Source Georgetown University Medical Center Volume: n/a Number: n/a March 1999

Staged Breast Reconstruction with Saline-Filled Implants
in the Irradiated Breast: Recent Trends and Therapeutic Implications

Scott L. Spear, M.D. and Chukwuemeka Onyewu, M.D.
Washington, D.C.

A retrospective review was performed of one surgeon's experience with 40 consecutive patients who had undergone two-stage saline-filled implant breast reconstruction and radiation during the period from 1990 through 1997. A randomly selected group of 40 other two-stage saline-filled implant breast reconstructions from the same surgeon and time period served as controls. This review was undertaken because of the absence of specific information on the outcome of staged saline implant reconstructions in the radiated breast. Previously published reports on silicone gel implants and radiation have been contradictory. At the same time, the criteria for the use of radiation in the treatment of breast cancer have been expanded and the numbers of reconstruction patients who have been radiated are increasing dramatically. For example, in a 1985 report on immediate breast reconstruction, only 1 of 185 patients over a 6-year period underwent adjuvant radiation therapy, whereas in this review, there were 40 radiated breasts with saline-filled implants,19 of which received adjuvant radiation therapy during their expansion.

The study parameters included patient age, breast cup size, implant size, length of follow-up, number of procedures, coincident flap operations, Baker classification, complications, opposite breast procedures, patholigic stage, indications for and details about the radiation, and outcomes.

The use of radiation in this review of reconstructed breasts can logically be divided into four groups: previous lumpectomy and radiation (n=7), mastectomy and radiation before reconstruction (n=9), mastectomy and adjuvant radiation during reconstruction/expansion (n=19), and radiation after reconstruction (n=5). The largest and most rapidly growning group of patients is of those receiving postmastectomy adjuvant radiation therapy.

A total of 47.5 percent (19 of 40) of radiated breasts with saline implants ultimately needed the addition of or replacement by, a flap. Ten percent of a control group with nonradiated saline implant reconstructions also had flaps, none as replacements. Fifty percent or more of both the radiated and control groups had contralateral surgery. Complications were far more common in the radiated group: for example, there were 32.5 percent capsular contractures compared with none in the control group.

The control nonradiated implant-only group and the flap plus implant radiated group did well cosmetically. The radiated implant-only group was judged the worst.

The increasing use of radiation after mastectomy has important implications for breast reconstruction. The possibility for radiation should be thoroughly investigated and anticipated preoperatively before immediate breast reconstruction. Patients with invasive disease, particularly with large tumors or palpable axillary lymph nodes, are especially likely to be encouraged to undergo postmastectomy radiation therapy. The indications for adjuvant radiation therapy have included four or more positive axillary lymph nodes, tumors 4cm (or more) in diameter, and tumors at or near the margin of resection. More recently, some centers are recommending adjuvant radiation therapy for patients with as few as one positive lymph node or even in situ carcinoma close to the resection margin.

The use of latissimus dorsi flaps after radiation has proven to be an excellent solution to postradiation tissue contracture, which can occur during breast expander reconstruction. The use of the latissimus flap electively with skin-sparing mastectomy preradiation is probably unwise, unless postmastectomy radiation is unlikely. Skin-sparing mastectomy with a latissimus flap thus should be preserved for patients unlikely to undergo adjuvant radiation therapy. Purely autologous reconstruction such as a TRAM flap is another option for these patients, either before or after radiation therapy. (Plast. Reconstr. Surg. 105:930, 2000.)

The analysis and discussion of prosthetic reconstruction of the radiated breast are in need of critical reevaluation. The indications, timing, and techniques of radiation are evolving, as are the options for breast reconstuction. (1-27) Research and publications that purport to show either that radiation is totally incompatiable with any type of implant breast reconstruction or that radiation does not interfere with reconstruction are overly simplified. (1,4-6,8-11,17-19)

A recent publication from the M.D. Anderson Hospital was so pessimistic about irradiated breast implant reconstructions that it dismissed the use of implants even in conjunction with flaps in the radiated breast. (12) Other publications such as that by Stabile et al. in 1980 suggest the opposite position that radiation poses few problems at all. (1,4,9,19) This study was undertaken with the intention of reviewing this information and increasing the sophistication of the dialogue surrounding breast reconstruction in the context of changing patterns of radiation. By reviewing the literature and our own most recent experience with saline-filled implant reconstruction in the radiated breast, we hope to better elucidate the trends, problems, alternatives, and solutions associated with this subject.

The role of radiation therapy in the treatment of breast cancer hs evolved and will continue to evolve. In the period before 1980, radiation was used primarily as a supplement to mastectomy either as preventive treatment or to help manage recurrence. Because of doublts about its efficacy and concerns about morbidity, radiation as a preventive or adjuvant treatment after mastectomy achieved only moderate popularity. However, it has continued for decades to be widely used to treat local/regional recurrence. (2,4,14,15)

Meanwhile, throughout the 1980s and 1990s, breast conservation with lumpectomy and local radiation therapy began to challenge mastectomy as the primary local treatment for breast cancer in many women. (3,7,20-22) The pathologic stage of the disease may alter the site and the dosage of recommended radiation treatment, whereas the facility location may determine which equipment is available. The individual preferences of the radiation oncologist and the nature of the disease may also determine treatment techniques and dosage. (6,8,9,18,19,21,22)

Although radiation therapy as an adjuvant to mastectomy had achieved only modest acceptance over the preceding three decades, it resurfaced as a mainstream treatment during the 1990s, coincident with several published reports demonstrating improved local recurrence rates and possibly longer survival with its use. (2,14,15) Whereas previously radiation was rarely seen immediately after mastectomy, more recently, many women have been encouraged to undergo radiation during the early stages of their immediate breast reconstruction. The short-term and long-term impact of such adjuvant radiation therapy on tissue expansion and transverse rectus abdominis muscolocutaneous (TRAM) flaps remains uncertain.

During the same three decades, the techniques of breast reconstruction underwent dramatic changes of their own. Throughout most of the 1970s, breast reconstructions were infrequent and of generally poor quality. The latissimus flap of the late 1970s and the TRAM flaps of the early 1980s revolutionized breast reconstruction by improving outcomes and predictability. Tissue expansion, skin-sparing mastectomy techniques, and microsurgery more recently have continued to improve outcomes, increase the scope of reconstruction, and retexturing, saline fill, and anatomic designs have expanded again the options and variables available to patients for breast reconstruction. (26,27)

This review is focused on one type of reconstruction: staged reconstruction using tissue expanders followed by saline-filled implants. Because the literature and our experience at Georgetown University would already strongly suggest that autologous breast reconstructions with musculocutaneous flaps are the best option in the radiated breast, comparing such autologous to implant reconstructions is not our focus here. (11,12) Our own experience with autologous tissue reconstruction of the radiated breast will be a separate report. In this study, we chose rather to review stages, expander/saline implant reconstruction for several reasons. First, staged prosthetic reconstsructions are generally superior to one-stage prosthetic procedures and, therefore, have replaced the on-stage option in our practice. (26) Second, anatomic saline-filled implants have been the dominant device used in our practice this decade. Third, there have not been any previous reports reviewing saline-filled implants in the radiated breast. And fourth, and most importantly, many individual surgeons have not had enough experience with modern radiation and saline-filled expanders or implants to have developed reasonable judgement as to their problems or effectiveness. This finding is particularly true regarding the relatively recent practice of adjuvant radiation therapy of women with tissue expanders in place. Although our experience and that reported in the literature would agree that the TRAM flap or other autologous options generally yield cosmetic results superior to those of implants, especially in radiated patients, nevertheless prosthetic breast reconstructions overall are still more commonly performed. That is in part because some women are not suitable candidates for the TRAM flap, and other simply refuse it. The issue for this review is not then whether saline-filled implants are the best option for reconstruction of the radiated breast but whether such implants have any role at all in the context of evolving modern radiation techniques in the treatment of breast cancer. This review specifically does not address autologous reconstruction of the radiated breast or one-stage breast reconstruction with silicone gel-filled implants-those have been covered previously by other authors. (1,4-6,8-13,18,23) It also does not cover the interesting but separate subject of the outcome of breast conservation and radiation therapy in the previously augmented breast.

Material and Methods

The records of all women operated on by the senior author who had undergone two-stage expander/saline filled implant brest reconstruction between the years of 1990 and 1998 and had local radiation were reviewed. Parameters studied included patient age; cup size; implant size; length of follow-up; number of breast procedures; coincident flap procedure; Baker classification; infection; extrusion; failure; treatment of the opposite breast; pathologic stage; indication for radiation; timing, type, and dose of radiation; and the cosmetic result as judged in a blind manner by a panel of independent objective observers using a modification of a previously published 4-point scale. (8,11) A control group of 40 women was randomly selected out of 200 patients with nonradiated saline implant reconstructions that were performed during the same time period. Statistical analysis of the data was performed by using chi-square and exact chi-square tests.

Results

A total of 40 records were found of women who had undergone breast radiation and two-stage expander/implant reconstruction with saline-filled implants. The patients could readily be separated into four groups (Table I). In the first group, there were seven breasts that were radiated in association with breast conservation as part of the primary treatment of breast cancer (Fig. 1 and 2). The second group of nine were radiated after mastectomy but before any attempt at reconstruction (Figs. 3 and 4). The third, largest, and fastest growing group of 19 were radiated during reconstruction with tissue expanders in place after immediate breast reconstruction (Figs. 5 through 7). The fourth and smallest group of five were radiated after the completion of reconstruction as the local treatment for various reasons, including local recurrence after mastectomy (Fig. 8).

Some patients received radiation only to the breast, some to the breast and regional nodal basins; some received boosts to the tumor bed as part of their breast conservation, by using electron beam or proton theray. Some were treated with tissue equivalent skin boluses to increase the effective dose of radiation to the skin. The total amount of radiation to the skin. The total amount of radiation delivered ranged from 5,020 cGy to 11,715 cGy (Table II).

Nineteen (47.5 percent) of the 40 radiated breasts reconstructed with saline-filled implants, ultimately had flap procedures (Table III). There were 11 latissimus flaps and 8 TRAM flaps. Five of the latissimus flaps were done electively, whereas six were done to improve, correct, or salvage saline implant reconstructions that were unsatisfactory because of poor cosmesis, capsular constracture, or threatened extrustion. However, all the latissimus flap reconstructions were completed with saline implants still in place. Within the four subgroups of radiation, four of the seven breasts reconstructed after previous radiation and breast conservation ultimately required latissimus flaps, one electively and three secondarily to correct problems with their initial postmastectomy reconstructions. Of nine patients who were radiated prophylactically before reconstruction but after their mastectomy, four had latissimus flaps: two electively, and two to correct what would have been an unsatisfactory saline implant reconstruction. Three also had elective TRAM flaps: one in addition to a saline implant, one to replace a satisfactory saline implant reconstruction because of "silicone anxiety," and one to replace a satisfactory saline implant at the time of a contralateral prophylactic mastectomy. Three of the 19 patients radiated during expansion had latissimus flaps: one electively, preradiation, to allow the creation of a pendulous breast. The other two latissimus flaps were performed after expansion and radiation to relieve excessive periprosthetic tightness. Several other of these 19 radiated expanders are likely candidates in the future for latissimus release because of unsatisfactory tightness after radiation.

Five of the 19 breasts radiated during expansion ultimately had TRAM flaps. None of these were elective, and all five were done to salvage or correct unsatisfactory saline implant reconstructions. in three breasts, the TRAM flaps replaced the implants altogether, whereas in the other two of the five, TRAM flaps were used to replace some of the radiated breast skin, but saline implants were still used as part of the reconstruction (Figs. 3 and 4). Among the five breasts radiated for local recurrences after reconstruction, there were no flaps used. In summary, of 19 flaps used in reconstruction of these 40 breasts that used saline implants, there were 7 elective flaps (4 latissimus and 3 TRAM) and 12 salvage flaps (7 latissimus and 5 TRAM).

Flaps were used significantly less often as part of the reconstruction in the nonradiated conrol group (p=0.0019). Among the 40 randomly selected control patients with saline implant reconstructions, there were four (10 percent) flaps used: two latissimus flaps and two TRAM flaps. Three of the four flaps were elective and were performed only to give improved cosmetic results. One of the two TRAM flaps was done on an urgent basis to salvage catastrophic skin loss after a prophylactic subcutaneous mastectomy done by a general surgeon.

Among the radiated group, patient age varied from 31 to 66 years (mean, 47.9 years). In the control group, patient age varied from 35 to 76 years (mean, 49.9 years). The saline implants in the radiated group ranged from 200 to 680 cc (mean, 395 cc). In the control group, the range extended from 230 to 600 cc (mean 423 cc).

Measured beginning from the time of the initiation of the reconstruction, follow-up by physician examination in the office in the radiated group ranged from 11 to 76 months (mean, 28 months). Among the controls, follow-up extended from 4 to 73 months (mean, 30 months).

Reconstructive procedures needed to reconstruct the radiated breast (excluding the nipple and tattoo) were as few as two and as many as seven (mean, 2.6). Twenty-three of 40 irradiated saline implant reconstructions were completed in two stages, 12 needed three steps, and 5 needed four or more steps. Among the controls, there were as few as two, and as many as three steps required (mean, 2.3). Thirty of the 40 controls had their reconstructions in two steps, whereas 10 needed three steps.

The opposite breast was frequently operated on in both the radiated and control groups (Table IV). There was no significant difference in the type of incidence of opposite breast surgery between these two groups (p=0.128). Among the radiated group, 27 of 40 opposite breasts were operated on, including 14 that underwent cntralateral mastectomy and reconstruction, 5 mastopexies, 5 augmentations (two primaries and three revisions of previous augmentations), and 3 reductions. Thirteen of the 40 had nothing done on the opposite side. Among the control group, 20 of the 40 had contralateral surgery, 13 contralateral implant reconstructions after mastectomy, 4 reductions, 2 contralateral TRAMS, and 1 mastopexy. There were no contralateral augmentations, and 20 control patients had nothing done on the opposite side.

All of the 40 radiated saline implant reconstructed breasts ultimately completed reconstruction successfully. Thirty-five of the 40 completed reconstruction with a saline implant in place. Five of the 40 were ultimately reconstructed with a TRAM flap only, whereas, as mentioned previously, 19 of the 40 included a flap in the reconstruction. Two of the five implants replaced with TRAM flaps were entirely elective, and three were done to correct capsular contracture or an otherwise unsatisfactory outcome. All together, 14 of the TRAM or latissimus flaps were used not to replace but, instead, in association with saline implants to give improved results in a radiated environment. Eleven of the 19 flaps were used to treat complications of reconstruction, including symptomatic capsular contracture, threatened or actual extrusion, or unacceptable cosmetic results (Table V).

The incidence of complication in the radiated group was significantly higher than within the control group (Table V, p < 0.00005). The radiated group suffered 13 (32.5 percent) symptomatic capsular contractures, whereas there were no symptomatic contractures in the control group. Nine of the 13 contractures were treated, eight with flaps and one by capsulotomy. Flap treatment of contractures consisted of three TRAMs replacing implants, three latissimus flaps to release radiated skin, and two TRAMs with implants left in place. Four capsular contractures remain tolerated by the patient and are uncorrected at this time.

There were three threatened extrusions; one was averted with the expeditious use of a latissimus flap. One extrusion resulted in the temporary loss of an implant, which was later replaced with the help of a latissimus flap. The final extrusion of an expander occurred beneath a TRAM flap that had been performed to eigher replace or resurface an excessively tight expander, which had been radiated during reconstruction. The expander had been left in place as a "lifeboat" and ultimately was not needed for the reconstruction. There were five infections among the 40 radiated saline implant reconstructions; all were treated successfully with antibiotics and, thus, none of the 40 were lost to infection.

Among the controls, all of the 40 saline implant breast reconstructions were successful and were completed with a saline implant in place. Of the four flaps in this group, only one was used to correct the complications of the threatened expander exposure after mastectomy flap necrosis. There were no symptomatic capsular contractures, and none of these 40 patients underwent a flap procedure or capsulotomy to correct capsular contracture. None of the 40 implants were lost or replaced acutely, and none became infected. One threatened early exposure was treated successfully by delayed primary closure of the wound. Two of the implants deflated later and were replaced uneventfully.

The cosmetic results as judged by a panel of five independent blinded observers ranged from a low of 1.4 to a high of 4.0 (mean, 2.98) out of a possible 4 for the entire radiated group (Table VI). For the breast conservation lumpectomy and radiation failure group, the range was 1.75 to 4.0 (mean, 2.65). For the mastectomy and radiation before reconstruction group, the range was 2.5 to 4.0 (mean, 3.1). The group radiated during expansion ranged from 1.4 to 3.85 (mean, 2.925). Those radiated after reconstruction ranged from 1.75 to 4.0 (mean, 3.25). The control group was scored between 2.125 and 3.875 (mean, 3.28).

The patients who were radiated and reconstructed with a combination of saline implants and flaps scored between 2.5 and 4.0 (mean, 3.25) The patients reconstructed with only saline implants in two stages ranged from 1.4 to 3.875 (mean, 2.2). The benefit of a flap with an implant was most conspicuous in the large group of patients radiated during expansion. The members of that group who completed reconstruction without a flap had cosmetic scores of 1.4 to 3.875 (mean, 2.45). Those who had a flap added to the breast at the time of implant replacement of the breast at the time of implant replacement of the expander were judged from as low as 3.0 to as high as 3.875 (mean, 3.475).

The women in the control group had more uniform outcomes with their two-stage saline implant breast reconstruction. Their outcomes, which were judged at a mean of 3.28, were better than the radiated roup (2.98). When the radiated patients reconstructed with saline implants alone were compared with the control group, the difference in outcome was more striking, with implant-only patients scoring a mean of 2.2 compared with the control implant only group score of 3.28. The addition of a latissimus or TRAM flap to the radiated breast reconstructed with a saline implant raised the outcome to a mean of 3.25, which compares favorably to the control group mean cosmetic score of 3.28.

Discussion

The nature of radiation therapy in the treatment of breast cancer is changing. Breast conservation, with lumpectomy, axillary sampling, and radiation therapy, now plays a major role in the treatment of primary breast cancer. damage to surrounding tissues depends on the dose and distribution of the radiation, the use of a tissue equivalent material ("bolus") applied to the surface of the skin to increase the radiation dose at the skin surface and, thus, eliminate the skin sparing property of high energy (megavoltage) protons, and the use of a boost of radiation to the tumor bed. The fact that the type of radiation therapy differs from center to center, and even between radiation oncologists in the same center makes analysis of various reports difficult. As our review demonstrates, there are also four distinct subcategories of radiation therapy. The largest and fastest growing reconstruction group are those who receive adjuvant breast radiation after mastectomy and coincident with their reconstruction. Patients receiving radiation or recurrence after reconstruction and those receiving radiation after mastectomy but before reconstruction are, and are likely to remain, the two smallest groups. Our experience demonstrates dramatically the need to consider the lessons learned from modern expander/saline implant staged reconstruction, particularly in the fast growing postmastectomy adjuvant radiation therapy group.

In our experience, the use of flaps in addition to saline implants in 47.5 percent of reconstructed radiated breasts stands in marked contrast to their use in only 10 percent of controls. In three (7.5 percent) of the radiated breasts, TRAM flaps were used to replace unsatisfactory implants, which never occurred in the control group. Eleven (27.5 percent) of the 19 flaps of the 40 implants in the radiated group were performed to salvage unsatisfactory reconstructions, whereas, only one (2.5 percent) of the 40 flaps in the control group was for salvage.

The greater use of elevtive flaps along side breast prostheses in patients radiated before beginning reconstruction reflects our judgement that the reconstruction will go better and achieve better results when nonradiated tissue replaces some or all of the radiated tissues. As mentioned earlier, many other additional patients underwent entirely autologous tissue reconstruction after mastectomy and radiation therapy and were never treated with expanders or implants, but they are not the subject of this report, which deals only with saline implant patients. The use of five latissimus flaps to salvage unsatisfactory saline implant reconstructions in patients radiated before expansion is a result of three women who chose initially to refuse flaps before expansion, despite our urging them to have a flap. The other two salvage latissimus flaps in that group were a result in part of early errors in judgement on our part that a flap might not be necessary.

The 19 patients radiated during expansion had only one elective latissimus flap and resembled in that regard the 40 control patients who had only two elective latissimus flaps. Because these 19 patients had not yet been radiated, there was no reason preoperatively to recommend a flap to help manage the problems of radiation. Once they had been radiated, the use of five salvage TRAM flaps and two salvage latissimus flaps made them look more like the patients radiated prereconstruction, who frequently needed flaps. Furthermore, several more of those 19 patients who were radiated during expansion might benefit in the future from some sort of flap correction but have deferred that decision for the time being.

Although all 40 of the radiated breasts completed reconstruction, as did all 40 of the controls, 5 of the radiated breasts ultimately were reconstructed without implants, whereas all the controls retained their implants. The incidence of complications was extremely low in the control group and, as expected, much higher in the radiated group. The problems of symptomatic capsular contracture, impending or actual extrusion, or unacceptable aesthetic outcome were managed successfully with the assistance or, less commonly, the replacement of the implant by a flap. The need for additional flap procedures in some of the radiated implant cases resulted in a mean of 2.6 procedures per breast compared with 2.3 for controls.

The cosmetic evaluations of the saline implant radiated breasts reveal that on average, good results can be obtained with implants, even in the presence of radiation. The control patients were judged better, but not dramatically so. The radiated breasts that were reconstructed with saline implants and flaps together were cosmetically equivalent to the implant-only control group. The advantage of adding a flap to the implant was most dramatic in the patients who were radiated during expansion. When a flap was added at the time of expander/implant exchange, the results were equivalent to those in the nonradiated group. Radiated expanders without the help of a flap fared less well and averaged results that were judged just slightly better than fair, and conspicuously worse than those of the controls.

The incidence and distribution of contralateral breast procedures in this study are of interest. Twenty-seven (67.5 percent) of the 40 patients with radiated breasts had contralateral breast surgery, including 14 (35 percent) mastectomy/implant reconstructions, 5 (12.5 percent) augmentations, and 8 (20 percent) reduction/mastopexies. Even in the control group, 20 of 40 patients (50 percent) had bilateral breast procedures, including 13 (32.5 percent) mastectomy/implant reconstructions, 2 (5 percent) earlier mastectomy/TRAM reconstructions, and 5 (12.5 percent) reduction/mastopexies. The high percentage of bilateral procedures in both groups suggest that those women who are directed tward mastectomy and implant reconstruction may be especially inclined toward bilateral procdures for oncologic reasons or for reasons of facilitated reconstruction. For example, those patients with diffuse ductal or lobular carcinoma in situ, breast cancer genetic mutations, bilateral breast pathology, or other conditions may be advised to undergo bilateral mastectomies. It is also our experience that bilateral implant reconstructions are easier to perform than unilateral ones, because the implanted breasts need to match each other and not a natural breast. The similar frequency of reduction/mastopexy in both groups confirms the benefit of such procedures to help achieve symmetry with implant reconstruction.

Our experience with implant reconstructions whether radiated or not is not in uniform agreement with most other reported series. The control group in this series is similar to our report in 1998 of 171 expander/saline implant reconstructions that had a high degree of success both technically and cosmetically. So, to begin with, 100 percent of the control breasts after expansion were successful, and the cosmetic results were generally quite good. That alone is in contradistinction to many previous published series, which describe poor results with frequent, often devastating, complications. (26)

The same principles and materials that yield such consistent and successful reconstructions in the nonradiated patient also make possible the highest percentage of successful reconstructions in the radiated patient. However, although it is clear that radiation has deleterious effects on any type of breast reconstruction, (11,13,23) historical studies of radiated one-stage reconstructions with silicone gel-filled implants may have little relevance to what we are confronted with today.

On the basis of the data presented here, it is clear that two-stage expander/saline implant reconstruction in the nonradiated breast is very safe and very successful, with an acceptable incidence of complications. The complication rate with radiation added is substantially higher; but the complications, most of which are associated with soft-tissue contracture, are generally manageable with the addition of a flap. The final outcomes, although certainly not as good as those obtainable with autologous tissue alone, can nevertheless be acceptable if not quite good. The fact remains that although autologous tissue is our preferred method of reconstructing the radiated breast, some patients are not suitable candidates for a TRAM flap reconstruction. Therefore, it is worthwhile knowing that a saline-filled implant alone or with the help of a latissimus or TRAM flap can effectively reconstruct the breast in most patients, even in the face of radiation.

The increasing use of adjuvant radiation therapy after mastectomy has the unwelcome potential for catching plastic surgeons by surprise. Of particular concern is the scenario in which a skin-sparing mastectomy followed by reconstruction with a latissimus flap and expander might be followed by radiation therapy during the expansion. This would result in the needless radiation of the flap and the likely corresponding damage to it. The elective use of skin-sparing mastectomy with an immediate latissimus flap without anticipating the possibility later of radiation therapy, thus, risks wasting a valuable resource, which could have been used later to correct radiation-induced contracture. Such skin-sparing latissimus reconstructions might best be reserved for those patients for whom postoperative adjuvant radiation therapy is highly unlikely, for example in the patient with noninvasive ductal carcinoma. On the basis of our experience, 50 percent or more of irradiated breasts reconstructed by our expander/implant technique will eventually benefit from the addition of some flap coverage. Thus, a woman with an expander in place after immediate breast reconstruction who is considering adjuvant radiation therapy should know that her reconstruction can likely still be successful, but with at least a 50 percent likelihood of requiring a flap at the second stage.

Careful review of the literature and our own rapidly growing experience elucidates some important principles:

(1) Not all radiation is the same. Patients who receive less radiation particularly to the skin may do better with implants than other patients.

(2) More aggressive radiation will likely yield more prosthetic reconstruction complications and worse cosmetic results. The use of tissue equivalent boluses to increase the effective dose of radiation to the skin may be particualarly deleterious to the prosthetic reconstruction. Thus, in evaluating a radiated breast from reconstruction, both the condition of the soft tissues and the details of the exact type of radiation are important pieces of information for decision making.

(3) Posthetic breast reconstruction in the radiated breast have a substantially higher complication rate than in the nonradiated breast, particularly capsular contracture.

(4) Two-stage reconstructions with integrated valve expanders followed by anatomically shaped, saline-filled implants do better than in many historical reports of one-stage silicone gel-filled implant reconstructions. This finding may be in part because of the opportunity at the second stage to use flaps to correct radiation-related problems.

(5) The largest and fastest growing radiation group consists of those receiving adjuvant radiation after their mastectomy. This frequently occurs during expansion or with the expander still in place.

(6) A total of 90 percent or more of two stage expander/saline implant reconstructions can be successfully completed with the implant in place in the radiated breast, but 50 percent or more of these will likely need a flap as well.

(7) The latissimus flap is an excellent resource for salvaging periprosthetic contracture in the implant-reconstructed radiated breast, particularly in patients who for whatever reason are not good candidates for a TRAM flap.

(8) The elective use of the latissimus flap as immediate breast reconstruction should be done with caution because of the significant and increasing risk of the addition of postmastectomy adjuvant radiation therapy.

(9) When planning immediate breast reconstructions, plastic surgeons should carefully review the stage of the patient's disease and the likelihood of adjuvant radiation therapy. The likelihood of such radiation in a given patient increases the desirability of autologous reconstruction, or the delay of the reconstruction until after the mastectomy and radiation therapy.

(10) Although totally autologous reconstruction is undoubtedly the best option for managing the radiated breast, staged reconstruction with saline-filled implants, often with the help of a flap, can be successful.

Scott L. Spear, M.D.
Plastic Surgery
Georgetown University Medical Center
3800 Reservoir Road, N.W.
Washington, D.C. 20007
spears@gunet.georgetown.edu

References 1-27