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Postmastectomy Radiation Therapy on Flap Outcomes in Breast Reconstruction: A Systematic Review and Meta-analysis
Fatima Alameri1, Anne-Sophie Reguesse1, Pierre Tawa1
1From the Department of Plastic Surgery, Paris Saint-Joseph Hospital, Paris, France.
Background:
Breast reconstruction is an important aspect of the process of recovery for patients recovering from mastectomy. However, postmastectomy radiation therapy (PMRT) disrupts flap perfusion and cosmetic results. These complications have prompted comparisons of irradiated and nonirradiated flaps, especially in immediate and delayed reconstruction.
Methods:
Using preferred reporting items for systematic reviews and meta-analyses guidelines, a PubMed and Cochrane Library search from the year 2000 to 2024 was performed to compare the irradiated and nonirradiated flaps. The inclusion criteria restricted the analysis to comparing flap viability, flap complications, aesthetic outcome, or satisfaction level of patients. The meta-analysis was used, and variance was reduced by using fixed- and random-effects models.
Results:
The analysis involved 12 studies showing that flaps receiving irradiation, particularly in immediate reconstructions, had higher complication rates, including fat necrosis and flap contracture. Nevertheless, delayed reconstruction following PMRT was linked to reduced postoperative complication rates and favorable reconstructive results, whereas flap survival did not differ between immediate and delayed reconstruction. Subgroup analysis demonstrated lower fat necrosis in deep inferior epigastric perforator flaps (≈12%) compared with transverse rectus abdominis muscle (≈25%) and latissimus dorsi flaps (≈40%), suggesting that flap-specific planning is necessary for irradiated patients. These pooled percentages reflect averaged values across included studies.
Conclusions:
Patients undergoing immediate reconstruction in the PMRT setting have increased rates of postoperative complications, especially fat necrosis, fibrosis, and flap contracture, and worse aesthetic outcomes. On the contrary, delayed reconstruction is associated with lower complications and better cosmetic results, whereas no significant difference is noted in flap survival between immediate and delayed reconstruction.