Delayed breast reconstruction with autologous free flap after radiation therapy: Vascular complications and aesthetic outcomes

Delayed breast reconstruction with autologous free flap after radiation therapy: Vascular complications and aesthetic outcomes | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Delayed breast reconstruction with autologous free flap after radiation therapy: Vascular complications and aesthetic outcomes Kimie Miyazawa, Toshihiko Satake, Mayu Muto, Yui Tsunoda, Tomoyuki Koike, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3822676/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 Jun, 2024 Read the published version in Breast Cancer → Version 1 posted 4 You are reading this latest preprint version Abstract Background The safety and outcome of breast reconstruction after radiotherapy are controversial, and the aesthetic aspects have not been studied extensively. We compared the results of vascular anastomosis, the incidence of postoperative complications, and aesthetic appearance between patients who had and had not received radiotherapy who then had undergone delayed breast reconstruction with autologous free flaps from abdomen, thighs, and buttocks. Methods We investigated 196 flaps implanted in patients who did not receive radiotherapy and 78 flaps implanted in patients who received radiotherapy before breast reconstruction in 256 patients. Of the 274 flaps, 230 came from the abdomen, 27 from the thighs, 14 from the buttocks, and 3 from other anatomic locations. We evaluated aesthetic outcomes in 107 patients who had not received radiotherapy and 45 who had. Results We found no significant differences between the two groups in incidence of vascular reanastomosis, time required for anastomosis, or incidence of unplanned reoperation. Complications such as flap necrosis were rare in both groups. Aesthetic outcomes were significantly better in the patients who had not received radiotherapy. Among the patients who had received radiotherapy, the aesthetic results were superior after two-stage reconstruction than after one-stage reconstruction. Conclusions Breast reconstruction with autologous free flaps can be performed safely in patients who have received radiotherapy, but the aesthetic result is slightly inferior to that in patients who had not received radiotherapy. In patients who have received radiotherapy, two-stage reconstruction tends to produce more aesthetically pleasing results than does one-stage reconstruction, but one-stage reconstruction is recommended if the breast skin exhibits radiation-induced changes. Delayed breast reconstruction Radiation therapy Free autologous flap Vascular complication Aesthetic outcome Figures Figure 1 Figure 2 Figure 3 Introduction Patients with breast cancer are concerned not only about curing the disease but also about their aesthetic appearance after treatment. Breast reconstruction is performed widely, and a growing number of patients who have undergone radiation therapy can benefit from breast reconstruction; however, the safety and outcome of this procedure are controversial because the effects of irradiation on the skin and blood vessels must be considered. Breast reconstruction can be accomplished with artificial materials such as implants or with the patient’s own tissues, such as skin, fat, and muscle; in the case of muscle, abdominal tissue is widely used. In previous studies, breast reconstruction after radiation therapy has been evaluated according to the materials used (prosthetic or autologous) [ 1 – 3 ] and the timing (immediately after cancer surgery or delayed) [ 4 – 6 ]. Other reports have focused on the intraoperative complications and the success or failure of reconstruction with abdominal flaps, such as free flaps from the transverse rectus abdominus muscle or from the deep inferior epigastric perforator (DIEP flaps) [ 5 , 7 , 8 ]. Few investigations have focused on breast reconstructions with other flaps. In addition, the aesthetic appearance of breasts reconstructed after irradiation has not been widely discussed. In this study, we examined the surgical results of patients who underwent delayed breast reconstruction with free flaps from the abdomen, thighs, and buttocks after radiation therapy, including aspects of intraoperative vascular anastomosis, postoperative complications, and aesthetic results. Patients and methods Participants This retrospective observational study included data from 256 patients who underwent delayed breast reconstruction with free autologous single flaps at the Department of Plastic and Reconstructive Surgery, Yokohama City University Medical Center, Yokohama, Japan, between 2012 and 2019. Surgical technique Delayed breast reconstruction is performed at least 1 year after mastectomy. In delayed one-stage breast reconstruction, autologous tissue transfer is performed in a single operation without insertion of a tissue expander. In delayed two-stage breast reconstruction, a tissue expander is placed at least 1 year after mastectomy; after the tissue has expanded sufficiently, the tissue expander is removed, and autologous tissue is transferred simultaneously for breast reconstruction. In cases of bilateral reconstruction, only the delayed reconstructed side was evaluated in this study. At Yokohama City University Medical Center, in cases of delayed breast reconstruction, a tissue expander is placed into the chest, and two-stage reconstruction is performed if the skin and subcutaneous tissue of the breast are preserved and skin extensibility is adequate. In a patient who has received radiation therapy, a tissue expander is also used before two-stage reconstruction if the patient has sufficient breast tissue and little radiation-related skin damage. In patients with blood flow disorders, hyperpigmentation, or thinning and little extensibility of the breast skin, the breast skin is replaced temporarily with a skin flap without insertion of a tissue expander in one-stage reconstruction (Fig. 1 ). Both one- and two-stage reconstructive procedures are performed at least 1 year after completion of radiation therapy. With regard to the choice of flaps, the policy at Yokohama City University Medical Center is not to use abdominal flaps for patients who may become pregnant and give birth. The reason is that even if the rectus abdominis muscle and fascia are preserved and repaired, the fragility of the abdominal wall might adversely affect pregnancy and delivery and lead to subsequent complications. In such cases, flaps from the thighs or buttocks are used for breast reconstruction. Because these flaps have less tissue volume than do abdominal flaps, two flaps are combined when necessary. In this study, however, patients with two-flap reconstructions were excluded; only patients who underwent single-flap reconstruction on either side or both sides were included. When flaps from the thighs or buttocks are used, tissue expanders are implanted as much as possible for two-stage reconstruction to avoid extensive skin islands, which result because the skin color of the flaps differs from that of the chest. Alternatively, such flaps are selected when nipple-sparing mastectomy leaves residual chest skin. Internal mammary arteries or veins (IMA/Vs) are the first choice of vessels for anastomosis in breast reconstruction; these vessels have not been expanded at the time of breast cancer surgery. Other vessels are chosen only if IMA/Vs cannot be used for anastomoses. All procedure were performed by two plastic surgeons (T.S.and M.M.) as operating surgeons or teaching assistants. Data collection In this investigation, we studied medical and surgical records and photographs. We documented each patient’s age, body mass index (BMI), medical history (e.g., hypertension, diabetes), smoking history, surgical procedure, and preoperative and postoperative therapy for breast cancer. Furthermore, we documented the type of reconstruction, recipient vessels, arterial and venous reanastomosis, time required for anastomosis (ischemic time), and early and late postoperative complications. Aesthetic evaluation The aesthetic appearance of reconstructed breasts was evaluated in 152 patients more than 6 months after the last revision surgery. The 45 patients who received radiation therapy on one or both sides and who underwent bilateral reconstruction were considered the “irradiated group”; 107 patients who did not receive radiation treatment before breast reconstruction were considered the “nonirradiated group.” Revision surgery included adjustment of the volume and structure of the reconstructed breast, nipple–areola reconstruction, and weight reduction or lifting of the healthy breast. Symmetry and structure of breast projection, breast volume, décolleté, cleavage, and the inframammary line were scored 0–2, whereby 2 represented very good form with almost no left–right difference, 1 represented relatively good form with a slight left–right difference, and 0 represented a considerable left–right difference and noticeable deformation. Nipple–areola structure and position were not included in this evaluation because some patients had not completed nipple–areola reconstruction. The evaluation was performed by three certified plastic surgeons, none of whom were the primary surgeons, and the average of the three scores was calculated for each item; the highest possible total score was 10. The evaluators were unaware of patients’ radiation history or type of reconstruction. A total score of \(\ge\) 9 represented a very good aesthetic outcome; scores of \(\ge\) 6 to <9, good outcomes; scores of \(\ge\) 4 to <6, fair outcomes; and scores of <4, poor outcomes. Statistical analysis For statistical analysis, we used IBM SPSS Statistics for Windows, Version 28.0 (IBM Corporation, Armonk, NY, USA; released 2021). To compare the nonirradiated and irradiated groups, we used Student’s t test and the Mann–Whitney U test for continuous variables and the chi-square test and Fisher’s exact test for categorical variables. We considered p values of < 0.05 statistically significant. Results The 256 patients in this study received a total of 274 flaps, of which 196 were implanted in patients who did not radiotherapy and 78 were implanted in patients who received radiotherapy before breast reconstruction.. Table 1 lists the ages, BMIs, comorbidities, and cancer treatment in each group. We found no significant differences in age ( p = 0.32), BMI ( p = 0.56), prevalence of hypertension ( p = 0.15), prevalence of diabetes ( p = 0.63), or smoking status ( p = 0.58) between the two groups. Among patients in the nonirradiated group, 159 flaps (81.1%) were implanted after total mastectomy and 2 flaps (1.0%) after partial mastectomy; among patients in the irradiated group, 52 flaps (66.7%) were implanted after total mastectomy and 15 flaps (19.2%) after partial mastectomy. The rate of total mastectomy was significantly higher in the nonirradiated group than in the irradiated group ( p = 0.01), whereas the rate of partial mastectomy was higher in the irradiated group than in the nonirradiated group ( p < 0.01). We found no significant difference in the rates of nipple-sparing mastectomy between the two groups ( p = 0.99) or those of skin-sparing mastectomy ( p = 0.41). The rate of axillary lymph node dissection was significantly higher in the irradiated group than in the nonirradiated group ( p < 0.01). With regard to breast cancer treatment before reconstruction, the percentage of patients who received chemotherapy was higher in the irradiated group, but the difference was not statistically significant ( p = 0.13). Table 1 Patient characteristics and oncologic data Characteristic Non-irradiated group (196 flaps) Irradiated group (78 flaps) p value Age (years) Mean ± SD 51.6 ± 7.2 50.6 ± 7.2 0.32 Range 34–70 34–69 \(\ge\) 65 12 (6.1%) 3 (3.8%) 0.57 Body mass index (kg/m 2 ) Mean ± SD 22.0 ± 2.6 22.4 ± 3.2 0.56 Range 17.1–35.1 17.3–32.5 \(\ge\) 25 22 (11.2%) 15(19.2%) 0.08 Comorbidities Hypertension 24 (12.2%) 5(6.4%) 0.15 Diabetes mellitus 3 (1.5%) 2 (2.6%) 0.63 Past or current smoker 62 (31.6%) 2 (28.2%) 0.58 Type of mastectomy Radical mastectomy 1 (0.5%) 0 (0.0%) 1 Total mastectomy 159 (81.1%) 52 (66.7%) 0.01 Skin-sparing mastectomy 14 (7.1%) 3 (3.8%) 0.41 Nipple-sparing mastectomy 20 (10.2%) 8 (10.2%) 0.99 Partial mastectomy 2 (1.0%) 15 (19.2%) < 0.01 Lymph node treatment Axillary lymph node dissection 81 (41.3%) 50 (64.1%) < 0.01 Sentinel node biopsy 109 (55.6%) 22 (28.2%) < 0.01 Unknown 6 (3.1%) 6 (7.7%) 0.17 Combination therapy Chemotherapy (neoadjuvant, adjuvant, or both) 98 (50.0%) 47 (60.3%) 0.13 Hormonal therapy 157 (80.1%) 62 (79.5%) 0.09 SD standard deviation Of the 256 patients, 234 underwent unilateral reconstruction and 22 underwent bilateral reconstruction. Of the latter, 18 patients underwent delayed reconstruction on both sides, and 4 patients underwent reconstruction immediately after surgery on one side and delayed reconstruction on the other side. In 8 of the 234 patients, autologous tissue was used in reconstruction because of complications after implant reconstruction; 1 of those 8 had received radiotherapy. Table 2 lists flap types used in reconstruction. One-stage reconstruction was performed significantly more often in the irradiated group (70.5%) than in the nonirradiated group (46.9%; p < 0.01). The flaps used most commonly for reconstruction were abdominal flaps, in 164 patients (83.7%) in the nonirradiated group and in 66 patients (84.6%) in the irradiated group. We found no significant difference in the proportion of abdominal flap, thigh flap, and buttock flap between the two groups. Table 2 Flap type, vascular anastomoses, and complications Aspects of treatment Non-irradiated group (196 flaps) Irradiated group (78 flaps) p value Type of delayed reconstruction < 0.01 One-stage 92 (46.9%) 55 (70.5%) Two-stage 104 (53.1%) 23 (29.5%) Flap type Abdomen 164 (83.7%) 66 (84.6%) 0.77 DIEP flap 159 63 SIEA flap 2 1 DIEP flap + SIEA flap 1 2 Other 2 0 Thigh 18 (9.2%) 9 (11.5%) 0.56 PAP flap 16 9 TMG flap 2 0 Buttock 12 (6.1%) 2 (2.6%) 0.36 S-GAP flap 12 1 I-GAP flap 0 1 Other 2 (1.0%) 1 (1.3%) 1 Recipient vessels Internal mammary 179 (91.3%) 68 (87.2%) 0.23 Thoracodorsal 13 (6.6%) 8 (10.3%) 0.44 Lateral thoracic 1 (0.5%) 0 (0%) Subscapular 1 (0.5%) 1 (1.3%) Unknown 2 (1.0%) 1 (1.3%) Re-anastomoses Artery 45 (23.0%) 13 (16.7%) 0.27 Vein 21 (10.7%) 9 (11.5%) 0.82 Time required for anastomoses Mean ± SD (min) 89.6 ± 44.6 82.4 ± 36.4 0.41 Unplanned reoperation (early phase) 4 (2.0%) 4 (5.1%) 0.23 Complication Total flap loss 0 (0%) 0 (0%) Partial flap loss 1 (0.5%) 2 (2.6%) Fat necrosis 5 (2.6%) 4 (5.1%) 0.48 Breast skin necrosis 0 (0%) 1 (1.3%) DIEP deep inferior epigastric artery perforator, I-GAP inferior gluteal artery perforator, PAP profunda artery perforator, SD standard deviation, S-GAP superior gluteal artery perforator, SIEA superficial inferior epigastric artery, TMG transverse musculocutaneous gracilis The results of vascular anastomosis are also listed in Table 2 . IMA/Vs were used as recipient vessels for the majority of flaps in both the nonirradiated group (179 [91.3%]) and in the irradiated group (68 [87.2%]); the difference was not significant ( p = 0.23). We found no significant differences between the two groups in the percentages of flaps subjected to intraoperative arterial reanastomosis ( p = 0.27) or venous reanastomosis ( p = 0.82). We also found no significant difference in time required for anastomoses (from vessel clamping to resumption of blood flow after anastomosis) between the two groups ( p = 0.41). Unplanned reoperations were performed within a week after reconstruction for 4 flaps (2.0%) in the nonirradiated group and 4 (5.1%) in the irradiated group; the difference was not significant ( p = 0.23). The reasons for reoperation included arterial and venous thrombosis and hematoma. No cases of total flap necrosis occurred in either group, but partial flap necrosis occurred in 1 flap (0.5%) in the nonirradiated group and 2 (2.6%) in the irradiated group. Although the numbers of complications in both groups were too small to evaluate statistically, they were similarly low. Fat necrosis as a late complication occurred in 5 flaps (2.6%) in the nonirradiated group and 4 (5.1%) of the irradiated group; the difference was not significant ( p = 0.48). In the 8 patients who received autologous tissue after implant reconstruction, including 1 who had received radiation therapy, no unplanned reoperation was required, and no complications such as flap necrosis or fat necrosis occurred. The results of the aesthetic evaluation are listed in Tables 3 and 4 . In the nonirradiated group, 98 outcomes (91.6%) were rated “very good” and “good”; in the irradiated group, 34 (75.6%) were rated “very good” and “good”; the difference between the groups was significant ( p < 0.01). On the 10-point scale, the aesthetic scores were significantly higher in the nonirradiated group (7.9 ± 1.6) than in the irradiated group (7.1 ± 1.6; p < 0.01; Table 3 ). The scores for one- and two-stage reconstruction did not differ significantly in the whole cohort ( p = 0.52), the nonirradiated group ( p = 0.37), or the irradiated group ( p = 0.36); however, in the irradiated group, two-stage reconstruction tended to be scored higher (6.9 ± 1.7) than was one-stage reconstruction (7.5 ± 1.5; p = 0.36; Table 4 ). Table 3 Aesthetic outcome: comparison of non-irradiated and irradiated groups Aesthetic outcome Non-irradiated group Irradiated group p value All (n) 107 (100%) 45 (100%) Acceptable (n) 98 (91.6%) 34 (75.6%) < 0.01 Very good 38 7 Good 60 26 Unacceptable (n) 9 (8.4%) 11 (24.4%) < 0.01 Fair 7 9 Poor 2 2 Mean score (10 points) 7.9 ± 1.6 7.1 ± 1.6 < 0.01 Table 4 Aesthetic outcome: comparison of delayed one- and two-stage reconstructions Aesthetic outcome Delayed one-stage reconstruction Delayed two-stage reconstruction p value All (n) 87 (100%) 65 (100%) Acceptable 74 (85.1%) 58 (89.2%) 0.60 Unacceptable 13 (14.9%) 7 (10.8%) Mean score (out of 10) 7.6 ± 1.6 7.7 ± 1.6 0.52 Non-irradiated group (n) 54 (100%) 53 (100%) Acceptable 51 (94.4%) 47 (88.7%) 0.32 Unacceptable 3 (5.6%) 6 (11.3%) Mean score (out of 10) 8.0 ± 1.5 7.7 ± 1.6 0.37 Irradiated group (n) 33 (100%) 12 (100%) Acceptable 23 (69.7%) 11 (91.7%) 0.24 Unacceptable 10 (30.3%) 1 (8.3%) Mean score (out of 10) 6.9 ± 1.7 7.5 ± 1.5 0.36 Representative case 1: delayed one-stage reconstruction after radiation therapy A 57-year-old woman underwent a total mastectomy and sentinel node biopsy for right-sided breast cancer (Fig. 2 , left), followed by axillary dissection, postoperative chemotherapy, radiation therapy, and hormone therapy. Her BMI was 23.7, she had smoked in the past, and she did not have hypertension or diabetes. Delayed one-stage breast reconstruction with a DIEP flap was performed 4 years and 2 months after total mastectomy. The IMA/Vs were used as the recipient vessels. The anastomosis time was 51 minutes, and neither arterial nor venous reanastomosis was required. The flap was well attached, and the postoperative breast structure was very good, with no visible difference between the right and left breasts (Fig. 2 , right). The remaining breast skin had mildly different pigmentation. In the aesthetic evaluation, the score was 9 out of 10. Representative case 2: delayed two-stage reconstruction after radiation therapy A 57-year-old woman underwent partial mastectomy and axillary dissection after preoperative chemotherapy for right-sided breast cancer (Fig. 3 , left). She also received postoperative chemotherapy, radiation therapy, and hormone therapy. Her BMI was 22.5, she had never smoked, and she had neither hypertension nor diabetes. Eight years and 9 months after breast cancer surgery, a tissue expander was inserted into her chest, and saline was injected to expand the tissue, but the tissue expansion was not sufficient (Fig. 3 , middle). Delayed two-stage breast reconstruction with a DIEP flap was performed 2 years and 2 months after tissue expander insertion. The IMA/Vs were used as the recipient vessels. The anastomosis time was 85 minutes; venous reanastomosis was required, but arterial reanastomosis was not required. No postoperative complications occurred, and the flap survived. Slight laterality in volume and projection and differences in pigmentation on the breast skin were observed (Fig. 3 , right). In the aesthetic evaluation, the score was 7.7 out of 10. Discussion Many reports have shown that the risk of complications of breast reconstruction after radiation therapy is lower when autologous tissue is used than when implants are used [ 1 – 3 ]. Patients have also been reported to be more satisfied with autologous tissue reconstruction than with implants [ 1 , 2 , 9 ]. The superiority of autologous breast reconstruction is clear for patients who have received radiation therapy, and autologous reconstruction is preferred at Yokohama City University Medical Center. Jens et al. investigated the effect of radiotherapy on delayed two-stage breast reconstruction with tissue expanders and implants. In their irradiation group, 30% of reconstructions failed (14% at the expander stage, 16% at the implant stage), and tissue expanders or implants had to be removed. They stated that prereconstruction radiotherapy was a significant predictor of reconstruction failure [ 10 ]. In patients who have received radiation therapy, delayed two-stage reconstruction is performed with a tissue expander at Yokohama City University Medical Center if the skin and subcutaneous tissue have been preserved and little skin damage is caused by irradiation. The reason is that the stretching of the remaining breast skin to reproduces the structure of the breast and inframammary fold produces a better cosmetic result than does replacement of the skin with a flap. Tadiparthi et al. reported on 65 patients, including some who had received radiation therapy, who underwent two-stage delayed reconstruction with tissue expanders and free abdominal flaps. Extrusion of tissue expanders occurred in 3 patients, all of whom had received radiation therapy; 2 of them proceeded to two-stage reconstruction [ 11 ]. Tadiparthi et al. noted that the use of anatomical tissue expanders enabled reproduction of the natural shape of the reconstructed breast with breast ptosis and a well-defined and stable inframammary fold, and they stated that the quality of the mastectomy skin flaps and the suitability for expansion must be assessed in individual patients. We carefully evaluated the condition of the skin and subcutaneous tissue, and in patients with blood flow disorders, hyperpigmentation, or thinning of the breast skin, we replaced the skin and tissue temporarily with a flap, without inserting a tissue expander. In our study, the IMA/Vs were the first choice as the recipient vessels, which had not yet been expanded at the time of breast cancer surgery. We found no significant difference between the nonirradiated and irradiated groups in the rates of anastomosis performed on the IMA/Vs. Fracol et al., who studied cases of bilateral breast reconstruction after unilateral radiation therapy, reported similar choices of anastomotic vessels [ 12 ]. In a study of delayed breast reconstruction with DIEP flaps, Shechter et al. compared postmastectomy radiotherapy alone with postmastectomy radiotherapy plus irradiation of the internal mammary nodes; they found that the rate of complications (flap loss and vascular anastomosis failure) was higher in the latter group, but the difference was not significant [ 13 ]. They noted that DIEP flap reconstruction with IMA/Vs anastomosis should be performed with caution in patients who have received radiation therapy. In our study, of the patients in whom a vessel other than the IMA/Vs was used as the recipient vessel, one had undergone partial mastectomy through a lateral incision, and the thoracodorsal vessels were selected because they were easier to approach. In other patients who had received radiation therapy, the internal mammary artery was poorly visualized on preoperative contrast material–enhanced computed tomography, and during anastomosis, the choice of vessel was changed because of extensive scarring around the IMA/Vs, vessel atrophy, or, in one case, deficiency of the internal mammary vein [ 14 ]. In patients who have received radiation therapy, as in those who have not, it is reasonable to prefer using the IMA/Vs as recipient vessels, but if they cannot be used, other options should be considered. With regard to whether irradiation affects the difficulty of anastomosis, we found no difference between the two groups in the rate of intraoperative vascular reanastomosis or in time required for anastomosis. Previous studies on breast reconstruction with abdominal flaps have shown that intraoperative vascular complications and anastomotic difficulties are more common among patients who have received radiation therapy, but these problems are not related to postoperative complications or to the success or failure of reconstruction [ 7 , 12 ]. Our study of abdominal, thigh, and buttock flaps revealed that the difficulty in establishing anastomoses in such patients is no different from that in patients who have not received radiation therapy if dissection and suturing are performed carefully. In our study, rates of early postoperative reoperation because of thrombus or hematoma did not differ significantly between the two groups. The incidences of flap necrosis and mastectomy flap necrosis as early complications were similarly low in both groups; the small number of cases precluded statistical studies. Previous reports comparing post-irradiation reconstruction and post-reconstruction irradiation groups[ 4 , 5 ], or irradiated and non-irradiated groups[ 7 , 12 ], found no differences in rates of postoperative vascular complications or early complications such as flap necrosis and mastectomy skin necrosis. We also found no significant difference between the two groups in the incidence of fat necrosis as a late complication, which was consistent with previous findings [ 8 , 12 , 15 , 16 ]. At our institution, intraoperative indocyanine green–enhanced angiography has been used since 2013 to evaluate the blood flow in the flaps, and areas that are not stained by indocyanine green are removed. The frequency of fat necrosis has decreased since the introduction of this technique. The irradiated skin may stiffen as a result of fibrosis and have poor extensibility; the grafted flap could therefore be compressed by the hard skin and cause a blood flow disorder in the flap. Replacing the irradiated skin with the grafted flap may reduce the risk of thrombus formation and flap necrosis caused by vascular compression. In this study, the percentage of patients who underwent chemotherapy was higher in the irradiated group, although the difference was not significant. With regard to the effect of prereconstruction chemotherapy on breast reconstruction, some reports showed no difference in the frequency of complications [ 17 , 18 ], and we also found that treatment with or without chemotherapy does not seem to affect the results of reconstruction. Nakazono et al. reported that internal mammary lymph nodes were identified more frequently in patients with artificial materials than in patients with autologous materials and, in most cases, at the third intercostal space [ 19 ]. In two-stage reconstruction with tissue expanders, the lymph nodes near the IMA/Vs where the vascular anastomosis is performed might be swollen, but this did not affect the anastomosis in either the irradiated or nonirradiated group. Although methods for evaluating aesthetic outcome after breast reconstruction have not been standardized, a 4- or 5-point categorical scale is often used [ 20 ]. In breast reconstruction with free abdominal flaps, one report indicated that irradiation has a negative effect on aesthetic outcome [ 21 ], whereas another indicated no difference in aesthetic outcome with or without irradiation [ 6 ]. According to a study of both implant-based and autologous reconstruction, aesthetic outcome does not differ by the sequence of reconstruction and radiotherapy [ 22 ]. The novelty of our study is that we evaluated the aesthetic outcome of patients who underwent free autologous reconstruction, with abdominal and nonabdominal flaps, after irradiation. In comparing the two groups, we found that both the percentages of “very good”/“good” scores and the mean scores were significantly higher in the nonirradiated group, which indicated better aesthetic outcomes. Furthermore, in comparing one- and two-stage reconstruction, we found that cosmetic scores were higher for two-stage reconstruction than for one-stage reconstruction in the irradiated group, although the difference was not statistically significant. The irradiated group had a higher percentage of patients who underwent one-stage reconstruction in which the chest wall skin was replaced with a flap without insertion of tissue expanders because remaining chest tissue was insufficient and extensibility was poor, which may have contributed to lower scores in that group than in the nonirradiated group. In addition, as in representative case 2, some patients did not obtain sufficient expansion even with tissue expanders, which resulted in a left–right difference in appearance. Furthermore, a higher percentage of patients in the irradiated group underwent axillary dissection, but in some cases, the lack of axillary volume was not adequately compensated for by flap tissue. In this study, the aesthetic evaluation accounted only for structure but not skin tone, texture, or scarring; we speculate that some of those factors may partly explain why appearance in the irradiated group was inferior to that in the nonirradiated group. Limitations Although the radiation field and dose were not investigated in this study, it is possible that location of the recipient vessels inside or outside the radiation field and the dose of radiation may affect the outcome of the reconstructive surgery. In addition, the aesthetic evaluation reflected only the health care provider’s opinion; patient satisfaction was not investigated, and it may differ from the health care provider’s opinion. Conclusions We compared results of delayed free flap breast reconstruction in patients who had and had not received earlier radiation therapy, and we examined the difficulty and success or failure of vascular anastomoses, postoperative complications, and aesthetic outcomes. Breast reconstruction with free flaps, including nonabdominal flaps, was performed safely in the irradiated group, but the aesthetic results were slightly inferior to those in the nonirradiated group. In the irradiated group, two-stage reconstruction tended to produce better aesthetic results than did one-stage reconstruction, but one-stage reconstruction is recommended when irradiation causes changes in the chest skin. Declarations Compliance with ethical standards Conflict of Interest Disclosure All the authors declare no conflicts of interest. Ethical approval This is a joint research project by the Department of Plastic and Reconstructive Surgery, Yokohama City University Medical Center, and the Department of Plastic, Reconstructive and Aesthetic Surgery of the University of Toyama, approved by the Ethics Committee of the University of Toyama (Study No. 2022177). All procedures performed in this study were in accordance with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent Because this study was retrospective and observational, formal consent was not required. Instead of obtaining informed consent from patients, information about the research was disclosed to research subjects and others, and the opportunity was guaranteed for research subjects and others to refuse to allow the research to be conducted or continued. References Jagsi R, Momoh AO, Qi J, Hamill JB, Billig J, Kim HM, et al. 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Comparison of immediate versus delayed DIEP flap reconstruction in women who require postmastectomy radiotherapy. Plast Reconstr Surg. 2018;142:594–605. 10.1097/PRS.0000000000004676 . Fosnot J, Fischer JP, Smartt JM Jr, Low DW, Kovach SJ, Wu LC, et al. Does previous chest wall irradiation increase vascular complications in free autologous breast reconstruction? Plast Reconstr Surg. 2011;127:496–504. 10.1097/PRS.0b013e3181fed560 . Mull AB, Qureshi AA, Zubovic E, Rao YJ, Zoberi I, Sharma K, et al. Impact of time interval between radiation and free autologous breast reconstruction. J Reconstr Microsurg. 2017;33:130–6. 10.1055/s-0036-1593806 . Duraes EFR, Schwarz GS, de Sousa JB, Duraes LC, Morisada M, Baker T, et al. Factors influencing the aesthetic outcome and quality of life after breast reconstruction: A cross-sectional study. Ann Plast Surg. 2020;84:494–506. 10.1097/SAP.0000000000002157 . Hoejvig JH, Pedersen NJ, Gramkow CS, Bredgaard R, Kroman N, Bonde CT. Delayed two-stage breast reconstruction: the impact of radiotherapy. J Plast Reconstr Aesthet Surg. 2019;72:1763–8. 10.1016/j.bjps.2019.06.003 . Tadiparthi S, Alrawi M, Collis N. Two-stage delayed breast reconstruction with an expander and free abdominal tissue transfer: outcomes of 65 consecutive cases by a single surgeon. J Plast Reconstr Aesthet Surg. 2011;64:1608–12. 10.1016/j.bjps.2011.06.046 . Fracol ME, Basta MN, Nelson JA, Fischer JP, Wu LC, Serletti JM, 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. 10.1097/SAP.0000000000000545 . Shechter S, Arad E, Inbal A, Friedman O, Gur E, Barnea Y. DIEP flap breast reconstruction complication rate in previously irradiated internal mammary nodes. J Reconstr Microsurg. 2018;34:399–403. 10.1055/s-0038-1625986 . Muto M, Satake T, Masuda Y, Kobayashi S, Tamura S, Kobayashi S, et al. Absent internal mammary recipient vein in autologous breast reconstruction. Plast Reconstr Surg Glob Open. 2020;8:e2660. 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. 10.1055/s-0040-1716846 . Kelley BP, Ahmed R, Kidwell KM, Kozlow JH, Chung KC, Momoh AO. A systematic review of morbidity associated with autologous breast reconstruction before and after exposure to radiotherapy: are current practices ideal? Ann Surg Oncol. 2014;21:1732–8. 10.1245/s10434-014-3494-z . Beugels J, Meijvogel JLW, Tuinder SMH, Tjan-Heijnen VCG, Heuts EM, Piatkowski A, et al. The influence of neoadjuvant chemotherapy on complications of immediate DIEP flap breast reconstructions. Breast Cancer Res Treat. 2019;176:367–75. 10.1007/s10549-019-05241-9 . Narui K, Ishikawa T, Satake T, Adachi S, Yamada A, Shimada K, et al. Outcomes of immediate perforator flap reconstruction after skin-sparing mastectomy following neoadjuvant chemotherapy. Eur J Surg Oncol. 2015;41:94–9. 10.1016/j.ejso.2014.09.001 . Nakazono M, Satake T, Tsunoda Y, Muto M, Hirotomi K, Narui K, et al. Internal mammary lymph node biopsy during delayed free flap breast reconstruction: case series and review of the literature. Eur J Plast Surg. 2022;45:277–84. 10.1007/s00238-021-01879-1 . El-Sabawi B, Ho AL, Sosin M, Patel KM. Patient-centered outcomes of breast reconstruction in the setting of post-mastectomy radiotherapy: A comprehensive review of the literature. J Plast Reconstr Aesthet Surg. 2017;70:768–80. 10.1016/j.bjps.2017.02.015 . Huis in ’t Veld, Long EA, Sue C, Chattopadhyay GR, Lee A. Analysis of aesthetic outcomes and patient satisfaction after delayed-immediate autologous breast reconstruction. Ann Plast Surg. 2018;80:303–7. 10.1097/SAP.0000000000001418 . Anderson PR, Hanlon AL, Fowble BL, McNeeley SW, Freedman GM. Low complication rates are achievable after postmastectomy breast reconstruction and radiation therapy. Int J Radiat Oncol Biol Phys. 2004;59:1080–7. 10.1016/j.ijrobp.2003.12.036 . Cite Share Download PDF Status: Published Journal Publication published 12 Jun, 2024 Read the published version in Breast Cancer → Version 1 posted Reviewers agreed at journal 08 Jan, 2024 Reviewers invited by journal 04 Jan, 2024 Editor assigned by journal 29 Dec, 2023 First submitted to journal 29 Dec, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3822676","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":265322023,"identity":"43b3863f-96fb-4cbf-953a-f0e244cfc348","order_by":0,"name":"Kimie Miyazawa","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABMElEQVRIie2RMUvDQBiGvxJIBC9mvVCofyFQcAr4V3LLucRScHHokBBIl0DXdPQfBApdTTiIi+Ka4qIUsglxEByk+AVTHLxqR5F7OLiXu3tC3jsAheIPQjWAHMAllhHl7YKngxZo3a73g8IHdlJ6ndL7RfmcxNCpfKc79aVIsaeHLG+As6DyXxfkEkZH1lW4HmOwAOpHidLXzKxIwWVh8rx8ILdwodOnaJhisAM4cyTKABVhbjiLjPPlah4Di2kR900MWQ6c7lLeQbAY/Ho132wVDNc7lPbHRFufHPh69RKgYoWoYMhArtgRdknwkikpT6qmpNilh11KylIh70Lv7xbNGz7l6U1UV97EHR3PRLEeT1w2myZcdmPfPoHD64JG+B5Gi5Vvk1HuqSgUCsX/5gMmR2jNpMaH5QAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0009-0003-9559-7654","institution":"Nagano Matsushiro General Hospital","correspondingAuthor":true,"prefix":"","firstName":"Kimie","middleName":"","lastName":"Miyazawa","suffix":""},{"id":265322024,"identity":"e25adc96-78ae-4b0b-a3f3-6210442b763c","order_by":1,"name":"Toshihiko Satake","email":"","orcid":"https://orcid.org/0000-0002-4122-628X","institution":"University of Toyama, Faculty of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Toshihiko","middleName":"","lastName":"Satake","suffix":""},{"id":265322025,"identity":"c9b3f091-3cc9-4810-bb61-b38be9462600","order_by":2,"name":"Mayu Muto","email":"","orcid":"","institution":"Lala Breast Reconstruction Clinic Yokohama","correspondingAuthor":false,"prefix":"","firstName":"Mayu","middleName":"","lastName":"Muto","suffix":""},{"id":265322026,"identity":"34ebbcfa-5257-4ba1-bc57-d295b6002482","order_by":3,"name":"Yui Tsunoda","email":"","orcid":"","institution":"Yokohama City University Medical Center: Yokohama Shiritsu Daigaku Fuzoku Shimin Sogo Iryo Center","correspondingAuthor":false,"prefix":"","firstName":"Yui","middleName":"","lastName":"Tsunoda","suffix":""},{"id":265322027,"identity":"e507aee0-a00e-4ff7-b161-038546bae31c","order_by":4,"name":"Tomoyuki Koike","email":"","orcid":"","institution":"Saitama Hand and Microsurgery Institute","correspondingAuthor":false,"prefix":"","firstName":"Tomoyuki","middleName":"","lastName":"Koike","suffix":""},{"id":265322028,"identity":"a3227508-72dd-47a5-8c35-a048c140c66d","order_by":5,"name":"Kazutaka Narui","email":"","orcid":"","institution":"Yokohama City University Medical Center: Yokohama Shiritsu Daigaku Fuzoku Shimin Sogo Iryo Center","correspondingAuthor":false,"prefix":"","firstName":"Kazutaka","middleName":"","lastName":"Narui","suffix":""},{"id":265322029,"identity":"cddeceb3-e402-40d0-8c70-4da2bc7c1a54","order_by":6,"name":"Ryouhei Katsuragi","email":"","orcid":"","institution":"University of Toyama: Toyama Daigaku","correspondingAuthor":false,"prefix":"","firstName":"Ryouhei","middleName":"","lastName":"Katsuragi","suffix":""},{"id":265322030,"identity":"5b1b7078-a9ef-40b9-95f3-c0c91e808a66","order_by":7,"name":"Satoshi Onoda","email":"","orcid":"","institution":"University of Toyama: Toyama Daigaku","correspondingAuthor":false,"prefix":"","firstName":"Satoshi","middleName":"","lastName":"Onoda","suffix":""},{"id":265322031,"identity":"a62ff00b-477b-45df-8546-8b7d6a1c4042","order_by":8,"name":"Takashi Ishikawa","email":"","orcid":"","institution":"Tokyo Medical University: Tokyo Ika Daigaku","correspondingAuthor":false,"prefix":"","firstName":"Takashi","middleName":"","lastName":"Ishikawa","suffix":""}],"badges":[],"createdAt":"2023-12-29 23:56:52","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3822676/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3822676/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s12282-024-01593-3","type":"published","date":"2024-06-12T14:49:41+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":49325475,"identity":"e37cd0cc-f388-48e6-b25e-c4ac4f6f1401","added_by":"auto","created_at":"2024-01-08 17:25:28","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":383291,"visible":true,"origin":"","legend":"\u003cp\u003eAlgorithm of reconstruction procedures.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3822676/v1/f9047a86c2e207f49fb3723a.jpeg"},{"id":49325474,"identity":"921038d4-bfa5-4b04-9644-bb2c24092b65","added_by":"auto","created_at":"2024-01-08 17:25:28","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":114486,"visible":true,"origin":"","legend":"\u003cp\u003eDelayed one-stage reconstruction after radiation therapy\u003c/p\u003e\n\u003cp\u003e(Left) Photograph taken after radiation therapy and before delayed one-stage reconstruction. (Right) Photograph 14 months after breast reconstruction with a deep inferior epigastric artery perforator (DIEP) flap.\u003c/p\u003e","description":"","filename":"F2.png","url":"https://assets-eu.researchsquare.com/files/rs-3822676/v1/e4200318e5cfbf6daabcf67b.png"},{"id":49325476,"identity":"8d0fe34d-9fd4-44d7-8df8-c000a2965038","added_by":"auto","created_at":"2024-01-08 17:25:28","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":245728,"visible":true,"origin":"","legend":"\u003cp\u003eDelayed two-stage reconstruction after radiation therapy\u003c/p\u003e\n\u003cp\u003eDelayed two-stage reconstruction after radiation therapy. (Left) Photograph taken after radiation therapy and beforetwo-stage reconstruction case. (Middle) Photograph taken 26 months after tissue expander insertion surgery. Saline was injected into the tissue expander, but the skin was not sufficiently expanded. (Right) Photograph taken 2 years and 5 months after breast reconstruction with a deep inferior epigastric artery perforator (DIEP) flap.\u003c/p\u003e","description":"","filename":"F3.png","url":"https://assets-eu.researchsquare.com/files/rs-3822676/v1/11af2af9fd3b382cf0080f52.png"},{"id":58822100,"identity":"3ce1d930-21eb-41bf-a0e9-51624a405519","added_by":"auto","created_at":"2024-06-21 16:31:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1540830,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3822676/v1/02d6ce8a-8994-4259-8517-f558f1ee3fe1.pdf"}],"financialInterests":"","formattedTitle":"Delayed breast reconstruction with autologous free flap after radiation therapy: Vascular complications and aesthetic outcomes","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePatients with breast cancer are concerned not only about curing the disease but also about their aesthetic appearance after treatment. Breast reconstruction is performed widely, and a growing number of patients who have undergone radiation therapy can benefit from breast reconstruction; however, the safety and outcome of this procedure are controversial because the effects of irradiation on the skin and blood vessels must be considered.\u003c/p\u003e \u003cp\u003eBreast reconstruction can be accomplished with artificial materials such as implants or with the patient\u0026rsquo;s own tissues, such as skin, fat, and muscle; in the case of muscle, abdominal tissue is widely used. In previous studies, breast reconstruction after radiation therapy has been evaluated according to the materials used (prosthetic or autologous) [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] and the timing (immediately after cancer surgery or delayed) [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Other reports have focused on the intraoperative complications and the success or failure of reconstruction with abdominal flaps, such as free flaps from the transverse rectus abdominus muscle or from the deep inferior epigastric perforator (DIEP flaps) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Few investigations have focused on breast reconstructions with other flaps. In addition, the aesthetic appearance of breasts reconstructed after irradiation has not been widely discussed.\u003c/p\u003e \u003cp\u003eIn this study, we examined the surgical results of patients who underwent delayed breast reconstruction with free flaps from the abdomen, thighs, and buttocks after radiation therapy, including aspects of intraoperative vascular anastomosis, postoperative complications, and aesthetic results.\u003c/p\u003e"},{"header":"Patients and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eThis retrospective observational study included data from 256 patients who underwent delayed breast reconstruction with free autologous single flaps at the Department of Plastic and Reconstructive Surgery, Yokohama City University Medical Center, Yokohama, Japan, between 2012 and 2019.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSurgical technique\u003c/h2\u003e \u003cp\u003eDelayed breast reconstruction is performed at least 1 year after mastectomy. In delayed one-stage breast reconstruction, autologous tissue transfer is performed in a single operation without insertion of a tissue expander. In delayed two-stage breast reconstruction, a tissue expander is placed at least 1 year after mastectomy; after the tissue has expanded sufficiently, the tissue expander is removed, and autologous tissue is transferred simultaneously for breast reconstruction. In cases of bilateral reconstruction, only the delayed reconstructed side was evaluated in this study.\u003c/p\u003e \u003cp\u003eAt Yokohama City University Medical Center, in cases of delayed breast reconstruction, a tissue expander is placed into the chest, and two-stage reconstruction is performed if the skin and subcutaneous tissue of the breast are preserved and skin extensibility is adequate. In a patient who has received radiation therapy, a tissue expander is also used before two-stage reconstruction if the patient has sufficient breast tissue and little radiation-related skin damage. In patients with blood flow disorders, hyperpigmentation, or thinning and little extensibility of the breast skin, the breast skin is replaced temporarily with a skin flap without insertion of a tissue expander in one-stage reconstruction (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Both one- and two-stage reconstructive procedures are performed at least 1 year after completion of radiation therapy.\u003c/p\u003e \u003cp\u003eWith regard to the choice of flaps, the policy at Yokohama City University Medical Center is not to use abdominal flaps for patients who may become pregnant and give birth. The reason is that even if the rectus abdominis muscle and fascia are preserved and repaired, the fragility of the abdominal wall might adversely affect pregnancy and delivery and lead to subsequent complications. In such cases, flaps from the thighs or buttocks are used for breast reconstruction. Because these flaps have less tissue volume than do abdominal flaps, two flaps are combined when necessary. In this study, however, patients with two-flap reconstructions were excluded; only patients who underwent single-flap reconstruction on either side or both sides were included. When flaps from the thighs or buttocks are used, tissue expanders are implanted as much as possible for two-stage reconstruction to avoid extensive skin islands, which result because the skin color of the flaps differs from that of the chest. Alternatively, such flaps are selected when nipple-sparing mastectomy leaves residual chest skin.\u003c/p\u003e \u003cp\u003eInternal mammary arteries or veins (IMA/Vs) are the first choice of vessels for anastomosis in breast reconstruction; these vessels have not been expanded at the time of breast cancer surgery. Other vessels are chosen only if IMA/Vs cannot be used for anastomoses.\u003c/p\u003e \u003cp\u003eAll procedure were performed by two plastic surgeons (T.S.and M.M.) as operating surgeons or teaching assistants.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eIn this investigation, we studied medical and surgical records and photographs. We documented each patient\u0026rsquo;s age, body mass index (BMI), medical history (e.g., hypertension, diabetes), smoking history, surgical procedure, and preoperative and postoperative therapy for breast cancer. Furthermore, we documented the type of reconstruction, recipient vessels, arterial and venous reanastomosis, time required for anastomosis (ischemic time), and early and late postoperative complications.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eAesthetic evaluation\u003c/h2\u003e \u003cp\u003eThe aesthetic appearance of reconstructed breasts was evaluated in 152 patients more than 6 months after the last revision surgery. The 45 patients who received radiation therapy on one or both sides and who underwent bilateral reconstruction were considered the \u0026ldquo;irradiated group\u0026rdquo;; 107 patients who did not receive radiation treatment before breast reconstruction were considered the \u0026ldquo;nonirradiated group.\u0026rdquo; Revision surgery included adjustment of the volume and structure of the reconstructed breast, nipple\u0026ndash;areola reconstruction, and weight reduction or lifting of the healthy breast. Symmetry and structure of breast projection, breast volume, d\u0026eacute;collet\u0026eacute;, cleavage, and the inframammary line were scored 0\u0026ndash;2, whereby 2 represented very good form with almost no left\u0026ndash;right difference, 1 represented relatively good form with a slight left\u0026ndash;right difference, and 0 represented a considerable left\u0026ndash;right difference and noticeable deformation. Nipple\u0026ndash;areola structure and position were not included in this evaluation because some patients had not completed nipple\u0026ndash;areola reconstruction. The evaluation was performed by three certified plastic surgeons, none of whom were the primary surgeons, and the average of the three scores was calculated for each item; the highest possible total score was 10. The evaluators were unaware of patients\u0026rsquo; radiation history or type of reconstruction. A total score of \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\ge\\)\u003c/span\u003e\u003c/span\u003e9 represented a very good aesthetic outcome; scores of \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\ge\\)\u003c/span\u003e\u003c/span\u003e6 to \u0026lt;9, good outcomes; scores of \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\ge\\)\u003c/span\u003e\u003c/span\u003e4 to \u0026lt;6, fair outcomes; and scores of \u0026lt;4, poor outcomes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eFor statistical analysis, we used IBM SPSS Statistics for Windows, Version 28.0 (IBM Corporation, Armonk, NY, USA; released 2021). To compare the nonirradiated and irradiated groups, we used Student\u0026rsquo;s \u003cem\u003et\u003c/em\u003e test and the Mann\u0026ndash;Whitney \u003cem\u003eU\u003c/em\u003e test for continuous variables and the chi-square test and Fisher\u0026rsquo;s exact test for categorical variables. We considered \u003cem\u003ep\u003c/em\u003e values of \u0026lt;\u0026thinsp;0.05 statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe 256 patients in this study received a total of 274 flaps, of which 196 were implanted in patients who did not radiotherapy and 78 were implanted in patients who received radiotherapy before breast reconstruction.. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e lists the ages, BMIs, comorbidities, and cancer treatment in each group. We found no significant differences in age (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.32), BMI (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.56), prevalence of hypertension (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.15), prevalence of diabetes (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.63), or smoking status (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.58) between the two groups. Among patients in the nonirradiated group, 159 flaps (81.1%) were implanted after total mastectomy and 2 flaps (1.0%) after partial mastectomy; among patients in the irradiated group, 52 flaps (66.7%) were implanted after total mastectomy and 15 flaps (19.2%) after partial mastectomy. The rate of total mastectomy was significantly higher in the nonirradiated group than in the irradiated group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.01), whereas the rate of partial mastectomy was higher in the irradiated group than in the nonirradiated group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). We found no significant difference in the rates of nipple-sparing mastectomy between the two groups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.99) or those of skin-sparing mastectomy (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.41). The rate of axillary lymph node dissection was significantly higher in the irradiated group than in the nonirradiated group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). With regard to breast cancer treatment before reconstruction, the percentage of patients who received chemotherapy was higher in the irradiated group, but the difference was not statistically significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.13).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient characteristics and oncologic data\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-irradiated group (196 flaps)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIrradiated group (78 flaps)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51.6\u0026thinsp;\u0026plusmn;\u0026thinsp;7.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50.6\u0026thinsp;\u0026plusmn;\u0026thinsp;7.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34\u0026ndash;70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34\u0026ndash;69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\ge\\)\u003c/span\u003e\u003c/span\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (6.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (3.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBody mass index (kg/m\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.1\u0026ndash;35.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.3\u0026ndash;32.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\ge\\)\u003c/span\u003e\u003c/span\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (11.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15(19.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComorbidities\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (12.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(6.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePast or current smoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62 (31.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (28.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of mastectomy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRadical mastectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal mastectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e159 (81.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52 (66.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkin-sparing mastectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (7.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (3.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNipple-sparing mastectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (10.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (10.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePartial mastectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (19.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLymph node treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAxillary lymph node dissection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81 (41.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 (64.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSentinel node biopsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e109 (55.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (28.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (3.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (7.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCombination therapy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChemotherapy (neoadjuvant, adjuvant, or both)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e98 (50.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47 (60.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHormonal therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e157 (80.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62 (79.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eSD\u003c/em\u003e standard deviation\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOf the 256 patients, 234 underwent unilateral reconstruction and 22 underwent bilateral reconstruction. Of the latter, 18 patients underwent delayed reconstruction on both sides, and 4 patients underwent reconstruction immediately after surgery on one side and delayed reconstruction on the other side. In 8 of the 234 patients, autologous tissue was used in reconstruction because of complications after implant reconstruction; 1 of those 8 had received radiotherapy. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e lists flap types used in reconstruction. One-stage reconstruction was performed significantly more often in the irradiated group (70.5%) than in the nonirradiated group (46.9%; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). The flaps used most commonly for reconstruction were abdominal flaps, in 164 patients (83.7%) in the nonirradiated group and in 66 patients (84.6%) in the irradiated group. We found no significant difference in the proportion of abdominal flap, thigh flap, and buttock flap between the two groups.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFlap type, vascular anastomoses, and complications\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAspects of treatment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-irradiated group (196 flaps)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIrradiated group (78 flaps)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of delayed reconstruction\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOne-stage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92 (46.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55 (70.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTwo-stage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e104 (53.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (29.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFlap type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAbdomen\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e164 (83.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66 (84.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDIEP flap\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSIEA flap\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDIEP flap\u0026thinsp;+\u0026thinsp;SIEA flap\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eThigh\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (9.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (11.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePAP flap\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTMG flap\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eButtock\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (6.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eS-GAP flap\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI-GAP flap\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOther\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRecipient vessels\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternal mammary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e179 (91.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68 (87.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThoracodorsal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (6.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (10.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.44\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLateral thoracic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubscapular\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRe-anastomoses\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArtery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (23.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVein\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (10.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (11.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTime required for anastomoses\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e89.6\u0026thinsp;\u0026plusmn;\u0026thinsp;44.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82.4\u0026thinsp;\u0026plusmn;\u0026thinsp;36.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnplanned reoperation (early phase)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (2.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (5.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComplication\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal flap loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePartial flap loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFat necrosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (2.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (5.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreast skin necrosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eDIEP\u003c/em\u003e deep inferior epigastric artery perforator, \u003cem\u003eI-GAP\u003c/em\u003e inferior gluteal artery perforator, \u003cem\u003ePAP\u003c/em\u003e profunda artery perforator, \u003cem\u003eSD\u003c/em\u003e standard deviation, \u003cem\u003eS-GAP\u003c/em\u003e superior gluteal artery perforator, \u003cem\u003eSIEA\u003c/em\u003e superficial inferior epigastric artery, \u003cem\u003eTMG\u003c/em\u003e transverse musculocutaneous gracilis\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe results of vascular anastomosis are also listed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. IMA/Vs were used as recipient vessels for the majority of flaps in both the nonirradiated group (179 [91.3%]) and in the irradiated group (68 [87.2%]); the difference was not significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.23). We found no significant differences between the two groups in the percentages of flaps subjected to intraoperative arterial reanastomosis (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.27) or venous reanastomosis (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.82). We also found no significant difference in time required for anastomoses (from vessel clamping to resumption of blood flow after anastomosis) between the two groups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.41). Unplanned reoperations were performed within a week after reconstruction for 4 flaps (2.0%) in the nonirradiated group and 4 (5.1%) in the irradiated group; the difference was not significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.23). The reasons for reoperation included arterial and venous thrombosis and hematoma. No cases of total flap necrosis occurred in either group, but partial flap necrosis occurred in 1 flap (0.5%) in the nonirradiated group and 2 (2.6%) in the irradiated group. Although the numbers of complications in both groups were too small to evaluate statistically, they were similarly low. Fat necrosis as a late complication occurred in 5 flaps (2.6%) in the nonirradiated group and 4 (5.1%) of the irradiated group; the difference was not significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.48). In the 8 patients who received autologous tissue after implant reconstruction, including 1 who had received radiation therapy, no unplanned reoperation was required, and no complications such as flap necrosis or fat necrosis occurred.\u003c/p\u003e \u003cp\u003eThe results of the aesthetic evaluation are listed in Tables\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. In the nonirradiated group, 98 outcomes (91.6%) were rated \u0026ldquo;very good\u0026rdquo; and \u0026ldquo;good\u0026rdquo;; in the irradiated group, 34 (75.6%) were rated \u0026ldquo;very good\u0026rdquo; and \u0026ldquo;good\u0026rdquo;; the difference between the groups was significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). On the 10-point scale, the aesthetic scores were significantly higher in the nonirradiated group (7.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6) than in the irradiated group (7.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01; Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The scores for one- and two-stage reconstruction did not differ significantly in the whole cohort (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.52), the nonirradiated group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.37), or the irradiated group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.36); however, in the irradiated group, two-stage reconstruction tended to be scored higher (6.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7) than was one-stage reconstruction (7.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.36; Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAesthetic outcome: comparison of non-irradiated and irradiated groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAesthetic outcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-irradiated group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIrradiated group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAll (n)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e107 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAcceptable (n)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e98 (91.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (75.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery good\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUnacceptable (n)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (8.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (24.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMean score (10 points)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAesthetic outcome: comparison of delayed one- and two-stage reconstructions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAesthetic outcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDelayed one-stage reconstruction\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDelayed two-stage reconstruction\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAll (n)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcceptable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74 (85.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58 (89.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnacceptable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (14.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (10.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean score (out of 10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNon-irradiated group (n)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcceptable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51 (94.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47 (88.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnacceptable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (5.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (11.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean score (out of 10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIrradiated group (n)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcceptable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (69.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (91.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnacceptable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (30.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean score (out of 10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eRepresentative case 1: delayed one-stage reconstruction after radiation therapy\u003c/h2\u003e \u003cp\u003eA 57-year-old woman underwent a total mastectomy and sentinel node biopsy for right-sided breast cancer (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, left), followed by axillary dissection, postoperative chemotherapy, radiation therapy, and hormone therapy. Her BMI was 23.7, she had smoked in the past, and she did not have hypertension or diabetes. Delayed one-stage breast reconstruction with a DIEP flap was performed 4 years and 2 months after total mastectomy. The IMA/Vs were used as the recipient vessels. The anastomosis time was 51 minutes, and neither arterial nor venous reanastomosis was required. The flap was well attached, and the postoperative breast structure was very good, with no visible difference between the right and left breasts (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, right). The remaining breast skin had mildly different pigmentation. In the aesthetic evaluation, the score was 9 out of 10.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eRepresentative case 2: delayed two-stage reconstruction after radiation therapy\u003c/h2\u003e \u003cp\u003eA 57-year-old woman underwent partial mastectomy and axillary dissection after preoperative chemotherapy for right-sided breast cancer (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, left). She also received postoperative chemotherapy, radiation therapy, and hormone therapy. Her BMI was 22.5, she had never smoked, and she had neither hypertension nor diabetes. Eight years and 9 months after breast cancer surgery, a tissue expander was inserted into her chest, and saline was injected to expand the tissue, but the tissue expansion was not sufficient (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, middle). Delayed two-stage breast reconstruction with a DIEP flap was performed 2 years and 2 months after tissue expander insertion. The IMA/Vs were used as the recipient vessels. The anastomosis time was 85 minutes; venous reanastomosis was required, but arterial reanastomosis was not required. No postoperative complications occurred, and the flap survived. Slight laterality in volume and projection and differences in pigmentation on the breast skin were observed (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, right). In the aesthetic evaluation, the score was 7.7 out of 10.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eMany reports have shown that the risk of complications of breast reconstruction after radiation therapy is lower when autologous tissue is used than when implants are used [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Patients have also been reported to be more satisfied with autologous tissue reconstruction than with implants [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The superiority of autologous breast reconstruction is clear for patients who have received radiation therapy, and autologous reconstruction is preferred at Yokohama City University Medical Center.\u003c/p\u003e \u003cp\u003eJens et al. investigated the effect of radiotherapy on delayed two-stage breast reconstruction with tissue expanders and implants. In their irradiation group, 30% of reconstructions failed (14% at the expander stage, 16% at the implant stage), and tissue expanders or implants had to be removed. They stated that prereconstruction radiotherapy was a significant predictor of reconstruction failure [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn patients who have received radiation therapy, delayed two-stage reconstruction is performed with a tissue expander at Yokohama City University Medical Center if the skin and subcutaneous tissue have been preserved and little skin damage is caused by irradiation. The reason is that the stretching of the remaining breast skin to reproduces the structure of the breast and inframammary fold produces a better cosmetic result than does replacement of the skin with a flap.\u003c/p\u003e \u003cp\u003eTadiparthi et al. reported on 65 patients, including some who had received radiation therapy, who underwent two-stage delayed reconstruction with tissue expanders and free abdominal flaps. Extrusion of tissue expanders occurred in 3 patients, all of whom had received radiation therapy; 2 of them proceeded to two-stage reconstruction [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Tadiparthi et al. noted that the use of anatomical tissue expanders enabled reproduction of the natural shape of the reconstructed breast with breast ptosis and a well-defined and stable inframammary fold, and they stated that the quality of the mastectomy skin flaps and the suitability for expansion must be assessed in individual patients. We carefully evaluated the condition of the skin and subcutaneous tissue, and in patients with blood flow disorders, hyperpigmentation, or thinning of the breast skin, we replaced the skin and tissue temporarily with a flap, without inserting a tissue expander.\u003c/p\u003e \u003cp\u003eIn our study, the IMA/Vs were the first choice as the recipient vessels, which had not yet been expanded at the time of breast cancer surgery. We found no significant difference between the nonirradiated and irradiated groups in the rates of anastomosis performed on the IMA/Vs. Fracol et al., who studied cases of bilateral breast reconstruction after unilateral radiation therapy, reported similar choices of anastomotic vessels [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In a study of delayed breast reconstruction with DIEP flaps, Shechter et al. compared postmastectomy radiotherapy alone with postmastectomy radiotherapy plus irradiation of the internal mammary nodes; they found that the rate of complications (flap loss and vascular anastomosis failure) was higher in the latter group, but the difference was not significant [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. They noted that DIEP flap reconstruction with IMA/Vs anastomosis should be performed with caution in patients who have received radiation therapy. In our study, of the patients in whom a vessel other than the IMA/Vs was used as the recipient vessel, one had undergone partial mastectomy through a lateral incision, and the thoracodorsal vessels were selected because they were easier to approach. In other patients who had received radiation therapy, the internal mammary artery was poorly visualized on preoperative contrast material\u0026ndash;enhanced computed tomography, and during anastomosis, the choice of vessel was changed because of extensive scarring around the IMA/Vs, vessel atrophy, or, in one case, deficiency of the internal mammary vein [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In patients who have received radiation therapy, as in those who have not, it is reasonable to prefer using the IMA/Vs as recipient vessels, but if they cannot be used, other options should be considered.\u003c/p\u003e \u003cp\u003eWith regard to whether irradiation affects the difficulty of anastomosis, we found no difference between the two groups in the rate of intraoperative vascular reanastomosis or in time required for anastomosis. Previous studies on breast reconstruction with abdominal flaps have shown that intraoperative vascular complications and anastomotic difficulties are more common among patients who have received radiation therapy, but these problems are not related to postoperative complications or to the success or failure of reconstruction [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Our study of abdominal, thigh, and buttock flaps revealed that the difficulty in establishing anastomoses in such patients is no different from that in patients who have not received radiation therapy if dissection and suturing are performed carefully.\u003c/p\u003e \u003cp\u003eIn our study, rates of early postoperative reoperation because of thrombus or hematoma did not differ significantly between the two groups. The incidences of flap necrosis and mastectomy flap necrosis as early complications were similarly low in both groups; the small number of cases precluded statistical studies. Previous reports comparing post-irradiation reconstruction and post-reconstruction irradiation groups[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], or irradiated and non-irradiated groups[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], found no differences in rates of postoperative vascular complications or early complications such as flap necrosis and mastectomy skin necrosis. We also found no significant difference between the two groups in the incidence of fat necrosis as a late complication, which was consistent with previous findings [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. At our institution, intraoperative indocyanine green\u0026ndash;enhanced angiography has been used since 2013 to evaluate the blood flow in the flaps, and areas that are not stained by indocyanine green are removed. The frequency of fat necrosis has decreased since the introduction of this technique. The irradiated skin may stiffen as a result of fibrosis and have poor extensibility; the grafted flap could therefore be compressed by the hard skin and cause a blood flow disorder in the flap. Replacing the irradiated skin with the grafted flap may reduce the risk of thrombus formation and flap necrosis caused by vascular compression.\u003c/p\u003e \u003cp\u003eIn this study, the percentage of patients who underwent chemotherapy was higher in the irradiated group, although the difference was not significant. With regard to the effect of prereconstruction chemotherapy on breast reconstruction, some reports showed no difference in the frequency of complications [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], and we also found that treatment with or without chemotherapy does not seem to affect the results of reconstruction.\u003c/p\u003e \u003cp\u003eNakazono et al. reported that internal mammary lymph nodes were identified more frequently in patients with artificial materials than in patients with autologous materials and, in most cases, at the third intercostal space [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In two-stage reconstruction with tissue expanders, the lymph nodes near the IMA/Vs where the vascular anastomosis is performed might be swollen, but this did not affect the anastomosis in either the irradiated or nonirradiated group.\u003c/p\u003e \u003cp\u003eAlthough methods for evaluating aesthetic outcome after breast reconstruction have not been standardized, a 4- or 5-point categorical scale is often used [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In breast reconstruction with free abdominal flaps, one report indicated that irradiation has a negative effect on aesthetic outcome [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], whereas another indicated no difference in aesthetic outcome with or without irradiation [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. According to a study of both implant-based and autologous reconstruction, aesthetic outcome does not differ by the sequence of reconstruction and radiotherapy [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The novelty of our study is that we evaluated the aesthetic outcome of patients who underwent free autologous reconstruction, with abdominal and nonabdominal flaps, after irradiation. In comparing the two groups, we found that both the percentages of \u0026ldquo;very good\u0026rdquo;/\u0026ldquo;good\u0026rdquo; scores and the mean scores were significantly higher in the nonirradiated group, which indicated better aesthetic outcomes. Furthermore, in comparing one- and two-stage reconstruction, we found that cosmetic scores were higher for two-stage reconstruction than for one-stage reconstruction in the irradiated group, although the difference was not statistically significant. The irradiated group had a higher percentage of patients who underwent one-stage reconstruction in which the chest wall skin was replaced with a flap without insertion of tissue expanders because remaining chest tissue was insufficient and extensibility was poor, which may have contributed to lower scores in that group than in the nonirradiated group. In addition, as in representative case 2, some patients did not obtain sufficient expansion even with tissue expanders, which resulted in a left\u0026ndash;right difference in appearance. Furthermore, a higher percentage of patients in the irradiated group underwent axillary dissection, but in some cases, the lack of axillary volume was not adequately compensated for by flap tissue. In this study, the aesthetic evaluation accounted only for structure but not skin tone, texture, or scarring; we speculate that some of those factors may partly explain why appearance in the irradiated group was inferior to that in the nonirradiated group.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eAlthough the radiation field and dose were not investigated in this study, it is possible that location of the recipient vessels inside or outside the radiation field and the dose of radiation may affect the outcome of the reconstructive surgery. In addition, the aesthetic evaluation reflected only the health care provider\u0026rsquo;s opinion; patient satisfaction was not investigated, and it may differ from the health care provider\u0026rsquo;s opinion.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eWe compared results of delayed free flap breast reconstruction in patients who had and had not received earlier radiation therapy, and we examined the difficulty and success or failure of vascular anastomoses, postoperative complications, and aesthetic outcomes. Breast reconstruction with free flaps, including nonabdominal flaps, was performed safely in the irradiated group, but the aesthetic results were slightly inferior to those in the nonirradiated group. In the irradiated group, two-stage reconstruction tended to produce better aesthetic results than did one-stage reconstruction, but one-stage reconstruction is recommended when irradiation causes changes in the chest skin.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCompliance with ethical standards\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest Disclosure\u003c/strong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;All the authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e This is a joint research project by the Department of Plastic and Reconstructive Surgery, Yokohama City University Medical Center, and the Department of Plastic, Reconstructive and Aesthetic Surgery of the University of Toyama, approved by the Ethics Committee of the University of Toyama (Study No. 2022177). All procedures performed in this study were in accordance with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Because this study was retrospective and observational,\u0026nbsp;formal consent was not required. Instead of obtaining informed consent from patients, information about the research was disclosed to research subjects and others, and the opportunity was guaranteed for research subjects and others to refuse to allow the research to be conducted or continued.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJagsi R, Momoh AO, Qi J, Hamill JB, Billig J, Kim HM, et al. Impact of radiotherapy on complications and patient-reported outcomes after breast reconstruction. 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Analysis of aesthetic outcomes and patient satisfaction after delayed-immediate autologous breast reconstruction. Ann Plast Surg. 2018;80:303\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/SAP.0000000000001418\u003c/span\u003e\u003cspan address=\"10.1097/SAP.0000000000001418\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnderson PR, Hanlon AL, Fowble BL, McNeeley SW, Freedman GM. Low complication rates are achievable after postmastectomy breast reconstruction and radiation therapy. Int J Radiat Oncol Biol Phys. 2004;59:1080\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ijrobp.2003.12.036\u003c/span\u003e\u003cspan address=\"10.1016/j.ijrobp.2003.12.036\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"breast-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"brca","sideBox":"Learn more about [Breast Cancer](http://link.springer.com/journal/12282)","snPcode":"12282","submissionUrl":"https://www.editorialmanager.com/brca/default2.aspx","title":"Breast Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Delayed breast reconstruction, Radiation therapy, Free autologous flap, Vascular complication, Aesthetic outcome","lastPublishedDoi":"10.21203/rs.3.rs-3822676/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3822676/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe safety and outcome of breast reconstruction after radiotherapy are controversial, and the aesthetic aspects have not been studied extensively. We compared the results of vascular anastomosis, the incidence of postoperative complications, and aesthetic appearance between patients who had and had not received radiotherapy who then had undergone delayed breast reconstruction with autologous free flaps from abdomen, thighs, and buttocks.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe investigated 196 flaps implanted in patients who did not receive radiotherapy and 78 flaps implanted in patients who received radiotherapy before breast reconstruction in 256 patients. Of the 274 flaps, 230 came from the abdomen, 27 from the thighs, 14 from the buttocks, and 3 from other anatomic locations. We evaluated aesthetic outcomes in 107 patients who had not received radiotherapy and 45 who had.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWe found no significant differences between the two groups in incidence of vascular reanastomosis, time required for anastomosis, or incidence of unplanned reoperation. Complications such as flap necrosis were rare in both groups. Aesthetic outcomes were significantly better in the patients who had not received radiotherapy. Among the patients who had received radiotherapy, the aesthetic results were superior after two-stage reconstruction than after one-stage reconstruction.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eBreast reconstruction with autologous free flaps can be performed safely in patients who have received radiotherapy, but the aesthetic result is slightly inferior to that in patients who had not received radiotherapy. In patients who have received radiotherapy, two-stage reconstruction tends to produce more aesthetically pleasing results than does one-stage reconstruction, but one-stage reconstruction is recommended if the breast skin exhibits radiation-induced changes.\u003c/p\u003e","manuscriptTitle":"Delayed breast reconstruction with autologous free flap after radiation therapy: Vascular complications and aesthetic outcomes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-08 17:25:23","doi":"10.21203/rs.3.rs-3822676/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2024-01-08T22:47:05+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-01-04T07:27:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-12-30T04:55:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"Breast Cancer","date":"2023-12-29T22:41:50+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"breast-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"brca","sideBox":"Learn more about [Breast Cancer](http://link.springer.com/journal/12282)","snPcode":"12282","submissionUrl":"https://www.editorialmanager.com/brca/default2.aspx","title":"Breast Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"c4452398-1fb9-480f-b610-2ae371a3dddf","owner":[],"postedDate":"January 8th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-06-21T14:49:41+00:00","versionOfRecord":{"articleIdentity":"rs-3822676","link":"https://doi.org/10.1007/s12282-024-01593-3","journal":{"identity":"breast-cancer","isVorOnly":false,"title":"Breast Cancer"},"publishedOn":"2024-06-12 14:49:41","publishedOnDateReadable":"June 12th, 2024"},"versionCreatedAt":"2024-01-08 17:25:23","video":"","vorDoi":"10.1007/s12282-024-01593-3","vorDoiUrl":"https://doi.org/10.1007/s12282-024-01593-3","workflowStages":[]},"version":"v1","identity":"rs-3822676","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3822676","identity":"rs-3822676","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}