Discussion: Should Immediate Autologous Breast Reconstruction Be Considered in Women Who Require Postmastectomy Radiation Therapy? A Prospective Analysis of Outcomes
Autologous reconstruction is an ideal option for many patients following mastectomy, particularly in the setting of radiotherapy. The transition from predominantly superiorly based inflow to inferior inflow has improved overall perfusion to the flaps, and it has arguably improved abdominal wall morbidity. As technical experience has been gained, the incidence of total and partial flap loss has decreased and the rates of fat necrosis continue to improve. Unquestionably, the vitality of the flap in immediate reconstruction is related directly to the outcome following radiation therapy.
Immediate autologous reconstruction has several advantages, including the psychological benefit of awakening from mastectomy surgery with a breast mound, and the practical benefits of fewer operations and decreased operative time if the reconstruction is begun simultaneously with the mastectomy. However, experience gained from large series in the past showed high incidences of fat and flap necrosis, volume loss, and complications when immediate autologous reconstruction was performed before radiation therapy.3 Therefore, delayed autologous reconstruction has been the most common choice in patients destined to undergo postmastectomy radiotherapy. However, with improvements in surgery and radiation techniques combined, several authors have begun to reexplore immediate autologous reconstruction in this setting.
The Mastectomy Reconstruction Outcomes Consortium Study offered a potential way to answer the question of whether immediate autologous reconstruction should be performed in women who require postmastectomy radiation therapy. In this article, immediate reconstruction was performed in 108 patients. This cohort was unique in having no total or partial flap losses and a very low (3.7 percent) rate of fat necrosis, which is a testament to the technical skills of the surgeons involved. Although the study plan was meant to have multicenter representation, the vast majority of these patients (93.5 percent) came from one center.