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Rebuilding the shape of a breast after a mastectomy, either with an implant or with the woman's own tissue, at the same operation or years later. In England every woman having a mastectomy for breast cancer must be offered it, and must be offered both timings whether or not the local hospital provides them.
Answer a few questions from a report and read the guideline statement that applies, quoted word for word with its source. Educational aids to prepare for an appointment, not advice.
There are two families of technique. Implant-based reconstruction uses a silicone implant, either placed at the mastectomy (direct to implant) or after a tissue expander has stretched the skin, and either behind the pectoralis major (sub-pectoral) or in front of it (pre-pectoral). Autologous reconstruction moves the woman's own skin and fat, most often from the lower abdomen as a deep inferior epigastric perforator flap, which spares the rectus muscle, and less often from the back (latissimus dorsi) or elsewhere. Reconstruction is immediate, at the same operation as the mastectomy, or delayed.
The honest comparison comes from the Mastectomy Reconstruction Outcomes Consortium, which followed 2,343 women for two years with both complications and a validated patient-reported questionnaire. Autologous reconstruction gave better satisfaction with the breasts (7.94 points higher, 5.68 to 10.20, p<0.001), psychosocial wellbeing and sexual wellbeing at two years. It also roughly doubled the odds of a complication: 1.97 (1.41 to 2.76) for a deep inferior epigastric perforator flap against expander-implant reconstruction. Implants failed more often, 7.1 percent against 1.3 percent for those flaps.
British practice has been measured twice and neither reading is comfortable. In iBRA, 2,081 women having immediate implant-based reconstruction at 81 units had implant loss of 9 percent, infection needing treatment of 25 percent, return to theatre of 18 percent and readmission of 18 percent within three months, all above the National Quality Standards of under 5 percent for the first three and under 10 percent for infection. Pre-BRA followed the newer pre-pectoral technique in 343 women and found implant loss of 8.2 percent and a complication in 42.0 percent, with physical and sexual wellbeing significantly below baseline at three and eighteen months.
The mesh question is unresolved. Biological or synthetic mesh, including acellular dermal matrix, is used to support the implant, and in iBRA 65 percent of reconstructions used it, 54 percent biological and 12 percent synthetic, without randomised evidence that it helps. Best-BRA, a pilot randomised trial of pre-pectoral against sub-pectoral placement, is the attempt to put that right.
On timing, NICE NG101 recommendation 1.5.1 offers reconstruction to everyone after a mastectomy for breast cancer, 1.5.3 offers both immediate and delayed options whether or not they are available locally, and 1.5.4 offers immediate reconstruction even to women who may need radiotherapy, unless another illness rules out the surgery. The guideline's own table warns that immediate reconstruction using implants may be affected by radiotherapy more than immediate flap reconstruction, and recommendation 1.13.14 allows the three-week radiotherapy schedule rather than the one-week one for women who have had implant-based reconstruction.
Breast implant-associated anaplastic large cell lymphoma is a rare cancer of the capsule around an implant and is covered separately.
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