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Delayed autologous breast reconstruction (ABR) with DIEP flap after irradiation remains a challenging scenario, as outcomes may differ according to the flap insetting design - buried (if native breast skin is preserved) versus external (with replacement of irradiated integument). To date, clear guidance on managing irradiated breast skin is lacking. This study aimed to compare patient-reported satisfaction and outcomes between these two approaches.

A two-center retrospective analysis (2018-2024) included all delayed DIEP flap breast reconstructions performed after irradiation, with ≥ six months follow-up. Patients were categorized into three groups: (0) primary delayed ABR with external insetting; (1) implant-to-autologous conversion with buried insetting; (2) implant-to-autologous conversion with external insetting. Complication rates were compared using Chi-square and Fisher’s exact tests. Patient-reported outcomes were assessed through the BREAST-Q Reconstruction Module. Non-parametric tests (Kruskal–Wallis, Mann–Whitney) and multivariable linear regression models (adjusted for age and BMI) were applied.

125 consecutive patients were included (37, 42, and 46 per group, respectively). Flap loss occurred in 6 cases (4.8%), with a significantly higher rate in the buried insetting group (p=0.018). “Satisfaction with Breasts” scores differed across groups (p=0.034), being significantly higher in group 0 versus 1 (p=0.028) and in (0+2) versus 1 (p=0.007). Satisfaction was also higher in patients without previous reconstruction (0 vs 1+2; p=0.025). Among implant-to-autologous conversions, external insetting showed a non-significant trend toward higher satisfaction than buried insetting (p=0.112). In regression analysis, insetting type remained an independent predictor of satisfaction (p=0.009), while BMI and age were not associated with outcomes.

Resecting and replacing irradiated breast integument with a large skin paddle placed in the inframammary fold enhances patient satisfaction while reducing complications. This design avoids flap compression produced by the inextensible radiated envelope, limiting flap loss and partial necrosis, and provides a more natural breast contour and ptosis, particularly beneficial in overweight patients with large contralateral breasts.

Radiotherapy (RT) is frequently part of breast cancer treatment. Although autologous reconstruction is less adversely affected by radiotherapy than implant-based reconstruction, irradiation may still reduce tissue softness and increase fat necrosis rates. Conventionally, delayed autologous reconstruction is recommended at least 6 months after completion of radiotherapy. We aimed to evaluate the feasibility and safety of DIEP flap breast reconstruction performed within 2–6 weeks after radiotherapy, delivered either in the neoadjuvant or adjuvant setting (as suggested in the PRADA study).

Between 2023 and 2024, we conducted a prospective feasibility study including 10 consecutive patients who underwent radiotherapy prior to autologous breast reconstruction with a DIEP flap. Radiotherapy was delivered according to institutional protocols (maximum dose 50 Gy). Surgery was performed at a standardized interval of 2–6 weeks following completion of radiotherapy. This interval of time allows acute inflammation coming from RT to resolve, anticipating the fibrotic changes to tissue which happen after 6 weeks, together with increase in microvascular complications rate.
Primary endpoints were surgical feasibility and postoperative complications. Secondary endpoints included need for secondary reshaping procedures, patient-reported satisfaction, and early oncologic outcomes. Patients were followed for at least 12 months.

All patients completed the planned multimodal treatment. DIEP flap reconstruction was successfully performed in 100% of cases. One flap (10%) required surgical revision for hematoma evacuation. No total flap loss occurred. No other early postoperative complications were observed, and wound healing was satisfactory in all patients. No clinically relevant radiation-related morbidity was recorded. At 12-month follow-up, patients reported high satisfaction regarding breast shape and softness. No oncologic events were observed during follow-up.

DIEP flap reconstruction performed within 2–6 weeks after radiotherapy appears feasible and surgically safe in selected patients. Complication rates were acceptable, and flap viability was preserved in all cases. Shortening the interval between radiotherapy and reconstruction may represent a meaningful advantage of this approach. Larger studies with longer follow-up are needed to confirm these findings.

Autologous breast reconstruction using a deep inferior epigastric perforator (DIEP) flap is an established standard following mastectomy for breast cancer. In patients with advanced-stage disease, adjuvant radiotherapy (RT) is frequently indicated; however, its impact on long-term aesthetic outcomes and patient-reported satisfaction remains unclear. This study evaluated the effect of adjuvant RT on long-term aesthetic outcomes, quality of life, and patient satisfaction following autologous breast reconstruction.

In this prospective single-centre cohort study, patients who underwent autologous breast reconstruction with or without adjuvant RT between 2009 and 2023 were followed up. Patient-reported outcomes were assessed using validated questionnaires (BREAST-Q, BIS, and POSAS). Standardized photographs were obtained, and long-term aesthetic outcomes were independently evaluated by four plastic surgeons using the Breast Aesthetic Scale. Patients were stratified into RT and non-RT cohorts.

Of 263 patients who underwent DIEP flap–based reconstruction, 118 were included (RT: n = 51; non-RT: n = 67). Baseline demographic and clinical characteristics were comparable between groups. The mean radiation dose in the RT-cohort was 49,54 Gy. In the BREAST-Q, 4 of 20 subscales showed significant differences favouring the non-RT cohort (psychosocial well-being, satisfaction with the reconstructed breast, physical well-being, and arm swelling). POSAS scores revealed no significant differences, and BIS results were largely comparable, except for “body image after breast reconstruction” (p = 0.008). In contrast, independent expert assessment demonstrated predominantly significantly poorer long-term aesthetic outcomes in the RT cohort.

These findings suggest that adjuvant radiotherapy, at a mean dose of 49.54 Gy, appears to primarily impair the long-term aesthetic outcome of DIEP flap–based autologous breast reconstruction, while having comparatively limited effects on patient-reported satisfaction and health-related quality of life.

Delayed autologous breast reconstruction after postmastectomy radiotherapy (PMRT) is commonly recommended 6–12 months after radiation due to concerns regarding fibrosis, vascular compromise, and wound complications . However, radiation-induced microvascular sclerosis and progressive soft tissue contracture evolve over time and may negatively affect recipient vessel quality and aesthetic outcomes. Recent data question rigid timing thresholds and suggest that earlier reconstruction may not necessarily increase morbidity . We hypothesized that performing reconstruction within 3–4 weeks after PMRT—before advanced fibrosis and chest wall contracture develop—may preserve vessel integrity, reduce flap-related complications, and improve aesthetic results.

We report a consecutive case series of patients undergoing microsurgical autologous breast reconstruction within 3–4 weeks after completion of PMRT. Patients were selected after multidisciplinary evaluation. Operative feasibility, recipient vessel quality, flap viability, and postoperative complications were assessed.

All reconstructions were technically feasible despite acute radiation changes. Recipient vessels were suitable for microvascular anastomosis without clinically relevant fibrosis. No total flap loss occurred. Minor wound healing disturbances were managed conservatively. Early reconstruction appeared to prevent progressive contracture and secondary skin deficiency, contributing to satisfactory aesthetic outcomes.

Very early autologous reconstruction following PMRT appears feasible and safe in selected patients. A biologically driven timing strategy—rather than a fixed delay—may help preserve vessel quality, potentially reduce flap loss risk, and optimize aesthetic outcomes. Further prospective evaluation is warranted.

Autologous fat grafting (AFG) is an increasingly popular adjunct used for reconstruction of the breast. Emerging evidence supports its role in both volumetric enhancement and therapeutic biomodulation, particularly in patients who have received radiotherapy. Data pertaining to aesthetic and patient-reported outcome measures (PROMs) of individuals who have received lipomodelling after radiation therapy remains limited. This comprehensive review aims to synthesise the current evidence on this topic.

In accordance with PRISMA guidelines, a comprehensive literature search of MEDLINE, Embase, Cochrane Library, Web of Science and CiNAHL was conducted from inception until the 22nd of February 2026. All studies involving female patients (>=18 years), who had undergone both oncological radiotherapy and AFG for breast reconstruction, were assessed. Primary outcomes of interest were aesthetic scores/PROMs, including validated measures such as BREAST-Q, in addition to patient satisfaction and cosmetic questionnaires. Secondary outcomes included cyst formation rates following AFG procedures.

23 studies, encompassing 960 irradiated patients were included. Patient-reported outcomes were highly heterogeneous, with only 3 studies using the validated BREAST-Q instrument, and the majority (n=17) using non-validated numerical rating scales to assess outcomes. All 23 studies reported that AFG led to favourable aesthetic and patient-reported outcomes. Moreover, all 5 comparative studies showed significantly higher PROMs in irradiated patients who received lipomodelling to those who did not. In studies, where pre-operative scores were also reported, lipomodelling produced an improvement of 19.0–31.9% in aesthetic ratings, with additional studies remarking a 32.0% improvement in visual analogue score for pain and significant improvements in post-operative satisfaction/psychosocial well-being using the BREAST-Q instrument. Cyst formation rates were generally low, with a weighted mean incidence of 6.41% reported across 8 studies.

The results of this comprehensive review support the idea that lipomodelling is associated with improved quality of life amongst irradiated patients. However, the substantial heterogeneity of reported outcomes remains a limiting factor and demonstrates that there is a need for future research to use standardised and validated PROMs.