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Impact of Prior Ipsilateral Chest Wall Radiation on Pedicled TRAM Flap Breast Reconstruction
Yoon S. Chun, M.D.1, Kapil Verma, B.A.2, Indranil Sinha, M.D.1, Heather Rosen, M.D., M.P.H.3, Stuart R. Lipsitz, Sc.D.1, Charles Hergrueter, M.D.1, Julia Wong, M.D.4, Julian J. Pribaz, M.D.1.
1Brigham and Women's Hospital, Boston, MA, USA, 2Harvard Medical School, Boston, MA, USA, 3University of Southern California/Keck School of Medicine, Los Angeles, CA, USA, 4Dana Farber Cancer Institute, Boston, MA, USA.
PURPOSE: Many breast cancer patients interested in pedicled transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction have undergone prior ipsilateral chest wall radiation. Previous treatment frequently includes initial breast conservation therapy, mantle radiation, or prior post-mastectomy radiation. Many reconstructive surgeons avoid basing the TRAM flap on the previously irradiated superior epigastric pedicle system in this subset of patients. The current study was performed to compare the complication rates between TRAM flaps based on previously irradiated superior epigastric pedicle versus TRAM flaps based on non-irradiated superior pedicle to assess the impact of prior ipsilateral chest wall radiation on pedicled TRAM flap breast reconstruction.
METHODS: The authors performed a retrospective analysis of consecutive breast reconstructions using pedicled TRAM flaps performed over an 8-year period. A total of 302 pedicled TRAM flaps were divided into two groups: TRAM flaps based on a previously irradiated superior epigastric pedicle (N=76) and TRAM flaps based on a non-irradiated superior epigastric pedicle (N=226). Demographic information, co-morbidities, oncologic data, neoadjuvant therapy, and post-operative complications were collected for comparison. A Pearson chi-square test, adjusted for bilateral reconstructions from the same patient, was used to test for differences in complication rates between the previously irradiated and non-irradiated groups.
RESULTS: A total of 215 patients underwent 302 pedicled TRAM flap breast reconstructions (128 unilateral and 87 bilateral). 76 TRAM flaps were based on a previously irradiated superior epigastric system due to prior chest wall radiation ipsilateral to the flap, and 226 TRAM flaps were based on a non-irradiated superior epigastric system. Among the 76 patients who had prior ipsilateral chestwall radiation, 41 patients had undergone breast conservation therapy, 29 patients had received post-mastectomy radiation, and 6 patients had received mantle radiation. There was no statistically significant difference in the rate of flap-related complications between the previously irradiated group and non-irradiated group including flap loss (1.3% vs. 0.4%, p=0.418), partial flap loss (4.0% vs. 2.2%, p=0.416), infection (1.3% vs. 1.8%, p=0.789), and fat necrosis (15.8% vs. 9.7%, p=0.164). However, there was a statistically non-significant trend towards higher revision rate in the previously irradiated TRAM flap group compared to the non-irradiated TRAM flap group (26.3% vs. 16.4%, p=0.056).
CONCLUSION: Many breast cancer patients considering pedicled TRAM flap breast reconstruction may have had a history of ipsilateral chest wall radiation in the setting of prior breast conservation therapy, mantle radiation, or post-mastectomy radiation. Previous radiation to the chest wall ipsilateral to the TRAM flap is not associated with significant flap-related complications and may not be a contraindication for considering pedicled TRAM flap as a reconstructive option.
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