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BACKGROUND: The optimal time of expander/implant exchange in the setting of post mastectomy radiation (PMRT) remains unclear. Studies investigating the sequencing of reconstruction and PMRT are inconclusive, with some reporting exchange prior to PMRT results in fewer complications, while others report no difference. When the exchange follows PMRT, most reconstructive surgeons wait between 3-6 months, however, little is known about the optimal time for exchange. The primary aim of the study was to characterize complications associated with sequencing expander/implant breast reconstruction before or after PMRT. The secondary aim was to compare the outcomes between early (<4 months) and late (>4 months) expander-implant exchange in the subset of patients who first received PMRT.
METHODS: The medical records of all patients undergoing PMRT in the setting of tissue expander/implant breast reconstruction between June 2004 - June 2011 at our institution were reviewed retrospectively. For aim 1, patients were classified as having undergone expander/implant exchange prior to the initiation of PMRT (group I) or after the completion of PMRT (group II). For aim 2, patients who underwent expander/implant exchange after PMRT were then classified as having undergone exchange less than 4 months after PMRT (group III) or 4 months or more after PMRT (group IV). Complications were classified as severe requiring surgery, minor revisions, or hospitalizations not requiring surgery. Statistical analysis was performed using student's t test and Fischer exact test. RESULTS: Fifty five patients were identified as having undergone two-stage tissue expander/implant breast reconstruction by 6 different plastic surgeons, 22 (40%) in group I and 33 (60%) in group II. There was no significant difference in severe complications (18.2% vs 30.3%, p = 0.361), hospitalizations not requiring surgery (9.1% vs 12.1%, p = 1.0), or reconstructive failure rate (13.6% vs 21.2%, p = 0.723) between the two groups. Patients in group I did experience significantly more minor revision surgeries (45.5% vs 12.1%, p = 0.01). These were most frequently capsulotomies secondary to radiation induced implant deformities. From the 33 patients who underwent expanders/implant exchange following PMRT, 19 (57.58%) were in group III and 14 (42.42%) were in group IV. There was no significant difference in severe complications (36.8% vs 21.4%, p = 0.455), minor revisions (10.5% vs 14.3%, p = 1.0), hospitalizations not requiring surgery (10.5% vs 14.3%, p = 1.0), or reconstructive failure rate (26.3% vs 14.3%, p = 0.67) between the two groups.
CONCLUSIONS: Our findings suggest that neither the sequencing nor timing of expander/implant exchange in the setting of PMRT has an impact on severe complication or reconstruction failure rate. Of note, patients who underwent implant exchange prior to PMRT did experience more minor revision surgeries such as capsulotomies. Capsulotomy is frequently performed as part of the expander/implant exchange operation in patients undergoing exchange after PMRT. This may account for the difference seen between the groups. With respect to the optimal timing of expander/implant exchange following PMRT, this study suggests that it may not be necessary to wait beyond 4 months before proceeding with exchange.