Short-Term Surgical Complications of Skin-Sparing Mastectomy and Direct-to-Implant Immediate Breast Reconstruction in Women Concurrently Treated with Adjuvant Radiotherapy for Breast Cancer

Abstract

Background Postmastectomy radiotherapy (PMRT) is allegedly associated with a higher risk of complications of combined nipple-sparing or skin-sparing mastectomy and subpectoral direct-to-implant immediate breast reconstruction ([N]SSM/SDTI-IBR). For this reason, this combination is usually advised against or, even, refused in women who need to undergo PMRT. Because this advice has never been justified, we assessed the short-term complications that may potentially be associated with PMRT after [N]SSM/SDTI-IBR.

Methods We compared the complications requiring reintervention and implant loss occurring after 273 [N]SSM/SDTI-IBR that were exposed to PMRT within the first 16 postoperative weeks (interventional group) to those occurring in 739 similarly operated breasts that were not (control group). Additionally, we compared the fraction of complications requiring reintervention occurring after the onset of radiotherapy in the interventional group to that occurring after a comparable postoperative period in the control group.

Results The fraction of breasts requiring unscheduled surgical reinterventions for complications and the loss of implants did not differ significantly between both groups but significantly more reinterventions were needed among the controls (p = 0.00). The fraction of events after the onset of radiotherapy in the interventional group was higher than the fraction of events after 6.2 weeks in the control group, but not significantly so.

Conclusion We found no prove for the alleged increase of short-term complications of adjuvant radiotherapy. Therefore, we advise that these should not be considered valid arguments to advice against [N]SSM/SDTI-IBR.

Keywords

breast reconstruction - breast implant - radiotherapy

Author Contributions

Conceptualization: M.M.L.K. and J.J.H. Data curation: M.M.L.K. and L.A.E.W. Formal analysis: M.M.L.K and J.J.H. Methodology: M.M.L.K., J.J.H., and L.A.E.W. Project administration: J.J.H. Visualization: M.M.L.K. and J.J.H. Writing-original draft: M.M.L.K. and J.J.H. Writing-review and editing: M.M.L.K., J.J.H., A.N.S, M.-J.T.F.D.V.-P., and L.A.E.W. All authors read and approved the final manuscript.

Publication History

Article published online:
27 May 2022

• References

• 1 Cordeiro PG. Breast reconstruction after surgery for breast cancer. N Engl J Med 2008; 359 (15) 1590-1601
• 2 Barry M, Kell MR. Radiotherapy and breast reconstruction: a meta-analysis. Breast Cancer Res Treat 2011; 127 (01) 15-22
• 3 Albornoz CR, Bach PB, Mehrara BJ. et al. A paradigm shift in U.S. breast reconstruction: increasing implant rates. Plast Reconstr Surg 2013; 131 (01) 15-23
• 4 Panchal H, Matros E. Current trends in postmastectomy breast reconstruction. Plast Reconstr Surg 2017; 140 (5S Advances in Breast Reconstruction): 7S-13S
• 5 Naoum GE, Salama L, Niemierko A. et al. Single stage direct-to-implant breast reconstruction has lower complication rates than tissue expander and implant and comparable rates to autologous reconstruction in patients receiving postmastectomy radiation. Int J Radiat Oncol Biol Phys 2020; 106 (03) 514-524
• 6 Serrurier LCJ, Rayne S, Venter M, Benn CA. Direct-to-implant breast reconstruction without the use of an acellular dermal matrix Is cost effective and oncologically safe. Plast Reconstr Surg 2017; 139 (04) 809-817
• 7 Manrique OJ, Kapoor T, Banuelos J. et al. Single-stage direct-to-implant breast reconstruction: a comparison between subpectoral versus prepectoral implant placement. Ann Plast Surg 2020; 84 (04) 361-365
• 8 Dolen UC, Schmidt AC, Um GT. et al. Impact of neoadjuvant and adjuvant chemotherapy on immediate tissue expander breast reconstruction. Ann Surg Oncol 2016; 23 (07) 2357-2366
• 9 Sbitany H, Wang F, Peled AW. et al. Immediate implant-based breast reconstruction following total skin-sparing mastectomy: defining the risk of preoperative and postoperative radiation therapy for surgical outcomes. Plast Reconstr Surg 2014; 134 (03) 396-404
• 10 Ricci JA, Epstein S, Momoh AO, Lin SJ, Singhal D, Lee BT. A meta-analysis of implant-based breast reconstruction and timing of adjuvant radiation therapy. J Surg Res 2017; 218: 108-116
• 11 Cordeiro PG, Pusic AL, Disa JJ, McCormick B, VanZee K. Irradiation after immediate tissue expander/implant breast reconstruction: outcomes, complications, aesthetic results, and satisfaction among 156 patients. Plast Reconstr Surg 2004; 113 (03) 877-881
• 12 Kronowitz SJ. Current status of implant-based breast reconstruction in patients receiving postmastectomy radiation therapy. Plast Reconstr Surg 2012; 130 (04) 513e-523e
• 13 Spear SL, Onyewu C. Staged breast reconstruction with saline-filled implants in the irradiated breast: recent trends and therapeutic implications. Plast Reconstr Surg 2000; 105 (03) 930-942
• 14 Lee KT, Mun GH. Optimal sequencing of postmastectomy radiotherapy and two stages of prosthetic reconstruction: a meta-analysis. Ann Surg Oncol 2017; 24 (05) 1262-1268
• 15 Kooijman MML. The short-term complications of radiotherapy after immediate breast reconstruction by use of an implant - a survey of the literature. Master thesis. Department of Plastic, Reconstructive and Hand Surgery, VU Medical Center, Amsterdam, The Netherlands; 2017
• 16 Woerdeman LA, Hage JJ, van Turnhout AA. Extended deepithelialization to secure double-breasted closure of the skin. Ann Plast Surg 2005; 55 (03) 338-340
• 17 Woerdeman LA, Hage JJ, Hofland MM, Rutgers EJ. A prospective assessment of surgical risk factors in 400 cases of skin-sparing mastectomy and immediate breast reconstruction with implants to establish selection criteria. Plast Reconstr Surg 2007; 119 (02) 455-463
• 18 Donker M, Hage JJ, Woerdeman LA, Rutgers EJ, Sonke GS, Vrancken Peeters MJ. Surgical complications of skin sparing mastectomy and immediate prosthetic reconstruction after neoadjuvant chemotherapy for invasive breast cancer. Eur J Surg Oncol 2012; 38 (01) 25-30
• 19 Spear SL, Seruya M, Rao SS. et al. Two-stage prosthetic breast reconstruction using AlloDerm including outcomes of different timings of radiotherapy. Plast Reconstr Surg 2012; 130 (01) 1-9
• 20 Altman DG. Practical Statistics for Medical Research. 1st ed.. London, New York: Chapman Hall; 1991
• 21 Shah C, Kundu N, Arthur D, Vicini F. Radiation therapy following postmastectomy reconstruction: a systematic review. Ann Surg Oncol 2013; 20 (04) 1313-1322
• 22 Jagsi R, Jiang J, Momoh AO. et al. Complications after mastectomy and immediate breast reconstruction for breast cancer: a claims-based analysis. Ann Surg 2016; 263 (02) 219-227
• 23 Lin AM, Christensen JM, Liao EC. et al. Postmastectomy radiation therapy on permanent implants or tissue expanders: which is better?. Ann Surg 2021; 274 (06) e974-e979
• 24 Safran T, Al-Halabi B, Viezel-Mathieu A, Boileau JF, Dionisopoulos T. Direct-to-implant, prepectoral breast reconstruction: a single-surgeon experience with 201 consecutive patients. Plast Reconstr Surg 2020; 145 (04) 686e-696e
• 25 Bilezikian JA, Tenzel PL, Bebb GG, Kays CR. The broad application of prepectoral direct-to-implant breast reconstruction with acellular dermal matrix drape and fluorescent imaging in a community setting. Plast Reconstr Surg 2020; 145 (02) 291-300
• 26 Cordeiro PG, Snell L, Heerdt A, McCarthy C. Immediate tissue expander/implast breast reconstruction after salvage mastectomy for cancer recurrence following lumpectomy/irradiation. Plast Reconstr Surg 2012; 129 (02) 341-350
• 27 Rey P, Martinelli G, Petit JY. et al. Immediate breast reconstruction and high-dose chemotherapy. Ann Plast Surg 2005; 55 (03) 250-254
• 28 Kooijman MML, Hage JJ, Oldenburg HSA. et al. Surgical complications of skin-sparing mastectomy and immediate implant-based breast reconstruction in women concurrently treated with adjuvant chemotherapy for breast cancer. Ann Plast Surg 2020
• 29 Sbitany H. Discussion: impact of prior unilateral chest wall radiotherapy on outcomes in bilateral breast reconstruction. Plast Reconstr Surg 2016; 138 (04) 581e-582e