title: Is immediate autologous breast reconstruction with postoperative radiotherapy good practice?: a systematic review of the literature.
abstract: BACKGROUND
  There remains controversy as to whether immediate autologous breast reconstruction with postoperative radiotherapy is associated with acceptable complications and aesthetic outcomes. This systematic review analyses the literature regarding outcomes of immediate autologous breast reconstruction with postoperative radiotherapy compared with no radiotherapy, as well as with delayed autologous breast reconstruction following post-mastectomy irradiation.
  
  
  METHODS
  Pubmed (1966 to October 2012), Ovid MEDLINE (1966 to October 2012), EMBASE (1980 to October 2012), and the Cochrane Database of Systematic Reviews (Issue 10, 2012) were searched. Overall complications (including fat necrosis), fat necrosis, revisional surgery, loss of volume, and aesthetic outcome, were analysed individually. Comparable data from observational studies were combined for meta-analysis where possible and quality assessment of the studies was performed.
  
  
  RESULTS
  The majority of studies of immediate autologous breast reconstruction and postoperative radiotherapy reported satisfactory outcomes (19 of 25 studies; n=1,247 patients). Meta-analysis of observational studies demonstrated no significant differences in total prevalence of complications (p=0.59) or revisional surgery (p=0.38) and a summary measure for fat necrosis favouring the group without radiotherapy (OR 2.82, 95% CI 1.35-5.92, p=0.006). The majority of studies comparing immediate reconstruction and postoperative radiotherapy with delayed reconstruction following post-mastectomy radiotherapy (10 of 12 observational studies; n=1,633 patients) reported satisfactory outcomes following immediate reconstruction. Meta-analysis of observational studies demonstrated no significant difference in overall incidence of complications (p=0.53) and fat necrosis (OR 0.63, 95% CI 0.29-1.38, p=0.25), and a summary measure for revisional surgery (OR 0.15, 95% CI 0.05-0.48, p=0.001) favouring the delayed surgery group. No randomised-controlled trials met the inclusion criteria, and all of the observational studies included were missing more than one important component for reporting of observational studies.
  
  
  CONCLUSIONS
  The majority of studies reported satisfactory outcomes and a similar incidence of complications for immediate autologous breast reconstruction and adjuvant radiotherapy when compared with no radiotherapy or delayed reconstruction following radiotherapy; the proportion that required revisional surgery was higher though for immediate than delayed breast reconstruction. The findings are limited by the paucity of high quality data in the published literature, and until better data is available the findings of this review suggest that immediate autologous breast reconstruction should at least be considered when adjuvant chest wall radiotherapy is anticipated.
authors.affiliation: Department of Plastic Surgery, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, UK; Department of Breast Surgery, Nottingham Breast Institute, City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK. Electronic address: markschaverien@fastmail.fm.
authors.forename: Mark V
authors.initials: MV
authors.lastname: Schaverien
authors.forename: R Douglas
authors.initials: RD
authors.lastname: Macmillan
authors.forename: Stephen J
authors.initials: SJ
authors.lastname: McCulley
mesh_terms: D064592:Autografts; D001943:Breast Neoplasms / Q000532:radiotherapy* / Q000601:surgery*; D005260:Female; D006801:Humans; D016462:Mammaplasty / Q000379:methods; D018714:Radiotherapy, Adjuvant; D012086:Reoperation / Q000706:statistics & numerical data; D013995:Time; D016896:Treatment Outcome
keywords: Aesthetic outcome; Autologous breast reconstruction; Complications; Delayed; Fat necrosis; Immediate; Meta-analysis; Outcomes; Radiotherapy; Revisional surgery; Systematic review; Volume loss