Outcomes of Immediate Tissue Expander Breast Reconstruction Followed by Reconstruction of Choice in the Setting of Post-Mastectomy Radiation Therapy

Purpose: One common sequence for performing staged tissue expander/implant (TE/I) breast reconstruction is to immediately insert a tissue expander, complete expansion prior to radiotherapy, and then perform the tissue expander to implant exchange after radiotherapy is complete.  The goal of this study is to examine the outcomes of this approach to TE/I breast reconstruction, in the setting of post-mastectomy radiotherapy.

Methods:   The charts of 244 patients who underwent immediate TE/I breast reconstruction in the setting of post-mastectomy radiotherapy at Northwestern Memorial Hospital between 08/1999-07/2008 were retrospectively reviewed.  The average follow-up time was 43 months.  Five charts were incomplete and were excluded from analysis. 

Demographic, surgical, and oncologic factors were recorded.  Only complications in radiated breasts were recorded. Complications were divided into: Minor complications treated conservatively (minor), major complications requiring surgical intervention (MSI), and major complications requiring explant/conversion to flap (MEF). Multiple linear regression analysis was used to determine statistical significance of the results.

Results: The average patient age in this study was 47 years (range 21-79 years).  The average BMI was 25.8 kg/m².  In the tissue expander stage, there were a total of 110 complications (in 97 patients) for a complication rate of 46%.  This included 20 minor complications, 27 MSI, and 64 instances of MEF.  In the tissue expander to implant exchange stage, there were 46 complications (in 38 patients) for a complication rate of 28%.  This included 1 minor complication, 25 MSI, and 20 instances of MEF. Increased BMI and increased age were found to be statistically significant independent risk factors for both increased complication rates as well as increased explant or conversion to flap rates (p<0.05).

Conclusions:  This study confirms that TE/I reconstruction can be safely performed in the majority of patients in the setting of post-mastectomy radiation therapy. While complications are expected, they should be managed with effective patient-physician communication.  Patients should be reassured that they can safely complete their cancer therapy and afterwards will be able to achieve an acceptable reconstruction, approximately 60% of the time with implants alone and approximately 40% of the time with the addition of autologous tissue.  In order to more clearly deliniate the etiology of radiation induced contracture, a modification to the Baker-Spear classification should be considered.