title: Radiation therapy and expander-implant breast reconstruction: an analysis of timing and comparison of complications.
abstract: BACKGROUND
  The optimal timing of expander-implant exchange in the setting of postmastectomy radiation therapy (PMRT) remains unclear with prior reports yielding inconsistent and variable results. The purpose of this study was to characterize complications associated with the sequencing of expander-implant breast reconstruction before or after PMRT and to compare the outcomes between early (<4 months) and late (>4 months) expander-implant exchange in the subset of patients who received PMRT before exchange.
  
  
  METHODS
  The medical records of all patients PMRT in the setting of tissue expander-implant breast reconstruction between June 2004 and June 2011 at our institution were reviewed retrospectively. Patients were first classified as having undergone expander-implant exchange before the initiation of PMRT or after the completion of PMRT. Patients who underwent expander-implant exchange after PMRT were then classified as having undergone exchange early (<4 months after PMRT) or late (>4 months after PMRT). All complications requiring additional surgery or hospitalization were recorded.
  
  
  RESULTS
  Fifty-five eligible patients were identified as having undergone 56 two-stage tissue expander-implant breast reconstructions. Twenty-two reconstructions underwent exchange before PMRT and 34 reconstructions underwent exchange after PMRT. There was no significant difference in overall complication rate (54.55% vs 47.06%, P = 0.785) or reconstruction failure rate (13.64% vs 20.59%, P = 0.724) between the 2 cohorts. Twenty reconstructions underwent exchange less than 4 months after PMRT and 14 underwent exchange more than 4 months after PMRT. There was no significant difference in overall complication rate (40% vs 57.14%, P = 0.487) or failure rate (25% vs 14.29%, P = 0.672) between the 2 groups. Trends suggest a higher rate of infection in patients who underwent exchange earlier (30% vs 14.29%, P = 0.422) and a higher rate of capsular contracture in patients who underwent exchange later (5% vs 21.43%, P = 0.283); however, statistical significance was not reached.
  
  
  CONCLUSIONS
  Our findings suggest that neither the sequencing nor timing of expander-implant exchange in the setting of PMRT affects overall complication or reconstruction failure rate. However, the timing of exchange may impact the type of complication encountered. Further investigation is necessary to determine an optimal time for expander-implant exchange.
authors.affiliation: Section of Plastic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT 06519-8062, USA. Rachel.Lentz@yale.edu
authors.forename: Rachel
authors.initials: R
authors.lastname: Lentz
authors.forename: Reuben
authors.initials: R
authors.lastname: Ng
authors.forename: Susan A
authors.initials: SA
authors.lastname: Higgins
authors.forename: Stefano
authors.initials: S
authors.lastname: Fusi
authors.forename: Michael
authors.initials: M
authors.lastname: Matthew
authors.forename: Stephanie L
authors.initials: SL
authors.lastname: Kwei
mesh_terms: D000328:Adult; D019928:Breast Implantation / Q000295:instrumentation / Q000379:methods*; D018427:Breast Implants; D001943:Breast Neoplasms / Q000532:radiotherapy* / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D016015:Logistic Models; D008408:Mastectomy; D008875:Middle Aged; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000453:epidemiology; D018714:Radiotherapy, Adjuvant; D012086:Reoperation; D012189:Retrospective Studies; D013997:Time Factors; D015626:Tissue Expansion / Q000295:instrumentation / Q000379:methods*; D015625:Tissue Expansion Devices; D016896:Treatment Outcome