|89th Annual Meeting Abstracts
Immediate tissue expander/implant breast reconstruction in the setting of previous irradiation
Peter Cordeiro, MD, Laura Snell, MD, Alexandra Heerdt, MD, Colleen McCarthy, MD, MSc.
Memorial Sloan Kettering, New York, NY, USA.
PURPOSE: The performance of implant-based, postmastectomy reconstruction in the setting of irradiated tissues remains controversial. Patients who have a history of prior irradiation are often considered ineligible for tissue expander/implant (TE/I) reconstruction, as much of the existing literature would suggest that the rate of complications is high and aesthetic outcomes are poor. Because of relatively recent advances in expander technology and the advent of skin-sparing mastectomy, more patients with a history of prior chest wall irradiation are now expanded with success. The purpose of this study was to review a single surgeon’s experience with immediate, tissue expander/implant reconstruction in patients undergoing salvage mastectomy for cancer recurrence following breast conservation therapy (lumpectomy/radiation).
METHODS: A review of all TE/I reconstructions performed by a single surgeon over a 11-year period from 1997 to 2008 was performed. Two patient cohorts were identified: i) patients who underwent salvage mastectomy for a cancer recurrence following prior breast conservation therapy; and, ii) patients who underwent primary mastectomy without a history of prior irradiation. Reconstructive, complication and outcomes data were retrieved from a prospectively-maintained, reconstruction database. The incidence of early complications (defined as those occurring ≤ 12 months from initiation of reconstruction) and long-term outcomes (including aesthetic grade and capsular contracture) was determined for each cohort. Chi-square and fisher’s exact tests, where appropriate, were performed.
RESULTS: Immediate, tissue expander/implant reconstruction was initiated in 1699 patients. 121 patients had a history of prior BCT; 1578 did not have a history of prior irradiation. Mean follow-up was 46.4 and 43.2 months, respectively. The incidence of early complications in the previously-irradiated cohort was significantly higher compared to that in the non-irradiated cohort (29.7% vs. 15.5%; p-value = <0.001). The most common complication in both groups was mastectomy flap necrosis (18.0% in irradiated group vs. 7.7% in non-irradiated group; p-value: 0.05), the distribution of aesthetic grade within the good-excellent range was different. That is, most previously irradiated patients had good or very good results, while most non-irradiated patients had excellent results. The distribution of capsular contracture grade was significantly higher in previously irradiated patients vs. non-irradiated patients (p-value=0.02; Mann Whitney U Test). The overall grade III/IV capsular contracture rate was higher in the previously radiated patients (10.6% vs. 6.3%), although this difference was not statistically significant (p-value = 0.2; Chi square test).
CONCLUSIONS: Carefully selected patients who have had prior BCT who require salvage mastectomy can successfully complete post-mastectomy tissue expander/implant reconstruction. The rate of early complications in this patient group is higher than in the non-irradiated cohort but remains acceptable. The majority of previously-irradiated patients have a good to excellent aesthetic result and an acceptable rate of Grade III/IV capsular contractures. These types of results are attainable in a very highly-select group of patients with favorable skin and soft tissue quality undergoing salvage mastectomy following breast conservation therapy.