The effect of radiation on pedicled TRAM flap breast reconstruction: outcomes and implications

The purpose of this study was to examine the effect of postreconstruction radiation therapy on patients undergoing pedicled TRAM flap breast reconstruction. Post-TRAM radiation patients were compared with patients who received pre-TRAM radiation and a control TRAM-only group who received no radiation. Overall aesthetic appearance, evidence of symmetry, flap contracture, and hyperpigmentation were assessed by blinded reviewers. A total of 171 pedicled TRAM reconstructions were performed in 150 patients. Total flap complications were seen in 49.5 percent of the control patients, 57.1 percent of pre-TRAM radiation patients, and 50 percent of post-TRAM radiation patients but were not statistically different. The complete flap necrosis rate was 0.6 percent and the partial flap necrosis rate was 7.6 percent, again with no statistical differences among the groups. Donor-site complications occurred in approximately one third of patients in each of the groups. Deep venous thrombosis and pulmonary embolus each occurred once and only in the post-TRAM radiation group. In terms of overall aesthetic outcome, symmetry, and contracture, the control group consistently rated better than the pre-TRAM (p = 0.021, p = 0.03, p = 0.03, respectively) and the post-TRAM (p = 0.0001, p = 0.0001, and p =0.0001, respectively) radiation groups. The control group also had clinically and statistically significant less hyperpigmentation than the post-TRAM radiation group (p = 0.0002). In contrast, irradiated postreconstruction patients had scores, including aesthetic outcome, symmetry, and contracture, worse than those of irradiated prereconstruction patients. When these two groups were compared with each other, except for contracture, no statistical significance, because of a small patient sample, was found. Neither preoperative nor postoperative radiation increased the risk for flap or donor-site complications. In contrast, radiation of any type did affect aesthetic appearance, symmetry, contracture, and hyperpigmentation. The authors recommend that TRAM flap breast reconstruction be postponed in those patients known or expected to receive postmastectomy radiation.