|89th Annual Meeting Abstracts
Does Previous Chest Wall Irradiation Affect Vascular Complications in Free Flap Breast Reconstruction?
Joshua Fosnot, MD, John P. Fischer, MD, James M. Smartt, Jr., MD, Stephen J. Kovach, III, MD, Liza C. Wu, MD, Joseph M. Serletti, MD.
University of Pennsylvania, Philadelphia, PA, USA.
Purpose: Autologous breast reconstruction using free tissue transfer has increased in the past 20 years owing to advances in microsurgical technique, improved outcomes and patient satisfaction. Prior radiation therapy to the chest in the setting of delayed breast reconstruction or for previous breast conservation therapy, in theory, has a detrimental impact on recipient vessel quality and microvascular success. The purpose of this study was to determine if pre-reconstruction radiation therapy affects the rate of vascular complications in free flap breast reconstruction.
Methods: The design of this study was a retrospective review of patients who underwent free flap breast reconstruction between 2005 and 2009 by the senior authors. Patients were included if a complete medical record including operative note was available and if they had undergone free flap breast reconstruction. Medical records were evaluated with particular attention paid to history and timing of radiation therapy and all intra and post operative arterial and venous thromboses. Also recorded were technical difficulties such as variations in standard approach, double venous drainage, anastomotic revision, unusable target vessel or additional dissection. Radiated patients were compared to non-irradiated patients using Χ2 testing and linear regression modeling.
Results: In total, 711 patients underwent 1025 autologous free flaps. Of these, 226 were placed into a previously irradiated field, whereas 799 flaps were transposed to a radiation naïve defect. Overall, patients who underwent pre-reconstruction radiation therapy tended toward increased rates of intraoperative arterial thrombosis (4.9% vs. 2.8%, p = 0.11), intraoperative venous thrombosis (1.3% vs. 0.4%, p = 0.10), and intraoperative technical difficulties (8.0% vs. 5.1%, p = 0.11). When these three outcomes are taken in aggregate, there is a significantly higher rate of intraoperative vascular complications following radiation therapy (14.2% vs. 8.0%, p < 0.01). Preoperative radiation therapy had no effect on delayed vascular complications including arterial or venous thromboses (4.0% vs. 2.5%, p = 0.24), nor did it have a significant effect on flap loss (3.1% vs. 1.5%, p = 0.12). Using multiple linear regression models, pre-reconstruction radiation therapy was identified as an independent risk factor for intraoperative vascular complications (p = 0.03) regardless of surgical defect, recipient vessel or timing of reconstruction with relation to mastectomy. In a subanalysis, there was no significant difference in vascular complications in patients who had radiation therapy for breast conservation versus chest wall irradiation following mastectomy (20.6% vs.14.8%, p = 0.34). There were no differences in rates of fat necrosis (8.0% vs. 5.8%, p = 0.23), infection (4.9% vs 4.9%, p = 0.99), skin flap necrosis (9.7% vs. 11.8%, p = 0.40), hematoma (1.8% vs. 1.9%, p = 0.92), seroma (4.4% vs. 2.8%, p = 0.20) or delayed wound healing (30.5% vs. 28.7%, p = 0.59).
Conclusions: Pre-reconstruction radiation therapy increases the rate of intraoperative vascular complications during free flap autologous breast reconstruction. Although radiation does not hinder overall success of reconstruction nor contribute to post operative complications, surgeons should be congnizant that working in a previously irradiated field carries additional technical risk and challenge.