The reconstructive approach to breast defects is challenging, as the resultant glandular tissue deficiency not only needs to be replaced or reconstructed following the "tissue-like" principle but also necessitates a contour deformity restoration. Conservative breast surgery with postoperative irradiation has replaced modified radical mastectomy as the preferred treatment for early invasive breast cancer. Breast-conservation surgery with quadrantectomy or lumpectomy procedures creates primary or delayed secondary (postradiation) defects of the conical breast shape with or without involvement, and subsequent repositioning, of the nipple–areola complex (NAC).
The objective in breast-conservation surgery is to establish disease-free surgical margins while the reconstructive part will tend to preserve as much glandular tissue as possible allowing primary, tension-free closure with an acceptable aesthetic appearance and satisfying breast symmetry. When primary closure without tissue distortion is not feasible, mobilization of adjacent or locoregional tissue is warranted.
Up to 30% of patients are dissatisfied with the aesthetic result after partial mastectomy with irradiation.1 Distortion, retraction, and mammary volume changes together with NAC repositioning extenuating asymmetry all have a profound impact on the aesthetic appearance of the breast. Therefore, we prefer to perform immediate reconstruction whenever it is indicated and feasible, as operating on irradiated breasts has high complication rates with frequently poor esthetic results. During immediate reconstruction, the breast can be manipulated prior to radiation. This potentially decreases complications and improves the outcome. As for any conservative breast therapy, tumors up to 3 cm in diameter are generally considered safe for quadrantectomy associated with postoperative radiotherapy. On the other hand, any immediate partial reconstruction should be delayed if the surgeon is uncertain about the margins or tumor extension despite the preoperative radiologic assessment. A delayed immediate reconstruction can still be performed within a few days after the definitive margins become known.2
The combination of wide glandular breast tissue excision with subsequent immediate reconstruction has been considered a decisive stage in the evolution of breast cancer surgery. This approach allows not only wider tumor resection to obtain safer margins but is also advantageous in handling the healthy resultant glandular tissue to achieve better aesthetic outcomes. However, if there is any doubt about the margins of resection or tumor extension, the procedure should be delayed and the delayed stage can still be done a few days later when the definitive margins are known. Many surgeons have suggested incorporating a reduction mammaplasty procedure during the tumor resection in hypertrophic breasts.3-7
The size and location of the breast defect and the ratio of breast volume to resection volume are fundamental determinants to choose the methods of reconstruction. One of the relative contraindications for rearranging the breast parenchyma is a large tumor to breast ratio, with smaller breasts requiring different, more challenging reconstruction approaches. An extensive resection in a smaller breast necessitates the recruitment of nonglandular tissue, and different flaps are available to fill the tissue deficiency.