Impact of Radiotherapy on Breast Reconstruction

doi:10.1016/j.cps.2006.11.013

Clinics in Plastic Surgery

Volume 34, Issue 1, January 2007, Pages 29-37

https://doi.org/10.1016/j.cps.2006.11.013 Get rights and content

Breast reconstruction in the face of radiotherapy poses a unique set of challenges to the plastic surgeon and thus alters the algorithm of the reconstruction. The impact of radiation changes on alloplastic and autologous breast reconstruction is unpredictable. This article reviews the pathophysiology of radiation changes and the alterations to the reconstructive process.

Section snippets

Radiotherapy

RT is the therapeutic use of ionizing radiation for the treatment of malignant disorders. For breast cancer treatment, RT is most commonly delivered by way of external beam radiation and usually involves the chest wall and the supraclavicular, infraclavicular, and axillary apical lymph node areas.

Breast reconstruction

The goal of any breast reconstruction is to recreate a breast that is soft, symmetrical, and has a texture and color similar to that of the native breast. However, RT of any form, whether administered before or after reconstructive surgery, has potential to negatively affect cosmesis, symmetry, contracture, and pigmentation of the reconstructed breast.

Summary

Breast irradiation does not eliminate the possibility of breast reconstruction, rather, it changes the algorithm. Tissue expansion and implantation have a limited role because of the high incidence of complications and often less than ideal cosmetic outcome. When this technique is chosen, however, patient selection is of paramount importance. Ideal candidates have adequate soft tissue coverage, minimal radiation skin changes, and are compliant with postoperative instructions. Such patients can

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Cited by (43)

A multicentre study of the relationship between abdominal flap and mastectomy weights in immediate unilateral free flap breast reconstruction and the effect of adjuvant radiotherapy
2022, Journal of Plastic, Reconstructive and Aesthetic Surgery
Citation Excerpt :
Similarly, when patients had RT, the radiation caused the index breast to fibrose and shrink and thus were more likely to need adjustment surgery in the form of flap scar revision. The effects of RT include causing scarring in the tissues and accentuating fibrosis in the irradiated tissues.28–30 Therefore, this patient group had a significantly high incidence of flap scar revisions, which accounted for the higher ipsilateral adjustment surgery rate.
Abdominal free flaps are considered the gold standard for post-mastectomy autologous breast reconstruction. A key element of outcome assessment is breast symmetry often achieved by approximating the reconstructed breast dimensions such as weight (wt) to those of the mastectomy. However, the ideal relationship between these two entities remains unclear.
525 immediate unilateral abdominal free flap breast reconstruction (FFBR) patients were enrolled in a multicentre study (UK 141; Italy 384) and subdivided into Group A (flap wt < mastectomy wt, n = 163), Group B (flap wt > mastectomy wt, n = 260) and Group C (flap wt = mastectomy wt, n = 102). Their rates of contralateral balancing and ipsilateral revision surgeries were compared using Chi-Square tests. Radiotherapy influence on these adjustment procedures was also assessed.
More contralateral balancing procedures (17%) were performed than ipsilateral revisions (10%). Group A rates of contralateral balancing procedures were three times higher than Group B's with a ratio of 37 to 1 versus Group C (37% vs 11% vs 1% respectively, p < 0.001). Similarly, the ipsilateral breast revision surgery rate in Group A was double that of Group B and almost three times that of Group C (17% vs 8% vs 6% respectively, p = 0.01). Adjuvant radiotherapy disproportionately increased ipsilateral revisions versus contralateral balancing surgeries (p = 0.028).
A flap-to-mastectomy weight ratio of less than 1 (Group A) significantly increases subsequent adjustments on both contralateral and reconstructed breasts whilst irradiation predisposes to ipsilateral revisions. This is important in patient counselling and intraoperative flap contouring. Flap weight should ideally approximate or exceed mastectomy weight in unilateral FFBR.
Effects of radiation on toxicity, complications, revision surgery and aesthetic outcomes in breast reconstruction: An argument about timing and techniques
2021, Journal of Plastic, Reconstructive and Aesthetic Surgery
Citation Excerpt :
This may be because nicotine is associated with increased vasoconstriction and deterioration in microcirculation, while carbon monoxide can decrease blood oxygen transport.25,26 Our findings are supported by those of many other studies, in which current and long-term smoking were found to cause an increased incidence of complications.27–31 Therefore, perhaps not all patients are suitable candidates for reconstruction, especially smokers.
Radiotherapy (RT) combined with breast reconstruction can reduce the risk of cancer recurrence and increase the survival rate. However, this approach seems to worsen aesthetic outcomes and increase complication rates. The impact of breast reconstruction timing and techniques on clinical outcomes, however, remains unclear. For this reason, we aimed to perform a more comprehensive analysis of a series of patients undergoing RT and breast reconstruction.
Patients were divided into 4 groups according to the timing of reconstruction (before RT and after RT) and surgical technique (heterologous reconstruction and autologous reconstruction (AR)). The median time between RT and reconstruction, number of revision surgeries, incidence of complications, toxicity, aesthetics and associated clinical risk factors were used to assess the clinical outcomes. An objective system of skin toxicity evaluation was performed.
Ninety-five patients were included in this study. No significant differences in the median time between RT and reconstruction, incidence of complications, toxicity or aesthetics were noted between different timings or techniques of reconstruction. Patients undergoing AR needed more revision surgeries to complete reconstruction. However, the total number of surgical procedures was similar between the groups. In a comparison between the treated and untreated breasts by an objective system, RT produced an increase in erythema and pigmentation and a decrease in elasticity in the treated breast (p<0.05 for all parameters). On multivariate analysis, smoking was a significant predictor associated with complications.
Combined breast reconstruction and RT seem to be successful regardless of the order of treatment or the type of reconstruction.
Post-reconstruction dermatitis of the breast
2017, Journal of Plastic, Reconstructive and Aesthetic Surgery
Citation Excerpt :
Although both implant and autogenous tissue reconstructions have high success rates with low overall rates of complications, the most commonly reported complications of tissue expansion and permanent implants or autogenous tissue reconstruction include infection, hematoma, extrusion, capsular contracture, leak, flap necrosis, and donor site complications.3–5 The rates of complications with either reconstruction are substantially increased by radiation therapy.6,7 In general, skin rashes are an infrequently described complication of patients who undergo mastectomy with or without reconstruction.
Approximately one-third of women diagnosed with breast cancer undergo mastectomy with subsequent implant-based or autogenous tissue-based reconstruction. Potential complications include infection, capsular contracture, and leak or rupture of implants with necessity for explantation. Skin rashes are infrequently described complications of patients who undergo mastectomy with or without reconstruction.
A retrospective analysis of breast cancer patients referred to the Dermatology Service for diagnosis and management of a rash post-mastectomy and expander or implant placement or transverse rectus abdominis myocutaneous (TRAM) flap reconstruction was performed. Parameters studied included reconstruction types, time to onset, clinical presentation, associated symptoms, results of microbiologic studies, management, and outcome.
We describe 21 patients who developed a rash on the skin overlying a breast reconstruction. Average time to onset was 25.7 months after expander placement or TRAM flap reconstruction. Clinical presentations included macules and papules or scaly, erythematous patches and plaques. Five patients had cultures of the rash, which were all negative. Skin biopsy was relatively contraindicated in areas of skin tension, and was reserved for non-responding eruptions. Treatments included topical corticosteroids and topical antibiotics, which resulted in complete or partial responses in all patients with documented follow-ups.
Our findings suggest that tension and post-surgical factors play a causal role in this hitherto undescribed entity: “post-reconstruction dermatitis of the breast.” This is a manageable condition that develops weeks to years following breast reconstruction. Topical corticosteroids and antibiotics result in restoration of skin barrier integrity and decreased secondary infection.
Prophylactic amifostine prevents a pathologic vascular response in a murine model of expander-based breast reconstruction
2016, Journal of Plastic, Reconstructive and Aesthetic Surgery
Citation Excerpt :
Autologous tissue reconstruction requires a more invasive operation than expander based reconstruction, with longer operative times and recovery periods, but the well-vascularized tissue that is introduced to the reconstruction site is able to withstand the scourge of XRT-induced side effects.3,4 In comparison, expander-based reconstruction is a less invasive option, with shorter operative times and recovery periods; however, when combined with adjuvant XRT, it is associated with an unacceptably high complication rate and low patient satisfaction, and therefore rarely is utilized for patients undergoing XRT.4,5 XRT-induced injury in soft tissue has been extensively studied, yet remains poorly understood.
Although expander-based breast reconstruction is the most commonly used method of reconstruction worldwide, it continues to be plagued with complication rates as high as 60% when radiotherapy is implemented. We hypothesized that quantitative measures of radiotherapy-induced vascular injury can be mitigated by utilizing amifostine in a murine model of expander-based breast reconstruction.
30 rats were divided into three groups: expander placement (Control), expander placement followed by radiotherapy (XRT), and expander placement followed by radiotherapy with amifostine (AMF/XRT). All groups underwent placement of a sub-latissimus tissue expander. After a 45 day recovery period, all groups underwent vascular perfusion and micro-CT analysis.
Micro-CT analysis was used to calculate vessel volume fraction (VVF), vessel number (VN), and vessel separation (VSp). A significant increase in VN was seen in the XRT group as compared to the Control (p = 0.021) and the AMF/XRT (p = 0.027). There was no difference between Control and AMF/XRT (p = 0.862). VVF was significantly higher in XRT than either Control (p = 0.043) and AMF/XRT (p = 0.040), however no difference was seen between Control and AMF/XRT (p = 0.980). VSp of XRT was smaller when compared to both Control and AMF/XRT specimens (p = 0.05 and p = 0.048, respectively), and no difference was seen between Control and AMF/XRT (p = 0.339).
Amifostine administered prior to radiotherapy preserved vascular metrics similar to those of non-radiated specimens. Elevated vascularity demonstrated within the XRT group was not seen in either the Control or AMF/XRT groups. These results indicate that amifostine protects soft tissue in our model from a radiotherapy-induced pathologic vascular response.
Is immediate autologous breast reconstruction with postoperative radiotherapy good practice?: A systematic review of the literature
2013, Journal of Plastic, Reconstructive and Aesthetic Surgery
There remains controversy as to whether immediate autologous breast reconstruction with postoperative radiotherapy is associated with acceptable complications and aesthetic outcomes. This systematic review analyses the literature regarding outcomes of immediate autologous breast reconstruction with postoperative radiotherapy compared with no radiotherapy, as well as with delayed autologous breast reconstruction following post-mastectomy irradiation.
Pubmed (1966 to October 2012), Ovid MEDLINE (1966 to October 2012), EMBASE (1980 to October 2012), and the Cochrane Database of Systematic Reviews (Issue 10, 2012) were searched. Overall complications (including fat necrosis), fat necrosis, revisional surgery, loss of volume, and aesthetic outcome, were analysed individually. Comparable data from observational studies were combined for meta-analysis where possible and quality assessment of the studies was performed.
The majority of studies of immediate autologous breast reconstruction and postoperative radiotherapy reported satisfactory outcomes (19 of 25 studies; n = 1247 patients). Meta-analysis of observational studies demonstrated no significant differences in total prevalence of complications (p = 0.59) or revisional surgery (p = 0.38) and a summary measure for fat necrosis favouring the group without radiotherapy (OR 2.82, 95% CI 1.35–5.92, p = 0.006). The majority of studies comparing immediate reconstruction and postoperative radiotherapy with delayed reconstruction following post-mastectomy radiotherapy (10 of 12 observational studies; n = 1633 patients) reported satisfactory outcomes following immediate reconstruction. Meta-analysis of observational studies demonstrated no significant difference in overall incidence of complications (p = 0.53) and fat necrosis (OR 0.63, 95% CI 0.29–1.38, p = 0.25), and a summary measure for revisional surgery (OR 0.15, 95% CI 0.05–0.48, p = 0.001) favouring the delayed surgery group. No randomised-controlled trials met the inclusion criteria, and all of the observational studies included were missing more than one important component for reporting of observational studies.
The majority of studies reported satisfactory outcomes and a similar incidence of complications for immediate autologous breast reconstruction and adjuvant radiotherapy when compared with no radiotherapy or delayed reconstruction following radiotherapy; the proportion that required revisional surgery was higher though for immediate than delayed breast reconstruction. The findings are limited by the paucity of high quality data in the published literature, and until better data is available the findings of this review suggest that immediate autologous breast reconstruction should at least be considered when adjuvant chest wall radiotherapy is anticipated.
Radiotherapy and breast reconstruction techniques
2013, Revista de Senologia y Patologia Mamaria
Actualmente, la cirugía conservadora es el estándar quirúrgico en el tratamiento del cáncer de mama, pero en un 15-35% de los casos, debe ofrecerse la mastectomía. Hasta no hace mucho tiempo, si estas pacientes necesitaban radioterapia, la opción de la reconstrucción se retrasaba o incluso se rechazaba. Actualmente, los avances técnicos permiten poder ofrecer reconstrucción e irradiación.
En el presente artículo se revisan los diferentes tipos de cirugía reconstructiva y su relación con la irradiación, de forma que se incluyen: reconstrucción inmediata con técnica heteróloga, prótesis definitivas, expansores tisulares, reconstrucción diferida con técnica heteróloga y/o autóloga, reconstrucción del complejo aréola-pezón y lipoinfiltración. Se revisan las complicaciones de la combinación de cirugía reconstructiva y radioterapia, y se establecen unas recomendaciones prácticas.
Currently, conservative surgery is the standard management in breast cancer. However, in 15-35% of patients, mastectomy should be offered. Until recently, if these patients needed radiotherapy, the option of reconstruction was delayed or even rejected. Current technical advances allow both reconstruction and irradiation to be offered.
This article reviews the different types of reconstructive surgery and their relationship with irradiation, including immediate heterologous reconstruction techniques, definitive prostheses, tissue expanders, delayed reconstruction with heterologous and/or autologous techniques, nipple-areola complex reconstruction, and lipofilling. We review the complications of combining radiotherapy and reconstructive surgery, and establish practical recommendations.

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Impact of Radiotherapy on Breast Reconstruction

Section snippets

Radiotherapy

Breast reconstruction

Summary

Clin Oncol (R Coll Radiol)

Lancet

Clin Oncol (R Coll Radiol)

Clin Oncol (R Coll Radiol)

Clin Oncol (R Coll Radiol)

Trends Cell Biol

Semin Roentgenol

Clin Plast Surg

Clin Plast Surg

Clin Plast Surg

Int J Radiat Oncol Biol Phys

Clin Oncol (R Coll Radiol)

Clin Oncol (R Coll Radiol)

Int J Radiat Oncol Biol Phys

Curr Probl Surg

Eur J Surg Oncol

Int J Radiat Oncol Biol Phys

Radiother Oncol

Clin Oncol (R Coll Radiol)

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

J Plast Reconstr Aesthet Surg

J Plast Reconstr Aesthet Surg

Br J Plast Surg

10-year results after sector resection with or without postoperative radiotherapy for stage I breast cancer: a randomized trial

J Clin Oncol

Favourable and unfavourable effects on long-term survival of radiotherapy for early breast cancer: an overview of the randomised trials. Early Breast Cancer Trialists' Collaborative Group

Lancet

Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer

N Engl J Med

Radiotherapy for early breast cancer (Cochrane Review). 4th edition. The Cochrane Library

Survival effects of postmastectomy adjuvant radiation therapy using biologically equivalent doses: a clinical perspective

J Natl Cancer Inst

Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy. Danish Breast Cancer Cooperative Group 82b trial

N Engl J Med

Adjuvant radiotherapy and chemotherapy in node-positive premenopausal women with breast cancer

N Engl J Med

Assessing the benefit of radiation therapy after breast-conserving surgery for ductal carcinoma-in-situ

J Clin Oncol

Effectiveness of radiation therapy for older women with early breast cancer

J Natl Cancer Inst

Defying death after DNA damage

Nature

Surgical problems in the excision and repair of radiated tissue

Plast Reconstr Surg

Complications of surgery for radiotherapy skin damage

Plast Reconstr Surg

The ultrastructure of chronic radiation damage in rat skin

Surg Gynecol Obstet

The histopathological changes in irradiated vs. nonradiated tissue-expanded skin in the porcine model

Ann Plast Surg

Microvasculature and radiation damage

Recent Results Cancer Res

Postmastectomy radiation therapy after TRAM flap breast reconstruction

Breast J

Cause-specific mortality in long-term survivors of breast cancer who participated in trials of radiotherapy

J Clin Oncol

Mortality by laterality of the primary tumour among 55,000 breast cancer patients from the Swedish Cancer Registry

Br J Cancer

Coronary artery dosimetry in intact left breast irradiation

Cancer J

Radiation induced lung reactions in breast cancer therapy. Modulating factors and consequential effects

Strahlenther Onkol

Does delay in starting treatment affect the outcomes of radiotherapy? A systematic review

J Clin Oncol

Timing of radiotherapy and survival benefit in breast cancer

Breast Cancer Res Treat