Radiation therapy has proven to be life life-saving tool in the battle against breast cancer. However, when radiation treatments of the breast or post-mastectomy chest wall are delivered, breast reconstructive options change. The effects of radiation therapy continue and permanently alter the blood supply and therefore the nutrition to the radiated area. This situation limits both the healing capability of the radiated site and its response to plastic surgical manipulation.
The consequence of radiation affects breast cancer patients in several fashions. If postoperative radiation is anticipated at the time of mastectomy, then reconstruction should be delayed until appropriate chest wall healing is recognized on follow-up examination. This typically takes nine to twelve months. Radiation treatments may also impact the breast conservation patient. If the patient is unhappy with the aesthetic result of her cancer excision and radiation, reconstruction options should be tailored to consider the radiation treatment. Further, the same consideration needs to be given should a second cancer develop in a previously treated breast in the future.
So what does all this mean to the patient who desires the best aesthetic result from breast reconstruction? It means that the selection of the reconstruction method is very patient-specific. Breast reconstructive options should be tailor-made to the patient’s health status, body type, anticipated breast cancer treatments, soft tissue availability, and post-reconstruction expectations.
One of the most common and gratifying reconstruction options is the Tissue Expander method. Here, a deflated implant is placed beneath the muscle which lies beneath the site of the former breast. The implant is then filled with saline slowly in the weeks after placement to achieve a new breast shape. It is then replaced with a permanent implant. The effects of radiation preclude this method without the addition of healthy native muscle and skin to the site. The radiation will not permit appropriate stretch of the overlying skin. This can lead to infection, loss of the implant, or an aesthetically compromised result.
The use of the Latissimus Dorsi muscle which is swung around from the back to the former breast site provides for excellent implant coverage, soft tissue stretch, and aesthetic outcome. The advantages of the Lat. Dorsi flaps are reliable and shape control. It works well for the broadest spectrum of female body types. With this method, post-reconstruction breast size may vary from a B cup to over D simply by extending the period of expansion and changing permanent implant sizes. Modern tissue expansion techniques continue to improve yearly with more sophisticated implants making the Lat. Dorsi. and tissue expander reconstruction method is the “workhorse” of my practice.
Other reconstruction methods include, of course, the TRAM flap. Here skin, fat, and muscle are moved from the abdomen to the chest wall. This method also works very well in the radiated chest but is not appropriate for as many patients as the Lat. Dorsi. I find that it is more physiologically challenging to the patient, and even in the best hands carries a higher operative complication rate.
Breast reconstruction is a complex multidisciplinary process. Particularly with radiation added to the mix, careful consideration regarding reconstructive timing and method is paramount in producing a reliable, safe, and aesthetically optimal result.
