J. A. Ricci1, B. T. Lee1 1Beth Israel Deaconess Medical Center,Plastic And Reconstructive Surgery,Boston, MA, USA
Introduction: Postmastectomy radiation (PMRT) in the setting of implant based immediate breast reconstruction has been associated with higher rates of complications and poorer aesthetic outcomes. Many centers have attempted to avoid deleterious complications such as implant loss or capsular contracture associated with PMRT by implementing an algorithmic approach to breast reconstruction. As such, PMRT may be delivered directly to a tissue expander (TE) before an exchange for a permanent implant (PI) or afterwards. However, the literature regarding the optimal timing of radiotherapy and breast reconstruction remains controversial. This study aims to systematically review all recent literature on this subject to identify differences in patient outcomes related to the timing of PMRT.
Methods: A PubMed literature search was performed to summarize the latest data (2000-2016) regarding the impact of the timing of PMRT on the outcomes of implant based breast reconstruction. The search was conducted using the parameters: breast reconstruction AND radiation AND (implant OR expander). Data was pooled from relevant articles and outcomes compared based on whether PMRT occurred before or after exchange of tissue expander for permanent implant.
Results: The search returned 336 articles, of which 20 were acceptable for inclusion. Primary outcomes of interest included capsular contracture and reconstructive failure (implant loss). A total of 2348 patients were identified, with PMRT administered to 1479 before exchange and 869 after exchange. The mean follow-up for all patients was 39.5 months (14.3 to 73.5) and a majority of studies (14, 70%) were retrospective in nature (6 prospective, 30%). Patients receiving PMRT to TE before exchange to PI were at higher risk for reconstructive failure (20.0% vs 13.4%; p= 0.001) while patients receiving PMRT after exchange had higher rates of Grade III/IV capsular contracture (49.4% vs 24.5%; p= 0.0001). The average level of evidence of all studies was III.
Conclusion: While PMRT remains an undesired event when pursuing an implant-based breast reconstruction, it does not represent an absolute contraindication. However, high rates of significant complications, often necessitating operative intervention, occur regardless of whether PMRT is delivered before or after exchange of TE for PI. Accordingly, a case should be made for the use of autologous breast reconstruction when faced with the prospect of PMRT, regardless of the timing, to improve patient outcomes by avoiding unnecessary complications and prevent unplanned returns to the operating room.