In the treatment of cancer, radiation therapy uses high-energy radiation (X-rays, gamma rays and charged particles) to kill malignant cells by damaging their DNA. Radiation will also damage normal, healthy cells if it comes in contact with them, so this treatment must be precisely planned to minimize side effects. Breast cancer patients may undergo radiation before, during or after surgery, and some have radiation alone while others are treated with chemotherapy in conjunction. When radiation is targeted at the breast or chest, it causes a precise burn to specific tissues. The radiated tissue may redden and become sensitive throughout radiation treatment, but it is not often that wounds develop. Once radiation is completed, the affected skin and tissues heal gradually.
Check out Dr. Kim’s article entitled “Outcomes of Tissue Expander/Implant Breast Reconstruction in the Setting of Prereconstruction Radiation” here.
Radiation is not a required part of breast cancer treatment for all women having a mastectomy after their cancer diagnosis. Several factors influence radiation oncologists‘ (colleagues of Dr. John Kim) decision to pursue this therapy. Cancer stage, tumor size and number of affected lymph nodes are the most important considerations. Typically, radiation is indicated for women with large breast tumors and greater than three positive lymph nodes. Other factors radiation oncologists take into account include patient age and medical conditions, general health of the patient, how close the cancer is to normal tissues that are sensitive to radiation, and how far into the body the radiation must travel. It is important to note that prior to radiation, patients will not know how it will affect them specifically. Some individuals experience few or no side effects, while others notice skin-related changes, particularly discolored, firm or contracted skin. Discomfort and swelling of the chest or breast area are common side effects as well.
Dr. Kim makes a point of informing his breast reconstruction patients who have had prior radiation at any point in time that when he performs reconstructive surgery on these tissues, the healing is largely unpredictable. Unfortunately, radiated patients are at higher risk for post-operative complications like infection as well as poorer aesthetic outcomes like asymmetry than non-radiated patients. For this reason, Dr. Kim typically performs autologous reconstruction on his radiated patients, including abdominal and latissimus flaps. As compared to tissue expanders and implants, flaps offer more support and coverage of the compromised skin, and they offer a more natural breast look and feel, which is particularly important when the native breast region can be so contracted and firm from the radiation.
Scenarios in which Dr. Kim and his patients must discuss radiation
- Patients who have already undergone mastectomy and radiation and now desire reconstruction
Dr. Kim recommends that these patients have a TRAM flap or latissimus flap reconstruction. Expander/implant reconstruction is not recommended because radiated tissue does not expand well. If an expander is placed, infection is quite common. It is also possible that the expander or implant may become exposed through the weakened skin. Because the flaps taken from the tummy or back regions have not been previously radiated, this healthy tissue assists with healing in the radiated breast region.
- Patients who have had a prior lumpectomy and underwent radiation who now want mastectomy with reconstruction
For similar reasons as in the first scenario, Dr. Kim counsels these patients to choose some type of flap reconstruction for their surgery.
- Patient with newly diagnosed breast cancer who desire or necessitate a mastectomy and will receive radiation after breast removal
Dr. Kim and his breast surgery and radiation oncology colleagues will communicate about the need for radiation after the mastectomy and surrounding the reconstruction. Typically, patients have two options in this scenario. First, they can delay their reconstruction until after both the mastectomy and radiation courses are complete. Second, they can have a tissue expander placed at the time of the mastectomy, and they can undergo tissue expansions for several weeks prior to radiation. Then, they undergo their course of radiation. After this therapy is completed (and they have waited ample time for healing, which is typically six months) they can finish their reconstruction by exchanging the tissue expander for the permanent implant. Or, they can finish their reconstruction with a latissimus or abdominal flap instead of an implant. Patients who choose to finish with an implant may have a firmer reconstructed breast with greater capsular contracture and asymmetry than would be the case with a flap.
Take a look at Dr. Kim’s article “Differences in breast aesthetic outcomes due to radiation: a validated, quantitative analysis of expander-implant reconstruction” here.
Upon diagnosis with breast cancer, women are presented with often overwhelming amounts of information with which they need to make key decisions about their treatment. The most important being how best to treat the cancer itself and reduce the risk of it spreading (metastasizing) or recurring. A secondary but still important issue to consider is cosmetic outcomes. In fact, studies show that aesthetic outcomes largely influence women’s quality of life after surgery. Dr. John Kim understands the importance of optimal cancer management and good cosmetic results after reconstruction, so he encourages his patients to be in regular communication with their whole team of practitioners, including the breast surgeon, plastic surgeon and radiation and medical oncologists.
Take a look at Dr. John Kim’s article entitled “Utility of acellular dermis-assisted breast reconstruction in the setting of radiation: a comparative analysis” here.
For more information on radiation and breast reconstruction, please schedule a consultation with board-certified plastic surgeon Dr. John Kim at his downtown Chicago office today.