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Ewing et al. Plast Aesthet Res 2024;11:22 https://dx.doi.org/10.20517/2347-9264.2024.11 Page 5 of 15

While autologous breast reconstruction remains a favorable surgical approach for a previously irradiated
field, there has been a growing interest in pre-pectoral breast reconstruction. With the advancement of
microsurgical techniques, application of fat grafting principles, and monitoring of intraoperative flap
perfusion, pre-pectoral breast reconstruction continues to be revisited and appreciated as it has shown
promising outcomes [37-39] .

Although it is beyond the scope of this review, it is important to highlight an emerging treatment for
previously irradiated areas: the adjunctive use of fat grafting. It is believed that fat has a regenerative
potential and is particularly useful in those who have previously undergone radiation [39-40] . It is recognized as
a tool that can reverse the aforementioned radiation-induced fibrotic skin changes . Despite surgical
[41]
preference for free-flap-based autologous breast reconstruction, additional fat grafting in the setting of
implant-based breast reconstruction has been found to achieve good reconstructive outcomes with
improved skin quality .
[42]

The pedicled latissimus dorsi flap is another great option for reconstruction, as it provides well-vascularized
tissue to the radiated field . Offering soft tissue and even skin coverage to the defected area, it restores the
[43]
form of the natural breast mound in conjunction with tissue expansion/implant. Indications for this option
include high-risk patients with comorbidities who are not good candidates for free tissue transfer, or
inadequate donor sites.

Despite a growing interest in pre-pectoral implant-based reconstruction, fat grafting, and pedicled
latissimus dorsi flaps, autologous breast reconstruction remains a favorable surgical approach for a
previously irradiated field due to its acceptable complication risk profile and improved patient satisfaction
and quality of life.

Technical pearls for the challenging microsurgery case in a radiated field
The irradiated field presents a unique challenge for the reconstructive surgeon. The effect of radiation
creates distorted tissue planes with non-ideal qualities: fibrosis and sclerosis secondary to chronic
inflammation. Furthermore, vasculature may be compromised, resulting in hypoxia, which further leads to
impaired wound healing. Therefore, standard reconstructive techniques may be insufficient and inadequate.
Here, we present additional modalities and pearls that may be elicited for microsurgical reconstruction of
an irradiated breast, aside from the essential practice of handling tissue and vessels with exceptional delicacy
due to their increased fragility [Figure 2].

Supercharging, turbocharging, and vascular augmentation: hook up two instead of one
The concept of supercharging aims to enhance flap vascularity by anastomosing multiple arteries and/or
veins. This concept, also dubbed turbocharging or venous super-drainage, is part of a broader concept
called vascular augmentation that once arose from necessity in cases of compromised perfusion and from
non-plastic surgery operations such as renal transplant . Supercharging utilizes a distant blood supply,
[44]
[44]
whereas turbocharging uses one within the flap territory . The technique is theorized to prevent
complications of poor perfusion by increasing vascularity and predictability of pedicles. Prior literature has
mixed reviews on efficacy. Some studies have shown that venous supercharging helps prevent venous
congestion and flap tip necrosis , and that two-vein anastomosis shows a lower incidence of re-exploration
[45]
and fat necrosis . Conversely, some data show more vascular complications with supercharging , though
[46]
[47]
it is unclear whether these adverse events are secondary to graft choice or the fact that anastomoses are not
in normal tissue .
[42]