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Complications Of Immediate Tissue Expander Breast Reconstruction In Pre-mastectomy Breast Radiation
Kanad Ghosh, B.A., Jocellie Marquez, M.D., M.B.A., Hunter Rogoff, B.S., Phoebe McAuliffe, B.A., Christopher Medrano, B.A., Alyssa Mangino, B.S., Austin Ferrier, B.S., Kaitlin Monroig, B.S., Sagar Mulay, M.D., Tara Huston, M.D., FACS, Jason Ganz, M.D., Alexander Dagum, M.D., Sami Khan, M.D., FACS, Duc Bui, M.D..
Stony Brook University School of Medicine, Stony Brook, NY, USA.

PURPOSE:
Patients with history of prior breast irradiation may require prophylactic and/or therapeutic mastectomies with reconstruction. In this population, autologous tissue transfer is the preferred option for many plastic surgeons, but is associated with longer operating and recovery times, donor site morbidity and prolonged length of stay that contributes to the patient's burden of care. Immediate tissue expander breast reconstruction (ITE-BR) is an option which mitigates several of these factors and may lead to successful reconstructive outcomes. However, there is a lack of data to aid proper patient selection. This study examines the differences in complications after ITE-BR between patients with a history of pre-mastectomy radiation therapy (PrMRT) and those without. METHODS: A retrospective chart review was performed on patients who underwent unilateral or bilateral ITE-BR from 2001 to 2018 at a single-institution. Minimum follow-up was one year.
RESULTS: A total of 678 patients were analyzed. Group 1 (n=54 patients) underwent PrMRT and Group 2 (n=624 patients) did not. There were no demographic differences between these two groups. Group 1 had higher rates of implant loss (14.8% vs 10.9%), infection (16.7% vs 13.5%), skin necrosis (9.3% vs 4.8%), and wound dehiscence (7.4% vs 4.3%) though these values were not significant. Within Group 1, comparison of time between PrMRT and mastectomy revealed shorter intervals in patients who had implant loss (4.63 years 3.07 vs 7.84 years 5.45, p=.113) and infections (5.44 years 4.69 vs 7.74 years 5.34, p=.237). Group 1 patients with hypertension had significantly higher rates of implant loss (50.0% vs 15.2%, p=0.024). In addition, Group 1 patients also undergoing post-operative chemotherapy had significantly higher rates of skin necrosis (60.0% vs 20.4%, p=0.049). Otherwise, there was no differences in demographics, comorbidities, age, smoking, post-mastectomy radiation, or pre-operative chemotherapy between any of the groups. Group 1 was further stratified by specific breast exposed to radiation. Group 1a (n=58 breasts) were directly irradiated breasts and Group 1b (n=39 breasts) were not. Group 1a had significantly higher rates of skin necrosis (10.3% vs 0%, p=0.038). Group 1a also had higher rates of implant loss (12.1% vs 7.7%), infection (15.5% vs 5.1%), and wound dehiscence (8.6% vs 2.6%) though these did not reach significance.
CONCLUSION: Immediate TE-BR can be a safe reconstructive option in patients with history of prior breast irradiation. Our data indicates that hypertensive patients who have undergone PrMRT have increased rates of implant loss, while patients requiring post-operative chemotherapy have increased rates of skin necrosis. Comparison of irradiated versus non-irradiated breasts also reveals increased skin necrosis in irradiated breasts. Careful patient selection and patient counseling should be an integral part of planning for reconstruction of these patients.


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