Use of Sentinel Lymph Node Incision for Second Stage Implant-Based Breast Reconstruction After Radiation.

[BACKGROUND] Staged expander to implant breast reconstruction is associated with a high complication rate when the patient has had postmastectomy radiation. With an increasing number of American women undergoing implant-based breast reconstruction after postmastectomy radiation, surgeons may find themselves operating in a radiated field with synthetic devices. We report the performance characteristics of a novel surgical modification to the second stage expander to implant exchange after adjuvant radiation using a transaxillary approach through a prior sentinel lymph node incision, a site remote from the breast implant pocket.

[METHODS] We performed a retrospective review of a prospectively maintained database to evaluate the surgical outcomes of serial patients undergoing second staged expander to implant exchange through the sentinel lymph node incision 6 months or more after completing whole breast radiation. A case matched cohort to age, body mass index, and comorbid status was used to compare outcomes between patients in the group of interest versus a traditional skin sparing incision on the anterior breast mound through the radiated skin envelope. All patients included demonstrated grade 1 or 2 skin changes on the Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer Late Radiation Morbidity Scoring Schema for the skin organ system.

[RESULTS] Nineteen breasts were reconstructed for 18 women after immediate tissue expander placement and adjuvant whole breast radiation were included in our group of interest. Forty-one case-matched second controls were identified for the comparison group. There were no intraoperative complications. Two postoperative complications were reported for the sentinel lymph node approach group (10.5%) with an average of 9 months of follow-up: 1 operative exploration for hematoma and 1 minor wound requiring recloser in the office. The case matched cohort demonstrated significantly more minor postoperative complications (P = 0.037) with a total complications rate of 41.4%. There were 31.7% of the patients that experienced a minor complication alone, whereas 9.7% of the case-matched cohort experienced a major complication.

[CONCLUSIONS] These data support the use of the existing axillary sentinel lymph node access incision for second stage placement of a gel implant after immediate expander and adjuvant radiation therapy. The sentinel lymph node incision approach facilitates layered closure over the breast pocket at a site remote from irradiated tissue, reducing the incidence of postoperative minor complications. Forthcoming long-term data will determine if differences in reported capsular contracture rates can be achieved with a remote transaxillary approach to second stage implant reconstruction after radiation.