In patients who have undergone breast-conserving therapy, the location of the surgical scar, quality and quantity of skin remaining, use of radiation and any resulting sequelae, and type of prior axillary surgery all influence the choice of reconstruction method. Many studies have suggested that implant-based reconstruction in the setting of prior radiotherapy leads to inferior results and an increased incidence of complications, including infection, extrusion, capsular contracture, and reconstruction failure (12). Given the high complication rates associated with implant-based breast reconstruction in the setting of prior radiotherapy, most surgeons prefer to use autologous tissue to reconstruct a previously irradiated breast. Furthermore, completion mastectomy following failed breast-conserving therapy often results in a relatively large skin defect that requires the use of an autologous flap.

In certain patients with insufficient amount of autologous tissue for adequate breast reconstruction, an implant can be added to provide more volume. Using an autologous flap to protect an implant from the negative effects of further irradiation in a previously irradiated breast has been evaluated (13). Freeman et al. evaluated the use of two-stage implant-based breast reconstruction with latissimus dorsi (LD) myocutaneous flap coverage in 12 patients in whom breast-conserving therapy had failed and found satisfactory aesthetic results and a capsular contracture rate of 12.5% with a mean follow-up time of 50 months (38). More recently, Spear et al. evaluated 28 patients with previously irradiated breasts who underwent breast reconstruction with an LD flap and implant and found an implant-related complication rate of 14%, a mean cosmetic satisfaction rating of 8.5 of 10, and a mean overall satisfaction rating of 8.8 of 10 (14). They concluded that although breast reconstruction with autologous tissue alone may be the best choice for patients who have undergone radiotherapy, breast reconstruction with an LD flap and implant also provides an acceptable cosmetic result and complication rate (14). In addition, Chang et al. found that, among patients who received radiotherapy prior to mastectomy and reconstruction, significantly fewer reconstructions failed in patients who had undergone breast reconstructions with an LD flap and implant (15%) or a transverse rectus abdominis myocutaneous (TRAM) flap and implant (10%) than in patients who had undergone breast reconstructions with an expander and implant alone (42%; p < 0.03) (15).

In our experience, using an autologous tissue flap combined with an implant for breast reconstruction appears to reduce the incidence of implant-related complications in previously irradiated breasts. A well-vascularized flap may improve wound healing and thus reduce the risk of wound dehiscence and infection. An autologous tissue flap also provides a well-vascularized pocket for the implant, which minimizes the contact between the implant and the surrounding irradiated tissue. Although the implant sits on the chest wall, covering the
implant with well-vascularized tissue may reduce the risk of capsular contracture associated with radiotherapy.

As previously mentioned, completion mastectomy following failed breast-conserving therapy often results in relatively large skin defect, and thus immediate reconstruction would be needed in many cases just to provide the wound closure (Fig. 79.2). However, the situation in unlike most other immediate breast reconstructions, the axilla have already been violated surgically and the chest wall has been irradiated.

In a patient who has had prior axillary surgery or radiotherapy, the status of the thoracodorsal vessels is uncertain. The status of the thoracodorsal vessels is pertinent when considering the use of a LD flap for breast reconstruction. Although studies have shown that the thoracodorsal pedicle often remains intact despite surgical scarring and radiation sclerosis (15), fibrosis due to radiotherapy makes dissecting the pedicle difficult, necessitating greater care during exploration. We recommend exploring the axilla first to ensure the viability of the thoracodorsal vessels before committing to raising the LD flap (Fig. 79.3).