Radiation after Reconstruction
It is extremely difficult to make a decision about reconstruction. Women who need or opt for a mastectomy are then faced with the choice of whether or not to have reconstruction surgery--and, if so, which kind to choose. I always recommend that a woman talk with more than one plastic surgeon, no matter how highly recommended and respected the first was. Different plastic surgeons frequently make different recommendations, and it is wise to have as much information as possible. If both suggest the same surgery, that makes the decision a bit easier. I digress, however as this article is about the possible risk of having radiation therapy after reconstruction, and that is often an unknown factor at the time of surgical choice.
It may be apparent from the start that radiation will be part of the treatment, but that is frequently unknown until after the final pathology report has been released. Obviously, that path report cannot be done until after surgery, so women and their doctors need to make a decision in the absence, sometimes, of all the facts. The worry about radiation after reconstruction is that the treatment may damage the reconstruction. The worry about waiting to do reconstruction until after radiation (and it would need to be at least several months after in order to give the tissue time to heal) is that reconstruction options are frequently constrained by previous radiation.
This is a study from the Annals of Plastic Surgery, as reported in MedWire. The conclusion is that free flap reconstructions do not necessarily need to be delayed until after radiation, and that reconstruction after radiation is technically more difficult. Many plastic surgeons are hesitant to perform expander/implant reconstruction after radiation (although I know some women who have had this surgery, and it went well), and those surgeries continue to be generally ill advised before radiation.
Here is the start of the story and then a link to read more:
Radiotherapy ‘does not preclude’ immediate breast reconstruction
By Lynda Williams, Senior medwireNews Reporter
09 April 2013
Ann Plast Surg 2013; Advance online publication
: Women who receive radiotherapy after free-flap breast reconstruction are no more likely to require revision surgery than
those who do not, say US researchers who believe immediate autologous surgery is feasible in this group.
Writing in the
Annals of Plastic Surgery, the team challenges the consensus that reconstruction should be delayed until radiation is
complete to reduce the risk for complications and poor aesthetic outcome, even though it may not be clear at the time of surgery
whether or not a patient will require radiotherapy.
Liza Wu (University of Pennsylvania, Philadelphia) found that 80.43% of 46 patients who received radiation after unilateral immediate
reconstruction required a further procedure, compared with 88.50% of the 113 women who did not have postoperative radiotherapy. The
corresponding values for bilateral reconstruction patients was 29.6% of 81 and 34.13% of 167 patients. Neither comparison reached
Radiotherapy after reconstruction was associated with a significantly increased risk for volume loss in both unilateral (28.26 vs 4.42%)
and bilateral surgery patients (19.75 vs 1.0%), as well as an increased risk for fat necrosis (19.57 vs 3.54%) in the unilateral patients.
However, volume loss in bilateral surgery patients was significantly more common in radiated perforated flaps than muscle-sparing free
transverse rectus abdominis myocutaneous flaps (39 vs 12%).
The researchers say that their study questions whether these post-radiation changes are significant enough to justify delaying
reconstruction and the need for multiple procedures, and say that further quantitative research on volume loss and fat necrosis is now
ongoing to determine the true impact of postradiation changes on patient satisfaction.
Wu et al also emphasize that reconstruction after radiation is technically harder and has a high vascular complication rate, especially
within the recommended time scale of within 3 months of radiotherapy,