There is an active debate about the timing of radiation for patients undergoing autogenous breast reconstruction. Postoperative radiation has been recommended following mastectomy for a variety of clinical and pathological factors, most commonly tumor fixation to the chest wall, greater than four positive axillary lymph nodes, close surgical margins, and vascular invasion.

Historically, breast reconstruction has been delayed after mastectomy and radiation to minimize the effects of radiation therapy on the reconstructed breast and supposedly to improve the efficacy of radiation. However, there have been significant advances in both the delivery of radiation and mastectomy techniques. Increasing numbers of skilled cancer ablative surgeons are now performing skin sparing mastectomies. This increases the value of immediate reconstruction and allows for the reconstructive surgeon to create a more natural-appearing breast from the original breast skin pocket. The inframammary crease and contour of the breast is preserved, and the final scar is circumareolar and can be adapted to nipple reconstruction. Mastectomy without immediate reconstruction prevents the use of the skin sparing mastectomy. The delivery and dosage of radiation has changed in quantity and technique, and is designed to decrease the impact of radiation on skin and increase delivery to underlying tissue.

We present a retrospective review of twenty-five patients who received skin sparing mastectomy, immediate pedicled TRAM flap breast reconstruction, and post-reconstruction radiation. Data was collected from physical examination and medical history. All patients were examined later than one year after the initial surgery. Patients were scored on degree of fibrosis, fat necrosis, breast symmetry, skin changes, and complication rates.

Results show significantly lower complication rates compared to patients receiving post-reconstruction radiation in previous studies. In addition, they maintained the aesthetic advantage of skin sparing mastectomy, despite radiation. The advances in oncological surgery and radiation have made a positive impact on patient outcome, warranting the re-thinking of the standard protocol of delayed reconstruction.