Postoperative adjuvant irradiation: effects on tranverse rectus abdominis muscle flap breast reconstruction.
Tran NV, Evans GR, Kroll SS, et al.
The use of postoperative irradiation following oncologic breast surgery is dictated by tumor pathology, margins, and lymph node involvement. Although irradiation negatively influences implant reconstruction, it is less clear what effect it has on autogenous tissue. This study evaluated the effect of postoperative irradiation on transverse rectus abdominis muscle (TRAM) flap breast reconstruction. A retrospective review was performed on all patients undergoing immediate TRAM flap breast reconstruction followed by postoperative irradiation between 1988 and 1998. Forty-one patients with a median age of 48 years received an average of 50.99 Gy of fractionated irradiation within 6 months after breast reconstruction. All except two received adjuvant chemotherapy. Data were obtained from personal communication, physical examination, chart, and photographic review. The minimum follow-up time was 1 year, with an average of 3 years, after completion of radiation therapy. Nine patients received pedicled TRAM flaps and 32 received reconstruction with microvascular transfer. Fourteen patients had bilateral reconstruction, but irradiation was administered unilaterally to the breast with the higher risk of local recurrence. The remaining 27 patients had unilateral reconstruction. All patients were examined at least 1 year after radiotherapy. No flap loss occurred, but 10 patients (24 percent) required an additional flap to correct flap contracture. Nine patients (22 percent) maintained a normal breast volume. Hyperpigmentation occurred in 37 percent of the patients, and 56 percent were noted to have a firm reconstruction. Palpable fat necrosis was noted in 34 percent of the flaps and loss of symmetry in 78 percent. Because the numbers were small, there was no statistical difference between the pedicled and free TRAM group. However, as a group, the findings were statistically significant when compared with 1,443 nonirradiated TRAM patients. Despite the success of flap transfer, unpredictable volume, contour, and symmetry loss make it difficult to achieve consistent results using immediate TRAM breast reconstruction with postoperative irradiation.
TRAM flap reconstruction in this setting should be approached cautiously, and delayed reconstruction in selected patients should be considered. Patients should be aware that multiple revisions and, possibly, additional flaps are necessary to correct the progressive deformity from radiation therapy.
Plast Reconstr Surg. 2000 Aug 1;106(2);313-7
Editor Comment - ABRAM RECHT, M.D. 11/01/01
This very important article reports on one of the largest experiences of patients receiving postmastectomy radiotherapy (PMRT) following reconstruction using a transverse rects abdominis (TRAM) flap. The authors found a disturbingly high risk of complications in the irradiated patients. One of the unique strengths of this series is that some patients had bilateral TRAM flap reconstruction but PMRT to only one side, and therefore they served as their own controls. My own (admittedly impressionistic) experience has been less pessimistic, however. Perhaps this is due to subtle differences in the patient population (e.g., a smaller proportion of smokers in Boston, compared to Houston) or PMRT technique (I use 1.8-Gy fractions to a dose of 50.4 Gy to the chest wall, compared to 2-Gy fractions being commonly used at MD Anderson in the past; and perhaps some of the patients in this study were treated on cobalt-60 machines or 4-MV accelerators). However, this series suggests that patients may have better cosmetic results if reconstruction is performed after PMRT (as was commonly done in the past).
Although I see no problem with this with regards to tumor control, this would represent a major psychological blow to many patients, who find having reconstruction at the time of mastectomy a way to lessen the impact of diagnosis and treatment. Unfortunately, I suspect this dilemma is likely to be a real one
present I have not altered my recommendations to patients with regards to the timing of reconstruction and PMRT, but I would very much like to have more data on this subject to know if my beliefs are correct.
The American Surgeon, 5/02
The Breast Journal, 3/04
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