Autologous Breast Reconstruction and Post-Mastectomy Radiation: Is Delayed Reconstruction a Thing of the Past?

Purpose:

Post-mastectomy radiation therapy (PMRT) is a mainstay of treatment for women with node positive disease¹. In these women, delayed autologous breast reconstruction is typically recommended in efforts to minimize flap complications while optimizing aesthetic results². With the advent of advanced radiation techniques that improve dose homogeneity and increased ease of microsurgical tissue transfer, some surgeons are attempting immediate autologous breast reconstruction in patients who will receive PMRT³, challenging the traditional paradigm. We aim to prospectively evaluate the postoperative morbidity and satisfaction reported by women undergoing delayed or immediate autologous breast reconstruction in the setting of PMRT.

Methods:

Patients were enrolled in the Mastectomy Reconstruction Outcomes Consortium (MROC) Study, a prospective, multi-center, NCI-funded project. The analysis included those receiving PMRT and free abdominally-based autologous breast reconstruction. Immediate reconstructions were performed prior to PMRT, and delayed reconstructions were performed after PMRT. Demographic and clinical treatment data were collected. Postoperative complications at one year after reconstruction were assessed. Patient-reported outcomes were also evaluated using the BREAST-Q questionnaire preoperatively and at one year post-operatively. Univariate and mixed effects regression analyses were performed to assess relationships among demographic, clinical variables, and outcomes of interest.

Results:

A total of 169 patients undergoing PMRT and free abdominally-based autologous breast reconstruction met inclusion criteria. Immediate reconstructions were performed in 104 patients and delayed reconstructions in 65 patients. Demographic data were similar between the immediate and delayed breast reconstruction groups. Overall complication rates did not vary based on reconstructive timing (27.9% immediate and 26.2% delayed; p-value=0.81). Patients with delayed reconstruction reported significantly lower preoperative scores (p<0.0001) for satisfaction with breast, psychosocial and sexual well-being than did patients with immediate reconstruction. However, at one-year postoperatively, both groups of patients reported comparable levels of satisfaction with breast (p-value=0.39) and in all other evaluated BREAST-Q domains.

Conclusion:

Immediate autologous breast reconstruction provides important psychosocial and physical benefits to women undergoing mastectomy and radiation⁴. Breast aesthetics and quality of life, evaluated from the patient’s perspective, do not appear to be compromised by flap exposure to PMRT. Furthermore, with similar flap complication rates, immediate autologous breast reconstruction in the setting of PMRT seems to be just as safe as delayed autologous breast reconstruction. Immediate autologous breast reconstruction should be strongly considered even in patients who will require PMRT.