Should Immediate Autologous Breast Reconstruction Be Considered in Women Who Require Postmastectomy Radiation Therapy? A Prospective Analysis of Outcomes

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We would like to congratulate Billig et al. for their article entitled “Should Immediate Autologous Breast Reconstruction Be Considered in Women Who Require Postmastectomy Radiation Therapy? A Prospective Analysis of Outcomes,”1 and we agree with the authors’ conclusion that immediate abdominally based breast reconstruction in women undergoing postmastectomy radiotherapy can be safe and effective. However, we think that the decision on when to perform a breast reconstruction on a woman requiring postmastectomy radiotherapy, and what type of procedure is most suitable, are still controversial topics among reconstructive surgeons. Most surgeons are less likely to perform immediate breast reconstruction when postmastectomy radiotherapy is required.2 The adverse effects of radiotherapy after implant-based reconstruction have been well described,3 but the timing of autologous reconstruction in the setting of postmastectomy radiotherapy is still unclear. A recent study has shown similar satisfaction rates in a homogeneous cohort of patients undergoing immediate breast reconstruction, comparing those who received postmastectomy radiotherapy and those who did not.
The authors describe similar BREAST-Q responses between both cohorts (delayed versus immediate), although these two groups have different baseline characteristics. Aesthetic outcomes are usually better in immediate reconstruction compared with delayed reconstruction.2 It has to be kept in mind that patients undergoing delayed reconstruction may tend to score higher on the satisfaction scales in spite of a worse cosmetic result: their baseline situation was a nonreconstructed breast, compared with patients with immediate breast reconstruction, who never perceived themselves without their breast.4
In this setting, analyzing the cost-efficiency of autologous reconstruction with postmastectomy radiotherapy might be helpful in decision-making. There is evidence suggesting that reconstruction using a prosthesis might not be the most cost-efficient.5 Some studies support that autologous reconstruction, regardless of the need for postmastectomy radiotherapy, in specialized centers, by experienced teams might be the most cost-efficient answer, particularly in those with a long life expectancy.6 Future prospective multicenter studies will have to clarify the best alternative for patients and society.
The accuracy in mastectomy technique and reconstruction is as crucial as the radiotherapy regimen. At our institution, in comparison with the authors’ protocol, a higher daily radiotherapy dose is used (2 Gy/day versus 1.8 Gy/day), with satisfactory results. To mitigate the possible effects of radiotherapy, intraoperative caution should be taken, such as discarding poorly vascularized tissues. In addition, in our experience, the effects of radiotherapy on the flap seem to diminish with time.
There is a growing core of evidence supporting immediate autologous reconstruction with a free flap as the first choice in patients who are candidates for mastectomy, regardless of the need for postmastectomy radiotherapy. A prospective, multicenter study assessing satisfaction and surgical outcomes in the setting of autologous immediate breast reconstruction with postmastectomy radiotherapy with a lengthy follow-up would shed light on the management of these complex patients.

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