Plastic Surgery Research Council

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Postsurgical Complications Associated with Tissue-Expander Placement into the Previously Irradiated Breast
Shanique Martin, BS1, Lawrence Cai, MD2, Adeyemi Ogunleye, MD2, Gordon Lee, MD2, Rahim Nazerali, MD, MHS2
1Stanford University School of Medicine, Palo Alto, CA, USA, 2Division of Plastic and Reconstructive Surgery, Stanford Hospital and Clinics, Palo Alto, CA, USA.

Breast-conservation therapy (BCT) consisting of lumpectomy followed by radiation therapy (XRT) is commonly used in the treatment of breast cancer, with high rates of success. However, a small percentage of these patients eventually develop recurrence of breast cancer necessitating a mastectomy. Previous radiation therapy is known to be a significant risk factor for surgical complications, but few studies have quantified the effect of XRT on breast reconstruction. We report our institution's experience of breast cancer patients who initially underwent unilateral BCT, followed by bilateral mastectomy and immediate tissue-expander reconstruction.
A retrospective review of all postmastectomy breast reconstructions performed at our institution over a 4 year period (2014-2018) was conducted. The initial search yielded 958 breast reconstruction patients, of which 90 had a history of BCT. Of these, 29 patients underwent unilateral BCT followed by bilateral mastectomy and reconstruction with immediate tissue-expander insertion.
Overall there were 58 breasts with mastectomies and immediate tissue-expander reconstruction. The time between completion of radiation therapy and mastectomy ranged from 1 year to 21 years, with a median of 5 years.
At the time of mastectomy, 26 breasts had cancer, 17 of which were recurrences in a previously irradiated breast. Skin sparing mastectomies were performed in 19 breasts, while nipple sparing mastectomies were performed on 38 breasts. A radical, non-skin sparing mastectomy was performed on 1 breast. There were 42 partial submuscular tissue-expander insertions and 8 each of prepectoral and total submuscular tissue-expander insertions.
The rate of postsurgical complications was greater in previously irradiated breasts (37.9 vs 13.5%). The most prevalent complication was surgical site infection, which occurred in 11 breasts (19%) and previously irradiated breasts had a higher rate of this complication (p=0.041). Instances of major infection, requiring salvage reoperation or explantation, were only observed in previously irradiated breasts (3 breasts, 10.3%). The quantity of salvage reoperations for any complication was greater in previously irradiated breasts (0.73 vs 0.25) and an analysis of all irradiated breasts demonstrated trends in associations between time since XRT, intraoperative tissue expander fill volume, days before surgical site drain removal and postsurgical complication.
Immediate placement of a tissue expander in a previously irradiated breast can be accomplished, though not without increases in both the quantity and severity of complications. These findings indicate the need for further investigation of the risks associated with tissue expander placement into a previously irradiated field.

Table 1. Surgical Factors and Complications by XRT Exposure
Cancer at the Time of Mastectomy26 (44.8%)9 (31%)17 (58.6%)1
Mastectomy Type
SS/NNS19 (32.8%)9 (31%)10 (34.5%)1
NAS38 (65.5%)19 (65.5%)19 (65.5%)1
NSS/Modified Radical1 (1.7%)1 (3.4%)0 (0%)1
Lymph Node Procedure at Time of Mastectomy
ALND3 (5.2%)2 (6.9%)1 (3.4%)1
SLNB17 (29.3%)6 (20.7%)11 (37.9%)0.2483
Days to Drain Removal
Any Complication 154 (13.8%)11 (37.9%)0.07
Infection 112 (6.9%)9 (31.0%)0.041*
Oral Abx41 (3.4%)3 (10.3%)0.611
IV Abx41 (3.4%)3 (10.3%)0.611
Washout10 (0%)1 (3.4%)-
Explantation/Implant Loss20 (0%)2 (6.9%)-
Hematoma 20 (0%)2 (6.9%)-
Seroma 21 (3.4%)1 (3.4%)1
Mastectomy Flap Necrosis 62 (6.9%)4 (13.8%)0.670
Number of Salvage Procedures 0.60.25 (0-1)0.73 (0-2)0.226

Table 2. Patient and Treatment Factors Contributing to Complications in Breast with Prior XRT
FactorNo Complication (n=18)Complication (n=11)p-value
Age (31-73)50.56 (10.47)56.0(8.52)0.139*
BMI (19.6-41.6)24.18 (3.5)27.44 (6.16)0.132*
Hypertension3 (16.7%)4 (36.4%)0.375
Diabetes1 (5.6%)2 (18.2%)0.539
History of Tobacco Use5 (27.8%)0 (0%)-
Hyperlipidemia3 (16.7%)1 (9.1%)1
Time Between XRT and Mastectomy (years)6.72 (6.36)9.27 (4.2)0.206*
Cancer at the Time of Mastectomy12 (66.7%)5 (45.5%)0.438
Lymph Nodes at Mastectomy
ALND1 (5.6%)0 (0%)-
SLNB7 (38.9%)4 (36.4%)1
TE Placement
PrePec2 (11.1%)2 (18.2%)0.622
Partial SubPec13 (72.2%)8 (72.7%)1
Total SubPec3 (16.7%)1 (9%)1
FlexHD3 (16.7%)2 (18.2%)1
Alloderm8 (44.4%)5 (45.5%)1
Surgimend1 (5.6%)1 (9.1%)1
DermaCell1 (5.6%)0 (0%)-
Unknown1 (5.6%)1 (9.1%)1
None4 (22.2%)2 18.2%)1
Mastectomy Type
SS/NNS7 (38.9%)3 (27.25)0.694
NAS11 (61.1%)8 (72.7%)0.694
IntraOp Fill
Saline13 (72.2%)8 (72.7%)1
Air0 (0%)1 (9.1%)-
Empty5 (27.8%)2 18.2%)0.677
IntraOp Fill Volume99.17()138.18 ()0.382
Days to Drain Removal14.28 (6.39)17.09 (7.76)0.326

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