Autologous vs implant-based breast reconstruction: a PROs-focused review on radiotherapy impact

Background. The choice between Autologous Tissue Breast Reconstruction (ABR) and Implant-Based Reconstruction (IBR) is a fundamental decision in breast cancer survivorship. This choice is influenced by surgical evolution – specifically the shift to muscle-sparing techniques – and a modern focus on Patient-Reported Outcomes (PROs). This review critically compares these two modalities, focusing on long-term satisfaction, functional morbidity, and the definitive impact of radiotherapy (RT).
Methods. A structured literature review was conducted in accordance with PRISMA principles, utilizing MEDLINE and Embase databases from January 2015 to September 2025. The search strategy combined MeSH terms for “Mammaplasty”, “Patient Reported Outcome Measures” (BREAST-Q), and “Radiotherapy”. We prioritized systematic reviews, meta-analyses, and large comparative cohort studies (n = 60) that provided objective complication rates and subjective outcomes in both irradiated and non-irradiated settings.
Results. Evidence confirms that ABR provides statistically superior longterm satisfaction, psychosocial well-being, and sexual well-being ^1-3. This is driven by its biological integration and “like-with-like” properties. Conversely, IBR carries a high cumulative burden of re-operation (> 50% at 10 years) due to capsular contracture and aesthetic failure 4. Most critically, RT is the dominant predictor of failure, causing IBR failure rates exceeding 30%, whereas vascularized ABR flaps demonstrate robust resilience ^5,6.
Conclusions. While modern pre-pectoral IBR is a viable, low-morbidity option for select non-irradiated patients, ABR provides the most durable and psychologically favorable long-term outcome. The anticipated need for post-mastectomy radiation must be the primary driver in clinical decision-making, favoring autologous reconstruction as the gold standard in the irradiated setting.