Impact of Evolving Radiation Therapy Techniques on Implant-Based Breast Reconstruction

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We read with great interest the article entitled “Impact of Evolving Radiation Therapy Techniques on Implant-Based Breast Reconstruction” (Plast Reconstr Surg. 2017;139:1232e–1239e).1 The authors performed a retrospective study in which they compared the complication rate of 533 nonirradiated reconstructions and 125 irradiated reconstructions. This study showed that the irradiation group was significantly more likely to experience later complications (such as capsular contracture) than the nonirradiated group (30.9 percent versus 20.2 percent; p = 0.05). Within the irradiated group, complication rates did not vary significantly between patients with tissue expanders versus patients with implants except in the development of capsular contracture (tissue expander group, 12.7 percent; implant group, 35.7 percent; p = 0.06).
The authors evaluated the radiation dose to the skin, 1 cc of skin, to the breast, body, and tissue expander/implant, and demonstrated that only the first two radiation doses are associated with significantly increased complication rates. In accordance with the authors, we think that the role of skin damage is crucial in the development of complications.2 For this reason, in our practice, we usually perform fat grafting after radiotherapy.3 Fat injection helps to prevent and avoid skin damage by increasing tissue thickness and promoting tissue healing because of the presence of mesenchymal stem cells and growth factors.
The development of capsular contracture may be also linked to radiation-induced alteration of biomaterials (implants).4 Therefore, the prevention of implant damage is carried out by performing radiation therapy on the expander and not on the definitive implant fallowed by multiple sessions of fat grafting performed before the time of expander-implant exchange.5
We believe that achieving a breast reconstruction with a nonirradiated implant is safer. This is confirmed by both our clinical results and biomaterial analysis; however, further clinical and experimental studies are necessary to confirm our preliminary results.

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