Aesthetic success in breast reconstruction depends on achieving harmonious bilateral balance, including appropriate breast shape and accurate nipple-areola complex (NAC) position. Symmetry is especially difficult to achieve when the contralateral breast is ptotic, because balancing procedures may be necessary to establish a realistic target nipple level and overall breast contour [1-3].

Delayed reconstruction after multimodal adjuvant therapy presents additional challenges. In patients who experience prosthetic reconstruction failure during systemic treatment and subsequently undergo postmastectomy radiation therapy (PMRT), progressive soft-tissue fibrosis and contracture can severely distort the reconstructed breast envelope and displace the NAC. In this setting, conventional nipple repositioning on compromised skin may be unreliable, making durable nipple symmetry one of the most technically demanding aspects of reconstruction [1,2,4,5].

Here, we report a salvage case of delayed autologous free-flap reconstruction combined with simultaneous free NAC grafting and contralateral mastopexy in a patient who developed a periprosthetic infection during adjuvant chemotherapy and later developed radiation-associated breast and NAC contracture. We outline a stepwise reconstructive strategy intended to restore nipple position and improve overall symmetry in an irradiated, contracted breast.

A 50-year-old woman with invasive ductal carcinoma of the right breast underwent nipple-sparing mastectomy with axillary lymph node dissection and immediate breast reconstruction using a 450-cc moderate-profile tissue expander (Mentor CPX4; Mentor Worldwide LLC) and human acellular dermal matrix (CGDerm One-step; CGBIO). The mastectomy specimen weighed 380 g. Adjuvant chemotherapy and PMRT were planned.

During adjuvant chemotherapy, the patient developed clinical signs of periprosthetic infection, including erythema, localized warmth, swelling, and breast tenderness. Empiric intravenous vancomycin was started. Ultrasonography demonstrated a periprosthetic fluid collection, and culture and cytology identified Staphylococcus lugdunensis. Although the organism was susceptible to vancomycin, the local inflammatory findings persisted. Explantation of the tissue expander, together with capsulectomy and thorough debridement, was therefore performed.

After recovery, the patient completed the planned systemic therapy and then underwent PMRT. Following PMRT, progressive soft-tissue fibrosis developed, leading to marked breast contracture, deformity of the reconstructed breast mound, and severe distortion and malposition of the NAC. The contralateral breast also showed moderate ptosis, which further accentuated the asymmetry (Fig. 1).

Ten months after completion of PMRT, delayed breast reconstruction was performed using a muscle-sparing free transverse rectus abdominis myocutaneous flap. Intraoperatively, poor-quality scarred skin, including the distorted NAC, was excised. A well-vascularized flap skin paddle was used to reconstruct the breast envelope and provide an optimal recipient bed. To improve overall symmetry, contralateral mastopexy with a vertical pattern was performed during the same operation. The NAC was harvested from the excised contracted breast skin as a full-thickness graft and was gently defatted by removing excess subcutaneous tissue while preserving the deep dermal layer. The final graft position was determined by comparing distances from key landmarks, including the sternal notch, midsternal line, and inframammary fold, with the corresponding landmarks on the contralateral breast. To facilitate intraoperative planning, a sterile electrocardiogram lead with a central metal button was used to simulate nipple position while the patient was placed in the sitting position. Once the new nipple position had been established, the recipient site was created on a de-epithelialized portion of the flap skin paddle (Fig. 2A). The graft was secured with 5-0 black silk sutures and stabilized with a tie-over bolster dressing. The dressing was maintained for 1 week (Fig. 2B and C). On postoperative day 4, the bolster sutures were partially released to assess early graft viability and evaluate for complications such as hematoma, seroma, or infection. At that time, the NAC graft showed satisfactory take, and flap perfusion was good. The bolster dressing was then reapplied with a light compressive foam dressing for an additional 3 days to support graft take.

The postoperative course was uncomplicated, and breast mound symmetry and nipple position were maintained throughout 3 months of follow-up (Fig. 3). The patient was satisfied with the aesthetic result; however, secondary NAC revision under local anesthesia was planned for 6 months postoperatively because of residual contracture-related size discrepancy.

Reconstruction after adjuvant therapy is constrained primarily by the quality of the breast envelope and the mechanical properties of the surrounding tissue. Infection-related scarring and radiation-associated fibrosis can reduce skin extensibility, distort anatomical landmarks, and diminish the reliability of implant salvage or minor revision procedures. When contralateral ptosis is also present, achieving a stable NAC position becomes an additional determinant of aesthetic success and often necessitates a symmetry-oriented reconstructive strategy [2,4,5].

Within this context, PMRT is a major driver of long-term deterioration of the breast envelope. It has a dose-dependent adverse effect on soft tissues and is associated with fibrosis, discoloration, edema, and impaired wound healing. Consistent with these biological effects, clinical cohort studies have shown that PMRT is strongly associated with increased capsular contracture and higher overall complication rates in prosthetic reconstruction. By contrast, autologous reconstruction shows less pronounced differences in complication rates between irradiated and nonirradiated patients. Taken together, these findings support the use of vascularized tissue transfer when the breast envelope is scarred, contracted, or otherwise unreliable after PMRT [2,4-6].

Systemic therapy can further increase risk in implant-based reconstructive pathways. In two-stage expander/implant reconstruction, adjuvant chemotherapy has been associated with higher adjusted risks of infection and severe capsular contracture in multivariable analyses [5]. Although chemotherapy may not uniformly worsen outcomes across all reconstructive methods, these findings suggest that prosthetic reconstruction performed over a prolonged adjuvant treatment course may accumulate risk. This pattern is consistent with the clinical course of the present patient [5,7]. In this case, implant infection requiring explantation occurred before PMRT and was followed by progressive contracture and NAC distortion. This sequence created a high-risk reconstructive environment characterized by compromised soft-tissue quality and limited predictability of implant-based salvage. Delayed definitive autologous reconstruction was therefore selected as the most appropriate reconstructive option [2,4,5].

The timing of delayed autologous reconstruction after PMRT remains an important clinical consideration. A large microvascular series found no significant difference in major complications among reconstructions performed within 0–12 months, 12–18 months, or 18–50 months after PMRT. The same study suggested that reconstruction can be performed safely beginning approximately 6 months after PMRT, while still advising caution during the early postradiation interval. These findings support proceeding once acute radiation effects have stabilized rather than delaying reconstruction indefinitely in patients with symptomatic contracture and deformity [4].

The central technical challenge in this case was restoration of a symmetric NAC in the setting of radiation-associated contracture and malposition. Free NAC grafting represents a practical option when nipple malposition or distortion makes pedicled relocation unreliable. In microvascular breast reconstruction, free NAC grafting commonly results in hypopigmentation and partial loss of projection; however, these features do not necessarily determine the overall aesthetic result. Instead, aesthetic outcomes correlate most strongly with NAC size, position, and symmetry. This observation is particularly relevant in complex delayed reconstruction, in which surgeons can most reliably optimize these controllable parameters at the index operation [1-3,8]. In the present patient, simultaneous free-flap reconstruction and free NAC grafting allowed the NAC to be transferred onto a well-perfused flap skin paddle, thereby facilitating accurate positioning on the basis of anatomical landmarks. Contralateral mastopexy addressed the preexisting ptosis and provided an appropriate reference point for nipple level and overall breast balance.

This case illustrates a practical reconstructive option for severe radiation-associated NAC distortion after prosthetic reconstruction failure. In selected patients with a contracted and unreliable irradiated breast envelope, simultaneous autologous free-flap reconstruction with immediate free NAC grafting onto the flap skin paddle, together with contralateral mastopexy, may help improve nipple position and overall breast symmetry.

Several limitations of this case report should be acknowledged. First, we do not suggest that simultaneous free NAC grafting is universally preferable to a staged reconstructive approach. In other clinical settings, staged expansion or delayed nipple reconstruction may be appropriate and may permit additional aesthetic refinement. In the present case, however, the native NAC was markedly distorted and malpositioned on irradiated, contracted tissue after implant failure and PMRT, and the patient preferred one-stage autologous reconstruction rather than a staged reconstructive course. Under these circumstances, immediate repositioning of the preserved NAC as a free graft onto a well-vascularized flap skin paddle was considered a practical option during index autologous reconstruction. Second, because this is a single-case report, it cannot establish indications, comparative effectiveness, or relative risk. Third, free NAC grafting involves inherent trade-offs, including loss of sensation and the potential for pigment alteration or loss of projection, particularly when additional thinning is required for oncologic or reconstructive reasons. Standardized patient-reported outcome measures and objective aesthetic assessments were not included. Finally, the current postoperative findings should be interpreted as interim outcomes, and longer follow-up is needed to better characterize late remodeling and the long-term stability of the reconstructed NAC, including pigment retention, projection maintenance, scar maturation, recurrent contracture, nipple position stability, and contracture-related size discrepancy.

In patients who experience prosthetic reconstruction failure during systemic therapy and subsequently develop radiation-associated breast and NAC contracture, delayed autologous reconstruction may provide a reliable foundation for restoring breast form. Simultaneous free NAC grafting onto a well-vascularized flap skin paddle may facilitate nipple repositioning, and contralateral mastopexy may be required to improve overall symmetry. Patients should be counseled regarding expected graft-related trade-offs and the potential need for secondary revision.