Bilateral breast reconstruction in the setting of unilateral postmastectomy radiation therapy (PMRT) remains one of the most difficult reconstructive challenges due to significant radiation-induced asymmetry from capsular contracture and superior migration of the irradiated reconstructed breast. We describe a novel and straightforward intraoperative technique for creating compensatory asymmetry to maximize postradiation symmetry in immediate bilateral tissue expander (TE) and acellular dermal matrix (ADM) reconstruction requiring unilateral PMRT.
A cohort of 25 bilateral TE/ADM breast reconstructions with planned unilateral PMRT was performed using this approach, and outcomes were reviewed. On the PMRT side, the ADM edge was inset to a lower inframammary fold (IMF) position resulting in a near “bottoming-out” effect. On the non-PMRT side, the ADM was inset using a triple point stitch onto the IMF in a higher chest wall location. The planned PMRT side TE was overexpanded and second-stage exchanges were performed 6+ months post-PMRT.
Post-PMRT results showed improved symmetry as the PMRT side migrated superiorly to match the contralateral non-irradiated side. Minimal pocket or IMF adjustments were required during second-stage procedures, with just 6 patients (24%) requiring minor lowering and 1 patient (4%) requiring elevation of the PMRT side IMF. Thus, most (72%) patients undergoing bilateral mastectomy and unilateral PMRT did not require any IMF modifications during the second-stage procedure.
A differential ADM inset and TE pocket creation for bilateral TE/ADM breast reconstructions with planned unilateral PMRT can minimize the typical adverse aesthetic effects of PMRT on reconstruction results and maximize symmetry.
From the *Harvard Combined Plastic Surgery Residency Program; and †Division of Plastic Surgery, Brigham & Women's Hospital, Boston, MA.
Received March 14, 2016, and accepted for publication, after revision July 7, 2016.
D.S.R. and M.D.T. are co-first authors and contributed equally to this work.
Conflict of interest and sources of funding: none declared.
Reprints: Yoon S. Chun, MD, Division of Plastic Surgery, Brigham & Women's Faulkner Hospital, 1153 Center Street, Suite 21, Boston, MA 02130. E-mail: firstname.lastname@example.org.