The Effects of Postmastectomy Adjuvant Radiotherapy on Immediate Two-Stage Prosthetic Breast Reconstruction

Sir: We read with interest the article entitled “The Effects of Postmastectomy Adjuvant Radiotherapy on Immediate Two-Stage Prosthetic Breast Reconstruction: A Systematic Review” (Plast Reconstr Surg. 2013;132:511–518). Lam and colleagues have published a very interesting systematic review that examined the published evidence on the effects of radiotherapy on immediate two-stage prosthetic breast reconstruction to verify the correct timing of radiation therapy in relation to each stage. A total of 12 studies fulfilled inclusion criteria with a total of 1853 patients (715 irradiated and 1138 nonirradiated). The authors found that adjuvant radiotherapy resulted in a significantly higher reconstruction failure rate in immediate two-stage prosthetic breast reconstruction compared with controls (18.6 percent versus 3.1 percent; p < 0.00001). The failure rate was worst when radio therapy was given after stage 1 (expander) (29.7 percent versus 5 percent; p < 0.00001) compared with stage 2 (permanent implant) (7.7 percent versus 1.5 percent; p= 0.0003). Considering the data listed in the article, we would like to add the protocol followed in our Breast Unit regarding radiotherapy after immediate two-stage breast reconstruction As described by one of the references included in the review,1 our radiation oncologist prefers to begin the radiation treatments within 6 weeks after mastectomy if it is indicated, and within 6 months if the patient has to undergo adjuvant chemotherapy. In both cases, we do not have sufficient time to finish the expansion and to consolidate and substitute tissue expander for a definitive prosthesis. For these reasons, the clinical practice in our Breast Unit is to perform radiotherapy after stage 1 breast reconstruction, interrupting tissue expansion during radiation therapy. We restart the expansion 1 to 3 months after radiotherapy. Relying on our clinical experience in scar treatment,2,3 postmastectomy pain syndrome treatment,4 and on the study by Rigotti et al.,5 we widely applied autologous fat grafting in irradiated breasts after first-stage reconstruction. In fact, our studies demonstrated a stimulation of local neoangiogenesis (with histologic and histochemical proofs) that allows us to lower the rate of complications caused by the radiation-induced vascular damage. In summary, we begin the radiation treatment within 9 weeks after mastectomy and within 6 months if chemotherapy is indicated. We restart the expansion 1 to 3 months after the end of radiotherapy and we perform fat grafting 3 months before or at the time of expander substitution. We recently started to analyze the breast reconstruction failure rate in our study population from 2010 to 2013. Our failure rate at a mean follow-up of 18 months is lower (20 percent) than the one described by other studies. We believe that our practice could efficiently reduce the complication rate in irradiated breasts after stage 1 breast reconstruction and, because of autologous fat transplantation, we are able to highly increase reconstructive outcome for Breast Units that follow our oncologic guidelines for patients submitted to radiotherapy on tissue expanders. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. Luca Maione, M.D. University of Milan Reconstructive and Aesthetic Plastic Surgery School Department of Medical Biotechnology and Translational Medicine BIOMETRA Plastic Surgery Unit Humanitas Clinical and Research Center Rozzano Davide Forcellini, M.D. University of Milan Reconstructive and Aesthetic Plastic Surgery School Plastic Surgery Unit MultiMedica Holding S.p.A. Sesto San Giovanni Valeriano Vinci, M.D. University of Milan Reconstructive and Aesthetic Plastic Surgery School Department of Medical Biotechnology and Translational Medicine BIOMETRA Plastic Surgery Unit Humanitas Clinical and Research Center Rozzano Andrea Lisa, M.D. University of Milan Reconstructive and Aesthetic Plastic Surgery School Department of Medical Biotechnology and Translational Medicine BIOMETRA Plastic Surgery Unit Humanitas Clinical and Research Center Rozzano Fabio Caviggioli, M.D. Francesco Klinger, M.D. University of Milan Reconstructive and Aesthetic Plastic Surgery School Plastic Surgery Unit MultiMedica Holding S.p.A. Sesto San Giovanni, Italy