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Breast Reconstruction and Radiation Therapy:
An Update
Jonas A. Nelson, MD
Summary: With the indications for radiation therapy in the treatment of breast
Joseph J. Disa, MD
cancer continuing to expand, many patients present for reconstruction having
New York, N.Y. previously had radiation or having a high likelihood of requiring radiation
following mastectomy. Both situations are challenging for the plastic surgeon,
with different variables impacting the surgical outcome. To date, multiple stud-
ies have been performed examining prosthetic and autologous reconstruction
in this setting. The purpose of this article was to provide a general platform
for understanding the literature as it relates to reconstruction and radiation
through an examination of recent systematic reviews and relevant recent pub-
lications. We examined this with a focus on the timing of the radiation, and
within this context, examined the data from the traditional surgical outcomes
standpoint as well as from a patient-reported outcomes perspective. The data
provided within will aid in patient counseling and the informed consent pro-
cess. (Plast. Reconstr. Surg. 140: 60S, 2017.)

s breast conserving therapy (BCT) has simi- to undergo IBR,14,16 this cohort has seen recent
lar survival benefit compared with mastec- increases in IBR overall.16,17 This increase appears
tomy when appropriately utilized,1–4 the to again be isolated to implant-based modalities,
majority of eligible women opt for this option as it which are now the most common modality in
has demonstrated superior psychosocial results.5 these patients.16,17
However, a small portion of women who undergo Both premastectomy and PMRT present a
BCT experience a locoregional recurrence ulti- significant challenge for the reconstructive sur-
mately requiring salvage mastectomy.6–8 geon. The purpose of this article was to provide
Additionally, the indications for postmastec- an understanding of the literature as it relates to
tomy radiation therapy (PMRT) are expanding. breast reconstruction and radiation with an exam-
Although the American College of Radiology cur- ination of recent systematic reviews and relevant
rently recommends radiation for tumors greater publications. We will focus on the timing of the
than 5 cm or > 4 involved lymph nodes,9,10 PMRT radiation and will examine the data from the tra-
is often applied more broadly, given its benefit in ditional surgical outcomes standpoint as well as
preventing local recurrence,11 especially given the from a patient-reported outcomes perspective.
National Comprehensive Cancer Network’s rec-
ommendation to expand PMRT to patients with
tumors 5 cm or smaller and 1–3 positive nodes.12
Although BCT is the central component of WALL TISSUES
surgical breast cancer treatment, recent popula- Radiation therapy induces tissue injury that
tion-based studies have demonstrated increasing can be categorized as acute or chronic.18 The
rates of mastectomies.13 Associated with this trend spectrum of acute injury includes erythema,
is an increase in immediate breast reconstruc- edema, desquamation, hyperpigmentation, and
tion (IBR) rates,14,15 which is related to utiliza- ulceration,19 ranging from mild to severe. Acute
tion of implant-based modalities.14,15 Interestingly, radiation dermatitis occurs in upward of 85% of
although patients who need PMRT are less likely treated patients.19,20 Chronic injury involves skin
atrophy, dryness, telangiectasia, dyspigmentation,
and dyschromia.21 In the breast, it leads to chronic
From the Memorial Sloan Kettering Cancer Center, Plastic fibrosis of the skin and subcutaneous tissues. This
and Reconstructive Surgery Service.
Received for publication June 27, 2017; accepted August
17, 2017. Disclosure: Neither of the authors has any conflicts
Copyright © 2017 by the American Society of Plastic Surgeons of interest to report. No funding was received.
DOI: 10.1097/PRS.0000000000003943

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Volume 140, Number 5S • Breast Reconstruction and Radiation Therapy

fibrosis and surrounding injury can lead to pain Pooling the analysis, the authors demonstrated
and restricted movement of the arm. The chronic an increase in nearly all complications exam-
changes from radiation can take months to years ined. A significantly higher risk of reconstruc-
to fully manifest.20,22 tive failure [14% rate overall; relative risk, 2.58
(1.86–3.57)] and total complications [36% rate
overall; relative risk, 1.89 (1.57–2.28)] was noted
TIMING OF RECONSTRUCTION AND in radiated patients. Capsular contracture risk
RADIATION was also higher [relative risk, 3.32 (1.36–8.13)],
Patients generally present at 2 time points as it as was risk for infection, mastectomy flap necro-
relates to radiation. They have either been previ- sis, and seroma formation. Subgroup analyses
ously radiated or have a high likelihood of requir- were performed in nipple-sparing mastectomies
ing PMRT. While both involve radiated fields, the and in the application of ADM to the recon-
decision points are very different and require a structions, with similar findings of increased
specific discussion in the preoperative, informed complications.
consent process. Additional recent studies continue to cast a
Breast radiation protocols and dosing can vary concerning shadow on this modality in the setting
greatly by institution, and differences in radiation of prior radiation. In 2016, Chen et al.29 published a
timing even exist within standard institutional retrospective cohort study comparing prosthetic-
protocols depending on the nature of the cancer based reconstruction in patients with preradia-
and neoadjuvant therapy that has been initiated.23 tion, PMRT, and no radiation. They found an
Radiation oncology continues to evolve with trials increased risk of complications in the preradia-
and utilization of more directed radiation delivery tion cohort, with reconstructive failure occurring
instead of simply whole breast radiation.24 In an in 50% of breasts. As such, the authors advocate
effort to streamline reconstruction in the setting for autologous reconstruction in this setting.
of PMRT, many institutions follow an algorithmic Kearney et al.30 also published a study examining
approach.20,25,26 The general protocol for radia- these 3 cohorts but found fewer overall differ-
tion following prosthetic reconstruction at Memo- ences in complications. They did, however, note
rial Sloan Kettering has been recently outlined.27 a significant increase in conversion from pros-
thetic to autologous reconstruction in the prera-
diation cohort compared with patients without
PREVIOUS RADIATION THERAPY radiation (10.5% versus 0.6%; P = 0.03).30 Reish
Patients who have had previous radiation et al.31 similarly compared these cohorts and also
and present for reconstruction generally fit into demonstrated higher rates of complications in
2 main categories. They (1) failed BCT requir- preradiation and higher rates of explantation in
ing salvage mastectomy and desiring IBR or (2) patients with PMRT. Secondary procedures were
are true delayed reconstruction following mastec- also higher in the radiated cohort.
tomy and PMRT. SUMMARY POINT: Previous radiation intro-
duces significant risk for implant reconstructive
Tissue Expander/Implant Reconstruction failure and complications though incidence var-
Patients who have undergone previous radia- ies widely across institutions. Pooled analysis
tion traditionally have been discouraged from suggests the incidence of reconstructive failure
implant-only breast reconstruction, given a poor to be 14%.
complication profile. This setting conveys some of
the highest reported rates of reconstructive fail- Autologous and Tissue Expander/Implant
ure in patients with prosthetic reconstruction but Reconstruction
with significant variations and conflicting results Traditional teaching encouraged the use of
existing in the literature. However, recent stud- autologous tissue in conjunction with a prosthetic
ies demonstrate that implant reconstruction is device in previously radiated fields, which most
more popular in this scenario than autologous commonly employs the latissimus dorsi (LD) myo-
modalities.17 cutaneous flap. This allows for the recruitment
Lee and Mun28 in 2015 published a systematic of healthy tissue to the breast, which covers the
review to better understand the outcomes fol- device and expands to a better degree than the
lowing prosthetic reconstruction in this patient irradiated surrounding tissues following salvage
population. They examined 20 studies all but mastectomy (Fig. 1) or in delayed reconstruction
one of which were retrospective cohort designs. cases following completion of radiation.

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Plastic and Reconstructive Surgery • November Supplement 2017

Fig. 1. Preoperative and postoperative images (1 year) in a patient with lumpectomy defect and radiation to left breast. She had
bilateral mastectomies with immediate tissue expander placement bilaterally and a LD flap to the left breast.

Fischer et al.32 published in 2016 a system- we published a series of 57 patients demonstrating
atic review on the use of prosthetic breast recon- the safety of this technique in salvage mastectomy,
struction with and without autologous tissue in with a very acceptable complication profile.33
the radiated field. Pooled results from 31 studies Other recent studies demonstrate that using this
demonstrated a significant decrease in implant for IBR in a salvage setting demonstrate compa-
loss in the LD/implant group compared with rable complication profiles to use of the LD and
implant-only (15% versus 5%; P < 0.001). Further- prosthesis in a completely delayed fashion after
more, odds of loss was 4.33 (P = 0.0003) favoring PMRT.34
LD-assisted reconstruction. A similar difference SUMMARY POINT: Use of autologous tissue
was noted for postoperative infections, although (LD) with implant significantly reduces incidence
no difference was found in capsular contracture of reconstructive failure in previously radiated
incidence.32 fields (72% decreased risk).28
As part of their systematic review of prosthetic
reconstruction following premastectomy radia- Autologous Reconstruction
tion, Lee and Mun28 also analyzed the use of the Autologous tissue has long been considered
LD. They noted a 72% decreased risk of recon- the cornerstone of breast reconstruction in a radi-
structive failure when autologous tissue and a ated field. Bringing healthy, distant tissue into
prosthetic device was utilized as compared with a previously radiated site enables a much more
prosthetic device alone (relative risk, 0.28; CI, supple, aesthetic reconstruction to be achieved.
0.15–0.52). Reconstructive failure for prosthetic Compared with implant reconstruction in the set-
device with autologous tissue was 6.9% compared ting of previous radiation, the risk of reconstruc-
with 33.7% for prosthetic-only reconstruction. tive loss is 92% decreased.28 However, radiation
Rate of infection and capsular contracture did not damage still introduces additional challenges to
differ. the reconstruction.
Use of the LD has been utilized for years in Autologous reconstruction in a radiated field
this setting at our center and is often the choice requires operating in a fibrosed environment.
of reconstruction when the previously radiated tis- The microvasculature is impacted in the sur-
sues are fibrosed and not pliable and the patient rounding tissues, as are the more macroscopic
desires implant-based reconstruction or is not a vessels.35 Several studies have directly examined
candidate for an autologous only option. In 2008, the impact of prereconstruction radiation. In

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Volume 140, Number 5S • Breast Reconstruction and Radiation Therapy

2016, Fracol et al.36 at the University of Penn- POSTMASTECTOMY RADIATION
sylvania examined outcomes following prior THERAPY
unilateral radiation in bilateral reconstruction. Debate surrounds the timing and method of
They showed that microvascular arterial com- reconstruction in the setting of PMRT. For pros-
plications were significantly more common in thetic reconstruction, the discussion relates to
the radiated field—but that this did not impact radiating the tissue expander or the final implant.
outcomes overall. This was a follow-up study to a For autologous reconstruction, the debate cen-
similar study by Fosnot et al.37, which examined ters on directly radiating the flap or delaying the
1,025 flaps, 226 of which were placed into radi- reconstruction until after radiation. It is important
ated beds. Again, an increase in intraoperative to remember when considering the following dis-
vascular complications was noted (14.2% versus cussion that radiation protocols vary greatly from
7.6%; P = 0.003) without a change in individual 1 institution to another. The protocols often differ
outcomes such as fat necrosis, delayed vascu- in terms of timing and radiation dose, which can
lar complications, or flap loss.37 Flap loss was make comparison difficult as radiation has dose-
noted to be 3.1% in the radiated cohort com- dependent effects.
pared with 1.5% in patients without radiation
(P = 0.13). The authors suggest that such micro- Tissue Expander/Implant Reconstruction
vascular complications were typically technical Radiation following immediate prosthetic
and involved the need to revise an anastomosis breast reconstruction occurs at 2 general time
or further dissect the recipient vessels for a more points—following the placement of the tissue
useable target. As such, additional care and a expander (Fig. 2) or following the final exchange
heightened vigilance for issues with anastomo- for the permanent implant (Fig. 3). Numerous
ses should be employed in this setting. studies have examined this topic, with conflicting
In 2016, de Araujo et al.38 also examined out- results and conclusions.
comes following prior unilateral chest wall radia- In 2013, Lam et al.39 published a systematic
tion in bilateral patients. Radiation increased review attempting to determine optimal sequenc-
the odds for breast-related complications (OR, ing for radiation in 2-stage reconstruction. Over-
2.98; P < 0.0001), infection (OR, 2.59; P = 0.027), all, 12 studies were included (only 1 prospective),
and major skin loss (OR, 3.47; P = 0.0266). Inter- which pooled 715 radiated patients and 1,138
estingly, no difference was noted by modality nonradiated patients. Radiation increased recon-
comparing autologous to implant-based recon- structive failure (18.6% versus 3.1%; P < 0.00001),
structions (P = 0.76). Furthermore, subgroup and more specifically, failure occurred at higher
analysis yielded no difference in extrusion of rates not only when applied to the expander
implants or in flap losses comparing the radiated (29.7% versus 5.0%; P < 0.00001) but also when
to nonradiated sides. given directly to the implant (7.7% versus 1.5%;
SUMMARY POINT: Autologous tissue is the P = 0.0003). This review also noted increased risk
gold standard for reconstruction in previously of severe capsular contracture for both radiation
radiated fields, though intraoperative microvas- to the tissue expander (TE) (8.9% versus 0.5%;
cular vascular complications as well as postopera- P = 0.01) and also to the permanent implant
tive minor complications may be more common (7.9% versus 0.2%; P = 0.002), although no differ-
in this setting. ence between timing was noted.

Fig. 2. Preoperative and postoperative images (2 months, 2 years) of a patient who underwent bilateral mastectomies and PMRT
to the left expander, with subsequent exchange to permanent implant.

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Plastic and Reconstructive Surgery • November Supplement 2017

Fig. 3. Preoperative and postoperative images (1 month, 7 months) of a patient who underwent unilateral right mastectomy with
tissue expander placement. She was exchanged and subsequently underwent radiation to the permanent implant.

Lee and Mun40 built upon this in 2017, focus- reconstruction, a project which was included in
ing only on the difference between timing of radia- both the reviews by El-Sabawi et al.20 and Lee.40
tion to either the expander or permanent implant. This article detailed a 9-year period at Memorial
Their analysis included 8 studies and 899 patients. Sloan Kettering Cancer Center and specifically
Again, only 1 prospective study was included. compared radiation with the expander (n = 94)
Although the pooled risk of failure tended to be and radiation to the implant (n = 210). Cordeiro
higher in the radiation to TE cohort compared et al.27 found higher rates of loss when radiat-
with the radiation to permanent implant cohort ing the expander (32% versus 16%; P < 0.01),
(16% versus 10%), no statistical difference was however importantly noted that radiation to the
noted [relative risk, 1.72 (0.81–3.64)]. However, a permanent implant resulted in a lower aesthetic
significant difference was noted with regard to cap- result (P < 0.01) and higher rates of capsular con-
sular contracture, with the radiation to TE cohort tracture (P < 0.01).
having lower risk compared with the radiation to In 2016, Santosa et al.44 published results from
implant cohort (relative risk, 0.44; P < 0.001). the Mastectomy Reconstruction Outcomes Con-
El-Sabawi et al.20 also published a review sortium (MROC) study in an effort to provide
examining evidence-based outcomes and algo- new data to this discussion. Overall, 150 patients
rithmic approaches to PMRT. Seventeen studies with PMRT were included (104 TE, 46 implant).
were included, the majority of which were level All patients had follow-up for at least 6 months
III evidence. Most studies examined radiation to following their last procedure. No significant dif-
the TE, with complication rates ranging widely. ferences were noted in any complication or out-
Reconstructive failures ranged from 4.8% to 40%, come. On examination of the data, the rates of
and capsular contracture rates ranged from 12.5% complications were slightly lower in general for
to 53.3%. This review further commented on tim- the implant group, but not significant. It is pos-
ing of exchange to permanent implant following sible that a difference was not noted secondary to
PMRT, with results demonstrating increased time small sample size or short overall follow-up time.
from radiation having improved outcomes.41,42 However, these are high-quality data that were
Complication rates following radiation to the prospectively obtained.44 These results continue
permanent implant were slightly lower for loss to demonstrate the challenge in this area of study,
(0–29%), but higher for capsular contracture with many studies with differing results. That
(46.6–57.8%). Studies directly comparing timings being said, these results are consistent with the
were not pooled in this review but presented as systematic review from Lee and Mun.40
individual study data. Each study demonstrated In 2014, Momoh et al.45 published a systematic
a decrease in rate of loss of the prosthesis when review comparing prosthetic reconstruction in
PMRT was performed postexchange.20 This group prereconstruction radiated fields compared with
also published a review examining PMRT and PMRT. Interestingly and in contrast to what would
breast reconstruction overall. PMRT to the per- be anticipated, given the majority of the other
manent implant was again favored compared with studies discussed above, they found no significant
PMRT to the expander (loss rate 18.8% versus differences comparing the 2 reconstructive time
14.7%; P = 0.006).43 points. Reconstructive failure was similar, at 19%
Cordeiro et al.27 examined the ideal tim- for prereconstruction and 20% for postrecon-
ing of radiation therapy in 2-stage prosthetic struction radiation.45 Although they conclude that

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Volume 140, Number 5S • Breast Reconstruction and Radiation Therapy

in both groups there are clinically significant fail- Several recent systematic reviews have been
ure rates, it is important to note that in both nearly completed on the use of autologous abdomi-
80% of patients achieved stable reconstruction. nally based breast reconstruction in the setting of
It should be noted that some groups radiate PMRT. Schaverian et al.48 in 2013 examined IBR
the expander instead of the implant at the request with PMRT compared with IBR without PMRT and
of the radiation oncologists, who at times desire then also examined IBR with PMRT compared
a deflated tissue expander to radiate the internal with true delayed autologous reconstruction.
mammary lymph nodes and better contour the The pooled results comparing IBR with PMRT
heart and lungs. to IBR alone (1,247 patients in total) showed an
SUMMARY POINT: PMRT significantly increased odds of fat necrosis with PMRT (OR,
increase the risk of reconstructive failure, be it to 2.82; P = 0.006), but no significant differences in
the tissue expander or implant. Meta-analyses and further complications.
recent prospective studies suggest no significant Rochlin et al.49 in 2015 performed an updated,
difference in the timing of radiation (pooled inci- more narrow review that included 11 studies and
dence approaches 20%), though many level III 337 patients. They found an increased odds of fat
studies exist demonstrating contrary findings. necrosis when flaps were directly radiated (OR,
3.13; P = 0.005) among 3 studies with radiated
Autologous Reconstruction control cohorts, with rates of revision surgery,
For patients electing autologous reconstruc- fat necrosis, and contour irregularities ranging
tion in the setting of PMRT, the ideal timing between 16% and 35%. Variable results were
of reconstruction is debated. Some surgeons noted in aesthetic outcomes. No significant dif-
believe that IBR is ideal in all situations, and that ferences were noted regarding revisions, contour
it is okay to radiate a free flap (Fig. 4). Others, irregularities, or aesthetic results.
wish to not radiate a flap, given the resulting Yet, while these reviews overall demonstrate
fibrosis and contracture that could be induced a potential increase in fat necrosis, a growing
to the reconstruction. Out of this debate was body of recent literature continues to advocate
born the concept of delayed immediate recon- for immediate free tissue reconstruction.50–52 Kel-
struction,46,47 a technique for patients desiring ley et al.53 in 2014 reviewed 20 articles examining
autologous reconstruction in which case a tissue autologous reconstruction with a slightly different
expander is placed at the time of mastectomy and focus—they pooled and compared prereconstruc-
acts as a space holder until the definitive need for tion radiation and PMRT following IBR. Interest-
radiation is determined. Should a patient need ingly, they found similar rates of complications
to undergo radiation, they would be radiated between the timing of radiation and reconstruc-
with an expander in place, preserving some of tion, with no significant differences including an
the breast boundaries. If radiation is not needed, examination of fat necrosis rates. Flap contrac-
autologous reconstruction could then be per- ture rates were noted to be 27% in patients with
formed. This would avoid direct radiation to PMRT.53 Mirzabeigi et al.50 presented the Uni-
the flap itself. The alternative for surgeons who versity of Pennsylvania experience over a 4-year
wish to avoid irradiating the flap would be true period and demonstrated that while volume loss
delayed reconstruction. (28.3% versus 4.4%; P < 0.0001) and fat necrosis

Fig. 4. Preoperative and postoperative images (3 months, 10 months) of a patient who underwent bilateral mastectomies with
immediate deep inferior epigastric perforator flap reconstruction followed by right PMRT.

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Plastic and Reconstructive Surgery • November Supplement 2017

(19.6% versus 3.6%; P = 0.002) were higher in the disease process. The decision point is typically not
irradiated IBR cohort, rates of revision surgery whether or not to undergo radiation but instead
did not differ. This finding is somewhat surpris- is in the choice of timing and modality for recon-
ing and counterintuitive but supported by other struction. To date, unfortunately, there is little
in the implant revision literature.54 This could be data to help with this specific decision-making
related to both patient factors (more advanced process.
breast cancer) or surgeon preference (lower like- El-Sabawi et al.60 recently performed a com-
lihood of successful revision in a radiated field). prehensive review examining patient-reported
The authors also present data supporting a dif- outcomes of breast reconstruction and PMRT.
ference in fat necrosis based upon the type of They examined 29 articles and demonstrated
flap utilized in this setting, favoring the muscle- that PMRT was associated with poorer outcomes.
sparing free transverse rectus abdominis muscu- Yet, they do note that most studies demonstrate
locutaneous flap over the deep inferior epigastric acceptable rates of aesthetic outcomes and satis-
perforator. There is conflicting data on this final faction. However, more importantly, this review
point, however, in the literature, as Garvey et al.55 brings to light the lack of appropriate PROM data
in 2014 demonstrated no difference in this setting to help accurately address this question.
based on flap type utilized, but continued higher Examining what PROMs were utilized to
rates of fat necrosis. reach this conclusion, the authors found that
In one of the most important recent studies the methodology was generally inadequate for
to date on IBR and PMRT, Billig et al.56 presented comparison. The majority of studies examined
an examination of patients undergoing PMRT included reported aesthetic outcomes, only 33%
and autologous reconstruction from the MROC of which had data that were actually patient-
study. No significant differences over 2 years were reported. Within the aesthetic measures, multiple
noted in complications (P = 0.54) comparing IBR scales and tools were utilized. Only 4 studies were
to delayed reconstruction, although patients with included that utilized the validated Breast-Q, the
delayed reconstruction had lower prereconstruc- majority of which were out of Memorial Sloan
tion Breast-Q scores for satisfaction and Psycho- Kettering Cancer Center.27,59,61,62 Unfortunately,
social and Sexual Well-Being. Most importantly, all these articles examined prosthetic reconstruc-
no difference in postoperative scores were noted tion, and only 1 examined a specific decision
comparing timing of autologous reconstruction point—to radiate the expander or the implant.
and radiation. In the setting of reconstruction, Comparing these timings in just over 300 patients
this study demonstrates a similar complication demonstrated no significant differences in scores.
and patient-reported outcome measure (PROMs) The MROC study has recently helped to add
profile, but given the small sample size should be some important data to this discussion point,
interpreted with some caution. This study is the which was published after the review by El-Sabawi.60
first focused attempt in autologous reconstruction As mentioned above, Billig et al.56 demonstrate no
and PMRT to assess PROMs. significant difference in Breast-Q scores as they
SUMMARY POINT: Existing data suggest that related to timing of PMRT with autologous recon-
directly PMRT following immediate autologous struction. To date, the MROC study has yet to pres-
reconstruction may increase the odds of fat necro- ent PRO data from prosthetic reconstructions,
sis but has little impact on complications and rates which undergo PMRT. This study begins to move
of revision surgeries. us in the right direction of a multi-institutional
prospective examination of breast reconstruction.
However, controlling for institutional variance
is challenging. It is also not a randomized study,
PROMs are an increasingly utilized metric which would certainly be a difficult study design
whereby success of a treatment is determined. to carry out in this setting. Continued research is
The data generated from tools such as the Breast- certainly warranted in this field, with a focus on
Q effectively put the final judgment of treatment PROMs as a main focus.
back into the hands of the patient.57 Autologous
reconstruction has become the gold standard for
long-term overall breast reconstruction patient- CONCLUSIONS
reported satisfaction.58 However, radiation sig- Radiation is an essential component to breast
nificantly decreases patient satisfaction,59 yet cancer treatment but often has a detrimen-
is a needed component of the treatment of the tal effect on the reconstructive result. Patients

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Volume 140, Number 5S • Breast Reconstruction and Radiation Therapy

who undergo radiation prior to reconstruction 10. Horst KC, Haffty BG, Harris EE, et al. Expert panel on

experience high rates of prosthetic device loss radiation oncology—breast. ACR Appropriateness Criteria®
Postmastectomy Radiotherapy. Reston (VA): American College
but can have low rates of autologous flap loss of Radiology (ACR); 2012.
yet higher rates of intraoperative microvascu- 11. Clarke M, Collins R, Darby S, et al.; Early Breast Cancer
lar issues. Furthermore, PMRT can also lead to Trialists’ Collaborative Group (EBCTCG). Effects of radio-
prosthetic device loss, capsular contracture, and therapy and of differences in the extent of surgery for early
breast cancer on local recurrence and 15-year survival: an over-
higher rates of infection. In autologous recon-
view of the randomised trials. Lancet. 2005;366:2087–2106.
structions, higher rates of fat necrosis and con- 12. Carlson RW, Allred DC, Anderson BO, et al.; NCCN Breast
tour deformities are noted, but without changes Cancer Clinical Practice Guidelines Panel. Breast cancer.
in revision rates. To date, PROMs are lower in Clinical practice guidelines in oncology. J Natl Compr Canc
radiated patients, but few differences have been Netw. 2009;7:122–192.
13. Cemal Y, Albornoz CR, Disa JJ, et al. A paradigm shift in
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