title: 'Reconstruction: before or after postmastectomy radiotherapy?' A systematic review of the literature.
abstract: OBJECTIVE
  The aim of this review is to investigate the effect of timing of the reconstruction and radiotherapy, with respect to complication rate and cosmetic outcome, with a special focus on the timing of the placement of the definite implant.
  
  
  METHODS
  PubMed was searched for publications between January 2000 and December 2012. Of 37 eligible studies, timing of reconstruction, type, and incidence of complications were recorded. First, we calculated the weighted mean including confidence intervals for complications and cosmetic outcome overall, and for the following subgroups: (1) Autologous reconstruction after radiotherapy; (2) Definite implant reconstruction after radiotherapy; (3) Autologous reconstruction before radiotherapy; (4) Definite implant reconstruction before radiotherapy. A second analysis was performed using only studies that directly compared group 1 versus 3 and 2 versus 4.
  
  
  RESULTS
  A large variation in complication rates (8.7-70.0%) and in acceptable cosmetic outcome (41.4-93.3%) was reported. The first analysis showed more complications and a higher revision rate if an implant reconstruction was performed after radiotherapy; for autologous reconstruction fibrosis occurred more often if reconstruction was applied first. The second analysis showed no significant differences in total complication rate. Only implant failure occurred more often if applied after radiotherapy (odds ratio (OR) 3.03 [1.59-5.77]). No differences were found in both patient and physician satisfaction.
  
  
  CONCLUSIONS
  A definite implant reconstruction placed before radiotherapy limits the rate of complications. For autologous reconstruction, less fibrosis is seen if reconstruction is performed after radiotherapy, but timing had no significant impact on total complication rate.
authors.affiliation: Maastricht University Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht, The Netherlands.
authors.forename: Judith
authors.initials: J
authors.lastname: Berbers
authors.affiliation: Maastricht University Medical Center, Dept. Radiation Oncology (MAASTRO Clinic), GROW, Maastricht, The Netherlands.
authors.forename: Angela
authors.initials: A
authors.lastname: van Baardwijk
authors.affiliation: Maastricht University Medical Center, Dept. Radiation Oncology (MAASTRO Clinic), GROW, Maastricht, The Netherlands.
authors.forename: Ruud
authors.initials: R
authors.lastname: Houben
authors.affiliation: Maastricht University Medical Center, Dept. Surgical Oncology, Maastricht, The Netherlands.
authors.forename: Esther
authors.initials: E
authors.lastname: Heuts
authors.affiliation: Maastricht University Medical Center, Dept. Surgical Oncology, Maastricht, The Netherlands.
authors.forename: Marjolein
authors.initials: M
authors.lastname: Smidt
authors.affiliation: Maastricht University Medical Center, Dept. Surgical Oncology, Maastricht, The Netherlands.
authors.forename: Kristien
authors.initials: K
authors.lastname: Keymeulen
authors.affiliation: Maastricht University Medical Center, Dept. Surgical Oncology, Maastricht, The Netherlands.
authors.forename: Maud
authors.initials: M
authors.lastname: Bessems
authors.affiliation: Maastricht University Medical Center, Dept. Reconstructive Surgery, Maastricht, The Netherlands.
authors.forename: Stefania
authors.initials: S
authors.lastname: Tuinder
authors.affiliation: Maastricht University Medical Center, Dept. Radiation Oncology (MAASTRO Clinic), GROW, Maastricht, The Netherlands. Electronic address: liesbeth.boersma@maastro.nl.
authors.forename: Liesbeth J
authors.initials: LJ
authors.lastname: Boersma
mesh_terms: D018427:Breast Implants / Q000009:adverse effects; D003131:Combined Modality Therapy; D005355:Fibrosis; D006801:Humans; D016462:Mammaplasty / Q000009:adverse effects / Q000379:methods*; D008408:Mastectomy / Q000379:methods*; D016017:Odds Ratio; D011183:Postoperative Complications / Q000175:diagnosis / Q000209:etiology; D011878:Radiotherapy / Q000379:methods*; D019651:Plastic Surgery Procedures / Q000009:adverse effects / Q000379:methods*; D013997:Time Factors
keywords: Autologous reconstruction; Breast cancer; Breast reconstruction; Complications; Cosmetic outcome; Delayed reconstruction; Immediate reconstruction; Implant reconstruction; Mastectomy; Radiotherapy