Practical Plastic Surgery

High condylar fractures which occur within the TMJ capsule itself may or may not involve the articular surface of the condylar head. If the proximal segment is small and the vascularity of the fragment is compromised, the fracture may eventually undergo avascular necrosis. These should be treated by closed reduction. In addition, open reduction is very difficult to complete due to the thin cortical bone at this site. On the other hand, subcondylar fractures that have a proximal segment that is adequate may be treated with rigid fixation. The decision tree on ORIF vs. MMF should incorporate the clinicians’ operative experience, the patients’ desires,

40anatomic feasibility of rigid fixation, and a risk stratification of the associated morbidity of either treatment.

Relative indications for ORIF include the following:

1.Patient compliance/preference

2.A history of recent seizure disorder

3.Poorly controlled psychiatric issues

4.Failed attempt at previous MMF

5.Bilateral subcondylar fractures with resultant malocclusion due to significant

bony displacement

Absolute indications for ORIF of a unilateral subcondylar fractures include:

1.Displacement of the condyle into the middle cranial fossa or external auditory canal

2.Lateral extracapsular displacement of the condyle

3.The displaced condyle functionally blocks the opening and closing of the mandible

4.Severe anteromedial angulation of more than 45˚ with dislocation of the condylar head from the glenoid fossa

5.Open joint wound with presence of a foreign body

Severe facial trauma is the etiology of bilateral subcondylar fractures which are

associated with malocclusion. An anterior open bite can be seen secondary to shortening of the ramus condyle unit (RCU) and associated clockwise rotation of the mandible. Comprehensive management is required, including a thorough work-up and algorithmic evaluation. Definitive management of bilateral subcondylar fractures remains controversial as well. In general, the approach depends on the surgeon’s experience and institutional philosophy. Many centers advocate closed reduction of both condyles.

When open reduction is being considered, we recommend following these basic principles: If both condyles are accessible and capable of being plated, then bilateral ORIF will allow an early return of function. It is our recommendation to treat bilateral subcondylar fractures with ORIF of at least one condyle. ORIF of the more accessible RCU will reestablish the vertical dimension of occlusion in a manner that allows for adequate closed reduction of the contralateral RCU. It is the reestablishment if the proximal and distal segments of the RCU that will restore the vertical dimension of occlusion and thus allow for the possibility of closed manipulation and adequate realignment of the contralateral RCU. Again, once one RCU is treated by ORIF, the contralateral RCU should follow the same closed reduction protocol outlined above (10 days of MMF, followed by 10 days of guiding elastics). If a malocclusion develops, then the protocol should be extended by an additional 10 days of MMF followed by elastics.

In edentulous patients that have sustained either unilateral or bilateral subcondylar fractures, the recommended treatment is closed reduction. When a splint, existing

dentures, or a gunning splint is available, then 10 days of closed reduction followed by a mechanical soft diet for 4-5 weeks is appropriate management. In cases where either the splint is unavailable or impossible to position because of alveolar ridge atrophy, we recommend a soft diet for approximately 6 weeks, followed by a general dental consult for refabrication of the dentures.

Inappropriate treatment of condylar fractures may lead to severe functional complications, including: avascular necrosis of the condylar head, persistent TMJ pain, arthritic changes to the TMJ (resulting in pain and decreased mobility of the jaw)

and facial nerve injury. Injury to the branches of the facial nerve can occur during 40 operative exploration and repair of subcondylar fractures with a reported incidence

as high as 30%. Most nerve injuries result in only temporary paralysis. The search for a surgical approach that minimizes the risk to the facial nerve has led to the use of endoscopy-assisted ORIF of subcondylar fractures. This technique has a decreased risk of iatrogenic nerve palsy. Other advantages of the endoscopic approach over traditional ORIF include better access to the condyle through smaller incisions, and better outcomes with decreased morbidity and faster recovery. Specifically, there is less tissue dissection and manipulation, resulting in less tissue edema and postoperative pain and swelling. Disadvantages of the procedure include its higher cost and a learning curve that may initially result in a much longer surgical time. The subcondylar fracture can be approached intraorally or extraorally. The intraoral approach is of limited use, especially for the management of medially displaced and dislocated fractures.

Mandibular Body Fractures

Anatomically, the mandibular body is defined as the region bounded anteriorly by the parasymphysis and posteriorly by the angle. Body fractures represent approximately 30% of all adult mandibular fractures.

Favorable body fractures occur when the direction of the fracture and the pull of the masseter and medial pterygoid muscles resist bony displacement. In contrast, unfavorable body fractures are displaced at the fracture site due to the angulation of the masseter and medial pterygoid muscle pull.

In body fractures, both MMF (with closed reduction) and ORIF can be utilized. A common MMF technique is the use of prefabricated arch bars that are adapted and circumferentially wired to the teeth in each arch, maintained for 4-6 weeks.

Although MMF is more economical and lowers the overall risk of infection, it also possesses several disadvantages. Wiring of the teeth often leads to poor nutrition and oral hygiene. Patients cannot return to full preinjury function for a minimum of 4 weeks, thus requiring postoperative therapy to regain maximal incisal opening. Therefore, patient compliance is necessary. There is also a risk of aspiration in patients suffering from seizure disorders. Furthermore, patients with traumatic brain injuries have a tendency to generate forces that lead to the loosening of wire fixation.

ORIF is recommended for unfavorable and displaced body fractures or continued displacement of the body fracture fragments despite MMF. ORIF with rigid fixation of the body is a relatively simple surgical operation that can allow the patient to rapidly return to function. An incision is made at the depth of the vestibule. Intraoperatively, the surgeon should identify and protect the mental nerve. A rigid inferior border plate should be passively adapted and screwed into the bone. If the arch bars are to be removed at the end of the case, then a maxillomandibular tension band should be

applied using monocortical screws. If the arch bars are to be kept on, they can act as the tension band. Although the arch bars can be left on, the patient should not be placed into MMF since the rigid plate fixation is adequate for fracture stabilization.

Angle Fractures

The mandibular angle is the triangular area defined by the anterior border of the masseter muscle and a line extending from the third molar region to the posterosuperior attachment of the masseter muscle. At the angle, the horizontal segment joins the

40vertical segment. It is the most common site of fracture in the edentulous mandible. Loss of alveolar bone due to lack of teeth weakens the mandible in the region of the angle, thus making it more susceptible to fracture. In addition, the third molars and long root of the premolars weaken the angle, causing fracture in dentate patients. Angle fractures constitute approximately 25% of all adult mandibular fractures.

In unfavorable angle fracture the proximal fragment is elevated and drawn forward by the action of the masseter and medial pterygoid muscles. Favorable fractures of the angle may have minimal or no displacement because the vector of fracture is opposite to the vector of muscle displacement or because there is bone stabilization of the proximal segment.

While angle fractures can sometimes be treated with closed reduction, more often they are unfavorable and displaced and accordingly require ORIF. In such cases, arch bars and MMF are not sufficient since they do not reach the displaced proximal segment. This can lead to fragment mobility and a risk of either malunion or nonunion.

Surgical intervention for unfavorable displaced angle fracture can employ several techniques. For minimally displaced fracture we advocate ORIF via an intraoral approach. In angle fractures that are significantly displaced, we advocate a rigid inferior boarder plate and a semirigid superior boarder plate. This is easily accomplished via an extraoral approach. Some clinicians will attempt this rigid fixation intraorally with a percutaneous trocar to facilitate screw placement. At the end of the case, the MMF and arch bars can be removed.

Symphyseal and Parasymphyseal Fractures

Symphyseal and parasymphyseal fractures usually result from direct trauma to the chin. With a simple isolated symphyseal fracture we recommend ORIF, since the operation is associated with minimal morbidity and allows for an early return to function. Some clinicians may elect a 4-6 period of MMF as opposed to ORIF.

Parasymphyseal fractures with coexisting condylar fractures require a different approach. Surgeons may elect to treat both fractures by ORIF, returning the patient to full function immediately. Some will treat the symphyseal fracture by ORIF and leave the arch bars on with the patient in MMF for 2 weeks to address the condylar fracture. This provides predictable, acceptable results and is the preferred treatment in the overwhelming majority of cases. In our opinion, the surgeon should not treat both fractures by closed reduction. This would require 4-6 weeks of immobilization for the symphyseal fracture, placing the patient at risk for ankylosis secondary to prolonged immobilization.

As a general rule, symphyseal and parasymphyseal fractures should be treated by compression plates and screws. Plates should be bent and molded to the angulation of the bone at the symphysis. Irregularities of the bone should be smoothened by burr to facilitate better placement of the plate and screws. Two screws should be

placed on either side of the fracture line. Lag screws are often used to provide adequate compression at the fracture site. Screws should engage both anterior and posterior cortices. Fragmentation of the cortices should be carefully avoided.

Dentoalveolar Fractures

Fractures of the teeth and alveolus, while common, are often not treated in the emergency department. Frequently, the patient’s dentist manages these injuries in an outpatient setting. Patients complain of loose teeth, bleeding from the gingiva,

pain and malocclusion. Physical examination reveals an injury to the dentition re- 40 sulting in chipped, fractured, displaced or avulsed teeth and possibly an associated alveolar bone fracture. Palpation reveals mobility of the alveolar segment and associ-

ated dentition. Imaging recommendations include a panoramic radiograph and dental spot or occlusal films. Most of these injuries can be treated by a composite splint or arch bar applied to the adjacent dentition to achieve immobility of the fractured dentoalveolar segment.

If a tooth is avulsed, attempt to replace it into the socket and contact a dentist or oral surgeon for definitive management. Antibiotic coverage is indicated and the patient should be urged to follow up with the dental or oral surgical service for definitive management. Also consider prescribing an antibacterial mouth rinse such as 0.12% chlorhexidine.

Fractures of the Edentulous Atrophic Mandible

Fixation of fractures of the edentulous atrophic mandible remains controversial because of two issues concerning the quantity and quality of the bone involved. First, due to resorption of the alveolar bone following the loss of teeth, the vertical height of the area is significantly reduced. Secondly, the edentulous atrophic mandible usually becomes osteopenic and weaker with thin cortical plates. Edentulous atrophic mandible fractures normally occur amongst the elderly, age-related diseases and other chronic, debilitating diseases (e.g., diabetes). These common comorbidities contribute to less than optimum results.

Many edentulous patients with fractured mandibles can be treated by wiring their own denture or by fabricating a gunning-type splint. Each side of the fracture is secured with circumferential mandibular wires. Adequate immobilization is difficult to achieve because the denture or splint may not sit well on the underlying soft tissue. Unstable edentulous mandibular fractures should be considered for ORIF. Advantages of the open method include better visualization of the fracture and early restoration of mastication.

Pediatric Dentoalveolar and Mandibular Injuries

Dentoalveolar injuries are more commonly seen in children than mandibular fractures and usually do not require hospitalization. Common causes of dentoalveolar and mandibular injuries in children include falls from bikes and less frequently from direct blunt trauma or motor vehicle accidents. Both types of injuries can lead to complications, especially malocclusion. When examining the patient, the clinician must rule out associated injuries (e.g., closed head injury or fractures of the face, skull, cervical spine and extremities).

The most common location of pediatric dentoalveolar trauma is the anterior maxilla. Children with protruding maxillary teeth are especially susceptible to dentoalveolar trauma, with associated lip and soft tissue injuries. After the anterior maxilla, the ante-

rior mandible is the most common site of dentoalveolar injuries. Intrusion and avulsion of teeth is frequently seen in pediatric dentoalveolar injuries. A significant portion of intrusion injuries (25%) will involve the tooth bud which eventually will lead to enamel hypoplasia. A key prognostic factor in avulsion injuries is the status of the periodontal ligament cells at the time of reimplantation. Damaged cells can provoke an inflammatory response resulting in ankylosis or tooth loss. A tooth in isolated dentoalveolar injury should be stored in milk or saliva until attempted reimplantation.

Following completion of a thorough physical examination concentrating on as-

40sociated injuries and stabilization of the child’s condition, it is important to determine whether there are missing or chipped teeth involved in the injury. Foreign bodies may also be observed in the surrounding soft tissues. If teeth are missing upon examination, a plain film of the chest should be obtained to help locate them. Treatment of dentoalveolar injuries depends on the extent of injury and the association of primary or permanent dentition. In general, dentoalveolar fractures should be reduced and immobilized with either an acrylic bar, dental splints or a small arch bar for 3 to 4 weeks.

In contrast to mandibular injuries in the adult population, the most common site of pediatric mandibular fracture is the condyle. Diagnosis of mandible fractures in children is multifaceted. Associated cervical spine injuries should be ruled out with a thorough physical examination and radiographic studies (especially children under the age of two). Children may experience pain in the TMJ region or malocclusion. Pediatric mandibular fractures are most often treated with closed reduction because of the rapid bone growth rate and mixed dentition.

An anterior open bite and associated retruding jaw are usually indicative of a bilateral subcondylar fracture. A contralateral open bite and ipsilateral crossbite with prematurity is generally indicative of a unilateral subcondylar fracture. Panorex®, X-rays and CT scans are often useful in assessing the nature and extent of the injury.

Treatment should be instituted as soon as possible. Rapid rate of bony repair in the pediatric population makes mandibular fractures difficult to reduce even one week after the injury. There are additional considerations when treating pediatric subcondylar fractures: (1) it is easy to pull a wire through the mandible, because the cortex is much thinner in children; and (2) placement of wires and arch bars on the crowns of developing teeth is difficult and Ivy loops are preferred.

Fractures of the body and symphysis are rarely displaced and require only periodic observation. If the fracture is displaced, it should be treated with closed reduction. In children under two years of age, splints should first be attempted to immobilize the fracture. If the splints fail, MMF should then be utilized. Parasymphyseal fractures should be treated with a lingual splint.

Fractures of the condyle have the greatest risk of causing growth abnormalities in the pediatric mandible. It is critical to maintain the function of the condyle and ensure that normal ramus height is achieved. If these two tasks are accomplished, growth usually proceeds normally. Children with intracapsular subcondylar fractures are at particular risk for growth disturbances.

In summary, the majority of pediatric condylar fractures can be treated with noninvasive means, such as observation, simple exercise, or wires. Open reduction is only necessary if significant mandibular dysfunction is observed or if the child has permanent dentition and experiences persistent malocclusion after the undergoing noninvasive alternatives.

Pearls and Pitfalls

•It is important to preserve any teeth in the posterior fracture fragment; the tooth can provide stability, alignment, and can function as an occlusal stop with the corresponding tooth on the maxilla.

•Avulsed or loose teeth should be reimplanted and splinted in place as soon as possible (ideally within 90 minutes of injury). In such cases, a dentist should be consulted. Loose teeth with extensive periodontal disease should be removed.

•During the postoperative period of MMF, the average patient loses 15-20 pounds.

Patients must be counseled on consuming a nutritious liquid diet during this 40 period.

•A cuff of soft tissue should be preserved around the mental foramen to prevent traction injury to the mental nerve. Preserve at least 0.5 cm of tissue below the mental foramen since the nerve travels inferiorly.

•Proper reduction and stabilization of the fracture is more important than preservation of periosteal attachments of soft tissue. Whenever possible, a cuff of mentalis muscle attached to bone should be preserved and the muscle reapproximated at the time of soft tissue closure.

•The intraoral incision should be closed with a water tight seal by using a running locking stitch reinforced with interrupted sutures.

•Use monocortical screws adjacent to a tooth root or next to the inferior alveolar canal in order to avoid injury to these structures.

•Larger plates should be overbent so that they arc 2 to 3 mm off the fracture site. The overbent plate flattens against the outer border of the mandible after screw placement, anatomically reducing the lingual cortex in the process.

•Soft tissue interposed between the fracture fragments must be removed before proper alignment can be achieved. A lack of bone-to-bone contact will result in delayed union and potentially nonunion. In older fractures undergoing reduction, any extra callus in the fracture site must be removed to permit precise reduction in occlusion.

Suggested Reading

1.Baumann A, Troulis MJ, Kaban LB. Facial trauma II: Dentoalveolar injuries and mandibular fractures. In: Kaban LB, Troulis MJ, eds. Pediatric oral and maxillofacial surgery. Philadelphia: Saunders, 2004.

2.Halpern LR, Kaban LB, Dodson TB. Perioperative neurosensory changes associated with treatment of mandibular fractures. J Oral Maxillofac Surg 2004; 62:576.

3.Hammoudeh JA, Dodson TB, Kaban LB. Evaluation and acute management of maxillofacial trauma. In: Sheridan RL, ed. The Trauma Handbook of the MGH. Lippincott, Williams and Wilkens, 2003.

4.Haug RH, Assael LA. Outcomes of open versus closed treatment of mandibular subcondylar fractures. J Oral Maxillofac Surg 2001; 59:370-375.

5.Marciani RD, Hill O. Treatment of the fractured edentulous mandible. J Oral Surg 1979; 37:569.

6.Newman L. A clinical evaluation of the long-term outcome of patients treated for bilateral fracture of the mandibular condyles. Br J Oral Maxillofac Surg 1998; 36:176.

7.Ochs MW, Tucker MR. Management of facial fractures. In: Peterson LJ, ed. Contemporary oral and maxillofacial surgery. 4th ed. St. Louis: Mosby, 2003.

8.Spina AM, Marciani RD. Mandibular fractures. In: Fonseca RJ, ed. Oral and maxillofacial surgery. Philadelphia: Saunders, 2000.

9.Troulis MJ, Kaban LB. Endoscopic Open reduction and internal rigid fixation of subcondylar fractures. J Oral Maxillofac Surg 2004; 62:1269-1271.

In women with DCIS contained to one quadrant, excision with breast-conserving therapy (BCT) is recommended. If DCIS is present in more than one quadrant, then total mastectomy is the treatment of choice. Local failure is reduced by half with the use of radiation after excision of DCIS and is equivalent to mastectomy; however this does not effect overall survival. Tamoxifen treatment should be considered in these women, especially in those with estrogen receptor positive DCIS.

Operable locoregional invasive cancers may be treated with mastectomy, sentinel lymph node biopsy (SLNBx) +/- axillary dissection, or breast-conserving therapy with lumpectomy, SLNBx +/- axillary dissection followed by breast irradiation. These two treatments have been shown to be equivalent primary treatment options in multiple 41 randomized trials. If the sentinel lymph node is positive for metastasis, then a formal axillary lymph node dissection including level I and II lymph nodes is performed. For those under age 70, the current guidelines recommend adjuvant systemic therapy for tumors greater than 1 cm in diameter and for node-positive disease. If adjuvant chemotherapy is indicated, then radiation therapy should be given after chemotherapy is completed. In women undergoing mastectomy, tumors greater than 5 cm or positive surgical margins necessitate postmastectomy chest wall radiation due to the high risk

of local recurrence. Furthermore, if greater than three axillary lymph nodes are involved, then regional lymph node radiation is also recommended. All tumors should be tested for hormone receptor content and level of HER2/neu expression to help guide adjuvant therapy. In some patients with large clinical stage tumors, preoperative chemotherapy may allow for breast-conserving therapy if the tumor responds favorably, otherwise a mastectomy with lymph node dissection is required.

Contraindications to breast-conserving therapy include previous irradiation to the chest wall, pregnancy, multicentric disease, positive margins after reexcision, active connective tissue diseases and tumors greater than 5 cm.

Inoperable locoregional invasive cancers are initially treated with chemotherapy. Local therapy after treatment includes mastectomy with lymph node dissection or lumpectomy with lymph node dissection. Regardless of surgical treatment option, post-surgical chemotherapy and radiation are also warranted.

Stage IV metastatic disease is treated with multiple modalities including chemotherapy, endocrine therapy and radiation. Women with recurrent local disease who have received breast-conserving therapy should undergo a total mastectomy whereas mastectomy treated women should undergo surgical resection of the recurrence plus radiation therapy. Following treatment of the local recurrence, chemotherapy or endocrine therapy should then be offered.

Overview of Breast Reconstruction

Breast reconstruction is now often considered as part of the breast cancer treatment when mastectomy is required or in women undergoing lumpectomy in cases where the specimen represents a large portion of the breast. The increasing number of women undergoing reconstruction after breast cancer surgery is related to several factors including increased patient awareness and screening, the number of mastectomies performed, greater awareness of reconstruction options, and change in insurer reimbursement. In 1998, Congress passed the Women’s Health and Cancer Rights Act, guaranteeing insurance reimbursement for breast reconstruction or external prostheses, contralateral procedures for symmetry and treatment for any sequelae of mastectomy.

Patients should be educated at the plastic surgery consultation concerning the potential for multiple procedures required to ablate the breast cancer, fashion the

260 Practical Plastic Surgery

breast mound and create a projecting nipple and areola along with the potential complications that may occur with each technique. This should especially be discussed in the context of immediate reconstruction where avoiding any delay to adjuvant treatment is an important consideration. On physical exam of the breast cancer patient it is important to note size, ptosis, asymmetry and scars, palpable axillary lymph nodes and whether previous radiation has been given, and if so, the quality of the breast and chest wall. The abdomen, back and other possible donor sites should be carefully inspected taking note of scars, overall fat content and strength.

A detailed description of the various breast reconstructive procedures can be 41 found in the upcoming chapters of this section.

Immediate Breast Reconstruction

The previous fears that immediate breast reconstruction might delay recurrent cancer detection or have a negative impact on prognosis of breast cancer have been alleviated.

Furthermore, there is no evidence that immediate reconstruction increases the rate of local or systemic relapse. Overall, women benefit from the reduction in psychological trauma experienced after mastectomy by undergoing immediate breast reconstruction.

One of the major advantages of immediate breast reconstruction includes a reduction in the number of operations ultimately necessary to create a reconstructed breast mound following extirpation of the breast. In addition, the emotional benefit of having begun reconstruction at the time of breast removal may reduce the psychological impact of losing the breast. Disadvantages of immediate reconstruction include extended surgical time and potential complications of the mastectomy, such as skin loss or infection, which may adversely affect the reconstruction. Perhaps the greatest disadvantage of immediate reconstruction is the inability to predict (in many cases) who will need adjuvant radiation.

All patients undergoing immediate reconstruction should be marked preoperatively by the plastic surgeon. Markings include the inframammary folds, the midline, the sternal notch and the donor site in cases of autogenous reconstruction. In addition, many surgical oncologists will allow the plastic surgeon to design the incision through which the mastectomy will be performed. This usually involves an oval, periareolar incision for removal of the nipple-areola complex and a linear extension of the oval incision. This extension need not always be directed towards the axilla. For example, if no axillary dissection is indicated, the incision can be designed vertically towards the inframammary fold, simulating a tear-drop shaped mastopexy-like incision. Finally, in certain cases a nipple-sparing mastectomy may be planned. In such instances, the mastectomy can be performed through a horizontal, inframammary incision, an approach that is familiar to the plastic surgeon as it is commonly used for breast augmentation.

Delayed Breast Reconstruction

Delayed reconstruction may be performed several days to years after mastectomy; however waiting three to six months is generally recommended. Advantages to delayed reconstruction include increased time to allow for adequate skin flap healing making the tissues more mobile and pliable, as well as increased time to allow for patient recovery. Some surgeons feel it allows them to achieve better symmetry than with a single stage approach. Disadvantages include multiple procedures to obtain the same result as with immediate reconstruction and increased psychological trauma from losing the breast.

Intraoperative Considerations

The plastic surgeon should be present during the prepping and draping of the patient, since not all breast surgeons are familiar with the exposure required for the reconstruction. For instance, both breasts should always be prepped even in unilateral procedures.

Although cancer surgery should never be compromised for the sake of the reconstruction, there is a way to perform a mastectomy that is oncologically sound, yet ideal for the reconstructive procedure. The skin flaps should be handled gently during the mastectomy without excessive retraction. They should be kept as thick as possible, preserving all of the subcutaneous fat external to the breast capsule. In

cases of DCIS, prophylactic mastectomy and small tumors distant from the chest 41 wall, there is no need to remove the pectoralis fascia along with the breast specimen. Preservation of this fascia will make the expander/implant reconstruction much easier. Finally, if autogenous reconstruction is being planned in the setting of an axillary dissection, it is imperative that the thoracodorsal pedicle remain untouched, and

that the branches arising from these vessels be ligated rather than cauterized to avoid thermal injury to the main artery and vein.

Chemotherapy and Reconstruction

As mentioned previously, adjuvant systemic therapy in the form of chemotherapy or hormonal therapy is routinely administered to women under the age of 70 if they are node positive and to the majority of women with tumors > 1 cm. Chemotherapy can be delivered to patients with implants, tissue expanders or flaps as soon as the wound has healed and there are no sign of underlying infection. There is no significant difference in postoperative complication rates between patients undergoing mastectomy alone followed by chemotherapy or mastectomy with immediate reconstruction followed by chemotherapy. Regardless of the reconstructive method, four weeks is usually the maximum time elapsed between reconstruction and the start of chemotherapy. Most studies have shown that a delay in the initiation of chemotherapy following immediate breast reconstruction happens only 1% of the time.

Radiation and Reconstruction

When discussing reconstructive options, special consideration should be given to women who will require adjuvant radiation and women who have received chest radiation in the past. For example, some women will require adjuvant radiotherapy following mastectomy for locoregional control and some women will have local recurrence following lumpectomy and radiation therapy, which would require treatment with a mastectomy. Both of these scenarios pose unique reconstructive challenges. Regardless of timing, radiation forever compromises the quality of the skin and underlying muscle, resulting in a higher incidence of complications, unsatisfactory expansion and a poorer aesthetic result.

Many surgeons will not use expanders/implants in patients with previous chest wall irradiation. However, studies of irradiated patients who undergo subsequent implant reconstruction have shown that, although the complication rates are much higher compared to autogenous reconstruction, the majority of women are satisfied with the final outcome. Therefore, all options should be presented to a patient with a prior history of radiation, with a detailed discussion of the risks and benefits of each type of reconstruction. Any woman undergoing radiation to the breast after implant reconstruction has a high risk of developing capsular contracture and tissue firmness ultimately requiring a salvage procedure using autogenous tissue. Women with obvious radiation-induced skin changes prior to reconstruction should undergo autogenous tissue reconstruction. Not surprisingly, myocutaneous flap reconstruction does not