Rib Fractures: A Complication of Radiation Therapy and Tissue Expansion for Breast Reconstruction

This is the authors' abstract. We don't add key points for this paper.

Sir: Radiotherapy has long been considered a relative contraindication to tissue expander placement and implant reconstruction, as it causes deleterious bony changes.1,2 Nonetheless, tissue expansion for breast reconstruction continues to be used in previously irradiated fields. We conducted a 6-year retrospective review of tissue expander use for breast reconstruction. A total of 144 tissue expanders were placed in 91 patients; 15 patients (16 percent) had a history of radiation to their affected breast(s). We present two cases of rib fractures found in this subset of irradiated breast reconstruction patients. The first patient was a 46-year-old woman with left breast cancer who had immediate placement of subpectoral breast tissue expanders after bilateral mastectomies. During the expansion period, the left side tolerated smaller filling volumes per visit than the nonirradiated right side. Despite a higher fill volume on the left (430 ml) compared with the right tissue expander (260 ml), there was less projection. To evaluate for the possibility of rib depression secondary to expansion, a computed tomographic scan was obtained. This revealed a healing anterolateral fifth rib fracture and a concave chest wall deformity deep to the implant (Fig. 1). Because of this, she opted for less volume during her final implant reconstruction.Fig. 1.: Computed tomographic scan demonstrating a bony concavity involving the fourth rib secondary to tissue expansion in a previously irradiated left side of the chest wall (above). An arrow demonstrates a left fifth rib fracture under the lateral aspect of the tissue expander. Full (center) and magnified (below) images are shown.The second patient was a 55-year-old woman with recurrent left breast cancer who elected to undergo bilateral mastectomy and immediate reconstruction. During the expansion process, the patient reported sudden onset of chest pain under her left breast tissue expander with associated mild skin erythema. She was taken to the operating room for concern of an acutely infected tissue expander. Intraoperatively, there was no evidence of infection around the tissue expander, but a mobile rib segment was observed. A postoperative chest computed tomographic scan confirmed the presence of a left fifth rib fracture and a moth-eaten appearance to the surrounding left ribs, consistent with postirradiation skeletal changes (Fig. 2). She eventually settled for less tissue expansion volume and went on to a transverse rectus abdominis musculocutaneous flap reconstruction.Fig. 2.: Computed tomographic scan demonstrating the moth-eaten appearance of the left fifth rib, consistent with previous radiation therapy. Full (above) and magnified (below) areas of radiation changes are shown.Radiation causes zones of hyperpigmentation and telangiectasia predisposing to scarring.3 Implants cannot be fully expanded because of this additional fibrotic tissue. Analysis of our tissue expansion experience demonstrates lower average and maximum fill volumes during expansion of previously irradiated patients. In addition to these tissue changes, radiation weakens the skeletal bony matrix. Although there is a paucity of literature, studies cite a risk of rib fractures between 0.3 and 1.8 percent.4,5 The vast majority of them are spontaneous and asymptomatic, rarely occurring within 1 year after irradiation.5 Our review revealed an incidence of 13.3 percent. Given the frequency of patient chest wall complaints during tissue expansion, the true incidence may be even higher. Based on our experience, we recommend that plastic surgeons counsel patients requesting tissue expanders in an irradiated field about the possibility of rib fracture and subsequent need to alter reconstructive plans. A lower clinical threshold is warranted for obtaining imaging studies when previously irradiated patients complain of sudden onset of chest wall pain or postoperative pain beyond expected levels during the tissue expansion process. Jennifer Tseng, B.A. Andrew H. Huang, M.D. Michael S. Wong, M.D. Thomas P. Whetzel, M.D. Thomas R. Stevenson, M.D. Department of Surgery Division of Plastic Surgery University of California Davis Medical Center Sacramento, Calif. DISCLOSURE The authors have no financial interests related to this article.