Does Post-Operative Radiation Increase Complications or the Need for Revision Surgery in Patients Undergoing Immediate Free Flap Breast Reconstruction?
James M. Smartt, Jr., M.D., Joshua Fosnot, M.D., Nilton D. Medina, M.D., Liza C. Wu, M.D., Joseph M. Serletti, M.D..
University of Pennsylvania Health System, Philadelphia, PA, USA.
Background: The utility of immediate autologous breast reconstruction in patients likely to undergo radiation therapy is controversial. The purpose of this study is to perform a quantitative outcomes assessment of patients undergoing immediate free flap breast reconstruction and subsequent radiation therapy.
Methods: A retrospective chart review was performed of all patients undergoing free flap breast reconstruction by the senior authors (LCW, JMS) between 2005 and 2009. The treatment group included all patients who underwent unilateral free flap breast reconstruction and received subsequent radiation therapy. The control group consisted of patients undergoing immediate unilateral breast reconstruction without any form of radiation therapy. Outcome variables collected included rates of: 1) fat necrosis, 2) wound infection, 3) mastectomy skin flap necrosis, 4) hematoma, 5) seroma, and 6) delayed wound healing, 7) volume loss, and 8) contour deformities of the reconstructed breast. Furthermore, the need for revision surgery to attain optimal breast symmetry and contour was quantified by examining the overall rates of: 1) revision surgery on the reconstructed breast, and 2) balancing procedures of the contralateral breast. Additionally, rates of various revision procedures to the reconstructed and contralateral breast were quantified: 1) fat grafting, 2) placement of additional prosthetic implants, 3) performance of additional flaps, 4) local tissue rearrangement, and 5) liposuction.
Results: Forty-six patients were included in the study group. The control group of non-irradiated patients included 115 patients. Patients undergoing immediate breast reconstruction and subsequent radiation were more likely to suffer from volume loss (28% vs. 5%, p = .001), fat necrosis (20% vs. 4%, p = .001), and delayed wound healing (48% vs. 26%, p = .008), of the reconstructed breast. Rates of contour deformity (44% vs. 53%, p = .32), wound infection (15% vs. 9%, p = .224), mastectomy skin flap necrosis (14% vs. 7%, p = .189), hematoma (4% vs. 3%, p = .792), and seroma (2% vs. 4%, p = .23) were not significantly different. Patients undergoing immediate breast reconstruction did not undergo significantly different rates of revisional surgery (52% vs. 57%, p = .616), fat grafting (11% vs. 5%, p = .20), implant placement (9% vs. 4%, p = .262), additional flap placement (0% vs. 1%, p = .526), or local tissue rearrangement (30% vs. 22%, p = .245) of the reconstructed breast to attain symmetry or improved aesthetic outcomes. However, patients in the treatment group were less likely to undergo revisional liposuction (11% vs. 29%, p = .019) and more likely to undergo revision procedures on the contralateral breast (33% vs. 16%, p = .016).
Conclusions: Post-mastectomy radiation is now being offered to a wider group of patients. Traditionally, autologous reconstruction was delayed in these instances due to shrinkage of the reconstructed breast mound. We have demonstrated that although post reconstruction radiation does shrink the breast mound, it does not result in any greater complications or revision rates in the unilateral breast patient. In conclusion, in selected patients likely to undergo radiation therapy, immediate free flap breast reconstruction is a reasonable treatment option.
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