Radiation and Microsurgical Breast Reconstruction
Although radiation therapy is an important treatment regimen in many patients, radiation can and does have damaging effects on skin and other tissues. Radiation alters the DNA in the cells of skin, fat, muscle and even bone in the treated area. This can be beneficial because it damages the ability of cancerous cells to reproduce, and this characteristic is precisely the reason that radiation is used in cancer treatment. But non-cancerous tissues that are in the path of the radiation are also changed permanently. Fortunately, with time some of the initial harm done to these tissues heals. But it never resolves completely. We like to wait approximately three to six months before performing a reconstruction on tissue that has been radiated, although this time period may vary depending on the circumstances.
Operating in a field that has been radiated is more difficult because of changes in the elasticity of skin and alterations in natural tissue planes. Often, bleeding is increased. What this translates into for patients is slower healing, increased bruising, and a potential for an increase in wound complications. But, radiation does not preclude reconstruction with DIEP, SIEA or TUG flaps. In fact, excellent results can still be achieved with these techniques both before and after radiation. A side benefit of microsurgical reconstruction is that it brings non-radiated healthy vascular tissue into the radiated area, actually aiding in the healing process.
There are essentially three different circumstances to consider when discussing radiation and it's effects on reconstruction.
- Immediate reconstruction followed by radiation.
- Previous mastectomy and radiation followed by reconstruction.
- Previous lumpectomy and radiation followed by mastectomy and reconstruction.
Skin sparing mastectomy results are aesthetically superior to those seen in delayed reconstruction when skin sparing is not an option. But, radiation of the reconstructed breast can and often does change the appearance, shape and feel of even an immediate reconstruction. These changes can be severe enough to require further reconstructive surgery, but they are difficult to predict in advance. For this reason some microsurgeons recommend undergoing radiation after mastectomy and delaying reconstruction until a later date - like three to six months after radiation is completed. Many women do not want to awaken from anesthesia without a breast and prefer to undergo the reconstruction before radiation. This is certainly an acceptable option as long as the potential for changes in breast appearance and feel with the passage of time after radiation are understood.
Breast reconstruction after mastectomy and radiation can be performed safely and effectively with excellent aesthetic outcomes. Some of the radiated skin must be removed during the reconstruction, leaving a skin island or skin paddle on the reconstructed breast. We remove some of the radiated skin because of the loss of skin elasticity. By removing this skin, it allows the surgeon to shape the new breast more naturally. Although radiated tissue heals more slowly than normal tissue, healing still does occur.
Although more rare than the previously mentioned scenarios, there are patients that require mastectomy after local recurrence of breast cancer following lumpectomy and radiation. Indeed, one of the main drawbacks of lumpectomy and radiation is the potential for recurrence in the treated breast. If recurrence of cancer occurs, a reconstruction can be performed at the time of the mastectomy of the radiated breast, sometimes even with a skin sparing component.