Delayed-immediate breast reconstruction: technical and timing considerations.

BACKGROUND: In 2002, the author implemented a new two-stage approach, "delayed-immediate breast reconstruction," for patients who desire breast reconstruction and who are at an increased risk for conditions necessitating postmastectomy radiotherapy. There is increasing acceptance of this approach in clinical practice. This report highlights important technical and timing considerations in delayed-immediate reconstruction that help ensure the best outcomes with low rates of expander loss.
METHODS: Stage 1 of delayed-immediate reconstruction consists of skin-sparing mastectomy with insertion of a saline-filled tissue expander to serve as an adjustable scaffold to preserve the three-dimensional shape of the breast skin envelope. Patients who do not require postmastectomy radiation therapy undergo stage 2 (definitive breast reconstruction) within 2 weeks after stage 1 to avoid delays in the start of adjuvant chemotherapy and to preserve the ptotic shape of the preserved breast skin envelope. In patients who do require radiation, the tissue expander is deflated before the therapy to create a flat chest wall surface to permit modern three-beam radiation delivery. Beginning 2 weeks after completion of radiation therapy, the expander is reinflated to the predeflation volume. Three months after the therapy, a "skin-preserving" delayed reconstruction is performed, with removal of the expander and transfer of an autologous tissue flap.
CONCLUSIONS: Delayed-immediate reconstruction allows patients who do not require postmastectomy radiation therapy to receive the benefits of skin-sparing mastectomy with aesthetic outcomes similar to those of immediate reconstruction. Patients who do require radiation receive a skin-preserving delayed reconstruction, while avoiding the problems that can be associated with radiation delivery after an immediate breast reconstruction.