Examining the Effects of Postmastectomy Radiation Therapy in Prepectoral Versus Subpectoral Autologous Breast Reconstruction

Abstract

Background Postmastectomy radiation therapy (PMRT) is known to increase the risk of multiple adverse outcomes after breast reconstruction. In the context of delayed-immediate autologous breast reconstruction, PMRT is typically conducted after placement of subpectoral (SP) tissue expanders. With the re-emergence of prepectoral (PP) reconstruction, there are little data assessing the outcomes of PP reconstruction in breasts receiving PMRT. We compared postoperative outcomes of PMRT patients undergoing delayed-immediate, autologous breast reconstruction with placement of tissue expanders in either the PP or SP plane. Methods A retrospective chart review was conducted on all consecutive patients who underwent delayed-immediate autologous breast reconstruction and received PMRT at either the Stanford University or the Johns Hopkins University Hospitals between January 2009 and December 2018. Demographics, comorbidities, perioperative information, and oncologic data were collected for all patients. Complications were collected and analyzed after stage 1 surgery, between 30 days of stage 1 and up to stage 2 surgery, and after stage 2 surgery. Multivariable regressions were used to determine predictors of 1 or more complications. Results A total of 71 patients (73 breasts) were included. Prepectoral reconstruction comprised of 52.2% of the cohort, and the remaining 47.8% were SP reconstructions. Demographics and comorbidities were similar between groups, except for premastectomy radiation, which was more prevalent in the PP cohort (P = 0.010). Complications were similar between cohorts after stage 1 surgery (P = 0.420), between stages 1 and 2 (P = 0.100), and after stage 2 (P = 0.570). There were higher rates of skin necrosis in the SP cohort between stages 1 and 2 (PP: 2.6%, SP: 20%, P = 0.004). Multivariable analysis revealed body mass index to be the only predictor of complication (P = 0.041). The mean number of revisionary surgeries was higher in the SP cohort (PP: 0.8 vs SP: 1.9, P = 0.002). The mean follow-up was 385.5 days and similar between groups (P = 0.870). Conclusions Rates of overall complication were similar between PP and SP expander placement. However, in SP reconstructions, skin necrosis was significantly higher between stages 1 and 2. The patients in the SP cohort also underwent a greater number of revisionary surgeries, although overall rates of pursuing any revisionary surgery were similar between groups.

A systematic review and meta-analysis of postmastectomy radiation therapy on prepectoral versus subpectoral breast reconstruction

“…Breast reconstruction in the setting of postmastectomy radiation therapy(PMRT) presents a unique challenge, because radiation therapy has an impact on the skin and soft tissues of the chest wall, leading to fibrosis that increases risks of contracture, infection, pain, necrosis, and atrophy in reconstructed tissues ( 10 ). Consequently, the discussion of the optimum operative method of breast reconstruction has not been stopped.…”

Advances in Prepectoral Breast Reconstruction

“…65 Recent studies have shown that prepectoral breast reconstruction may be a viable option for patients who require PMRT, with comparable outcomes to subpectoral reconstruction. 66 For example, a study published in Plastic and Reconstructive Surgery Global Open found that prepectoral reconstruction had lower rates of complications and higher patient satisfaction compared to subpectoral reconstruction in patients who underwent PMRT. 67 Overall, the impact of PMRT on prepectoral and subpectoral breast reconstruction techniques continues to be an area of active research.…”

Breast Implant Position and Its Impact on Clinical Outcome in Breast Cancer Patients

“…Implant placement beneath the pectoralis major muscle can lead to loss of its function, known as the "contrived breast" effect, posing the need for physiotherapy [16]. Fat grafting is valuable for reducing pain and deformation animation [18,[63][64][65][66][67][68][69]. On the contrary, prepectoral placement is characterized by a lower postoperative pain and deformation animation rate.…”