Wednesday, April 8, 2009

Impact of Radiation on Breast Reconstruction

Radiation therapy is often recommended as part of breast cancer treatment. Patients undergoing lumpectomy receive radiation routinely once they've healed from surgery. Some mastectomy patients also need radiation after surgery depending on the size and characteristics of the breast cancer.

I think it is fair to say that most reconstructive breast surgeons, myself included, are not particularly fond of radiation because of the way it can impact the patient's tissues and breast reconstruction in general. Nonetheless, it is important to remember that "life comes before breast" and in certain cases there is a definite benefit for the patient in having radiation therapy.

Radiation techniques have improved significantly over the years which has decreased the potential side effects. Having said that, it is important patients realize what these potential side effects are. Anyone who is facing radiation therapy must discuss all the potential risks with their their radiation oncologist beforehand.

So what's the problem with radiation therapy from a plastic surgeon's perspective?... It can cause toughening (fibrosis) and shrinking (contracture) of the patient's tissue which makes the tissue lose its elasticity - the skin can become more tough and rigid. Skin color changes are common, red at first turning more brown over time. Radiation can also cause mild, superficial burn injuries. More serious long-term risks include damage to underlying organs such as the lungs and heart.

Women undergoing lumpectomy are often told that most of their breast will be preserved and that radiation is given "as insurance" to decrease the risk of the cancer returning (ie recurrence). What many women don't appreciate is that the breast can end up looking vastly different after radiation (shrinking, firmness, etc), even though they chose treatment that would "save the breast". Many women end up going to see a plastic surgeon because of these changes and the resulting significant asymmetry.

Radiation after a tissue reconstruction (eg tram flap, diep flap) can cause the reconstructed breast to shrink and become more firm. Fortunately, recent advances in radiation technology have made it more "reconstruction friendly" and it is rare for us to see significant radiation damage to the reconstructed breast in patients treated in centers specializing in breast cancer care. However, patients facing radiation after flap breast reconstruction should know that there is still a risk of needing further reconstructive surgery to correct changes caused by the radiation therapy. One study found a re-operation rate of almost 30% in patients receiving radiation after TRAM flap reconstruction.

Tissue expander and implant reconstructions fair worse with radiation than tissue reconstructions. The complication rates in this setting are much higher than with flaps, including complete failure of the reconstruction altogether and removal of the implant. Some surgeons routinely offer implant reconstructions to patients that are either facing or have already had radiation therapy. There are articles published in the plastic surgery literature supporting it. I have to respectfully disagree (strongly). In my experience mixing implants with radiation typically ends badly. I will only offer this in very rare instances.

I hope this info helps.

Dr C

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Dr Chrysopoulo is a board certified plastic surgeon specializing in breast reconstruction surgery after mastectomy. In-Network for most US insurance plans. For more information please call (800) 692-5565 or email patientadvocate@prmaplasticsurgery.com.

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