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Ewing et al. Plast Aesthet Res 2024;11:22 https://dx.doi.org/10.20517/2347-9264.2024.11 Page 3 of 15

Alternative options include postmastectomy flat closure, or an external prosthesis, which is non-invasive.
The timing of breast reconstruction relative to radiation is discussed later in this article. Many studies have
revealed that more complications (i.e., infection, capsular contracture) arise in irradiated patients than non-
irradiated patients in both implant-based reconstruction [17-20] and autologous breast reconstruction [21,22] .

Radiation effects on breast reconstruction
Complications of radiation to the reconstructed breast include capsular contracture, infection, reduced
patient satisfaction, and adverse cosmetic outcomes. These complications may lead to loss of tissue
expander or implant, and reconstructive failure requiring secondary breast reconstruction or revision. A
systematic review reported a total complication rate of 48.7% and a revision surgery rate of 42.4% in implant
[23]
reconstruction after radiotherapy . These rates were significantly higher than those who had implant
reconstruction before radiotherapy (19.6% and 8.5%, respectively). Capsular contracture, the most common
complication of radiation after implant reconstruction, affects nearly half of patients who have a history of
radiation [24-26] . It is important to note that capsular contracture behaves similarly to radiation-induced
fibrosis.

Adverse cosmetic outcomes of radiation therapy in breast reconstruction have global, surface, and
parenchymal effects . Globally, radiation therapy may result in edema or shrinkage. These global effects
[27]
can cause asymmetry in the nipple-areolar complex, breast size, and breast shape. Surface effects include
hyper- or hypopigmentation of the nipple-areolar complex, telangiectasia, and subcutaneous fibrosis. Like
global effects, these effects may create asymmetry in breast shape, size, color, and texture. Parenchymal
effects include fat necrosis, cysts, or radiation-induced malignancy such as angiosarcoma.

Early toxicity is associated with the duration of radiation, whereas late toxicity is associated with dose
[28]
variation per fraction . Symptoms include fatigue, neuropathy, and pain in the chest, shoulders, and neck.
The heart, lungs, liver, and spinal cord are organs at risk for damage . Proper surgical and radiotherapy
[5]
planning is essential for minimizing symptoms and radiation dose to organs at risk. Figure 1 summarizes
the literature reviewed and discussed in the previous commentary.

OBJECTIVE
In this article, we briefly review radiation-induced tissue effects and their impact on breast reconstruction.
More specifically, we comment on the traditional use of autologous tissue, microsurgical technical pearls for
irradiated fields, reconstructive timing paradigms, and lymphedema prevention. With continued progress,
derivation, and innovation, plastic and reconstructive surgery has consistently advanced and revolutionized
both medicine and surgery. This review considers the future implications of breast reconstruction and how
it will impact patients, healthcare, and the field. While not an exhaustive review, we aim to provide a
comprehensive discussion and insights on all breast reconstruction options.

METHODS
A comprehensive literature review was meticulously conducted using the PubMed database from
12/01/2023-12/15/2023 by three independent researchers. Systematic reviews, literature reviews, clinical
research, randomized controlled trials, and case series published between January 1995 and December 2023
were included. This review included studies on breast cancer treatment, breast reconstruction, radiation or
radiotherapy, various types of breast reconstruction (e.g., autologous, implant), patient satisfaction, clinical
outcomes, microsurgical technical pearls for irradiated fields, reconstructive timing paradigms, and
lymphedema. With a structured outline as a guide, we curated over 100 references relevant to our research
inquiry. This flexible yet robust methodology ensured a comprehensive coverage of pertinent literature.