Surgical Outcomes of Implant Versus Autologous Breast Reconstruction in Patients with Previous Breast-Conserving Surgery and Radiotherapy

Abstract

T he management of early-stage breast cancer has largely shifted over the past few decades from mastectomy to breast-conserving surgery (BCS) and ipsilateral postoperative radiotherapy. [1][2][3] This change in surgical management has been driven by similar long-term survival outcomes between the two surgical techniques as demonstrated by several landmark randomized trials. 1,2 A recent analysis of the American College of Surgeons National Surgical Quality Improvement Program databases showed that 51% of breast cancer patients in 2016 underwent BCS and radiotherapy. 4 However, the 5-year local recurrence following BCS and radiotherapy ranged from 3% to 6% in recent years. 5 These recurrences are generally managed with mastectomy, which demonstrates good survival outcomes. [6][7][8] Postmastectomy breast reconstruction in patients with a history of BCS and radiotherapy is challenging. Radiotherapy has been shown to induce an inflammatory reaction, fibrosis Background: Postmastectomy breast reconstruction in patients with a history of breast-conserving surgery (BCS) and radiotherapy is challenging, with a paucity of literature on the outcomes of different breast reconstructive techniques. The authors hypothesized that implant-based breast reconstruction (IBR) would be associated with higher complication rates compared to either IBR combined with latissimus dorsi (LD) or free flap breast reconstruction (FFBR). Methods: The authors conducted a retrospective review of patients who underwent mastectomy with a history of BCS and radiotherapy between January of 2000 and March of 2016. Surgical and patient-reported outcomes (BREAST-Q) were compared between IBR versus IBR/LD versus FFBR. Results: The authors identified 9473 patients who underwent BCS and radiotherapy. Ninety-nine patients (105 reconstructions) met the authors' inclusion criteria, 29% (n = 30) of whom underwent IBR, 26% (n = 27) of whom underwent IBR/LD, and 46% (n = 48) of whom underwent FFBR. The overall complication rate was not significantly different between the three groups (50% in IBR versus 41% in IBR/LD versus 44% in FFBR; P = 0.77), whereas reconstruction failures were significantly lower in the FFBR group (33% in IBR versus 19% in IBR/LD versus 0% in FFBR; P < 0.0001). The time between the receipt of radiotherapy and reconstruction was not a significant predictor of overall complications and reconstruction failure. No significant differences were identified between the three study cohorts in any of the three studied BREAST-Q domains. Conclusions: In patients with prior BCS and radiotherapy, FFBR was associated with lower probability of reconstruction failure compared to IBR but no significant difference in overall and major complication rates. The addition of LD flap to IBR did not translate into lower complication rates but may result in decreased reconstruction failures.