Staged Breast Reconstruction with Saline-Filled Implants in the Irradiated Breast: Recent Trends and Therapeutic Implications

Abstract

A retrospective review was performed of one surgeon's experience with 40 consecutive patients who had undergone two-stage saline-filled implant breast reconstruction and radiation during the period from 1990 through 1997. A randomly selected group of 40 other two-stage saline-filled implant breast reconstructions from the same surgeon and time period served as controls. This review was undertaken because of the absence of specific information on the outcome of staged saline implant reconstructions in the radiated breast. Previously published reports on silicone gel implants and radiation have been contradictory. At the same time, the criteria for the use of radiation in the treatment of breast cancer have been expanded and the numbers of reconstruction patients who have been radiated are increasing dramatically. For example, in a 1985 report on immediate breast reconstruction, only 1 of 185 patients over a 6-year period underwent adjuvant radiation therapy, whereas in this review, there were 40 radiated breasts with saline-filled implants, 19 of which received adjuvant radiation therapy during their expansion. The study parameters included patient age, breast cup size, implant size, length of follow-up, number of procedures, coincident flap operations, Baker classification, complications, opposite breast procedures, pathologic stage, indications for and details about the radiation, and outcomes. The use of radiation in this review of reconstructed breasts can logically be divided into four groups: previous lumpectomy and radiation (n = 7), mastectomy and radiation before reconstruction (n = 9), mastectomy and adjuvant radiation during reconstruction/expansion (n = 19), and radiation after reconstruction (n = 5). The largest and most rapidly growing group of patients is of those receiving postmastectomy adjuvant radiation therapy. A total of 47.5 percent (19 of 40) of radiated breasts with saline implants ultimately needed the addition of, or replacement by, a flap. Ten percent of a control group with nonradiated saline implant reconstructions also had flaps, none as replacements. Fifty percent or more of both the radiated and control groups had contralateral surgery. Complications were far more common in the radiated group; for example, there were 32.5 percent capsular contractures compared with none in the control group. The control nonradiated implant-only group and the flap plus implant radiated group did well cosmetically. The radiated implant-only group was judged the worst. The increasing use of radiation after mastectomy has important implications for breast reconstruction. The possibility for radiation should be thoroughly investigated and anticipated preoperatively before immediate breast reconstruction. Patients with invasive disease, particularly with large tumors or palpable axillary lymph nodes, are especially likely to be encouraged to undergo postmastectomy radiation therapy. The indications for adjuvant radiation therapy have included four or more positive axillary lymph nodes, tumors 4 cm (or mor...

New concept for immediate breast reconstruction for invasive cancers: feasibility, oncological safety and esthetic outcome of post-neoadjuvant therapy immediate breast reconstruction versus delayed breast reconstruction: a prospective pilot study

“…Our results demonstrated that the CC rate was similar in the IBR and DBR groups (15.3 and 11.9%, P = 0.616), as was the esthetic outcome, which is known to be highly dependent on the CC rate [47]. Furthermore, the capsular formation rate compared favorably with the rates reported in series of immediate breast reconstructions plus adjuvant RT [37,[46][47][48]. The CC rate varies considerably in the literature-from 17 to 68%-because of the inhomogeneity of the selected patients and the surgical procedures used.…”

“…The complication rate was comparable in this sample, with five of the eight patients presenting a complication [37]. Spear and Onyewu recently found that, of 40 patients treated from 1990 to 1998 who underwent staged breast reconstruction with an expander and implant and received radiation before, during or after the expansion, 47.5% required an additional flap procedure to improve, correct, or save the implant [46]. The overall complication rate was 52.5%, compared with 10% in a control group of 40 patients who did not undergo irradiation who were randomly sampled from 200 such patients treated during the same period.…”

Long‐term outcomes in breast cancer patients undergoing immediate 2‐stage expander/implant reconstruction and postmastectomy radiation

“…7,8 Existing studies of radiation and immediate reconstruction are confounded by small groups of patients with irradiated implants treated with heterogeneous radiotherapy and surgical sequencing and techniques. [9][10][11][12][13][14][15] In addition, the median follow-ups of these studies were relatively short, and end points were variably defined. These differences led to a wide spectrum of reported complication rates ranging from 5% to 48%, underscoring the need for reliable data with lengthy follow-up in homogeneously treated patients who received immediate implantbased reconstruction and radiation.…”

Patient satisfaction with postmastectomy breast reconstruction

“…Our finding, which suggests that both preoperative and postoperative radiotherapy are important predictors of patient satisfaction, is consistent with other published reports. Numerous studies have shown that patients who undergo postmastectomy, implant-based reconstruction after the receipt of preoperative chest wall irradiation have a higher incidence of complications, including capsular contracture, 19,[24][25][26] and that the receipt of postmastectomy adjuvant radiotherapy is correlated with both the development of complications and increased patient dissatisfaction. [27][28][29][30] Thus, the determination of effect size herein allowed clinically meaningful comparisons to be made between the effects of a known entity (such as postmastectomy radiotherapy) versus other clinical variables (such as implant type) that may have an impact on patients' satisfaction with their reconstructed breasts.…”