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Ewing et al. Plast Aesthet Res 2024;11:22 https://dx.doi.org/10.20517/2347-9264.2024.11 Page 7 of 15

inadequate/compromised vasculature. Size mismatches are sometimes present, as the left internal mammary
[56]
vessel is known to be significantly smaller than the contralateral side . More commonly, the decision to
utilize a salvage conduit arises from concerns of venous inadequacy, rather than compromised arterial
[57]
quality . Several conduits exist for a bailout. The cephalic vein is a classically used option and can also be
used to supercharge venous outflow [58,59] . The external jugular vein has also been described and is mostly
[52]
[60]
used due to size mismatch in a gluteal flap . Lastly, the contralateral internal mammary or thoracodorsal
vessels are viable options to avoid a previously radiated chest field. These were the previous gold standard
for microsurgical anastomosis, but the paradigm shifted when sentinel lymph node biopsy (SLNB) was
favored over complete axillary lymph node dissection (ALND), making dissection and exposure of
thoracodorsal vessels more extensive than deemed necessary.

In this review, we presented technical microsurgical pearls for breast reconstruction in irradiated fields,
including the enhancement of flap vascularity, expanded dissection of recipient vessels, postoperative
anticoagulation, and various salvage conduits. Understanding the challenges that radiation imposes can
enhance preoperative planning, and familiarity with the aforementioned technical concepts can broaden the
armamentarium of reconstructive surgeons, thus leading to optimal patient outcomes.

Delayed vs. immediate free flap reconstruction for the patient who will need radiation
Radiotherapy has clear survival rate benefits that warrant its inclusion when indicated [61,62] . Furthermore, in
the setting of PMRT, free flap reconstruction has been shown to have clear advantages over implant-based
reconstruction [32-34] . As a result, there is considerable debate about the timing and order of radiation therapy
and free flap reconstruction to produce the best aesthetic outcome with minimal risk of complication.

There are three general approaches to timing free flap reconstruction: immediate, delayed-immediate, and
delayed [63,64] . The immediate approach entails free flap transfer and anastomosis directly following the
mastectomy before closing the field. The flap must be able to tolerate post-procedure radiotherapy and
avoid complications such as wound breakdown, flap necrosis, and/or flap failure. The delayed-immediate
approach involves placing tissue expanders immediately after the mastectomy. Serial filling and expansion
allow for shape and volume retention until the patient is able to receive the flap after radiation treatment to
prevent damage from exposure . The delayed approach avoids reconstruction immediately after
[65]
mastectomy, and instead occurs after radiation treatment [63,65] .

Of these three, only the immediate approach always results in flap exposure to radiation. Due to early
studies demonstrating the increased risk of complication, revisions, and flap failure, consensus favored the
delayed or delayed-immediate approach [21,22,66] Of these two approaches, the delayed-immediate approach
was preferred due to its compromise between the aesthetic favorability of the immediate approach and the
avoidance of exposure to radiation [67,68] . Furthermore, the approach also offers time for the patient to
consider treatment options. This flexibility in the reconstructive approach, as well as favorable patient
outcomes, are the reasons for its preferred choice over the other reconstructive options.

However, current literature has contested the assertion that an immediate approach is inferior. Advances in
radiotherapy including optimized beam angles, dosages, and three-dimensional planning for administration
[69]
have resulted in reduced chest wall damage . Thus, while radiotherapy still damages the reconstructed
breast, this damage has been lessened and may be more tolerable than in earlier studies. Supporting
evidence includes multiple systematic reviews and meta-analyses, which found that immediate
reconstruction has similar results to delayed and delayed-immediate [70-72] . Heiman et al. found in their meta-
analysis that the immediate approach offered superior clinical outcomes and flap survival to the other