1. Morbidity associated with autologous breast reconstruction before and after exposure to radiotherapy

2. Literature
“Radiation has a deleterious effect on autologous flap reconstruction.
delayed reconstruction seems to be a safe option in most of the cases.”
“Autologous breast reconstruction can be performed safely regardless
of preoperative or postoperative radiation therapy.”
“Primary reconstruction with DIEP flaps can be performed successfully in patients who require PMRT.”
“Postmastectomy radiation therapy can result in volume loss and
fat necrosis.”
Consensus?

3. ‘Should autologous reconstructions be delayed if there is a probability of radiation therapy in the post-operative period?’

4. Radiotherapy Indications T3 T4 Positive LN Lymphovascular invasion
Positive margins
Triple negative tumors
 Pathology report?

5. Radiotherapy Impact on breast reconstruction? • Early changes
Erythema, desquamation, edema
• Late changes
Contracture, loss of volume and distortion
Progressive! 3-5y
“Pathofysiology of irradiated skin and breast” int. J. Radiation Oncology Biol. Phys. 1995

6. Influence of radiotherapy on the timing of reconstructions
Influence is dual
Oncological safety
Effects of RT on outcome of
reconstruction
Delayed
Immediate
ME + IR
Adjuvent therapy ME
Adjuvent therapy DR

7. Matter of debate
Studies are contradictory
Perforator flaps
Literature?
Only three studies

8. “Radiation effects on breast reconstruction with the deep inferior epigastric perforator flap” Nicole E. Rogers, Robert J. Allen PLASTIC AND RECONSTRUCTIVE SURGERY? MAY 2002
30 patients IR and PMRT
30 matched patients without PMRT
Structural changes
Esthetic outcome
Result: significant higher rate of fat necrosis, fibrosis and flap contracture in the irradiated group

10. “Effect of postoperative radiotherapy on autologous deep inferior epigastric perforator flap volume after immediate breast reconstruction” J. S. Chatterjee, A. Lee, W. Anderson, L. Baker, J. H. Stevenson, J. A. Dewar and A. M. Thompson Br J Surg. ocT 2009
22 patients with IR and PMRT
Measurement of flap-volume intra-operative
Measurement breast volume with Morris-mammometer
Result: reduction of 65ml in irradiated group, no volume
change in other group.

11. “Comparison of Irradiated Versus Nonirradiated DIEP Flaps in Patients Undergoing Immediate Bilateral DIEP Reconstruction with Unilateral Postmastectomy Radiation Therapy (PMRT)” Emily M. Clarke-Pearson? Manjeet Chadha? Erez Dayan, Joseph H. Dayan, William Samson? Mark R. Sultan, Mark L. Smith Annals of plastic surgery, 2003
11 patients with immediate bilateral DIEP-flap and unilateral PMRT
minor complications
no clinically significant fat necrosis
satisfactory esthetic outcome

12. Conclusion of literature
Limited study population
Follow-up time
Lack of objective measurements
Subjective parameter?
Comparison between radiotherapy before and after reconstruction

13. Lack of good quality studies
Timing remains controversial
Need for more investigation
Consensus
Develop guidelines

14. UZ Leuven
Retrospective single-centre study IR and PMRT PMRT and DR

15. Patients and methods August 1997- October 2013 : 1547 patients
Inclusion criteria:
Follow-up: >3y
Unilateral
Radiation therapy chest wall
20 patients with IR and PMRT
40 matched patients with PMRT and DR

16. Outcomes measured 1) Structural chances 2) Patients satisfaction
Infection
Wound dehiscence
Fat necrosis
Fibrosis/contracture
Revision
Flap failure
Secondary procedures
Contralateral procedures
2) Patients satisfaction
BREAST-Q questionnaire: QoL, satisfaction and expectations
3) Photographs

17. Patients characteristicsIR DR
No of patients 20 40
Age, y
- Mean
46,25
46,08
- Range
35-62
32-62
BMI
22,9
21,5
17-33,1
19-34,2
Type flap
- DIEP 18 37
- SGAP 1
- SIAE 2
Chemotherapy
- Yes 15 29
- No 5 11
Smoking 2 4 18 36
RT: 50 Gy, 25 sessions 20 40

18. Results structural changes
Variable
Statistic
Cases
Controls
P-value
infection
n/N (%)
16/20 ( 80.00%)
38/40 ( 95.00%)
0.089 1
4/20 ( 20.00%)
2/40 ( 5.00%)
wound dehiscence
17/20 ( 85.00%)
36/40 ( 90.00%)
0.676
3/20 ( 15.00%)
4/40 ( 10.00%)
fat necrosis
8/20 ( 40.00%)
35/40 ( 87.50%)
<.001
12/20 ( 60.00%)
5/40 ( 12.50%)
fibrosis/contracture
39/40 ( 97.50%)
1/40 ( 2.50%)
flap revision
20/20 (100.00%)
0.548
0/20 ( 0.00%)
flap failure
40/40 (100.00%)
Variables are analyzed using a Fishers Exact test. All reported p-values are two-sided.

19. Variable
Statistic
Cases
Controls
P-value
secondary procedures N 20 40
0.432
Mean
1.9
1.4
Std
1.79
1.37
Median
2.0
IQR
(0.0; 2.5)
(0.0; 2.0)
Range
(0.0; 5.0)
contralateral procedures
0.658
0.6
0.7
0.94
0.0
Variables are analysed using a Mann-Whitney U test. All reported p-values are two-sided.

20. Interpretation
Significantly higher rates of fat necrosis and fibrosis/contracture are observed among IR with PMRT than DR
A trend towards higher infection rate among IR is observed
No evidence is found for differences between both groups regarding other complications

21. Patient 1 Age: 37y BMI: 20,76 Chemo: / Non-smoker Contracture
Lipofilling
Patient 1

22. Patient 2 Age: 64y BMI: 29,40 Chemo: / Non-smoker
Fat necrosis and contracture
Lipofilling
Patient 2

23. Randomising Factors predicting outcome? Delayed-immediate?
Conclusion
Randomising
Factors predicting outcome?
Delayed-immediate?

24. Delayed-immediate? 2-staged approach
Stage 1: mastectomy + tissue expander
Stage 2: definitive reconstruction
Stage 2 depends on pathologic report:
when no PMRT is needed: stage 2 is performed after several days
PMRT is needed: stage 2 is performed after 3 months
Delayed-immediate?

26. Conclusion Randomising Factors predicting outcome Immediate-delayed?
First results in favor of delaying…