Reconstructive Strategies After Mastectomy: Comparative Outcomes, PMRT Effects, and Emerging Innovations

<b>Background:</b> Advances in breast reconstruction have transformed the recovery pathway for women undergoing mastectomy. What was once viewed mainly as a cosmetic option is now recognized as part of modern oncologic care, restoring not only body image but also confidence and quality of life. Yet, surgeons still face the same central dilemma: choosing between implant-based (IBR) and autologous reconstruction (ABR), particularly when postmastectomy radiotherapy (PMRT) is planned. <b>Methods:</b> We reviewed major studies published between 2014 and 2024, combining evidence from observational cohorts and recent meta-analyses that together report on more than 60,000 reconstructed breasts. Outcomes of interest included surgical complications, reconstructive failure, BREAST-Q patient-reported domains, and the impact of PMRT on both techniques. Data were interpreted in light of contemporary reconstructive innovations such as prepectoral implants, acellular dermal matrices, and robotic or sensory-nerve-enhanced autologous procedures. <b>Results:</b> Autologous reconstruction generally provided higher satisfaction and better psychosocial and sexual well-being, particularly in patients who received PMRT. Implant-based reconstruction offered faster recovery and shorter hospitalization but was more vulnerable to capsular contracture and reconstructive loss after irradiation. Across all eligible cohorts, reconstruction-immediate or delayed-did not increase local recurrence or compromise overall survival when adjuvant therapy was delivered without delay. <b>Conclusions:</b> Both IBR and ABR are oncologically safe and contribute meaningfully to recovery after mastectomy. Future progress will depend on combining precise surgical execution with new technologies-prepectoral implant positioning, robotic flap harvest, and sensory nerve coaptation-to achieve durable, natural, and patient-centered reconstruction.