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. The purpose of this study was to evaluate the safety of IBR in patients with LABC in the largest retrospective series to date. Methods: The records of 766 consecutive patients treated between 1992-2002 at UCLA Medical Center 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 157 unilateral and 13 bilateral reconstructions (183 flaps). The TRAM flap was used in the vast majority (162). The average age was 47 and 27.6% of patients had co-morbid conditions. The average hospital stay was 5.1 days, and 37 (21.8%) patients required banked blood transfusions. There were 15 major complications (8.8%; 1 complete flap loss; 7 partial flap losses, 3 arterial/venous thromboses, two of which were salvaged, and 4 hematomas). Adjuvant postoperative therapy was delayed in 8 patients (4.7%), 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. One hundred three patients received postoperative radiation. Although some degree of flap shrinkage was noted in nearly one-third of patients treated with postoperative radiation therapy, only 10% of patients experienced moderate to severe breast distortion. Importantly, the overall cosmetic outcome in patients who received postoperative radiation was the same as in those who did not require adjuvant radiation. Conclusions: 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.
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