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Updated: June 2009

Radiation and Reconstruction

Radiation therapy has been used to treat breast cancer for many years. For patients who choose breast conserving surgery, have multiple positive lymph nodes, or have a local recurrence, radiation therapy will likely be part of the treatment plan. Radiation acts directly on the cell nucleus. Cancer cells grow rapidly compared to normal cells, so by radiating the cancerous area, the cells are chemically damaged and changed, thereby preventing their growth. Unfortunately, radiation also has a negative effect on normal cells. Specifically, radiation damages the blood supply to normal skin at a microscopic level. This results in a significantly greater risk of complications following surgery. These risks include infection, delayed healing, wound breakdown, and fat necrosis, as well as implant related problems such as extrusion and capsular contracture. As such, despite its benefits, radiation therapy can be the source of potential problems when it comes to breast reconstruction.

It is important to discuss all of the information received in your pathology report with your entire breast team, including your breast surgeon, medical oncologist, radiation oncologist, and plastic surgeon. If you need radiation as a part of your treatment, the timing and approach to reconstruction can be coordinated in order to give you the best aesthetic result. Although radiation complicates breast reconstruction, most patients can still achieve an acceptable outcome with proper planning.

Immediate Reconstruction and Radiation

The need for radiation therapy can determine whether or not a patient is a good candidate for immediate breast reconstruction. A patient with advanced disease and with more than four positive lymph nodes will likely have radiation as a part of her treatment. A patient that has one to three positive nodes and a large tumor may also need radiation therapy after the mastectomy. In these patients, immediate breast reconstruction may not be ideal because of the adverse effects radiation can have on the reconstructed breast.

It is not possible to always predict who will need radiation before the mastectomy is completed. This is because pathology information provided after evaluation of the mastectomy specimen will help determine if radiation is needed. If it is decided that radiation is required and the patient has already begun the process of reconstruction, the negative effects of radiation therapy on the reconstructed breast will need to be managed.

For patients with a tissue expander in place, radiation will affect the quality of the breast skin overlying the expander. The skin may recover enough to allow exchange of the expander for a final implant. If the skin does not sufficiently recover, or if other problems arise, it may be necessary to salvage the reconstruction with the use of a flap. One alternative is to utilize a latissimus dorsi flap while retaining the implant as part of the reconstruction. The other alternative is to abandon the implant reconstruction altogether, and to proceed with an autogenous flap alone, such as TRAM flap or an abdominal microvascular free flap.

For patients with an autogenous flap reconstruction that is then radiated, the quality of the skin will be affected and the risk of fat necrosis within the flap will be higher. Should fat necrosis develop, an area of the reconstructed breast may become firm. Sometimes this prompts evaluation with an ultrasound or MRI. If needed, a biopsy may be done to confirm the diagnosis of fat necrosis in the flap. Usually, the firmness associated with fat necrosis will soften over time.

Photos and Doctor Commentary
 

Pre-operative

Right capsular contracture after right tissue expander was radiated

 

Radiation and Reconstruction

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This patient underwent bilateral mastectomies and tissue expander AlloDerm® reconstruction. Post-operatively, it was determined that radiation was needed on the right side. You can see that she has capsular contracture on the right radiated side.

 

Final implant reconstruction

Radiation and Reconstruction

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This is her final appearance after bilateral expander implant exchange and nipple areola reconstruction. As part of the expander implant exchange surgery, on the right breast she required release of the severe capsular contracture and correction of the inframammary fold. At that time, additional AlloDerm® was used to help expand the implant pocket, creating a rounded breast shape.

Delayed Reconstruction and Radiation

Radiation can also be a cause for concern with delayed reconstruction. In a woman undergoing breast reconstruction after previous radiation therapy, the radiation can contribute to poor wound healing and a greater risk of wound infection. These risks, coupled with the increased likelihood of capsular contracture, make the use of an implant a suboptimal choice for women with a history of prior radiation. When the patient’s anatomy allows it, a better choice for breast reconstruction in the setting of prior radiation is an autogenous tissue flap such as a TRAM flap or a microvascular free flap.

Reconstructing the Irradiated Lumpectomy Breast Deformity

Patients who choose breast conserving surgery, and undergo radiation therapy, often have noticeable deformities after the swelling subsides. The most common concerns are indentation of the breast, breast asymmetry, firmness, and changes in skin pigmentation. Correction of such deformities must be individualized for each patient. Occasionally, implants can be used to improve symmetry. More commonly, lumpectomy deformities are corrected with an autogenous flap such as a latissimus dorsi flap or an abdominal microvascular free flap.

Photos and Doctor Commentary
 

Right breast deformity after lumpectomy and radiation

After correction of lumpectomy deformity with latissimus flap and implants

Radiation and Reconstruction

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This patient had a right lumpectomy followed by radiation, resulting in a severe breast deformity. This deformity was corrected by excision of the depressed scar tissue on the side of her breast. Soft tissue was added using a latissimus dorsi flap. She later had bilateral breast augmentation.

 

Written and edited by our medical board