A Meta-Analysis of Autologous Microsurgical Breast Reconstruction and Timing of Adjuvant Radiation TherapyFunding None.
Background Postmastectomy radiation therapy (PMRT) decreases loco-regional recurrence and improves survival in patients with locally advanced breast cancer. Autologous free flap reconstruction, while more durable in the setting of radiation than alloplastic reconstruction, is still susceptible to radiation-induced fibrosis, contracture, fat necrosis, volume loss, and distortion of breast shape. Options for reconstruction timing (immediate vs. delayed) have been discussed to mitigate these effects, but a clear optimum is not known.
Methods A systematic review of the literature was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using search terms “breast reconstruction AND (radiation OR irradiation OR radiotherapy)” were used. Inclusion criteria consisted of studies reporting complications for free flap breast reconstruction in the setting of PMRT. Patients who underwent PMRT were pooled into two groups: those who underwent immediate free flap reconstruction prior to PMRT and those who underwent delayed reconstruction after PMRT.
Results Out of the 23 studies, 12 focused on immediate reconstruction, seven focused on delayed reconstruction, and four studies included both groups. Overall, 729 patients underwent immediate reconstruction, while 868 underwent delayed reconstruction. Complete and partial flap loss rates were significantly higher in patients undergoing delayed reconstruction, while infection and wound-healing complication rates were higher in those undergoing immediate reconstructions. Rates of unplanned reoperations, vascular complications, hematoma/seroma, and fat necrosis did not differ significantly between the two groups. However, rates of planned revision surgeries were higher in the delayed reconstruction group.
Conclusion Immediate free flap breast reconstruction is associated with superior flap survival compared with delayed reconstruction. Rates of complications are largely comparable, and rates of revision surgeries are equivalent. The differences in long-term aesthetic outcomes are not, however, clearly assessed by the available literature. Even in the face of PMRT, immediate free flap breast reconstruction is an effective approach.
Keywordsautologous breast reconstruction - immediate breast reconstruction - delayed breast reconstruction - microsurgery - postmastectomy radiation therapy
Received: 07 April 2020
Accepted: 15 August 2020
21 September 2020 (online)
© 2020. Thieme. All rights reserved.
Thieme Medical Publishers
333 Seventh Avenue, New York, NY 10001, USA.
- 1 Remick J, Amin NP. Postmastectomy breast cancer radiation therapy. In, StatPearls. Treasure Island (FL): StatPearls Publishing Copyright © 2020. Treasure Island, FL: StatPearls Publishing LLC.; 2020
- 2 (ASPS) ASoPS. ASPS Plastic Surgery Statistics Report. Arlington Heights, IL: 2018
- 3 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
- 4 (ASPS) ASoPS. ASPS Plastic Surgery Statistics Report. Arlington Heights, IL: 2010
- 5 El-Sabawi B, Carey JN, Hagopian TM, Sbitany H, Patel KM. Radiation and breast reconstruction: algorithmic approach and evidence-based outcomes. J Surg Oncol 2016; 113 (08) 906-912
- 6 Rogers NE, Allen RJ. Radiation effects on breast reconstruction with the deep inferior epigastric perforator flap. Plast Reconstr Surg 2002; 109 (06) 1919-1924 , discussion 1925–1926
- 7 Spear SL, Ducic I, Low M, Cuoco F. The effect of radiation on pedicled TRAM flap breast reconstruction: outcomes and implications. Plast Reconstr Surg 2005; 115 (01) 84-95
- 8 O'Connell RL, Di Micco R, Khabra K. et al. Comparison of immediate versus delayed DIEP flap reconstruction in women who require postmastectomy radiotherapy. Plast Reconstr Surg 2018; 142 (03) 594-605
- 9 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). PRISMA Transparent reporting of Systematic reviews and Meta-analyses. Accessed July 30, 2019 at: http://prisma-statement.org
- 10 Clarke-Pearson EM, Chadha M, Dayan E. et al. Comparison of irradiated versus nonirradiated DIEP flaps in patients undergoing immediate bilateral DIEP reconstruction with unilateral postmastectomy radiation therapy (PMRT). Ann Plast Surg 2013; 71 (03) 250-254
- 11 Cooke AL, Diaz-Abele J, Hayakawa T, Buchel E, Dalke K, Lambert P. Radiation therapy versus no radiation therapy to the neo-breast following skin-sparing mastectomy and immediate autologous free flap reconstruction for breast cancer: patient-reported and surgical outcomes at 1 year-a mastectomy reconstruction outcomes consortium (MROC) substudy. Int J Radiat Oncol Biol Phys 2017; 99 (01) 165-172
- 12 Foster RD, Hansen SL, Esserman LJ. et al. Safety of immediate transverse rectus abdominis myocutaneous breast reconstruction for patients with locally advanced disease. Arch Surg 2005; 140 (02) 196-198 , discussion 199–200
- 13 Garvey PB, Clemens MW, Hoy AE. et al. Muscle-sparing TRAM flap does not protect breast reconstruction from postmastectomy radiation damage compared with the DIEP flap. Plast Reconstr Surg 2014; 133 (02) 223-233
- 14 Hughes K, Neoh D. Neoadjuvant radiotherapy: changing the treatment sequence to allow immediate free autologous breast reconstruction. J Reconstr Microsurg 2018; 34 (08) 624-631
- 15 Mirzabeigi MN, Smartt JM, Nelson JA, Fosnot J, Serletti JM, Wu LC. An assessment of the risks and benefits of immediate autologous breast reconstruction in patients undergoing postmastectomy radiation therapy. Ann Plast Surg 2013; 71 (02) 149-155
- 16 Myung Y, Son Y, Nam TH. et al. Objective assessment of flap volume changes and aesthetic results after adjuvant radiation therapy in patients undergoing immediate autologous breast reconstruction. PLoS One 2018; 13 (05) e0197615
- 17 Pont LP, Marcelli S, Robustillo M. et al. Immediate breast reconstruction with abdominal free flap and adjuvant radiotherapy: evaluation of quality of life and outcomes. Plast Reconstr Surg 2017; 140 (04) 681-690
- 18 Sadideen H, Cleator S, McNaught P, Wood S, Jallali N. The safety of early adjuvant internal mammary lymph node irradiation following mastectomy and immediate autologous reconstruction. Plast Reconstr Surg 2018; 141 (03) 467e-468e
- 19 Taghizadeh R, Moustaki M, Harris S, Roblin P, Farhadi J. Does post-mastectomy radiotherapy affect the outcome and prevalence of complications in immediate DIEP breast reconstruction? A prospective cohort study. J Plast Reconstr Aesthet Surg 2015; 68 (10) 1379-1385
- 20 Zimmerman RP, Mark RJ, Kim AI. et al. Radiation tolerance of transverse rectus abdominis myocutaneous-free flaps used in immediate breast reconstruction. Am J Clin Oncol 1998; 21 (04) 381-385
- 21 Baumann DP, Crosby MA, Selber JC. et al. Optimal timing of delayed free lower abdominal flap breast reconstruction after postmastectomy radiation therapy. Plast Reconstr Surg 2011; 127 (03) 1100-1106
- 22 Lindegren A, Halle M, Docherty Skogh AC, Edsander-Nord A. Postmastectomy breast reconstruction in the irradiated breast: a comparative study of DIEP and latissimus dorsi flap outcome. Plast Reconstr Surg 2012; 130 (01) 10-18
- 23 Moran SL, Serletti JM, Fox I. Immediate free TRAM reconstruction in lumpectomy and radiation failure patients. Plast Reconstr Surg 2000; 106 (07) 1527-1531
- 24 Mull AB, Qureshi AA, Zubovic E. et al. Impact of time interval between radiation and free autologous breast reconstruction. J Reconstr Microsurg 2017; 33 (02) 130-136
- 25 Patel KM, Albino F, Fan KL, Liao E, Nahabedian MY. Microvascular autologous breast reconstruction in the context of radiation therapy: comparing two reconstructive algorithms. Plast Reconstr Surg 2013; 132 (02) 251-257
- 26 Shechter S, Arad E, Inbal A, Friedman O, Gur E, Barnea Y. DIEP flap breast reconstruction complication rate in previously irradiated internal mammary nodes. J Reconstr Microsurg 2018; 34 (06) 399-403
- 27 Temple CL, Strom EA, Youssef A, Langstein HN. Choice of recipient vessels in delayed TRAM flap breast reconstruction after radiotherapy. Plast Reconstr Surg 2005; 115 (01) 105-113
- 28 Billig J, Jagsi R, Qi J. et al. Should immediate autologous breast reconstruction be considered in women who require postmastectomy radiation therapy? A prospective analysis of outcomes. Plast Reconstr Surg 2017; 139 (06) 1279-1288
- 29 Maalouf C, Bou-Merhi J, Karam E, Patocskai E, Danino AM. The impact of autologous breast reconstruction using DIEP flap on the oncologic efficacy of radiation therapy. Ann Chir Plast Esthet 2017; 62 (06) 630-636
- 30 Tran NV, Chang DW, Gupta A, Kroll SS, Robb GL. Comparison of immediate and delayed free TRAM flap breast reconstruction in patients receiving postmastectomy radiation therapy. Plast Reconstr Surg 2001; 108 (01) 78-82
- 31 Fracol ME, Basta MN, Nelson JA. et al. Bilateral free flap breast reconstruction after unilateral radiation: comparing intraoperative vascular complications and postoperative outcomes in radiated versus nonradiated breasts. Ann Plast Surg 2016; 76 (03) 311-314
- 32 Ricci JA, Stranix JT, Lee ZH. et al. Comparing reconstructive outcomes in patients with gustilo type IIIB fractures and concomitant arterial injuries. Plast Reconstr Surg 2019; 143 (05) 1522-1529
- 33 Craig ES, Lentz R, Srinivasa D. et al. Three-dimensional analysis of how radiation affects deep inferior epigastric perforator (DIEP) flap volume, projection, and position in breast cancer reconstruction. Ann Plast Surg 2018; 81 (02) 235-239
- 34 Lee BT, Adesiyun TA, Colakoglu S. et al. Postmastectomy radiation therapy and breast reconstruction: an analysis of complications and patient satisfaction. Ann Plast Surg 2010; 64 (05) 679-683
- 35 López E, Guerrero R, Núñez MI. et al. Early and late skin reactions to radiotherapy for breast cancer and their correlation with radiation-induced DNA damage in lymphocytes. Breast Cancer Res 2005; 7 (05) R690-R698
- 36 Johansson S, Svensson H, Denekamp J. Dose response and latency for radiation-induced fibrosis, edema, and neuropathy in breast cancer patients. Int J Radiat Oncol Biol Phys 2002; 52 (05) 1207-1219
- 37 Brouwers PJAM, van Werkhoven E, Bartelink H. Young Boost Trial research group. et al. Predictors for poor cosmetic outcome in patients with early stage breast cancer treated with breast conserving therapy: results of the Young boost trial. Radiother Oncol 2018; 128 (03) 434-441
- 38 Chang EI, Liu TS, Festekjian JH, Da Lio AL, Crisera CA. Effects of radiation therapy for breast cancer based on type of free flap reconstruction. Plast Reconstr Surg 2013; 131 (01) 1e-8e
- 39 Lentz R, Ng R, Higgins SA, Fusi S, Matthew M, Kwei SL. Radiation therapy and expander-implant breast reconstruction: an analysis of timing and comparison of complications. Ann Plast Surg 2013; 71 (03) 269-273
- 40 Cheng H, Chen BP, Soleas IM, Ferko NC, Cameron CG, Hinoul P. Prolonged operative duration increases risk of surgical site infections: a systematic review. Surg Infect (Larchmt) 2017; 18 (06) 722-735
- 41 Liu EH, Zhu SL, Hu J, Wong N, Farrokhyar F, Thoma A. Intraoperative SPY reduces post-mastectomy skin flap complications: a systematic review and meta-analysis. Plast Reconstr Surg Glob Open 2019; 7 (04) e2060
- 42 Bartelink H, Maingon P, Poortmans P. European Organisation for Research and Treatment of Cancer Radiation Oncology and Breast Cancer Groups. et al. Whole-breast irradiation with or without a boost for patients treated with breast-conserving surgery for early breast cancer: 20-year follow-up of a randomised phase 3 trial. Lancet Oncol 2015; 16 (01) 47-56
- 43 Momoh AO, Colakoglu S, de Blacam C, Gautam S, Tobias AM, Lee BT. Delayed autologous breast reconstruction after postmastectomy radiation therapy: is there an optimal time?. Ann Plast Surg 2012; 69 (01) 14-18