Breast Reconstruction After Radiation?

I have undergone the first stage of breast reconstruction after a double mastectomy. I will be getting the expanders removed in 2 weeks with implants replacing them. I am hoping for a full C. The doc said he will be putting 415 cc's. Is this a full C? I am 5'2" weigh 135lbs. Also, following the surgery I will have 5 weeks of radiation on the left breast. I would like to know everything I need to know to offer me the best results for the radiated side.

Doctor Answers 19

Radiation and Breast Reconstruction

You ask an excellent question. There is some controvery on how to approach breast reconstruction when radiation therapy (XRT) is required. Radiation therapy is excellent in helping you reduce your risk for recurrence. This is the most important thing. As I tell my patients, radiation is excellent at killing microscopic cancer cells. However, radiation does "fry" the non cancer normal tissue as well. Radiated tissue will never be the same.

Although some notable studies have shown acceptable results with implant-based reconstruction in patients who required XRT, I tend to subscribe to the perspective that implants and radiation don't mix well in the long run. Why? Because we know that radiation therapy significantly increase the risks for capsular contracture (a vigorous scar tissue response). Given your specific situation, you currently have tissue expanders. It is not wrong to proceed with your implant exchange prior to XRT. However, in my breast reconstruction practice, I generally will clear a patient with a temporary tissue expander to proceed with radiation therapy (XRT). Then I allow approximately six months to pass after XRT to allow for the radiation effects (inflammation/skin burn) to cool off. At this time, I recommend delayed definitive autologous (tissue) reconstruction with excess abdominal tissue (DIEP flap) or back tissue (latissimus flap). The reason why I recommend autoloogus reconstruction following radiation is that the new tissue that is brought to the radiated site, I believe, brings new non-radiated soft tissue, new blood supply, and perhaps new healing potential to a radiated chest wall. Furthermore, a tissue-only reconstruction (DIEP flap) may not require a foreign body implant. Hence this eliminates any risk for foreign body (implant) scar tissue (post radiation capsular contracture). I believe a tissue-only reconstruction breast following radiation therapy will give my patient the best long lasting result.

Radiation definitely complicated breast reconstruction. But in experienced hands, you definitely have options following radiation therapy.

I hope this helps.

415 cc breast implants should be about a C cup

Given your size 415cc implants should end up with you being a C cup. This will depend a bit upon how thick your mastectomy flaps are. Also the fact that you will require radiation could effect your final result. Patients that get radiation have a higher incidence of capsular contracture or firmness around there implants. This sometimes can require further surgery to adjust the implant pocket.Your surgeon will be an excellent source of information in this regard.Good luck with your upcoming surgery,Dr T

Scott Tucker, MD
Winston Salem Plastic Surgeon
5.0 out of 5 stars 22 reviews

Radiation can affect the final result of breast reconstruction

Thank you for your question. Firstly, cup size is a difficult thing to predict whether you are talking about breast reconstruction, breast reduction or breast augmentation. Every bra manufacturer sizes breasts differently. You make a C with one brand, but a B with another and a very full C with another - all those changes without surgery.

Radiotherapy cause fibrosis and scarring. The body forms a wall of scar tissue around all implants called a capsule. Sometimes this capsule can become thickened and distort the shape of the breast. This is called capsular contracture. On average, the degree of capsular contracture is worse on the side that has had radiotherapy. This can be a cause of asymmetry.

Radiotherapy can also cause wound healing problems and increases the risk of implant infection. It is good that you are having your radiotherapy after all your surgery has been completed. All the studies suggest that it is better to have radiotherapy to the final implant, rather than irradiating the expander.

I hope this helps.

Radiation and implant base breast reconstruction

To reiterate my colleagues' answers, radiation therapy (XRT) has a deleterious effect on implant base breast reconstruction. It leads to capsular contracture, asymmetry, implant extrusion, infection, and pain from capsular contracture. On the other hand, XRT is very beneficial in the overall survival and recurrence rate for breast cancer and this is the most important factor in the overall treatment.

If a patient already has a tissue expander in and is about to have radiation, I would wait until the patient is finished with radiation prior to completing the final stage of the reconstruction. I would wait approximately 3 months after the radiation before embarking on the reconstruction. I prefer reconstruction with autologous tissue using the abdominal tissue (free TRAM or DIEP flaps). If a patient does not have abdominal tissue, I would reconstruct her breast using latissimus dorsi (back muscle) with implant.

I highly recommend that you seek a consultation with a board certified plastic surgeon who has extensive experience in breast reconstruction .

Mytien Goldberg, MD, FACS
Los Angeles Plastic Surgeon
5.0 out of 5 stars 4 reviews

Breast Reconstruction After Radiation?

Hello!  Thank you for your question.  Knowing that you will have radiation, it is a very reasonable decision to have the reconstruction that you had and still have excellent results.  While your expanders are in place, I would continue with creams and lotions to the radiated areas as well as massage of the area, in hopes of keeping the scarring to a minimum.  Afterwards, your plastic surgeon will continue with the 2nd stage of your reconstruction, at which time will likely remove as much scarring as possible to give you the best result.  Best wishes for a great outcome!

After radiation, you have a slightly increased rate of complications including wound problems, infections, thinning of the tissue, and decreased vascularity to the skin/tissue of the area.  The best method to reconstruct a breast following radiation therapy is with a flap, if you have failure of your implant-based breast reconstruction.  The flap, which is skin, fat, and sometimes muscle, will serve to bring in healthy, well-vascularized tissue to the chest/breast area that will significantly ameliorate the radiation issues compounding the problem.  Microsurgical perforator flaps (such as the DIEP flap and SGAP/IGAP flap) are the newest and most-innovative procedures in breast reconstruction today.  As these are muscle-sparing flaps, the pain, morbidity, and complications such as those above, of these procedures are much less.  They are highly-complex procedures that few plastic surgeons performed and consult with one who is well-versed, trained, and skilled in these procedures if you are interested.  

There are many options to breast reconstruction including implant-based and flap-based procedures.  Flap reconstruction is usually recommended, but there are several centers who perform implants following radiation with great success and results.  I typically prefer flaps, such as the DIEP flap.  Best wishes for a great outcome!

Lewis Albert Andres, MD
Scottsdale Plastic Surgeon
5.0 out of 5 stars 17 reviews

Radiation after Mastectomy

Thank you for your question.   Breast reconstruction after radiation is a frequently debated topic.   The textbook answer is to utilize one's own tissue to permanently reconstruct a breast after radiation.

This is the philosophy that I employ in my practice, as i have seen first hand how much radiation can damage an implant reconstruction.

My preferred method of tissue reconstruction is a DIEP flap because the flap can be quickly harvested compared to the buttock or thigh tissue, and it allows for the benefits of a tummy tuck without loss of muscle function.

I would consult with a few board certified plastic surgeons with expertise in breast cancer reconstruction, prior to making your final decision.

I wish you a safe recovery.

Dr. GIll

Paul S. Gill, MD
Houston Plastic Surgeon
5.0 out of 5 stars 75 reviews

Breast recon after radiation.

Radiation will change the quality of the skin and increase you chances of capsular contracture. You will likely have some asymmetry but is can be fixed.

Breast Reconstruction After Radiation

Unfortunately, Radiation therapy and implants don't work well together, although some reports out of Memorial/Sloan-Kettering show that radiation once the implants are in place is better tolerated than if one receives radiation to the tissue expander and then trys to put in the implants.  I don't think there is anything you can do personally to guarantee a good result.  Your radiation therapist will give you instructions on how to care for your skin during the therapy and I believe that will help.

Breast reconstruction after radiation

Mastectomies are performed to remove all of the breast tissue, including your tumor. Lumpectomies remove only the tumor and a small amount of surrounding normal breast tissue. Lumpectomies are always followed by radiation to eradicate any residual cancer cells. The surgical oncologist often recommends one of these two options to the patient, but sometimes either option is available.

After mastectomy, breast reconstruction may be performed in multiple steps, encompassing 3-4 procedures over approximately one year. The stages consist of:

  1. Building the breast mound to give the shape of the breast on your chest.

  2. Revising the reconstructed breast for improved contour and procedures to improve symmetry between your breasts.

  3. Building the papule of the nipple

  4. Tattooing the areola

There are two ways to build the breast mound: implant-based and tissue-based. For breast reconstruction using implants, an adjustable tissue expander is placed beneath the skin of the breast and periodically, over several weeks to months, a saline solution is injected to slowly stretch the overlaying skin. These injections of saline are performed in the office and typically cause minimal discomfort, similar to a sore muscle, that resolves over 1-2 days. After the ideal breast size is achieved, a more permanent breast implant, filled with saline or silicone gel, is inserted in place of the tissue expander to give a softer and more natural-appearing result. The procedure to exchange your tissue expander for a permanent implant is typically performed as an outpatient and has a healing time of approximately one week. Implant-based breast reconstruction is not a good option for patients who have been treated with radiation because of poor cosmetic outcomes and a high likelihood of healing problems.

The other technique for breast reconstruction is to use the patient's own tissue to recreate the shape of a breast. You may see this technique referred to as "flap reconstruction," autologous reconstruction, or "free flap reconstruction." Specific names that you may see are those referring to use of tissue from the abdomen: Transverse Rectus Abdominus Myocutaneous flaps (TRAM), free TRAM, muscle-sparing TRAM, Deep Inferior Epigastric Perforator flaps (DIEP) and others.

With autologous tissue reconstruction, skin, fat and sometime muscle from the abdomen, thighs or other parts of the body are utilized to reconstruct the breast mound. This healthy tissue replaces tissue that is lost with a mastectomy and can help the body to heal, even after damage caused by radiation. The most commonly used tissue for autologous reconstruction is the skin and fat from the abdomen, as this best replicates the breast tissue that has been lost. This procedure tightens the abdomen where tissue is removed and results in a long scar, extending from hipbone to hipbone.

There are numerous variations on the technique that is used to move the abdominal tissue to the chest for breast reconstruction. Some surgeons rotate the belly tissue to the chest, leaving an attachment at the ribcage, a procedure called a "pedicled TRAM." Surgeons at Plastic Surgery Northwest use a newer procedure, known as the "free TRAM" where the tissue is completely separated from the body before it is moved to the chest, regaining it's blood flow when small blood vessels from the abdominal tissue are sewn to blood vessels in the chest. This technique is known as the free TRAM, the muscle-sparing TRAM, or the DIEP flap, depending on the amount of abdominal muscle that is moved with the skin and fat.

Sometimes a woman may not be able to use her abdominal tissue for their breast reconstruction due to prior surgery, a paucity of abdominal fat, or other factors. These patients may be able to use inner thigh, buttock, or other tissue to replace the lost breast tissue. Tissue based breast reconstruction operations are much longer than operations to place implants for breast reconstruction and have a lengthy recovery time of 1-3 months. However, your own tissue yields the most natural appearance and a result that can endure for decades.

Lumpectomy, the removal of a tumor with a small amount of surrounding breast tissue, is the other form of surgical breast cancer treatment. This is sometimes called "breast conserving therapy." After lumpectomy, the breast is treated with radiation to eliminate residual cancer cells. Although treatment with lumpectomy and radiation does not remove all breast tissue, this treatment may result in changes to the breast appearance. These changes are most noticeable in women with smaller breasts or larger tumors and may result in significant distortion of the breast. Unfortunately, radiation therapy changes the breast's ability to heal after future surgery and can limit the reconstructive options available if a patient has a poor aesthetic outcome. Reconstruction after lumpectomy and radiation typically involves bringing in tissue from a non-radiated areas.

Diep flap

Breast reconstruction following mastectomy with post-mastectomy radiation can present a challenge.  In general, plastic surgeons prefer to use a woman's own tissue when reconstructing a radiated breast.  In this case, the tummy (or abdominal donor site) may be a good option.  Using advanced microsurgical techniques referred to as the DIEP flap (deep inferior epigastric artery flap) extra skin and fatty tissue from the lower abdomen can be transferred to the breast.  If there is insufficient tissue in the lower abdomen (ie too skinny), other options may include the inner thigh or buttock

Loren Schechter, MD
Chicago Plastic Surgeon
2.0 out of 5 stars 2 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.