Staged breast reconstruction with saline-filled implants in the irradiatedbreast: Recent trends and therapeutic implications

Sl. Spear et C. Onyewu, Staged breast reconstruction with saline-filled implants in the irradiatedbreast: Recent trends and therapeutic implications, PLAS R SURG, 105(3), 2000, pp. 930-942
Citations number
Categorie Soggetti
Surgery,"Medical Research Diagnosis & Treatment
Journal title
ISSN journal
0032-1052 → ACNP
Year of publication
930 - 942
SICI code
A retrospective review was performed of one surgeon's experience with 40 co nsecutive patients who had undergone two-stage saline-filled implant breast reconstruction and radiation during the period from 1990 through 1997. A r andomly selected group of 40 other two-stage saline-filled implant breast r econstructions from the same surgeon and time period served as controls. Th is 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 re construction patients who have been radiated are increasing dramatically. F or example, in a 1985 report on immediate breast reconstruction, only 1 of 185 patients over a 6-year period underwent adjuvant radiation therapy, whe reas in this review, there were 40 radiated breasts with saline-filled impl ants, 19 of which received adjuvant radiation therapy during their expansio n. The study parameters included patient age, breast cup size, implant size, l ength of follow-up, number of procedures, coincident flap operations, Baker classification, complications, opposite breast procedures, pathologic stag e, 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), mas tectomy and radiation before reconstruction (n = 9), mastectomy and adjuvan t radiation during reconstruction/expansion (n = 19),and radiation after re construction (n = 5). The largest and most rapidly growing group of patient s 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 an d control groups had contralateral surgery. Complications were far more com mon in the radiated group; for example, there were 32.5 percent capsular co ntractures compared with none in the control group. The control nonradiated implant-only group and the flap plus implant radiated group did well cosme tically. The radiated implant-only group was judged die worst. The increasing use of radiation after mastectomy has important: implication s for breast reconstruction The possibility for radiation should be thoroug hly investigated and anticipated preoperatively before immediate breast rec onstruction. Patients with invasive disease, particularly with large tumors or palpable axillary lymph nodes, are especially likely to be encouraged t o undergo postmastectomy radiation therapy. The indications for adjuvant ra diation therapy have included four or more positive axillary lymph nodes, t umors 4 cm (or more) in diameter, and tumors at or near the margin of resec tion. More recently, some centers are recommending adjuvant radiation thera py for patients with as few as one positive lymph node or even in situ carc inoma close to che resection margin. The use of latissimus dorsi flaps after radiation has proven to be an excel lent solution to postradiation tissue contracture, which call occur during breast expander reconstruction. The use of the latissimus flap electively w ith skin-sparing mastectomy preradiation is probably unwise, unless postmas tectomy radiation is unlikely. Skin-sparing mastectomy with a latissimus fl ap thus should be preserved for patients unlikely to undergo adjuvant radia tion therapy Purely autologous reconstruction such as a TRAM flap is anothe r option for these patients, either before or after radiation therapy.