Breast reconstruction may be an option for any woman undergoing surgical treatment for breast cancer. All women treated for breast cancer should be educated about breast reconstruction options that are appropriate for their individual clinical situation. However, breast reconstruction should not interfere with appropriate surgical treatment of cancer or the scope of appropriate surgical treatment. Coordinated consultation and surgical treatment should occur within a reasonable timeframe. The breast reconstruction process should not interfere with the timing or scope of reasonable surgical treatment for the disorder. The effectiveness or utility of breast reconstruction should not result in the delay or denial of appropriate surgical procedures. An evaluation of the possible cosmetic results of lesion excision should be completed preoperatively. Breast-conserving oncoplastic techniques can expand breast-conserving surgical options in cases where excision itself may not yield acceptable cosmetic results. Application of these methods may reduce mastectomy and decrease secondary re-excision with minimal breast deformity. Patients should be informed of the possibility of positive margins and the potential need for secondary surgery, including partial re-excision or possible mastectomy ± nipple removal. The oncoplastic procedure can be combined with surgery on the contralateral healthy breast to minimize distant asymmetry. For mastectomy, the possibility of reconstruction should be explored and preoperative evaluation of reconstruction options should be considered. Surgical options for post-mastectomy breast reconstruction include: 1. Integrated breast implant placement (i.e., tissue expansion site followed by implant placement and immediate implant placement) 2. Integrated autologous tissue grafting (i.e., tipped rectus abdominis flap, fat graft, and a variety of microsurgical flaps from the abdomen, back, buttocks, and thighs) 3. Integrated breast filler and autologous tissue grafting (e.g. latissimus dorsi flap) Breast reconstruction after mastectomy can begin at the same time as mastectomy (“immediate”) or sometime after cancer treatment is completed (“delayed”). In many cases, breast reconstruction including a staged approach requires more than one measure such as: 1. surgery on the contralateral breast to improve symmetry 2. revision surgery on the breast and/or donor site 3. nipple and areola remodeling with tattoo staining As with any type of mastectomy, there is a risk of local versus regional recurrence of cancer and evidence suggests that skin-preserving mastectomy is probably comparable to standard breast mastectomy is probably comparable to standard mastectomy in this regard. Skin-sparing mastectomy should be performed by a coordinated team of experienced breast surgeons who can properly guide the patient in a multidisciplinary manner in selecting skin-sparing mastectomy and determining the optimal sequence of reconstructive and adjuvant treatment and excision to obtain appropriate surgical margins. Radiation therapy should still be administered after mastectomy for patients undergoing skin-sparing mastectomy following the same selection criteria as standard mastectomy. In inflammatory breast cancer (IBC), immediate post-mastectomy reconstruction is contraindicated due to the high risk of recurrence, the aggressive nature of the disease, and the need for rapid subsequent postoperative radiotherapy for local control without any delay. In inflammatory breast cancer, because skin-preserving mastectomy has not been shown to be safe, the current or previously involved skin also needs to be removed at the time of mastectomy. Therefore, immediate reconstruction is not advantageous in this situation. Generally, skin-preserving mastectomy is performed for the loss of the nipple-areola complex (NAC) in order to treat cancer. However, the preserved nipple areolar complex approach may be an option in patients with cancer carefully selected by an experienced multidisciplinary collaborative team. For the treatment of early-stage, biologically well-behaved (e.g., Nottingham grade 1 or 2, lymph node negative, HER2/neu negative, no vascular invasion), invasive carcinoma or ductal carcinoma in situ located in the periphery of the breast (>2 cm from the nipple) with low nipple involvement and low local recurrence rates, retrospective data support the application of the preserved nipple areola complex approach. Nipple margin assessment is mandatory and nipple margins should be clearly labeled. Nipple involvement such as Paget’s disease or other nipple discharge associated with malignancy and/or imaging suggestive of malignant involvement of the nipple or subareolar tissue is a contraindication to nipple preservation. The use of tissue expanders/prostheses is a relative contraindication in previously irradiated patients. Tissue expansion of irradiated skin can significantly increase the risk of periosteal contracture, malposition, poor cosmetic outcome, prosthesis exposure, and reconstruction failure. In the setting of prior radiation therapy, autologous tissue reconstruction is the preferred method of breast reconstruction. In contrast, non-inflammatory, locally advanced breast cancer is not an absolute contraindication to immediate reconstruction, and radiation therapy should still be administered after mastectomy regardless of the method of reconstruction: 1. When radiation therapy is required after mastectomy and autologous tissue reconstruction is planned, reconstruction is either postponed until the end of radiation therapy or a tissue expander is placed at the same time as the mastectomy followed by autologous tissue reconstruction. In contrast, some experienced breast cancer groups have used protocols in which immediate tissue reconstruction sequential radiotherapy is usually preferred, as failure of radiotherapy sequential placement of autologous tissue for cosmetic reconstruction has been reported (category 2B). 2. When prosthetic reconstruction is planned in patients requiring radiotherapy, a staged approach with immediate tissue expander placement followed by prosthesis implantation is preferred. Permanent prosthetic replacement of the tissue expander can be done before or after radiotherapy. Immediate placement of the prosthesis in patients requiring postoperative radiation therapy increases the incidence of periosteal contracture, malposition, poor cosmetic outcome, and exposure of the prosthesis. Reconstructive selection is based on assessment of cancer treatment, patient body mass, obesity, smoking history, coexisting conditions, and patient concerns. Whether with implants or flaps smoking and obesity increase the risk of all types of complications of breast reconstruction. Therefore, smoking and obesity are considered a relative contraindication to breast reconstruction, and patients should be informed of the increased incidence of wound healing complications and partial or total flap failure among smokers and obese patients. A plastic surgery consultation should be proposed for women who are not satisfied with the cosmetic outcome after completion of breast cancer treatment.