Author: Dr. Minas Chrysopoulo

Can radiation therapy impact breast reconstruction results? 

Radiation therapy is often recommended as part of breast cancer treatment. Patients undergoing lumpectomy receive radiation routinely once they’ve healed from surgery. Some mastectomy patients may also need radiation after surgery depending on the characteristics of the tumor. I think it is fair to say that most plastic surgeons are not particularly fond of radiation because of the way it can impact the patient’s tissues, and breast reconstruction results in general.

Nonetheless, it is important to remember that “life comes before breast” and in certain situations, radiation therapy provides very significant benefits from a cancer care perspective, which of course must always remain the priority.

So what’s the problem with radiation therapy (from a plastic surgeon’s perspective)?

For starters, it can cause toughening (fibrosis) and shrinking (contracture) of the patient’s tissue which makes the tissue lose its elasticity and become more tough and rigid. Skin color changes are common, red at first, turning more brown over time. Radiation can also cause burn injuries as well as damage to underlying organs such as the lungs and heart. Radiation therapy technology has improved significantly over the years, and while this has decreased the potential complications considerably, anyone who is facing radiation therapy must discuss all the potential risks with their radiation oncologist beforehand.

Women undergoing lumpectomy are often told that most of their breast will be preserved and that radiation is given “as insurance” to decrease the risk of cancer recurrence. What many women don’t appreciate is that the breast can sometimes end up looking vastly different because of radiation changes, even though they underwent “breast conservation”. This is especially the case if they were small-breasted to begin with.

Not all patients have the same biological response to radiation. Despite the use of protocols, not all radiation oncologists deliver treatment the same way and experience with radiating breast reconstruction patients can vary tremendously. This means results with radiation after breast reconstruction can be quite variable and unpredictable, despite studies that show this is a safe approach in select patients and centers.

Radiation after a tissue (“flap”) reconstruction (eg tram flap, DIEP flap) can cause the reconstructed breast to shrink and harden. Unfortunately, this is a fairly common scenario, especially when the radiation is performed by teams not used to treating reconstruction patients. In rare instances (with heavy radiation doses), new wounds can develop in the reconstructed breast which may need wound care.

Patients who have a mastectomy and flap reconstruction and then have radiation should know that there is a risk of needing further reconstructive surgery to correct changes caused by radiation therapy, and to improve overall breast symmetry. One study found a re-operation rate of almost 30% in patients receiving radiation after TRAM flap reconstruction.

For these reasons, most plastic surgeons still favor delaying flap reconstruction until at least 6 months after completion of radiation treatment.

Tissue expander/implant reconstructions fair even worse with radiation than flaps. The complication rates in this setting are much higher than with tissue reconstructions, including the complete failure of the reconstruction altogether (and removal of the implant).

Some surgeons routinely offer implant reconstructions to patients that are either facing or have already had radiation therapy. Unfortunately, in my experience mixing implants with radiation often ends badly. I will personally only do this in the rare instance that there is no other option, or if the patient strongly prefers to avoid a tissue (flap) reconstruction altogether. The existing literature on breast reconstruction and radiation clearly favors the use of the patient’s own tissue rather than implants in the setting of radiation whenever possible.

So what’s the take-home message?

1) “Breast conservation” can sometimes fall short of the patient’s cosmetic expectations.

2) Breast implants and radiation usually do not mix well.

3) Radiation therapy after a flap reconstruction can significantly impact your reconstruction results, and may require more surgery to improve your overall results, especially if you are in a center that does not routinely care for reconstruction patients. For this reason, most plastic surgeons still advise patients to hold off on their flap reconstruction until after radiation therapy, especially if you are not receiving your treatment in a specialized center.