Risks of Breast Reconstruction with Implants After Radiation Therapy?

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.

Although the risks are greater using implants following radiation, very good results can be obtained. Generally one should wait until the initial reaction to the radiation has subsided, but not so long that subsequent severe scar reaction has occurred. Results are also better if you had significant tissue and the skin was relatively loose after the mastectomy. Also, since you have had a bilateral mastectomy, your results will usually be better than someone with a unilateral mastectomy, since matching the two sides will be easier. The only way to really know exactly what your options are is to see an experienced Plastic Surgeon who can review these options at length with you.

There is a very high, some say almost 100%, risk of capsular contracture with an implant reconstruction after radiation therapy. It is not that you can't give it a try, but at the first sign of the tissues not expanding, I would quit with this mode. Pushing farther will only lead to problems. I have taken care of far to many patients who have come to me after multiple attempts at this, all of which were either failures or where the results were so hard that they were worse than not doing it. Make sure you go to a plastic surgeon who specializes in breast reconstruction and can do all different types including free flaps so your best options can be determined.

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). It is not wrong to proceed with tissue expander implant reconstruction after radiation. However, I generally do not recommend this in my practice becasue radiated tissue is very diffcult to stretch out. There is an increased risk of complications in delayed implant reconstruction following XRT.

In my breast reconstruction practice, following XRT, I recommend delayed 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.

You are correct. Tissue reconstruction is more involved surgery and requires an incision. Although implant (tissue expander) reconstruction may not require surgery on another part of your body, I believe following radiation, I would not recommend implant based reconstruction on the radiated side for my aforementioned reasons.

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

Please visit: www.breastreconstructionhouston.com to learn more about your options. Our concierge service at the Institute of Advanced Breast Reconstruction is experienced in helping out of town patients meet their goals for breast restoration.

The use of breast implants in breast reconstruction after radiation has a high rate of wound complications(delayed healing, implant exposure) and capsular contracture. If an implant is anticipated you would probably go with an expander first, going through very slow expansion.

Another option would be a latissimus dorsi flap with an expander or implant.

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.

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 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.

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’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.