Selection criteria for expander/implant breast reconstruction following radiation therapy

Breast reconstruction with expander/implants is generally discouraged in patients who have undergone radiation therapy. However, not every patient treated with radiation develops sequelae severe enough to preclude the use of prostheses. To date, there have been no studies that have established criteria for selecting which patients may still be considered for expander/implant reconstruction. We present a series of 27 patients--the largest of its kind to date--all of whom underwent bilateral mastectomies, radiation therapy to only one chest wall, and delayed reconstruction with submuscular expander/implants. The aesthetic outcomes of the irradiated and the non-irradiated breasts were compared, and a classification of post-radiation skin changes was devised for selecting candidates for expander/implant reconstruction.

Patient records were reviewed to identify those who had undergone bilateral mastectomies, radiation treatment to only one chest wall, and delayed expander/implant reconstructions of both breasts. Twenty-seven patients were identified who met our inclusion criteria. Early post-radiation skin changes were classified as "moderate" or "severe," while aesthetic assessments were classified as "good," "acceptable" or "poor."

Irradiated chest walls with moderate skin changes and absent induration have aesthetic outcomes comparable to the nonirradiated chest walls (p > 0.50). In contrast, patients who develop induration or severe post-radiation skin changes have a greater rate of modified Baker class IV capsular contracture and poor results that range from 75% to 100% of reconstructed breasts.

A history of chest wall radiation should not itself exclude patients from receiving expander/implant reconstruction. Patients who develop neither severe skin changes nor induration may still be considered for prostheses.