Breast Reconstruction After Radiation. Will 415cc be a full C?

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!

In the most current issue of Plastic and Reconstructive Surgery, a new study shows very high rate of implant based failure related to radiation.  There are some nuances of the article that I won't get into, but be prepared to deal with increased risk of implant loss, infection, capsular contracture.  Though each patient is different, make sure that your PS is well versed in managing issues related to radiation and implant based reconstruction.  Autologous (flap) recon, can be used to salvage a poor or failed outcome due to 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:


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


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


Building the papule of the nipple


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.

There are no absolute or proven methods to minimize the potential adverse effects of radiation on a reconstructed breast other than the dose and technique of radiation. There have been some doctors who recommend the use of free radical scavengers (anti-oxidants) but controversy exists regarding the therapeutic benefits of the radiation.
The 415cc implants should be able to achieve a C cup but I would urge caution in selecting a large implant. Your tissue expander volume should give you an excellent idea of what cup size a 415cc implant will accomplish.

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

Dear hhtw2e,
Breast reconstruction after radiation treatment can be very challenging.  Although there are certainly some reports of successful reconstruction using implant based approaches, in my experience using your own tissue more consistently provides a natural appearing and durable long term result.  Autogenous tissue reconstructions can be technically more challenging and often have a more extended recovery but tend to work better in radiated fields.   In my practice, we preferentially reconstruct a previously radiated mastectomy with a DIEP flap when possible.  Other options include latissimus dorsi flaps and TRAM flaps.  Other microsurgical options are also available.

As previously explained by my colleagues, radiation has deleterious effects on the breast skin, and causes fibrosis which usually results in tightening of the skin. There are different approaches to the steps taken in breast reconstruction with implants in the setting of radiation. I prefer to leave the tissue expanders in place during the radiation process and exchange them for implants 6-8 months after the end of radiation. By this point much of the effects of radiation have taken place, and any specific adjustments can be made if warranted on the radiated side. 

A full C will be different depending on your body type and the bra manufacturer. Thus, it is impossible to know whether 415 cc will be a full C on you until the implants are placed in your body. With regard to implants and radiation, many surgeons believe that radiation is a relative contraindication to implant-based breast reconstruction. Radiation increases the chance of wound healing problems and infection, and since the implant is a foreign body without a blood supply it can make these problems worse. If you are going to undergo implant-based breast reconstruction and radiation, there is controversy over the timing of the breast implants. Many surgeons would radiate the tissue expander, and then wait at least 6 months before placing the permanent implant. The best aesthetic and medical results for the radiated side would involve undergoing autologous tissue breast reconstruction and avoiding implants altogether.

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.

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 .