Radiation and breast reconstruction: Algorithmic approach and evidence-based outcomes

Patient Outcomes after Fat Grafting to the Radiated Chest Wall before Delayed Two-stage Alloplastic Breast Reconstruction

Two-stage alloplastic breast reconstruction in patients having received mastectomy and radiation is associated with a high rate of complications. Fat grafting has been shown to mitigate the effects of radiation on the chest wall to allow for alloplastic reconstruction. In this study, we assess the outcomes (after a mean follow-up of 28 months), including complications and revisional procedures, of women who had fat grafting to the radiated chest wall before two-stage implant-based breast reconstruction.

Methods

A retrospective chart review was performed on consecutive patients seeking delayed implant-based reconstruction after simple mastectomy and postmastectomy radiation therapy between 2011 and 2015. All patients underwent two sessions of fat grafting to the radiated chest wall before inserting a tissue expander and subsequent exchange to a silicone implant.

Results

Twenty patients were included in the study. No reconstructive failures were recorded. The short-term complication rate was 5%, with one hematoma leading to a revisional procedure. The mean follow-up after reconstruction was 28 months. During follow-up, two patients (10%) developed capsular contracture grade IV with implant malposition, leading to capsular revision and implant exchange. Four patients (20%) underwent additional fat grafting for contour deformities.

Conclusions

Fat grafting before two-stage alloplastic breast reconstruction in patients treated with mastectomy and postmastectomy radiation therapy may provide an alternate method of alloplastic reconstruction in a select group of patients who are not suitable for autogenous reconstruction. Follow-up data show that additional surgery may be required for correction of implant malposition and capsular contracture.

Breast Cancer Tumor Board: A Radiologist's Guide to Postmastectomy Radiation Therapy

Radiation therapy represents a pillar in the current management of breast cancer. Historically, postmastectomy radiation therapy (PMRT) has been administered only in patients with locally advanced disease and a poor prognosis. These included patients with large primary tumors at diagnosis and/or more than three metastatic axillary lymph nodes. However, during the past few decades, several factors have prompted a shift in perspective, and recommendations for PMRT have become more fluid. Guidelines for PMRT in the United States are outlined by the National Comprehensive Cancer Network and the American Society for Radiation Oncology. Because evidence to support performing PMRT is frequently discordant, the decision to offer radiation therapy often requires team discussion. These discussions are usually held in multidisciplinary tumor board meetings in which radiologists play a pivotal role by providing critical information such as the location and extent of disease. Breast reconstruction after mastectomy is optional and is safe in cases in which the patient's clinical status allows it. The preferred method in the setting of PMRT is autologous reconstruction. If this is not possible, then a two-step implant-based reconstruction is recommended. Radiation therapy does involve a risk of toxicity. Complications can be seen in acute and chronic settings and range from fluid collections and fractures to radiation-induced sarcomas. Radiologists have a key role in detecting these and other clinically relevant findings and should be prepared to recognize, interpret, and address them. ^© RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Surgical Outcomes of Implant versus Autologous Breast Reconstruction in Patients with Previous Breast-Conserving Surgery and Radiotherapy

BACKGROUND

Postmastectomy breast reconstruction in patients with a history of breast-conserving surgery (BCS) and radiotherapy is challenging, with a paucity of literature on the outcomes of different breast reconstructive techniques. The authors hypothesized that implant-based breast reconstruction (IBR) would be associated with higher complication rates compared to either IBR combined with latissimus dorsi (LD) or free flap breast reconstruction (FFBR).

METHODS

The authors conducted a retrospective review of patients who underwent mastectomy with a history of BCS and radiotherapy between January of 2000 and March of 2016. Surgical and patient-reported outcomes (BREAST-Q) were compared between IBR versus IBR/LD versus FFBR.

RESULTS

The authors identified 9473 patients who underwent BCS and radiotherapy. Ninety-nine patients (105 reconstructions) met the authors' inclusion criteria, 29% ( n = 30) of whom underwent IBR, 26% ( n = 27) of whom underwent IBR/LD, and 46% ( n = 48) of whom underwent FFBR. The overall complication rate was not significantly different between the three groups (50% in IBR versus 41% in IBR/LD versus 44% in FFBR; P = 0.77), whereas reconstruction failures were significantly lower in the FFBR group (33% in IBR versus 19% in IBR/LD versus 0% in FFBR; P < 0.0001). The time between the receipt of radiotherapy and reconstruction was not a significant predictor of overall complications and reconstruction failure. No significant differences were identified between the three study cohorts in any of the three studied BREAST-Q domains.

CONCLUSIONS

In patients with prior BCS and radiotherapy, FFBR was associated with lower probability of reconstruction failure compared to IBR but no significant difference in overall and major complication rates. The addition of LD flap to IBR did not translate into lower complication rates but may result in decreased reconstruction failures.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Deferoxamine to Minimize Fibrosis During Radiation Therapy

Significance: By 2030, there will be >4 million radiation-treated cancer survivors living in the United States. Irradiation triggers inflammation, fibroblast activation, and extracellular matrix deposition in addition to reactive oxygen species generation, leading to a chronic inflammatory response. Radiation-induced fibrosis (RIF) is a progressive pathology resulting in skin pigmentation, reduced elasticity, ulceration and dermal thickening, cosmetic deformity, pain, and the need for reconstructive surgery. Recent Advances: Deferoxamine (DFO) is a U.S. Food and Drug Administration (FDA)-approved iron chelator for blood dyscrasia management, which has been found to be proangiogenic, to decrease free radical formation, and reduce cell death. DFO has shown great promise in the treatment and prophylaxis of RIF in preclinical studies. Critical Issues: Systemic DFO has a short half-life and is cumbersome to deliver to patients intravenously. Transdermal DFO delivery is complicated by its high atomic mass and hydrophilicity, preventing stratum corneum penetration. A transdermal drug delivery system was developed to address these challenges, in addition to a strategy for topical administration. Future Directions: DFO has great potential to translate from bench to bedside. An important step in translation of DFO for RIF prophylaxis is to ensure that DFO treatment does not affect the efficacy of radiation therapy. Furthermore, after an initial plethora of studies reporting DFO treatment by intravenous and subcutaneous routes, a significant advantage of recent studies is the success of transdermal and topical delivery. Given the strong foundation of basic scientific research supporting the use of DFO treatment on RIF, clinicians will be closely following the results of the ongoing human studies.

Association of Radiation Timing with Long-Term Satisfaction and Health-Related Quality of Life in Prosthetic Breast Reconstruction

BACKGROUND

Radiation therapy is increasingly used after breast cancer surgery, which may impact patients' postoperative quality of life. This study assessed differences in long-term patient satisfaction and health-related quality of life after radiation therapy administered at different stages of implant-based breast reconstruction or with no radiation after surgery.

METHODS

In this observational study, long-term outcomes were evaluated for four cohorts of women who completed breast reconstruction and received (1) no radiation, (2) radiation before tissue expander placement, (3) radiation after tissue expander placement, or (4) radiation after permanent implant between 2010 and 2017 at Memorial Sloan Kettering. Satisfaction and health-related quality of life were assessed using the prospectively collected Satisfaction with Breasts and Physical Well-Being of Chest BREAST-Q subscales. Score distributions were examined by radiation exposure status for 3 years after surgery using nonparametric analyses and regression models.

RESULTS

Of 2932 patients who met the inclusion criteria, 25.8 percent received radiation during breast cancer treatment, including before tissue expander placement ( n = 239; 8.2 percent), after tissue expander placement ( n = 290; 9.9 percent), and after implant placement ( n = 228; 7.8 percent). Radiotherapy patients had average scores 7 to 9 points lower at all postoperative time points for Satisfaction with Breasts and Physical Well-Being of Chest subscales ( p < 0.001). Although patient-reported outcomes did not differ by radiation timing, there were higher rates of severe capsular contracture with postimplant radiotherapy ( p < 0.001).

CONCLUSIONS

Radiation therapy significantly affected patient satisfaction and health-related quality of life following implant breast reconstruction through 3 years postoperatively. Patient perception of outcome was unaffected by radiotherapy timing; however, capsular contracture was higher after postimplant radiotherapy, suggesting there may be an advantage to performing radiotherapy before placement of the final reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Dosimetric and Clinical Factors Associated with Breast Reconstruction Complications in Patients Receiving Post-Mastectomy Radiation

PURPOSE/OBJECTIVE(S)

Approximately 30% of women who receive post-mastectomy radiation therapy (PMRT) in the setting of breast reconstruction suffer from reconstruction complications. This study aims to assess clinical and dosimetric factors associated with the risk of reconstruction complications after PMRT, with the ultimate goal of identifying a dosimetric constraint that can be utilized clinically to limit this risk.

MATERIALS/METHODS

We retrospectively identified 41 patients who underwent modified radical (MRM) or total mastectomy followed by immediate or delayed reconstruction (autologous or implant-based) and radiation at a single institution from 2014-2020. Reconstruction complications were defined as flap or implant failure, necrosis, capsular contracture, cellulitis/infection, implant rupture, implant malposition, leakage/rupture, unplanned operation, and hematoma/seroma. Clinical and dosimetric variables associated with complications were assessed with univariate analyses.

RESULTS

12 patients (29%) suffered reconstruction complications which led to flap or implant failure in 5 patients. Median time to complication following reconstruction was 8 months. 32% of patients with immediate and 20% with delayed reconstruction suffered a complication, respectively. There were no local failures. Smoking (p=0.02), use of bolus (p=0.03), and V107 > 11% (p=0.03) were associated with increased complication rates. The complication rates were 42% when V107 > 11% versus 12% when V107 < 11%; 58% in smokers versus 17% in nonsmokers; and 42% with bolus versus 7% without.

CONCLUSION

Plan heterogeneity appears to be associated with the risk of reconstruction complications. Pending further validation, V107 < 11% may serve as a reasonable guide to limit this risk. Further consideration should be given to the selective use of bolus in this setting and optimization of clinical factors such as smoking cessation.

Complications after breast reconstruction with alloplastic material in breast cancer patients submitted or not to post mastectomy radiotherapy

Background and purpose

Breast reconstruction following mastectomy is a relevant element of breast cancer treatment. The purpose of this study was to evaluate the influence of radiotherapy (RT) on local complications in patients with breast cancer that had undergone breast reconstruction with alloplastic material.

Materials and methods

Retrospective study of breast cancer patients submitted to mastectomy and breast reconstruction from 2009 to 2013. Clinical and treatment variables were correlated with early and late complications.

Results

251 patients were included; mean age was 49.7 (25 to 78) years. Reconstruction was immediate in 94% of the patients, with 88% performed with a temporary tissue expander. Postoperative radiotherapy (RT) was delivered to 167 patients (66.5%). Early complications were present in 26.3% of the patients. Irradiated patients presented 5.4% incidence of late complications versus 2.4% for non-irradiated patients (p = 0.327). Diabetes (OR = 3.41 95% CI: 1.23-9.45, p = 0.018) and high body mass index (BMI) (OR = 2.65; 95% CI: 1.60-4.37, p < 0.0001) were the main risk factors. The overall incidence of late complications was 4.4%, with predominance of severe capsular contracture (8/11). Arterial hypertension (OR = 4.78; 95% CI: 1.97-11.63, p = 0.001), BMI (OR = 0.170; 95% CI: 0.048-0.607, p = 0.006) and implant placement (OR = 3.55; 95% CI: 1.26-9.99, p = 0.016) were related to late complications.

Conclusions

The overall rate of complications was low in this population. Radiotherapy delivery translated into a higher but not statistically significant risk of late complications when compared with the non-irradiated patients. Already well-known clinical risk factors for complications after breast reconstruction were identified.

Effect of radiotherapy on expanders and permanent implants in immediate breast reconstruction: long-term surgical and patient-reported outcomes in a large multicentre cohort

BACKGROUND

Current evidence for the effects of radiotherapy (RT) on implant-based immediate breast reconstruction (IBR) is limited by short follow-up and lack of patient-reported outcomes (PROs). It is central to integrate long-term comprehensive outcome data into the preoperative decision-making process. The aim of the present study was to determine long-term surgical outcomes and PROs in relation to RT after implant-based IBR.

METHODS

This was a longitudinal cohort study of PRO data obtained in surveys conducted in 2012 and 2020 using the BREAST-Q questionnaire. All women undergoing therapeutic mastectomy and implant-based IBR between 1 January 2007 and 31 December 2011 at four breast centres in Stockholm, Sweden, were identified. The endpoint was implant removal owing to surgical complications or patient preference.

RESULTS

Median follow-up was 120 (range 1-171) months. After 754 IBRs in 729 women, implant removal occurred in 128 (17 per cent): 34 of 386 (8.8 per cent) in the no-RT group, 20 of 64 (31.3 per cent) in the group with previous RT, and 74 of 304 (24.3 per cent) in the postoperative RT group (P < 0.001). Implant removal was because of surgical complications in 60 instances (7.9 per cent), and patient preference in 68 (9.0 per cent). The BREAST-Q response rate was 72.2 per cent. Women with previous RT scored lower than those without RT on all scales, apart from psychosocial well-being. Women with postoperative RT scored lower only on physical well-being. No scores in the two RT groups had deteriorated between the survey time points, whereas satisfaction with breasts and overall outcome had decreased in the no-RT group.

CONCLUSION

Although RT was significantly associated with higher implant removal rates, PROs remained stable over 8 years despite irradiation.

Effect of Radiation Therapy on Microsurgical Deep Inferior Epigastric Perforator Flap Breast Reconstructions: A Matched Cohort Analysis of 4577 Cases

INTRODUCTION

Breast reconstruction with autologous tissue is a state-of-the art procedure. Several patient-related factors have been identified with regard to the safety and efficacy of these reconstructions. The presented study investigates the impact of prereconstruction radiation on outcomes of deep inferior epigastric perforator (DIEP) free-flap breast reconstructions using largest database available in Europe.

MATERIALS AND METHODS

Between 2011 and 2019, 3926 female patients underwent 4577 DIEP flap breast reconstructions in 22 different German breast cancer centers. The cases were divided into a no-radiation (NR) and a radiation (R) group, according to radiation status before reconstruction. Groups were compared with regard to surgical complications and free-flap outcome.

RESULTS

Overall, there was no significant difference between the groups regarding the rate of total flap loss [1.9% (NR) vs 2.1% (R), P = 0.743], partial flap loss [0.9% (NR) vs 1.5 (R), P = 0.069], and revision surgery [vascular revision: 4.4% (NR) vs 4.1% (R), P = 0.686; wound revision: 7.6% (NR) vs 9.4% (R), P = 0.122]. However, the patients had a significantly higher risk of developing wound healing disturbances at the recipient site [1.2% (NR) vs 2.1% (R), P = 0.035] and showed significantly longer hospitalization {8 [SD, 8.4 (NR)] vs 9 [SD, 15.4 {R}] days, P = 0.006} after prereconstruction radiation.

CONCLUSIONS

Our findings suggest that DIEP flap reconstruction after radiation therapy is feasible. Women with a history of radiation therapy should, however, be informed in detail about the higher risk for wound healing disturbances at the recipient site.

Prepectoral Dual-Port Tissue Expander Placement: Can This Eliminate Suction Drain Use?

OBJECTIVES

The most common method of performing breast reconstruction after a mastectomy is using tissue expanders. Significant drainage that can lead to seromas and possible infection is a common sequela after mastectomies, and therefore, closed suction drains are routinely placed during the initial surgery (Vardanian et al. Plast Reconstr Surg. 2011;128:403-410). Drains, however, are associated with increased pain and discomfort for the patient and have been attributed to an increased infection rate by some authors (Degnim et al. Ann Surg. 2013;258:240-247; Saratzis et al. Clin Breast Cancer. 2009;9:243-246). We report on our experience using a dual-chamber tissue expander placed in the prepectoral space without acellular dermal matrix or other supportive material, which allows for drainage of periprosthetic fluid and avoids drain placement.

PATIENTS AND METHODS

A retrospective, single-institution review of patients' records was performed for all patients who underwent prepectoral tissue expander placement between January 2018 and June 2019. Patients who had drains placed or who underwent autologous reconstruction in combination with expander placement were excluded. Thirty-nine patients were selected, with a total of 66 expander placements. Demographics including body mass index, comorbidities, history of smoking or steroid use, perioperative chemotherapy and radiation therapy, and intraoperative details and indications for surgery were retrospectively collected. Outcomes were separated into minor and major complications. Major complications were defined as complications that required surgical intervention.

RESULTS

There were 51 prepectoral reconstructions with a dual-chamber tissue expander and no further surgical drain and 15 reconstructions using a standard expander with an additional closed suction drain. Overall complications for the no-drain cohort were 13.7% compared with 20% in the drain cohort (P = 0.68). Surgical site infection rate is 7.84% in the no-drain cohort compared with 13.3% in the drain cohort (P = 0.61). Mean numeric postoperative pain score at 6 hours was 3.2 in the no-drain cohort compared with 4.3 in the drain cohort (P = 0.03) and 4.17 compared with 5.6 at 12 hours, respectively (P = 0.04). Mean time to exchange of implant in the no-drain cohort was 152 days versus 126 days in the drain cohort (P = 0.38). Median follow-up times were 157 days for the no-drain cohort and 347 days for the drain cohort.

CONCLUSIONS

Immediate breast reconstruction using a dual-chamber tissue expander offers a drain-free alternative to the immediate implant-based breast reconstruction. Our infection rate with 7.8% is lower than our own reported rates with subpectoral tissue expander reconstruction using either acellular dermal matrix or poly-4-hydroxybutyrate (17% and 11%). The overall complication rate is similar to historic data associated with breast reconstruction after mastectomy and suggests that dual-chamber expander placement offers a safe alternative possibly decreasing the patient's postoperative pain and discomfort that often is associated with closed suction drains (Saratzis et al. Clin Breast Cancer. 2009;9:243-246).

A Meta-Analysis of Autologous Microsurgical Breast Reconstruction and Timing of Adjuvant Radiation Therapy

BACKGROUND

 Postmastectomy radiation therapy (PMRT) decreases loco-regional recurrence and improves survival in patients with locally advanced breast cancer. Autologous free flap reconstruction, while more durable in the setting of radiation than alloplastic reconstruction, is still susceptible to radiation-induced fibrosis, contracture, fat necrosis, volume loss, and distortion of breast shape. Options for reconstruction timing (immediate vs. delayed) have been discussed to mitigate these effects, but a clear optimum is not known.

METHODS

 A systematic review of the literature was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using search terms "breast reconstruction AND (radiation OR irradiation OR radiotherapy)" were used. Inclusion criteria consisted of studies reporting complications for free flap breast reconstruction in the setting of PMRT. Patients who underwent PMRT were pooled into two groups: those who underwent immediate free flap reconstruction prior to PMRT and those who underwent delayed reconstruction after PMRT.

RESULTS

 Out of the 23 studies, 12 focused on immediate reconstruction, seven focused on delayed reconstruction, and four studies included both groups. Overall, 729 patients underwent immediate reconstruction, while 868 underwent delayed reconstruction. Complete and partial flap loss rates were significantly higher in patients undergoing delayed reconstruction, while infection and wound-healing complication rates were higher in those undergoing immediate reconstructions. Rates of unplanned reoperations, vascular complications, hematoma/seroma, and fat necrosis did not differ significantly between the two groups. However, rates of planned revision surgeries were higher in the delayed reconstruction group.

CONCLUSION

 Immediate free flap breast reconstruction is associated with superior flap survival compared with delayed reconstruction. Rates of complications are largely comparable, and rates of revision surgeries are equivalent. The differences in long-term aesthetic outcomes are not, however, clearly assessed by the available literature. Even in the face of PMRT, immediate free flap breast reconstruction is an effective approach.

Implant-based immediate breast reconstruction: failure rate when radiating the tissue expander or the permanent implant-a meta-analysis

Background

Implant-based immediate approach remains to be a first line option for reconstruction of mastectomy defects. When combined with post-mastectomy radiation therapy (PMRT) two different schemas are possible: radiating the temporary tissue expander (TTE) or the permanent implant (PI). The present article intends to be the biggest cohort meta-analysis to the date comparing reconstructive failure (RF) rate in these two scenarios: PMRT to TE compared with PMRT to PI.

Methods

A systematic search of the literature was performed on PUBMED/MEDLINE. The following key words were chosen: Breast Reconstruction AND Implant based AND Immediate. The time limit applied was from January 2008 to January 2019. We selected ten articles (n=1,130) to perform a meta-analysis due to the similarity of their approaches. Secondly, we did a simple literature review in order to identify some variables possibly working as predicting factors for RF.

Results

Previous meta-analysis are analysed. Some variables possibly working as risk factors for RF are summarized. We performed a meta-analysis in two scenarios: a fixed-effect model and a random effect model. For the random effect model an OR of 1.85 was obtained (0.96, 3.57; P=0.067). A funnel plot is performed showing no publication bias exists.

Conclusions

There is a tendency towards a higher RF rate when the TTE is irradiated compared with the irradiation of the PI. Further studies trying to elucidate the influence of the suggested risk factors for RF have to be performed to stablish a consensus about the indications and contraindications of this reconstructive modality.

Factors Influencing the Aesthetic Outcome and Quality of Life After Breast Reconstruction: A Cross-sectional Study

BACKGROUND

The most important purpose of reconstruction is to increase or restore the patient's quality of life (QOL). The purpose of our study was to evaluate the QOL and aesthetic outcomes of patients after autologous versus implant-based breast reconstruction.

METHODS

Patients who underwent breast reconstruction between 2009 and 2011 were included. The Breast-Q, a validated breast reconstruction QOL questionnaire, was used along with postoperative photographs panel analyses using a multiparameter breast-specific aesthetic outcome scale and retrospective evaluation of demographic and treatment data.

RESULTS

Of 820 patients, 261 complete questionnaires were evaluated. On the multivariable linear regression, the "satisfaction with breasts" was positively influenced by autologous and bilateral reconstructions, whereas radiation therapy (RTx), the time between the reconstruction and the questionnaire, and the number of surgeries due to complications were negative factors (adjusted R = 0.183; P < 0.001). The same factors influenced the "satisfaction with the outcomes." The mean "overall breast appearance" was also positively influenced by autologous and bilateral reconstructions, and RTx and the total number of surgeries were negative predictive factors (adjusted R = 0.311, P < 0.001).

CONCLUSIONS

The aesthetic result and QOL after breast reconstruction for breast cancer treatment are positively influenced by the use of autologous tissue and bilaterality. Factors that negatively influenced the aesthetic result and the QOL include use of RTx, a higher number of surgeries needed for the reconstruction, reoperations due to complications, higher body mass index, and a longer time elapsed between reconstruction and the questionnaire.

Higher reconstruction failure and less patient-reported satisfaction after post mastectomy radiotherapy with immediate implant-based breast reconstruction compared to immediate autologous breast reconstruction

PURPOSE

To improve shared decision making, clinical- and patient-reported outcomes between immediate implant-based and autologous breast reconstruction followed by postmastectomy radiotherapy (PMRT) were compared.

METHODS

All women with in situ and/or invasive breast cancer who underwent skin sparing mastectomy with immediate breast reconstruction (IBR) (autologous- or implant based, one- or two staged) followed by PMRT in the Utrecht region between 2012 and 2016 were selected from the Netherlands Cancer Registry, of which 112 (59%) agreed to participate. The primary outcome was reconstruction failure after the start of radiotherapy, and secondary outcomes were patient-reported outcomes measured with BREAST-Q.

RESULTS

109 patients underwent skin-sparing mastectomy, of which 29 (27%) underwent immediate autologous reconstruction and 80 (73%) received immediate implant-based reconstruction. After PMRT, reconstruction failure occurred in 17 patients (21%) with implant-based reconstruction, while no failure was seen in the autologous group (p = 0.04). Mean patient-reported 'Satisfaction with Breasts' (50.9 vs. 63.7, p = 0.001) and 'Sexual Well-being' (46.0 vs. 55.5, p = 0.037) were lower after implant-based reconstruction compared to autologous reconstruction. Thirteen patients with autologous flaps underwent surgical cosmetic corrections compared to ten patients in the implant group (45 vs. 13%, p = 0.001). IBR and PMRT in this study resulted in a high rate of severe capsular contraction in implant-based reconstruction (16.9%) and fibrosis in autologous reconstruction (13.8%).

CONCLUSIONS

Patients treated with PMRT and one or two stage immediate implant-based reconstruction were at greater risk of developing reconstruction failure and were less satisfied when compared to one or two stage immediate autologous reconstruction. Since fairly high complication rates in both reconstruction methods after PMRT are observed, it raises the question whether immediate breast reconstruction should be considered at all when PMRT is indicated. Patients considering or potential candidates for IBR should be informed about the consequences of PMRT and especially when opting for autologous reconstruction one should possibly perform reconstruction in a secondary setting.

Two-Staged Implant-Based Breast Reconstruction: A Long-Term Outcome Study in a Young Population

Background and objectives: Differences in patient anatomy and physiology exist between young and older patients undergoing breast reconstruction after mastectomy. Breast cancer has been described as being more aggressive, more likely to receive radiation, contralateral mastectomy, as well as bilateral reconstruction in young patients. Our purpose is to report long-term experience on two-staged implant-based breast reconstruction (IBR) in young females, with complication sub-analysis based on obesity and adjuvant radiation. Materials and Methods: Retrospective chart review of all consecutive young patients who underwent two-staged IBR at our institution, between 2000 and 2016, was performed. Patients between 15 and 40 years old with least 1-year follow-up were included. Univariate logistic regression models and receiver operating characteristic (ROC) curves were created. Results: Overall 594 breasts met our inclusion criteria. The mean age was 34 years, and the median follow-up was 29.6 months. Final IBR was achieved in 98% of breasts. Overall, 12% of breasts had complications, leading to explantations of 5% of the devices. Adjuvant radiation was followed by higher rates of total device explantations (p = 0.003), while obese patients had higher rates of total complications (p < 0.001). For each point increase in BMI, the odds of developing complications increased 8.1% (p < 0.001); the cutoff BMI to predict higher complications was 24.81 kg/m². Conclusions: This population demonstrates high successful IBR completion and low explantation rates. These data suggest that obese women and those with planned adjuvant radiation deserve special counseling about their higher risk of complications.

International multidisciplinary expert panel consensus on breast reconstruction and radiotherapy

BACKGROUND

Conflicting evidence challenges clinical decision-making when breast reconstruction is considered in the context of radiotherapy. Current literature was evaluated and key statements on topical issues were generated and discussed by an expert panel at the International Oncoplastic Breast Surgery Meeting in Milan 2017.

METHODS

Studies on radiotherapy and breast reconstruction (1985 to September 2017) were screened using MEDLINE, Embase and CENTRAL. The literature review yielded 30 controversial key questions. A set of key statements was derived and the highest levels of clinical evidence (LoE) for each of these were summarized. Nineteen panellists convened for dedicated discussions at the International Oncoplastic Breast Surgery Meeting to express agreement, disagreement or abstention for the generated key statements.

RESULTS

The literature review identified 1522 peer-reviewed publications. A list of 22 key statements was produced, with the highest LoE recorded for each statement. These ranged from II to IV, with most statements (11 of 22, 50 per cent) supported by LoE III. There was full consensus for nine (41 per cent) of the 22 key statements, and more than 75 per cent agreement was reached for half (11 of 22).

CONCLUSION

Poor evidence exists on which to base patient-informed consent. Low-quality studies are conflicting with wide-ranging treatment options, precluding expert consensus regarding optimal type and timing of breast reconstruction in the context of radiotherapy. There is a need for high-quality evidence from prospective registries and randomized trials in this field.

Postmastectomy Radiation Therapy (PMRT) before and after 2-Stage Expander-Implant Breast Reconstruction: A Systematic Review

Background: In those undergoing treatment for breast cancer, evidence has demonstrated a significant improvement in survival, and a reduction in the risk of local recurrence in patients who undergo postmastectomy radiation therapy (PMRT). There is uncertainty about the optimal timing of PMRT, whether it should be before or after tissue expander or permanent implant placement. This study aimed to summarize the data reported in the literature on the effect of the timing of PMRT, both preceding and following 2-stage expander-implant breast reconstruction (IBR), and to statistically analyze the impact of timing on infection rates and the need for explantation. Methods: A comprehensive systematic review of the literature was conducted using the PubMed/Medline, Ovid, and Cochrane databases without timeframe limitations. Articles included in the analysis were those reporting outcomes data of PMRT in IBR published from 2009 to 2017. Chi-square statistical analysis was performed to compare infection and explantation rates between the two subgroups at p < 0.05. Results: A total of 11 studies met the inclusion criteria for this study. These studies reported outcomes data for 1565 total 2-stage expander-IBR procedures, where PMRT was used (1145 before, and 420 after, implant placement). There was a statistically significant higher likelihood of infection following pre-implant placement PMRT (21.03%, p = 0.000079), compared to PMRT after implant placement (9.69%). There was no difference in the rate of explantation between pre-implant placement PMRT (12.93%) and postimplant placement PMRT (11.43%). Conclusion: This study suggests that patients receiving PMRT before implant placement in 2-stage expander–implant based reconstruction may have a higher risk of developing an infection.

HALFMOON TomoTherapy (Helical ALtered Fractionation for iMplant partial OmissiON): implant-sparing post-mastectomy radiotherapy reshaping the clinical target volume in the reconstructed breast

PURPOSE

To report the dosimetric feasibility of the radiation technique HALFMOON (Helical ALtered Fractionation for iMplant partial OmissiON) for post-mastectomy radiation therapy (PMRT) in intermediate-high-risk breast cancer patients with implant-based immediate breast reconstruction, where the clinical target volume (CTV) does not include the whole implant (implant-sparing approach).

METHODS

In the HALFMOON technique, the CTV consisted of skin, subcutaneous tissues, and pectoralis major muscle, excluding the implant, chest wall muscles, and rib plane. The HALFMOON plans were compared with conventionally contoured CTV plans, in which the whole implant, chest wall muscles, and ribs plane were included in the CTV, in a ratio 1:3. All patients underwent hypofractionated treatment of 40.05 Gy/15 fractions, using helical Tomotherapy^®.

RESULTS

Eighteen patients undergoing HALFMOON technique were compared to 54 subjects treated with conventionally contoured CTV plans. No difference was found in the planning target volume coverage between the two groups. Conversely, a statistically relevant dose reduction in HALFMOON patients was observed for ipsilateral lung (D_15%, p < 0.0001; D_20%, p < 0.0001; D_35%, p = 0.003), contralateral lung (D_20%, p = 0.048), contralateral breast (D_15%, p = 0.031; D_20%, p = 0.047), and stomach (D_mean, p = 0.011). Regarding the implant, V_90% and D_50% decreased by 46% and 8%, respectively, in the HALFMOON plans (p < 0.0001).

CONCLUSION

The HALFMOON approach is technically feasible and resulted in high-dose conformity of the target with a significant reduction of radiation dose delivered to implant and other organs. A clinical study is needed to assess the impact on reconstruction cosmetic outcome and local control.

Surgical Outcomes of Prepectoral Versus Subpectoral Implant-based Breast Reconstruction in Young Women

Background:

Two-staged implant-based reconstruction (IBR) is the most common breast reconstructive modality. Recently, technological and surgical advances have encouraged surgeons to revisit prepectoral IBR. Data comparing prepectoral against subpectoral IBR in women under the age of 40 are lacking.

Methods:

Retrospective chart review of patients under the age of 40 years old, who underwent immediate 2-staged IBR at our institution, was performed. Patient’s demographics, clinical characteristics, operative details, and early surgical outcomes of prepectoral and subpectoral reconstruction were compared. Data with values of P < 0.05 were considered statistically significant.

Results:

Between 2012 and 2016, 100 patients (187 breasts) who underwent prepectoral and 69 patients (124 breasts) who underwent subpectoral IBR were included. Median follow-up was 17.9 and 17.5 months in the prepectoral and subpectoral groups, respectively. Total number of complications including both stages of reconstruction was 20 (10.7%) and 19 (15.3%) in the prepectoral and subpectoral groups, respectively (P = 0.227). Specific complications, including hematoma, seroma, skin flap necrosis, wound dehiscence, and breast infections, were not significantly different among groups. Ten (5.4%) devices, including implants and tissue expander, required explantation in the prepectoral group and 8 (6.5%) in the subpectoral group (P = 0.683). Explantation was most commonly due to infection (n = 14), and all of them occurred during the first stage (P < 0.001).

Conclusions:

Early complications and implant explantation rates are comparable among prepectoral and subpectoral breast reconstruction in women under 40 years old. Based on these results, we believe that prepectoral IBR is a safe, reliable, and promising reconstructive option.

From the "Fat Capsule" to the "Fat Belt": Limiting Protective Lipofilling on Irradiated Expanders for Breast Reconstruction to Selective Key Areas

BACKGROUND

The number of patients undergoing mastectomy and immediate breast reconstruction with tissue expanders followed by post-mastectomy radiotherapy (PMRT) is exponentially increasing. To reduce the rate of complications, in 2011, the senior author of this manuscript described the use of protective lipofilling in patients undergoing unplanned PMRT to the expander with a specific protocol aiming to decrease the rate of complications.

OBJECTIVES

A study was performed to evaluate the thickness of the breast irradiated tissue to create a standard pattern of "protective" lipofilling infiltration on limited key areas that could re-establish a thickness similar to non-radiotreated tissues.

METHODS

We studied 15 patients who had modified radical mastectomy (MRM) with immediate breast reconstruction with tissue expanders and PMRT (Group 1) before expansion (Time1), before PMRT (Time2), after PMRT (Time3), 3 months after "protective" lipofilling (Time4), and 6 months after "protective" lipofilling (Time5). As a control group, we studied 15 patients who had MRM and immediate breast reconstruction with tissue expanders that would not undergo PMRT (Group 2) at the same time points of GROUP 1 (Time1,2,3). Tissue thickness was studied in specific areas using ultrasounds (US) and magnetic resonance imaging (MRI).

RESULTS

US and MRI measurements obtained 6 weeks after PMRT and 3 months after lipofilling showed an initial decrease and then an average increase in tissue thickness reaching values even higher than the non-radiotreated control group.

CONCLUSIONS

This preliminary report shows how a one-step "fat belt" surgical pattern of lipofilling delivered to central "selected" areas of the breast can achieve adequate tissue thickness in patients who underwent breast reconstruction with PMRT reaching a thickness similar (and in most cases higher) to non-radiotreated tissues. Further follow-up studies are needed to analyze long-term complications of tissue thinning such as ulceration and implant exposure, in comparison with the "fat capsule" pattern.

LEVEL OF EVIDENCE IV

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Management of a late breast implant rupture in the setting of previous radiation

Management of ruptured breast implants is scarcely discussed in the literature, especially in the setting of previous breast cancer and radiation. The authors present an uncommon presentation of late breast implant rupture with seroma and history of prior radiation. It is important to acknowledge the increased risk of wound healing complications in patients who are several years' postradiation therapy for breast cancer and should be an important factor when discussing treatment options with the patient.

Complications following immediate compared to delayed deep inferior epigastric artery perforator flap breast reconstructions

Purpose

As more breast cancer patients opt for immediate breast reconstruction, the incidence of complications should be evaluated. The aim of this study was to analyze the recipient-site complications and flap re-explorations of immediate compared to delayed deep inferior epigastric artery perforator (DIEP) flap breast reconstructions.

Methods

For this multicenter retrospective cohort study, the medical records of all patients who underwent DIEP flap breast reconstruction in three hospitals in the Netherlands between January 2010 and June 2017 were reviewed. Patient demographics, risk factors, timing of reconstruction, recipient-site complications, and flap re-explorations were recorded.

Results

A total of 910 DIEP flap breast reconstructions (n = 397 immediate and n = 513 delayed reconstructions) in 737 patients were included. There were no significant differences in major complications or flap re-explorations between immediate and delayed reconstructions. The total flap failure rate was 1.5 and 2.5% in the immediate and delayed group, respectively. Significantly more hematomas (OR 2.91; 95% CI 1.59–5.30; p = 0.001) and seromas (OR 3.60; 95% CI 1.14–11.4; p = 0.029) occurred in immediate reconstructions, whereas wound problems were more frequently observed in delayed reconstructions (OR 1.99; 95% CI 1.27–3.11; p = 0.003). Correction for potential confounders still showed significant differences for hematoma and seroma, but no longer for wound problems (p = 0.052).

Conclusions

This study demonstrated similar incidences of major recipient-site complications and flap re-explorations between immediate and delayed DIEP flap breast reconstructions. However, hematoma and seroma occurred significantly more often in immediate reconstructions, while wound problems were more frequently observed in delayed reconstructions.

Electronic supplementary material

The online version of this article (10.1007/s10549-018-4695-0) contains supplementary material, which is available to authorized users.

Breast Reconstruction and Radiation Therapy: An Update

With the indications for radiation therapy in the treatment of breast cancer continuing to expand, many patients present for reconstruction having previously had radiation or having a high likelihood of requiring radiation following mastectomy. Both situations are challenging for the plastic surgeon, with different variables impacting the surgical outcome. To date, multiple studies have been performed examining prosthetic and autologous reconstruction in this setting. The purpose of this article was to provide a general platform for understanding the literature as it relates to reconstruction and radiation through an examination of recent systematic reviews and relevant recent publications. We examined this with a focus on the timing of the radiation, and within this context, examined the data from the traditional surgical outcomes standpoint as well as from a patient-reported outcomes perspective. The data provided within will aid in patient counseling and the informed consent process.

A meta-analysis of implant-based breast reconstruction and timing of adjuvant radiation therapy

BACKGROUND

Implant-based breast reconstruction is the most common type of reconstruction after postmastectomy radiation therapy (PMRT). The impact of the timing of PMRT to a tissue expander or permanent implant is not well understood. The purpose of this systematic review was to evaluate outcomes in implant-based reconstruction and the timing of PMRT.

METHODS

A review of the English literature in the PubMed/MEDLINE database (2000-2016) was performed to identify all articles on implant-based breast reconstruction and PMRT. Cases from each study were grouped by PMRT to a tissue expander or PMRT to a permanent implant. Outcomes of interest included reconstructive failure and capsular contracture as overall rates and associations were pooled. Effect sizes (z values), risk ratios (RRs), and heterogeneity scores (I²) were calculated on meta-analysis.

RESULTS

There were 20 studies meeting inclusion criteria with 2348 patients identified. Pooled analysis revealed an overall rate of reconstructive failure of 17.6% and Baker grade III/IV capsular contracture of 37.5%. PMRT applied to tissue expanders resulted in higher rates of reconstructive failure compared with PMRT applied to permanent silicone implants (20% versus 13.4%, RR = 2.33, P = 0.0083, 95% confidence interval 1.24-4.35), but lower rates of capsular contracture (24.5% versus 49.4%, RR = 0.53, P = 0.083, 95% confidence interval 0.26-1.09).

CONCLUSIONS

Regardless of timing, PMRT applied to implant-based breast reconstruction was associated with high risk of reconstructive failure and capsular contracture. Surgeons should consider alternative strategies, such as autologous tissue reconstructions, in patients requiring PMRT.

Impact of different type of cancer treatment on the effectiveness of breast reconstruction

For women undergoing mastectomy as part of their breast cancer treatment, breast reconstruction is an important part of therapy. However, neoadjuvant, adjuvant treatments as well as other patient-related factors can compromise the results of breast reconstruction techniques. In this article we have reviewed current approaches to the management of complications and risks that neoadjuvant and adjuvant therapies pose on breast reconstruction after mastectomy for breast cancer. Non-treatment related factors influencing reconstruction techniques were reviewed as well.