More breast cancer patients are treated with conservation therapy (lumpectomy, axillary lymph node dissection, and whole breast irradiation) than with mastectomy. Historically, patients with very large breasts were considered to be poor candidates for such conservative therapy because they often obtained cosmetically less acceptable results; however, more recent radiotherapeutic techniques have led to increased cases of women with macromastia and breast cancer receiving radiation therapy (1,2). Thus, we have seen and will continue to see patients with symptomatic breast enlargement who have already been treated for breast cancer with lumpectomy, axillary dissection, and radiation therapy.

Impairment of wound healing in irradiated tissue by fibroblast inhibition and microvascular disease is supported in numerous studies (3). There is an increased rate of infections, fat necrosis, and seromas in irradiated patients. Overweight women or women with large pendulous breasts tend to have more fibrosis of the breast, leading to poorer cosmetic outcome. However, the increased fat content in large breasts, or the greater dose inhomogeneities due to the greater tangent separation, could also explain the poorer results in these women (1).

Although there has been little data in the literature on breast reduction in the irradiated patient, it is clear from the data on breast reconstruction in patients after breast irradiation that reconstructive surgery on a radiated breast is more prone to complications and yields cosmetically suboptimal results (3,4).

This chapter addresses the nature of breast reduction in the previous irradiated patient and the safety of performing such a procedure. It also addresses the preferable methods and evaluates the cosmetic results. Finally, the question of the effect of breast reduction on cancer surveillance is discussed.

Reduction of the radiated breast could be performed safely using a variety of techniques. The method of reduction alone does not seem critical as long as the pedicle is wider and shorter than normal to avoid nipple necrosis or loss. Flaps must be designed to avoid complications such as seroma or flap necrosis (5). This includes less or no undermining or elevation of the flaps. For that reason, the Lejour technique, as well as other reduction mammoplasty techniques, which requires extensive undermining and redraping of significant amounts of remaining breast skin, would not seem safe for the irradiated breast.

Reduction mammoplasty for the irradiated breast should be delayed until the acute postradiation response has subsided. At 1 year postoperatively, breast edema has significantly subsided, with very few patients displaying edema at longer follow-up. Telangiectasia is essentially nonexistent at 1 year, and skin thickening after 1 year is no different in patients with macromastia compared with the average patients. One advantage of delaying the reduction for 1 year is that the procedure can be performed with a more accurate estimate of how much tissue should be removed to obtain symmetry. It is unclear whether there is any advantage or disadvantage to postponing the procedure for longer intervals. From the psychological point of view, most patients are unlikely to seek reduction mammoplasty immediately after radiation therapy because they are still preoccupied with the issues surrounding their breast cancer, including the possible need for adjuvant chemotherapy. To avoid any delay in cancer treatment, the breast reduction procedure should not be performed until the cancer treatment is complete.

Although lumpectomy combined with reduction and followed by radiation therapy is the subject of another chapter in this book, there are several related issues to be raised. Simultaneous lumpectomy and reduction might create the awkward situation of residual positive margins, which could be difficult to locate in the patient if the reduction has already been performed. Does reduction after lumpectomy complicate the delivery of radiation therapy? Should the site of lumpectomy be somehow marked with surgical clips during the reduction process so the site can be subsequently identified for radiation planning and long-term follow-up? In patients with clean margins after lumpectomy, there would not appear in principle to be any adverse effect of reduction prior to radiation. The surgical margins would be greater; there would be less breast tissue left to examine and follow; the patient would be relieved of the breast enlargement; and by performing the reduction prior to radiation, the risks of operating on a radiated breast would be avoided (5).