What is the impact of radiation on breast reconstruction?
By: Dr. Minas Chrysopoulo
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 also need radiation after surgery depending on the size and characteristics of the tumor, and lymph node status.
I think it is fair to say that most reconstructive breast surgeons, myself included, are not particularly fond of radiation because of the way it can impact breast reconstruction results. Nonetheless, it is very important to remember that "life comes before breast" and in certain situations studies have shown definite benefits from radiation therapy including decreasing the risk of local recurrence and even improving overall survival.
Radiation therapy has come a long way over the years but it can still be associated with significant side effects. Radiation often causes toughening (fibrosis) and shrinking (contracture) of the patient's tissues which makes the tissue lose its elasticity and become more firm. Skin color changes are common, red at first turning more brown over time. Radiation can also cause burn injuries (usually superficial) as well as damage to underlying organs such as the lungs and heart. Anyone who is facing radiation therapy must discuss all the potential risks with their their radiation oncologist extensively beforehand, as well discussing the potential impact on the reconstructive plan and timing with their plastic surgeon.
Radiation after a tissue ("flap") reconstruction can cause the reconstructed breast to shrink and become firmer. Unfortunately, this is a common scenario (in varying degrees of severity) and usually exaggerates breast asymmetry. Rarely, radiation therapy can create new wounds on the reconstructed breast which need wound care. Patients facing radiation after flap breast reconstruction should know that there is a significant risk of needing further reconstructive surgery to correct changes caused by the radiation therapy and improve breast symmetry.
Tissue expander / implant reconstructions usually fair much worse than flaps with radiation: the complication rates in this setting are much higher than with flap reconstructions. Some surgeons routinely offer implant reconstructions to patients that have had or will be having radiation therapy. In my experience, mixing implants with previous radiation often ends badly; the complication rate is high (eg poor expansion of the radiated skin, thinning of the overlying skin, implant hardening, pain, implant exposure, need for removal of the implant) and the cosmetic results are often unfavorable compared to tissue reconstruction.
Immediate breast reconstruction with either flaps or tissue expanders can be performed in appropriate candidates when post-mastectomy radiation is planned, however, a coordinated team approach involving a radiation oncologist experienced in treating breast reconstruction patients is crucial in decreasing the risk of complications. I also strongly advise against direct-to-implant breast reconstruction (also know as single stage or "one-step" implant reconstruction) if post mastectomy radiation is planned as this combination is associated with the highest risk of complications.