Risks of Breast Reconstruction with Implants After Radiation Therapy?

Question

I have recently had a bilateral mastecomy due to breast cancer in my left breast. I am currently undergoing chemotherapy and will be having radiation therapy. There is much conflicting information about whether breast reconstruction with implants is recommended or even feasible after radiation therapy.  I have had multiple surgeries previously, and I am concerned about having multiple surgical sites (such as those from TRAM or DIEP procedures). What are the risks of utilizing breast implants after radiation, and how long should one wait to have the implants to minimize risk (if possible to do so)?

Rodger Shortt, FRCSC · Answer

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

Lewis Albert Andres, MD · Answer

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.

James N. Romanelli, MD, FACS · Answer

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.

Otto Joseph Placik, MD · Answer

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.

William Albright, MD · Answer

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.

Aldona J. Spiegel, MD · Answer

Thank you for your question, as this is a frequent point of discussion when patients are deciding on reconstruction options after radiation. The procedure options mainly depend on the amount of breast skin and tissue preserved after the mastectomy, hence the answers are different for specific situations. 
Radiated tissue does not expand well, therefore if the remaining breast skin is inadequate to provide a pleasing breast shape then additional tissue needs to be used, most frequently from the abdominal area. 
It is possible to perform reconstruction with implants after radiation, but this is generally planned at the time of mastectomy where the initial reconstruction is performed with a tissue expander and the skin is stretched prior to radiation. Complications can occur when there is thin radiated tissue over an implant, specifically infection and capsular contracture. Therefore it is best for you to be evaluated by a board certified plastic surgeon who specializes in both autologous as well as implant based reconstruction to develop a surgical plan that is specifically tailored to your situation.

Damian Marucci, MBBS, PhD, FRACS · Answer

Thanks for your question.Breast reconstruction with expanders/ implants alone is NOT recommended following mastectomy and radiotherapy as the risk of implant infection/ exposure/ loss (is complete reconstructive failure) is around 40%. Further, as you require bilateral reconstruction, the final cosmetic result on the non-irradiated side will be different and a degree or two better than the irradiated side even if there are no major complications.
If implants are to be used after chest wall radiotherapy, it is safer to cover those implants with tissue (usually the back muscle) which has not had radiotherapy. This obviously is a larger surgical procedure and results in extra scars etc, but it is a safer and more effective form of reconstruction after radiotherapy. If you have enough spare tissue you of your own, an even better option is to avoid an implant altogether and just reconstruct the breasts using your own tissue. This is, again, larger and more complicated surgery that simply placing an implant, but the results are more natural and long-lasting.That said, there are still some patients who are adamant that they do not want any scars elsewhere in the body and wish to give expander/ implant reconstruction a try after being fully informed of the risks. If the chest wall soft tissues are supple, your surgeon may agree. Some of my colleagues will prepare the chest wall with some fat grafting (which had been show to improve the quality of soft tissues following radiotherapy). I have one such patient currently undergoing tissue expansion, and so far so good.Good luck with your decision and reconstruction.

C. Edwin Pittman, MD · Answer

Breast reconstruction is not a one-size-fits-all procedure.  The timing and technique best for your specific breast reconstruction case will be highly influenced by the amount of healthy, natural breast tissue you have after your mastectomy as well as the elasticity of your skin.

	 

	Because you also mention previous surgeries, the presence of existing scar tissue may also influence your procedure. It is possible to undergo breast reconstruction with implants after chemo and radiation; however, it is usually necessary to use a tissue expander to stretch the skin in order to make an adequately sized envelope for your implants. It’s best to speak with your oncologist and prospective reconstructive surgeon in person so that they can assess how you are healing and give you more customized advice as to the timing and type of reconstruction that would be best.

David Greenspun, MD, MSc · Answer

When radiation is used in the treatment of breast cancer, non-cancerous tissues in the path of the radiation are also affected. Radiation therapy can mean a significant loss of skin elasticity, which can profoundly affect the aesthetic results of breast reconstruction. And because the body&rsquo;s wound-healing mechanisms are altered by exposure to radiation, complications from all types of reconstructive breast surgery occur at a higher rate.

	Even in the absence of radiation, the re-operation rate for women who undergo breast reconstruction with breast implants is about 50% within 5 years of surgery (according to the FDA). Complications of implant reconstruction including capsular contracture,  implant exposure/extrusion, unsatisfactory cosmetic appearance, infection and pain all occur at a higher rate if radiation is part of a woman's treatment plan.

	Radiation is especially problematic for women who undergo implant reconstructions, regardless of whether the radiation is administered before or after the implant is placed. Natural-tissue reconstruction has the benefit of bringing non-radiated, healthy, well-vascularized tissue to the mastectomy site, and this can actually aid in the healing process.

	Because of the potential complications associated with implants, breast reconstruction using natural tissue is generally considered the best and most reliable method of reconstruction for women who will require or have already had radiation. While you may be reluctant to accept another surgical site for a procedure such as a DIEP flap reconstruction, I would encourage you to get a firm handle on all of the risks and benefits of the implants and natural tissue reconstruction before deciding on which, if any, method of reconstruction is best for you.

Tim Sayed, MD, MBA, FACS · Answer

Clearly, there is substantial data that the administration of radiation to the breast/chest wall AT ANY TIME IN THE PATIENT'S LIFE is associated with an increased risk of capsular contracture if the patient has implants placed. By that I mean that even patients who had prior lumpectomy/radiation and are now coming for completion mastectomy may be at increased risk for radiation-related capsular contracture around implants even though the radiation preceded the implant placement. Certainly, the risk is higher when radiation FOLLOWS implant placement.

	I do not favor the use of implants in radiation patients, but unfortunately we do not always have the ability to predict who will require radiation after a mastectomy. Because of this, protocols have been developed that involve the use of tissue expanders placed in the patient at the time of mastectomy.  Expanders can serve as "place-holders" of the space that would be occupied by an eventual implant even if radiation is undertaken. Depending on how the patient's tissue responds to radiation, completing the reconstruction with implants is often possible, although the implant size and projection and wound healing may not be optimal compared to a non-irradiated patient, or a contralateral (other side) non-radiated reconstruction in the same patient.

	If, after radiation, the expanded breast does not look like it will accept an implant with a satisfactory result, there are many autologous tissue options that might be available, like the TRAM, DIEP or latissimus flaps. In most cases, the latissimus flap does not have enough bulk to build a reasonably projected breast without the concomitant use of an implants, so some of these radiation issues might still compromise the outcome. Nonetheless, it is often used as a good salvage technique for the radiated patient whose attempt at reconstruction with implants has been compromised.

	Another reason to use tissue expanders in many patients at the time of mastectomy is that if an autologous flap (like a TRAM) is performed initially, and is then radiated, the result can be quite poor with hardening and distortion of the flap. This obviously burns a bridge and also potentially commits the patient to an implant when the original autologous flap was being used to try to avoid implants. So I believe the expander keeps all options open initially and can still potentilally be converted to a permanent implant reconstruction in many radiated patients, with the above considerations.

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