Risks of Breast Reconstruction with Implants After Radiation Therapy?

You are absolutely right that there are risks and conflicting reports about implants in the setting of radiation.  The radiation will prevent your tissue from stretching well.  It will take longer.  It may be more uncomfortable (rarely painful).  There is higher risk of infection and a higher rate of wound opening up and implants becoming exposed.  These are reasons that many surgeons won't do expansion in this setting.That being said, most of the time it works well.  The most common problem is that the tissue is tighter than it would be otherwise.  You should choose a smaller expansion than if you  did not have radiation.Flap reconstruction can bring in healthy tissue to offset the radiation damage.  Either your abdomen (DIEP or TRAM) or your back (lat dorsi to cover an implant).  Your surgeon is the best one to assess you and go over your options, risks and benefits.Rodger Shortt, MDPlastic Surgeon Oakville

Although a beneficial adjunct for breast cancer in several circumstances, radiation therapy (RT) has also detriments to both the patient as well as plastic surgeon in breast reconstruction. Above all, treatment for cancer comes before the aesthetics of breast reconstruction, and the proven benefit outweighs the ill-effects of RT. The impact that RT has on the skin, as evidenced by the radiation dermatitis/radiation burn, angiofibrosis, contrcture/fibrosis of the skin, and soft tissue, as well as the healing/infection issues are not favorable.

From the plastic surgery standpoint, these effects are troublesome, especially when dealing with reconstruction. This should be discussed with your plastic surgeon, as it impacts the type of reconstruction you should have. Women undergoing lumpectomy are often told that most of their breast will be preserved and that radiation will be needed postoperatively. However, what is not conveyed, is that the above changes may occur and account for some of the breast asymmetry or contractures. Although a "breast conserving" therapy is performed, many women end up seeking a plastic surgeon to assist with these issues, which often times, include the same procedures as if a mastectomy was performed anyhow.

Implant-based reconstruction is not a recommended reconstructive procedure following RT. The complication rates are markedly increased with often times, poor aesthetic results, let alone the wound healing, infection, and capsular contracture/asymmetry rates, among others. This type of reconstruction usually fairs poorly following RT. There are several studies showing good results following implant-based reconstruction, however. Many times, RT is not known until final pathology returns several days later. 

Radiation after flap-based procedures are significantly better following RT. After a flap procedure (e.g., latissismus, TRAM, or DIEP flap, recruiting well-vascularized tissue from a remote area negates some of the ill-effects that RT has done. There still is a chance for the reconstructed breast to shrink or contract if followed by radiation, but it resists the effects much better than implants. Usually, performing this in a delayed fashion would allow your plastic surgeon to excise all of the affected tissue, and use the flap to reconstruct the defect. This is my preference after, or for known RT. The flap-based reconstructions (e.g., latissimus, TRAM, or notably the DIEP), are excellent options as discussed in previous posts.

Breast implants placed after radiation have a higher risk of infection. There is the potential for loss of the implant or scar tissue, capsular contracture, and pain. If possible, the preferred approach is to have tissue expanders placed at the time of mastectomy and prior to any radiation therapy. After radiation, if there are no implants or tissue expanders in place, the surgeon typically would wait 3 to 12 months prior to attempting implant surgery. The waiting period depends on the patient's skin characteristics and overall medical condition.

There is no doubt that there are increased risks of complications with implants following radiation therapy. This does not mean that it should not be done but that you should be aware of this. Clearly you have an understanding as is indicated by your mention of the autologous tissue flaps which are generally preferred with a history of radiation. There are conflicting reports about the timing, some studies suggest within 6 weeks while others advise waiting 3-4 months. In any situation, you should wait until infalmmatory changes to the skinhave subsided.

These patients have a very high complication rate. The most important reason why this happens is because the radiation has already caused permanent damage to the tissues by restricting blood flow. Attempting to reconstruct these tissues when they have already been damaged is less predictable for wound healing and infection. Even if patients get through the initial healing from surgery, most patients will develop capsular contracture around an implant within 5 years. Dr. Albright is rightfully cautious and highly selective when offering (or not offering) implant-based breast reconstruction to patients who had previous breast radiation.