Irradiated Autologous Breast Reconstructions: Effects of Patient Factors and Treatment Variables
ABSTRACT Postmastectomy irradiation often negatively impacts breast reconstruction outcomes. Further investigation is necessary to recognize factors contributing to adverse results. The purpose of this study was to (1) accurately assess the impact of radiation on autologous breast reconstruction and (2) identify patient and treatment factors affecting reconstructive outcomes.
One hundred twenty-six patients were considered after postmastectomy breast reconstruction and irradiation. The records of 76 patients were studied after excluding for radiation therapy before reconstruction, complications before irradiation, implant reconstruction, mastectomy for recurrent disease, and history of cancer. Patient demographics and comorbidities, operative details, adjuvant therapy, and treatment outcomes were assessed.
Seventy-six patients underwent autologous microsurgical breast reconstruction. Complications occurred in 53 patients (70 percent) 7.2 +/- 6 months after irradiation; 36 cases (47 percent) required reoperation for postirradiation effects. Parenchymal complications (fat necrosis or parenchymal fibrosis) were noted in 19.7 percent, skin complications (tissue envelope retraction or hypertrophic scarring) were recorded in 30.3 percent, and general dissatisfaction (physician or patient dissatisfaction) arose in 27.6 percent of patients. Parenchymal complications were associated with smoking (odds ratio, 9.3; p = 0.03), type II diabetes mellitus (odds ratio, 8.5; p = 0.02), and age (odds ratio, 1.1; p = 0.02). Neoadjuvant chemotherapy increased the development of complications (odds ratio, 4.4; p = 0.04), particularly skin changes (odds ratio, 2.4; p = 0.01).
Patient-specific factors, including diabetes mellitus and smoking, increase the risk of postirradiation parenchymal changes, and neoadjuvant chemotherapy is associated with a greater than twofold increase in skin complications. Breast reconstruction followed by irradiation can be successful, but patients with specific risks should be aware of increased complication rates.
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ABSTRACT: Radiation therapy results in permanent damage to the microvasculature, leading to dermal damage and inelasticity in normal tissues. Deferoxamine is a U.S. Food and Drug Administration-approved iron-chelating medication that has also been shown to increase angiogenesis. The authors hypothesize that the application of deferoxamine will result in increased vascularity and improved tissue elasticity in a rat irradiated transverse rectus abdominis musculocutaneous flap model. Fifteen rats underwent a transverse rectus abdominis myocutaneous flap and were randomized to three groups: control, radiation therapy, and radiation therapy plus deferoxamine. The flaps in the radiation therapy and radiation therapy plus deferoxamine groups were irradiated with 35 Gy in a single dose. Four weeks after irradiation, rats in the radiation therapy plus deferoxamine group were treated with deferoxamine. Flaps were imaged with micro-computed tomographic angiography. Flap creep and stress relaxation were assessed using a tensiometer. Hematoxylin and eosin, picrosirius red, and Verhoeff-van Gieson staining was performed. Irradiated flaps demonstrated gross stigmata of cutaneous radiation injury within 4 weeks. Histologically, the epidermis in the radiation therapy flaps was found to be thicker than in the radiation therapy plus deferoxamine and control flaps (p < 0.001). Micro-computed tomographic angiography demonstrated a statistically significant (p < 0.05) increase in vascularity in the radiation therapy plus deferoxamine flaps compared with radiation therapy alone. The creep curve was indicative of increased elasticity in the radiation therapy plus deferoxamine flaps compared with radiation therapy flaps. Deferoxamine appears to mitigate radiation-induced hypovascularity and improve tissue elasticity in a rat model of soft-tissue reconstruction.Plastic & Reconstructive Surgery 01/2015; 135(1):124e-34e. DOI:10.1097/PRS.0000000000000844 · 3.33 Impact Factor
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ABSTRACT: Objective: The aim of this review is to investigate the effect of timing of the reconstruction and radiotherapy, with respect to complication rate and cosmetic outcome, with a special focus on the timing of the placement of the definite implant. Methods: PubMed was searched for publications between January 2000 and December 2012. Of 37 eligible studies, timing of reconstruction, type, and incidence of complications were recorded. First, we calculated the weighted mean including confidence intervals for complications and cosmetic outcome overall, and for the following subgroups: (1) Autologous reconstruction after radiotherapy; (2) Definite implant reconstruction after radiotherapy; (3) Autologous reconstruction before radiotherapy; (4) Definite implant reconstruction before radiotherapy. A second analysis was performed using only studies that directly compared group 1 versus 3 and 2 versus 4. Results: A large variation in complication rates (8.7-70.0%) and in acceptable cosmetic outcome (41.4-93.3%) was reported. The first analysis showed more complications and a higher revision rate if an implant reconstruction was performed after radiotherapy; for autologous reconstruction fibrosis occurred more often if reconstruction was applied first. The second analysis showed no significant differences in total complication rate. Only implant failure occurred more often if applied after radiotherapy (odds ratio (OR) 3.03 [1.59-5.77]). No differences were found in both patient and physician satisfaction. Conclusions: A definite implant reconstruction placed before radiotherapy limits the rate of complications. For autologous reconstruction, less fibrosis is seen if reconstruction is performed after radiotherapy, but timing had no significant impact on total complication rate. (c) 2014 Elsevier Ltd. All rights reserved.European journal of cancer (Oxford, England: 1990) 08/2014; 50(16). DOI:10.1016/j.ejca.2014.07.023 · 4.82 Impact Factor
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ABSTRACT: BackgroundThe technique of delayed-immediate breast reconstruction includes immediate insertion of a tissue expander, post-mastectomy radiation, followed by reconstruction. The aesthetic benefits of delayed-immediate reconstruction compared to delayed reconstruction are postulated but remain unproven. The purpose of this study was to compare aesthetic outcomes in patients following delayed and delayed-immediate autologous breast reconstruction.MethodsA retrospective analysis was performed of all patients who underwent delayed or delayed-immediate autologous breast reconstruction by the senior author from 2005 to 2011. Postoperative photographs were used to evaluate aesthetic outcomes: skin quality, scar formation, superior pole contour, inferior pole contour, and overall aesthetic outcome. Ten non-biased reviewers assessed outcomes using a 5-point Likert scale. Fisher's Exact and Wilcoxon-Mann-Whitney tests were used for comparative analysis.ResultsPatient age and body mass index were similar between delayed (n=20) and delayed-immediate (n=20) cohorts (P>0.05). Skin and scar quality was rated significantly higher in the delayed-immediate cohort (3.74 vs. 3.05, P<0.001 and 3.41 vs. 2.79, P<0.001; respectively). Assessment of contour-related parameters, superior pole and inferior pole, found significantly improved outcomes in the delayed-immediate cohort (3.67 vs. 2.96, P<0.001 and 3.84 vs. 3.06, P<0.001; respectively). Delayed-immediate breast reconstruction had a significantly higher overall score compared to delayed breast reconstructions (3.84 vs. 2.94, P<0.001). Smoking and the time interval from radiation to reconstruction were found to affect aesthetic outcomes (P<0.05).ConclusionsPreservation of native mastectomy skin may allow for improved skin/scar quality, breast contour, and overall aesthetic outcomes following a delayed-immediate reconstructive algorithm as compared to delayed breast reconstruction.05/2014; 41(3):264-70. DOI:10.5999/aps.2014.41.3.264