ABSTRACT Background As bariatric surgery becomes increasingly common, reconstructive surgeons are encountering more massive weight loss (MWL) patients requiring breast reconstruction. MWL alters breast anatomy, tissue characteristics, and healing capacity, potentially impacting reconstructive outcomes. Objective To update and evaluate the evidence on how MWL affects complication and revision rates, flap‐relevant anatomy, and patient‐reported outcomes (PROMs) following postmastectomy breast reconstruction. In addition, research gaps were identified. Methods This systematic review updated a previous review and followed PRISMA guidelines. Eligible studies included cohort studies and case series of postmastectomy breast reconstruction after MWL. Data extraction and appraisal were performed independently by two reviewers, with evidence quality rated using the GRADE system. Results Fifteen studies met the inclusion criteria, including three case–control studies and twelve case series, reporting outcomes for 102 patients after massive weight loss (MWL). Most reconstructions used abdominally based free flaps, with few MWL‐specific modifications. MWL patients experienced significantly higher rates of delayed wound healing, surgical‐site infection, fat necrosis, and need for revision compared with controls, while total flap loss rates were similar. Evidence on implant‐based reconstruction, vascular anatomy, and PROMs was scarce. The overall certainty of evidence was very low (GRADE ⊕⊝⊝⊝). Conclusion Breast reconstruction after MWL is associated with increased wound‐healing complications and revision rates, though patient satisfaction appears acceptable. Evidence remains limited by small, heterogeneous studies and a lack of controlled or prospective data. Future research should address optimal reconstructive techniques, timing, and patient selection, including the identification of modifiable risk factors and the use of PROMs to guide evidence‐based care.
Paganini et al. (2026) studied this question.