I’ve Had (or Need) Post-Mastectomy Radiation, What Are My Reconstructive Options?

Patients with stage III breast cancer, and now some patients with stage II breast cancer, are recommended to have ‘post–mastectomy radiation’. This will often be referred to as ‘chest wall radiation’. Contrast this to ‘whole breast radiation’, which is offered to all patients undergoing breast conservation (lumpectomy + radiation), regardless of stage.

To clarify, ‘post–mastectomy radiation’ typically involves treating the remaining chest wall skin, underlying pectoralis major muscle, and regional lymph nodes (in the arm pit or axilla). Whereas ‘whole breast radiation’ treats the remaining breast tissue, and only on occasion includes the regional lymph nodes in the axilla as part of the treatment.

Patients who have had post-mastectomy radiation present a reconstructive challenge because the radiated chest wall skin can’t be expanded, so addition of skin is required. Our preferred donor site for reconstruction is the lower abdominal skin and fat (DIEP flap) as enough skin and fat can be harvested to reconstruct a breast without the need for an implant. The abdominal skin provides a close match to breast skin. If the abdomen isn’t an option other donor sites exist for total breast reconstruction without an implant. A flap from the back (latissimus flap) is an option but, because of limited amount of tissue from this area, addition of an implant is typically required to complete the reconstruction.

In some scenarios a tissue expander is placed at the time of mastectomy and then chest wall radiation is required. In this scenario the second stage of reconstruction can occur with an implant, but with higher risk of healing problems and infection, either of which can lead to loss of the implant. Alternatively, the reconstruction can be converted to tissue-based reconstruction, which is generally considered a safer approach.