A: We have never, fortunately (as far as I can recall) encountered findings in surgery that caused us to suddenly think that radiation would be needed when we didn’t suspect it previously. The two things that COULD be found intra-operatively and would lead to that would be positive lymph nodes or a very large tumor. The mammogram and MRI are pretty good at seeing these kinds of things preoperatively. Additionally, if there is any suspicion of positive nodes, we routinely have the sentinel node biopsy done as a separate procedure before the mastectomy.
When we DO know that the patient will need radiation, we sometimes offer them placement of a temporary tissue expander if they do not want to go several months without having a breast mound. This has several disadvantages, including 1) doing unnecessary damage to the chest wall and pectoralis muscle, 2) taking up some of the eventual flap’s volume to fill the divet in the ribs left by the tissue expander, and 3) potentially interfering with the delivery of radiation. Some surgeons think the scar pattern can be favorably altered by and expander in this scenario by keeping the skin stretched, but I’ve never been very convinced by this argument, at least not when the expander is ultimately going to be removed and replaced with a flap.If we did, for whatever reason, unexpectedly determine in surgery that the patient needed radiation, I would probably just do nothing (no tissue expander) and come back after radiation and do the flap(s).Dr. Richard Kline Center for Natural Breast Reconstruction
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