Comparison of Immediate and Delayed Free TRAM Flap Breast Reconstruction in Patients Receiving Postmastectomy Radiation Therapy

Abstract

Tumor pathologic features and the extent of nodal involvement dictate whether radiation therapy is given after mastectomy for breast cancer. It is generally well accepted that radiation negatively influences the outcome of implant-based breast reconstruction. However, the long-term effect of radiation therapy on the outcome of breast reconstruction with the free transverse rectus abdominis myocutaneous (TRAM) flap is still unclear. For patients who need postmastectomy radiation therapy, the optimal timing of TRAM flap reconstruction is controversial. This study compares the outcome of immediate and delayed free TRAM flap breast reconstruction in patients who received postmastectomy radiation therapy. All patients at The University of Texas M. D. Anderson Cancer Center who received postmastectomy radiation therapy and who also underwent free TRAM flap breast reconstruction between January of 1988 and December of 1998 were included in the study. Patients who received radiation therapy before delayed TRAM flap reconstruction were compared with patients who underwent immediate TRAM flap reconstruction before radiation therapy. Early and late complications were compared between the two groups. Early complications included vessel thrombosis, partial or total flap loss, mastectomy skin flap necrosis, and local wound-healing problems, whereas late complications included fat necrosis, volume loss, and flap contracture of free TRAM breast mounds. Late complications were evaluated at least 1 year after the completion of radiation therapy for patients who had delayed reconstruction and at least 1 year after reconstruction for patients who had immediate reconstruction. During the study period, 32 patients had immediate TRAM flap reconstruction before radiation therapy and 70 patients had radiation therapy before TRAM flap reconstruction. Mean follow-up times for the immediate reconstruction and delayed reconstruction groups were 3 and 5 years, respectively. The mean radiation dose was 50 Gy in the immediate reconstruction group and 51 Gy in the delayed reconstruction group. One complete flap loss occurred in the delayed reconstruction group, and no flap loss occurred in the immediate reconstruction group. The incidence of early complications did not differ significantly between the two groups. However, the incidence of late complications was significantly higher in the immediate reconstruction group than in the delayed reconstruction group (87.5 percent versus 8.6 percent; p = 0.000). Nine patients (28 percent) in the immediate reconstruction group required an additional flap to correct the distorted contour from flap shrinkage and severe flap contraction. These findings indicate that, in patients who are candidates for free TRAM flap breast reconstruction and need postmastectomy radiation therapy, reconstruction should be delayed until radiation therapy is complete.

Advances and surgical decision‐making for breast reconstruction

“…8). 20 It is also a good option for thin patients who are not candidates for a TRAM flap procedure because of inadequate tissue for reconstruction or for closure of the abdominal donor site. Unlike the tissue-expansion method, breast reconstruction with a latissimus dorsi flap plus an implant can create a ptotic-appearing breast.…”

“…A disadvantage with latissimus dorsi flap-based reconstruction is that the latissimus muscle tends to atrophy over time, which makes the underlying breast implant more pro- minent and can reveal even subtle irregularities in the implant caused by capsular contracture. 20 Breast reconstruction using the patient's own tissues results in the most natural-appearing reconstructed breasts…”

“…Therefore, if the intraoperative examination reveals a positive sentinel lymph node, then the decision whether to proceed with an immediate breast reconstruction or to delay reconstruction until after the results of the permanent pathology are known will have to be made beforehand by the multidisciplinary breast cancer team and the patient. The preoperative consultation with the patient should include emphasis on the potentially adverse effects that radiation treatment can have on aesthetic outcome of an immediate breast reconstruction 20 and on the technical problems with delivery of radiation to a reconstructed breast. 28 At our institution, the decision of whether to proceed with breast reconstruction if the sentinel lymph node is positive or to delay the reconstruction is influenced greatly by existing treatment guidelines.…”

Breast Cancer Version 3.2014

“…Furthermore, postmastectomy irradiation may have a negative impact on breast cosmesis when autologous tissue is used in immediate breast reconstruction, and may interfere with the targeted delivery of radiation when immediate reconstruction is performed using either autologous tissue or breast implants. 129,130 Some studies, however, have not found a significant compromise in reconstruction cosmesis after irradiation. 131 The preferred approach to breast reconstruction for these patients was a subject of controversy among the panel.…”

Cost-Effectiveness Analysis of Breast Reconstruction Options in the Setting of Postmastectomy Radiotherapy Using the BREAST-Q

“…Complications with relevant probabilities were included for each treatment based on a PubMed literature review. 5,[11][12][13][14][15][16][17][18][19] Outcomes were considered mutually exclusive to allow probabilities to add up to one; therefore, each patient could have only one complication. The base case analysis for the study was determined using a weighted average of years remaining to live for a typical woman diagnosed at age of 48 years with stage 2 or 3-breast cancer (American College of Surgeons National Cancer Database).…”