Every October, Breast Cancer Awareness Month, widely known as “Pink Ribbon Month,” returns to raise awareness. Supported by healthcare organizations and public interest groups around the world, this initiative aims to improve public understanding of breast cancer, promote early screening, diagnosis, and treatment, and highlight the importance of long-term quality of life for survivors. With rapid advances in systemic therapies and surgical techniques, the goals of breast cancer treatment have evolved beyond simply prolonging survival to include quality of life and a sense of bodily wholeness. As an important component of comprehensive breast cancer care, breast reconstruction can restore physical appearance while also having a profound impact on patients’ psychological well-being, family relationships, and social functioning.On this occasion, Oncology Frontier invited Professor Shunrong Li of the Sixth Affiliated Hospital of Sun Yat-sen University for an in-depth interview covering the clinical value of breast reconstruction, barriers to wider adoption, the evolution of surgical techniques, individualized decision-making, strategies for special patient populations, and multidisciplinary collaboration.
Breast Reconstruction Goes Beyond Restoring Appearance
Q — Oncology Frontier:
Based on your clinical experience, could you explain the clinical scenarios in which breast reconstruction is appropriate and its value within the breast cancer treatment pathway?
Professor Shunrong Li:
Breast reconstruction is highly significant for patients with breast cancer today. Twenty years ago, many patients underwent mastectomy for breast cancer, but reconstructive techniques were not widely available in China. As a result, many women were left with absent, deformed, or partially missing breasts, which severely affected their psychological well-being and social participation. Some even developed psychiatric conditions or experienced lasting regret affecting their marriages.
With the 10-year survival rate for early-stage breast cancer now exceeding 90%, treatment goals have shifted from simply prolonging survival to also preserving quality of life. Against this background, breast reconstruction has irreplaceable clinical value. It is not merely a means of restoring appearance; it can help preserve family life, alleviate psychological trauma, restore a sense of bodily wholeness, and rebuild patients’ confidence in life.
Patient Awareness, Financial Burden, and Technical Limitations All Constrain Wider Adoption
Q — Oncology Frontier:
What are the main factors currently limiting the wider adoption of breast reconstruction in China? What are the most common misconceptions among patients, and how has patient acceptance changed in recent years?
Professor Shunrong Li:
The main barriers to wider adoption of breast reconstruction in China arise from both patients and physicians.
On the patient side, a common misconception is that losing a breast does not affect physical function, particularly mobility, and therefore reconstruction is unnecessary. Financial considerations also influence decisions. Some patients believe that reconstruction increases medical expenses without providing additional survival benefits, so they prioritize completing cancer treatment first. However, some subsequently experience reduced income and miss the opportunity to undergo reconstruction.
On the physician side, breast reconstruction in China is often performed by breast surgeons, many of whom have not received systematic training in reconstructive or plastic surgery techniques. This can lead to less satisfactory postoperative breast shape, making technical limitations another barrier.
Real-world studies also show that breast-conserving rates in China are significantly lower among older patients, at primary hospitals with lower surgical volumes, and in economically underdeveloped regions. The field of breast reconstruction may face similar disparities in access.
In recent years, changes have mainly reflected improvements in physician awareness and surgical techniques. Increasingly, doctors recognize breast reconstruction as an indispensable component of breast surgery. Its share of breast surgical practice has reportedly increased from approximately 1% to 20%–30%.
Meanwhile, more than two decades of increasingly specialized breast cancer case management have helped patients understand that a missing breast can be reconstructed, often with satisfactory shape and aesthetic outcomes. Demand has therefore gradually increased. However, this growth in demand is still concentrated primarily in economically developed regions, and substantial regional disparities remain.
The Evolution of Breast Reconstruction: Toward Minimally Invasive Techniques and More Natural Results
Q — Oncology Frontier:
Could you review the development of breast reconstruction techniques and explain the tangible benefits these advances have brought to patients? Which technical approaches do you find most promising?
Professor Shunrong Li:
In recent years, breast reconstruction techniques have increasingly focused on minimally invasive procedures and more natural-looking results. Advances in autologous tissue flap reconstruction, implant-based reconstruction, and fat grafting have brought tangible benefits to patients. Techniques such as deep inferior epigastric perforator (DIEP) flaps, latissimus dorsi flaps, and robot-assisted reconstruction have expanded the range of eligible patients and improved aesthetic outcomes.
Among the various reconstruction approaches, I am most optimistic about fat grafting because it is a relatively new technique whose clinical application remains limited, and it offers the advantage of being minimally invasive.
My second preference is autologous tissue flap reconstruction. Although this technique has been practiced in China for many years, its technical complexity means that many physicians and hospitals are reluctant to offer it.
I have become increasingly cautious about implant-based reconstruction. Overall, I believe that flap reconstruction combined with liposuction can meet more than 80% of clinical needs in breast reconstruction.
Immediate Reconstruction as a Priority, With Skin Defects Guiding Technique Selection
Q — Oncology Frontier:
In clinical practice, how should the timing and type of reconstruction be individualized based on these factors? Which patients are better suited to immediate reconstruction, and which may benefit more from delayed reconstruction?
Professor Shunrong Li:
Breast reconstruction is challenging because every patient differs in breast shape, disease characteristics, the volume of tissue that needs to be removed, and the condition of the skin.
First, when immediate reconstruction is feasible, I would generally favor it over delayed reconstruction or a two-stage immediate reconstruction approach. The latter approaches can result in outcomes that are typically 10%–30% less favorable.
Second, when there is a skin defect, autologous tissue flap reconstruction is preferred. If only the glandular tissue needs to be removed and the skin can be preserved intact, either an implant or autologous tissue can be considered. Fat grafting is suitable for patients with smaller breasts or localized defects, allowing minimally invasive reconstruction through fat injection.
Regarding timing, my view is that almost all patients can undergo immediate reconstruction, provided that complete tumor removal has been achieved. If the surgeon cannot be certain during the operation that the tumor has been completely excised, delayed reconstruction may be more appropriate, giving the patient time to consider the options.
Immediate reconstruction can preserve aesthetic structures to the greatest extent and help avoid the psychological impact of losing a breast without immediate restoration. Delayed reconstruction may be more suitable for patients who require radiotherapy or when the completeness of tumor excision remains uncertain.
Balancing Implant-Based and Autologous Reconstruction When Radiotherapy Is Anticipated
Q — Oncology Frontier:
For patients who still require mastectomy after neoadjuvant therapy and may receive radiotherapy, how should the timing and type of reconstruction be selected?
Professor Shunrong Li:
For patients who require mastectomy after neoadjuvant chemotherapy and may need postoperative radiotherapy, the timing and technique of reconstruction must be selected after carefully weighing the available options.
Although immediate reconstruction can preserve aesthetic structures, radiotherapy significantly increases the risk of capsular contracture around implants, and this risk is difficult to eliminate. Clinical studies have also confirmed that implant-based reconstruction after radiotherapy carries substantially higher complication and failure risks than autologous reconstruction. Autologous reconstruction generally tolerates radiotherapy better.
Another option is to place a tissue expander first and replace it with a permanent implant after radiotherapy. In theory, this approach can accommodate both cancer treatment and reconstruction, but clinical outcomes have not been ideal.
After radiotherapy, the skin often develops fibrosis, becomes thinner, and has a poorer blood supply. Removing the tissue expander requires capsular dissection, which can further compromise the condition of the skin. Capsular contracture may still occur after the permanent implant is placed.
Therefore, for patients undergoing mastectomy who require radiotherapy, both implant-based and autologous reconstruction remain possible options. Autologous reconstruction may include a tissue flap combined with liposuction and fat grafting.
Clinical decision-making should not be restricted to a single approach. Instead, the choice should be tailored to each patient’s individual circumstances. Although implant-based reconstruction currently accounts for approximately 80% of procedures in clinical practice and is relatively straightforward to perform, its long-term management can be more complex and therefore requires careful consideration.
An Integrated Breast Surgery Model Better Meets Reconstructive Needs
Q — Oncology Frontier:
How should a multidisciplinary team (MDT) coordinate the different specialties to ensure that curative treatment remains the priority while also achieving satisfactory reconstructive outcomes?
Professor Shunrong Li:
Breast reconstruction primarily involves collaboration between breast surgeons and plastic surgeons. In China, however, a distinctive model has developed in which breast surgeons perform both tumor resection and breast reconstruction as an integrated procedure.
I believe this model is particularly well suited to the practical needs of breast reconstruction. Its advantage is that the surgeon can anticipate which skin and tissue should be preserved during tumor resection, allowing the reconstruction to be better aligned with the overall surgical plan.
However, this approach places higher demands on breast surgeons. Operations take longer, and the required skill set is broader: surgeons must be proficient in both oncologic surgery and reconstructive techniques.
In many other countries, the two procedures are performed by separate teams, with tumor resection and plastic reconstruction handled independently. Both models have advantages and disadvantages.
Around 2018, China’s integrated model was already at an advanced international level. Teams in Europe and the United States have also gradually moved toward more integrated collaboration, although progress has been slower than in China. The rapid adoption of this model in China has been facilitated in part by a relatively flexible regulatory environment and the faster implementation of reforms.
Ultimately, regardless of the model adopted, the guiding principle should be to maximize patient benefit rather than rigidly assigning reconstruction to plastic surgeons and tumor removal exclusively to breast surgeons.
The MDT should also include medical oncologists, radiation oncologists, pathologists, radiologists, and other relevant specialists. Their collaboration is essential to coordinate systemic treatment and surgical scheduling while ensuring that curative treatment remains the priority.
Breast Reconstruction Is an Essential Component of Treatment, Not Merely “The Finishing Touch”
Q — Oncology Frontier:
What core message would you most like to convey to patients who are facing decisions about mastectomy or breast reconstruction? How can clinicians help them overcome their concerns, understand the benefits of reconstruction, and make the choice that best suits their needs?
Professor Shunrong Li:
Breast reconstruction is itself a component of breast cancer treatment, rather than merely “the finishing touch,” as it has traditionally been perceived. This misconception urgently needs to be corrected.
After losing a breast, many patients experience severe disturbances in body image and struggle to accept themselves. Their distress may progress from low mood to psychological problems, depression, or social withdrawal. In some cases, this suffering can feel even more overwhelming than the threat the disease poses to their lives, yet it is often overlooked.
Those who have not experienced this situation may find it difficult to understand, but it affects many patients. This is precisely why breast reconstruction can be so important in restoring body image and why its psychological benefits cannot be replaced by medication alone.
At the same time, the goals of breast cancer treatment have evolved from simply prolonging survival to also preserving quality of life. Quality of survival is just as important as the length of survival.
Different patients have different needs and preferences regarding reconstruction. Clinicians should provide adequate technical support and explain the available options, allowing patients to make informed decisions for themselves. Doctors should also proactively guide patients by using photographs and case examples to demonstrate the feasibility of reconstruction and the results they can reasonably expect.
However, many patients still know little about reconstruction and mistakenly believe that mastectomy means living permanently without a breast. Some medical institutions lack the technical capabilities to perform reconstruction and therefore cannot readily recommend it. In outpatient clinics, many patients report that during previous consultations they were never informed about alternative reconstruction methods and were told only that implant-based reconstruction was available.
In reality, many patients report high satisfaction after reconstruction. The psychological improvement that comes from regaining a sense of bodily wholeness can be profound.
Professor Shunrong Li
