Failed Breast Reconstruction Research Articles

The lumbar artery perforator flap in large volume salvage autologous breast reconstruction: a case report

The authors describe a case where a lumbar artery perforator (LAP) flap was used to salvage a failed breast reconstruction and address concerns about the use of LAP flaps.

Patients’ and surgeons’ experiences after failed breast reconstruction: A qualitative study

The goal of postmastectomy breast reconstruction (BR) is to improve the quality of life of patients. However, complications following autologous BR (A-BR) and implant-based BR (I-BR) occur frequently and may even lead to BR-failure, which can be a distressing event for both patients and surgeons. The current study, therefore, examines the experiences of both patients and surgeons after a BR-failure. Patients with a failed BR from a large multicenter cohort study and participating plastic surgeons were invited to participate in semi-structured interviews focusing on their experiences. The interviews were analyzed according to the principles of grounded theory. Fourteen patients with a failed I-BR, four patients with a failed A-BR, and four plastic surgeons were participated. Three main categories emerged from the data: personal experiences with BR-failure, the motives for a redo of a failed BR, and patient-surgeon communication. Patients would like to be treated with more attention to their personal feelings and lives, instead of being approached from a purely medical-technical perspective. Surgeons may experience feelings of guilt leading to the strong urge to fix the failed BR, whereas patients may be less inclined to undergo additional operations. Patients want to know what the choice for a particular type of BR would mean to their personal lives. The impact of I-BR-failure may be underestimated and requires the same degree of intensive aftercare and attention. Implementing the recommendations of this study in clinical practice may facilitate improvements in how both patients and surgeons cope with a BR-failure.

A classification system and treatment algorithm for mastectomy flap ischemia in alloplastic breast reconstruction

Mastectomy flap necrosis remains a major cause of failed breast reconstruction with an associated significant financial/psychological burden. Language describing ischemic mastectomy flaps is imprecise as ischemia can result from many causes and can manifest in different ways. Similarly, management of mastectomy flap ischemia varies depending on its etiology. Intraoperative near-infrared imaging (NIR) with indocyanine green (ICG) is an established modality for evaluation of mastectomy flap perfusion. Herein, we define the types of flap ischemia demonstrated via NIR imaging and propose an algorithm for its management. A retrospective review was performed of patients who underwent mastectomy and NIR imaging of mastectomy flaps from 2014 to 2017. Patient characteristics, operative details, and outcomes were recorded. Following retrospective review, distinct patterns of ischemia were identified, and a classification system and treatment algorithm were developed. Type A; diffuse hypoperfusion can be caused by a number of factors (hypotension, vasoconstrictive agents, etc.). It is best treated with delayed reconstruction. Type B; geographic hypoperfusion may be caused by electro-cautery burn, inaccurate dissection, or retractor injury. It can be treated by resection/primary closure or delayed reconstruction. Type C; marginal/incisional hypoperfusion is best treated with debridement. Type D; diffuse marginal perfusion is seen with overfilled tissue-expanders or an oversized implant within a smaller skin envelope. Management includes deflation/downsizing. An algorithm was developed for treatment of the four ischemia types. NIR imaging aides in delineating the type of ischemic injury. Classification of mastectomy flap ischemia allows precise communication between providers and provides a framework for decision-making.

Abstract P4-12-08: Patients' and surgeons' experiences after failed breast reconstruction: A qualitative study

Abstract Background: Breast cancer reconstructive surgery is supposed to contribute to patients' body image and quality of life. However, complications after autologous breast reconstruction (A-BR) and implant-based breast reconstruction (I-BR) do occur in approximately 40% of the women, and may even lead to complete failure in rare cases. This study explores both patients' and surgeons' experiences after failed breast reconstruction. Increased knowledge in this field could help to improve not only the care for women with failed breast cancer reconstructive surgery but may also help to guide professionals in dealing with such failures. Methods: Patients with reconstructive failure form a large multicenter cohort study and participating plastic surgeons were invited to participate in this study. A topic list consisting of ten topics served as a general outline of a semi-structured interview on their experiences with the reconstructive failure, lasting about one hour. The interview data were transcribed and after that analyzed according to the principles of grounded theory by two researchers independently of each other. Data were coded in NVivo software. Next, data were discussed in a larger team, thereby moving back and forth between data and emerging theory. Results: Fourteen patients with a failed I-BR, four patients with failed A-BR and four plastic surgeons participated in this study. Three main categories emerged from the data: personal experiences, the motivation for a redo of the failed reconstructive surgery and patient-doctor communication. With regard to personal experiences, a main patient category was the importance of being (appreciated as) a person as a whole, in his/her specific context (versus focusing on reconstructive technique). This in contrast to the surgeons, for whom it did matter whether the failure concerned an I-BR or A-BR. The latter was perceived as more intense. Some took it as a personal failure, leading to insecurity and feelings of regret towards the patient. This was especially true if they felt a strong bond with that particular patient. With regard to motivation for a redo of the failed reconstructive surgery, both patients and surgeons emphasized the importance of shared decision making. Nevertheless, patients seemed to remain more ambivalent than surgeons about pursuing additional reconstruction after failure. Finally, regarding patient-doctor communication, we found that surgeons were more distant or reflective on these matters, whereas patients expressed their experiences in a more emotional way. Patients expressed a desire to be seen and treated as an unique individual. Experiencing trustfulness, sincerity and empathy from the surgeon in discussing the failure were highly valued. Discussion: Implementing the results of this study in clinical practice may facilitate coping with the distressing or even traumatic event of failed breast reconstruction, in both patients and surgeons. Citation Format: Kouwenberg CA, Hoogdalem LE, Gopie JP, Tibben A, Mureau MA, Ismail SY, Kranenburg LW. Patients' and surgeons' experiences after failed breast reconstruction: A qualitative study [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-12-08.

The use of contralateral free extended latissimus dorsi myocutaneous flap for a tertiary failed breast reconstruction: Is it still an option?

Unsuccessful breast reconstruction management represents a complex challenge for the plastic surgeon. Although these events rarely occur, many patients are not suitable candidates for conventional flaps, because of either previous donor-site surgery or lack of sufficient tissue. In this study, a contralateral free latissimus dorsi musculocutaneous flap (CL-LDMF) was planned for correction of major lesions in the anterior chest wall. Twelve patients underwent secondary/tertiary breast reconstruction with CL-LDMF with a customized shape (horizontal, oblique, or "fleur-de-lis") depending on the amount of tissue necessary. The technique was indicated in patients with large thoracic defects who lacked a donor site and had undergone previous unsuccessful pedicled LDMF. The mean follow-up time was 42.5 months (range: 18-72 months). Five local complications occurred in four of the 12 patients. Dorsal dehiscence was observed in one, local wound infection in one, small partial CL-LDMF necrosis in one, and dorsal seroma in one patient. All cases of complications were limited and treated with a conservative approach except for one implant extrusion 4 months after reconstruction. No total flap loss was reported. All patients achieved a satisfactory thoracic and breast reconstruction. The results of this study demonstrate that free CL-LDMF is a reliable technique and should be considered in selected cases of tertiary reconstructions. The majority of complications were immediate, minor, and comparable to other reconstructive techniques. We believe that in selected patients, especially those who do not have available donor-site areas, free CL-LDMF is advantageous and should be part of the armamentarium of all plastic surgeons who deal with tertiary breast reconstructions.

Vascular Variations of the Transverse Upper Gracilis Flap in Consideration for Breast Reconstruction

The transverse upper gracilis (TUG) myocutaneous flap has served as an alternative to abdominally based autologous breast reconstruction since its introduction by Yousif et al in 1992. The reliability of the overlying skin paddle of the gracilis myocutaneous flap depends on the perforator anatomy as well as the vascular pedicle. Although much attention recently has been given to variations in the septocutaneous as well as myocutaneous perforators, we believe that relevant variations in pedicle anatomy have been underappreciated. We would like to report our experience with pedicle variability. A retrospective review of records was performed on patients undergoing a TUG flap for autologous breast reconstruction from July 2006 and November 2011 by a single surgeon (L.C.W.). A total of 36 TUG flaps were performed on 24 patients. Twelve patients underwent bilateral simultaneous TUG reconstruction, and 12 patients underwent unilateral TUG reconstruction. Pedicle variability was found in 6 (17%) of 36 dissections. In 5.5% of dissections, there was a split pedicle and 11% were found to have a double main pedicle. There was 1 partial flap loss that resulted in a failed breast reconstruction. Four limbs had some degree of resultant lymphedema as a consequence of flap harvest. Although still a viable alternative to abdominally based autologous reconstruction, we find that the variability of the main pedicle has been quite underestimated in earlier reports. We also present a logical algorithm for flap dissection when the microsurgeon encounters such aberrancies.

Circumvertical Mastectomy Incision

Different surgical incisions have been proposed for skin-sparing mastectomy in an attempt to better disguise the remaining scar. These techniques are more hidden than the Stewart incision but can still leave scars in visible places and can restrict the natural shape of the upper pole. They can also add complexity and time to the mastectomy, requiring extensive retraction that could damage the salvaged skin flaps to perform an adequate mastectomy. We present a circumvertical mastectomy incision technique, which limits the mastectomy scar to the inferior pole, provides natural lateral contour, superior pole fullness, and contributes to a more youthful breast projection. Between November 2011 and November 2012, 51 women underwent circumvertical AlloDerm/tissue expansion reconstruction at our institution by a single surgeon. The reconstruction was bilateral in 30 patients and unilateral in 21 patients for a total of 81 breasts. Of the 81 reconstructed breasts, 5 patients went on to require a latissimus dorsi flap for definitive reconstruction and 3 failed breast reconstruction for a completion rate of 96%. The goal of creating breast reconstruction results comparable to those of cosmetic breast surgery is becoming a reality. Circumvertical incision is a technique that can prevent visible upper hemispheric breast scarring, limit upper pole constriction by scar placement, and preserves or restores breast projection. Following the principles of aesthetic breast surgery and repositioning the mastectomy scar, one can reconstruct a breast with a more disguised scar, which can be hidden from the patient's downward gaze.

Salvage of the Failed Breast Reconstruction

Failure of a breast reconstruction is a devastating event for both the patient and the physician alike. By the very nature of reconstructive surgery, much is invested by the patient and the surgeon to accomplish a successful breast reconstruction. It is sometimes difficult to think rationally about the fate of a reconstruction once failure looms on the horizon and the decision-making process can become clouded. The reconstructive surgeon must play an active role in the decision-making process regarding salvage of a reconstructed breast versus abandonment of a failed reconstruction. Although many reconstructive options are available, the patient's prognosis, need for adjuvant therapy, physiologic and mental state, and desires must all be factored into any decision regarding the ultimate fate of the breast reconstruction.