Our retrospective study concerned a heterogeneous population of patients who all opted for immediate breast reconstruction out of personal choice. The expander/implant technique was applied without selection criteria. Bias was therefore possible, and the results must be interpreted with caution.

The overall complication rate was 40%, comparable to the 42.3% rate reported in a series of 52 nonirradiated women who underwent immediate breast reconstruction with an expander The complication rate in the set of patients without RT (14%) is comparable to rates reported by other series . However, as already noted the complication rate was significantly greater in patients who received RT than in those who did not (51% vs. 14%). After RT, tissue expansion can be difficult and painful, with a risk of rib deformation consecutive to skin fibrosis, even in selected patients This may be especially true in patients irradiated before reconstruction. In 1 reported case, the expander created a bony chest wall deformity (documented by CT scan), because the soft tissue did not yield after RT . In our series, 8 of 55 patients had been irradiated before reconstruction because of ipsilateral recurrence. Five of these 8 patients presented with a complication. It was severe in two (pain in one and necrosis leading to expander removal in the other). Although improvements in RT techniques (discontinuation of cobalt use, CT-based dosimetry) may have lessened the risk of complications, and even though our complication rate was no greater in patients irradiated before rather than after reconstruction, before it can be advocated, immediate reconstruction of previously irradiated patients needs additional study to determine selection criteria.

Lymphorrhea/hematoma, capsular contracture, pain, and inflammation occurred more often in the irradiated than in the nonirradiated patients. Present before RT, lymphorrhea was certainly related to surgery. According to the adage that “nature hates an empty space,” the empty space was filled by lymph. The overall complication rate was greater in patients who received adjuvant chemotherapy than in those who did not (54% vs. 25%, p = 0.02), but the effects of chemotherapy could not be dissociated from those of RT, because all except three of our patients who received chemotherapy also received RT. No statistically significant difference was found in the complication rate in irradiated patients according to whether they received adjuvant chemotherapy (53% vs. 47%, respectively; p = 0.92) or between patients who received chemotherapy before or after reconstruction (p = 0.21). Thus, no definitive conclusion can be made on adverse role of chemotherapy on the complication rate after IBR with an expander. No identical finding has been reported in the literature

Contrary to previous reports  tamoxifen treatment did not significantly increase the complication rate. Because tamoxifen was always prescribed to steroid receptor-positive patients 2–3 weeks after RT completion, transforming growth factor-ß secretion, which is induced by both RT and tamoxifen, may have been minimized, so that fibrosis might be of lower importance. No adjuvant treatment was delayed because of immediate breast reconstruction

Our overall reconstruction failure rate was 19%. It was 9% in the nonirradiated group of 22 patients, which agrees with published values (8% in 62 patients and 8% in 115 patients . One study reported a failure rate of 21% in 87 patients , but Grade 4 reconstructions (poor esthetic results) were defined as “failures” in that study. Using these criteria, the authors concluded that, in the absence of RT, failure was more common with use of an expander/implant than with other types of reconstruction.

Our failure rate was greater in the women who received RT (24% vs. 9%, p = 0.2). These results are also in line with published findings (e.g., 37% vs. 8% . A very high failure rate of 60% (6 of 9 patients) found in one study was not much different from the rates obtained with other reconstruction techniques (e.g., use of autologous tissue) followed by RT and was attributed to nonoptimal RT and outdated implants. The higher failure rate in irradiated patients might be reduced by patient selection, because the incidence of capsular contracture is <15%. Adjuvant chemotherapy was related to a higher failure rate, with the reservation that all these patients (except three) also received RT. Most failures were either due to capsular contracture, with or without pain, or skin necrosis. This suggests a possible relationship with RT worsened by a radiosensitization effect and an impairment of the vessel quality  with chemotherapy.

The esthetic results in irradiated women were judged to be good to excellent in 54%, fair in 11%, poor in 11%, and failures in 24%. They may be biased because they reflect the surgeon’s viewpoint. Salvage reconstruction with a musculocutaneous flap was offered in instances of failure or poor results. The expander was removed in 13 irradiated patients, but RT was the cause of failure in only 9 of them (16% failure rate; 9 of 55). Reconstruction should not have been attempted in 2 hesitant women, and 1 case of inflammation and another of infection could have arisen even without RT. The median follow-up was too short, and an evaluation of the esthetic results is necessary at 5 years, because modifications of prosthesis aspect might occur with time. The literature noted no statistically significant difference in patient satisfaction between irradiated and nonirradiated women, even though RT results in a higher Baker class and thus a reduced esthetic score . Patient satisfaction with tissue expansion often surpasses expectations. Autologous reconstruction may give better esthetic results (i.e., more symmetrical breasts), but it is an involved procedure. Tissue expansion before insertion of a silicone breast prosthesis is relatively easy and swift and gives rise to no extraneous scars or loss of muscle function. The prosthesis, however, has to be replaced every 10 years, and late failures because of infection or exposure may arise A sufficiently long (30 min) preoperative visit is needed to explain the possible complications, the percentage of failure that might be expected, and the possibility of salvage reconstruction by alternative techniques. Moreover, a greater number of reconstructions can be undertaken, because the operation is safer and easier than reconstruction with a musculocutaneous flap. The widest choice should be offered to the patient who has to undergo RT