The Impact of Post-Mastectomy Radiation Therapy on Permanent Implants in Direct-to-Implant Breast Reconstruction versus Tissue Expanders in Two-Stage Breast Reconstruction.
Alex M. Lin, MS1,2, Joani M. Christensen, MD1, Eric C. Liao, MD, PhD1, Curtis L. Cetrulo, MD1, Alphonse G. Taghian, MD, PhD1, Jonathan M. Winograd, MD1, Barbara L. Smith, MD, PhD1, William G. Austen, Jr., MD1, Amy S. Colwell, MD1.
1Massachusetts General Hospital, Boston, MA, USA, 2Frank H. Netter MD. School of Medicine at Quinnipiac University, North Haven, CT, USA.
Purpose: Post-mastectomy radiotherapy (PMRT) plays a key role in influencing the reconstructive outcome of implant-based breast reconstruction. While some studies have reviewed the effects of PMRT on a tissue expander (TE) in two-stage breast reconstruction, few studies have assessed the impact of PMRT after direct-to-implant reconstructions (DTI) breast reconstruction. This study evaluates complications and reconstructive outcomes of PMRT in DTI compared to two-stage breast reconstruction.
Methods: Single-institution retrospective review of immediate implant-based breast reconstruction patients that received post-mastectomy radiotherapy from 2006-2014 with a minimum of a 2-year follow-up were reviewed. All patients who received preoperative radiotherapy were excluded.
Results: Out of the 1671 patients, 265 patients were identified to have received post-mastectomy radiation. Of the 265, 149 received DTI and 116 had two-stage tissue expander to implant (TE-I) reconstruction. The overall mean age was 46.5 and BMI 26.9. There were no significant differences in demographics except more smokers in the TE group (7.7% vs. 1.3%, p=0.009). The DTI group had a significantly higher use of Alloderm compared to the TE group (72.5% vs. 41.4%, p<0.001).
Patients who received PMRT with a tissue expander in place had more complications (32.7% vs. 10.7%, p<0.001), skin-necrosis (10.3% vs 4.0%, p<0.001), wound breakdown (9.5% vs. 2.0%, p=0.011) and infections (16.3% vs. 4.03%, p<0.001) leading to a higher rate of explantation (16.3% vs. 3.3%, p<0.001).
When comparing the reconstructive outcomes, the TE group had a higher failure rate (20.6% vs. 10.7%, p=0.025). However we found the revision for capsular contracture rates to be similar between the two cohorts (11.4% vs. 10.3%, p=0.783) as well as revision rates for contour asymmetry, size mismatch and malposition. Subgroup analysis of DTI with ADM vs. TE-I with ADM showed similar complication findings; however, the DTI group had significantly higher revision rates (21.1% vs. 7.4%, p=0.029). In our multivariate regression analysis, radiation to the TE had a higher risk of reconstruction failure than radiation after DTI reconstruction (OR 2.004, 95% CI: 0.987-4.067, p=0.05).
Conclusion: The optimal timing of post-mastectomy radiotherapy on implant-based breast reconstruction remains to be determined. Our study showed that PMRT after direct-to-implant breast reconstruction had a lower reconstructive failure rate compared to two-stage reconstruction.
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