Breast reconstruction is an option for patients following a unilateral or bilateral mastectomy, or after breast conservation therapy (BCT) with a less than ideal cosmetic result. Breast reconstruction provides psychological, social, emotional, and functional improvements, including improved psychological health, self-esteem [1-4], sexuality, and body image [1-9]. Patients who choose breast reconstruction are presented with complex decisions, including the type and timing of reconstruction.
This topic review will discuss the preoperative assessment and evaluation of candidates for immediate or delayed breast reconstruction, special clinical settings (contralateral mastectomies, radiation therapy), and physical and psychologic outcomes. The approaches for reconstruction, including autologous tissue reconstruction and prosthetic devices (implants), are reviewed separately. (See "Breast reconstruction: Autologous tissue" and "Breast reconstruction: Prosthetic devices".)
UTILIZATION AND PATTERNS OF CARE
Outcomes research on quality of life (QOL) improvements and psychosocial benefits associated with breast reconstruction served as the driving force for the 1998 Women's Health and Cancer Rights Act, which mandated healthcare payer coverage for breast and nipple reconstruction, contralateral procedures to achieve symmetry, and treatment for the sequelae of mastectomy . This was followed in 2001 by additional legislation imposing penalties on noncompliant insurers. Whether passage of these laws has contributed to changes in clinical practice is unclear.
Although the rate of breast reconstruction has increased, the number of women who undergo reconstruction after mastectomy remains low [11,12]. Data collected from the American Society of Plastic Surgeons showed that the number of breast reconstructions performed annually increased from 78,832 in 2000 to 95,589 in 2013 [11-13]. The low rates of breast reconstruction are in part due to a low referral rate to plastic surgeons. A survey of attending general surgeons from a population-based sample of 1844 women diagnosed with breast cancer in 2002 showed that only 24 percent of surgeons referred more than 75 percent of their mastectomy patients to plastic surgeons prior to surgery . A survey of patients diagnosed with breast cancer reported that the desire to avoid additional surgery was the most common reason given for not pursuing reconstruction . Inadequate education about reconstructive options also plays a role. In a study of 84 women treated with mastectomy, participants were able to answer only 38 percent of questions about reconstruction options correctly .
Approximately 40 percent of all patients undergoing a mastectomy undergo breast reconstruction, and immediate breast reconstruction is increasing by approximately 5 percent per year . Implant-based reconstruction has been increasing at a rate of 11 percent per year, while the rate of autologous reconstruction has remained unchanged. Additional studies have demonstrated that unilateral mastectomy rates are decreasing by 2 percent per year, whereas contralateral and bilateral prophylactic mastectomies are increasing at the rate of 15 percent and 12 percent per year, respectively .