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Examining The Effects Of Postmastectomy Radiation Therapy In Prepectoral And Subpectoral Autologous Breast Reconstruction
Ashraf A. Patel, BS1,2, Mimi R. Borrelli, MBBS2, Jennifer C. Cheesborough, MD2, Rahim S. Nazerali, MD, MHS2.
1SUNY Upstate Medical University, Syracuse, NY, USA, 2Stanford University, Palo Alto, CA, USA.

PURPOSE
Efforts to minimize complication rates following breast reconstruction remains challenged by complex patients requiring adjuvant or salvage therapies. Postmastectomy radiation therapy (PMRT) is known to increase the risk of multiple adverse outcomes following breast reconstruction, including infection, skin necrosis, and seroma formation. Typically, in the context of delayed-immediate autologous breast reconstruction, PMRT is conducted following placement of tissue expanders in the subpectoral plane. With the reemergence of prepectoral reconstruction, there is little data assessing the outcomes of prepectoral reconstruction in breasts receiving PMRT. In this retrospective cohort analysis, we compare the outcomes of PMRT patients undergoing delayed-immediate, autologous breast reconstruction with placement of tissue expanders in either the prepectoral or subpectoral plane.
METHODS
A retrospective chart review was conducted on all consecutive patients who underwent delayed, immediate autologous breast reconstruction and received PMRT at a single institution between January 2009 and December 2018. Demographics, comorbidities, perioperative information, and oncologic data was collected for all patients. Complications following stage 2 were collected for up to twelve months postoperative.
RESULTS
A total of 51 patients (56 breasts) were included in this cohort with a mean follow-up time of 350.8 days. Prepectoral (PP) reconstruction comprised of 35.7% of the cohort, and the remaining 64.3% were subpectoral (SP) reconstructions. All comorbidities were similar between groups, except for diabetes, which was more prevalent in the PP cohort (SP: 0% vs. PP: 11.1%, p = 0.041). Complications following stage 2 were significantly higher in the SP cohort (SP: 19.4%, vs. PP 0%, p = 0.035). Complications within the subpectoral cohort included dehiscence (8.3%), seroma (2.8%), hematoma (8.3%), fat necrosis (8.3%), and partial flap loss (2.8%) (Table 1). Univariable analysis revealed chemotherapy (p = 0.023) and subpectoral expander placement (p = 0.035) to be the only significant predictors of complication. Revisionary breast surgery was more prevalent in subpectoral reconstruction (SP: 44.4% vs. PP 15.0%, p = 0.026).
CONCLUSION
PMRT increases the risk of multiple complications following breast reconstruction. Our data indicate, for the first time, that the risk following PMRT is more apparent in breasts receiving subpectoral reconstructions as compared to prepectoral reconstruction.

Table 1. Factors predictive of any complication at stage 2
Any complicationvs.No complicationP value
N = 7 %N = 49%
Age48.5 +/- 13.4245.59 +/- 9.430.311
BMI32.69 +/- 6.1328.25+/- 5.80.896
ADMYes457.143367.340.444
No342.861632.65
Expander PlacementPrepec002040.80.035
Subpec71002959.18
DiabetesDiabetic0036.120.501
Non-diabetic71004693.88
DyslipidemiaYes00612.240.327
No71004387.76
ChemoYes 71002755.100.023
No002244.90
Mastectomy typeNipple Sparing571.422346.940.533
Skin Sparing228.571632.65
Areolar Sparing0024.1
Modified Radical00816.32


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