title: Technique to Promote Symmetry in 2-Staged Bilateral Breast Reconstruction in the Setting of Unilateral Postmastectomy Radiation.
abstract: BACKGROUND
  Bilateral breast reconstruction in the setting of unilateral postmastectomy radiation therapy (PMRT) remains one of the most difficult reconstructive challenges due to significant radiation-induced asymmetry from capsular contracture and superior migration of the irradiated reconstructed breast. We describe a novel and straightforward intraoperative technique for creating compensatory asymmetry to maximize postradiation symmetry in immediate bilateral tissue expander (TE) and acellular dermal matrix (ADM) reconstruction requiring unilateral PMRT.
  
  
  METHODS
  A cohort of 25 bilateral TE/ADM breast reconstructions with planned unilateral PMRT was performed using this approach, and outcomes were reviewed. On the PMRT side, the ADM edge was inset to a lower inframammary fold (IMF) position resulting in a near "bottoming-out" effect. On the non-PMRT side, the ADM was inset using a triple point stitch onto the IMF in a higher chest wall location. The planned PMRT side TE was overexpanded and second-stage exchanges were performed 6+ months post-PMRT.
  
  
  RESULTS
  Post-PMRT results showed improved symmetry as the PMRT side migrated superiorly to match the contralateral non-irradiated side. Minimal pocket or IMF adjustments were required during second-stage procedures, with just 6 patients (24%) requiring minor lowering and 1 patient (4%) requiring elevation of the PMRT side IMF. Thus, most (72%) patients undergoing bilateral mastectomy and unilateral PMRT did not require any IMF modifications during the second-stage procedure.
  
  
  CONCLUSIONS
  A differential ADM inset and TE pocket creation for bilateral TE/ADM breast reconstructions with planned unilateral PMRT can minimize the typical adverse aesthetic effects of PMRT on reconstruction results and maximize symmetry.
authors.affiliation: From the *Harvard Combined Plastic Surgery Residency Program; and †Division of Plastic Surgery, Brigham & Women's Hospital, Boston, MA.
authors.forename: Daniel S
authors.initials: DS
authors.lastname: Roh
authors.forename: Matthew D
authors.initials: MD
authors.lastname: Treiser
authors.forename: Emily H
authors.initials: EH
authors.lastname: Lafleur
authors.forename: Yoon S
authors.initials: YS
authors.lastname: Chun
mesh_terms: D000328:Adult; D018427:Breast Implants; D001943:Breast Neoplasms / Q000473:pathology / Q000532:radiotherapy* / Q000601:surgery*; D015331:Cohort Studies; D004954:Esthetics; D005260:Female; D006801:Humans; D016462:Mammaplasty / Q000379:methods*; D008408:Mastectomy / Q000379:methods*; D008875:Middle Aged; D018714:Radiotherapy, Adjuvant; D012189:Retrospective Studies; D018570:Risk Assessment; D016896:Treatment Outcome; D014945:Wound Healing / Q000502:physiology*