Postmastectomy Radiation Therapy and Two-Stage Implant-Based Breast Reconstruction: Is There a Better Time to Irradiate?

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We read with interest the article entitled “Postmastectomy Radiation Therapy and Two-Stage Implant-Based Breast Reconstruction: Is There a Better Time to Irradiate? (Plast Reconstr Surg. 2016;138:761–769).1 Santosa et al. have published a very interesting multicenter study from 11 institutions across North America. They identified a total of 150 patients who underwent two-stage implant-based breast reconstruction. Of these, 104 women underwent tissue-expander x-ray therapy, whereas 46 underwent implant x-ray therapy. They found no significant differences in the incidence of postoperative complications for patients undergoing radiation therapy after expander-implant exchange compared with patients undergoing radiation therapy before exchange. Moreover, timing of postmastectomy radiotherapy was not a predictor of overall complications, major complications, or reconstructive failure. Their results confirmed the fact that complications are not unusual following breast reconstruction. Over 25 percent of all patients, regardless of timing of postmastectomy radiotherapy, developed some type of complication. Regarding this challenging topic, we would like to share our experience. The senior author (D.R.) published several articles about this topic and described a specific protocol to minimize postoperative complications.2,3 In particular, we perform tissue-expander x-ray therapy, followed by one or two sessions of fat injection. Finally, we exchange the tissue expander with the permanent implant.
We believe that achieving a breast reconstruction with a nonirradiated implant is safer. This is confirmed by both our clinical preliminary results and biomaterial analysis. Recently, we demonstrated that radiotherapy causes some variations on the implant surface that could increase postoperative complications such as capsular contracture.4 A multicenter, prospective, randomized study with longer follow-up, as suggested by Cordeiro,5 would probably help to confirm our data. Again, we congratulate Santosa et al. for the interesting study, pursuing solutions to this difficult problem.

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