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Optimal Timing Of Post-Mastectomy Radiation in Immediate Prosthetic Breast Reconstruction Reduces The Need for Tertiary/Salvage Breast Reconstruction
Ahmed Suliman, MD, Andrew Vardanian, MD, Jason Roostaeian, MD, Fernando Herrera, MD, Christopher Crisera, MD, Andrew Da Lio, MD, Joan Lipa, MD, Jaco Festekjian, MD.
University of California, Los Angeles, Los Angeles, CA, USA.

PURPOSE:
Although autogenous breast reconstruction has been considered the “Gold Standard” in women who will receive post mastectomy radiation (PMR), there are increasing reports of women receiving radiation in the setting of implant based reconstructions. Outcomes of these studies have unfortunately included a heterogeneous group of patients and results have been contradictory. The optimal timing of PMR in the setting of implant based reconstruction has not been fully elucidated and thus the purpose of our study was to determine if differential timing of post mastectomy radiation influenced the need for tertiary/salvage breast reconstruction, defined as a redo reconstruction secondary to an unsatisfactory primary breast reconstruction.
Conclusions: PMR delivered to an expander is associated with increased rates of capsular contracture and need for tertiary/salvage breast reconstruction when compared to radiation given to the permanent implant.
METHODS:
A retrospective chart review of all patients that underwent immediate prosthetic breast reconstructions and received PMR at our institution was conducted. Patients were divided into two groups: those that received radiation after expansion but before permanent implant exchange (Expander Radiation, ER) and those that received radiation after permanent implant (Permanent Implant Radiation, PIR). Demographics, complications, and reconstructive outcomes were compared.
Comparison between groups was performed using a two sided Student’s t test for continuous variables and Pearson chi square test for dichotomous variables.
RESULTS:
18 patients were identified in the ER and 13 in the PIR groups. Both groups were similar in baseline characteristics, breast disease, cancer stage, chemotherapy, radiation, hormonal treatment, oncologic surgery, and implant technique (P>.05). The ER group had a significantly higher rate of reconstructive failure compared to the PIR group. 44% of the patients in this group developed severe radiation contracture requiring a salvage procedure versus 9% in the PIR group (p<.05). Four patients underwent salvage implant exchange/capsulotomy and 4 patients underwent salvage autogenous reconstruction (2 free TRAM, 1 DIEP, 1 Latissimus flap). No patients in the PIR group required autogenous salvage. ER patients had a 50% chance of requiring salvage breast reconstruction compared with only 10% in the PIR group (p<.05). ER patients developed greater capsular contracture (Baker 3.1 vs 1.5, p<.05) and this was the main reason for a salvage procedure. Subgroup analysis of bilateral reconstructions and unilateral radiation demonstrated a significant increase in capsular contracture (Baker 3.3 vs 1.6) and reconstructive failure (50% vs 0%) between the irradiated and non-radiated breasts of ER patients but not PIR patients.
CONCLUSION:
PMR delivered to an expander is associated with increased rates of capsular contracture and need for tertiary/salvage breast reconstruction when compared to radiation given to the permanent implant.


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