Introduction: Numerous studies have demonstrated that immediate breast reconstruction (IBR) after mastectomy is associated with improvements in quality of life and body image. However, IBR of locally advanced breast cancer (LABC) remains controversial due to concerns about delays in postoperative adjuvant therapy, as well as, a theoretical potential for increased incidence of local recurrence or delays in diagnosis of recurrence. The purpose of this study was to evaluate the safety of IBR in patients with LABC in the largest series to date.

Methods: The records of 766 consecutive patients treated over the last 10-year period were reviewed. Patients with the diagnosis of stage IIB or worse breast cancer who were treated with mastectomy followed by IBR were identified and analyzed.

Results: 170 patients with LABC who underwent IBR were identified. There were 158 unilateral and 12 bilateral reconstructions (176 flaps). The TRAM flap was used in the vast majority (158). The average age was 48 and 24% of patients had comorbid conditions. The average hospital stay was 5.1 days, and 23 (13.5%) patients required banked blood transfusions. There were 7 major complications (4.1%; 1 complete flap loss; 2 partial flap losses, 1 arterial and 1 venous thrombosis, both of which were salvaged, and 2 hematomas). There were 70 minor complications (41%; 9 infections, 33 patients with fat necrosis; 9 hernias or abdominal wall laxities; 4 mild fluid overload, and 13 donor site complications). Adjuvant postoperative therapy was delayed in 8 patients (5%), and the maximum delay was 3 weeks in one patient. There were no delays in the diagnosis of local recurrences that were attributable to the reconstruction. Although flap shrinkage was noted in nearly one-third patients treated with postoperative radiation therapy, only a hand full of patients experienced severe breast distortion.

Discussion: We have shown that IBR in the setting of locally advanced breast cancer is safe, well tolerated, and not associated with significant delays in adjuvant therapy. In addition, in a subset of patients IBR with free tissue transfer enabled wide en-bloc resection and avoided skin grafting of the chest wall and irradiated tissues. These findings, together with the convenience, improved cosmetic outcome, and the known psychological and economic benefits of IBR make a strong argument for immediate reconstruction in otherwise healthy patients regardless of cancer stage. Patients who are likely to receive postoperative radiation therapy must be counseled regarding the risks of flap shrinkage and distortion.