Radiation and Reconstructive Failure: Long-Term Outcomes in Two-Stage Flap Versus Implant Breast Reconstruction

The long-term risk of reconstructive failure and patient-reported outcomes (PROs) among patients undergoing two-stage flap or implant reconstruction combined with radiation is unknown. We assessed the risk of reconstructive failure and PROs after two-stage flap or implant reconstruction with radiation.

We analyzed all patients who underwent two-stage flap or implant reconstruction and radiation between 2017 and 2023. Reconstructive failure was defined as loss of the TE, implant, or flap, or the need to convert an implant to flap reconstruction. PROs were assessed using BREAST-Q. Predictors of reconstructive failure were identified with Cox proportional hazards models, and predicted rates were evaluated using Kaplan-Meier curves.

In total, 1210 patients underwent TE placement followed by flap (n = 215) or implant-based (n = 930) reconstruction. Reconstructive failure was seen in 157 (13%) patients; 65 in the TE stage, 89 after implant reconstruction, and 3 after flap reconstruction. Predicted rates of reconstructive failure at 72-months after mastectomy were 12% for implant and 1.4% for flap reconstruction. Patients who underwent implant reconstruction were 7.5 times more likely to experience failure than flap reconstruction (HR: 7.5, 95% CI: 2.36-24.2, p < 0.001). Median BREAST-Q satisfaction with breast scores at 3 years were significantly higher in patients who underwent flap (65, IQR:52, 73) versus implant reconstruction (57, IQR:46, 67).

Patients who undergo implant reconstruction and radiation face a higher risk of long-term reconstructive failure and report lower PROs. This emphasizes the need to counsel patients about the long-term risks and quality of life associated with implant reconstruction in the setting of radiation.