Radiation is often critical in the proper treatment of breast cancer. It is usually required for larger tumors or tumors that have spread to the lymph nodes in the axilla (armpit). Radiation has been shown to have increased-benefit, both towards lessening the chance of a tumor recurrence in the chest or “axilla” and as an overall survival benefit in selected patients.
The treatment courses of radiation have improved significantly over the last several years. Patients appear to enjoy improved rates of efficacy in the treatment of cancer and reduced side effects with newer treatment regimens. However, radiation has been repeatedly shown to have significant damaging effects on breast reconstruction. In the course of therapy, radiation treatment causes a burn to the affected tissues, causing the skin underlying chest wall muscle and fascia to become firm, hardened and scarred. These damaging effects may take several years to become fully apparent.
Studies repeatedly have shown that radiation worsens the overall outcome and appearance of breast reconstructions, especially if tissue expanders and implants are used. Tissue expanders and implants have much higher rates of complications, including scarring and capsular contracture, infection, extrusion (expander coming out through the skin) as well as simply decreasing the overall aesthetic appearance of the result.
Nationally collected data available from the FDA for breast implants used in breast reconstruction reveals a 50% rate of unplanned reoperation in the first 5-7 years following breast reconstruction with tissue expander implants without radiation. The rates of these complications in unplanned operations are significantly higher with radiation.
While some surgeons have advocated the use of tissue expanders and implants in certain situations, the use of these devices in a radiated field can be compared to “fitting a square peg into a round hole.” For these reasons, I rarely suggest the use of tissue expanders and implants for breast reconstruction in most patients who have or are scheduled to receive radiation.
Breast reconstruction methods which employ a patient’s own tissue, known as a “flap,” tend to fare much better. This is especially true if the radiation therapy is completed before the final flap reconstruction is done. A small number of studies exist, usually with limited long-term follow-up, that suggest radiation is less damaging on these soft tissue flaps. However, the vast majority of medical publications and the majority of plastic surgeons who routinely perform breast reconstruction indicate that radiation can cause significant damage to these types of reconstructions as well if the radiation is performed after the flap is in place.
So what can patients who need radiation in the proper treatment of their disease do?
The best option for a patient who has had or will have radiation is to have the radiation therapy completed first, followed by the final breast reconstruction later. This allows the radiation to properly treat the cancer but spares the reconstructed tissue of the harmful effects of the treatment. Tissues that have been burned, scarred or otherwise compromised can be removed and replaced with healthy tissue with a fresh blood supply that brings vital oxygen and nutrients to the radiated field.
The transferred, unradiated tissue will remain soft and supple, just as in a case where no radiation has been given. Because tissue damaged by radiation, such as chest wall skin, may need to be removed, the overall appearance may be different than a breast reconstructed immediately at the same time as the mastectomy. However, the overall shape and feel of the reconstruction can be excellent.
Another good option is called “delayed immediate” breast reconstruction. This involves placement of a partially filled tissue expander temporarily placed at the time of initial mastectomy. This expander fills the overlying breast skin, which can be spared in most mastectomies, and prevents it from collapsing and scarring together during the radiation. Proper radiation therapy is then given with this temporary tissue expander in place.
Once the radiation is completed and the tissue has been given time to heal, the burned tissue expander and its capsule are removed and this pocket is filled with the patient’s own healthy tissue. This tissue is taken from an area of excess, often the abdomen, using advanced techniques such as a DIEP flap to bring in healthy, well-oxygenated, soft and supple tissue for a long-term, better result.
Overall, radiation is critical in the treatment of certain breast cancers and should be used, if needed, in the proper treatment of the disease. While this may complicate the breast reconstruction process, multiple options still exist to allow the achievement of an excellent result.