The psychological benefit of immediate reconstruction is tremendous for the patient. Shortly after the operation, she will be able to dress and wear a swimsuit without using external breast prosthesis, and without people noticing she underwent a full mastectomy. Not so long ago, some said it was necessary for the patient to endure the psychological suffering of mastectomy and « mourn her breasts », to appreciate better the reconstruction later on. From my experience, I don’t believe this to be necessary, although it is easier to satisfy with an average result a patient that went through a secondary reconstruction. Some patients that had an immediate reconstruction imagine that it is simply a plastic surgery and can be quite picky and hard to satisfy.
In any case, it is important to explain clearly before the operation that the reconstructed breast, even in the best way possible, will never be like a non-operated breast. There will always be, at least, a loss of sensitivity, even if the appearance and consistency of the reconstructed breast are identical to the opposite breast.
Patients demanding a reconstruction do usually so from the beginning, when opting for a full mastectomy. The reconstruction, whether done with prosthesis or with flap, doesn’t prevent from starting chemotherapy, when necessary, within normal schedule after surgery.
On the contrary, radiotherapy will interfere with the quality of the result in immediate reconstruction, by altering the skin tissue. For this reason, the decision of an immediate reconstruction is sometimes only taken during the operation, depending on the analysis of the sentinel node that determines the need for a post-operative parietal radiotherapy. Overall, if the node is normal, there will be no parietal radiotherapy and an immediate reconstruction can be done. If the node is affected, an additional dissection is accomplished and the surgery will be followed by chemotherapy and radiotherapy. Under these conditions, the reconstruction will only take place thereafter.
However, there are special situations, with possible exceptions depending on each patient. For instance, when the patient is thin, with substantial breast volume and no possibility of secondary reconstruction with TRAM flap. We can then immediately reconstruct using an expander, knowing that the result, despite radiotherapy, will maybe be better than a secondary reconstruction with prosthesis (or with dorsal flap and prosthesis) on irradiated skin.
In other situations, after a conservative treatment, analyses indicate an additional mastectomy. If a chemotherapy and a radiotherapy were also to be indicated, the mastectomy, rather than being carried out prior to adjuvant chemotherapy, could be done at the end of treatment after radiotherapy, with the possibility of immediate reconstruction with an autologous flap.
An immediate reconstruction with prosthesis would be risky due to wound healing problems on irradiated skin.
Similarly, there is a major complication risk (around 30% reconstruction failure in my experience) when immediate reconstruction with a prosthesis is done on an irradiated breast, even with moderate distance from the irradiation. The decision of an additional mastectomy may be related to the occurrence of local recurrence or to the late discovery of a genetic disorder, the patient then requesting a prophylactic mastectomy. In these situations, if immediate reconstruction is chosen, it is safer to use flaps without prosthesis.