Download PDF
Review  |  Open Access  |  23 Jun 2024

The radiated breast and autologous reconstruction: benefits and alternatives

Views: 128 |  Downloads: 10 |  Cited:  0
Plast Aesthet Res 2024;11:22.
10.20517/2347-9264.2024.11 |  © The Author(s) 2024.
Author Information
Article Notes
Cite This Article

Abstract

Despite advancements in research and technology, breast cancer remains the second leading cause of cancer-related mortality affecting women worldwide. Radiation therapy is a widely recommended adjunct to surgery due to its significant role in reducing loco-regional recurrence. Its use, however, is not without consequences. Radiation triggers a series of pathophysiologic events leading to tissue injury; reactive oxygen species incites (1) vascular damage and chronic hypoxia; (2) an inflammatory response; and (3) activation of myofibroblasts to induce fibrosis. As a result, radiotherapy interferes with wound healing and negatively impacts the quality of the skin. These pathophysiologic consequences complicate the sequence of breast reconstruction and require surgeons to consider timing and the type of reconstruction (autologous vs. implant), with respect to radiotherapy to improve patient outcomes. 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. In summary, the authors discuss the possibilities of a paradigm shift in breast reconstruction, emphasizing the need for surgeons to have an armamentarium capable of all breast reconstruction options for the best possible patient outcomes.

Keywords

Breast reconstruction, autologous reconstruction, radiation, radiated field, radiotherapy
Author's Talk
Download PDF 0 2

INTRODUCTION

Despite advancements in research and technology, breast cancer remains the second leading cause of cancer-related mortality affecting women worldwide. About 1 in 8 women in the US are diagnosed during their lifetime[1]. The primary goal for breast cancer management is eradication of cancer, prevention of metastasis, and reduction of local recurrence. Surgery, sometimes combined with radiotherapy, effectively manages localized cancer, whereas systemic therapy (i.e., hormonal therapy, chemotherapy, targeted therapy, combined therapy) controls for metastatic relapse. Over time, breast conservation therapy (BCT) and, more recently, oncoplastic surgery have evolved to the forefront of management. With recent emphasis on cosmetic outcomes, BCT combined with postoperative radiotherapy has emerged as the preferred standard of care for early-stage breast cancer (stage I and II), replacing highly invasive surgeries such as simple and modified radical mastectomy[2].

Radiation therapy is a widely recommended adjunct to surgery due to its significant role in reducing loco-regional recurrence[3]. Radiation reduces the 10-year risk of local cancer recurrence by approximately 50% and the 15-year risk of mortality by approximately 20% when combined with breast-conserving therapy[1]. It is indicated for large tumors (> 5 cm), chest wall invasion, involvement of the lymph nodes, patients with partial or incomplete resection, and relief of widespread metastasis in palliative patients[1,4]. Furthermore, postmastectomy radiation therapy (PMRT) has been employed for decades in patients with locally advanced disease with a high risk of recurrence. Relative contraindications to radiation therapy include small tumors, absence of nodal involvement, age > 70 years old, and hormone receptor-positive (HR+) cancers that lack evidence for improved survival with radiotherapy.

Radiation is commonly delivered by standard external beams for whole breast and nodal irradiation, brachytherapy for internal radiation, or a combination of both[5]. The conventional radiation dosage of 45-50 Gray (Gy) is applied to the breast, with a boost treatment of 10-16 Gy for the lumpectomy site[6]. An additional 45-50 Gy dose, dependent on recurrence risk, is applied to the regional node. Administration may take about six weeks, while hypofractionation, or lower doses of smaller fractionations, is reserved for low-risk individuals.

Radiation induces the production of reactive oxygen species (ROS)[7,8], ultimately leading to a cancer cell’s destruction. However, surrounding healthy tissues are at risk for damage. Radiation triggers a series of pathophysiologic events leading to tissue injury; ROS cause (1) vascular damage and chronic hypoxia[9]; (2) an inflammatory response[10]; and (3) activation of myofibroblasts to induce fibrosis[11]. As a result, radiation interferes with wound healing and negatively impacts the quality of the skin. Patients may present with skin breakdown, hair and gland loss, ischemia, and ulcer formation.

Fibrosis-related complications are categorized as acute or chronic. Acute radiodermatitis (i.e., erythema, edema, desquamation, and ulceration) occurs within three months of radiotherapy[12]. Chronic radiation-induced fibrosis occurs 4-6 months post-radiotherapy and can be irreversible[13]. Radiation-induced fibrosis complicates the sequence of breast reconstruction and forces surgeons to consider the timing of radiation and the type of reconstruction (autologous vs. implant) to improve patient outcome, as elaborated later[14-16].

The types of breast reconstruction to consider include implant-based (direct-to-implant/immediate or delayed with tissue expanders) and autologous reconstruction. In contrast to the immediate approach (i.e., reconstruction at the time of mastectomy), the delayed approach may take months to years. Autologous breast reconstruction involves taking tissue from a donor site and transferring it to a recipient site. 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 reconstruction after radiotherapy[23]. 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[27]. Globally, radiation therapy may result in edema or shrinkage. These global effects 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 variation per fraction[28]. 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[5]. Proper surgical and radiotherapy 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.

The radiated breast and autologous reconstruction: benefits and alternatives

Figure 1. General overview of the literature on radiation and its effects on cancer treatment and wound healing.

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.

DISCUSSION

Traditional use of autologous tissue in a previously irradiated breast

Breast reconstruction aims to rebuild the breast mound using several types of flaps. Local pedicled flaps are adjacent to the defect and remain attached to the original blood supply. Free flaps are donated vascularized tissues (abdomen, back, buttocks, or thigh) transferred to the breast blood supply[29]. Discussing the different types of free flaps is beyond the scope of this article. However, these include transverse rectus abdominis muscle (TRAM), muscle-sparing free TRAM, deep inferior epigastric perforator (DIEP), superficial inferior epigastric artery (SIEA), profunda artery perforator (PAP), transverse upper gracilis (TUG), diagonal upper gracilis (DUG), vertical upper gracilis (VUG), latissimus dorsi flap, gluteal artery perforator (GAP) flaps, and others.

Autologous tissue is traditionally preferred for patients with previously irradiated breasts, as it enables the transfer of healthy tissue to the irradiated tissue[23,24]. Radiation-induced complications in implant-based reconstruction consist of capsular contracture, infection, and mastectomy flap necrosis. Radiation-induced complications in autologous reconstruction involve volume loss, contracture, wound dehiscence, fat necrosis, and flap fibrosis[30-31]. Compared to autologous tissue reconstruction, implant-based reconstruction has a greater risk of surgical-site infection and reconstructive failure[32-34]. The optimal timing of autologous tissue transfer relative to radiation continues to be a subject of debate and will be discussed later in this article.

Autologous breast reconstruction in the irradiated field is associated with greater patient satisfaction and improved quality of life compared to implant-based reconstruction. Reported complications of autologous breast reconstruction following failed implant-based reconstruction include partial flap loss (3%), hematoma (3%), vascular compromise (1%), and total flap loss (1%)[35,36]. Despite these complications, autologous breast reconstruction as a salvage technique for failed implant-based breast reconstruction has been found to have an acceptable complication risk profile and is associated with significantly improved patient satisfaction and quality of life.

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[41]. Despite surgical 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[43]. Offering soft tissue and even skin coverage to the defected area, it restores the 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].

The radiated breast and autologous reconstruction: benefits and alternatives

Figure 2. Technical pearls for the challenging microsurgery case in a radiated field.

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[44]. Supercharging utilizes a distant blood supply, whereas turbocharging uses one within the flap territory[44]. 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[45], and that two-vein anastomosis shows a lower incidence of re-exploration and fat necrosis[46]. Conversely, some data show more vascular complications with supercharging[47], though it is unclear whether these adverse events are secondary to graft choice or the fact that anastomoses are not in normal tissue[42].

Expanded dissection of recipient vessels: go higher on the chest wall

The internal mammary vessels, now widely accepted as the first-choice recipient vessels, have well-described anatomic variability[48,49]. Bifurcation points may differ depending on laterality, and vessel cross-sectional area decreases in the superior-inferior direction as the vessel travels along the sternal body. Furthermore, prior work has demonstrated the minimum necessary vessel caliber for certain flap sizes[50]. For this reason, it may be necessary to extend the dissection of the recipient vessels more superiorly along the chest wall to expose larger mammary vessel recipients for anastomoses.

Postoperative anticoagulation

The radiation-induced chronic inflammation renders vessels hypercoagulable[8], which raises concerns for flap failure. Jakobsson et al. found that hematoma was the most common reason for re-exploration after free flap, and that the use of a triple anti-thrombotic regimen was significantly associated with hematoma formation[51]. The triple anti-thrombotic regimen referenced in the study consisted of preoperative low molecular weight heparin (LMWH), intraoperative heparin, and dextran. However, cessation of the regimen was associated with fewer hematomas and did not increase flap thromboembolic events[51]. Postoperative immobility is often a concern in flap patients. The risk of postoperative anticoagulation has long been mitigated against bleeding and hematoma formation risk. Recent studies have found that post-op DVT prophylaxis significantly reduces DVT incidence[45], and that heparin is more cost-effective than Lovenox[52]. Furthermore, Lovenox dosing does not seem to reach adequate activated Factor Xa levels for prophylaxis in patients undergoing head/neck/breast free flap procedures[53]. Other centers have implemented a 2-week prophylaxis protocol that lowers DVT but does not increase the incidence of hematoma[54].

Salvage conduits: the bailout options

It is often said that the best postoperative results come with proper preoperative planning. As such, reconstructive microsurgeons must have backup options: a “plan B”, which serves as a tactical remedy for unforeseen complications or situations. Imaging modalities such as ultrasound or contrast-enhanced CT can assist in the identification of suitable vascular conduits. The authors emphasize both preoperative planning and preparation. Deviations from the initial surgical plan must be discussed, and the team/operating room must have the necessary tools/equipment on hand. Salvage conduits may be necessary for various reasons, necessitating the use of a bailout option. This may be due to missing/absent vasculature, as prior literature has reported absent internal mammary veins[55]. Moreover, the surgeon may encounter inadequate/compromised vasculature. Size mismatches are sometimes present, as the left internal mammary vessel is known to be significantly smaller than the contralateral side[56]. More commonly, the decision to utilize a salvage conduit arises from concerns of venous inadequacy, rather than compromised arterial quality[57]. 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[52] and is mostly used due to size mismatch in a gluteal flap[60]. 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[65]. The delayed approach avoids reconstruction immediately after 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 have resulted in reduced chest wall damage[69]. 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 approaches[72]. Prospective trials and retrospective reviews also match these assertions, with results that suggest patient quality of life and aesthetic perception are similar between immediate and delayed, and that immediate reconstruction in the setting of PMRT does not appear to affect patient outcomes[73,74].

This shift in interest and results favoring the immediate approach in research have new clinical implications for the debate between immediate and delayed reconstruction. Timing for the delayed-immediate approach avoids flap exposure to radiation while retaining the aesthetic outcomes of the immediate approach. The delayed-immediate approach is also applicable to high-risk patients at risk of flap complications. However, recent research suggests that immediate reconstruction is a reliable option in low-risk patients and can be offered as a treatment alternative. Figure 3 provides a preferred algorithm by the senior author for radiation considerations in the breast cancer patient. When consulting patients on reconstruction, an immediate approach may be a valid option for patients, particularly if their radiotherapy will be administered over a small area or at a low dosage that the flap can tolerate[67,75,76]. However, this shift should be tempered by prior studies that have demonstrated an increased risk of complications with flap radiation exposure, including flap contracture, volume loss, and fat necrosis[74,77]. As a result, based on existing literature, surgical planning should consider offering delayed-immediate reconstruction as an option for patients with PMRT.

The radiated breast and autologous reconstruction: benefits and alternatives

Figure 3. Radiation considerations in the breast cancer patient. ADM: acellular dermal matrix; PAP: profunda artery perforator; DIEP: deep inferior epigastric perforator; msTRAM: muscle-sparing transverse rectus abdominis myocutaneous.

Autologous reconstruction with lymph node transfer to prevent lymphedema in the radiated breast

With the aforementioned effects of radiation on tissue quality and the resultant vascular compromise, coupled with the effects of surgical dissection, breast reconstruction patients are prone to lymphedema, especially after ALND[78]. An estimated 3%-8% of patients develop lymphedema even after just SLNB alone, with other known risks such as neoadjuvant/adjuvant chemoradiation (CRT) and obesity[79]. The management of lymphedema is outside the scope of this special topic; however, it sometimes requires surgical techniques. Technological advances such as microscopes, and evolutionary techniques of lymphovenous bypass (LVB) and lymphovenous anastomosis (LVA) have demonstrated efficacy in reducing sequelae of lymphedema[80]. However, equally important as treating lymphedema is preventing it. Vascularized lymph node transfer (VLNT) includes the microsurgical transplant of lymph nodes and an associated vascular pedicle from a donor to a recipient site. Lymph node transfer is believed to stimulate lymphangiogenesis, thereby improving lymphatic drainage of the recipient region and consequently reducing lymphedema[81]. The procedure can be useful for both treating and preventing lymphedema. It is typically reserved for more advanced cases and poor candidates for LVA/LVB[82], but can also be considered at the time of the index surgery.

Various techniques exist, and there are several options for nodal harvest. Some of the most commonly used basins for VLNT include the supraclavicular[82], submental[83], lateral thoracic[84], inguinal[85] (which can be taken at the time of DIEP harvest, i.e., a single operation)[86], and the omentum[87] (which can also be taken at the harvest of DIEP or msTRAM)[86,88]. Although options for successive or combined operations are feasible, combined operations may have better results[89] and also demonstrate better postoperative patient-reported quality of life (QOL)[90]. Recently, the omental lymph node transfer has gained popularity, as current research continually demonstrates that it is a safe and feasible procedure without the additional risk of donor site lymphedema[91].

Regardless of the nodal basin used, clinical judgment and provider discretion are paramount. Donor site morbidity such as scar location or lymphedema risk must be accounted for, and further studies are warranted to determine the long-term outcomes of such flaps and lymph node transfers[92,93].

A recent study in Japan compared conservative management versus combined-modality LVA and compression therapy for lymphedema in early breast cancer[94]. The single-center retrospective analysis found that surgical lymphovenous anastomosis and compression therapy were more efficacious than conservative treatment alone, citing reductions in limb circumference and cellulitis incidence[94]. Newer literature advocates for multidisciplinary approaches combining surgical modalities and medical therapies. Ciudad et al. present a multi-national algorithm for breast cancer-related lymphedema[95]. The authors employed the breast cancer-related lymphedema multidisciplinary approach (B-LYMA) and found that the addition of suction-assisted lipectomy to LVA significantly reduced limb circumference, compared to LVA, VLNT, and combined DIEP flap and VLNT[95].

In this review, we discuss the management of breast cancer-related lymphedema, including lymphovenous bypass and vascularized lymph node transfer. While each method has its own advantages and limitations, newer research calls for multidisciplinary and multimodal algorithmic treatment aimed at both prevention and treatment.

SUMMARY

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. In this review, we presented technical microsurgical pearls for radiated breasts, including the enhancement of flap vascularity, expanded dissection of recipient vessels, postoperative anticoagulation, and various salvage conduits. Furthermore, we propose an algorithm that describes the multiple approaches to timing free flap reconstruction for the previously irradiated patient. Lastly, we reviewed the prevention of lymphedema through several surgical techniques including LVB, LVA, and VLNT. When caring for the previously irradiated patient, we must consider all levels of care in which a paradigm shift in breast reconstruction may occur. This could mean a change in microsurgical techniques, reconstructive timing, preoperative optimization, and postoperative care.

FUTURE DIRECTIONS

Since its emergence from the core principles of general surgery, plastic and reconstructive surgery has consistently advanced and revolutionized both medicine and surgery. Microsurgery and even supermicrosurgery have evolved alongside medical and surgical technology, allowing practitioners and researchers to explore new frontiers. With each advancement, we must consider the future implications and how it will impact patients, healthcare, and the field. Here, the authors comment on potential future directions.

Equally as important to mitigating the effects of radiation is preventing them. However, preventing the adverse effects of radiation is not always feasible or possible, as radiotherapy cannot, and should not, be deferred when its benefits outweigh the risks. Predictive models that could analyze patient factors could serve as clinical decision support tools, enhancing multidisciplinary care, patient education, and shared decision-making. Healthcare professionals could utilize these models to predict, to a reasonable degree, the post-radiation course in any given patient. Understanding the potential risk factors and associated complication profiles could enable more accurate surgical planning and management. This, in turn, could enhance preparedness and overall outcomes. Radiation oncologists have stressed the need for radiation estimation since the 1980s, so as to better evaluate the pros, cons, and cost-effectiveness of radiotherapy[96]. Palma et al. have described an algorithm for radiation complication prediction models in normal tissues[96]. Other studies have investigated the risks of specific complications, such as hypothyroidism after supraclavicular radiation in breast cancer[97]. In Germany, a team of researchers have described an algorithm of predictive factors for radiotherapy complications in normal tissue with increasing age as a risk factor for telangiectasia and fibrosis[98]. Smoking was also associated with an increased risk of telangiectasia[99].

Personalized healthcare is becoming increasingly more common in modernized medicine. With an emphasis on improved patient outcomes and experience, treatment and management algorithms that are patient-centered and patient-specific are essential tools to achieve these outcomes. There exists a large body of literature outlining individualized breast cancer risk assessment[99-101]. Other works attempt to create individualized breast cancer risk prediction models with the use of machine learning and artificial intelligence[102,103]. Less research, however, focuses on complication or morbidity prediction. One study developed a protocol to investigate radiation-induced skin fibrosis resulting from breast cancer treatment, in an effort to derive an algorithm for personalized risk estimation[104].

Adjuncts have also been employed to mitigate the effects of radiation. Intraoperatively, fat grafting, decellularized fat matrices, and/or acellular dermal matrix (ADM) have shown promise in reducing the negative effects of skin fibrosis. Adipose-derived stem cells have demonstrated a therapeutic effect in radiated fields, with the ability to amplify wound healing and alter genetic expression, modifying hypoxia and inflammation[105,106]. Prophylactic lipofilling has been shown to be beneficial in mitigating radiation effects on tissue at both a qualitative and a quantitative level[107,108]. Potential uses of hyperbaric oxygen and other pharmaceutical agents have also been utilized[8]. ADM has shown promise in inhibiting capsular contracture in post-mastectomy radiotherapy[109]. These findings were corroborated in a large Spanish multicenter analysis of 1,450 pre-pectoral breast reconstructions with ADM, reporting a low incidence of capsular contracture (2.1%)[110]. Postoperative wound care with hydrogel and hydrocolloid dressings have also been used, citing the benefits of moist environments to prevent pain and accelerate wound healing[111,112].

CONCLUSION

While certain dogma has prevailed due to important data in our literature, advances in radiation and multidisciplinary care have changed paradigms at certain institutions. With continued progress, derivation, and innovation, plastic surgery and microsurgery are rapidly evolving. While the authors are not suggesting that this is inevitable, plastic and reconstructive surgeons, along with patients and other healthcare providers, must consider the possibility of paradigm shifts in breast reconstruction. This could mean a change in microsurgical techniques, reconstructive timing, preoperative optimization, or postoperative care[113,114]. Nonetheless, free tissue transfer will remain a vital reconstructive option not only for the breast, but also for extremities and other body regions. Reconstructive surgeons must have an armamentarium capable of these options for the best possible patient outcomes.

DECLARATIONS

Authors’ contributions

Made substantial contributions to the conception and design of the article and performed literature review and interpretation: Ewing JN, Gala Z, Lemdani MS, Kovach III SJ, Azoury SC

Availability of data and materials

Not applicable.

Financial support and sponsorship

None.

Conflicts of interest

Dr. Stephen Kovach is a consultant and speaker for Becton Dickinson, WL Gore and Company, Integra Life Sciences, Checkpoint Surgical, and Abvie Consulting. Dr. Said C. Azoury serves as a Youth Editorial Board member of the Plastic and Aesthetic Research (PAR) journal. All other listed authors declared that there are no conflicts of interest.

Ethical approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Copyright

© The Author(s) 2024.

REFERENCES

1. Alkabban FM, Ferguson T. Breast cancer. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482286/ [Last accessed on 21 Jun 2024].

2. Bertozzi N, Pesce M, Santi PL, Raposio E. Oncoplastic breast surgery: comprehensive review. Eur Rev Med Pharmacol Sci 2017;21:2572-85.

3. Castaneda SA, Strasser J. Updates in the treatment of breast cancer with radiotherapy. Surg Oncol Clin N Am 2017;26:371-82.

4. Classen J, Nitzsche S, Wallwiener D, et al. Fibrotic changes after postmastectomy radiotherapy and reconstructive surgery in breast cancer. A retrospective analysis in 109 patients. Strahlenther Onkol 2010;186:630-6.

5. Supakalin N, Pesee M, Thamronganantasakul K, Promsensa K, Supaadirek C, Krusun S. Comparision of different radiotherapy planning techniques for breast cancer after breast conserving surgery. Asian Pac J Cancer Prev 2018;19:2929-34.

6. Kim CS, Algan O. Radiation therapy for early-stage breast cancer. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459174/ [Last accessed on 21 Jun 2024].

7. Najafi M, Motevaseli E, Shirazi A, et al. Mechanisms of inflammatory responses to radiation and normal tissues toxicity: clinical implications. Int J Radiat Biol 2018;94:335-56.

8. Nepon H, Safran T, Reece EM, Murphy AM, Vorstenbosch J, Davison PG. Radiation-induced tissue damage: clinical consequences and current treatment options. Semin Plast Surg 2021;35:181-8.

9. Straub JM, New J, Hamilton CD, Lominska C, Shnayder Y, Thomas SM. Radiation-induced fibrosis: mechanisms and implications for therapy. J Cancer Res Clin Oncol 2015;141:1985-94.

10. Wang B, Wei J, Meng L, et al. Advances in pathogenic mechanisms and management of radiation-induced fibrosis. Biomed Pharmacother 2020;121:109560.

11. Yarnold J, Brotons MC. Pathogenetic mechanisms in radiation fibrosis. Radiother Oncol 2010;97:149-61.

12. Hymes SR, Strom EA, Fife C. Radiation dermatitis: clinical presentation, pathophysiology, and treatment 2006. J Am Acad Dermatol 2006;54:28-46.

13. Mendelsohn FA, Divino CM, Reis ED, Kerstein MD. Wound care after radiation therapy. Adv Skin Wound Care 2002;15:216-24.

14. Ho AY, Patel N, Ohri N, et al. Bilateral implant reconstruction does not affect the quality of postmastectomy radiation therapy. Med Dosim 2014;39:18-22.

15. Clemens MW, Kronowitz SJ. Current perspectives on radiation therapy in autologous and prosthetic breast reconstruction. Gland Surg 2015;4:222-31.

16. Javaid M, Song F, Leinster S, Dickson MG, James NK. Radiation effects on the cosmetic outcomes of immediate and delayed autologous breast reconstruction: an argument about timing. J Plast Reconstr Aesthet Surg 2006;59:16-26.

17. See MS, Farhadi J. Radiation therapy and immediate breast reconstruction: novel approaches and evidence base for radiation effects on the reconstructed breast. Clin Plast Surg 2018;45:13-24.

18. Ho AL, Bovill ES, Macadam SA, Tyldesley S, Giang J, Lennox PA. Postmastectomy radiation therapy after immediate two-stage tissue expander/implant breast reconstruction: a University of British Columbia perspective. Plast Reconstr Surg 2014;134:1e-10e.

19. Tallet AV, Salem N, Moutardier V, et al. Radiotherapy and immediate two-stage breast reconstruction with a tissue expander and implant: complications and esthetic results. Int J Radiat Oncol Biol Phys 2003;57:136-42.

20. Krueger EA, Wilkins EG, Strawderman M, et al. Complications and patient satisfaction following expander/implant breast reconstruction with and without radiotherapy. Int J Radiat Oncol Biol Phys 2001;49:713-21.

21. Rogers NE, Allen RJ. Radiation effects on breast reconstruction with the deep inferior epigastric perforator flap. Plast Reconstr Surg 2002;109:1919-24; discussion 1925.

22. Spear SL, Ducic I, Low M, Cuoco F. The effect of radiation on pedicled TRAM flap breast reconstruction: outcomes and implications. Plast Reconstr Surg 2005;115:84-95.

23. Berbers J, van Baardwijk A, Houben R, et al. 'Reconstruction: before or after postmastectomy radiotherapy?' ? A systematic review of the literature. Eur J Cancer 2014;50:2752-62.

24. Whitfield GA, Horan G, Irwin MS, Malata CM, Wishart GC, Wilson CB. Incidence of severe capsular contracture following implant-based immediate breast reconstruction with or without postoperative chest wall radiotherapy using 40 Gray in 15 fractions. Radiother Oncol 2009;90:141-7.

25. Cordeiro PG, Snell L, Heerdt A, McCarthy C. Immediate tissue expander/implast breast reconstruction after salvage mastectomy for cancer recurrence following lumpectomy/irradiation. Plast Reconstr Surg 2012;129:341-50.

26. Ricci JA, Epstein S, Momoh AO, Lin SJ, Singhal D, Lee BT. A meta-analysis of implant-based breast reconstruction and timing of adjuvant radiation therapy. J Surg Res 2017;218:108-16.

27. Agrawal A. Oncoplastic breast surgery and radiotherapy-adverse aesthetic outcomes, proposed classification of aesthetic components, and causality attribution. Breast J 2019;25:207-18.

28. Barnett GC, West CM, Dunning AM, et al. Normal tissue reactions to radiotherapy: towards tailoring treatment dose by genotype. Nat Rev Cancer 2009;9:134-42.

29. Tachi M, Yamada A. Choice of flaps for breast reconstruction. Int J Clin Oncol 2005;10:289-97.

30. Fracol ME, Basta MN, Nelson JA, et al. Bilateral free flap breast reconstruction after unilateral radiation: comparing intraoperative vascular complications and postoperative outcomes in radiated versus nonradiated breasts. Ann Plast Surg 2016;76:311-4.

31. El-Sabawi B, Sosin M, Carey JN, Nahabedian MY, Patel KM. Breast reconstruction and adjuvant therapy: a systematic review of surgical outcomes. J Surg Oncol 2015;112:458-64.

32. Tsoi B, Ziolkowski NI, Thoma A, Campbell K, O'Reilly D, Goeree R. Safety of tissue expander/implant versus autologous abdominal tissue breast reconstruction in postmastectomy breast cancer patients: a systematic review and meta-analysis. Plast Reconstr Surg 2014;133:234-49.

33. Saksornchai K, Ganoksil P, Rongkavilit S, Suwajo P. Impact of radiation on immediate breast reconstruction: a retrospective single institution cohort study. Gland Surg 2023;12:1050-9.

34. Kronowitz SJ. Delayed-immediate breast reconstruction: technical and timing considerations. Plast Reconstr Surg 2010;125:463-74.

35. Coriddi M, Shenaq D, Kenworthy E, et al. Autologous breast reconstruction after failed implant-based reconstruction: evaluation of surgical and patient-reported outcomes and quality of life. Plast Reconstr Surg 2019;143:373-9.

36. Antony AK, Robinson EC. An algorithmic approach to prepectoral direct-to-implant breast reconstruction: version 2.0. Plast Reconstr Surg 2019;143:1311-9.

37. Sigalove S, Maxwell GP, Sigalove NM, et al. Prepectoral implant-based breast reconstruction and postmastectomy radiotherapy: short-term outcomes. Plast Reconstr Surg Glob Open 2017;5:e1631.

38. Elswick SM, Harless CA, Bishop SN, et al. Prepectoral implant-based breast reconstruction with postmastectomy radiation therapy. Plast Reconstr Surg 2018;142:1-12.

39. Turner A, Abu-Ghname A, Davis MJ, Winocour SJ, Hanson SE, Chu CK. Fat grafting in breast reconstruction. Semin Plast Surg 2020;34:17-23.

40. Kolasinski J. Total breast reconstruction with fat grafting combined with internal tissue expansion. Plast Reconstr Surg Glob Open 2019;7:e2009.

41. Borrelli MR, Patel RA, Sokol J, et al. Fat chance: the rejuvenation of irradiated skin. Plast Reconstr Surg Glob Open 2019;7:e2092.

42. Serra-Renom JM, Muñoz-Olmo JL, Serra-Mestre JM. Fat grafting in postmastectomy breast reconstruction with expanders and prostheses in patients who have received radiotherapy: formation of new subcutaneous tissue. Plast Reconstr Surg 2010;125:12-8.

43. Sood R, Easow JM, Konopka G, Panthaki ZJ. Latissimus dorsi flap in breast reconstruction: recent innovations in the workhorse flap. Cancer Control 2018;25:1073274817744638.

44. Jeong EC, Hwang SH, Eo SR. Vascular augmentation in renal transplantation: supercharging and turbocharging. Arch Plast Surg 2017;44:238-42.

45. Bachleitner K, Weitgasser L, Amr A, Schoeller T. Autologous unilateral breast reconstruction with venous supercharged imap-flaps: a step by step guide of the split breast technique. J Clin Med 2020;9:3030.

46. Huang TC, Cheng HT. One-vein vs. two-vein anastomoses utilizing the retrograde limb of the internal mammary vein as supercharge recipient vessel in free DIEP flap breast reconstruction: a meta-analysis of comparative studies. J Plast Reconstr Aesthet Surg 2020;73:184-99.

47. El-Mrakby HH, Milner RH, McLean NR. Supercharged pedicled TRAM flap in breast reconstruction: is it a worthwhile procedure. Ann Plast Surg 2002;49:252-7.

48. Kroll SS. Bilateral breast reconstruction in very thin patients with extended free TRAM flaps. Br J Plast Surg 1998;51:535-7.

49. Le ELH, Saifee J, Constantine R, et al. Extended venous thromboembolism chemoprophylaxis following microsurgical breast reconstruction: analysis of trends in postoperative anticoagulation. Plast Reconstr Surg 2023;152:20-7.

50. Ballestín A, Akelina Y. Basic and advanced microvascular anastomotic techniques. In: Nikkhah D, Rawlins J, Pafitanis G, eds. Core techniques in flap reconstructive microsurgery: A stepwise guide. Springer International Publishing; 2023:11-18.

51. Jakobsson S, Kamali A, Edsander Nord Å, Sommar P, Halle M. Free flap surgery outcome related to antithrombotic treatment regime: an analysis of 1000 cases. Plast Reconstr Surg Glob Open 2021;9:e3961.

52. Lee CC, Lo A, Lorenz FJ, Martinazzi BJ, Johnson TS. Use of thromboprophylaxis after autologous breast reconstruction: a cost-effective break-even analysis. Plast Reconstr Surg 2023:Online ahead of print.

53. Ambani SW, Bengur FB, Varelas LJ, et al. Standard fixed enoxaparin dosing for venous thromboembolism prophylaxis leads to low peak anti-factor Xa levels in both head and neck and breast free flap patients. J Reconstr Microsurg 2022;38:749-56.

54. Tuaño KR, Yang JH, Fisher MH, et al. Venous thromboembolism after deep inferior epigastric perforator flap breast reconstruction: review of outcomes after a postoperative prophylaxis protocol. Plast Reconstr Surg 2023; doi: 10.1097/prs.0000000000010949.

55. Muto M, Satake T, Masuda Y, et al. Absent Internal mammary recipient vein in autologous breast reconstruction. Plast Reconstr Surg Glob Open 2020;8:e2660.

56. Feng LJ. Recipient vessels in free-flap breast reconstruction: a study of the internal mammary and thoracodorsal vessels. Plast Reconstr Surg 1997;99:405-16.

57. Moran SL, Nava G, Behnam AB, Serletti JM. An outcome analysis comparing the thoracodorsal and internal mammary vessels as recipient sites for microvascular breast reconstruction: a prospective study of 100 patients. Plast Reconstr Surg 2003;111:1876-82.

58. Casey WJ 3rd, Rebecca AM, Smith AA, Craft RO, Buchel EW. The cephalic and external jugular veins: important alternative recipient vessels in left-sided microvascular breast reconstruction. Microsurgery 2007;27:465-9.

59. Barnett GR, Carlisle IR, Gianoutsos MP. The cephalic vein: an aid in free TRAM flap breast reconstruction. Report of 12 cases. Plast Reconstr Surg 1996;97:71-6; discussion 77.

60. Mehrara BJ, Santoro T, Smith A, et al. Alternative venous outflow vessels in microvascular breast reconstruction. Plast Reconstr Surg 2003;112:448-55.

61. Ragaz J, Olivotto IA, Spinelli JJ, et al. Locoregional radiation therapy in patients with high-risk breast cancer receiving adjuvant chemotherapy: 20-year results of the British Columbia randomized trial. J Natl Cancer Inst 2005;97:116-26.

62. Ayoub Z, Strom EA, Ovalle V, et al. A 10-year experience with mastectomy and tissue expander placement to facilitate subsequent radiation and reconstruction. Ann Surg Oncol 2017;24:2965-71.

63. Fertsch S, Munder B, Hagouan M, et al. Immediate-DElayed AutoLogous (IDEAL) breast reconstruction with the DIEP flap. Chirurgia 2017;112:387-93.

64. Marquez JL, Sudduth JD, Kuo K, et al. A comparison of postoperative outcomes between immediate, delayed immediate, and delayed autologous free flap breast reconstruction: analysis of 2010-2020 NSQIP data. J Reconstr Microsurg 2023;39:664-70.

65. Cuffolo G, Pandey A, Windle R, Adams T, Dunne N, Smith B. Delayed-immediate breast reconstruction: An assessment of complications and outcomes in the context of anticipated post-mastectomy radiotherapy. J Plast Reconstr Aesthet Surg 2023;77:319-27.

66. Carlson GW, Page AL, Peters K, Ashinoff R, Schaefer T, Losken A. Effects of radiation therapy on pedicled transverse rectus abdominis myocutaneous flap breast reconstruction. Ann Plast Surg 2008;60:568-72.

67. Koesters EC, Chang DW. Radiation and free flaps: what is the optimal timing? Gland Surg 2023;12:1122-30.

68. Kronowitz SJ, Hunt KK, Kuerer HM, et al. Delayed-immediate breast reconstruction. Plast Reconstr Surg 2004;113:1617-28.

69. Bazan J, DiCostanzo D, Kuhn K, et al. Likelihood of unacceptable normal tissue doses in breast cancer patients undergoing regional nodal irradiation in routine clinical practice. Pract Radiat Oncol 2017;7:154-60.

70. Hershenhouse KS, Bick K, Shauly O, et al. "Systematic review and meta-analysis of immediate versus delayed autologous breast reconstruction in the setting of post-mastectomy adjuvant radiation therapy". J Plast Reconstr Aesthet Surg 2021;74:931-44.

71. Liew B, Southall C, Kanapathy M, Nikkhah D. Does post-mastectomy radiation therapy worsen outcomes in immediate autologous breast flap reconstruction? A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2021;74:3260-80.

72. Heiman AJ, Gabbireddy SR, Kotamarti VS, Ricci JA. A meta-analysis of autologous microsurgical breast reconstruction and timing of adjuvant radiation therapy. J Reconstr Microsurg 2021;37:336-45.

73. Billig J, Jagsi R, Qi J, et al. Should immediate autologous breast reconstruction be considered in women who require postmastectomy radiation therapy? A prospective analysis of outcomes. Plast Reconstr Surg 2017;139:1279-88.

74. Mirzabeigi MN, Smartt JM, Nelson JA, Fosnot J, Serletti JM, Wu LC. An assessment of the risks and benefits of immediate autologous breast reconstruction in patients undergoing postmastectomy radiation therapy. Ann Plast Surg 2013;71:149-55.

75. Al-Ghazal SK, Sully L, Fallowfield L, Blamey RW. The psychological impact of immediate rather than delayed breast reconstruction. Eur J Surg Oncol 2000;26:17-19.

76. Metcalfe KA, Zhong T, Narod SA, et al. A prospective study of mastectomy patients with and without delayed breast reconstruction: long-term psychosocial functioning in the breast cancer survivorship period. J Surg Oncol 2015;111:258-64.

77. Tran NV, Chang DW, Gupta A, Kroll SS, Robb GL. Comparison of immediate and delayed free TRAM flap breast reconstruction in patients receiving postmastectomy radiation therapy. Plast Reconstr Surg 2001;108:78-82.

78. Chang EI, Masià J, Smith ML. Combining autologous breast reconstruction and vascularized lymph node transfer. Semin Plast Surg 2018;32:36-41.

79. Ribeiro Pereira ACP, Koifman RJ, Bergmann A. Incidence and risk factors of lymphedema after breast cancer treatment: 10 years of follow-up. Breast 2017;36:67-73.

80. Chang DW, Suami H, Skoracki R. A prospective analysis of 100 consecutive lymphovenous bypass cases for treatment of extremity lymphedema. Plast Reconstr Surg 2013;132:1305-14.

81. Raju A, Chang DW. Vascularized lymph node transfer for treatment of lymphedema: a comprehensive literature review. Ann Surg 2015;261:1013-23.

82. Maldonado AA, Chen R, Chang DW. The use of supraclavicular free flap with vascularized lymph node transfer for treatment of lymphedema: a prospective study of 100 consecutive cases. J Surg Oncol 2017;115:68-71.

83. Tzou CH, Meng S, Ines T, et al. Surgical anatomy of the vascularized submental lymph node flap: anatomic study of correlation of submental artery perforators and quantity of submental lymph node. J Surg Oncol 2017;115:54-9.

84. Tinhofer IE, Meng S, Steinbacher J, et al. The surgical anatomy of the vascularized lateral thoracic artery lymph node flap-A cadaver study. J Surg Oncol 2017;116:1062-8.

85. Cheng MH, Chen SC, Henry SL, Tan BK, Chia-Yu Lin M, Huang JJ. Vascularized groin lymph node flap transfer for postmastectomy upper limb lymphedema: flap anatomy, recipient sites, and outcomes. Plast Reconstr Surg 2013;131:1286-98.

86. Nguyen AT, Chang EI, Suami H, Chang DW. An algorithmic approach to simultaneous vascularized lymph node transfer with microvascular breast reconstruction. Ann Surg Oncol 2015;22:2919-24.

87. Nguyen AT, Suami H, Hanasono MM, Womack VA, Wong FC, Chang EI. Long-term outcomes of the minimally invasive free vascularized omental lymphatic flap for the treatment of lymphedema. J Surg Oncol 2017;115:84-9.

88. Crowley JS, Liu FC, Rizk NM, Nguyen D. Concurrent management of lymphedema and breast reconstruction with single-stage omental vascularized lymph node transfer and autologous breast reconstruction: a case series. Microsurgery 2024;44:e31017.

89. Akita S, Tokumoto H, Yamaji Y, et al. Contribution of simultaneous breast reconstruction by deep inferior epigastric artery perforator flap to the efficacy of vascularized lymph node transfer in patients with breast cancer-related lymphedema. J Reconstr Microsurg 2017;33:571-8.

90. Di Taranto G, Coleman GJ, Hardwicke J, Wallis KL, Skillman J. A comparative study between deep inferior epigastric artery perforator flap breast reconstruction and DIEP flap breast reconstruction coupled with vascularized lymph node transfer: Improving the quality of life of patients with breast cancer related lymphedema without affecting donor site outcomes. Microsurgery 2023;43:213-21.

91. Liu FC, Thawanyarat K, Navarro Y, Nguyen DH. Current research on the use of the omental flap in breast reconstruction and post-mastectomy lymphedema: a focus on omental-vascularized lymph node transfer. Life 2023;13:1380.

92. Schaverien MV, Badash I, Patel KM, Selber JC, Cheng MH. Vascularized lymph node transfer for lymphedema. Semin Plast Surg 2018;32:28-35.

93. Ciudad P, Agko M, Perez Coca JJ, et al. Comparison of long-term clinical outcomes among different vascularized lymph node transfers: 6-year experience of a single center's approach to the treatment of lymphedema. J Surg Oncol 2017;116:671-82.

94. Shimbo K, Kawamoto H, Koshima I. Comparative study of conservative treatment and lymphaticovenular anastomosis with compression therapy for early-stage breast cancer-related lymphoedema. J Plast Reconstr Aesthet Surg 2024;88:390-6.

95. Ciudad P, Bolletta A, Kaciulyte J, et al. The breast cancer-related lymphedema multidisciplinary approach: algorithm for conservative and multimodal surgical treatment. Microsurgery 2023;43:427-36.

96. Palma G, Monti S, Conson M, Pacelli R, Cella L. Normal tissue complication probability (NTCP) models for modern radiation therapy. Semin Oncol 2019;46:210-8.

97. Huang H, Roberson J, Hou W, et al. NTCP model for hypothyroidism after supraclavicular-directed radiation therapy for breast cancer. Radiother Oncol 2021;154:87-92.

98. Lilla C, Ambrosone CB, Kropp S, et al. Predictive factors for late normal tissue complications following radiotherapy for breast cancer. Breast Cancer Res Treat 2007;106:143-50.

99. Siettmann JM, Arun B, Gasparini J, Mina LA. Personalized breast cancer risk assessment: incorporation of genetic and high-risk factorson breast cancer risk and management. Chirurgia 2021;116:S22-34.

100. Román M, Sala M, Domingo L, Posso M, Louro J, Castells X. Personalized breast cancer screening strategies: a systematic review and quality assessment. PLoS One 2019;14:e0226352.

101. Chowdhury M, Euhus D, Arun B, Umbricht C, Biswas S, Choudhary P. Validation of a personalized risk prediction model for contralateral breast cancer. Breast Cancer Res Treat 2018;170:415-23.

102. Stark GF, Hart GR, Nartowt BJ, Deng J. Predicting breast cancer risk using personal health data and machine learning models. PLoS One 2019;14:e0226765.

103. Pesapane F, Battaglia O, Pellegrino G, et al. Advances in breast cancer risk modeling: integrating clinics, imaging, pathology and artificial intelligence for personalized risk assessment. Future Oncol 2023;19:2547-64.

104. Williams NR, Williams S, Kanapathy M, Naderi N, Vavourakis V, Mosahebi A. Radiation-induced fibrosis in breast cancer: a protocol for an observational cross-sectional pilot study for personalised risk estimation and objective assessment. Int J Surg Protoc 2019;14:9-13.

105. Tang H, He Y, Liang Z, Li J, Dong Z, Liao Y. The therapeutic effect of adipose-derived stem cells on soft tissue injury after radiotherapy and their value for breast reconstruction. Stem Cell Res Ther 2022;13:493.

106. Lindegren A, Schultz I, Sinha I, et al. Autologous fat transplantation alters gene expression patterns related to inflammation and hypoxia in the irradiated human breast. Br J Surg 2019;106:563-73.

107. Gentilucci M, Mazzocchi M, Alfano C. Effects of prophylactic lipofilling after radiotherapy compared to non-fat injected breasts: a randomized, objective study. Aesthet Surg J 2020;40:NP597-607.

108. Vaia N, Lo Torto F, Marcasciano M, et al. From the "fat capsule" to the "fat belt": limiting protective lipofilling on irradiated expanders for breast reconstruction to selective key areas. Aesthetic Plast Surg 2018;42:986-94.

109. Kim IK, Park SO, Chang H, Jin US. Inhibition mechanism of acellular dermal matrix on capsule formation in expander-implant breast reconstruction after postmastectomy radiotherapy. Ann Surg Oncol 2018;25:2279-87.

110. Masià J; iBAG Working Group. The largest multicentre data collection on prepectoral breast reconstruction: The iBAG study. J Surg Oncol 2020;122:848-60.

111. Wei J, Meng L, Hou X, et al. Radiation-induced skin reactions: mechanism and treatment. Cancer Manag Res 2019;11:167-77.

112. Wasiak J, Cleland H, Campbell F, Spinks A. Dressings for superficial and partial thickness burns. Cochrane Database Syst Rev 2013;2013:CD002106.

113. Speck NE, Grufman V, Farhadi J. Trends and innovations in autologous breast reconstruction. Arch Plast Surg 2023;50:240-7.

114. Elver AA, Egan KG, Cullom ME, et al. A paradigm shift: outcomes of early autologous breast reconstruction after radiation therapy. J Reconstr Microsurg 2023;39:111-9.

Cite This Article

Export citation file: BibTeX | EndNote | RIS

OAE Style

Ewing JN, Gala Z, Lemdani MS, III SJK, Azoury SC. The radiated breast and autologous reconstruction: benefits and alternatives. Plast Aesthet Res 2024;11:22. http://dx.doi.org/10.20517/2347-9264.2024.11

AMA Style

Ewing JN, Gala Z, Lemdani MS, III SJK, Azoury SC. The radiated breast and autologous reconstruction: benefits and alternatives. Plastic and Aesthetic Research. 2024; 11: 22. http://dx.doi.org/10.20517/2347-9264.2024.11

Chicago/Turabian Style

Jane N. Ewing, Zachary Gala, Mehdi S. Lemdani, Stephen J. Kovach III, Said C. Azoury. 2024. "The radiated breast and autologous reconstruction: benefits and alternatives" Plastic and Aesthetic Research. 11: 22. http://dx.doi.org/10.20517/2347-9264.2024.11

ACS Style

Ewing, JN.; Gala Z.; Lemdani MS.; III SJK.; Azoury SC. The radiated breast and autologous reconstruction: benefits and alternatives. Plast. Aesthet. Res. 2024, 11, 22. http://dx.doi.org/10.20517/2347-9264.2024.11

About This Article

Special Issue

© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, sharing, adaptation, distribution and reproduction in any medium or format, for any purpose, even commercially, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Data & Comments

Data

Views
128
Downloads
10
Citations
0
Comments
0
2

Comments

Comments must be written in English. Spam, offensive content, impersonation, and private information will not be permitted. If any comment is reported and identified as inappropriate content by OAE staff, the comment will be removed without notice. If you have any queries or need any help, please contact us at support@oaepublish.com.

0
Author's Talk
Download PDF
Share This Article
Scan the QR code for reading!
See Updates
Contents
Figures
Related
Plastic and Aesthetic Research
ISSN 2349-6150 (Online)   2347-9264 (Print)

Portico

All published articles are preserved here permanently:

https://www.portico.org/publishers/oae/

Portico

All published articles are preserved here permanently:

https://www.portico.org/publishers/oae/