Breast Reconstruction Trends in the Setting of Postmastectomy Radiation Therapy: Analysis of Practices among Plastic Surgeons in the United States

A Comparison of Capsular Contracture Rates after Immediate Implant-based Breast Reconstruction Using Biologic versus Synthetic Mesh

Background

Capsular contracture is one of the most common reasons for reoperation after implant-based breast reconstruction. Prior investigations have suggested that biologic mesh may mitigate capsular contracture development. This study sought to compare capsular contracture rates between patients undergoing immediate implant-based breast reconstruction with biologic versus synthetic mesh.

Methods

A retrospective review was conducted of the senior author's primary implant-based breast reconstructions between 2008 and 2023. Demographics and the incidence of clinically significant Baker grade III or IV capsular contractures were compared between biologic and synthetic mesh cohorts. Univariate and multivariate logistic regressions were then performed to assess potential risk factors for the development of capsular contracture.

Results

A total of 772 breasts underwent immediate reconstruction, of which 689 (89.2%) used biologic and 83 (10.8%) used synthetic mesh. Capsular contracture occurred in 15 (2.2%) biologic mesh breasts and three (3.6%) synthetic mesh breasts with no significant difference between the two groups (P = 0.430). Logistic regression showed that radiation was a borderline significant risk factor for developing capsular contracture, but the use of either biologic or synthetic mesh was not significant (P = 0.351).

Conclusions

Biologic and synthetic meshes function as effective tools in prosthetic breast reconstruction. Our long-term data suggest that the risk of capsular contracture with these devices is low, and there does not seem to be a difference between the two materials. However, there does need to be a shift in how capsular contracture is assessed and discussed in the reconstruction population.

The impact of the new ESTRO-ACROP target volume delineation guidelines for postmastectomy radiotherapy after implant-based breast reconstruction on breast complications

The European Society for Radiotherapy and Oncology-Advisory Committee in Radiation Oncology Practice (ESTRO-ACROP) updated a new target volume delineation guideline for postmastectomy radiotherapy (PMRT) after implant-based reconstruction. This study aimed to evaluate the impact on breast complications with the new guideline compared to the conventional guidelines. In total, 308 patients who underwent PMRT after tissue expander or permanent implant insertion from 2016 to 2021 were included; 184 received PMRT by the new ESTRO-ACROP target delineation (ESTRO-T), and 124 by conventional target delineation (CONV-T). The endpoints were major breast complications (infection, necrosis, dehiscence, capsular contracture, animation deformity, and rupture) requiring re-operation or re-hospitalization and any grade ≥2 breast complications. With a median follow-up of 36.4 months, the cumulative incidence rates of major breast complications at 1, 2, and 3 years were 6.6%, 10.3%, and 12.6% in the ESTRO-T group, and 9.7%, 15.4%, and 16.3% in the CONV-T group; it did not show a significant difference between the groups (p = 0.56). In multivariable analyses, target delineation is not associated with the major complications (sHR = 0.87; p = 0.77). There was no significant difference in any breast complications (3-year incidence, 18.9% vs. 23.3%, respectively; p = 0.56). Symptomatic RT-induced pneumonitis was developed in six (3.2%) and three (2.4%) patients, respectively. One local recurrence occurred in the ESTRO-T group, which was within the ESTRO-target volume. The new ESTRO-ACROP target volume guideline did not demonstrate significant differences in major or any breast complications, although it showed a tendency of reduced complication risks. As the dosimetric benefits of normal organs and comparable oncologic outcomes have been reported, further analyses with long-term follow-up are necessary to evaluate whether it could be connected to better clinical outcomes.

Technical consideration for breast reconstruction in patients requiring neoadjuvant or adjuvant radiotherapy: a narrative review

Background and Objective

Surgical considerations for breast reconstruction (BR) in patients requiring neoadjuvant radiotherapy (NART) or adjuvant radiotherapy (ART) cannot be understated. The management of irradiated tissue leads surgeons to face several challenges. Therefore, it is essential to comprehensively understand the proper patient selection and preoperative planning to ensure the best outcomes and minimize the risk of complications. This narrative review aims to provide an update and summary of the most important technical considerations every breast surgeon must contemplate reconstructing the irradiated breast.

Methods

The search strategy was performed on January 10th, 2023. The PubMed, Embase, Cochrane Library, and Web of Science databases were queried to capture all publications regarding surgical considerations in BR of patients undergoing NART and ART.

Key Content and Findings

This review shows that the effects of radiotherapy (RT) on BR are still being studied. RT represents an essential factor for overall patient survival, and its use is increasing. However, the range of RT treatments across different cancer centers complicates the creation of a single treatment protocol. BR improves women's quality of life, so finding the proper integration of BR and RT is essential. When deciding on the reconstructive method, there are several factors to consider, such as the patient's body characteristics, tumor stage, RT protocol, and chemotherapy. To achieve the best surgical results and the most satisfied patient, using less aggressive and safer RT methods in the treatment sequence is recommended.

Conclusions

The timing of the radiation will influence the selection of the best reconstructive methods to be employed in the breast cancer patient. However, there is clear evidence of preference for immediate autologous-based BR in cases due to the low rate of complications in the long term. But patient individualization is the key. Therefore, the benefits and risks of immediate versus delayed and autologous versus implant-based reconstruction must be weighed in every single case.