Re: National Breast Reconstruction Utilization in the Setting of Postmastectomy Radiotherapy: Two-Stage Implant-Based Breast Reconstruction

National Breast Reconstruction Utilization in the Setting of Postmastectomy Radiotherapy: Two-Stage Implant-Based Breast Reconstruction

Response to Letter to the Editor

We read with interest your article “National Breast Reconstruction Utilization in the Setting of Postmastectomy Radiotherapy: Two-Stage Implant-Based Breast Reconstruction.” [1] Surprisingly, there is a trend for implants-based reconstruction in breast cancer patients, even though plenty of studies in current literature report clinically relevant adverse outcomes in postradiotherapy cancer patients. Clinical decision making and options for breast reconstruction varies across units and relies on patients' characteristics, disease progression, and surgeons' expertise.

The authors describe that 33% of all breast reconstruction being immediate; however, this setting seems to be far from ideal.[1] Recent survey reports results of surgeons across U.K. using acellular dermal matrix and delayed breast reconstructions for patients undergoing postmastectomy radiotherapy, even if the surgeons perceive that immediate breast reconstruction is considered a superior option in cosmesis and quality of life.[2]

Quality of life is considered the primary outcome to evaluate the patients' related success after breast reconstruction. Studies demonstrated the inferiority of implant-based techniques in relation to quality of life outcomes, specifically in long-term follow-up assessment.[3] In our experience, in the setting of postmastectomy radiotherapy, poor outcomes have been observed in implant-based breast reconstructions, therefore, we consider radiotherapy a contraindication for this reconstructive modality. In addition, implant-based reconstruction has been associated with an increase in the complications when axillary surgery is required.[4]

Considering that an implant-based reconstruction always requires reoperation for exchange of implant and knowing that revisions surgery in irradiated fields should be avoided, due to the poor healing potential, similarly we believe that autologous tissue could be offering better clinical outcomes to patients. Moreover, the psychological effect of consecutive procedures should not be underestimated.

Cost-effective analysis of both options of reconstruction have proven the superiority of autologous tissue over implants in patients with long life expectancy;[3] however, this question remains unanswered when comparing immediate versus delayed autologous reconstruction in the setting of postmastectomy radiotherapy.

It seems reasonable to think that autologous tissue, presents an ideal breast reconstruction option: one-stage technique, longevity of clinical outcomes, patients' satisfaction, and low rates of complications in postradiotherapy with or without simultaneous axillary lymph node clearance. However, autologous breast reconstruction requires a demanding microsurgical skill-set and demands team expertise to provide adequate results.

We have previously reported that good patients' related and cosmetic outcomes with the associated quality of life can be achieved with immediate breast reconstruction with autologous tissue; however, further randomized trials are required to evaluate current trends and options of reconstruction to optimize results in postmastectomy radiotherapy patients.[5]

• References

• 1 Razdan SN, Cordeiro PG, Albornoz CR. , et al. National breast reconstruction utilization in the setting of postmastectomy radiotherapy. J Reconstr Microsurg 2017; 33 (05) 312-317
• 2 Duxbury PJ, Gandhi A, Kirwan CC, Jain Y, Harvey JR. Current attitudes to breast reconstruction surgery for women at risk of post-mastectomy radiotherapy: a survey of UK breast surgeons. Breast 2015; 24 (04) 502-512
• 3 Razdan SN, Cordeiro PG, Albornoz CR. , et al. Cost-effectiveness analysis of breast reconstruction options in the setting of postmastectomy radiotherapy using the BREAST-Q. Plast Reconstr Surg 2016; 137 (03) 510e-517e
• 4 Wang F, Peled AW, Chin R. , et al. The impact of radiation therapy, lymph node dissection, and hormonal therapy on outcomes of tissue expander-implant exchange in prosthetic breast reconstruction. Plast Reconstr Surg 2016; 137 (01) 1-9
• 5 Parra L, Marcelli S, Robustillo M. , et al. Immediate breast reconstruction with abdominal free flap and adjuvant radiotherapy, evaluation of quality of life and outcomes, plastic and reconstructive surgery. Plast Reconstr Surg 2017; 140 (04) 681-690