Prepectoral breast reconstruction and radiotherapy-a closer look

Abstract

Background: Prosthetic breast reconstruction in the setting of post-mastectomy radiation therapy (PMRT) has historically been plagued by complications and poor outcomes. We study the effects of PMRT in the setting of prepectoral prosthetic breast reconstruction in an attempt to ascertain the value of this muscle sparing technique as it relates to complications and outcomes.

Methods: A retrospective analysis was performed on patients who underwent immediate, prepectoral, direct-to-implant or two-staged expander/implant breast reconstruction following skin-sparing mastectomy (SSM) or nipple-sparing mastectomy (NSM) and had postmastectomy radiotherapy. Results and complications were recorded.

Results: In patients who underwent two-staged reconstruction, at the second stage, on visual inspection, the acellular dermal matrix was noted to be completely integrated in all breasts, including those that had been irradiated after expander placement. Postoperative complications in irradiated breasts were limited to two breasts. In one breast, there was one incidence of wound dehiscence after expander irradiation, which led to expander removal and salvage with transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction. In the second breast, there was one incidence of seroma after implant irradiation, which was managed conservatively as an outpatient. The seroma was drained and the patient treated with oral antibiotics. There were no complications in nonirradiated breasts. There was no incidence of clinically significant capsular contracture (grade III/IV) in irradiated or nonirradiated breasts.

Conclusions: Prepectoral breast reconstruction has been an important addition to our reconstructive armamentarium and is proving to be a safe and effective means of performing prosthetic breast reconstruction in a wide array of patient populations. We have seen excellent physiologic and aesthetic outcomes in our patients following PMRT with minimal complications. Indeed, long-term follow-up will be required to elucidate the true effectiveness of this technique but preliminary results are quite promising.

Keywords: Prepectoral breast reconstruction; breast reconstruction; post-mastectomy radiation; prosthetic breast reconstruction; radiotherapy; tissue expander-based breast reconstruction.

Figure 1

Bilateral nipple sparing mastectomy with immediate single-stage reconstruction and post-mastectomy proton beam therapy. (A) A 49-year-old woman with a diagnosis of invasive right breast cancer; (B) patient at 4 weeks postoperatively following bilateral mastectomy and immediate direct-to-implant reconstruction with anatomical gel implants (Natrelle Style 410 445 cc) and AlloDerm RTU (extra thick, 640 cm²); (C) patient 1 week into radiotherapy; (D,E) 4 weeks into radiotherapy; (F,G) 8 months post-irradiation and 9 months postoperative. Patient did not undergo fat grafting and her breasts remain soft without contracture at 8 months post-reconstruction.

Figure 2

Bilateral skin sparing mastectomy with immediate implant reconstruction followed by post-mastectomy photon beam therapy. (A,B) A 53-year-old woman with a diagnosis of invasive right breast cancer. She underwent PMRT of her right breast following bilateral mastectomy and immediate direct-to-implant reconstruction with anatomical gel implants (Natrelle Style 410 MX 685 cc) and AlloDerm RTU (extra thick, 640 cm²); (C,D) patient at 6 months following completion of radiotherapy and no fat grafting. PMRT, post-mastectomy radiation therapy.