IRRADIATION AND RECONSTRUCTION

Radiation causes temporary and long-term changes to the area of the breast. If there is a chance that radiation will be necessary, immediate-delayed reconstruction with autologous tissue is the preferred option of reconstruction. Immediate reconstruction, especially with implants is dissuaded.

Delayed-immediate autologous reconstruction balances the benefits and constraints of both immediate and delayed reconstruction. It provides an improved aesthetic and psychological outcomes compared with delayed reconstruction but does not impede radiation delivery, if it is indicated postoperatively.

Temporary changes induced by radiation include reduced blood circulation, red discolouration of the skin, injury to the superficial skin layer, and delayed wound healing. Long-term changes include scar tissue, dark pigmentation of the skin, reduced ability of the skin to heal following subsequent procedures, capsular contracture around breast implants and other radiation-induced skin changes. Irradiated breasts are also associated with higher rates of distortion, asymmetry, fat necrosis, capsular contracture, and need for multiple revisions.

The dilemma is that the need for post-mastectomy radiation is not definitive until postoperative histologic analysis of the mastectomy specimen is completed. Immediate-delayed autologous reconstruction represents a solution to this problem. In the first stage of this two-stage procedure, a mastectomy is performed followed by placement of the tissue expander to maintain the breast skin envelope. If postoperative staging and pathologic assessment demonstrate no need for radiation, patients proceed to the second stage, during which they undergo definitive breast reconstruction using either autologous tissue or an implant. If, however, radiation is recommended the patients are monitored during radiotherapy, and in cases where the mastectomy skin becomes too thin, the expander is deflated. A couple of months after radiation therapy has been finished, a second stage in which expander is replaced most commonly with a flap is performed. Because of the potential complications associated with implants, breast reconstruction using autologous tissue is generally considered the best method for women who will require or have already had irradiation. With flap based reconstruction a healthy, well-vascularised tissue is brought to the mastectomy site, and this can aid in the healing process.