Although radiation therapy is generally not recommended before or after breast reconstruction, an increasing number of patients are requesting breast reconstruction despite having a history of radiotherapy for the chest wall. We investigated complications and prognosis in patients with breast reconstruction and chest wall irradiation treatment for breast cancer in our hospital. Subjects comprised 26 breasts in 26 patients who underwent breast reconstruction and chest wall irradiation in our hospital between April 2007 and March 2014. We evaluated indication for irradiation, irradiation timing, the presence or absence of complications, and prognosis. Ages ranged from 35 to 63 years and disease stages were I (3 cases) , II (11 cases) , III (11 cases) , and IV (1 case) . Radiation therapy was performed prior to breast reconstruction in 5 cases and after reconstruction in 21 cases. Complications were noted in 2 cases, comprising 1 case of myocutaneous flap necrosis after transverse rectus abdominis myocutaneous flap reconstruction and 1 case of tissue expander (TE) exposure during radiation therapy performed while a TE was inserted. Recurrence was observed in 6 of 26 cases (23%) . These included 1 case of local recurrence and 5 cases of distant metastasis. The breast reconstruction success rate was 100%. Thus, results suggested that if the method of reconstruction was carefully considered, breast reconstruction could be safely performed even on patients who underwent radiotherapy.

　A retrospective review was performed on 537 breasts of 516 breast cancer patients who underwent endoscopic skin-sparing or nipple-sparing mastectomy. A positive margin was encountered in 47 (8.8%) breasts of 47 patients. The location of the positive margin was superficial, deep, lateral, and under the nipple in 24 (51%) , 11 (23%) , 9 (19%) , and 3 (6.4%) patients, respectively. Histologically, the positive margin exhibited non-invasive carcinoma in 77% and invasive carcinoma in 23% of cases. Among the 47 patients with a positive margin, 4 patients received radiotherapy, 8 patients underwent additional resection, and the remaining 35 patients received no additional local treatment. During the median follow-up time of 51 months, local recurrence (LR) occurred in 13 of the 537 breasts (2.4%) . The rate of LR was higher in patients with a positive margin than in those with a negative margin (5/47, 11% vs. 8/490, 1.6%, p<0.01) . The LR rate was not affected by the presence/absence of additional treatment (0/12, 0% vs. 5/35, 14%) in patients with a positive margin.

As the patients with a positive margin had a high risk of LR, careful attention is needed to avoid obtaining a positive margin during skin-sparing or nipple-sparing mastectomy.

　In Japan, the tissue expander (Natrelle^®, Allergan Inc.) for breast reconstruction has been authorized by national health insurance since July 2013. An increasing number of patients await breast reconstruction. For patients who have undergone breast reconstruction with the expander, infection is a frustrating and costly complication. 150 patients underwent 160 reconstructions at our institution using the Natrelle^® tissue expander from 2013 to 2015. 5 of the 8 infection cases required reoperation. For these, we used a continuous irrigation system to reinsert the new tissue expander following removal of the infected expander. Finally, tissue expander was removed in 2 cases. Investigation of risk factors for postoperative infection revealed that obesity, axillary lymph node dissection and being a MRSA carrier were identified as risk factors for infection, which should be addressed as soon as possible.

　Regular checkups with an imaging examination is recommended for every woman who has undergone breast reconstruction surgery using silicone breast implants. We performed ultrasound to detect silent implant rupture in 829 SBIs, 3 years after breast reconstruction or contralateral breast augmentation surgery. Ten had clear evidence of rupture and 17 had minor signs indicating suspected rupture. We observed two signs of rupture, one is separation between the capsule and shell, and the other is high echo level of the inner silicone gel. Patients who have minor signs, such as inner-gel liquid or slight shell splitting, should be observed carefully. Replacement is recommended for patients whose SBI is obviously ruptured. Follow-up is recommended for patients who have minor signs and replacement surgery should be performed at an appropriate time so as not to lower their quality of life. Furthermore, these abnormal ultrasound signs are known to medical staff in not only special hospitals, but also in medical checkup facilities.

　The purpose of breast reconstruction is the comfort for the patient as well as symmetry of the breast. To achieve this, we have to understand the characteristics of the breast implant (SBI) , which has no mobility and cannot be molded.

　In the second stage surgery of breast reconstruction based on the breast implant, insertion of a suitable SBI in a suitable pocket made by capsulotomy and inframammary fold reconstruction is important. However, the suitable SBI size and position are not always symmetrical. An SBI which projects outside may cause unpleasant symptoms and obstruction of daily life. The location of the SBI also influences on how a bra is worn.

　Even if a perfect SBI is chosen, several changes can happen to a patient long after the operation. Therefore, it is important to continue follow-up in order to correspond with patient changes.

　In this article, we present data on immediate breast reconstruction at two hospitals without a full-time plastic surgeon, performing a retrospective chart review of patients. A reconstructive surgeon performed physical examinations on all patients and obtained their informed consent preoperatively. We explained to the patients about the limitations of reconstructive methods, for example, that free deep inferior epigastric artery flap transfer and primary silicone breast implant reconstruction were unavailable. From October 2012 to January 2016, we performed 30 immediate breast reconstructions (28 patients, 30 sites) in these hospitals ; 19 sites with autologous breast reconstruction by pedicled flap (latissimus dorsi musculocutaneous flap 18, rectus abdominis musculocutaneous flap 1) and, 11 sites (9 patients) with the tissue expander. The average length from consulting a plastic surgeon to the operation date was 26.0±14.9 days. As reconstructive methods are limited in our collaborations, this limitation was explained to the patients. Therefore, it was necessary for the reconstructive surgeon to perform a physical examination preoperatively.