RT Not Necessarily an Impedance to Breast Reconstruction

NEW ORLEANS—Mastectomy patients who have undergone radiation therapy can still have attractive results from breast reconstruction, providing the surgeon does not underestimate the extent of reconstruction required, according to results of a prospective study presented at the 68th Annual Scientific Meeting of the American Society of Plastic and Reconstructive Surgeons.

 “When dealing with patients who have been irradiated, you shouldn’t lower the patient’s expectations of the results. Just prepare patients for the extent of the surgery,” said Laurie Casas, MD, assistant professor of surgery, Northwestern University Medical School, and head of the Division of Plastic Surgery, Glenbrook Hospital, Glenview, Illinois.

Radiation causes permanent and progressive changes to the blood supply, skin texture, subcutaneous tissue, and muscles, and these changes affect the entire irradiated field—tissues from clavicle to the inframammary crease and from sternum to the posterior axillary line, Dr. Casas said.

Thus, patients who have undergone radiation therapy, as well as their team of doctors, must understand and respect the extensive area involved and the complexity of the reconstruction. “We found that if you merely reconstruct the breast mound, you do not have an excellent esthetic result,” she said. Patients will have a depression along the cleavage and axillary areas that can restrict their choice of clothing, particularly eveningwear and bathing suits.

“Well-vascularized tissue, in the form of the double pedicle TRAM or a free TRAM flap, must be interposed between irradiated skin and the chest wall to the full extent of the anatomic defect, in order to produce a stable, superior, cosmetic result,” she said.

The study, with 1 to 9 years of follow-up, involved 13 patients who had undergone mastectomy and radiation therapy for their breast cancer. The study group (mean age, 44) included six ex-smokers and five patients who quit smoking before the surgery. All the reconstructions were performed by the same surgeon.

The first two cases in which only the breast mound was reconstructed indicated that the defect to be reconstructed had been underestimated. Over the follow-up period, the irradiated skin adhered to the chest wall in these patients.

Therefore, the subsequent 11 reconstruction procedures involved the breast mound and subcutaneous tissue of the entire chest wall using a double pedicle TRAM flap. One of these patients had a 2 cm² parasternal area that did not undergo enough subcutaneous reconstruction, resulting in a skin-to-sternum adhesion. Other complications included small areas of necrosis and abdominal seromas in two cases. There were no repeat operations or flap losses.

Dr. Casas emphasized that the flap procedure used in the study patients was the surgeon’s preference, but the results could potentially apply to any autologous tissue reconstruction.