Skin-sparing mastectomy and radiotherapy: an update

Despite the lack of randomised controlled trials and paucity of the published data, the current evidence suggests that the post-mastectomy radiation therapy (PMRT) does not represent a contraindication to skin-sparing mastectomy (SSM) and immediate breast reconstruction (IBR) in the multidisciplinary setting. Although PMRT is associated with a higher incidence of complications, a satisfactory cosmetic outcome can be achieved in most patients. Radiation has a deleterious effect on autologous flap reconstruction that relies on fat for volume replacement such as the deep inferior epi-gastric perforator (DIEP) flap reconstruction and this method of reconstruction should be delayed until RT is completed. Until better methods of RT delivery are developed to minimise complications, women at high risk of requiring PMRT, can be safely offered SSM and IBR with a sub-pectoral saline-filled tissue expander and this can be replaced with a permanent prosthesis or converted into an autologous flap reconstruction after the completion of RT. Any capsule formation can be surgically treated at this stage. This new concept, known as immediate-delayed reconstruction, can avoid the cosmetic and RT delivery problems that can occur after IBR. Furthermore, prior RT does not represent a contra-indication to SSM and IBR, however it increases the incidence of complications.