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Page 6 of 18 Laustsen-Kiel et al. Plast Aesthet Res 2024;11:17 https://dx.doi.org/10.20517/2347-9264.2024.32

[34]
mastectomy , all contribute to the explanation behind the worldwide increase in demand for breast
reconstruction during the last two decades [101-103] . The number of patients opting for reconstruction has
[104]
generally risen but varies between countries, with rates of approximately 18% in Australia , 30% in
[106]
[103]
Sweden , 40% in Denmark , and 50% in South Korea .
[105]
TIMING OF THE RECONSTRUCTION
Several studies have investigated the timing of breast reconstruction and found IBR to be preferable when
looking at the psychosocial impact, as well as the socioeconomic cost of breast reconstruction [107-112] .
Considering the rate of complications, IBR has been associated with significantly higher complication rates
than delayed procedures . Nevertheless, Saheb-Al Zamani et al. could only confirm the higher
[113]
complication rate for implant-based but not autologous reconstructions , and other studies found no
[114]
significant difference in flap loss between IBR and delayed breast reconstruction (DBR) [115,116] . The latest
meta-analysis concluded that IBR generally increases the risk of complication, but additional prospective
and observational studies are needed to assess if one reconstructive technique is superior to another . QoL
[117]
has increasingly been examined as an outcome in studies assessing the difference between IBR and DBR,
and no difference in postoperative QoL between IBR and DBR was found [118,119] .

AUTOLOGOUS AND IMPLANT-BASED BREAST RECONSTRUCTION
Autologous reconstruction was found to improve upper extremity outcomes in patients undergoing breast
[33]
reconstruction . Dauplat et al. found latissimus dorsi (LD) flaps to have the lowest risk of major
complication compared to implant alone, LD flap with implant, or the transverse rectus abdominus
myocutaneous (TRAM) flap . There are multiple options for reconstruction. However, the right choice of
[31]
reconstruction method depends on several factors, including donor-site availability, medical history,
previous oncologic treatment, and most importantly, the patient’s preferences. Reports have shown that
implant-based reconstruction is the more commonly used technique [120,121] .

One of the more dreaded complications in free flap breast reconstruction is venous congestion. Therefore,
additional venous drainage using the cephalic vein is sometimes incorporated into the flap. It is currently
unclear if this increases the risk of ipsilateral lymphedema, although Svee et al. did not find an increased
[122]
risk . In this relation, it is, however, relevant to note that their sample size was small and that another
[123]
group found lymphedema to develop or worsen when using the cephalic vein .
BREAST CANCER-RELATED LYMPHEDEMA AND BREAST RECONSTRUCTION
The most recent systematic review on the impact of breast reconstruction on BCRL from 2017 concluded
that breast reconstruction was associated with lower rates of lymphedema . However, due to high
[124]
heterogenicity in the included studies, further prospective studies were deemed necessary to identify the
mechanism by which breast reconstruction contributes to reduced rates of lymphedema.

In our systematic literature search, 23 studies, including a total of 85,584 patients, were published since the
review by Siotos et al. on BCRL and breast reconstruction . In various studies, the incidence of
[124]
lymphedema was found to be lower in cases with breast reconstruction compared to mastectomy
alone [125-134] , while other studies did not specify the incidence of lymphedema for breast
reconstruction [31,122,135-139] , type of reconstruction [128,129,140] , or BCRL incidence at all . Figure 1 presents an
[31]
overview of the incidence reported for BCRL in the different studies, where possible, by reconstruction type.
Further aspects emerged from the studies: