Effects of radiation therapy on pedicled transverse rectus abdominis myocutaneous flap breast reconstruction.
myocutaneous flap breast reconstruction
Carlson GW, Page AL, Peters K et al.
Annals of Plastic Surgery, 2008, 60, 568-572
This paper describes the Emory University experience of radiotherapy following a pedicled transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. The study was retrospective and there are few details of the follow-up interval. In total, 199 patients underwent 232 pedicled TRAM flap reconstructions. The patients fell into five broad categories: (1) no radiation with immediate reconstruction; (2) no radiation with delayed reconstruction; (3) immediate reconstruction with adjuvant radiotherapy; (4) pre-operative radiotherapy with immediate reconstruction; and (5) delayed reconstruction after pre-operative radiation. Post-operative complications and aesthetic outcomes were evaluated.
The authors did not find any difference in radiotherapy effect on immediate reconstructions in any group. There was a trend towards a higher risk of fat necrosis in patients who had radiotherapy following a TRAM flap (32%). The overall complication rate for all five groups taken together was 35.3%. The highest complication rates were observed in patients who had pre-operative radiotherapy, usually after failed breast conservation, when immediate reconstruction was used following mastectomy.
Four blinded judges reviewed post-operative photographs to grade aesthetic outcome using a subscale analysis (considering the breast mound, breast contour, breast position and the inframammary fold) and global aesthetic score comparing one breast to the contralateral side. The global aesthetic score showed a statistically significant difference of outcome with immediate reconstruction where no radiotherapy was delivered. No differences in subscale analysis and summed subscale scores were identified between the various groups. No mention is made of what contralateral procedures were performed to achieve symmetry. The lack of significance may thus not have simply been related to the radiotherapy effect on the ipsilateral breast reconstruction.
There is considerable evidence in the literature that autologous tissue is affected by radiotherapy and the authors discuss this comprehensively. Recent trends have been to use perforator flaps and in particular the deep inferior epigastric perforator (DIEP) flap reconstruction. Rogers and Allen  had shown that there was significant fat necrosis and radiation fibrosis within patients who have had this type of surgery followed by radiotherapy compared with those who did not have radiotherapy, despite a theoretically better blood supply in free flaps compared to pedicled flaps.
While the authors could have used these data to argue that radiotherapy may have had a non-significant impact on the aesthetic scores, they rightly concluded that it may have been the limitations of the assessment tools they used that resulted in the apparent lack of difference between the various subsets. Long-term aesthetic outcome needs to be viewed with caution when radiotherapy is recommended for oncological management in patients considering immediate breast reconstruction using autologous tissue.
[1.] Rogers NE and Allen RJ. Radiation effects on breast reconstruction with the DIEP flap. Plast Reconstr Surg, 2001, 109, 1919-1924.
Commentary by Gerald Gui
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|Publication:||Advances in Breast Cancer|
|Date:||Jun 1, 2008|
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