Rates of Reconstruction Failure in Patients Undergoing Immediate Reconstruction With Tissue Expanders and/or Implants and Postmastectomy Radiation Therapy

Published:February 20, 2015DOI:


      Mastectomy rates for breast cancer have increased, with a parallel increase in immediate reconstruction. For some women, tissue expander and implant (TE/I) reconstruction is the preferred or sole option. This retrospective study examined the rate of TE/I reconstruction failure (ie, removal of the TE or I with the inability to replace it resulting in no final reconstruction or autologous tissue reconstruction) in patients receiving postmastectomy radiation therapy (PMRT).

      Methods and Materials

      Between 2004 and 2012, 99 women had skin-sparing mastectomies (SSM) or total nipple/areolar skin-sparing mastectomies (TSSM) with immediate TE/I reconstruction and PMRT for pathologic stage II to III breast cancer. Ninety-seven percent had chemotherapy (doxorubicin and taxane-based), 22% underwent targeted therapies, and 78% had endocrine therapy. Radiation consisted of 5000 cGy given in 180 to 200 cGy to the reconstructed breast with or without treatment to the supraclavicular nodes. Median follow-up was 3.8 years.


      Total TE/I failure was 18% (12% without final reconstruction, 6% converted to autologous reconstruction). In univariate analysis, the strongest predictor of reconstruction failure (RF) was absence of total TE/I coverage (acellular dermal matrix and/or serratus muscle) at the time of radiation. RF occurred in 32.5% of patients without total coverage compared to 9% with coverage (P=.0069). For women with total coverage, the location of the mastectomy scar in the inframammary fold region was associated with higher RF (19% vs 0%, P=.0189). In multivariate analysis, weight was a significant factor for RF, with lower weight associated with a higher RF. Weight appeared to be a surrogate for the interaction of total coverage, thin skin flaps, interval to exchange, and location of the mastectomy scar.


      RFs in patients receiving PMRT were lowered with total TE/I coverage at the time of radiation by avoiding inframammary fold incisions and with a preferred interval of 6 months to exchange.
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        • Albornoz C.R.
        • Cordeiro P.G.
        • Pusic A.L.
        • et al.
        Diminishing relative contraindications for immediate breast reconstruction: A multicenter study.
        J Am Coll Surg. 2014; 219: 788-795
        • Jagsi R.
        • Jiang J.
        • Momoh A.O.
        • et al.
        Trends and variation in use of breast reconstruction in patients with breast cancer undergoing mastectomy in the United States.
        J Clin Oncol. 2014; 32: 919-926
        • McGale P.
        • Taylor C.
        • Correa C.
        • et al.
        • EBCTG
        Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: Meta-analysis of individual patient data for 8135 women in 22 randomised trials.
        Lancet. 2014; 383: 2127-2135
        • Barry M.
        • Kell M.R.
        Radiotherapy and breast reconstruction: A meta-analysis.
        Breast Cancer Res Treat. 2011; 127: 15-22
        • Hvilsom G.B.
        • Holmich L.R.
        • Steding-Jessen M.
        • et al.
        Delayed breast implant reconstruction: Is radiation therapy associated with capsular contracture or reoperations?.
        Ann Plast Surg. 2012; 68: 246-252
        • Krueger E.A.
        • Wilkins E.G.
        • Strawderman M.
        • et al.
        Complications and patient satisfaction following expander/implant breast reconstruction with and without radiotherapy.
        Int J Radiat Oncol Biol Phys. 2001; 49: 713-721
        • Shah C.
        • Kundu N.
        • Arthur D.
        • et al.
        Radiation therapy following postmastectomy reconstruction: A systematic review.
        Ann Surg Oncol. 2013; 20: 1313-1322
        • Nava M.B.
        • Pennati A.E.
        • Lozza L.
        • et al.
        Outcome of different timings of radiotherapy in implant-based breast reconstructions.
        Plast Reconstr Surg. 2011; 128: 353-359
        • Ho A.L.
        • Bovill E.S.
        • Macadam S.A.
        • et al.
        Postmastectomy radiation therapy after immediate two-stage tissue expander/implant breast reconstruction: A University of British Columbia perspective.
        Plast Reconstr Surg. 2014; 134: 1e-10e
        • Berry T.
        • Brooks S.
        • Sydow N.
        • et al.
        Complication rates of radiation on tissue expander and autologous tissue breast reconstruction.
        Ann Surg Oncol. 2010; 17: 202-210
        • Kronowitz S.J.
        Current status of implant-based breast reconstruction in patients receiving postmastectomy radiation therapy.
        Plast Reconstr Surg. 2012; 130: 513e-523e
        • Christante D.
        • Pommier S.J.
        • Diggs B.S.
        • et al.
        Using complications associated with postmastectomy radiation and immediate breast reconstruction to improve surgical decision making.
        Arch Surg. 2010; 145: 873-878
        • Beatty J.D.
        Start by decreasing unnecessary postmastectomy irradiation.
        Arch Surg. 2010; 145: 878-879
        • Anderson P.R.
        • Hanlon A.L.
        • Fowble B.L.
        • et al.
        Low complication rates are achievable after postmastectomy breast reconstruction and radiation therapy.
        Int J Radiat Oncol Biol Phys. 2004; 59: 1080-1087
        • Peled A.W.
        • Foster R.D.
        • Garwood E.R.
        • et al.
        The effects of acellular dermal matrix in expander-implant breast reconstruction after total skin-sparing mastectomy: Results of a prospective practice improvement study.
        Plast Reconstr Surg. 2012; 129: 901e-908e
        • Peled A.W.
        • Foster R.D.
        • Ligh C.
        • et al.
        Impact of total skin-sparing mastectomy incision type on reconstructive complications following radiation therapy.
        Plast Reconstr Surg. 2014; 134: 169-175
        • Peled A.W.
        • Foster R.D.
        • Esserman L.J.
        • et al.
        Increasing the time to expander-implant exchange after postmastectomy radiation therapy reduces expander-implant failure.
        Plast Reconstr Surg. 2012; 130: 503-509
        • Ho A.
        • Cordeiro P.
        • Disa J.
        • et al.
        Long-term outcomes in breast cancer patients undergoing immediate 2-stage expander/implant reconstruction and postmastectomy radiation.
        Cancer. 2012; 118: 2552-2559
        • Baschnagel A.M.
        • Shah C.
        • Wilkinson J.B.
        • et al.
        Failure rate and cosmesis of immediate tissue expander/implant breast reconstruction after postmastectomy irradiation.
        Clin Breast Cancer. 2012; 12: 428-432
        • Anderson P.R.
        • Freedman G.
        • Nicolaou N.
        • et al.
        Postmastectomy chest wall radiation to a temporary tissue expander or permanent breast implant—Is there a difference in complication rates?.
        Int J Radiat Oncol Biol Phys. 2009; 74: 81-85
        • Cowen D.
        • Gross E.
        • Rouannet P.
        • et al.
        Immediate post-mastectomy breast reconstruction followed by radiotherapy: Risk factors for complications.
        Breast Cancer Res Treat. 2010; 121: 627-634
        • Seth A.K.
        • Hirsch E.M.
        • Fine N.A.
        • et al.
        Utility of acellular dermis-assisted breast reconstruction in the setting of radiation: A comparative analysis.
        Plast Reconstr Surg. 2012; 130: 750-758
        • Jhaveri J.D.
        • Rush S.C.
        • Kostroff K.
        • et al.
        Clinical outcomes of postmastectomy radiation therapy after immediate breast reconstruction.
        Int J Radiat Oncol Biol Phys. 2008; 72: 859-865
        • Pestana I.A.
        • Campbell D.C.
        • Bharti G.
        • et al.
        Factors affecting complications in radiated breast reconstruction.
        Ann Plast Surg. 2013; 70: 542-545
        • Spear S.L.
        • Seruya M.
        • Rao S.S.
        • et al.
        Two-stage prosthetic breast reconstruction using alloderm including outcomes of different timings of radiotherapy.
        Plast Reconstr Surg. 2012; 130: 1-9
        • Burdge E.C.
        • Yuen J.
        • Hardee M.
        • et al.
        Nipple skin-sparing mastectomy is feasible for advanced disease.
        Ann Surg Oncol. 2013; 20: 3294-3302
        • Ho A.Y.
        • Morrow M.
        • Krause K.
        • et al.
        The effect of radiation timing implant-based reconstruction [abstract].
        Int J Radiat Oncol Biol Phys. 2014; 90: S45
        • Ibrahim A.M.
        • Shuster M.
        • Koolen P.G.
        • et al.
        Analysis of the National Surgical Quality Improvement Program database in 19,100 patients undergoing implant-based breast reconstruction: Complication rates with acellular dermal matrix.
        Plast Reconstr Surg. 2013; 132: 1057-1066
        • Clemens M.W.
        • Kronowitz S.J.
        Acellular dermal matrix in irradiated tissue expander/implant-based breast reconstruction: Evidence-based review.
        Plast Reconstr Surg. 2012; 130: 27S-34S
        • Sbitany H.
        • Serletti J.M.
        Acellular dermis-assisted prosthetic breast reconstruction: A systematic and critical review of efficacy and associated morbidity.
        Plast Reconstr Surg. 2011; 128: 1162-1169
        • Moyer H.R.
        • Pinell-White X.
        • Losken A.
        The effect of radiation on acellular dermal matrix and capsule formation in breast reconstruction: Clinical outcomes and histologic analysis.
        Plast Reconstr Surg. 2014; 133: 214-221
        • Colwell A.S.
        • Tessler O.
        • Lin A.M.
        • et al.
        Breast reconstruction following nipple-sparing mastectomy: Predictors of complications, reconstruction outcomes, and 5-year trends.
        Plast Reconstr Surg. 2014; 133: 496-506
        • Pierce L.J.
        • Strawderman M.
        • Narod S.A.
        • et al.
        Effect of radiotherapy after breast-conserving treatment in women with breast cancer and germline BRCA1/2 mutations.
        J Clin Oncol. 2000; 18: 3360-3369
        • Shanley S.
        • McReynolds K.
        • Ardern-Jones A.
        • et al.
        Late toxicity is not increased in BRCA1/BRCA2 mutation carriers undergoing breast radiotherapy in the United Kingdom.
        Clin Cancer Res. 2006; 12: 7025-7032
        • Gaffney D.K.
        • Brohet R.M.
        • Lewis C.M.
        • et al.
        Response to radiation therapy and prognosis in breast cancer patients with BRCA1 and BRCA2 mutations.
        Radiother Oncol. 1998; 47: 129-136
        • Huszno J.
        • Budryk M.
        • Kolosza Z.
        • et al.
        The influence of BRCA1/BRCA2 mutations on toxicity related to chemotherapy and radiotherapy in early breast cancer patients.
        Oncology. 2013; 85: 278-282
        • Chen S.A.
        • Hiley C.
        • Nickleach D.
        • et al.
        Breast reconstruction and post-mastectomy radiation practice.
        Radiat Oncol. 2013; 8: 45
        • Thomas K.
        • Rahimi A.
        • Spangler A.
        • et al.
        Radiation practice patterns among United States radiation oncologists for postmastectomy breast reconstruction and oncoplastic breast reduction.
        Pract Radiat Oncol. 2014; 4: 466-471
        • Woody N.M.
        • Durand P.
        • Naik M.
        • et al.
        Impact of breast radiotherapy on late toxicities and reoperation following mastectomy with tissue expander based reconstruction.
        Int J Radiat Oncol Biol Phys. 2014; 90: S46
        • Tallet A.V.
        • Salem N.
        • Moutardier V.
        • et al.
        Radiotherapy and immediate two-stage breast reconstruction with a tissue expander and implant: Complications and esthetic results.
        Int J Radiat Oncol Biol Phys. 2003; 57: 136-142
        • Ascherman J.A.
        • Hanasono M.M.
        • Newman M.I.
        • et al.
        Implant reconstruction in breast cancer patients treated with radiation therapy.
        Plast Reconstr Surg. 2006; 117: 359-365
        • Kansal K.J.
        • Dominici L.S.
        • Tolaney S.M.
        • et al.
        Neoadjuvant bevacizumab: Surgical complications of mastectomy with and without reconstruction.
        Breast Cancer Res Treat. 2013; 141: 255-259


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