Delivered directly to the breast, radiation reduces the risk of recurrence. It works by delivering high-energy x-rays that disrupt the DNA of cancer cells, so that they’re unable to divide and reproduce. Unfortunately, radiation also affects adjacent healthy cells in the same way; some cells repair themselves, eventually recovering and operating normally. But much of the remaining skin and tissue is forever changed. Surgeons generally recommend delayed reconstruction for at least three to six months after radiation to give the skin time to heal. Long-term cosmetic outcome after radiation tends to be better with delayed reconstruction.
Operating with radiated tissue is more challenging for a plastic surgeon, because blood flow is reduced and the skin’s elasticity is compromised.
Radiation and breast implants are generally considered to be a poor combination. The chance of short- and long-term complications is high. Radiated skin can be difficult to expand: if the breast skin is especially thin after mastectomy, the tissue expander may break through. Radiated skin is often more susceptible to infection, wound complications, and delayed healing. Slow, conservative expansion sometimes works; frequently it doesn’t. Capsular contracture (a hardening of the natural capsule of scar tissue that forms around the expander or implant) may squeeze the implant so much that it distorts shape and/or causes pain. Expanders and implants produce better results and fewer complications when they’re placed before radiation; even then radiation may sabotage the reconstruction.
Padding the mastectomy site with fat grafts appears to reduce the risk of complications by surrounding the implant with a bed of healthy tissue. Direct-to-implant reconstruction, which utilizes an acellular dermal matrix, doesn’t require expansion and may decrease the risk of capsular contracture.
Reconstruction with a DIEP, TUG, LAT or other tissue flap is generally considered to be a better option for women after radiation, but that too can be affected. Although a flap of your own skin, fat and/or muscle brings healthy tissue to the mastectomy site, the new breast might feel harder or shrink as the tissue contracts. A portion of the flap may die, and in rare cases, the entire flap may fail.
Overall, compared to breast implants, flaps often produce better cosmetic results and fewer problems after radiation. Microsurgical tissue flaps that include only skin and fat, (without muscle), also improve the mastectomy site by bringing new blood supply to the radiated tissue.