Microsurgical Strategies in Post-Radiation and Revision Breast Reconstruction: Optimizing Outcomes in High-Risk Patients

Patients requiring breast reconstruction following radiation therapy or prior failed autologous breast reconstruction (ABR) or implant-based breast reconstruction (IBBR) represent a challenging cohort and often present with compromised vascularity, scarred anatomy, and subsequent increased rates of complications. In this review, we discuss microsurgical strategies designed to optimize donor tissue in these challenging clinical scenarios, including the use of stacked or bipedicled flaps, and the utility of intraoperative indocyanine green angiography. We also review approaches to alternate recipient vessel selection in the suboptimal chest, and we address specific strategies for the revision setting, like soft tissue support and hybrid reconstruction with ABR and IBBR. By synthesizing the current literature and expert experience, this narrative review provides a practical framework for microsurgeons managing complex breast reconstruction in higher-risk patients.