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Immediate Two-Stage Prosthetic Breast Reconstruction Failure: Radiation Is Not the Only Culprit

Lam, Thomas C., F.R.C.S.Ed., F.R.A.C.S.; Borotkanics, Robert, Dr.P.H., M.S., M.P.H.; Hsieh, Frank, M.A., M.B., B.Chiro.; Salinas, James, B.Sc., M.B.B.S.; Boyages, John, F.R.A.N.Z.C.R.

Plastic and Reconstructive Surgery: June 2018 - Volume 141 - Issue 6 - p 1315-1324
doi: 10.1097/PRS.0000000000004358
Breast: Original Articles
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Patient Safety CME

Background: Immediate prosthetic breast reconstruction produces a satisfactory aesthetic result with high levels of patient satisfaction. However, with the broader indication for postmastectomy adjuvant radiation therapy, many patients are advised against immediate breast reconstruction because of concerns of implant loss and infection, particularly as most patients also require chemotherapy. This retrospective cohort study examines outcomes for patients who underwent immediate two-stage prosthetic breast reconstruction after mastectomy with or without adjuvant chemotherapy or radiotherapy.

Methods: Between 1998 and 2010, 452 patients undergoing immediate two-stage prosthetic breast reconstruction involving a total of 562 breasts were included in this study. Stage 1 was defined as insertion of the temporary expander, and stage 2 was defined as insertion of the final silicone implant. Postoperative adjuvant radiotherapy was recommended with a tissue expander in situ for 114 patients. Complications, including loss of prosthesis, seroma, and infection, were recorded and analyzed. Cosmetic result was assessed using a four-point scale.

Results: Postoperative prosthesis loss was 2.7 percent, 5.3 percent for patients undergoing adjuvant chemotherapy and increasing to 11.3 percent for patients receiving chemotherapy plus radiotherapy. Chemotherapy and radiotherapy independently were the main, statistically significant risk factors for expander or implant loss [incidence rate ratio, 13.85 (p = 0.012) and 2.23 (p = 0.027), respectively]. Prosthesis loss for patients undergoing combination chemotherapy plus radiotherapy was also significant [incidence rate ratio, 4.791 (p < 0.001)].

Conclusions: These findings serve to better inform patients on risk in weighing treatment options. Postmastectomy radiation therapy doubles the risk of prosthesis loss over and above adjuvant chemotherapy but is an acceptable option following immediate two-stage prosthetic breast reconstruction in a multidisciplinary setting.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Sydney, New South Wales, Australia; and Auckland, New Zealand

From the Department of Plastic and Reconstructive Surgery, Westmead Hospital; the Faculty of Medicine and Health Sciences, Macquarie University; and the Department of Biostatistics and Epidemiology, School of Public Health and Psychosocial Studies, Faculty of Health and Environmental Sciences, Auckland University of Technology.

Received for publication July 31, 2017; accepted December 19, 2017.

Disclosure:The authors have no financial interest to declare in relation to the content of this article.

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Thomas C. Lam, F.R.C.S.Ed., F.R.A.C.S., Faculty of Medicine and Health Sciences, 2 Technology Place, Macquarie University, Sydney, New South Wales 2109, Australia, tlam@plasticsurgery.org.au

Copyright © 2018 by the American Society of Plastic Surgeons