Knowing whether you need radiation therapy after mastectomy makes it easier to plan the timing of your reconstruction, but it isn’t always obvious that radiation is needed until pathology results are available several days after mastectomy. If your oncologist suspects that you might need postmastectomy radiation, you’ll probably be advised to delay your reconstruction. While radiation therapy is a critical part of treatment to prevent recurrence and improve survival for many breast cancer patients, delaying reconstruction can be disappointing.
Delayed-immediate reconstruction is a two-stage approach to this dilemma. It’s a hybrid of immediate reconstruction (done at the same time as mastectomy) and delayed reconstruction (done as a separate surgery months or even years after mastectomy).
The first stage is performed before radiation therapy begins: A skin-sparing or nipple-sparing mastectomy removes your breast tissue. Then, while you’re still asleep, a tissue expander (a temporary implant) is placed under the breast skin or chest muscle and fully inflated to preserve your breast skin and shape.
If you don’t need radiation
If the pathology results show that you don’t need radiation, you can proceed with reconstructive surgery to replace the expander with a breast implant or an autologous tissue flap (your own fat and skin).
If you do need radiation
If it turns out that you do need radiation, the expander will be left in place but deflated before your first round of radiation (this addresses the concern that implants may interfere with the precise delivery of radiation). It will be gradually reinflated, beginning a couple of weeks after your last radiation session. In 4 to 6 months, when your skin and scars have healed, reconstructive surgery is performed to replace the expander with tissue from your tummy, hip, buttock, thigh or back. (Breast implants are usually not advised after radiation, due to the high potential for poor cosmetic results and complications following radiation therapy.)
Silver linings
While you may be disappointed if you’re unable to have immediate breast reconstruction, delayed-immediate reconstruction does offer advantages over delayed breast reconstruction:
You won’t have a flat chest when you wake up from your mastectomy.
You may be able to keep your natural nipple/areola.
You’ll have more time to research and consider your options for reconstruction
Your mastectomy incision/scar will be minimized and less noticeable on your newly reconstructed breast.
Note: An interesting clinical trial at MD Anderson Cancer Center concluded that receiving radiation first ("premastectomy radiation therapy") and then having mastectomy with immediate reconstruction is safe, effective and produces good cosmetic results.
Source: Schaverien MV, Sing P, Smith BD, et al. Premastectomy radiotherapy and immediate breast reconstruction: A randomized clinical trial. JAMA Network Open. 2024;7(4):245217. doi:10.1001/jamanetworkopen.2024.5217.