Introduction:

Implant breast reconstruction is an important option for women undergoing mastectomy, particularly as some patients are neither desiring of, nor are candidates for autogenous tissue reconstruction.  In patients with a history of prior chest wall irradiation, the suitability of implant reconstruction remains unclear as an increased incidence of postoperative complications and capsular contracture has been well documented.  Clinical experience, however, suggests that in a subset of well-selected patients, successful reconstruction can be achieved.  The purpose of this study was to identify potential predictors of successful aesthetic outcome following tissue expander/implant reconstruction in previously irradiated patients.     

Patients & Methods:

A review of all tissue expander/implant reconstructions performed in patients with a history of chest wall irradiation performed at single center from 1996 to 2003 was undertaken.  Two reconstruction patient cohorts were identified: i) patients who had delayed reconstruction following mastectomy and adjuvant radiotherapy, and ii) patients who had immediate reconstruction following salvage mastectomy for breast cancer recurrence after prior breast conservation therapy (lumpectomy/radiation).  Clinical records were reviewed to determine pre-operative skin texture, skin discoloration, time since radiotherapy, and radiation dosing.  Demographic and reconstruction data was also retrieved.  Overall aesthetic results were judged both by the attending surgeon and a panel of independent observers.  Multiple predictive factors of overall aesthetic result were analyzed using polytomous logistic regression.  Spearman's rank correlation coefficient was used to determine the association between ordinal variables.

 Results:

A total of 28 patients with a history of previous chest wall irradiation underwent tissue expander/implant postmastectomy reconstruction.   Mean patient age was 50.5 years (range, 35.7 – 65.3 yrs).  Mean time from completion of radiation to initiation of reconstruction was 5.3 years (range, 0.1 – 12.9 yrs).  Median radiation dose was 4400 cGy (range, 2000 - 5040 cGy) delivered in 16 fractions.  Eighteen percent of patients received a radiation boost. Ninety-three percent of patients successfully completed reconstruction. The overall rate of peri-operative complications was 21.4% (6/28).  Complications included: expander exposure (3); infection (1); failed expansion (1); and, expander deflation (1).  Mean follow-up was 2.6 years (range, 0.7 – 8.1 yrs).  Seventy-one percent of reconstructions had a ‘good' or ‘very good' result.  Pre-operative skin texture was a significant predictor of overall aesthetic outcome (p=0.03).  In contrast, neither pre-operative skin discoloration nor total radiation dose was a significant predictor of aesthetic result (p=0.12 and p=1.00, respectively).  Similarly, time from completion of radiotherapy to initiation of reconstruction did not correlate with the final aesthetic outcome (p=0.56).  Seven percent of patients developed a grade III capsular contracture.  One patient developed a grade IV capsular contracture requiring implant removal.  Capsular contracture grade was significantly correlated with aesthetic result (p=0.02).

Conclusions:

In patients with a history of chest wall irradiation, pre-operative skin texture is a significant, independent predictor of aesthetic outcome following tissue expander/implant breast reconstruction.  In a subset of well-selected patients, the rate of complication is acceptable and the aesthetic results satisfactory.  A careful pre-operative assessment of radiation induced skin changes may improve patient selection and final results following implant-based reconstruction in the setting of prior radiotherapy.