Radiation and Breast Reconstruction with Implants

By: Dr. Gary Arishita

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May 29, 2013

It is estimated that in 2013, more then 232,000 women will be diagnosed with invasive breast cancer with over 64,000 being diagnosed with in-situ disease. Of these women, half will be treated with lumpectomy and radiation treatments.

Radiation is an essential part of treatment for some women. Risk of recurrence and death can be significantly reduced with radiation in women undergoing lumpectomy. In locally advanced breast cancers, radiation can also be necessary after mastectomy.

Radiation works by damaging cellular DNA. Cells that are rapidly dividing are damaged more by radiation than normal cells. The beneficial effects of radiation following lumpectomy have been well proven. In the vast majority of cases, lumpectomy is not an acceptable treatment for breast cancer unless radiation is added as the breast cancer recurrence rate is too high after lumpectomy alone.

Radiation has deleterious effects on normal breast tissue as well. The radiation causes permanent changes to the normal breast tissue. It causes fibrosis of the tissues and decreases elasticity. The breast feels tighter and the skin and underlying tissues are less "stretchy". The microvascular circulation is damaged and blood flow is reduced. These effects are present in the breast and skin forever. The changes can be more pronounced in some patients, but all treated tissues are affected.

Radiation increases the risk of complications and poor outcomes in breast reconstruction. When tissue expander and implant reconstruction is used after radiation, major complications occur in about half of patients. A major complication usually means that more surgery was needed and the implant had to be removed. It is then more difficult to perform reconstruction in tissues that have been scarred by infection or wound breakdown in addition to the radiation. Some plastic surgeons offer implant reconstruction to patients that have been previously treated with radiation. They cite data showing that it can sometimes work. The early results can sometimes appear good but less than half of patients will have an acceptable reconstruction long-term.

I do not recommend attempting tissue expander or implant reconstruction in patients who have been previously treated with radiation. I believe that a 50% complication rate is too risky. If the reconstruction fails, it is even more difficult to get a great result. I recommend that a tissue flap be used for reconstruction following radiation. When transplanting healthy, non-irradiated tissue to the breast, the flap behaves more like normal tissues and the health of the surrounding tissues improves significantly.

Tissue can be taken as a flap from the abdomen, the back, the buttock, or the thigh. Often the reconstruction can be made entirely of transplanted flap tissues. In patients who do not have enough tissue available, I use a combination of a flap along with a tissue expander or implant. The addition of the healthy flap to the radiated breast improves the overall health of the tissues and allows use of implants. Healing is improved and the cosmetic appearance of the breast is better when a flap is used along with an implant.

There are always choices in treatment. This applies to cancer treatment as well as reconstruction. I strongly recommend looking at your options and the short and long term impact of those treatment choices.

I hope this helps.

Learn More About DIEP Flap Breast Reconstruction

48 Comments

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  • Robin

    I sure wish someone had told me this. I am now dealing with nothing but a hard lump and one breast is higher than the other one. And this is after 2 surgeries. One to put the implant in and one to try to correct it by removing the implant and simply putting in a new one. He told me to push down on it to make it more level with the other breast.

    Reply
  • PRMA Plastic Surgery

    Hi Robin, PRMA routinely performs corrective surgery on patients who are unhappy with a previous breast reconstruction. I would be happy to talk about your options. You can give me a call at 800.692.5565 and if you’d like to complete our virtual consultation form, one of our surgeons can review your case and give you a better idea of what he would recommend. You can find that form via this link—> http://prma-enhance.com/patient-forms/virtual-consultation. Hope to talk with you soon! -Brandy

    Reply
  • Tracy

    I wish I had been told this, as well Robin. I’ve had 2 surgeries as well and am looking at 1 or 2 more….that I know of so far and this process is taking a great deal of time. I don’t dare push down on my right implant because my scar hasn’t fully healed from when it broke open after a friend hugged me in March 2013. I’m saddened by all this and am tired of feeling discomfort and/or severe pain for close to 1 year. I don’t feel like a survivor, yet I still have hope.

    Reply
  • Dr. Arishita

    I am surprised to see how often implants are used in women after radiation treatments. In my residency, I was taught that it usually did not work. The use of ADMs (Acellular Dermal Matrix) has helped to decrease capsular contracture. I think that has encouraged some surgeons to attempt implant reconstructions in radiated tissues. It does work sometimes. But, I have seen too many patients with bad results, so I do not attempt to reconstruct radiated breasts with implants. I don’t believe it is the best way to do it. Fortunately, I belong to a group, PRMA where I am able to offer all methods of breast reconstruction to my patients. I believe that I always offer the best option for my patient. The options are not limited to only those operations that I can perform. For women who have had poor outcomes after reconstruction, there is usually something that can be done to make it better. Usually it does require surgery. And it may require a more involved procedure, but the choice is yours. Dr A

    Reply
  • Beverly

    I underwent a mastectomy last June in Italy, followed by chemotherapy. 4 weeks after finishing chemo finished I had an implant put in before starting my radiation. I started radiation 4 weeks after the reconstruction ( 25 sessions). My silicone implant is now smaller and harder (more ball shaped). My plastic surgeon wants to inject fat around it to correct the shape. I am not happy with the feel of the implant. What do you think my options are?

    Reply
  • PRMA Plastic Surgery

    Hey Beverly! The implants reaction to the radiation is a normal response. Fat grafting is always an available option for you to help improve the shape and feel. However, due to the tightness of your skin after radiation, the transferred fat could likely reabsorb. You may want to consider an autologous reconstruction such as a DIEP flap or even LAT flap with the addition to the implant for a better shape and softer feel.

    Reply
  • Dawn

    I’ve had lumpectomies and radiation treatments back in 2012, had a bilateral mastectomy done in sept of 2013. Just in march of 2014 had an emergency surgery to remove the left implant and now I have only one breast that has the expander in it. My surgeon is gonna take the fat from my belly to put in it’s place when I get surgery again. My breast size is like a large B ... He is saying there isn’t enough fat to make it the same size and the radiated skin is the problem as well. I don’t want to go thru all that pain and look like a boy. I’m going through all this alone, I have no husband or kids. I just want to be normal again. Now I also have lymph edema in my left arm. What do I do??? I’m sadden with all of this ... 2 years too long

    Reply
  • PRMA Plastic Surgery

    Hey Dawn, I am so sorry to hear you are experiencing so many complications! PRMA routinely performs corrective surgery on patients who have had failed implant reconstruction. Our surgeons also perform vascularized lymph node transfer surgery, which can sometimes help with lymphedema. I would love to talk about your options. You can give me a call at 800.692.5565 and if you’d like to complete our virtual consultation form, one of our surgeons can review your case and give you a better idea of what he would recommend. You can find that form via this link—> http://prma-enhance.com/patient-forms/virtual-consultation. Hope to talk with you soon! -Courtney

    Reply
  • Donna

    Hi Dr. A… I have read this article, and the comments. Thanks for posting this, I am looking forward to meeting you Friday, and see what your recommendations are for me. Feeling every confidence in you. Donna

    Reply
  • Joanna

    I have had breast implants since age 27. Age 31 I was diagnosed, had a lumpectomy with reexcision, chemo, and radiation. I soon developed a capsullary contracture after. I consulted a military doctor who was not comfortable with reconstruction to irradiated breast but offered fat grafting to the surgical site. I am now 34 and really dissatisfied having one breast that sits much higher than my healthy breast. I recently went back to the original plastic surgeon who did my implants to begin with and he felt reconstruction was safe at this point and would include doing a capsullectomy, replacing the implant and adding an ADM. He indicated this would require use of an expander (which after reading your recommendations sounds very concerning) and wanted to create a flap on my side near the affected breast to cover and improve the aesthetics of the scarring and surgical site. I am very confused at this point about my treatment options.

    Reply
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