Radiation therapy has been used to treat breast cancer for many years. Patients who choose breast conserving surgery, have multiple positive lymph nodes, or have a local recurrence will likely require radiation therapy.
Radiation acts directly on the cell nucleus. Cancer cells grow rapidly compared to normal cells. By radiating the cancerous area, the cells are chemically damaged and changed, thereby preventing their growth.
Unfortunately, radiation also negatively affects normal cells. Specifically, radiation damages the blood supply to normal skin at a microscopic level. This significantly increases the risk of complications following surgery, including infection and compromised wound healing. Additional risks include wound breakdown and fat necrosis, as well as implant related problems such as extrusion and capsular contracture. These risks mean that despite its therapeutic benefits, radiation therapy can create challenges 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, reconstruction timing and approach should 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. Should problems arise, there are a number of surgical options that can help mitigate and correct radiation related complications.
Breast Conservation Therapy
Radiation therapy can be a very effective element of breast cancer treatment, particularly among patients undergoing breast conservation therapy with lumpectomy. While lumpectomy removes the cancer, radiation treats the remaining breast tissue. This approach is designed to conserve as much breast tissue as possible.
Immediate Reconstruction and Radiation
Radiation therapy influences 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 their treatment. A patient who has one to three positive nodes and a large tumor may also need radiation therapy after 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 always possible to predict who will need radiation before the mastectomy is completed. Pathology information provided after evaluation of the mastectomy tissue helps determine if radiation is needed. If radiation is added to a treatment plan where the patient has already begun the reconstruction process, this therapy will have an impact on the aesthetic result. A plastic surgeon will need to work to manage the negative effects of treatment.
Radiation After Expander Implant Reconstruction
Radiation impacts the quality of overlaying breast skin in patients with a tissue expander in place. In some cases, the skin recovers enough to allow an implant exchange procedure to proceed as planned. If the skin does not sufficiently recover, or if other problems arise, it may be necessary to salvage the reconstruction using a natural tissue flap. One alternative is to utilize a latissimus dorsi flap to improve the quality of tissue overlaying the implant while retaining the implant as part of the reconstruction. The other alternative is to abandon the implant reconstruction altogether and proceed with an autologous flap alone.
Radiation After Autologous Flap Reconstruction
Radiation also impacts breast skin quality in patients with an autologous flap reconstruction that is then radiated. It also increases the risk of fat necrosis within the flap. Should fat necrosis develop, an area of the reconstructed breast may become firm. Sometimes this prompts evaluation with an ultrasound or MRI. A biopsy can confirm the presence of fat necrosis if needed. The firmness associated with this complication usually softens over time.
Delayed Reconstruction and Radiation
Radiation can also create challenges for patients undergoing delayed reconstruction. Previous radiation therapy can contribute to poor wound healing and greater risk of wound infection. It is also associated with capsular contracture, which can cause painful tightness and implant malposition. Because of the risks associated with implants, natural-tissue flap reconstruction techniques are preferred for patients treated with prior radiation.
Reconstructing an Irradiated Lumpectomy Breast Deformity
Patients who undergo radiation as part of breast conservation therapy often have noticeable deformities after the swelling subsides. The most common concerns are breast indentation, breast asymmetry, firmness, and changes in skin pigmentation. Deformity correction requires an individualized approach. Occasionally, implants can be used to improve symmetry. Lumpectomy deformities are most commonly corrected with an autologous flap.
Correcting Radiation-related Contour Abnormalities
There are several procedures that may help mitigate contour abnormalities in a reconstructed breast after radiation. Scar revision procedures, fat necrosis removal, fat grafting, and capsulectomy can all improve aesthetic outcomes.
Fat grafting can frequently correct radiation damage to skin and soft tissue. Improvements after fat grafting may take a few months to become evident and may require more than one fat grafting procedure. Fat grafting can be effective after lumpectomy and radiation or following mastectomy and breast reconstruction.
In some cases, implant problems related to radiation may be improved with removal of a tight capsule followed by soft tissue reinforcement using a dermal matrix. When radiation related capsular contracture and tightness is severe, implant removal may be needed. This can be followed by immediate or delayed natural-tissue flap breast reconstruction if desired.
Nipple Reconstruction After Radiation
Nipple reconstruction after radiation can be very difficult. There is a high risk of healing problems and potential flattening of the reconstructed nipple. In many cases, a three-dimensional nipple tattoo is a better, safer option. This type of specialized medical tattooing gives the illusion of a three-dimensional nipple through careful shading and anatomical drawing.