Breast Surgery

Asymmetry Correction in the Irradiated : Outcomes of Reduction and Mastopexy After Breast-Conserving Therapy

Michael S. Chin; Glen S. Brooks, MD; Kristin Stueber MD; Anoush Hadaegh, MD; John Griggs, MD; and Melissa A. Johnson, MD

Background: There is relatively scant evidence concerning radiation effects on reduction mammaplasty Downloaded from https://academic.oup.com/asj/article/29/2/106/270170 by guest on 02 October 2021 and mastopexy, two procedures which are often used in the irradiated breast to restore symmetry fol- lowing breast-conserving therapy (BCT). Objective: The purpose of this study is to further examine outcomes of reduction mammaplasty and mastopexy in patients previously treated with BCT and radiation. Methods: A retrospective search at Baystate Medical Center (Springfield, MA) identified 12 patients who had received external beam radiation and either reduction mammaplasty or mastopexy. Overall radiation doses, including tumor bed boost, ranged from 5000 to 6600 cGy. The mean time between completion of radiation therapy and asymmetry correction was 63 months (range, 5 to 169 months). An overall aver- age of 910 g of tissue was removed from the irradiated breast (range, 180 to 2925 g). The average length follow-up after asymmetry correction was 9 months (range, 1 to 44 months). Results: In our patients, there were no major complications such as flap loss, tissue , heavy - ring, , or severe deformity. Minor complications in the irradiated breast occurred in 25% of patients and included prolonged edema (n = 1), delayed closure (n = 1), and minor scarring (n = 1). Histopathology was unremarkable except for one patient who was found to have recurrent duc- tal carcinoma in situ. Conclusions: In the cases reviewed, we did not observe any complications commonly associated with operating in an irradiated field. Good cosmesis and acceptable symmetry were achieved in all patients. Our data suggest that reduction mammaplasty and mastopexy after radiation therapy are relatively safe procedures with risks not significantly higher than either operation performed in patients without radia- tion. (Aesthetic Surg J 2009;29:106–112.)

s the practice of breast-conserving therapy (BCT) and implant reconstruction outcomes in post-mastecto- has become more widespread, the use of radia- my patients.3-6 However, there is a paucity of evidence Ation on breast tissue after has regarding the effects of radiation on standard reduction become more common. Consequently, of mammaplasty and mastopexy, two procedures that are the breast is often performed in a previously irradiated often used in the irradiated breast to restore bilateral field. The potential adverse effects of radiation therapy symmetry following BCT.7,8 on breast tissue are well-established and suboptimal Two cases reported independently by Handel et al9 cosmetic outcomes have been particularly noted when and Tuncer et al10 suggested that reduction mamma- large have been treated with radiation and plasty could be carried out without the typical complica- lumpectomy.1,2 Furthermore, studies have confirmed tions associated with radiation. Spear et al11 confirmed that radiation treatment complicates both autologous from a case series of 3 patients that reduction mammaplasty in the irradiated breast did not lead to a higher incidence of complications. All authors concluded Mr. Chin is from the Tufts University School of Medicine, Boston, that the procedure could be carried out safely with care- MA, and Drs. Brooks, Stueber, Hadaegh, and Johnson are from the Tufts University School of Medicine and the Baystate Medical ful surgical technique. Center, Springfield, MA. Dr. Griggs is from the Baystate Medical Contrary evidence also exists suggesting that compli- Center, Springfield, MA. cations are increased in symmetry-restoring procedures

106 • Volume 29 • Number 2 • March/April 2009 Aesthetic Surgery Journal Table. Patient characteristics pedicle (n = 5) and breast amputation with free nip- Mastopexy ple graft (n = 2). For all mastopexy procedures (n = Number of Distinct Cases 7 6 6), vertical or T-shaped techniques were used. In the contralateral breast, a corresponding corrective proce- Average Age 49 yrs 48 yrs dure was performed simultaneously. An average of Average Weight 93.7 kg 82.4 kg 892 and 230 g of tissue were removed from the irradi- Average BMI 33.9 kg/m2 31.6 kg/m2 ated breast for reduction mammaplasty and Smoking 0 0 mastopexy, respectively. From available radiation records, average radiation 0 0 doses including tumor bed boost were 5970 cGy for Hypertension 1 2 reduction and 6160 cGy for mastopexy. Doses were Average radiation dose 5970 cGy 6160 cGy given in 180 to 200 cGy fractions. Seven patients Average time to correction 78 mos 52 mos received chemotherapy in addition to radiation before asymmetry correction. The mean times between com-

Average tissue removed 892 g 230 g Downloaded from https://academic.oup.com/asj/article/29/2/106/270170 by guest on 02 October 2021 pletion of radiation and reduction mammaplasty or Average follow-up time 10 mos 13 mos mastopexy were 78 and 52 months, respectively. Average follow-up times after asymmetry correction were 10 months for breast reduction and 13 months after radiation therapy. Kronowitz et al12 reported a for mastopexy. higher incidence of wound healing problems in breast The average patient ages at time of reduction reduction patients who had previously received radia- mammaplasty and mastopexy were 49 and 48 years, tion. In addition, there have been no reports in the liter- respectively. At the time of surgery, no patients were ature regarding the complications of mastopexy in the active smokers and none were diabetic. Three patients irradiated breast. had hypertension. The average patient body mass Although the intuitive conclusion is that radiation index was 33.9 kg/m2 for reduction mammaplasty and exposure would complicate reduction mammaplasty and 31.6 kg/m2 for mastopexy. mastopexy, more scholarship in this area is needed to clarify the effects of radiation on these symmetry-restor- RESULTS ing procedures. The purpose of this study is to further In our patients, there were no major complications such examine outcomes of reduction mammaplasty and as flap loss, tissue necrosis, heavy scarring, infection, or mastopexy in breast cancer patients previously treated severe deformity. Minor complications in the irradiated with BCT and radiation. breast occurred in 25% of patients, including prolonged edema (n = 1), delayed wound closure (n = 1), and METHODS minor scarring (n = 1). One reduction mammaplasty A retrospective search was conducted for patients patient required additional mastopexy for undercorrected who received both external beam radiation and either asymmetry. Ultimately, all patients achieved acceptable reduction mammaplasty or mastopexy at Baystate symmetry and none reported any dissatisfaction with the Medical Center from October 1997 to January 2007. final cosmetic outcome on routine postoperative inter- Only those patients who received either a reduction view. Figure 1 demonstrates typical preoperative asym- mammaplasty or mastopexy in the irradiated field metry and good postoperative cosmesis for our reduction were entered into the study. Data were obtained from mammaplasty patients. Figures 2 and 3 are representa- patient charts following institutional review board tive mastopexy results. approval. Complication rates and pathology on the A pathologic examination was conducted at the time reconstructed breast tissue were analyzed. of asymmetry correction for 8 of the 12 patients. The A search of the hospital database identified a total reports were significant for scar formation (1), dense of 12 patients (13 distinct cases) who qualified for the fibrosis (2), ulcerated with granulation tissue (1), study. All patients initially presented to the plastic focal stromal fibrosis with microcalcifications (1), lobu- surgeon with concerns of asymmetry secondary to lar atrophy (1), and features consistent with radiation BCT. All patients underwent surgery by 1 of 5 plastic effects. One patient was found to have recurrent ductal surgeons at Baystate Medical Center. Out of 386 carcinoma in situ on pathology during her mastopexy mastopexy patients, 5 (1%) received preoperative procedure. This patient underwent completion mastecto- radiation. Seven of 1822 reduction mammaplasty my and subsequent transverse abdominal muscle flap patients (0.4%) met the criteria. One reduction reconstruction. mammaplasty patient received a revision mastopexy in the same breast 5 months later. Select patient char- DISCUSSION acteristics are summarized in the Table. Plastic surgeons must be aware of the risks inherent in In the irradiated breast, the techniques used for operating in an irradiated field. Although results of post- reduction mammaplasty were Wise-pattern inferior radiation procedures such as trans-

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Figure 1. A, C, Preoperative views of a 60-year-old woman whose right side had been irradiated. B, D, Post-operative views 6 months after reduction mammaplasty.

verse abdominal muscle and latissimus flaps have shown old and none had a history of smoking or diabetes. Only a high incidence of major complications,3-6 there is not 3 of the patients reported hypertension. In contrast, the sufficient evidence to confirm that standard reduction unfavorable results reported by Kronowitz et al12 were mammaplasty or mastopexy leads to the same elevated based on a delayed reconstruction population in whom rate of complications in the previously irradiated patient. 71% were more than 50 years old and 22% were smok- Reduction mammaplasty alone has well-established ers. This difference in baseline patient health character- complication rates, ranging from 7% to 45%. The largest istics may account for the differences observed between study to date is the multicenter Breast Reduction our results and those reported by Kronowitz et al.12 Assessment: Values and Outcomes (BRAVO) study. The Concerns over operating on the irradiated breast arise authors reported a complication rate of 43%; complica- in part from the suboptimal outcomes of full mastecto- tions included delayed wound healing, suture abscess, my reconstruction procedures.3-6 By comparison, the , necrosis, fat necrosis, , hyper- severity of complications in these post- stud- trophic , and infection.13 Although our study sam- ies differ significantly from those observed in our ple was small, we observe that our post-radiation patients. We did not observe any tissue necrosis, flap complication rate was not higher than that expected for loss, or infection, which have been the more commonly reduction mammaplasty alone. Our favorable results associated complications related to post-mastectomy may be partially accounted for by health factors; we had reconstruction in the irradiated field. In addition, the a relatively healthy patient population at lower risk for prevailing sentiment that cosmetic outcome is ubiqui- complications. All of our patients were less than 50 years tously compromised by radiation is not supported by our

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Figure 2. A, C, Preoperative views of a 52-year-old woman whose left side had been irradiated. B, D, Post-operative views 6 months after vertical mastopexy.

results. Good cosmesis and acceptable symmetry were the skin to ensure that the underlying chest wall will achieved in all of our patients. receive the full prescribed dose when high energy beams We postulate 3 hypotheses accounting for the differ- are used.14 In these instances, the skin often receives an ence in outcomes between post-mastectomy and post- unnecessarily high dose of radiation in post-mastectomy BCT reconstructions. Anatomically, the relatively thicker patients. This undesirable increase in skin dose may flaps involved in reduction mammaplasty may preserve explain the higher incidence of major complications not- the blood supply to the skin to prevent wound healing ed in post-mastectomy reconstructions. Furthermore, complications. This hypothesis underlines the impor- because post-mastectomy irradiation usually involves tance of limiting undermining and maximizing thickness treatment of the internal mammary nodes, the supra- of skin flaps as proposed by Spear et al.11 clavicular fossa, and the axillary apex, overlapping fields An alternative hypothesis is based on the dosimetry may be unavoidable.15 Such overlap is a known factor of radiation treatment. For BCT patients, the skin usually that adversely affects cosmetic outcomes.16 receives a dose that is much lower than the prescribed Another major reason for previous avoidance of pro- dose, which is concentrated in deeper breast tissue. This cedures in the large irradiated breast is the publication lower skin dose results from the skin-sparing property of of studies that have reported poor cosmesis when large the high energy beams used for the irradiation. By con- breasts were treated with radiation and lumpectomy. trast, the skin in post-mastectomy patients does not ben- Despite these studies, we observed good cosmetic out- efit from this skin-sparing effect of high energy beams. comes in those patients in our series with large breasts. Because of its close proximity to the chest wall, which is It was proposed that dose inhomogeneity was greater for considered at risk, a bolus material is placed on top of larger breasts, which led to poor cosmetic effects.17 This

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Figure 3. A, C, Preoperative views of a 37-year-old woman whose right side had been irradiated. B, D, Post-operative views 11 months after T- shaped mastopexy. dose effect may have been circumvented by our use of operative approach, radiotherapy is performed after reduction mammaplasty because a significant amount of reduction. Advocates of immediate asymmetry repair irradiated tissue was removed. suggest that aesthetic outcomes are improved if radiation With current cultural values emphasizing the signifi- is performed after surgery.12,23-25 However, several fac- cance of outward appearance and the increasing public tors limit the potential of this technique. Immediate acceptance of plastic surgery, the use of asymmetry-cor- repair risks a possibility of completion mastectomy if recting procedures for BCT patients will continue to final histopathology reveals positive margins post-opera- increase. In addition to cultural pressures, asymmetry- tively.26 In the delayed approach, positive margins are correcting procedures may help to address the psycho- not an issue because all oncologic management has logical impact of BCT, which has been well studied.18-21 been completed well before asymmetry correction. Furthermore, current epidemiologic studies indicate Another factor supporting asymmetry repair after irradi- that half of the U.S. population is at least overweight, if ation is the recent advancement of intraoperative radia- not obese.22 The role of breast reduction for obese patients tion treatment, which is performed during the initial who have breast cancer will certainly increase as rates of resection. Intraoperative radiation treatment may eventu- both BCT and continue to increase in tandem. ally be preferred over nonoperative radiation because of Changes in radiation techniques may also affect the its advantage of decreasing radiation exposure to healthy role of postradiation asymmetry correction. Currently, tissue.27-30 This change would increase the prevalence of patients may undergo radiation therapy either before or post-radiation asymmetry correction candidates. after asymmetry-correcting procedures. Oncoplastic sur- There have been no reports in the literature of gery with immediate reduction mammaplasty at the time mastopexy in the previously irradiated breast. Results of tumor resection is becoming more popular. In this from the 6 mastopexy cases presented in this study sug-

110 • Volume 29 • Number 2 • March/April 2009 Aesthetic Surgery Journal gest that this procedure can be performed safely in the 8. Christiansen D, Kazmier FR, Puckett CL. Safety and aesthetic improve- setting of previous radiation. We obtained good cosmetic ment using the omega pattern reduction mammaplasty after breast con- outcomes with minimal complications in the previously servation surgery and radiation therapy. Plast Reconstr Surg 2008;121:374–380. irradiated field using only standard techniques. 9. Handel N, Lewinsky B, Waisman JR. Reduction mammaplasty follow- ing radiation therapy for breast cancer. Plast Reconstr Surg CONCLUSIONS 1992;89:953–955. The current rarity of post-BCT asymmetry correction lim- 10. Tuncer S, Bello-Rojas G, Ratiu C, Jackson IT. Reduction mammaplasty its our ability to draw any definitive conclusions. in the previously radiated breast: is it safe and does it interfere oncolog- ically? Eur J Plast Surg 2005;28:412–417. However, our data suggest that reduction mammaplasty 11. Spear SL, Burke JB, Forman D, Zuurbier RA, Berg CD. Experience with and mastopexy after radiation therapy are relatively safe reduction mammaplasty following breast conservation surgery and procedures with risks not higher than either operation radiation therapy. Plast Reconstr Surg 1998;102:1913–1916. performed in patients without radiation. In addition, 12. Kronowitz SJ, Feledy JA, Hunt KK, et al. Determining the optimal these procedures can still achieve good cosmetic results. approach to breast reconstruction after partial mastectomy. Plast Reconstr Surg 2006;117:1–11. Nonetheless, the plastic surgeon should take extra care 13. Cunningham BL, Gear AJ, Kerrigan CL, Collins ED. Analysis of breast to ensure minimal undermining of breast tissue, because reduction complications derived from the BRAVO study. Plast Reconstr Downloaded from https://academic.oup.com/asj/article/29/2/106/270170 by guest on 02 October 2021 irradiated fields carry an inherent risk of unpredictable Surg 2005;115:1597–1604. results. The surgeon should also be aware that circulato- 14. Vu TT, Pignol JP, Rakovitch E, Spayne J, Paszat L. Variability in radia- ry disease risk factors such as diabetes and smoking will tion oncologists’ opinion on the indication of a bolus in post-mastecto- my radiotherapy: an international survey. Clin Oncol (R Coll Radiol) affect an already challenged vascular supply. Patients at 2007;19:115–119. risk for vascular disease may not be candidates for these 15. Pierce LJ, Butler JB, Martel MK, et al. Postmastectomy radiotherapy of procedures and they should be informed of their the chest wall: dosimetric comparison of common techniques. Int J increased risk of complications when combined with Radiat Oncol Biol Phys 2002;52:1220–1230. exposure to radiation. 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Accepted for publication November 3, 2008. Presented at The Aesthetic Meeting 2008, San Diego, CA, May 2008. Reprint requests: Melissa A. Johnson, MD, Baystate Plastic Surgery Medical Office Building, 2 Medical Center Dr., Suite 309, Springfield, MA 01107. E- mail: [email protected]. Copyright ©2009 by The American Society for Aesthetic Plastic Surgery, Inc. 1090-820X/$34.00 doi:10.1016/j.asj.2008.12.004 Downloaded from https://academic.oup.com/asj/article/29/2/106/270170 by guest on 02 October 2021

112 • Volume 29 • Number 2 • March/April 2009 Aesthetic Surgery Journal