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

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As a research team that implements the BREAST-Q routinely, we thank the authors for their exploration of a clinically pertinent question. Recent literature has challenged the preference for delayed over immediate reconstruction by reporting similar surgical outcomes between the two procedures.1,2 As a result, patient-reported outcomes on their quality of life increasingly factor into deciding which procedure to perform. Research that explores quality-of-life outcomes therefore has implications for a physician’s decision-making, for educating patients and managing expectations, and for improving outcomes and patient satisfaction. Thus, we were very interested to read this study’s conclusion that breast aesthetics and quality of life, from the patient’s perspective, were not compromised by flap exposure to radiation therapy.
In response, we would like to highlight one BREAST-Q domain that we believe may have been compromised. Specifically, the Discussion notes a clinically and statistically significantly higher BREAST-Q score for the delayed group in “Physical Well-being (chest and upper body)” 2 years postoperatively. One of the main concerns in immediate autologous breast reconstruction is the potential for unnecessary damage to the flap tissue from radiation therapy.3 We would therefore be remiss not to emphasize this finding, for it is this precise domain that we would expect to suffer most from radiation therapy. We agree with the finding that the remaining four domains are less responsive to radiation therapy (indicated by the nonsignificant differences between groups at 2 years). When educating patients, we find it important to acknowledge that radiation therapy may reduce quality-of-life outcomes for Physical Well-being of the Chest in the setting of immediate reconstruction.
It is also worth noting that damage from radiation therapy is progressive, and 2 years of follow-up may not be a sufficient long-term time point to capture this effect. Indeed, it is not uncommon at our practice to remove, or significantly revise with secondary flaps, transverse rectus abdominis musculocutaneous and deep inferior epigastric perforator flaps that have been irradiated—even 10 years later. Under these circumstances, only a study with long-term (e.g., 10-year) follow-up will be able to capture the real effect of radiation therapy on autologous breast reconstruction.
Dr. Colwell’s Discussion of this article states that although immediate breast reconstruction should be considered, the question of whether to perform the procedure can only be answered at each institution.4 We echo this sentiment. At our breast center, whose experience with the BREAST-Q is comparable to that reported in this article, our preference is to perform staged reconstruction with tissue expanders in patients who might receive postmastectomy radiation therapy. Tissue expanders can be a means of bridging the positive aspects of both immediate and delayed procedures: patients receive immediate restoration of the breast envelope, and deep inferior epigastric perforator flaps avoid undue exposure to radiation.5 Future studies exploring surgical and quality-of-life outcomes in breast reconstruction might benefit from including patients with staged reconstruction as an additional group. In summary, we thank the authors for furthering the knowledge in this area and for inspiring discourse on an evolving practice in breast reconstruction.

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