Sunday, October 10, 2004

Nipple Areola Reconstruction Following Chest Wall Irradiation for Breast Cancer: Is it Safe?

Duc T. Bui, MD, Ernest S. Chiu, MD, Lawrence B. Drapier, BA, Babak J. Mehrara, MD, Peter G. Cordeiro, MD, FACS, and Joseph J. Disa, MD, FACS.

BACKGROUND: Nipple areola complex reconstruction (NAR) is an important final step in breast reconstruction. Radiation therapy (RT) is considered by some to be a contraindication to NAR particularly in patients with implant reconstruction. The objective of this study was, therefore, to examine our experience with NAR in patients who were reconstructed with implants and who had a history of RT.

METHODS: A retrospective review was performed on all patients who underwent NAR after breast reconstruction with tissue expanders and implants at a single cancer center over a 6-year period (1997-2003). All patients who had a history of RT (either preoperatively or postoperatively) were identified and their charts as well as a prospectively maintained database were analyzed with respect to: the timing of RT, interval of time to NAR after RT, interval of time to NAR after implant placement, surgical technique, and postoperative complications.

RESULTS: During the study period, only 13% (28/222) of patients with a history of RT underwent NAR after implant reconstruction. In contrast, 36% of similarly reconstructed patients (616/1726) who were not treated with RT underwent NAR (p<0.001). 18/28 patients who had a history of RT underwent NAR using local flaps only, while 10/28 patients underwent NAR using local skate flaps with full thickness skin grafts. The following local flaps were used for NAR: fishtail (12), skate (10), C-V (5), and star (1) flap(s). The median time interval from completion of RT to NAR was 58 months (21-121; pre-mastectomy RT, n=7) and 10 months (5-35; post tissue expander reconstruction RT, n=21) (p<0.001). The median time interval from permanent implant placement to NAR was 4 months (2-19; pre-mastectomy RT) and 9 months (2-30; post tissue expander reconstruction RT) (p=0.13). 15/28 patients underwent nipple tattoos and 9/18 patients underwent areolar tattoos. There was one total nipple loss followed by implant exposure and removal in a patient with a history of pre-mastectomy RT who underwent NAR with a skate flap and full thickness skin graft. There were no implant losses due to NAR in patients without a history of prior RT. Other complications in patients with a history of RT included total skin graft loss (n=1), partial nipple loss (n =4), and partial skin graft loss (n=1). These complications all healed with local wound care.

CONCLUSIONS: Nipple areola reconstruction after chest wall irradiation in patients reconstructed with breast implants should be performed in carefully selected patients. A variety of techniques can be used for nipple areola reconstruction with acceptable complications rates.

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