Radiation therapy has become increasingly common in the context of breast reconstruction. With the expanded use of breast conservation therapy (BCT) for early and localized cancers as opposed to traditional mastectomies, the indications for adjunct radiation therapy have been steadily growing. Recent studies have shown possible benefits for select women who undergo radiation therapy after mastectomy (1,2,3,4). Women may also seek reconstruction for deformities that have developed after breast conservation therapy. Other women may develop local-regional recurrence after mastectomy or reconstruction and require radiotherapy. The end result is an increase in the number of women who will require radiation therapy. Several papers have discussed the detrimental effects of radiation on tissues and breast reconstruction (5,6,7,8). Contracture, wound healing problems, implant exposure, infection, skin necrosis, and pigmentary changes are all commonly associated with radiation therapy (9,10). Additional studies demonstrate that autologous reconstructions after radiation therapy have fewer complications and better cosmetic outcomes than reconstructions with an implant. For this reason, the free or pedicled abdominal-based flaps have become the workhorse for reconstruction of the previously radiated breast (11,12,13,14). Despite the favorable outcomes of autologous reconstructions, not all women are candidates for or wish to undergo such a large procedure. Extremely overweight or thin patients, smokers, and those with prior abdominal surgery may be poor candidates for abdominal-based flaps. In addition, many women are deterred by the commitment, recovery time, and risks involved with autologous reconstructions. For such women who have had or will undergo radiation therapy, the remaining reconstructive options are limited.

Long-term results of staged breast reconstructions with saline-filled implants in patients who have undergone radiation therapy have been published (15). Some women had successful implant-only reconstruction, but during the study’s duration, half of the patients with saline implants eventually required flap coverage. Indications included infection, contracture, poor cosmesis, threatened exposure, and pain. Patients who underwent a latissimus flap either electively or for salvage had equivalent cosmetic outcomes to a cohort of patients who had not received radiation therapy and underwent implant-based reconstructions.

Because of these results, further study was performed to specifically evaluate the effectiveness of the latissimus dorsi musculocutaneous flap in patients who required radiation therapy and were not candidates for abdominal tissue transfer. A 10-year retrospective review was performed of all patients who underwent latissimus flap and prosthetic reconstruction in the setting of radiation therapy (16). Twenty-eight patients were reviewed and separated into five groups (Table 46.1). Group 1 (11 patients) had previous breast conservation therapy with local-regional recurrence followed by mastectomy and immediate breast reconstruction with an expander and simultaneous latissimus flap (Fig. 46.1). Group 2 (8 patients) had radiation therapy after mastectomy and underwent delayed reconstruction with an expander and latissimus flap (Fig. 46.2). Group 3 (4 patients) had a prior mastectomy and immediate expander reconstruction followed by radiation therapy after the expansion phase with exchange of the expander to an implant with latissimus flap coverage (Fig. 46.3). Group 4 (3 patients) had radiation following their mastectomy and immediate reconstruction and presented for secondary revision with a latissimus flap and new implant (Fig. 46.4). Group 5 (2 patients) had breast conservation therapy with a resultant deformity and underwent reconstruction with a latissimus flap and an implant (Fig. 46.5). These patients did not receive a mastectomy.

Patients frequently underwent a two-staged reconstructive process. Patients who received prior BCT (group 1) or mastectomy followed by radiation (group 2) had latissimus flaps and an expander placed with later implant exchange and nipple reconstruction. Patients who underwent immediate reconstruction with an expander and subsequent radiation therapy (group 3) had a latissimus flaps placed along with an implant exchange. Nipple reconstruction was performed at the same operation or as a planned second stage. A total of 70 procedures in 28 patients were performed (average of 2.5 procedures per patient) (Figs. 46.1 to 46.9). There were 14 revision procedures (average of 0.5 revision per patient). A total of 18 of 28 patients (65%) underwent a planned two-stage reconstruction without any revision surgeries (Table 46.1). Of the 10 patients who underwent revision surgeries, 4 had smaller implants replaced, 2 had contralateral breast procedures for symmetry, 1 had a subsequent exchange for a smaller implant, 1 underwent implant exchange for a deflated implant, one had their inframammary fold (IMF) elevated and had another subsequent exchange for a smaller implant, and 1 had a smaller implant placed and had another procedure to adjust the IMF.

The complications studied included capsular contracture, device extrusion, hematoma, infection, and back seroma. There were a total of 9 complications in 28, patients for a total complication rate of 32%. One patient had a capsular contracture that was successfully corrected with capsulectomy and implant exchange. Five patients had seromas at the latissimus flap donor site that resolved with intermittent aspiration in the office.