Can Breast Reduction Surgery Be Done Safely If The Breast Has Been Irradiated?
Q: Dr. Eppley, I have a question regarding the potential complications of performing breast reduction surgery on a breast that has been previously radiated for cancer. I was irradiated for a localized ductal carcinoma five years ago. The irradiated breast has finally softened a bit and the skin appears pink and healthy after significant initial burning at the time of radiation. Six months ago, a plastic surgeon performed reduction surgery on the normal breast (from a size DDD to a size C) in an attempt to alleviate chronic back pain. He unfortunately removed so much tissue from the healthy breast that the radiated breast remains 2 cup sizes larger than the post-reduction normal breast. I am quite upset with the unsightly asymmetric results. The plastic surgeon did not want to attempt reduction surgery on the previously radiated breast due to the risk of poor healing etc. This seems to be good advice but doesn’t solve the current lop-sided result. The plastic surgeon suggested that I undergo a full mastectomy and flap reconstruction but that seems a bit much. Do you know of any reduction alternatives or surgical techniques that can overcome the complications of operating on irradiated tissue? Thank you for any information or advice you might have.
A: In today’s world of early breast cancer detection and treatments, it is no longer rare to see a patient for breast reduction that has had either a biopsy or lumpectomy and radiation. I have performed several cases of breast reduction previously without undue wound healing. This being said, it is important to realize that the effects of radiation on wound healing do not actually improve with time. The sclerosis of the microvascular of the skin actually worsens past the early post-irradiation period, so there is never a completely safe time to operate on an irradiated breast. The risk of wound healing problems is very real and the extensive devascularizing nature of a breast reduction procedure can unmask how compromised the circulation of the breast skin is.
There are two approaches to operating on the irradiated breast for a reduction. The first is to change or alter the surgical technique used. Using a standard breast reduction approach, the inferior pedicle is keep very wide (10 cms) and the raised skin flaps are kept thick. (2 to 3 cms) The amount of breast reduction that is internally removed may be less than that of the opposite breast so ideal symmetry in breast size will not be obtained. But maximal microcirculation is obtained. It is also extremely important to keep the skin excisional pattern conservative so no tension is placed at the intersection of the vertical and horizontal closure. The surgical technique can also be altered to be a free nipple grafting method where the breast resection is through the central mound and the circulation to the remaining skin flaps is completely unaltered. The second technique is the safest and may allow the reduction to be optimally matched to the opposite but the appearance of the nipple-areolar complex will be slightly different and nipple sensation and erection will be lost.
The second approach, and one that is reserved for the most severely radiation-damaged breast, is a two-stage technique. The breast is initially injected with a combination of stem cella and PRP (platelet-rich plasma) to improve the vascular quality of the breast mound. Three months later, the breast reduction is performed.
Which of these approaches is best would be based on how the breast looks and feels and the radiation dose and length of time from when it was done.
I would agree that immediate conversion to a mastectomy and flap reconstruction is overtreatment and should be reserved in case there is a major healing problem…and can always be done.
Dr. Barry Eppley