Introduction:
The indications for postmastectomy radiation therapy (PMRT) have expanded over the past decade. Controversy exists over the appropriate timing of radiation therapy and reconstruction. Plastic surgeons are reluctant to perform an immediate reconstruction followed by radiation because of the perception that this sequence results in increased complications and unsatisfactory results. This study examines the relationship between the use and sequencing of radiation therapy on complication rates and patient satisfaction following reconstruction.
Methods:
A retrospective chart review was performed of all women at an academic institution who underwent mastectomy and reconstruction from 1999 to 2006. The 769 reconstructed breasts were separated into 4 groups: mastectomy and PMRT prior to delayed reconstruction (n = 60); immediate reconstruction then PMRT (n = 56); reconstruction with no PMRT (n = 540); and reconstruction after breast conservation therapy with radiation therapy (BCT-RT, n = 113).
All operative complications were categorized into early (≤90 days) or late. A questionnaire based on the Michigan Breast Reconstruction Outcomes Study assessed general and aesthetic satisfaction (response rate 73.2%). Dichotomous variables were evaluated using the Fisher’s exact or chi-squared test; statistical significance was set at p < 0.05.

Results:
The overall complication rate for patients having PMRT (given before or after reconstruction) was higher than for patients with reconstruction only (36.2% vs. 27.2%, p = 0.048). The overall complication rate for women receiving PMRT then reconstruction was lower than for reconstruction then PMRT, although this was not statistically significant (28.3% vs. 44.6%, p = 0.068). Patients having reconstruction then PMRT had increased overall and late complication rates, compared to patients having reconstruction only (44.6% vs.27.2%, p = 0.006; 33.9% vs. 20.7%, p = 0.023, respectively).
General patient satisfaction was similar among all four groups. Aesthetic satisfaction was significantly lower in the PMRT then reconstruction group, compared to reconstruction only (47.5% vs. 65%, p = 0.029). Patients that underwent reconstruction then PMRT had similar aesthetic satisfaction compared to patients having reconstruction only (62.1% vs. 65%).

Conclusions:
Patients who have reconstruction prior to PMRT have increased overall and late complication rates compared to patients having reconstruction without radiation, but they have similar rates of general and aesthetic satisfaction. In contrast, patients who receive PMRT prior to delayed reconstruction have similar complication rates and general satisfaction levels as patients undergoing reconstruction only; however, the former patients report decreased aesthetic satisfaction. Recommendations for reconstruction in patients requiring PMRT should consider both the risk of complications and patient satisfaction in the decision-making process.