ASO Author Reflections: An Evolving Approach to Autologous Reconstruction in the Setting of Postmastectomy Radiation
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ASO AUTHOR REFLECTIONS
ASO Author Reflections: An Evolving Approach to Autologous Reconstruction in the Setting of Postmastectomy Radiation Danielle R. Heller, MD, MHS1 Brigid K. Killelea, MD, MPH3
, Tomer Avraham, MD2, Donald R. Lannin, MD3, and
1
Department of Surgery, Yale University School of Medicine, New Haven, CT; 2Division of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, CT; 3The Breast Center, Department of Surgery, Yale University School of Medicine, New Haven, CT
Until recently, the question of when to perform breast reconstruction for women requiring postmastectomy radiation therapy (PMRT) appeared settled. Influential data out of MD Anderson, Georgetown University, and other prominent institutions classically supported delaying reconstructive surgery in an effort to spare the neo-breast from potentially tissue-toxic, shape-distorting effects of radiation.1,2 These effects were particularly well-documented in the setting of prosthetic implants and transverse rectus abdominis myocutaneous flaps. With refinement in reconstruction techniques and the emergence of innovative treatment protocols, this paradigm is now being challenged. A 2014 systematic review of data pooled from 20 studies published in this journal demonstrated similar rates of flap complications among women who underwent immediate versus delayed autologous reconstruction.3 A 2017 multi-institutional study from the Mastectomy Reconstruction Outcomes Consortium analyzing both clinical and patient-reported outcomes revealed similar complication rates and patient satisfaction levels among these dichotomous treatment groups.4 Renewed interest in immediate reconstruction spawned the current experimental protocol at MD Anderson, in which patients are treated with neoadjuvant radiotherapy prior to onestage mastectomy reconstruction.5 As reports of improved
surgical outcomes mount, the benefits of immediate reconstruction consolidating the pain, recovery time, inconvenience, and cost of breast cancer surgery are becoming better recognized by patients and practitioners. Our experience performing immediate autologous reconstruction followed by PMRT offers robust contemporary data in support of this approach. In our 130-patient series, we found a 36% complication rate, the majority of which included fat necrosis and chest wall asymmetry, and a 25% reoperation rate, the majority of which included excision of fat necrosis and flap contouring.6 These figures fall in the range of prior reports among delayed reconstruction cohorts. Beyond characterizing surgical outcomes, our analyses identified specific clinical factors that were associated with a heightened risk of adverse outcomes, including internal mammary nodal radiation and initiation of PMRT at a short interval after surgery. The impact of these factors on surgical outcomes in delayed reconstruction is unknown, but the data certainly call for similar analyses among cohorts treated with alternatively sequenced protocols. As indications for PMRT have expanded
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