IBR and rxth (Immediate breast reconstruction and adjuvant radiotherapy ): an emerging solution

Immediate breast reconstruction (IBR) and adjuvant radiotherapy is classically option, which is only available in highly specialised teams. But verygood results can be obtained.· An autologous latissimus dorsi flap is associated with intermediateaesthetic results as the muscle will experience atrophy and fibrosis atvarious proportions, but the fat part of the flap proves a very goodradiation tolerance, as in free flaps. The technique is really more robustand simple, shorter and feasible everywhere in comparison with freeflaps. Also, a significant improvement is available with secondarylipofilling, if necessary.· Mastectomy after radiotherapy is another emerging innovative option. Inother cancers, such as rectum, surgery after radiotherapy is really a betteroption than surgery first and this sequence is now a standard in thislocation. Consequently some teams tried the same option in the breast:for large tumors, when chemotherapy, radiotherapy and mastectomy isindicated: chemotherapy is done first, then radiotherapy and surgery after6-8 weeks with axillary clearance and IBR still with a flap (with orwithout an implant).an incompatible association.The reasons are related to a small increase of early complications (6-8%) andessentially a deleterious late effect of radiotherapy:· Breast implants are associated with up to 40% capsular contracture, withmany reinterventions for aesthetic improvement with a new implant orconversion to a flap, as well as a low aesthetic result[1].· Flaps are also damaged by radiotherapy, with 20% fibrosis also inducingdegradation of aesthetic results, even in less proportion than withimplants.Consequently classic indications for IBR are limited to mastectomy withoutradiotherapy.However, the impact for women being spared having an immediatereconstruction is more and more worrying and difficult to avoid in 2013.After mastectomy and radiotherapy, breast reconstruction is recommended oneyear after completion of radiotherapy, that is about 18 months after mastectomy.This can be a painful episode for many women, especially at a young age. Allpsychological and quality of life studies have proven the real benefit ofimmediate reconstruction [2].Last but not least, when a skin-sparring mastectomy can be undertaken, themean aesthetic results of IBR are significantly better than secondary. This isrelated to skin preservation, with a more natural look, less scars and a bettershape, as well as a lower need for second surgery.For these reasons, some teams have been trying to find a solution for manyyears. The situation has radically changed in recent years, because of increasedexperience related to autologous flaps, pedicled or free, as well as in lipofilling.We now have different options to offer in this situation:· The oldest option is the immediate-delayed technique, first reported bythe MD Anderson team [3]. Immediate reconstruction is performed by anexpander, which is deflated during radiotherapy and re-expanded justafter the last sequence. After about one year, the expander is changed fora flap.· Using a free flap without muscle is associated with very few or no latefibrosis. However, free flap is a long and highly technical operation,involving microsurgery. Operative time is about 6-8 hours, with 1% riskof total flap necrosis. In the special situation of IBR, a free flap is a heavy