Breast recon options for slim woman after radiation?

Radiation poses significant challenges to the reconstructive plastic surgeon, especially in thin and active patients such as yourself. The problem is two fold. First, thin patients often have thin mastectomy flaps and tenuous coverage of implants. Second, the radiation can worsen the situation with its inherent impact on wound healing, increased scar contracture and fibrosis or hardening of the skin. Implant only reconstructions in this setting can be extremely challenging even for a confident and experienced surgeon. Many surgeons would recommend staged reconstruction in this setting with the placement of tissue expanders at the time of mastectomy. This will give you a chance to see how your skin and soft tissue will react to the radiation. If your skin is very thin and you have significant radiation damage, you may require flap reconstruction as an alternative to or in addition to implant reconstruction. The latissimus muscle flap is very commonly used, but it does have the disadvantage of sacrificing a large and important muscle in the process. Alternatives would be complete autologous reconstruction using abdominal tissue(DIEP). This can be limited in thin patients who don't have enough volume to match the breast size. Strategies to maximize this would be to use a stacked DIEP where both halves of the abdomen are used to reconstruct one breast or to use the DIEP over an implant. The DIEP can also be combined with other donor sites to maximize volume such as the inner thigh or buttock region. These techniques require a skilled Microsurgeon with extensive experience.  One final alternative to the latissimus is the TDAP or thoracodorsal artery perforator flap.  This utilizes the skin and fat from the back to cover the implant while sparing the muscle.  This is not something that all plastic surgeons are experienced with and you will need to do some research to find an experienced surgeon in your area.

Hi Elise,

I'm sorry to hear that you are having to go through all of this.  Radiation makes wound healing more difficult, skin less elastic, and implant reconstruction more risky.  As you stated, the latissimus flap is how we sometimes help implant patients navigate these risks.  I would suggest seeing a board-certified plastic surgeon in your area who is well versed in breast reconstruction (in LA you will have many good options).  Two potentially appealing options for you: one would be to have a free gracilis flap for reconstruction.  It is a technically demanding microsurgery (but reliable for surgeons who do this often) which is sometimes a good option for thin women.  Even very thin women tend to have some extra tissue in the upper inner thigh which can be used for an aesthetic reconstruction of a small breast.  Another option to look into is BRAVA and fat grafting.  You and your surgeon will need to look for fat donor sites (medial thighs, hips, sometimes stomach in thin patients) but you may not be able to supply much fat from these areas.  If these don't sound like good first choices, you may want to try an implant based reconstruction, and use these two options as alternative or backup plans.  Hope this helps!

--
Erik Hoy, M.D.
Rhode Island Plastic Surgeon

Thank you for your question.  Breast reconstruction in radiated patients is challenging.  Some plastic surgeons consider radiation an absolute contraindication to implant-based reconstruction.  Skin break down and poor healing is multifactorial, this includes the radiation dose, length of treatment, the quality of your skin, the amount of tissue removed by your surgical oncologist, etc.  In my practice, I have successfully performed implant based reconstruction in radiated patients.  However, I delay the reconstruction for at least 6 - 12 months and explain to my patients that they are at a higher risk of complications. 

Good Day,

Nicholas Jones, MD