Considering the Optimal Timing of Breast Reconstruction With Abdominal Flaps With Adjuvant Irradiation in 370 Consecutive Pedicled Transverse Rectus Abdominis Myocutaneous Flap and Free Deep Inferior Epigastric Perforator Flap Performed in a Chinese Oncology Center: Is There a Significant Difference Between Immediate and Delayed?

Abstract

Purpose: There is an ongoing debate on the optimal sequence of radiation and breast reconstruction. The purpose of this article was to (a) assess the impact of radiation on autologous breast reconstruction and (b) analyze the best timing for autologous breast reconstruction in the setting of radiation in a Chinese population.

Methods: A retrospective review of patients undergoing breast reconstruction with autologous lower abdominal flaps between 2001 and 2014 in the Tianjin Medical University and Cancer Hospital was performed. Patients were grouped by their irradiation status (irradiated vs nonirradiated). The irradiated group was further stratified into 2 groups by the timing of irradiation (immediate breast reconstruction followed by radiation vs prior radiation and delayed breast reconstruction). The primary outcomes were early and late breast complications, secondary and revision surgeries to the reconstructed breast, whereas the secondary outcomes were aesthetic and psychological evaluations of the patients. Logistic regression was used to assess the potential association between irradiation, patient and treatment variables, and surgical outcomes.

Results: Three hundred sixty patients with 370 reconstructed breasts were included in the study. Two hundred seventy-eight cases were nonirradiated, of which 158 were immediate and 120 were delayed. Ninety-two cases were irradiated, of which 61 were immediate, and 31 were delayed. Three hundred thirty-two cases underwent pedicled transverse rectus abdominis myocutaneous flap, 38 had deep inferior epigastric perforator flap. The irradiated group had a significant increase in secondary surgery due to fat necrosis (P < 0.001) and in late complications (P = 0.011). A significant increase in flap contracture (P = 0.043) and an increasing trend in the severity of fat necrosis were observed when radiation was performed after breast reconstruction. However, radiation and its timing did not have an adverse impact on patients' aesthetic and psychological evaluations by the Breast-Q survey.

Conclusions: Radiation administered to the reconstructed breast mound increased the rate of late complications and the need for secondary surgery with increased abdominal flap shrinkage and contracture and the severity of flap fat necrosis. Irradiation on the reconstructed breast did not lead to worse aesthetic outcomes due to the generally different expectation in the Chinese female patients in that they were more focused on the breast shape when clothed. Immediate breast reconstruction followed by irradiated was a generally successful treatment sequence in the Chinese module.

FIGURE 1

A, (above left) Preoperative photograph of a 38-year-old patient diagnosed with invasive ductal carcinoma in the right breast. She had right mastectomy and axillary lymph node dissection and immediate unilateral pedicled TRAM reconstruction followed by adjuvant chemotherapy, radiation and anti-Her2 therapy. B, (above right) 3 months postoperative. C, (below, left) 6 months postoperative, during radiation therapy. D, (below, right) 2 years postcompletion of radiation therapy.

FIGURE 2

A, (left) Preoperative photograph of a 44-year-old patient who had previous right mastectomy and axillary lymph node dissection followed by adjuvant chemotherapy, radiation therapy, and hormonal therapy. She underwent unilateral pedicled TRAM reconstruction. B, (right) 2 years post delayed breast reconstruction.

FIGURE 3

A, (left) Preoperative photograph of a 41-year-old patient diagnosed with invasive ductal carcinoma in the left breast. She underwent left nipple sparing mastectomy, axillary lymph node dissection, and immediate pedicled TRAM breast reconstruction followed by chemotherapy and hormonal therapy. B, (right) 2 years postoperative.

FIGURE 4

A, (above left) Preoperative photograph of a 40-year-old patient with previous right mastectomy and axillary lymph node dissection. She had adjuvant chemotherapy and hormonal therapy and underwent DIEP reconstruction. B, (above right) 8 months post-DIEP reconstruction. C, (below left): 1 year and 9 months post-DIEP reconstruction.