. 465–83.CrossRefGoogle Scholar
  63. 63.
    Reid AW, et al. An international comparison of reimbursement for DIEAP flap breast reconstruction. J Plast Reconstr Aesthet Surg. 2015;68(11):1529–35.PubMedCrossRefPubMedCentralGoogle Scholar
  64. 64.
    Erdmann-Sager J, et al. Complications and patient-reported outcomes after abdominal-based breast reconstruction: results of the mastectomy reconstruction outcomes consortium (MROC) study. Plast Reconstr Surg. 2018;141(2):271–81.PubMedPubMedCentralGoogle Scholar
  65. 65.
    Blondeel N, et al. The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction. Br J Plast Surg. 1997;50(5):322–30.PubMedCrossRefPubMedCentralGoogle Scholar
  66. 66.
    Blondeel PN. One hundred free DIEP flap breast reconstructions: a personal experience. Br J Plast Surg. 1999;52(2):104–11.PubMedCrossRefPubMedCentralGoogle Scholar
  67. 67.
    Krishnan NM, et al. The cost effectiveness of the DIEP flap relative to the muscle-sparing TRAM flap in postmastectomy breast reconstruction. Plast Reconstr Surg. 2015;135(4):948–58.PubMedCrossRefPubMedCentralGoogle Scholar
  68. 68.
    Granzow JW, et al. Breast reconstruction with the deep inferior epigastric perforator flap: history and an update on current technique. J Plast Reconstr Aesthet Surg. 2006;59(6):571–9.PubMedCrossRefPubMedCentralGoogle Scholar
  69. 69.
    Roostaeian J, et al. The effect of prior abdominal surgery on abdominally based free flaps in breast reconstruction. Plast Reconstr Surg. 2014;133(3):247e–55e.PubMedCrossRefPubMedCentralGoogle Scholar
  70. 70.
    Pennington DG. The stacked DIEP flap. Plast Reconstr Surg. 2011;128(4):377e–8e. author reply 378ePubMedCrossRefPubMedCentralGoogle Scholar
  71. 71.
    DellaCroce FJ, Sullivan SK, Trahan C. Stacked deep inferior epigastric perforator flap breast reconstruction: a review of 110 flaps in 55 cases over 3 years. Plast Reconstr Surg. 2011;127(3):1093–9.PubMedCrossRefPubMedCentralGoogle Scholar
  72. 72.
    Healy C, Allen RJ. The evolution of perforator flap breast reconstruction: twenty years after the first DIEP flap. J Reconstr Microsurg. 2014;30(2):121–5.PubMedPubMedCentralGoogle Scholar
  73. 73.
    Rozen WM, et al. The SIEA angiosome: interindividual variability predicted preoperatively. Plast Reconstr Surg. 2009;124(1):327–8. author reply 328–30PubMedCrossRefPubMedCentralGoogle Scholar
  74. 74.
    LoTempio MM, Allen RJ. Breast reconstruction with SGAP and IGAP flaps. Plast Reconstr Surg. 2010;126(2):393–401.PubMedCrossRefPubMedCentralGoogle Scholar
  75. 75.
    Allen RJ, Levine JL, Granzow JW. The in-the-crease inferior gluteal artery perforator flap for breast reconstruction. Plast Reconstr Surg. 2006;118(2):333–9.PubMedCrossRefPubMedCentralGoogle Scholar
  76. 76.
    Hunter JE, et al. Evolution from the TUG to PAP flap for breast reconstruction: comparison and refinements of technique. J Plast Reconstr Aesthet Surg. 2015;68(7):960–5.PubMedCrossRefPubMedCentralGoogle Scholar
  77. 77.
    Bodin F, et al. The transverse musculo-cutaneous gracilis flap for breast reconstruction: how to avoid complications. Microsurgery. 2016;36(1):42–8.PubMedCrossRefPubMedCentralGoogle Scholar
  78. 78.
    de Weerd L, et al. Autologous breast reconstruction with a free lumbar artery perforator flap. Br J Plast Surg. 2003;56(2):180–3.PubMedCrossRefPubMedCentralGoogle Scholar
  79. 79.
    Hamdi M, et al. Lumbar artery perforator flap: an anatomical study using multidetector computed tomographic scan and surgical pearls for breast reconstruction. Plast Reconstr Surg. 2016;138(2):343–52.PubMedCrossRefPubMedCentralGoogle Scholar
  80. 80.
    Honart JF, et al. Lumbar artery perforator flap for breast reconstruction. Ann Chir Plast Esthet. 2018;63(1):25–30.PubMedCrossRefPubMedCentralGoogle Scholar
  81. 81.
    Peters KT, et al. Early experience with the free lumbar artery perforator flap for breast reconstruction. J Plast Reconstr Aesthet Surg. 2015;68(8):1112–9.PubMedCrossRefPubMedCentralGoogle Scholar
  82. 82.
    Sommeling CE, et al. Composite breast reconstruction: implant-based breast reconstruction with adjunctive lipofilling. J Plast Reconstr Aesthet Surg. 2017;70(8):1051–8.PubMedCrossRefPubMedCentralGoogle Scholar
  83. 83.
    Nava MB, Catanuto G, Rocco N. Hybrid breast reconstruction. Minerva Chir. 2018;73(3):329–33.PubMedPubMedCentralGoogle Scholar

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© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Breast UnitSan Raffaele University and Research HospitalMilanItaly
  2. 2.Department of Clinical Medicine and SurgeryUniversity of Naples Federico IINaplesItaly

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