NEW ORLEANSMastectomy patients who have undergone radiation
therapy can still have attractive results from breast reconstruction,
providing the surgeon does not underestimate the extent of
reconstruction required, according to results of a prospective study
presented at the 68th Annual Scientific Meeting of the American
Society of Plastic and Reconstructive Surgeons.
When dealing with patients who have been irradiated, you
shouldnt lower the patients expectations of the results.
Just prepare patients for the extent of the surgery, said
Laurie Casas, MD, assistant professor of surgery, Northwestern
University Medical School, and head of the Division of Plastic
Surgery, Glenbrook Hospital, Glenview, Illinois.
Radiation causes permanent and progressive changes to the blood
supply, skin texture, subcutaneous tissue, and muscles, and these
changes affect the entire irradiated fieldtissues from clavicle
to the inframammary crease and from sternum to the posterior axillary
line, Dr. Casas said.
Thus, patients who have undergone radiation therapy, as well as their
team of doctors, must understand and respect the extensive area
involved and the complexity of the reconstruction. We found
that if you merely reconstruct the breast mound, you do not have an
excellent esthetic result, she said. Patients will have a
depression along the cleavage and axillary areas that can restrict
their choice of clothing, particularly eveningwear and bathing suits.
Well-vascularized tissue, in the form of the double pedicle
TRAM or a free TRAM flap, must be interposed between irradiated skin
and the chest wall to the full extent of the anatomic defect, in
order to produce a stable, superior, cosmetic result, she said.
The study, with 1 to 9 years of follow-up, involved 13 patients who
had undergone mastectomy and radiation therapy for their breast
cancer. The study group (mean age, 44) included six ex-smokers and
five patients who quit smoking before the surgery. All the
reconstructions were performed by the same surgeon.
The first two cases in which only the breast mound was reconstructed
indicated that the defect to be reconstructed had been
underestimated. Over the follow-up period, the irradiated skin
adhered to the chest wall in these patients.
Therefore, the subsequent 11 reconstruction procedures involved the
breast mound and subcutaneous tissue of the entire chest wall using a
double pedicle TRAM flap. One of these patients had a 2 cm²
parasternal area that did not undergo enough subcutaneous
reconstruction, resulting in a skin-to-sternum adhesion. Other
complications included small areas of necrosis and abdominal seromas
in two cases. There were no repeat operations or flap losses.
Dr. Casas emphasized that the flap procedure used in the study
patients was the surgeons preference, but the results could
potentially apply to any autologous tissue reconstruction.