Background: The performance of implant-based, post-mastectomy reconstruction in the setting of irradiated tissues remains controversial. A review of a single surgeon’s extensive experience with tissue expander/implant (TE/I) reconstruction provides the opportunity to critically evaluate outcomes in a selected group of previously irradiated patients undergoing TE/I reconstruction. The objective of this study was to analyze early complications and long-term outcomes in patients undergoing salvage mastectomy and immediate TE/I reconstruction for cancer recurrence following breast conservation therapy (lumpectomy/radiation).
Methods: A review of all TE/I reconstructions performed by a single surgeon over a 11-year period from 1997 to 2008 was performed. Two patient cohorts were identified: i) patients who underwent salvage mastectomy for a cancer recurrence following prior breast conservation therapy; and, ii) patients who underwent primary mastectomy without a history of prior irradiation. Reconstructive, complication and outcomes data were retrieved from a prospectively-maintained, reconstruction database. The incidence of early complications (defined as those occurring ≤ 12 months from initiation of reconstruction) and long-term outcomes (including aesthetic grade, capsular contracture, and rippling severity) was determined for each cohort. Chi-square, Fisher’s exact, and Mann Whitney u-tests, in addition to multivariate regression analysis, where appropriate, were performed.
Results: Immediate, tissue expander/implant reconstruction was initiated in 1699 patients. 121 patients had a history of prior BCT (lumpectomy/radiation); 1578 did not have a history of prior irradiation. The incidence of early complications was significantly higher in the irradiated cohort compared to that in the non-irradiated cohort (29.7% vs. 15.5%; p-value = <0.001). The most common complication in both groups was mastectomy flap necrosis (18.0% in irradiated group vs. 7.7% in non-irradiated group; p-value: <0.001). 697 patients had long-term follow-up data available. For these patients, mean follow-up was 46.4 and 43.2 months, respectively. While the proportion of patients with “good to excellent” aesthetic results was not significantly different in the 2 groups (95.5% vs. 97.9%; p-value: >0.05), the distribution of aesthetic grade within the good-to-excellent range was different between the two groups ((p-value = 0.039; Mann-Whitney). That is, previously irradiated patients tended to have "good"-"very good" results, whereas non-irradiated patients had excellent results. Overall, capsular contracture grade was significantly higher in previously irradiated patients vs non-irradiated patients (p-value=0.02; Mann Whitney U Test). However, when comparing the incidence of grade III/IV capsular contractures, there was no significant difference in the two groups (10.6% vs. 6.3%; p-value = 0.2; Chi square test)
Conclusions: Patients who have had prior BCT who require salvage mastectomy can successfully complete post-mastectomy tissue expander/implant reconstruction. The rate of early complications in this patient group - although acceptable - is higher than in the non-irradiated cohort. The majority of previously-irradiated patients have a good to excellent aesthetic result and an acceptable rate of Grade III/IV capsular contractures. These types of results are attainable in a very highly-select group of patients with favorable skin quality undergoing salvage mastectomy following breast conservation therapy.