title: Treatment of irradiated expanders: protective lipofilling allows immediate prosthetic breast reconstruction in the setting of postoperative radiotherapy.
abstract: BACKGROUND
  Immediate two-stage prosthetic breast reconstruction in the setting of postmastectomy radiotherapy (PMRT) currently is hardly achieved with the fast-track expander exchange proposed by Cordeiro and colleagues or the delayed-immediate breast reconstruction proposed by Kronowitz and Robb. Each of these techniques has important drawbacks and complications. To overcome these problems, the authors in 2011 described lipofilling on irradiated expanders in patients undergoing unplanned PMRT (Cagliari University Hospital [CUH] protocol) for early breast cancers with specific risk factors. The authors report their experience after expanding the use of such a protocol for any immediate expander/implant reconstruction in a patient undergoing PMRT.
  
  
  METHODS
  The timing for advanced breast cancer involves immediate reconstruction with a tissue expander, complete tissue expansion, radiotherapy (RT) after neoadjuvant chemotherapy starting 2-3 months after mastectomy, one or two fresh fat-grafting sessions at least 6 weeks after RT, and an expander-implant exchange with anterior capsulectomy at least 3 months after the completion of fat grafting. The timing for early breast cancers with specific risk factors involves immediate reconstruction with a tissue expander, complete tissue expansion during postoperative chemotherapy, RT 6 months after mastectomy, one or two fat-grafting sessions 6 weeks after RT, and an expander-implant exchange with anterior capsulectomy at least 3 months after the completion of fat grafting. From 2008 to 2012, 16 patients undergoing total mastectomy and immediate expander-implant breast reconstruction with subsequent PMRT were treated according to the CUH protocol.
  
  
  RESULTS
  The results have been extremely encouraging, with rates of ulceration and implant exposure in the radiotreated area dropping to 0 %. These results were retrospectively compared with those for a control group of 16 patients who underwent immediate implantation of an expander. In this latter group, the extrusion rate of the implant in the end was 31.25 %, and this was statistically significant (p < 0.03). The shape and symmetry also were significantly better in the lipofilled patients.
  
  
  CONCLUSIONS
  Protective lipofilling on irradiated expanders appears to be a valid technique for avoiding ulceration and implant exposure after PMRT while allowing a complete expansion.
  
  
  METHODS
  This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
authors.affiliation: Section of Plastic Surgery, Department of Surgery, Cagliari University Hospital, Cagliari, Italy.
authors.forename: Diego
authors.initials: D
authors.lastname: Ribuffo
authors.forename: Matteo
authors.initials: M
authors.lastname: Atzeni
authors.forename: Maristella
authors.initials: M
authors.lastname: Guerra
authors.forename: Stefania
authors.initials: S
authors.lastname: Bucher
authors.forename: Carola
authors.initials: C
authors.lastname: Politi
authors.forename: Maura
authors.initials: M
authors.lastname: Deidda
authors.forename: Francesco
authors.initials: F
authors.lastname: Atzori
authors.forename: Mariele
authors.initials: M
authors.lastname: Dessi
authors.forename: Clelia
authors.initials: C
authors.lastname: Madeddu
authors.forename: Giancarlo
authors.initials: G
authors.lastname: Lay
mesh_terms: D000273:Adipose Tissue / Q000601:surgery / Q000637:transplantation*; D000328:Adult; D000368:Aged; D018427:Breast Implants; D001943:Breast Neoplasms / Q000473:pathology / Q000532:radiotherapy* / Q000601:surgery*; D015331:Cohort Studies; D003131:Combined Modality Therapy; D004954:Esthetics; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D016462:Mammaplasty / Q000379:methods*; D008408:Mastectomy / Q000379:methods; D008875:Middle Aged; D011182:Postoperative Care / Q000379:methods; D011183:Postoperative Complications / Q000517:prevention & control; D011475:Prosthesis Failure; D018714:Radiotherapy, Adjuvant; D012189:Retrospective Studies; D018570:Risk Assessment; D015626:Tissue Expansion / Q000379:methods*; D016896:Treatment Outcome; D014945:Wound Healing / Q000502:physiology