Comparison of immediate and delayed free TRAM flap breast reconstruction in patients receiving postmastectomy radiation therapy

Tumor pathologic features and the extent of nodal involvement dictate wheth er radiation therapy is given after mastectomy for breast cancer. It is gen erally well accepted that radiation negatively influences the outcome of im plant-based breast reconstruction. However, the long-term effect of radiati on therapy on the outcome of breast reconstruction with the free transverse rectus abdominis myocutaneous (TRAM) flap is still unclear. For patients w ho need postmastectomy radiation therapy, the optimal timing of TRAM flap r econstruction is controversial. This study compares the outcome of immediat e and delayed free TRAM flap breast reconstruction in patients who received postmastectomy radiation therapy. All patients at The University of Texas M. D. Anderson Cancer Center who received postmastectomy radiation therapy and who also underwent free TRAM flap breast reconstruction between January of 1988 and December of 1998 were included in the study. Patients who rece ived radiation therapy before delayed TRAM flap reconstruction were compare d with patients who underwent immediate TRAM flap reconstruction before rad iation therapy. Early and late complications were compared between the two groups. Early complications included vessel thrombosis, partial or total fl ap loss, mastectomy skin flap necrosis, and local wound-healing problems, w hereas late complications included fat necrosis, volume loss, and flap cont racture of free TRAM breast mounds. Late complications were evaluated at le ast 1 year after the completion of radiation therapy for patients who had d elayed reconstruction and at least 1 year after reconstruction for patients who had immediate reconstruction. During the study period, 32 patients had immediate TRAM flap reconstruction before radiation therapy and 70 patient s had radiation therapy before TRAM flap reconstruction. Mean followup time s for the immediate reconstruction and delayed reconstruction groups were 3 and 5 years, respectively. The mean radiation dose was 50 Gy in the immedi ate reconstruction group and 51 Gy in the delayed reconstruction group. One complete flap loss occurred in the delayed reconstruction group, and no fl ap loss occurred in the immediate reconstruction group. The incidence of ea rly complications did not differ significantly between the two groups. Howe ver, the incidence of late complications was significantly higher in the im mediate reconstruction group than in the delayed reconstruction group (87.5 percent versus 8.6 percent; p, = 0.000). Nine patients (28 percent) in the immediate reconstruction group required an additional flap to correct: the distorted contour from flap shrinkage and severe flap contraction. These f indings indicate that, in patients who are candidates for free TRAM flap br east: reconstruction and need postmastectomy radiation therapy, reconstruct ion should be delayed until radiation therapy is complete.