Anticancer agents and their impact on breast reconstruction: a guide for plastic surgeons based on systematic review and expert consensus

Authors: Zona EE, Thornton SM, Via EC, Burkard ME, Michelotti BF, Poore SO, Lautner MA, Israel JS

Affiliation: University of Wisconsin School of Medicine and Public Health

Journal: Plastic and Reconstructive Surgery, February 2026

PMID: 40707174

Key takeaways

• Evidence base is limited and mixed; most perioperative recommendations are consensus-driven rather than trial-proven.

• For major reconstruction, hold tamoxifen 2 weeks preop and restart 2 weeks postop.

• Most other agents are continued; select drugs warrant CBC-based screening and targeted short holds.

• Minor revision procedures generally do not require holding anticancer medications unless thrombocytopenia is a concern.

• If ANC < 1000 cells/µL, involve oncology ± G-CSF and postpone if ANC remains low close to surgery.

Background

Breast reconstruction patients increasingly receive adjuvant endocrine, targeted, and immunotherapies, yet perioperative medication management is inconsistent.

Objective

To summarize evidence on how adjuvant anticancer agents affect reconstructive outcomes and to provide expert consensus recommendations on perioperative holding/continuation.

Methods

• Design/setting/LOE: PRISMA-guided systematic review plus multidisciplinary expert consensus; available evidence predominantly observational.

• Databases/search: PubMed, Web of Science, Scopus; query included “breast reconstruction” AND “anticancer agent” plus individual drug names (initial query Dec 11, 2023).

• Selection: Dual-reviewer screening; excluded non–full text articles, case reports, editorials/commentary, and papers not linking agent exposure to reconstruction outcomes.

• Data extracted: Study design, sample size, agent, reconstruction type, complications/adverse effects, and any perioperative recommendations.

• Consensus panel: Medical oncology, surgical oncology, plastic surgery, advanced practice providers, and nurses.

• Procedure framework:

  • Major: autologous free flaps, tissue expander placement, oncoplastic reduction.

  • Minor: implant exchange, fat grafting, scar revision, fat necrosis excision, nipple reconstruction.

Results

• Included evidence: 19 studies; 5793 patients.

• Agents with outcome data: tamoxifen (18 studies), aromatase inhibitors (8), trastuzumab (2), pertuzumab (1).

• Evidence gaps: No reconstruction-outcome studies identified for several commonly used agents (e.g., GnRH agonists, pembrolizumab, olaparib, abemaciclib, capecitabine), necessitating consensus-based guidance for many drugs.

Medication-specific perioperative recommendations (major procedures)

• Tamoxifen

  • Literature is mixed; some studies associate tamoxifen with microvascular complications, wound issues, and fat necrosis, while others do not.

  • Consensus: Hold 2 weeks preop; restart 2 weeks postop.

• Aromatase inhibitors (e.g., anastrozole; extrapolated to letrozole/exemestane)

  • Consensus: Do not hold; resume when tolerating oral intake.

• Trastuzumab / pertuzumab

  • Consensus: Do not hold; resume near the usual every-3-week schedule after discharge.

  • Note: One study suggested a small, non-significant signal toward wound breakdown requiring OR with dual HER2 therapy, limited by low event counts.

• Olaparib

  • Consensus: Hold 48 hours preop; restart 1 week postop.

  • Obtain CBC with differential within 7 days preop.

• Abemaciclib

  • Consensus: Hold 1 week preop; restart 1 week postop.

  • Obtain CBC with differential within 7 days preop.

• Pembrolizumab

  • Consensus: Do not hold.

  • Consider morning cortisol if not checked within prior ~3 weeks (rare adrenal insufficiency).

• Capecitabine

  • Consensus: Do not hold.

  • Obtain CBC with differential within 7 days due to thrombocytopenia risk; coordinate if platelets are low.

• General cytopenia guidance

  • If ANC < 1000, consult oncology ± G-CSF and postpone if ANC remains low close to surgery.

Minor procedures

• Minor revisions generally do not require holding anticancer agents unless thrombocytopenia is a concern.

Conclusion

The authors propose a pragmatic perioperative framework: hold only a few higher-risk agents for major reconstruction (notably tamoxifen), continue most other anticancer therapies, and use targeted preoperative labs and oncology coordination to address cytopenias.

• Strengths

  • Structured multi-database, PRISMA-guided review with dual-reviewer screening.

  • Multidisciplinary consensus process and a clinically practical “major vs minor” procedural framework.

• Limitations

  • Sparse reconstruction-specific outcomes data for many contemporary systemic therapies; numerous recommendations necessarily rely on expert opinion.

  • Heterogeneous study designs, patient populations, and outcome definitions in the available literature.

Clinical relevance

For major breast reconstruction, this provides a straightforward medication-management playbook: hold tamoxifen around surgery, do not automatically stop most other agents, and incorporate CBC/ANC/platelet thresholds into readiness with early oncology involvement when cytopenias are present.

Editorial notes

• The “major vs minor” framework is useful, but it can underweight patient-specific modifiers (Caprini score, prior VTE, bilateral microsurgery, operative time, radiation, obesity). A risk-stratified algorithm would further improve applicability.

• For dual HER2 blockade, what perioperative mitigation strategies (timing relative to infusion, nutrition, drain/antibiotic strategy) do the authors recommend in immediate reconstruction, where wound issues are most consequential?

• Research need: prospective, reconstruction-specific registries capturing agent timing/dose, hematologic indices, reconstruction type, and standardized complications to move practice from consensus to evidence.