Breast reconstruction using tissue expanders and implants in Hodgkin's patients with prior mantle irradiation.

Women treated for Hodgkin's disease with mantle irradiation have an increased risk for developing breast cancer. Typically, breast malignancy in Hodgkin's patients presents bilaterally in a younger age group. Skin flap ischemia, poor skin expansion, implant extrusion, capsular contracture, and poor cosmesis are common sequelae of tissue expander/implant breast reconstruction after breast irradiation for failed breast conservation therapy. This has led most surgeons to favor autologous tissue reconstruction in this setting. This study was performed to determine the efficacy of tissue expander/implant breast reconstruction in breast cancer patients who have been treated with prior mantle irradiation for Hodgkin's disease. A retrospective analysis of all breast cancer patients with a history of Hodgkin's disease and mantle irradiation treated with mastectomy and tissue expander/implant reconstruction between 1992 and 1999 was performed. There were seven patients, with a mean age of 35 years (range, 28 to 42 years). The average interval between mantle irradiation and breast cancer diagnosis was 16 years (range, 12 to 23 years). All patients underwent two-stage reconstruction. Textured surface tissue expanders were placed in a complete submuscular position at the time of mastectomy. Expansion was initiated 2 weeks after insertion and continued on a weekly basis until completion. Expanders were replaced with textured surface saline-filled implants as a second stage. Patients were evaluated for skin flap ischemia, infection, quality of skin expansion, implant extrusion, capsular contracture, rippling, symmetry, and final aesthetic outcome. Breast cancer was bilateral in five patients and unilateral in two. Two patients did not undergo simultaneous bilateral breast reconstruction because of metachronous cancer development. One of the patients had an initial transverse rectus abdominis muscle flap breast reconstruction, followed by a tissue expander/implant reconstruction of the opposite breast. The average follow-up was 3 years. Complications were limited to one case of cellulitis after implant placement that resolved with intravenous antibiotics. There were no cases of skin flap ischemia, poor skin expansion, or implant extrusion. Overall patient satisfaction was high and revisions were not requested or required. Symmetry was best achieved with bilateral implants. This study demonstrates the efficacy of tissue expander/implant breast reconstruction in patients treated with prior mantle irradiation. In this series, tissue expansion was reliable with low morbidity. Second-stage placement of permanent implants yielded good aesthetic results without significant capsular contracture. Mantle irradiation did not appear to compromise the prosthetic breast reconstruction. Tissue expander/implant breast reconstruction should remain a viable option in this category of irradiated patients.     

Prediction of the intramembranous tissue formation during perisprosthetic healing with uncertainties. Part 2. Global clinical healing due to combination of random sources

This work proposes to examine the variability of the bone tissue healing process in the early period after the implantation surgery. The first part took into account the effect of variability of individual biochemical factors on the solid phase fraction, which is an indicator of the quality of the primary fixation and condition of its long-term behaviour. The next issue, addressed in this second part, is the effect of cumulative sources of uncertainties on the same problem of a canine implant. This paper is concerned with the ability to increase the number of random parameters to assess the coupled influence of those variabilities on the tissue healing. To avoid an excessive increase in the complexity of the numerical modelling and further, to maintain efficiency in computational cost, a collocation-based polynomial chaos expansion approach is implemented. A progressive set of simulations with an increasing number of sources of uncertainty is performed. This information is helpful for future implant design and decision process for the implantation surgical act.     

Autologous fat graft in nipple reconstruction

Reconstruction of the nipple is the penultimate step in breast reconstruction after mastectomy. A number of reconstructive techniques have been described for nipple reconstruction including skin grafts, composite grafts, and various local flaps. The authors' preferred reconstructive technique is the local C-V or modified star flap. This flap produces an excellent reconstruction, but it is dependent on underlying subcutaneous fat to provide bulk to the reconstructed nipple. In most instances, the subcutaneous tissue is adequate. However, under certain circumstances, the subcutaneous fat may be insufficient to produce a nipple of adequate projection. Two cases of bilateral nipple reconstruction after soft-tissue expansion and implant placement and subsequent nipple reconstruction with local flaps provided inadequate nipple projection. These instances, as well as a retrospective review of reconstructed nipples after mound restoration using a variety of techniques, led the authors to conclude that a more predictable alternative to sustain nipple projection was necessary. The authors identified two broad categories of breast reconstruction patients in whom this new technique would be beneficial. In the first category of patients, breast mounds are reconstructed with tissue expansion and implant insertion, and in the second category, breast mounds are reconstructed by any technique in which the nipple reconstruction subsequently flattens. This article describes the indications, techniques, and experience in 13 patients treated over a 10-month period with fat grafting for nipple reconstruction.     

Irradiation after immediate tissue expander/implant breast reconstruction: outcomes, complications, aesthetic results, and satisfaction among 156 patients

Chest wall irradiation is becoming increasingly common for mastectomy patients who have opted for immediate breast reconstruction with tissue expanders and implants. The optimal approach for such patients has not yet been defined. This study assesses the outcomes of a reconstruction protocol for patients who require irradiation after tissue expander/implant reconstruction. The charts of all patients who underwent immediate tissue expander/implant reconstruction at Memorial Sloan-Kettering Cancer Center between January of 1995 and June of 2001 and who had not previously undergone irradiation were retrospectively reviewed. A subgroup of patients who required chest wall irradiation after mastectomy and reconstruction was identified. Those patients were treated according to the following treatment algorithm: (1) reconstruction with tissue expander placement at the time of mastectomy , (2) tissue expansion during postoperative chemotherapy, (3) exchange of the tissue expander for a permanent implant approximately 4 weeks after the completion of chemotherapy, and (4) chest wall irradiation beginning 4 weeks after the exchange. All irradiated patients with at least 1 year of follow-up monitoring after the completion of radiotherapy were evaluated with respect to aesthetic outcomes, capsular contracture, and patient satisfaction. A control group of nonirradiated patients was randomly selected from the cohort of patients treated during the study period. During the 5-year study period, a total of 687 patients underwent immediate reconstruction with tissue expanders. Eighty-one patients underwent postoperative irradiation after placement of the final implant. A total of 68 patients who received postoperative chest wall irradiation underwent at least 1 year of follow-up monitoring after the completion of radiotherapy, with a mean follow-up period of 34 months. Seventy-five nonirradiated patients were evaluated as a control group. Overall, 68 percent of the irradiated patients developed capsular contracture, compared with 40 percent in the nonirradiated group (p = 0.025). Eighty percent of the irradiated patients demonstrated acceptable (good to excellent) aesthetic results, compared with 88 percent in the nonirradiated group (p = not significant). Sixty-seven percent of the irradiated patients were satisfied with their reconstructions, compared with 88 percent of the nonirradiated patients (p = 0.004). Seventy-two percent of the irradiated patients stated that they would choose the same form of reconstruction again, compared with 85 percent of the nonirradiated patients. The results of this study suggest that tissue expander/implant reconstruction is an acceptable surgical option even when followed by postoperative radiotherapy and should be considered in the reconstruction algorithm for all patients, particularly those who may not be candidates for autogenous reconstruction.     

Use of external reservoirs in tissue expansion

The use of tissue expanders having external reservoirs is presented. Twenty-four patients had 36 tissue expanders placed in the scalp, face, neck, upper limbs, chest, and lower limbs. All patients, apart from one, were taken to completion. This patient had erosion of the skin over expander and was only partially completed after removal of the expander. Apart from one instance of deflation at the end of the expansion where the skin could still be used, there were no other complications, in particular, no infections. The advantages of this technique are reduced operating time, ease of injection into the reservoir, lack of pain for the patient, early detection of reservoir or filling tube junction leakage, and lack of complications associated with the reservoir. This procedure is not recommended on at least theoretical grounds for breast expansion, where a permanent implant is to be inserted.     

Design optimization of cementless femoral hip prostheses using finite element analysis

Implant separation from bone tissue, resulting in the necessity for revision surgery, is a serious drawback of cementless total joint replacement. Unnatural stress distribution around the implant is considered the main reason for the failure. Optimization of the implant properties, especially its geometric parameters, is believed to be the right way to improve reliability of joint prosthetics. An efficient numerical model of thefemur-implant system is presented in the paper, including the finite element formulation featuring computation of sensitivity gradients, parametric mesh generator, and a gradient-based optimization scheme. Numerical examples show results of shape optimization of an implant for two sets of design parameters and for the initial stability criterion taken as the optimization goal. The optimum shape appears to be relatively long and proximally porous-coated on about half of its length. The method can be flexibly adjusted to various implant types, stress- and displacement-based optimum criteria, and geometric design parameters.     

Development of a statistical shape-function model of the implanted knee for real-time prediction of joint mechanics

Outcomes of total knee arthroplasty (TKA) are dependent on surgical technique, patient variability, and implant design. Non-optimal design or alignment choices may result in undesirable contact mechanics and joint kinematics, including poor joint alignment, instability, and reduced range of motion. Implant design and surgical alignment are modifiable factors with potential to improve patient outcomes, and there is a need for robust implant designs that can accommodate patient variability. Our objective was to develop a statistical shape-function model (SFM) of a posterior stabilized implanted knee to instantaneously predict joint mechanics in an efficient manner. Finite element methods were combined with Latin hypercube sampling and regression analyses to produce modeling equations relating nine implant design and six surgical alignment parameters to tibiofemoral (TF) joint mechanics outcomes during a deep knee bend. A SFM was developed and TF contact mechanics, kinematics, and soft tissue loads were instantaneously predicted from the model. Average normalized root-mean-square error predictions were between 2.79% and 9.42%, depending on the number of parameters included in the model. The statistical shape-function model generated instantaneous joint mechanics predictions using a maximum of 130 training simulations, making it ideally suited for integration into a patient-specific design and alignment optimization pipeline. Such a tool may be used to optimize kinematic function to achieve more natural motion or minimize implant wear, and may aid the engineering and clinical communities in improving patient satisfaction and surgical outcomes.     

Theoretical study of the fibrous capsule tissue growth around a disk-shaped implant

We analyze the mathematical properties of the fibrous capsule tissue concentration around a disk-shaped implant. We establish stability estimates as well as monotonicity results that illustrate the sensitivity of this growth to the biocompatibility index parameters of the implant. In addition, we prove that the growth of the tissue increases exponentially in time toward an asymptotic regime. We also study the mathematical properties of the solution of the inverse problem consisting in the determination of the values of the biocompatibility index parameters from the knowledge of some fibrous capsule tissue measurements. We prove that this model calibration problem admits a unique solution, and establish a characterization of the index parameters. Furthermore, we demonstrate analytically that such a solution is not continuous with respect to the data, and therefore the considered inverse problem is ill-posed due to the lack of the stability requirement.     

Capsular synovial metaplasia mimicking silicone leak of a breast prosthesis: a case report

Introduction

Synovial metaplasia around a prosthesis and in particular around silicone breast implants has been noted by various investigators, but has unknown clinical significance. We report on a patient where a large amount of synovial fluid mimicked rupture of an implant. We believe this to be an unusual clinical presentation of this phenomenon. Review of the English language literature failed to identify a comparable case.

Case presentation

A 25-year-old woman had undergone bilateral breast augmentation for cosmetic reasons. One implant was subsequently subjected to two attempts at expansion to correct asymmetry. The patient was later found to have a large quantity of viscous fluid around the port of that same prosthesis. Histological assessment of the implant had consequently confirmed capsular synovial metaplasia. This had initially caused the suspicion of a silicone 'bleed' from the implant and had resulted in an unnecessary explantation.

Conclusion

Capsular synovial metaplasia should be ruled out before the removal of breast implants where a leak is suspected. Manipulation and expansion of an implant may be risk factors for the development of synovial metaplasia.

     

A system for breast implant selection based on patient tissue characteristics and implant-soft tissue dynamics

Primary breast augmentation patients have widely varying characteristics of their breast envelope, parenchyma, and adjacent tissues. When preoperative breast implant selection does not specifically address critical soft-tissue parameters individual to each patient, risks of complications increase. Complications that occur from failure to reconcile a patient's wishes for breast size with her individual tissue characteristics include skin stretch and thinning, ptosis, atrophy of parenchyma, implant edge or shell visibility, implant edge or shell palpability, visible traction rippling, "bottoming" deformities, and lateral implant displacement with widening of the intermammary distance. Previous dimensional systems address implant parenchyma base width relative to implant base width, but no published system adequately addresses or attempts to quantitate the third dimension, tissue stretch, that is critical to estimate amount of fill necessary in a wide range of breast and tissue types. This system addresses the tissue characteristics (T) of the envelope (E), the parenchyma (P), and the implant (I), and the dynamics (D) of implant and filler distribution that affect soft tissues. The acronym TEPID summarizes the key factors that determine aesthetic results and occurrence of problems and reoperations following breast augmentation. This simple, efficient, and clinically practical system focuses on only three tissue measurements to estimate implant volume required to fill each patient's existing breast envelope, on the basis of her individual tissue characteristics: base width of the parenchyma, anterior pull skin stretch, and areola- and/or nipple-to-inframammary-fold distance measured under maximal stretch. The surgeon then adjusts initial volume to address differences in degree of skin stretch (anterior pull skin stretch) and contribution of the patient's existing parenchyma to stretched envelope fill, and to address differences in implant dimensions and filler distribution dynamics. To base decisions of implant pocket location on quantifiable soft-tissue coverage thickness, the system measures soft-tissue pinch thickness of the upper pole and at the inframammary fold. Surgeon time required to measure, estimate, and make preoperative implant selection decisions is less than 5 minutes. This system evolved from compiling and reviewing measurements and results from 330 primary breast augmentations from 1996 to 1999, including round and anatomic implant types with smooth shells and two different textured shells. The TEPID system was then used concurrently with the previous dimensional system for patient tissue evaluation and preoperative implant selection in 627 consecutive primary augmentation cases over a 3-year period from January of 1998 to January of 2001. Implant selection that did not comply with the parameters of the system was necessary in only eight cases. The TEPID system is a simple, efficient, and clinically practical method that allows surgeons to base implant selection on clinically quantifiable, individual patient tissue characteristics.     

Peri-implant bone remodeling after total hip replacement combined with systemic alendronate treatment: a finite element analysis

In order to decrease the peri-implant bone loss during the life-time of the implant, oral use of anti-osteoporosis drugs (like bisphosphonates) has been suggested. In this study, bone remodeling parameters identified from clinical trials of alendronate were used to simulate the effect of those drugs used after total hip arthroplasty on the peri-implant bone density. Results of the simulation show that the oral administrated drugs increase bone density around the implant and decreases, at the same time, the micromovements between the implant and the surrounding bone tissue. Incorporation of drug effect in numerical studies of bone remodeling is a promising tool especially to predetermine safe bisphosphonate doses that could be used with orthopedic implants.     

Continuous versus intraoperative expansion in the pig model.

Continuous tissue expansion utilizing a continuous infusion device that maintains a constant expander pressure was previously demonstrated to be feasible and successful in obtaining rapid tissue expansion in a canine model. Intraoperative tissue expansion has been described and has gained some clinical acceptance as a method to gain rapid expansion. We compared the efficacy of continuous tissue expansion versus intraoperative tissue expansion in a piglet model. After completing a pilot study, continuous tissue expansion was performed in six pigs (14.5 to 20 kg) on one flank over a 3-day period utilizing an improved prototype device; at the termination of continuous tissue expansion, intraoperative tissue expansion was performed on the opposite flank. There were no complications or continuous tissue expansion device malfunctions. Intraoperative tissue expansion gave a true gain in area of 7.4 percent, while continuous tissue expansion produced a 22 percent gain (p < 0.02). When the effects of both recruitment and expansion were added, continuous tissue expansion gave a dividend of 286 percent versus 192 percent for intraoperative tissue expansion (p < 0.01). Biomechanically, intraoperative tissue expansion skin showed few differences from unexpanded skin, while continuous tissue expansion skin showed a significant increase in stress relaxation (47.78 versus 38.74) and decrease in breaking strength. Histologic analysis revealed some epidermal hyperplasia and inflammation surrounding the continuous tissue expansion expander and some vascular congestion over the intraoperative tissue expansion expander. We conclude that continuous tissue expansion is superior to intraoperative tissue expansion and that the prototype device may be useful clinically.     

Effect of heparin and alendronate coating on titanium surfaces on inhibition of osteoclast and enhancement of osteoblast function

The failure of orthopedic and dental implants has been attributed mainly to loosening of the implant from host bone, which may be due to weak bonding of the implant material to bone tissue. Titanium (Ti) is used in the field of orthopedic and dental implants because of its excellent biocompatibility and outstanding mechanical properties. Therefore, in the field of materials science and tissue engineering, there has been extensive research to immobilize bioactive molecules on the surface of implant materials in order to provide the implants with improved adhesion to the host bone tissue.In this study, chemically active functional groups were introduced on the surface of Ti by a grafting reaction with heparin and then the Ti was functionalized by immobilizing alendronate onto the heparin-grafted surface. In the MC3T3-E1 cell osteogenic differentiation study, the alendronate-immobilized Ti substrates significantly enhanced alkaline phosphatase activity (ALP) and calcium content. Additionally, nuclear factor kappa B ligand (RANKL)-induced osteoclast differentiation of RAW264.7 cells was inhibited with the alendronate-immobilized Ti as confirmed by TRAP analysis. Real time PCR analysis showed that mRNA expressions of osteocalcin and osteopontin, which are markers for osteogenesis, were upregulated in MC3T3-E1 cells cultured on alendronate-immobilized Ti. The mRNA expressions of TRAP and Cathepsin K, markers for osteoclastogenesis, in RAW264.7 cells cultured on alendronate-immobilized Ti were down-regulated. Our study suggests that alendronate-immobilized Ti may be a bioactive implant with dual functions to enhance osteoblast differentiation and to inhibit osteoclast differentiation simultaneously.     

Increased survival and vascularity of random-pattern skin flaps elevated in controlled, expanded skin

Controlled clinical tissue expansion, a new technique of providing donor tissue, results in an increase in surface area of expanded skin. The aim of the present study was to determine the effect of controlled tissue expansion on the surviving lengths of random-pattern skin flaps elevated in expanded tissue. In five pigs the surviving lengths of flaps raised in skin expanded for 5 weeks using a 250-cc rectangular Radovan-type tissue expander were compared with the survival lengths of flaps elevated in tissue in which a similar prosthesis was not expanded, bipedicle flaps delayed for 5 weeks, and control acutely raised random-pattern flaps. The expanded flaps had a mean increase in surviving length of 117 percent over control flaps, which was statistically significant. The delay flaps had an increase in survival of 73 percent over control flaps, which was also statistically significant. There was no significant difference in survival between expanded flaps and delayed flaps. Morphologic studies using radiographic techniques on one pig demonstrated increased vascularity with tissue expansion. The results of this work demonstrate that in addition to providing increased surface area with controlled expansion, flaps raised in expanded skin have a significantly augmented surviving length. The mechanism for this increased vascularity with expansion is not known at this time, but it may be due to physical forces associated with expansion acting as a stimulus for angiogenesis.     

Peri-implant Bone Remodeling after Total Hip Replacement Combined with Systemic Alendronate Treatment: A Finite Element Analysis

In order to decrease the peri-implant bone loss during the life-time of the implant, oral use of anti-osteoporosis drugs (like bisphosphonates) has been suggested.

In this study, bone remodeling parameters identified from clinical trials of alendronate were used to simulate the effect of those drugs used after total hip arthroplasty on the peri-implant bone density. Results of the simulation show that the oral administrated drugs increase bone density around the implant and decreases, at the same time, the micromovements between the implant and the surrounding bone tissue.

Incorporation of drug effect in numerical studies of bone remodeling is a promising tool especially to predetermine safe bisphosphonate doses that could be used with orthopedic implants.     

Enhancement of tissue expansion by anticontractile agents

To evaluate the effect of anticontractile agents on the rate of tissue expansion, guinea pig back skin was expanded while being treated with various anticontractile agents. Expansion was carried out using standard percutaneous inflatable skin expanders modified by the addition of a catheter to deliver the anticontractile agents papaverine or cytochalasin D. Expansion proceeded for 25 days with one or other of the substances being infused through the catheter; saline was used in a separate control group. Measurements of the rate and extent of expansion showed that there was a statistically significant increase in these parameters for the experimental groups as compared with saline controls. Histologic examination of the expanded tissue suggests that the cellular basis for this phenomenon may involve the relaxation or inactivation of contractile fibroblasts in the fibrous capsule surrounding the expander.     

Cells,growth factors and bioactive surface properties in a mechanobiological model of implant healing

Interface conditions are of prime importance for implant fixation in the early post-operative period and modelling of specific biochemical interactions at implant surface is still missing. We hypothesized that updating osteoblast adhesion properties and growth factor source in an active zone located at the implant surface was relevant to model biochemical interactions of implant with its environment. We proposed an innovative set of diffusive–convective–reactive equations which relevant parameters were the cell decay factor, the cell motility and the growth factor balance.Initial comparison with histomorphometic results from a stable PMMA canine implant model provided an encouraging base to implement a numerical sensitivity analysis to evaluate the role of three types of bioactive surfaces: acid-etched titanium, coarse grit-blasted acid-etched titanium and coarse grit-blasted acid-etched titanium with RGDS peptide. We found that cell diffusion decrease (acid-etched+RGDS peptide vs. PMMA), and increase of local growth factor fraction (PMMA vs. acid-etched+RGDS peptide), significantly improved the amount of mineralized tissue on the implant surface. When the variation of structural fraction to cell motility and growth factor synthesis was investigated, an envelope pattern with an optimum was obtained but this could be exceeded for strong surface modifications and/or for high growth factor concentrations. The model also confirmed that implant bioactive properties should play a limited role to reduce heterogeneity of new-formed tissue. In conclusion, we suggested that our innovative theoretical approach was relevant to investigate implant fixation and could potentially help in reduction of implant revision.     

The influence of fiber orientation on the equilibrium properties of neutral and charged biphasic tissues

Constitutive models facilitate investigation into load bearing mechanisms of biological tissues and may aid attempts to engineer tissue replacements. In soft tissue models, a commonly made assumption is that collagen fibers can only bear tensile loads. Previous computational studies have demonstrated that radially aligned fibers stiffen a material in unconfined compression most by limiting lateral expansion while vertically aligned fibers buckle under the compressive loads. In this short communication, we show that in conjunction with swelling, these intuitive statements can be violated at small strains. Under such conditions, a tissue with fibers aligned parallel to the direction of load initially provides the greatest resistance to compression. The results are further put into the context of a Benninghoff architecture for articular cartilage. The predictions of this computational study demonstrate the effects of varying fiber orientations and an initial tare strain on the apparent material parameters obtained from unconfined compression tests of charged tissues.     

Breast reconstruction utilizing subcutaneous tissue expansion followed by polyurethane-covered silicone implants: a 6-year experience

Reconstruction of the breast after modified radical mastectomy can be safely and adequately performed in the subcutaneous plane. Placement of a subcutaneous tissue expander (as either an immediate or a delayed procedure), rapid expansion over a 3- to 4-month period, capsulotomy, and placement of a polyurethane-coated implant have led to satisfactory results over a 6-year period. Breast reconstruction methods are well documented; however, the utilization of expanded subcutaneous chest wall skin has not been reported heretofore.     

Staged breast reconstruction with saline-filled implants in the irradiated breast: recent trends and therapeutic implications

A retrospective review was performed of one surgeon's experience with 40 consecutive patients who had undergone two-stage saline-filled implant breast reconstruction and radiation during the period from 1990 through 1997. A randomly selected group of 40 other two-stage saline-filled implant breast reconstructions from the same surgeon and time period served as controls. This review was undertaken because of the absence of specific information on the outcome of staged saline implant reconstructions in the radiated breast. Previously published reports on silicone gel implants and radiation have been contradictory. At the same time, the criteria for the use of radiation in the treatment of breast cancer have been expanded and the numbers of reconstruction patients who have been radiated are increasing dramatically. For example, in a 1985 report on immediate breast reconstruction, only 1 of 185 patients over a 6-year period underwent adjuvant radiation therapy, whereas in this review, there were 40 radiated breasts with saline-filled implants, 19 of which received adjuvant radiation therapy during their expansion. The study parameters included patient age, breast cup size, implant size, length of follow-up, number of procedures, coincident flap operations, Baker classification, complications, opposite breast procedures, pathologic stage, indications for and details about the radiation, and outcomes. The use of radiation in this review of reconstructed breasts can logically be divided into four groups: previous lumpectomy and radiation (n = 7), mastectomy and radiation before reconstruction (n = 9), mastectomy and adjuvant radiation during reconstruction/expansion (n = 19), and radiation after reconstruction (n = 5). The largest and most rapidly growing group of patients is of those receiving postmastectomy adjuvant radiation therapy. A total of 47.5 percent (19 of 40) of radiated breasts with saline implants ultimately needed the addition of, or replacement by, a flap. Ten percent of a control group with nonradiated saline implant reconstructions also had flaps, none as replacements. Fifty percent or more of both the radiated and control groups had contralateral surgery. Complications were far more common in the radiated group; for example, there were 32.5 percent capsular contractures compared with none in the control group. The control nonradiated implant-only group and the flap plus implant radiated group did well cosmetically. The radiated implant-only group was judged the worst. The increasing use of radiation after mastectomy has important implications for breast reconstruction. The possibility for radiation should be thoroughly investigated and anticipated preoperatively before immediate breast reconstruction. Patients with invasive disease, particularly with large tumors or palpable axillary lymph nodes, are especially likely to be encouraged to undergo postmastectomy radiation therapy. The indications for adjuvant radiation therapy have included four or more positive axillary lymph nodes, tumors 4 cm (or more) in diameter, and tumors at or near the margin of resection. More recently, some centers are recommending adjuvant radiation therapy for patients with as few as one positive lymph node or even in situ carcinoma close to the resection margin. The use of latissimus dorsi flaps after radiation has proven to be an excellent solution to postradiation tissue contracture, which can occur during breast expander reconstruction. The use of the latissimus flap electively with skin-sparing mastectomy preradiation is probably unwise, unless postmastectomy radiation is unlikely. Skin-sparing mastectomy with a latissimus flap thus should be preserved for patients unlikely to undergo adjuvant radiation therapy. Purely autologous reconstruction such as a TRAM flap is another option for these patients, either before or after radiation therapy.