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J Reconstr Microsurg 2022; 38(06): 499-505
DOI: 10.1055/s-0041-1740123
Original Article

A Comparative Analysis of Immediate and Delayed-immediate Breast Reconstruction after Postmastectomy Radiation Therapy

Adrienne N. Christopher 
1   Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
2   Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
,
Martin P. Morris
1   Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
,
Robyn B. Broach
1   Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
,
Joseph M. Serletti
1   Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Abstract

Background Postmastectomy radiation therapy (PMRT) is an important component in the treatment of locally advanced breast cancer. Optimal timing of therapy in relation to autologous breast reconstruction (ABR) remains clinically debated. Herein, we comparatively analyze short- and long-term outcomes between immediate ABR (I-ABR) and delayed-immediate ABR (DI-ABR) in the setting of PMRT.

Methods Adult patients undergoing ABR with PMRT were separated into cohorts based on reconstructive timeline: I-ABR or DI-ABR. The groups were propensity matched 1:1 by age, body mass index, and comorbidities. Surgical site events and long-term clinical outcomes (readmissions, reoperations, and revision procedures) were collected. Univariate analyses were completed using Pearson's chi-squared tests and Fisher's exact tests, and statistical significance was set at p < 0.05.

Results One hundred and thirty-two flaps (66 in each cohort) were identified for inclusion. Patients with I-ABR were more likely to experience fat necrosis (p = 0.034) and skin necrosis (p < 0.001), require additional office visits (p < 0.001) and outpatient surgeries (p = 0.015) to manage complications, and undergo revision surgery after reconstruction (p < 0.001). DI-ABR patients, however, had a 42.4% incidence of complications following tissue expander placement prior to reconstruction, with 16.7% of patients requiring reoperation during this time. Only one patient (I-ABR) experienced flap loss due to a vascular complication.

Conclusion The complications encountered in both of these groups were not prohibitive to offering either treatment. Patients should be made aware of the specific and unique risks of these reconstruction timelines and involved throughout the entire decision-making process. Plastic surgeons should continue to strive to elucidate innovative approaches that facilitate enhanced quality of life without compromising oncologic therapy.

Keywords

postmastectomy radiation therapy - tissue expanders - delayed-immediate autologous breast reconstruction - immediate autologous breast reconstruction


Publication History

Received: 12 April 2021

Accepted: 26 September 2021

Article published online:
17 December 2021

© 2021. Thieme. All rights reserved.

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  • References

  • 1 Overgaard M, Hansen PS, Overgaard J. et al. Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy. Danish Breast Cancer Cooperative Group 82b Trial. N Engl J Med 1997; 337 (14) 949-955
    CrossrefPubMedGoogle Scholar
  • 2 Ragaz J, Olivotto IA, Spinelli JJ. et al. Locoregional radiation therapy in patients with high-risk breast cancer receiving adjuvant chemotherapy: 20-year results of the British Columbia randomized trial. J Natl Cancer Inst 2005; 97 (02) 116-126
    CrossrefPubMedGoogle Scholar
  • 3 Clarke M, Collins R, Darby S. et al; Early Breast Cancer Trialists' Collaborative Group (EBCTCG). Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet 2005; 366 (9503): 2087-2106
    CrossrefPubMedGoogle Scholar
  • 4 Albino FP, Patel KM, Smith JR, Nahabedian MY. Delayed versus delayed-immediate autologous breast reconstruction: a blinded evaluation of aesthetic outcomes. Arch Plast Surg 2014; 41 (03) 264-270
    Article in Thieme ConnectPubMedGoogle Scholar
  • 5 Spear SL, Onyewu C. Staged breast reconstruction with saline-filled implants in the irradiated breast: recent trends and therapeutic implications. Plast Reconstr Surg 2000; 105 (03) 930-942
    CrossrefPubMedGoogle Scholar
  • 6 Tran NV, Chang DW, Gupta A, Kroll SS, Robb GL. Comparison of immediate and delayed free TRAM flap breast reconstruction in patients receiving postmastectomy radiation therapy. Plast Reconstr Surg 2001; 108 (01) 78-82
    CrossrefPubMedGoogle Scholar
  • 7 Mirzabeigi MN, Smartt JM, Nelson JA, Fosnot J, Serletti JM, Wu LC. An assessment of the risks and benefits of immediate autologous breast reconstruction in patients undergoing postmastectomy radiation therapy. Ann Plast Surg 2013; 71 (02) 149-155
    CrossrefPubMedGoogle Scholar
  • 8 Kronowitz SJ, Hunt KK, Kuerer HM. et al. Delayed-immediate breast reconstruction. Plast Reconstr Surg 2004; 113 (06) 1617-1628
    CrossrefPubMedGoogle Scholar
  • 9 Ayoub Z, Strom EA, Ovalle V. et al. A 10-year experience with mastectomy and tissue expander placement to facilitate subsequent radiation and reconstruction. Ann Surg Oncol 2017; 24 (10) 2965-2971
    CrossrefPubMedGoogle Scholar
  • 10 Kamel GN, Nash D, Jacobson J. et al. Patient-reported satisfaction and quality of life in postmastectomy radiated patients: a comparison between delayed and delayed immediate autologous breast reconstruction in a predominantly minority patient population. J Reconstr Microsurg 2019; 35 (06) 445-451
    Article in Thieme ConnectPubMedGoogle Scholar
  • 11 Manum J, Veith J, Wei G, Kwok A, Agarwal J. Variables associated with length of stay in patients undergoing mastectomy and delayed-immediate breast reconstruction with tissue expander. Breast J 2019; 25 (05) 927-931
    CrossrefPubMedGoogle Scholar
  • 12 Sue GR, Chattopadhyay A, Long C, Huis in 't Veld EA, Lee GK. Practical applications of delayed-immediate autologous breast reconstruction: a flexible and safe operative strategy. Ann Plast Surg 2018; 80 (5S, Suppl 5): S299-S302
    CrossrefPubMedGoogle Scholar
  • 13 Phillips BT, Mercier-Couture G, Xue AS. et al. Is tissue expansion worth it? Comparative outcomes of skin-preserving versus delayed autologous breast reconstruction. Plast Reconstr Surg Glob Open 2020; 8 (11) e3217
    CrossrefPubMedGoogle Scholar
  • 14 Magarey CJ. Aspects of the psychological management of breast cancer. Med J Aust 1988; 148 (05) 239-242
    CrossrefPubMedGoogle Scholar
  • 15 Elder EE, Brandberg Y, Björklund T. et al. Quality of life and patient satisfaction in breast cancer patients after immediate breast reconstruction: a prospective study. Breast 2005; 14 (03) 201-208
    CrossrefPubMedGoogle Scholar
  • 16 Retrouvey H, Kerrebijn I, Metcalfe KA. et al. Psychosocial functioning in women with early breast cancer treated with breast surgery with or without immediate breast reconstruction. Ann Surg Oncol 2019; 26 (08) 2444-2451
    CrossrefPubMedGoogle Scholar
  • 17 Zhong T, Hu J, Bagher S. et al. A comparison of psychological response, body image, sexuality, and quality of life between immediate and delayed autologous tissue breast reconstruction: a prospective long-term outcome study. Plast Reconstr Surg 2016; 138 (04) 772-780
    CrossrefPubMedGoogle Scholar
  • 18 Macadam SA, Bovill ES, Buchel EW, Lennox PA. Evidence-based medicine: autologous breast reconstruction. Plast Reconstr Surg 2017; 139 (01) 204e-229e
    CrossrefPubMedGoogle Scholar
  • 19 Harris PA, Taylor R, Minor BL. et al; REDCap Consortium. The REDCap consortium: Building an international community of software platform partners. J Biomed Inform 2019; 95: 103208
    CrossrefPubMedGoogle Scholar
  • 20 Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap): a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009; 42 (02) 377-381
    Google Scholar
  • 21 Harris JR, Halpin-Murphy P, McNeese M, Mendenhall NP, Morrow M, Robert NJ. Consensus statement on postmastectomy radiation therapy. Int J Radiat Oncol Biol Phys 1999; 44 (05) 989-990
    CrossrefPubMedGoogle Scholar
  • 22 Recht A, Edge SB, Solin LJ. et al; American Society of Clinical Oncology. Postmastectomy radiotherapy: clinical practice guidelines of the American Society of Clinical Oncology. J Clin Oncol 2001; 19 (05) 1539-1569
    CrossrefPubMedGoogle Scholar
  • 23 Overgaard M, Jensen MB, Overgaard J. et al. Postoperative radiotherapy in high-risk postmenopausal breast-cancer patients given adjuvant tamoxifen: Danish Breast Cancer Cooperative Group DBCG 82c randomised trial. Lancet 1999; 353 (9165): 1641-1648
    CrossrefPubMedGoogle Scholar
  • 24 Kronowitz SJ, Robb GL. Radiation therapy and breast reconstruction: a critical review of the literature. In: Plastic Surgery Complete: The Clinical Masters of PRS—Breast Reconstruction. Vol. 124. Alphen aan den Rijn, The Netherlands: Wolters Kluwer Health Adis (ESP); 2015: 20-33
    Google Scholar
  • 25 Ascherman JA, Hanasono MM, Newman MI, Hughes DB. Implant reconstruction in breast cancer patients treated with radiation therapy. Plast Reconstr Surg 2006; 117 (02) 359-365
    Google Scholar
  • 26 Benediktsson K, Perbeck L. Capsular contracture around saline-filled and textured subcutaneously-placed implants in irradiated and non-irradiated breast cancer patients: five years of monitoring of a prospective trial. J Plast Reconstr Aesthet Surg 2006; 59 (01) 27-34
    CrossrefPubMedGoogle Scholar
  • 27 Behranwala KA, Dua RS, Ross GM, Ward A, A'hern R, Gui GPH. The influence of radiotherapy on capsule formation and aesthetic outcome after immediate breast reconstruction using biodimensional anatomical expander implants. J Plast Reconstr Aesthet Surg 2006; 59 (10) 1043-1051
    CrossrefPubMedGoogle Scholar
  • 28 Evans GRD, Schusterman MA, Kroll SS. et al. Reconstruction and the radiated breast: is there a role for implants?. Plast Reconstr Surg 1995; 96 (05) 1111-1115 , discussion, 1116–1118
    CrossrefPubMedGoogle Scholar
  • 29 Tsoi B, Ziolkowski NI, Thoma A, Campbell K, O'Reilly D, Goeree R. Safety of tissue expander/implant versus autologous abdominal tissue breast reconstruction in postmastectomy breast cancer patients: a systematic review and meta-analysis. Plast Reconstr Surg 2014; 133 (02) 234-249
    CrossrefPubMedGoogle Scholar
  • 30 Zhang SL, Song J, Wang YR. et al. Short-term outcomes and safety of radiotherapy for immediate breast reconstruction with autologous flap transfer following breast-conserving surgery. BMC Cancer 2021; 21 (01) 214
    CrossrefPubMedGoogle Scholar
  • 31 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
    CrossrefPubMedGoogle Scholar
  • 32 Mirzabeigi MN, Rhemtulla IA, Mcdonald ES. et al. Locoregional cancer recurrence after breast reconstruction: detection, management, and secondary reconstructive strategies. Plast Reconstr Surg 2019; 143 (05) 1322-1330
    CrossrefPubMedGoogle Scholar
  • 33 Stone HB, Coleman CN, Anscher MS, McBride WH. Effects of radiation on normal tissue: consequences and mechanisms. Lancet Oncol 2003; 4 (09) 529-536
    CrossrefPubMedGoogle Scholar
  • 34 Baumann DP, Crosby MA, Selber JC. et al. Optimal timing of delayed free lower abdominal flap breast reconstruction after postmastectomy radiation therapy. Plast Reconstr Surg 2011; 127 (03) 1100-1106
    CrossrefPubMedGoogle Scholar
  • 35 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
    Article in Thieme ConnectPubMedGoogle Scholar
  • 36 Kung TA, Kidwell KM, Speth KA. et al. Radiation-induced skin changes after postmastectomy radiation therapy: a pilot study on indicators for timing of delayed breast reconstruction. J Reconstr Microsurg 2019; 35 (03) 209-215
    Article in Thieme ConnectPubMedGoogle Scholar
  • 37 Chung SY, Chang JS, Shin KH. et al. Impact of radiation dose on complications among women with breast cancer who underwent breast reconstruction and post-mastectomy radiotherapy: a multi-institutional validation study. Breast 2021; 56: 7-13
    CrossrefPubMedGoogle Scholar