Radiation and Breast Reconstruction with Implants

By: Dr. Gary Arishita

Blogs
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

49 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
    • Sheila

      Hi Tracey and robin I agree I am having the same problem with implant failure after radiation, I am going in for my fifth surgery tomorrow, I wish someone would have explained that the tram flap was the recommendation

      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
  • PRMA Plastic Surgery

    Hey Joanna! It is understandable that you are feeling confused and uncomfortable with your reconstruction. PRMA does perform corrective breast reconstruction and we would be happy to review your case. You can fill our our virtual consultation at http://prma-enhance.com/patient-forms/virtual-consultation. After I receive your information, I can forward it onto our physicians to review. If you have any questions, please give me a call at 800-692-5565. Thanks, Courtney

    Reply
  • Sonia

    Hello I was diagnosed in 2010 and had chemo and radiation done in 2011. I didn’t loose much of my breast. I had a small lumpectomy. I always wanted to do breast argumentation and now I’m going to have implants. My doctor told me of the risk and also told me that the implants under the muscle and fat grafting under the skin would be the way do do my breast implants. He will do both at same time, fat grafting only on the breast I had radiation. My breast look that had radiation looks normal and soft. I understand the damage us inside but do you think the risk of implants is reduced when it’s done under muscle and with fat grafting? Thank you

    Reply
  • PRMA Plastic Surgery

    Hey Sonia! Vast majority of implant based breast reconstruction is performed by placing the implant under the muscle, so your risk would likely remain the same. Fat grafting will be beneficial in achieving symmetry and correcting any unwanted irregularities in the shape of the breast. Let us know if you have any other questions!—Courtney

    Reply
  • Kamila

    Hi everyone, I don’t even know where to begin! Well July 26th, 2013 I had a lumpectomy and lymph node dissection, 4 days later it was confirmed I was pregnant. I kept the pregnancy and started chemo on October 7th, 2013, had the baby prematurely on March 12 with one more chemo to go. Around April 10th I started radiation treatment on still swollen breasts even though I didn’t breast feed. Now, my right breast (Cancer side) which used to be smaller, is bigger than left. I lost a lot of weight with treatment but my right affected breast somehow froze in time, it stayed a little bigger and firm (very painful too) while the rest of my body shrank. I am 36, 5’9” and weigh now 126 lbs. I am sad about the way I look, angry at this situation and afraid that I’ll never be able to look even again. I don’t know what to do. I thought the cancer breast would look considerably smaller after treatment, but it just got harder and size didn’t change from right after giving birth. Sorry for the long story, I am just sad. Thank you!

    Reply
  • PRMA Plastic Surgery

    Sweet Kamila, I am so sorry you have had to endure such a struggle! Side effects of your radiation are likely to blame for your “situation.” Please know there are many options for reconstruction available to you. PRMA routinely performs delayed breast reconstruction on patients who have had radiation. Please feel free to contact me at 800-692-5565 or .(JavaScript must be enabled to view this email address) and we can work on setting you up with a consultation. Thanks—Courtney

    Reply
  • Lee

    I recieved implants in November 2006, then was diagnosed with BC in my left breast in April 2014. At that time, I had a lumpectomy and 6 weeks of radiation. Now just a few months later, in Janurary 2015, My left breast has moved upward on my cheast and become hard and painful. I reached out to my original plastic surgeon and we discussed capsulotomy and/or capsulectomy while leaving the implant in (if still in good condition if not replacing it). I am worried about my options and this might not ‘fix’ the problem or that it will reoccur and I will be back on the table in a few years or even worse months. Is there anyway to tell?

    Reply
  • PRMA Plastic Surgery

    Hello Lee! Unfortunately, there is no way to tell if complications could reoccur over time. One thing I might recommend is looking into having a free flap based surgery such as the DIEP flap in place of your implants. You can find more information about these procedures under the breast reconstruction tab on our website. I am always available to answer questions at 800-692-5565. Thanks, Courtney Floyd—PRMA patient liaison

    Reply
  • Kirstyn

    Hi there, I live in Sydney Australia and have been trolling the interenet looking for info on Anaplastic Large Cell Lymphoma. I am 43 yrs and first had saline implants in my early 20’s. Went on to have 2 pregnancies, no trouble with implants. Early 2010 my right implant ruptured and I had both replaced with silicone implants. My surgeon at the time, though reputable, mistakenly replaced my round implants with shaped implants (significantly different results). He also removed too much tissue in one area which left a distinct bony region on my chest wall. He exchanged the implants for a much larger size 240cc to 550cc to fill in the area without my knowledge. The result was hideous. I had surgery with another surgeon who did beautiful work and performed full lift, reduction down to 240cc. I then developed a staph infection and had the left implant removed for 6 months and then replaced. 12 months later my right breast started to swell with seroma fluid. Had a full exchange February this year, however the problem continued in the same breast. I have since been diagnosed with ALCL and been advised to have both implants removed and that they cannot be replaced. I am aware that this is a rare condition with only 6 reported cases in here Australia and in the region of 70 worldwide with very little information. I have been told that my results of the seroma testing showed an extremely light reading and only a very mild dose of radiation would be required. I am considering trying the radiation with the implants in situ and would appreciate any thoughts or feed back you may have. Many thanks

    Reply
  • PRMA Plastic Surgery

    Indeed ALCL is an extremely rare complication of breast implants. Essentially, chemotherapy and radiation are likely necessary to treat the condition. It is advisable that, at the very least, the affected implant AND capsule be removed. The contralateral side implant may or may not need to be removed. The capsule surrounding the implant is the location that harbors the malignant cells and MUST be removed. The patient may elect to keep the implant (with the capsule) in situ in the setting of radiation treatments, but the radiation will not be effective in preventing a recurrence of the disease. In addition, radiation will ultimately cause capsular contracture and the implant will eventually have to be removed due to cosmetic complications. If, after implant removal and radiation is complete, the patient needs additional volume to the radiated breast, autologous reconstruction could be performed. Hope this helps.

    Reply
  • Popylove

    Why can’t capsular contracture be corrected by removing the implant and replacing with a new one? I had chemo, mastectomy with immediate reconstruction (implant using ti-loop) then radiotherapy. My skin seems to have stuck to the implant and the Breast/implant has shrunk and hardened. The skin looks perfectly healthy and soft.

    Reply
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