Discussion: Reconstruction of the Irradiated Breast

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Drs. Chetta et al. from the University of Michigan have used the Truven Health MarketScan Commercial Claims and Encounters database to assess morbidity after implant-based and autologous breast reconstruction in the setting of radiation therapy. The evaluation period ranges from 2009 to 2012, and 4781 irradiated patients met the inclusion criteria. The study included a 15-month follow-up for each patient to capture complications and reconstructive failures.
Patients were included in the study if they received radiation therapy either before or after their breast reconstruction. Reconstructive failures were defined as any patient who had a primary expander removed or replaced with a new expander, had more than one implant replacement, needed a flap following an implant failure, or underwent a second flap operation.
In this study, 3846 patients (80 percent) had implant-based reconstruction and 935 (20 percent) had autologous tissue. The overall complication rate was 45.3 percent in the implant group and 30.8 percent in the autologous group. Reconstructive failure was identified in 29.4 percent of implant patients and 4.3 percent of autologous patients. The group with the highest reconstructive failure rate consisted of those who had been previously irradiated and had delayed reconstruction with an implant. Conversely, the fewest complications were seen in those previously irradiated and who had delayed reconstruction with autologous tissue.
The existing literature on breast reconstruction and radiation therapy clearly supports the use of autologous tissue in the setting of radiation therapy. However, in the setting of increasing numbers of bilateral mastectomies, established safety of silicone implants, and greater numbers of irradiated patients who need reconstruction, there must be a role for prosthetic reconstruction in the setting of radiation therapy.1,2 In this study, there is no difference in complications or reconstructive failure in patients who received radiation therapy before or after permanent implant placement, a finding that differs from existing literature. Meta-analysis demonstrates a reconstructive failure rate of approximately 30 percent in patients receiving radiation therapy to the tissue expander compared with only approximately 10 percent when delivered to the permanent implant.3 Similarly, the analysis by Cordeiro et al. of 304 patients with implant-based reconstruction included 94 patients with irradiated expanders and 210 with irradiated permanent implants. The 6-year failure rate was 32 percent with irradiated expanders and 16.4 percent with irradiated implants.4
There are other aspects of the current study that need to be carefully considered by the reader. First, claims databases, such as MarketScan, do not capture complications with as much sensitivity and specificity as databases built for such a purpose, such as the National Surgical Quality Improvement Program. Second, patients with the highest failure rate in the analysis were those who underwent a mastectomy followed by irradiation with delayed expander placement. In many centers, this group would not be offered pure prosthetic reconstruction, instead undergoing either autologous transfer or an expander with a latissimus dorsi flap. Removing these 641 patients would lower the overall rate of prosthetic failures to 23 percent. Lastly, the definition of reconstructive failure appears somewhat biased in favor of autologous flaps. As determined by the authors, failures are principally defined around prosthetics, and it is already well established in the literature that flap failures are rare events (i.e., <2 percent).5
In an ideal world, every woman who has a unilateral or bilateral mastectomy and has been or will be irradiated would have an autologous reconstruction. Unfortunately, because of patient factors, surgical expertise, and differential access to care, this is not always an option. As a result, we must individualize the care for our patients and strive to understand who may be a good candidate for implant reconstruction in the setting of radiation therapy.
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