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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20 comments:

Anonymous said...

My PS said due to my not being able to take much time off, I should get an implant placed over my muscle to allow for a little sagging to match the other side, after a lumpectomy with radiation.

But, another doctor is telling me that standard of care is to put the implant under the muscle and that it would reduce my risk of capsular contraction.

I am healthy and young for my 49 years, no smoking, normal weight, relatively fit, still losing some weight gradually from what I gained during treatment due to mild anemia and stopping exercise. Will likely end up with a BMI of about 20 rather than the 22.5 I am at now. I don't have a lot of extra fat, though I do have a little bit on my tummy now at this weight. I am athletic and don't want to do anything that would affect my muscles. Also, my affected breast is nicely shaped and I did not lose any skin or the nipple. So I only need volume to make it go from a small C cup to a DD like my unaffected breast.

Is an implant really a safe thing for me? What are my risks of capsular contracture if I have it over the muscle versus under the muscle? Are there any ways to use my own tissue to give volume only by using a tissue expander to stretch the skin and then putting the tissue under the skin? If so, what is the recovery rate like? How long before I can drive?

Don't want to cause myself more problems as I don't have family help and am a single mom. Should I give up on preserving my natural shape and just get the unaffected breast made smaller? Should I wait to see if new techniques make my options better?

Dr C said...

Dear Anon,

No doubt from reading my initial post you understand my personal reservation about implant reconstruction in the setting of radiation. While many plastic surgeons use implants to reconstruct irradiated breasts, I feel the complication rate is too high, especially long-term, as is better avoided.

Radiation can cause significant changes to your tissues, making them less elastic and more firm and "leathery". The risk of problematic capsular contracture over time is much greater when radiation is involved. I do agree with the second plastic surgeon though.... putting it under the muscle will probably decrease your risk.

From your description it sounds like you've had a lumpectomy and radiation and are now trying to regain the volume you've lost to match the other side.

If the lumpectomy side still has a good shape (and you're happy with it other than the size), you may be better served reducing the other breast to match. This of course means you'll have to settle for the smaller C cup size overall rather than the DD.

The other option is to replace the tissue you've lost with more tissue. Fat grafting is an option but I would wait until fat grafting with stem cells becomes available. This is currently available in Europe and is now making it's way over here. We've met with the company that will be offering it in the US and hopefully we'll be offering it soon through our practice. The stem cell fat grafting option is exciting as it seems to replace the stem cells that radiation kills and helps the tissues recover from the radiation as well as filling the defect. I'll be posting more about this in due course as things develop.

Hope that helps.

Dr C
http://www.prma-Enhance.com

Janis said...

What worked for me: Lt mastectomy (cancer side) with tissue expander to "hold the space" in February '09. Then, chemo and radiation. Then, on April 7th prophalactic rt mastectomy and bilateral Diep flap. Doing well one week post op. Radiated breast has a larger opening where the flap shows thru, but overall good cosmetic result.
I'm so glad I went this route!!

Dr C said...

Thanks a lot for your post Janis. What you describe is known as "delayed-immediate" breast reconstruction. This technique helps preserves as much of the natural breast skin as possible after skin sparing mastectomy in patients that will be undergoing radiation therapy after mastectomy. This usually helps improve the results of the reconstruction.

omauroc said...

I had radiation treatment five years ago, this year I had a mastectomy of the same breast, is it safe to get and implant in that breast?

Dr C said...

Hi omauroc,

As mentioned in the above post, in general, studies show though that placing an implant after radiation increases complications like hardening ("capsular contracture"), infection, extrusion (the implant breaking through the skin and becoming exposed), and also long-term pain.

For these reasons, at PRMA we prefer to use the patient's own tissue for reconstruction whenever possible.

Having said that, most plastic surgeons would say that it is perfectly acceptable to use an implant for reconstruction after radiation, especially if you had minimal skin changes from the radiation.

It sounds like you had a lumpectomy and radiation 5 years ago. You may have only had radiation to part of the breast. If your skin is soft and you have very little or no changes from the radiation then the risk of any of these "bad things" happening is less. It really depends on how your tissues look and feel.

Sorry I can't be more definitive.

Dr C

Anonymous said...

I had L breast cancer 2007 with partial masectomy-radiation. I have a recurrence in 2011 and had another partial masectomy. I need to have a full masectomy but am not happy with options off reconstruction. You mentioned fat grafting with stem cells helps with radiated breast tissue and should be coming avaliable. I am wondering when this will be availiable and if this technology can be used as full reconstruction option to build a new breast?

Dr C said...

The technology is available now and the techniques for fat grafting are constantly being refined. While more studies need to be done (especially in terms of long term safety), the early data is very encouraging.

Fat grafting can be a very good option for reconstruction of lumpectomy defects. It can also be used for reconstruction of the whole breast after mastectomy in small-breasted women but several fat grafting procedures are typically needed.

To make matters worse, many insurance companies view fat grafting as "experimental" and do not cover the procedure. Those insurance plans that do cover it usually only cover 1 fat grafting procedure.

In terms of previous radiation... we have seen fat grafting improve mild radiation damage. However, if the radiation damage is severe the results from fat grafting are limited in my experience.

Hope that info helps.

Dr C

Anonymous said...

I had lumpectomy and radiation 10 yrs ago..... And then poss brca with mastectomy 3 yrs ago with reconstructive silicone implants. Radiation was only on part of my rt breast but it still left tough dicolored skiin and not very well rounded. So my surgeon injected jat a few wks ago..... Really does look much better. However, I am still depressed about the look. I feel the only way to round my rt breast out more is to exchange the implants for a slightly larger size. Am I still at high risk of infection and complications due to the radiation even though the radiation was 10 yrs ago? If so then what r your thoughts of even more fat injections? Or even possibly taking the implants out and doing total fat or tram?
Thanks

Dr C said...

Great question.

Unfortunately, yes, you are still at higher risk of complications with further surgery because of the radiation, especially if it involves a larger implant. in many cases like yours swapping out the implant for a larger size leads to more disappointment. If the skin envelope is tight because of the radiation, it will prevent the larger implant giving you the extra projection you really want. You'll still have the flattened look, just bigger.

Further fat injections can help by increasing the padding under the skin. Fat grafting can also reverse some of the damage caused by radiation. Unfortunately you do need to be prepared for several sessions for the best results.

Removing the implant and reconstructing the breast just with fat grafting is an option, but not a great one unless you think you'll be happy with a much smaller breast. Again, you're looking at several procedures, more than if you keep the implant.

Another option, and probably the best long term, is to remove the implant and reconstruct the entire breast with another form of tissue reconstruction like a DIEP flap for example. This will allow new, healthy skin to be used in addition to fat. The additional healthy skin will allow for improved breast shaping and is the most likely way you'll be able to recreate the more natural, rounded breast shape you are seeking.

Please take a look at these before and after pictures to get an idea of the kind of results we can achieve:
http://www.prma-enhance.com/index.cfm/ProcedureNameID/19/PageID/1946

If you'd like to learn more about your options, please feel free to call us on 800-692-5565 or contact us via email at patientadvocate@PRMAplasticsurgery.com

Hope this info helps!

Dr C

JLC said...

I had neoadjuvant chemo then mastectomy then radiation. Reconstruction was delayed until after I completed radiation. During the mastectomy a tissue expander was placed. Six months later I had a DIEP. There were complications, one being the radiated skin not having the elasticity needed to expand with swelling. The flap was removed. Next fat grafting was attempted for reconstruction. As mentioned by Dr. C this is being done in Europe with success even on radiated, large breasts. My insurance did pay for both procedures. And my fat was banked in Dallas for future procedures. The results were not as hoped for and the suggestion was made to do another flap. That is scheduled for May with PRMA rather than my returning to New Orleans (a choice of convenience not lack of trust, we moved to TX just recently). My radiated skin does look and feel better since the fat grafting. I have hopes for the future in fat grafting for reconstruction. There is a clinical trial in California using the fat grafting with stem cells. You must be 5 years NED to apply. That let me out. I am glad I tried the fat grafting and hope the lessons learned from that experience will aid others.

Kim S said...

My radiation oncologist didn't inform me about the risk of developing lung cancer and/or heart disease after treatment. I wish I had asked more questions and was better informed.
I had a lumpectomy and am very unhappy with the results. I would really like reconstruction but my insurance company won't pay for it. Besides the big divot in my breast, the surgery & radiation acted like a little "lift" so I am left lopsided. I'm a c cup on the droopy side and can't even fill a b cup on the other side....I now hate shopping for bras!

Dr C said...

Thanks a lot for posting your experiences JLC. Every little bit of info helps others trying to navigate all the treatment options.

Dr C said...

Kim, we unfortunatley come across this situation very often. The good news is that we have been quite successful in getting subsequent procedures approved by insurance. Don't give up hope just yet.

If you'd like to look into your options with us at PRMA, please email us at patientadvocate@prmaplasticsurgery.com or call us on (800) 692-5565.

I hope this helps.

Anonymous said...

Dr. C
I had a LRM on 6/2011. I finished chemo and radiation last week. I saw so many women in the treatment rooms that had recon.same day has surgery. I want to wait a while for my body to heal before I have that done. Im a little confused when they say it depends what on what I am candidate for. Could you explain it for me. Im 49,147 lbs, usually 135 to 140 but gained during treatments. Gained it mainly in stomach(abdomen). I quit smoking when I got diagnosed.
ty ds

Dr C said...

Dear DS,

Good to hear you're through all that! Take as much time as you need before moving forward with reconstruction. Even from an Insurance stand point, there is no time constraint. The good news is that the worst is behind you!

If you've had radiation, I personally advise women to avoid implants if at all possible. Generally speaking, implants and radiation do not go well together and the risk of complications is much higher because of the radiation.

Using your own tissue is the best way to achieve a "natural" reconstruction in terms of how the breast feels. This is especially the case in women who have had radiation - the new healthy tissue is used to replace the tissue most injured by the radiation. We also know that bringing in new, healthy tissue can reverse radiation damage to some extent.

Women that have some tummy tissue to spare are generally candidates for the DIEP flap procedure. Based on the details you provided, it is very likely you are a candidate. Make sure you stay off the cigs though!

Here's some more info on the DIEP flap: http://www.prma-enhance.com/index.cfm/PageID/1754

I have also posted a video about the DIEP flap on this blog:
http://breast-cancer-reconstruction.blogspot.com/2011/12/diep-flap-breast-reconstruction.html

I hope this info helps. If you'd like to learn more about your options, please do get in touch. You can call us on (800) 692-5565 or reach us via email at patientadvocate@prmaplasticsurgery.com

Dr C

Y'sHub said...

Dr C. My wife had a bilateral masectomy with tissue expander placement two weeks ago due to carcinoma in the upper left quad of the left breast. She is an A cup, 34 naturally. The tumor ended up being much bigger than thought 5.5cm vs. two smaller tumors. This is because cancer was found in between the two smaller ones.

The surgeon was able to do a nipple and skin sparing on both sides but now since the size of the tumor, radiation will be needed.

What are your thoughts on how best to proceed ? The Oncologist is recommending expansion prior to radiation as it will allow radiation to be applied better. Is this a normal course of action ?

After radiation, (and of course not knowing the effects the radiation will have on her specifically), she is thinking of abandoning any implants to be placed afterwards because of complications with them could increase significantly after radiation.

Is fat grafting alone an option to give her some filling out of the breast areas and even with radiation to the left side do you think the result could be aesthetically ok ? (scars, radiation effects on skin, stretching due to tissue expanders, but breast areas shapely even though pretty much flat/no projection). She is thinking of a "sculpted flat chested look with both nipples intact"

Sorry to everyone for this post as I know a man's perspective is different from a woman's but my wife is not a native English speaker and she asked me to post on her behalf.

Thank you

Dr C said...

Hi Y'sHub,

Thanks for getting in touch.

It is now fairly common practice to "over-expand" the tissue expander for a patient that will be receiving radiation. This is to try to compensate for the "shrinking" effect the radiation will have on the skin.

Over-expansion can also thin out the tissues significantly which in turn decreases the thickness of the soft tissue covering the expander. If the tissues get too thin, the risk of the tissue expander breaking through the skin will increase once the radiation therapy begins. It's definitely a balancing act so you have to ensure that the radiation oncologist and plastic surgeon are experienced with this approach and are on the same page.

I think it's very good that your wife is considering reconstruction with tissue considering the surprise recommendation for radiation. Fat grafting alone can certainly be an option in women who want an A or B cup breast, though much will depend on the degree of radiation changes. She also has to be prepared for more than one fat grafting procedure for the best results.

I hope this info helps.

All the best,

Dr C
PRMA Plastic Surgery

Wendy Vycas said...

Wow- when I read your comment it looked like something I would write. I just saw a reputed breast reconstruction dr at the university of Chicago and she basically offered no options and went on to explain to me how I could live with this. It was very hurtful considering I have live with this for over 10 years now.

Minas Chrysopoulo MD said...

I'm sorry to hear that Wendy.

We may be able to help you. Please consider getting in touch with our Patient Liaison, Brandy, by calling (800) 692-5565 or emailing her at patientadvocate@prmaplasticsurgery.com.

Best wishes,

Dr C