More women are receiving radiation for their breast cancer than ever. In the past, radiation was reserved for women who were having lumpectomy or if they had certain findings at the time of mastectomy. These include: 4 or more positive lymph nodes, cancer > 5 cm, or close margin to the chest wall or skin. These indications have been expanded to include any positive lymph nodes and therefore the incidence of radiation has increased in women having mastectomy.

Unfortunately, most women do not realize that radiation causes permanent damage to their chest wall. This results in pain, possible deformity and irreparable damage. The skin and muscle lose their elasticity and the tissues develop decreased blood flow and atrophy or thinning of the tissue. This creates a hostile environment for reconstruction. Many women chose mastectomy wisely in an attempt to avoid radiation damage.

In the past, when a woman had a lumpectomy or mastectomy with radiation, no breast reconstruction was done. Reconstruction was delayed after mastectomy until radiation was completed. A flap or tissue from elsewhere on the body was then done to reconstruct the area. Currently, the preferred treatment would involve the oncologic breast surgeon and plastic surgeon working in conjunction for all these surgeries. If a lumpectomy is done, the plastic surgeon can design the incisions and then re-arrange the breast tissue so that there are no empty spaces in the breast before radiation is done. This is known as an oncoplastic breast reconstruction. A breast lift or reduction can be done on the opposite breast so that the patient will have symmetry. These procedures are covered by insurance.

If a mastectomy is being done and radiation is anticipated, my preference is to place a tissue expander at the time of mastectomy. The tissue expander is then inflated maximally to the goal size. At that point, a decision is made as to whether we are going to use an implant or convert to some type of tissue reconstruction. This decision depends on several factors including if whether or not a mastectomy was done on the other breast (easier to have symmetry with an implant on each side), how important the cosmetic result is to the patient and the patient’s overall health. The ideal situation would be to do some type of tissue reconstruction whether that would be using a back muscle (latissimus flap) with an implant or using the abdominal tissue for reconstruction. Alternatively, an implant alone can be done and the ideal way to place the implant would be before radiation is done. If this is not possible, the expander can be radiated then switched to an implant approximately 6 months after completion of radiation. Fat grafting is always incorporated in these reconstruction. A capsular contracture is anticipated and attempts are made to raise the opposite breast implant higher to match the radiated side.