Visual Perception of Breast Free Flap Size Is Influenced by Radiation Changes of Surrounding Tissue

Abstract

Background Microsurgical reconstruction for bilateral mastectomy defects after unilateral radiation often results in asymmetry, despite both flap tissues never being radiated.

Methods Photos of 16 patients who received prior radiation to one breast and underwent bilateral abdominal free flap reconstruction were taken postoperatively. Layperson and expert assessment were attained via online crowdsourcing and a panel of attending surgeons and senior residents. Stratification by interflap weight differences was done for subanalysis.

Results A total of 399 laypersons responded, with the majority (57.3%) reporting that the radiated breast appeared smaller than the nonradiated breast. When the photos were stratified by interflap weight differences, the photos with the radiated side flap weight over 3% more than nonradiated side were significantly more likely to be perceived by laypersons as the same size (odds ratio [OR] = 2.7; p < 0.001) and of similar aesthetic (OR = 1.9; p < 0.001) when compared with photos with same-sized flaps. Of the expert responses (n = 16), the radiated side was perceived as smaller 72.3% of the time and the nonradiated side appeared more aesthetic 52.7% of the time. Contrary to layperson responses, the experts tend to report the radiated side as smaller despite varying flap weight. Interestingly, expert raters were significantly more likely to rate the flaps of equal aesthetics when the radiated side has a flap larger by 3% or more (OR = 3.6; p < 0.001).

Conclusion Higher aesthetic scores were noted when larger flaps were inset to the radiated envelope by both laypersons and experts, suggesting potential technical refinement in reconstructive outcomes.

Keywords

breast reconstruction - crowdsourcing - radiation - volume

Author Contributions

Conceptualization and design: all.

Data collection, analysis, and interpretation: all.

Drafting and revision: all.

Manuscript approval: all.

Publikationsverlauf

Eingereicht: 14. November 2022

Angenommen: 28. Februar 2023

Accepted Manuscript online:
16. März 2023

Artikel online veröffentlicht:
12. April 2023

• References

• 1 Fahad Ullah M. Breast cancer: current perspectives on the disease status. Adv Exp Med Biol 2019; 1152: 51-64
• 2 Meattini I, Becherini C, Bernini M. et al. Breast reconstruction and radiation therapy: an Italian expert Delphi consensus statements and critical review. Cancer Treat Rev 2021; 99: 102236
• 3 Liew B, Southall C, Kanapathy M, Nikkhah D. Does post-mastectomy radiation therapy worsen outcomes in immediate autologous breast flap reconstruction? A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2021; 74 (12) 3260-3280
• 4 Clarke-Pearson EM, Chadha M, Dayan E. et al. Comparison of irradiated versus nonirradiated DIEP flaps in patients undergoing immediate bilateral DIEP reconstruction with unilateral postmastectomy radiation therapy (PMRT). Ann Plast Surg 2013; 71 (03) 250-254
• 5 Recht A, Comen EA, Fine RE. et al. Postmastectomy radiotherapy: an American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology focused guideline update. J Clin Oncol 2016; 34 (36) 4431-4442
• 6 Zehra S, Doyle F, Barry M, Walsh S, Kell MR. Health-related quality of life following breast reconstruction compared to total mastectomy and breast-conserving surgery among breast cancer survivors: a systematic review and meta-analysis. Breast Cancer 2020; 27 (04) 534-566
• 7 Myung Y, Son Y, Nam TH. et al. Objective assessment of flap volume changes and aesthetic results after adjuvant radiation therapy in patients undergoing immediate autologous breast reconstruction. PLoS One 2018; 13 (05) e0197615
• 8 Frasier LL, Holden S, Holden T. et al. Temporal trends in postmastectomy radiation therapy and breast reconstruction associated with changes in National Comprehensive Cancer Network Guidelines. JAMA Oncol 2016; 2 (01) 95-101
• 9 Chang EI, Liu TS, Festekjian JH, Da Lio AL, Crisera CA. Effects of radiation therapy for breast cancer based on type of free flap reconstruction. Plast Reconstr Surg 2013; 131 (01) 1e-8e
• 10 Ho AY, Hu ZI, Mehrara BJ, Wilkins EG. Radiotherapy in the setting of breast reconstruction: types, techniques, and timing. Lancet Oncol 2017; 18 (12) e742-e753
• 11 Waks AG, Winer EP. Breast cancer treatment: a review. JAMA 2019; 321 (03) 288-300
• 12 Mendelson EB. Radiation changes in the breast. Semin Roentgenol 1993; 28 (04) 344-362
• 13 Schnitt SJ, Connolly JL, Harris JR, Cohen RB. Radiation-induced changes in the breast. Hum Pathol 1984; 15 (06) 545-550
• 14 Yi A, Kim HH, Shin HJ, Huh MO, Ahn SD, Seo BK. Radiation-induced complications after breast cancer radiation therapy: a pictorial review of multimodality imaging findings. Korean J Radiol 2009; 10 (05) 496-507
• 15 Dvali LT, Dagum AB, Pang CY. et al. Effect of radiation on skin expansion and skin flap viability in pigs. Plast Reconstr Surg 2000; 106 (03) 624-629
• 16 Teo I, Reece GP, Huang SC. et al. Body image dissatisfaction in patients undergoing breast reconstruction: examining the roles of breast symmetry and appearance investment. Psychooncology 2018; 27 (03) 857-863
• 17 Eltahir Y, Bosma E, Teixeira N, Werker PMN, de Bock GH. Satisfaction with cosmetic outcomes of breast reconstruction: investigations into the correlation between the patients' Breast-Q outcome and the judgment of panels. JPRAS Open 2020; 24: 60-70
• 18 Steele KH, Macmillan RD, Ball GR, Akerlund M, McCulley SJ. Multicentre study of patient-reported and clinical outcomes following immediate and delayed Autologous Breast Reconstruction And Radiotherapy (ABRAR study). J Plast Reconstr Aesthet Surg 2018; 71 (02) 185-193
• 19 Rogers NE, Allen RJ. Radiation effects on breast reconstruction with the deep inferior epigastric perforator flap. Plast Reconstr Surg 2002; 109 (06) 1919-1924 , discussion 1925–1926
• 20 Carlson GW, Page AL, Peters K, Ashinoff R, Schaefer T, Losken A. Effects of radiation therapy on pedicled transverse rectus abdominis myocutaneous flap breast reconstruction. Ann Plast Surg 2008; 60 (05) 568-572
• 21 Spear SL, Ducic I, Low M, Cuoco F. The effect of radiation on pedicled TRAM flap breast reconstruction: outcomes and implications. Plast Reconstr Surg 2005; 115 (01) 84-95
• 22 Huis in 't Veld EA, Long C, Sue GR, Chattopadhyay A, Lee GK. Analysis of aesthetic outcomes and patient satisfaction after delayed-immediate autologous breast reconstruction. Ann Plast Surg 2018; 80 (5S, Suppl 5): S303-S307
• 23 Jugenburg M, Disa JJ, Pusic AL, Cordeiro PG. Impact of radiotherapy on breast reconstruction. Clin Plast Surg 2007; 34 (01) 29-37 , abstract v–vi
• 24 Suchyta M, Azad A, Patel AA, Khosla RK, Lorenz HP, Nazerali RS. Applied online crowdsourcing in plastic and reconstructive surgery: a comparison of aesthetic outcomes in unilateral cleft lip repair techniques. Ann Plast Surg 2020; 84 (5S, Suppl 4): S307-S310
• 25 Aguinis H, Villamor I, Ramani R. MTurk research: review and recommendations. J Manage 2021; 47: 823-837
• 26 Behrend TS, Sharek DJ, Meade AW, Wiebe EN. The viability of crowdsourcing for survey research. Behav Res Methods 2011; 43 (03) 800-813
• 27 SoSci Survey Online Tool. Accessed March 30, 2023 at: https://www.soscisurvey.de/
• 28 Elver AA, Egan KG, Cullom ME. et al. A paradigm shift: outcomes of early autologous breast reconstruction after radiation therapy. J Reconstr Microsurg 2023; 39 (02) 111-119
• 29 Arnautovic A, Karinja S, Olafsson S. et al. Optimal timing of delayed microvascular breast reconstruction after radiation therapy. J Reconstr Microsurg 2023; 39 (03) 165-170
• 30 Heiman AJ, Gabbireddy SR, Kotamarti VS, Ricci JA. A meta-analysis of autologous microsurgical breast reconstruction and timing of adjuvant radiation therapy. J Reconstr Microsurg 2021; 37 (04) 336-345
• 31 Pittelkow E, DeBrock W, Christopher L. et al. Advantages of the delayed-immediate microsurgical breast reconstruction: extending the choice. J Reconstr Microsurg 2022; 38 (07) 579-584
• 32 Christopher AN, Morris MP, Broach RB, Serletti JM. A comparative analysis of immediate and delayed-immediate breast reconstruction after postmastectomy radiation therapy. J Reconstr Microsurg 2022; 38 (06) 499-505
• 33 Lee MK, Park HY, Park JW, Mun GH, Woo KJ. Three-dimensional volume changes of the reconstructed breast following DIEP flap breast reconstruction. J Reconstr Microsurg 2023; 39 (06) 427-434
• 34 Long AS, Ching AH, Hauc SC. et al. Flap to mastectomy mass: are higher ratios associated with greater breast reconstruction satisfaction?. J Reconstr Microsurg 2023; 39 (03) 209-213
• 35 Teotia SS, Alford JA, Kadakia Y, Haddock NT. Crowdsourced assessment of aesthetic outcomes after breast reconstruction. Plast Reconstr Surg 2021; 147 (03) 570-577