Direct-to-implant versus two-stage implant-based breast reconstruction in patients requiring postmastectomy radiotherapy

Aim: Postmastectomy radiation therapy (PMRT) has played an important role in advanced breast cancer. It may negatively impact the outcomes of implant-based reconstruction. The aim of this study was to investigate the impact of PMRT on the outcome of implant-based reconstruction. Methods: A total of 36 patients from 2009 to 2019 were included, with 12 in the two-stage group (TE-XRT ± Implant), who received PMRT after mastectomy and tissue expander insertion, 14 received PMRT after immediate direct-to-implant (DTI-XRT) breast reconstruction, and 10 with history of breast conservation surgery and PMRT received mastectomy and DTI reconstruction for cancer recurrence (XRT-DTI). Morbidities, including acute and late poor wound healing, implant or expander loss, and final revision surgeries, were reviewed. Results: There were no significant differences in age, gender, BMI, or histological type among groups. Overall, complications were higher in the TE-XRT ± Implant group than in the DTI-XRT group (83.3% vs . 35.7%, P = 0.02). Wound breakdown was more frequent in the TE-XRT ± Implant group than in the DTI-XRT group (33.3% vs . 0.0%, P = 0.03). In two-stage reconstruction, implant exposure occurred predominantly in the late stage of the stage II surgery and stage II surgery tended to present higher overall and late complications than XRT-DTI or DTI-XRT. Conclusion: For patients requiring PMRT, two-stage implant-based breast reconstruction tends to have a higher complication rate than DTI breast reconstruction. Our results suggest that radiation’s impact on wound healing might outweigh other negative effects, and conversion from implant-based reconstruction to two-stage reconstruction may not always be necessary.