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Page 2 of 10 Dengsoe et al. Plast Aesthet Res 2024;11:25 https://dx.doi.org/10.20517/2347-9264.2024.20

Conclusion: The literature generally agrees that delays in adjuvant therapy beyond 12 weeks after surgery are
associated with increased breast cancer recurrence and mortality, but uniform data on the clinical effects of delays
within this interval are lacking. The association between postoperative complications and delays in adjuvant
therapy underlines the importance of careful patient selection, a multidisciplinary treatment approach, and other
measures known to reduce the risk of complications.

Keywords: Breast cancer, immediate autologous microsurgical breast reconstruction, immediate free-flap breast
reconstruction, adjuvant chemotherapy, adjuvant radiotherapy

INTRODUCTION
Breast cancer is the most common female cancer worldwide, with 2.3 million new cases diagnosed in
[1]
2020 . The treatment of breast cancer is multidisciplinary and often involves a combination of surgery,
chemotherapy, and radiotherapy. Surgery represents the treatment cornerstone, and despite improvements
in breast conserving surgery techniques, mastectomy remains the primary surgical treatment for almost 40%
of breast cancer patients .
[2]

Alongside improvements in survival rates, breast reconstruction has become increasingly more widespread
in recent decades. In general, breast reconstruction may be performed using implants, autologous tissue, or
a combination thereof. To that, autologous flap reconstruction can be based on either a pedicled flap or a
microvascular free flap. Free flap reconstruction is commonly used because it provides a life-long natural
reconstruction with a good cosmetic result . Examples of commonly used free flaps are the deep inferior
[3]
epigastric perforator (DIEP) flap, the free transversus rectus abdominis myocutaneous (TRAM) flap, the
Inferior/superior gluteal artery perforator (I/S-GAP) flap, the transversus upper gracilis (TUG) flap, and the
transverse musculocutaneous gracilis (TMG) flap. Historically, most reconstructions were delayed for
months or years after initial mastectomy and adjuvant therapy. However, it has been well established that
immediate reconstruction at the time of mastectomy has many advantages for the patient. Most notably,
these include avoidance of further operative procedures and maintenance of the patient’s body image,
resulting in improved sexuality and sense of femininity, improved quality of life, and better cosmetic
[4]
results . On the other hand, mastectomy combined with immediate reconstruction is a more extensive
procedure and many studies have found increased complication rates compared to simple mastectomy . It
[5-7]
is obvious that this particularly applies to microsurgical free flap reconstruction as these are especially
complex procedures with several critical steps and occasionally longer operating times.

As mentioned above, breast cancer surgery is often combined with adjuvant therapy, being it either
chemotherapy or radiotherapy and often both treatment modalities are indicated. It has been well
established that administration of adjuvant therapy is associated with reduced breast cancer recurrence and
mortality [8-10] . Initiation of adjuvant therapy in due time is important, but no randomized trials have
determined the optimal time from surgery to the start of adjuvant therapy or evaluated the effect of delays,
as this kind of trial would be unethical. However, several retrospective studies have sought to investigate this
question. Two recent large-scale multicenter studies [11,12] and one smaller single-center study have shown
[13]
that delays of more than 90 days in the delivery of chemotherapy are associated with a decline in overall and
cancer-specific survival. A meta-analysis by Yu et al. including seven studies and 34,097 patients found a
15% decrease in overall survival for every four-week delay in the delivery of adjuvant chemotherapy and
commented that adjuvant chemotherapy should optimally be initiated 4 weeks after surgery . Other
[14]
studies support the perception that chemotherapy should be initiated within four to twelve weeks after
surgery [7,15,16] , but we do not have solid and corresponding data on the clinical effects of delays within this
interval.