The potential ramifications of radiation use can be of particular concern in the breast reconstruction population, in which both surgical and aesthetic outcomes are important. Presently, there remains a paucity of data detailing the influence of radiation on specific reconstruction aesthetic outcomes.
Objective
To conduct a quantitative evaluation of aesthetic outcomes for expander-implant breast reconstruction in radiated and nonradiated patients using a validated scoring scale.
Methods
A series of consecutive expander-implant breast reconstruction operations performed by the senior author between 2004 and 2012 were reviewed. Four blinded members of the Division of Plastic and Reconstructive Surgery at Northwestern University (Illinois, USA) independently rated postoperative photographs of patients' breasts using a validated scoring scale with respect to five distinct aesthetic domains.
Results
Of the 206 patients meeting the inclusion criteria, 69 received radiotherapy and 137 did not. The radiated cohort had lower scores in each aesthetic domain, with significant differences in contour (1.33 versus 1.51; P=0.041) and placement (1.45 versus 1.73; P<0.001). Linear regression analysis revealed a significant association between placement scores and radiation, and radiated patients had a significantly higher overall rate of complications.
Discussion
Variances in scores may represent the relative difficulty of expansions and proper implant placement in irradiated tissue, with possible skin fibrosis and decreased flexibility hindering prosthesis manipulation.
Conclusion
Radiation adversely impacts breast contour and placement, with possible negative contributions to volume, scarring and inframammary fold definition, and results in higher rates of complications. Such detailed evaluation of the impact of radiation on aesthetics will enhance the management of patient expectations.
IwahiraYNagaseTNakagamiGHuangLOhtaYSanadaH. Histopathological comparisons of irradiated and non-irradiated breast skin from the same individuals.J Plast Reconstr Aesthet Surg.2012; 65: 1496–505.
2.
TibbsMK. Wound healing following radiation therapy: A review.Radiother Oncol1997; 42: 99–106.
3.
DrakeDBOishiSN. Wound healing considerations in chemotherapy and radiation therapy.Clin Plast Surg1995; 22: 31–7.
4.
HaubnerFOhmannEPohlFStrutzJGassnerHG. Wound healing after radiation therapy: Review of the literature.Radiat Oncol2012; 24: 162.
5.
KronowitzSJRobbGL. Breast reconstruction with postmastectomy radiation therapy: Current issues.Plast Reconstr Surg2004; 114: 950–60.
6.
RudolphR. Complications of surgery for radiotherapy skin damage.Plast Reconstr Surg1982; 70: 179–85.
7.
RudolphRArganeseTWoodwardM. The ultrastructure and etiology of chronic radiotherapy damage in human skin.Ann Plast Surg1982; 9: 282–92.
8.
RudolphRUtleyJWoodwardMHurnI. The ultrastructure of chronic radiation damage in rat skin.Surg Gynecol Obstet1981; 152: 171–8.
9.
BerryTBrooksSSydowN. Complication rates of radiation on tissue expander and autologous tissue breast reconstruction.Ann Surg Oncol2010; 17(Suppl 3):202–10.
10.
HvilsomGBHölmichLRSteding-JessenM. Delayed breast implant reconstruction: Is radiation therapy associated with capsular contracture or reoperations?Ann Plast Surg2012; 68: 246–52.
11.
KronowitzSJ. Current status of implant-based breast reconstruction in patients receiving postmastectomy radiation therapy.Plast Reconstr Surg2012; 130: 513e–524e.
12.
JhaveriJDRushSCKostroffK. Clinical outcomes of postmastectomy radiation therapy after immediate breast reconstruction.Int J Radiat Oncol Biol Phys2008; 72: 859–65.
13.
ParsaAAJackoweDJJohnsonEW. Selection criteria for expander/implant breast reconstruction following radiation therapy.Hawaii Med J2009; 68: 66–8.
14.
RoostaeianJPavoneLDa LioALipaJFestekjianJCriseraC. Immediate placement of implants in breast reconstruction: patient selection and outcomes.Plast Reconstr Surg2011; 127: 1407–16.
15.
CordeiroPGPusicALDisaJJMcCormickBVanZeeK. Irradiation after immediate tissue expander/implant breast reconstruction: Outcomes, complications, aesthetic results, and satisfaction among 156 patients.Plast Reconstr Surg2004; 113: 877–81.
16.
JavaidMSongFLeinsterSDicksonMGJamesNK. Radiation effects on the cosmetic outcomes of immediate and delayed autologous breast reconstruction: An argument about timing.Plast Reconstr Aesthet Surg2006; 59: 16–26.
17.
LoweryJCWilkinsEGKuzonWMDavisJA. Evaluations of aesthetic results in breast reconstruction: An analysis of reliability.Ann Plast Surg1996; 36: 601–6.
18.
MahmoodUHanlonALKoshyM. Increasing national mastectomy rates for the treatment of early stage breast cancer.Ann Surg Oncol2012 Nov 8. (Epub ahead of print).
19.
RosenbergSMTamimiRMGelberS. Body image in recently diagnosed young women with early breast cancer.Psychooncology2012 Nov 7. Epub ahead of print.
20.
ChunYSVermaKSinhaI. Impact of prior ipsilateral chest wall radiation on pedicled TRAM flap breast reconstruction.Ann Plast Surg2012 Nov 1. Epub ahead of print.
21.
McCarthyCMKlassenAFCanoSJ. Patient satisfaction with postmastectomy breast reconstruction: A comparison of saline and silicone implants.Cancer2010; 116: 5584–91.
22.
GrossEHannoun-LeviJMRouanetP. Evaluation of immediate breast reconstruction and radiotherapy: Factors associated with complications.Cancer Radiother2010; 14: 704–10.
23.
LeeBTAAdesiyunTColakogluS. Postmastectomy radiation therapy and breast reconstruction: An analysis of complications and patient satisfaction.Ann Plast Surg2010; 64: 679–83.
24.
McKeownDJHoggFJBrownIMWalkerMJScottJRWeiler-MithoffEM. The timing of autologous latissimus dorsi breast reconstruction and effect of radiotherapy on outcome.J Plast Reconstr Aesthet Surg2009; 62: 488–93.
25.
BarryMKellMR. Radiotherapy and breast reconstruction: A meta-analysis.Breast Cancer Res Treat2011; 127: 15–22.
26.
KronowitzSJLamCTerefeW. A multidisciplinary protocol for planned skin-preserving delayed breast reconstruction for patients with locally advanced breast cancer requiring postmastectomy radiation therapy: 3-year follow-up.Plast Reconstr Surg2011; 127: 2154–66.
ClassenJNitzscheSWallwienerD. Fibrotic changes after postmastectomy radiotherapy and reconstructive surgery in breast cancer: A retrospective analysis in 109 patients.Strahlenther Onkol2010; 186: 630–6.
29.
WongJSHoAYKaelinCM. Incidence of major corrective surgery after post-mastectomy breast reconstruction and radiation therapy.Breast J2008; 14: 49–54.
30.
PanettierePMarchettiLAccorsiD. The serial free fat transfer in irradiated prosthetic breast reconstructions.Aesthetic Plast Surg2009; 33: 695–700.
31.
Serra-RenomJMMuñoz-OlmoJLSerra-MestreJM. Fat grafting in postmastectomy breast reconstruction with expanders and prostheses in patients who have received radiotherapy: Formation of new subcutaneous tissue.Plast Reconstr Surg2010; 125: 12–8.
32.
PeledAWFosterRDEssermanLJParkCCHwangESFowbleB. Increasing the time to expander-implant exchange after postmastectomy radiation therapy reduces expander-implant failure.Plast Reconstr Surg2012; 130: 503–9.
33.
RobertsonSWengströmYEriksenCSandelinK. Breast surgeons performing immediate breast reconstruction with implants – assessment of resource-use and patient-reported outcome measures.Breast2012; 21: 590–6.
34.
McCarthyCMMehraraBJRiedelE. Predicting complications following expander/implant breast reconstruction: An outcomes analysis based on preoperative clinical risk.Plast Reconstr Surg2008; 121: 1886–92.
35.
StoneHBColemanCNAnscherMSMcBrideWH. Effects of radiation on normal tissue: Consequences and mechanisms.Lancet Oncol2003; 4: 529–36.
36.
LindegrenAHalleMDocherty SkoghACEdsander-NordA. Postmastectomy breast reconstruction in the irradiated breast: A comparative study of DIEP and latissimus dorsi flap outcome.Plast Reconstr Surg2012; 130: 10–8.
37.
ChangEILyDPWeyPD. Comparison of aesthetic breast reconstruction after skin-sparing or conventional mastectomy in patients receiving preoperative radiation therapy.Ann Plast Surg2007; 59: 78–81.
38.
McCarthyCMPusicALDisaJJMcCormickBLMontgomeryLLCordeiroPG. Unilateral postoperative chest wall radiotherapy in bilateral tissue expander/implant reconstruction patients: A prospective outcomes analysis.Plast Reconstr Surg2005; 116: 1642–7.
39.
RogersNEAllenRJ. Radiation effects on breast reconstruction with the deep inferior epigastric perforator flap.Plast Reconstr Surg2002; 109: 1919–24.
40.
KrollSSSchustermanMAReeceGPMillerMJSmithB. Breast reconstruction with myocutaneous flaps in previously irradiated patients.Plast Reconstr Surg1994; 93: 460–9.
41.
StoneHBColemanCNAnscherMSMcBrideWH. Effects of radiation on normal tissue: consequences and mechanisms.Lancet Oncol2003; 4: 529–36.
42.
SpearSLOnyewuC. Staged breast reconstruction with saline-filled implants in the irradiated breast: Recent trends and therapeutic implications.Plast Reconstr Surg2000; 105: 930–42.
43.
KruegerEAWilkinsEGStrawdermanM. Complications and patient satisfaction following expander/implant breast reconstruction with and without radiotherapy.Int J Radiat Oncol Biol Phys2001; 49: 713.
44.
NavaMBPennatiAELozzaLSpanoAZambettiMCatanutoG. Outcome of different timings of radiotherapy in implant-based breast reconstructions.Plast Reconstr Surg2011; 128: 353–9.
45.
OvergaardMHansenPSOvergaardJ. Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy.N Engl J Med1997; 337: 949.
46.
RagazKJacksonSMLeN. Adjuvant radiotherapy and chemotherapy in node-positive premenopausal women with breast cancer.N Engl J Med1997; 337: 956.
