Incidence of subsequent major corrective surgery after postmastectomy breast reconstruction and radiation therapy
J.S. Wong 1, C.M. Kaelin 2, A. Ho 3, K.L. Bishop 1, R. Gelman 4, C.A. Hergrueter 5, B. Silver 1 and J.R. Harris 1
 Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham & Women, Boston, MA, USA Department of Surgery, Dana-Farber Cancer Institute/Brigham & Women, Boston, MA, USA Tufts University School of Medicine, Boston, MA, USA Department of Biostatistical Sciences, Dana-Farber Cancer Institute, Boston, MA, USA Department of Plastic Surgery, Brigham & Women, Boston, MA, USA
To evaluate the likelihood of major corrective surgery (MCS) among patients who underwent modified radical mastectomy (MRM) and either tissue flap only (non-implant) reconstruction or implant reconstruction followed by RT to the reconstructed breast.
Sixty-three patients underwent MRM and breast reconstruction between 1990 and 1999, had postoperative RT as part of the management for primary breast cancer, had available RT records, and had at least 1 follow-up visit or procedure a minimum of 2 months after RT; these patients constitute the study population.
Breast reconstruction consisted of a pedicled transverse rectus abdominis muscle flap (TRAM) in 43 patients, latissimus dorsi flap (LD) in 5, LD plus implant in 7, and implant alone in 8 patients.
Patients in the first 2 categories constitute the non-implant group and the others constitute the implant group.
The median age was 45 (range: 28–74). All received adjuvant chemotherapy; 40 (69%) received tamoxifen. The median RT dose to the chest wall was 50.4 Gy (range: 45–54). Bolus was used in 47% of the 62 patients for whom this information was known.
Median time from reconstruction to start of RT was 187 days (range: 35–376). Median follow-up time was 13 months (range: 2–58) for non-implant patients, and 10 months (range: 4–57) for implant patients. Patients were censored at the time of disease recurrence.
Data on complications and cosmesis were abstracted from patient charts, operative notes, and personal communication. The primary endpoint was incidence of major complications after RT requiring MCS.
MCS was defined as complete revision of a reconstruction; implant removal or replacement; or surgical intervention for infection, recurrent skin ulceration or recurrent seroma. Median times are based only on patients who had the specified event. Physician-scored cosmetic results were available for 40 patients (63%).
Results: Twenty-six patients (41%, 95% CI 29–54%) underwent some type of additional surgical procedure (excluding reconstruction of the nipple-areolar complex) after RT.
The median time to such procedures was 6 months (range: 1–58). Ten patients (16%, 95% CI 8–27%) underwent MCS. Some patients had multiple reasons for MCS or had multiple procedures.
The most common procedures were complete revision of a reconstruction (6 procedures in 5 patients) and implant replacement (5 procedures in 4 patients), most often for infection, but also for pain and cosmetic reasons.
The median time to first MCS was 8 months (range: 1–28). Four of the 48 non-implant patients (8%) underwent MCS, compared to 6/15 (40%) of the implant patients. Of patients followed at least 6 months, 0/39 (0%) non-implant patients underwent MCS within 6 months compared to 3/13 (23%) implant patients (p=0.01); of patients followed at least 12 months, the rates within 12 months were 1/25 (4%) and 2/7 (29%), respectively (p=0.11); of patients followed at least 24 months, the rates within 24 months were 2/14 (14%) and 2/6 (33%), respectively (p=0.55).
24/29 TRAM patients, 3/3 LD patients, 3/3 LD and implant patients, and 4/5 implant alone patients had no cosmetic score less than excellent or good.
Conclusions: Patients who undergo postmastectomy breast reconstruction using an implant followed by RT have a high rate of subsequent major corrective surgery.
The difference in the rate of MCS between the implant and non-implant groups is significant in early follow-up (within 6 months). Non-implant reconstructions have a modest rate of major corrective procedures compared to implant reconstructions, even when followed for 2 years after RT.
Patients considering an implant followed by RT should be apprised of the high likelihood of requiring a major corrective procedure.
Prospective studies of these risks and the cosmetic outcomes are warranted.
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