medwireNews: Women who receive radiotherapy after free-flap breast reconstruction are no more likely to require revision surgery than those who do not, say US researchers who believe immediate autologous surgery is feasible in this group.
Writing in the Annals of Plastic Surgery, the team challenges the consensus that reconstruction should be delayed until radiation is complete to reduce the risk for complications and poor aesthetic outcome, even though it may not be clear at the time of surgery whether or not a patient will require radiotherapy.
Liza Wu (University of Pennsylvania, Philadelphia) found that 80.43% of 46 patients who received radiation after unilateral immediate reconstruction required a further procedure, compared with 88.50% of the 113 women who did not have postoperative radiotherapy. The corresponding values for bilateral reconstruction patients was 29.6% of 81 and 34.13% of 167 patients. Neither comparison reached statistical significance.
Radiotherapy after reconstruction was associated with a significantly increased risk for volume loss in both unilateral (28.26 vs 4.42%) and bilateral surgery patients (19.75 vs 1.0%), as well as an increased risk for fat necrosis (19.57 vs 3.54%) in the unilateral patients.
However, volume loss in bilateral surgery patients was significantly more common in radiated perforated flaps than muscle-sparing free transverse rectus abdominis myocutaneous flaps (39 vs 12%).
The researchers say that their study questions whether these post-radiation changes are significant enough to justify delaying reconstruction and the need for multiple procedures, and say that further quantitative research on volume loss and fat necrosis is now ongoing to determine the true impact of postradiation changes on patient satisfaction.
Wu et al also emphasize that reconstruction after radiation is technically harder and has a high vascular complication rate, especially within the recommended time scale of within 3 months of radiotherapy,
"Although multiple studies have demonstrated the deleterious effects of postoperative radiation on free breast flaps, it is the belief of the authors that this does not preclude the decision for immediate autologous reconstruction," the team comments.
"Instead, the probability of requiring and the effect of radiation must be kept in the context of the overall risks and benefits of immediate reconstruction."
The authors therefore recommend that patients should be counseled on the risk-benefit balance and given the opportunity to make an informed decision on the timing of their breast reconstruction.