An Estimation of Volume Loss after Radiation Therapy on Free Flap Breast Reconstruction

Sir: Postoperative radiation therapy is associated with significant deleterious effects on free flaps, the most significant being fat necrosis and volume loss.1 Plastic surgeons usually anticipate some volume loss to an autologous breast reconstruction flap after radiation. To balance this, some degree of overcorrection is performed. However, the ideal amount of overcorrection is unknown. If an intraoperative finding suggests a need for postoperative radiation therapy, classical teaching suggests an overcorrection to the reconstruction is needed to counteract the volume loss due to postoperative radiation therapy. We attempted to quantify the volume loss secondary to postoperative radiation therapy in patients with immediate autologous tissue breast cancer reconstruction. This would help give patients the best possible breast volume after radiation treatment to avoid described high rates (28 percent) of secondary procedures on radiated flaps.2 A retrospective review was conducted on all breast cancer reconstructions that were performed by the senior author over a 5-year period, from 2001 to 2006. The charts of the patients who received postoperative radiation therapy were reviewed. Of 356 breast reconstructions performed over the 5-year period, three free flaps (8 percent) received postoperative radiation therapy. Assessment of volume loss in a control subject (n = 1) and in a patient secondary to postoperative radiation therapy (n = 2) was performed with serial surface casting. Volume was estimated using displacement techniques. Serial surface casting and displacement techniques showed an average volume loss of 23 percent at 6 months after postoperative radiation therapy (Table 1).Table 1: Serial Surface Casting and Displacement Volumes before and after Postoperative Radiation TherapyThe control subject was a 58-year-old patient who had received no radiation and who had bilateral, immediate, free abdominal flap reconstruction. Over an interval of 9 months, serial castings showed a volume change of 513 ± 2ml to 522 ± 7ml. The first patient was a 47-year-old woman. She underwent an immediate free abdominal flap and contralateral mastopexy. She received postoperative radiation therapy for a positive intraoperative lymph node (Fig. 1). The total radiation dose was 4600 cGy over 23 fractions. There was a volume loss of 22.9 ± 0.65 percent, which stopped after 6 months.Fig. 1: A 47-year-old woman with immediate free abdominal flap and contralateral mastopexy received radiation for an intraoperative positive node. (Above, left) Six months postoperatively, before radiation. (Above, right) Fifteen months postoperatively, 9 months after radiation. (Below, left) Preradiation therapy cast volume: 915.5 ± 15.5 ml. (Below, right) Nine-month postradiation therapy cast volume: 706 ± 6 ml. Overall percentage of volume loss: 22.9 ± 0.65 percent.The second radiated patient was a 55-year-old woman who received an immediate free abdominal flap and contralateral mastopexy. She had a positive intraoperative sentinel node (Fig. 2). The total radiation dose was 5040 cGy over 25 fractions. The total volume loss was 23.4 ± 4.4 percent, which stopped after 6 months.Fig. 2: A 55-year-old woman with immediate free abdominal flap and contralateral mastopexy received radiation for a positive intraoperative sentinel node. (Above, left) Preoperative view. (Above, right) Fifteen months postoperatively, 9 months after radiation. (Below, left) Preradiation therapy cast volume: 301.5 ± 11.5ml. (Below, right) Nine-month postradiation therapy cast volume: 230.5 ± 4.5ml. Total percentage of volume loss: 23.4 ± 4.4 percent.The study showed us that there is no need for overcorrection of the autologous tissue reconstruction when radiation is not anticipated. A volume-appropriate breast mound can be created, as we observed no change in the control free flap that received no radiation. We were able to estimate, at 23 percent, the amount of overcorrection required to obtain an appropriate volume after radiation. This could allow the surgeon to precisely weigh the mastectomy sample and also weigh and select an appropriate free flap volume in an immediate reconstruction. The cases also show us that if a breast mound revision is required after radiation for asymmetry, it should be attempted more than 6 months after radiation. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. Siba Haykal, B.Sc., M.D. Division of Plastic and Reconstructive Surgery Department of Surgery Faculty of Medicine University of Toronto Toronto, Ontario, Canada Colin P. White, B.Sc., M.D. Nicolas A. Guay, B.Sc., M.D. Division of Plastic Surgery Department of Surgery Faculty of Medicine University of Ottawa Ottawa, Ontario, Canada

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