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Sergesketter AR, Shammas RL, Tian WM, Glenney A, Sisk GC, Hollenbeck ST. One-Stage Deep Inferior Epigastric Perforator Flap Salvage of Infected Tissue Expanders. Ann Plast Surg 2024; 92:S419-S422. [PMID: 38857007 DOI: 10.1097/sap.0000000000003947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
BACKGROUND Tissue expander-based breast reconstruction is associated with high rates of infectious complications, often leading to tissue expander explants and delays in receipt of definitive breast reconstruction and adjuvant therapy. In this study, we describe a single-stage technique where deep inferior epigastric artery perforator (DIEP) flaps are used to salvage actively infected tissue expanders among patients originally planning for free flap reconstruction. METHODS In this technique, patients with tissue expander infections without systemic illness are maintained on oral antibiotics until the day of their DIEP flap surgery, at which time tissue expander explant is performed in conjunction with aggressive attempt at total capsulectomy and immediate DIEP flap reconstruction. Patients are maintained on 1-2 weeks of oral antibiotics tailored to culture data. Patients undergoing this immediate salvage protocol were retrospectively reviewed, and complications and length of stay were assessed. RESULTS In a retrospective series, a total of six consecutive patients with culture-proven tissue expander infections underwent tissue expander removal and DIEP flap reconstruction in a single stage and were maintained on 7-14 days of oral antibiotics postoperatively. Within this cohort, no surgical site infections, microvascular complications, partial flap losses, reoperations, or returns to the operating room were noted within a 90-day period. CONCLUSIONS Among a select cohort of patients, actively infected tissue expanders may be salvaged with free flap breast reconstruction in a single surgery with a low incidence of postoperative complications. Prospective studies are needed to evaluate the influence of this treatment strategy on costs, number of surgeries, and dissatisfaction after staged breast reconstruction complicated by tissue expander infections.
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Affiliation(s)
- Amanda R Sergesketter
- From the Division of Plastic, Maxillofacial, and Oral Surgery, Duke University, Durham, NC
| | - Ronnie L Shammas
- From the Division of Plastic, Maxillofacial, and Oral Surgery, Duke University, Durham, NC
| | - William M Tian
- From the Division of Plastic, Maxillofacial, and Oral Surgery, Duke University, Durham, NC
| | - Anne Glenney
- Drexel University School of Medicine, Philadelphia, PA
| | - Geoffroy C Sisk
- From the Division of Plastic, Maxillofacial, and Oral Surgery, Duke University, Durham, NC
| | - Scott T Hollenbeck
- Department of Plastic Surgery, University of Virginia, Charlottesville, VA
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2
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Xie Y, Hu X, Du Z, Liang F, Lv Q, Li B. Minimally Invasive and Innovative Management of Prosthesis Infections in Endoscopic-Assisted Breast Reconstruction. Aesthetic Plast Surg 2024; 48:266-272. [PMID: 37605028 DOI: 10.1007/s00266-023-03525-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 07/08/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Implant infection continues to be the most common complication of breast reconstruction, and it can lead to serious consequences of implant loss. Recently, endoscopic-assisted nipple-sparing mastectomy with direct-to-implant breast reconstruction is being performed more frequently, with similar prosthetic infection incidence compared to conventional techniques. But there is little information published in the literature on the management of periprosthetic infection in endoscopic-assisted breast reconstruction. METHODS A retrospective review was performed of patients who underwent endoscope-assisted breast reconstruction and developed periprosthetic infection between January 2020 and December 2022. Prosthesis infection was defined as any case where antibiotics were given, beyond the surgeon's standard perioperative period, in response to clinical signs such as swelling, pain, erythema, increased temperature, fever, etc. We summarized our clinical approach and treatment protocol for periprosthetic infection patients. Collected data include preoperative basic information, surgical details, postoperative data, and outcomes. RESULTS A total of 580 patients (713 reconstructions) underwent endoscopic-assisted immediate breast reconstruction. There were 58 patients developed periprosthetic infection, 14 of whom had bilateral prosthesis reconstruction with unilateral prosthesis infection. The incidence of infection was 10.0%. Average follow-up was 17.3 ± 8.9 months (range = 2-37 months). Of the 58 patients, 53 (91.4%) patients successful salvaged implant and 5(8.6%) patients removed prosthesis. During follow-up, Baker III capsular contracture occurred in 2 patients (3.8%) who had radiotherapy. CONCLUSION Our management of prosthesis infections in endoscopic-assisted breast reconstruction is easy, minimally invasive, and inexpensive. This method can be repeated if the implant infection does not improve after the first drainage. What's more, our data suggest that our prosthesis salvage of periprosthetic infection is effective. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Yanyan Xie
- Department of General Surgery, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, China
- Breast Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoxia Hu
- Department of General Surgery, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, China
- Breast Center, West China Hospital, Sichuan University, Chengdu, China
| | - Zhenggui Du
- Department of General Surgery, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, China
- Breast Center, West China Hospital, Sichuan University, Chengdu, China
| | - Faqing Liang
- Department of General Surgery, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, China
- Breast Center, West China Hospital, Sichuan University, Chengdu, China
| | - Qing Lv
- Department of General Surgery, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, China.
- Breast Center, West China Hospital, Sichuan University, Chengdu, China.
| | - Bo Li
- Department of General Surgery, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, China.
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Mitchell D, Asaad M, Slovacek C, Selber JC, Clemens MW, Chu CK, Mericli AF, Largo RD, Butler CE. Outcomes of Autologous Free Flap Reconstruction Following Infected Device Explantation. J Reconstr Microsurg 2022; 39:327-333. [PMID: 35988578 DOI: 10.1055/s-0042-1755263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Abstract
Background Following implant-based breast reconstruction (IBR) infection and explantation, autologous reconstruction is a common option for patients who desire further reconstruction. However, few data exist about the outcomes of secondary autologous reconstruction (i.e., free flap breast reconstruction) in this population. We hypothesized that autologous reconstruction following infected device explantation is safe and has comparable surgical outcomes to delayed-immediate reconstruction.
Methods We conducted a retrospective analysis of patients who underwent IBR explantation due to infection from 2006 through 2019, followed by secondary autologous reconstruction. The control cohort comprised patients who underwent planned primary delayed-immediate reconstruction (tissue expander followed by autologous flap) in 2018.
Results We identified 38 secondary autologous reconstructions after failed primary IBR and 52 primary delayed-immediate reconstructions. Between secondary autologous and delayed-immediate reconstructions, there were no significant differences in overall complications (29 and 37%, respectively, p = 0.45), any breast-related complications (18 and 21%, respectively, p = 0.75), or any major breast-related complications (13 and10%, respectively, p = 0.74). Two flap losses were identified in the secondary autologous reconstruction group while no flap losses were reported in the delayed-immediate reconstruction group (p = 0.18).
Conclusion Autologous reconstruction is a reasonable and safe option for patients who require explantation of an infected prosthetic device. Failure of primary IBR did not confer significantly higher risk of complications after secondary autologous flap reconstruction compared with primary delayed-immediate reconstruction. This information can help plastic surgeons with shared decision-making and counseling for patients who desire reconstruction after infected device removal.
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Affiliation(s)
- David Mitchell
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Malke Asaad
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Cedar Slovacek
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jesse C. Selber
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mark W. Clemens
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Carrie K. Chu
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Alexander F. Mericli
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rene D. Largo
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Charles E. Butler
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Surgical and Patient-Reported Outcomes of Autologous versus Implant-Based Reconstruction following Infected Breast Device Explantation. Plast Reconstr Surg 2022; 149:1080e-1089e. [PMID: 35349553 DOI: 10.1097/prs.0000000000009091] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Implant-based breast reconstruction infections often require implant explantation. Whereas some plastic surgeons pursue autologous reconstruction following the first implant-based breast reconstruction failure caused by infection, others argue that a second attempt is acceptable. METHODS The authors conducted a retrospective study of patients who underwent a second reconstruction attempt with implant-based or free flap breast reconstruction following explantation because of infection between 2006 and 2019. Surgical and patient-reported outcomes were compared between the two groups. RESULTS A total of 6093 implant-based breast reconstructions were performed during the study period, of which 130 breasts met our inclusion criteria [implant-based, n = 86 (66 percent); free flap, n = 44 (34 percent)]. No significant differences in rates of overall (25 percent versus 36 percent; p = 0.2) or major (20 percent versus 21 percent; p = 0.95) complications were identified between the free flap and implant-based cohorts, respectively. Implant-based breast reconstruction patients were more likely to experience a second infection (27 percent versus 2 percent; p = 0.0007) and reconstruction failure (21 percent versus 5 percent; p = 0.019). Among irradiated patients, reconstruction failure was reported in 44 percent of the implant-based and 7 percent of the free flap cohorts (p = 0.02). Free flap patients reported significantly higher scores for Satisfaction with Breasts (73.7 ± 20.1 versus 48.5 ± 27.9; p = 0.0046). CONCLUSIONS Following implant-based breast reconstruction explantation because of infection, implant-based and free flap breast reconstruction had similar rates of overall and major complications; however, implant-based breast reconstruction had considerably higher rates of infection and reconstructive failures and lower patient-reported scores for Satisfaction with Breasts. Given the high rates of implant-based breast reconstruction failure in patients with prior radiotherapy and infection-based failure, plastic surgeons should strongly consider autologous reconstruction in this patient population. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Schwartz JCD. Salvage of infected implant-based breast reconstructions in morbidly obese patients with explantation and replacement with an autologous muscle-sparing latissimus dorsi flap. JPRAS Open 2022; 32:93-97. [PMID: 35340710 PMCID: PMC8941322 DOI: 10.1016/j.jpra.2022.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 02/27/2022] [Indexed: 11/14/2022] Open
Abstract
Morbidly obese patients who undergo reconstruction with implants after mastectomy are at higher risk of reconstructive failure. Prosthetic infection historically required explantation with plans for delayed implant-based reconstruction or conversion to autologous tissue. Loss of the skin envelope in the delayed setting often leads to poor aesthetic outcomes. Recently, several different approaches for salvage of infected implant-based reconstructions with immediate prosthetic replacement have been described. While these strategies have proven useful in many patients, we find a prohibitive risk of failure of this approach in the morbidly obese, especially in those undergoing chemotherapy or who have been radiated. Instead, we have offered these patients salvage of their reconstructions with explantation and immediate autologous conversion to a muscle-sparing latissimus dorsi flap. Here, we report on 11 morbidly obese patients where this strategy was utilized.
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Miseré RML, van der Hulst RRWJ. Self-Reported Health Complaints in Women Undergoing Explantation of Breast Implants. Aesthet Surg J 2022; 42:171-180. [PMID: 33252630 PMCID: PMC8756082 DOI: 10.1093/asj/sjaa337] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background Concerns about the safety of silicone breast implants (SBIs) have existed for years, but a causal relation between systemic complaints and SBIs has not been proven. Nevertheless, some women are worried and even request explantation. Objectives This study aimed to review the explantation procedures performed, focusing on patient-reported symptoms preoperatively, the effect of explantation, and the effect of breast reconstruction on these symptoms. Methods A retrospective chart review was performed for patients who had undergone explantation between 2010 and 2020 at Maastricht University Medical Center. Patients who had undergone tissue expander removal, tissue expander–implant exchange, or direct implant exchange were excluded. Results More than half of the patients undergoing explantation reported complaints, mostly pain. Some 15% reported systemic complaints they believed were implant related. Breast implant illness (BII) was found to be the fifth most common indication for explantation (11.2%). A history of either allergies or implant rupture resulted in higher odds ratios of having BII (odd ratios, 2.1 and 2.1, respectively). Subjective improvement of BII after explantation was reported by about 60% of patients. Conclusions A relatively low prevalence of suggested BII exists among women undergoing explantation; 1 in 9 procedures were performed for this reason. Allergy and implant rupture may increase the likelihood of having BII. About 60% of BII patients experienced an improvement in their complaints after implant removal. Autologous breast reconstruction appears a good alternative. Prospective studies into health complaints and quality of life should be performed to confirm the effectiveness of explantation as a therapy for BII. Level of Evidence: 4
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Affiliation(s)
- Renée M L Miseré
- From the Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - René R W J van der Hulst
- From the Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
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Marcasciano M, Kaciulyte J, Giuli RD, Marcasciano F, Torto FL, Guerra M, Prà GD, Barellini L, Mazzocchi M, Casella D, Ribuffo D. "Just Pulse it!" Introduction of a conservative implant salvage protocol to manage infection in pre-pectoral breast reconstruction: Case series and literature review. J Plast Reconstr Aesthet Surg 2021; 75:571-578. [PMID: 34794920 DOI: 10.1016/j.bjps.2021.09.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 04/25/2021] [Accepted: 09/27/2021] [Indexed: 10/20/2022]
Abstract
Post-operative implant infection is generally rare after breast augmentation, but it can occur in up to 35% of cases in post-mastectomy breast reconstruction. Standard treatment consists in the administration of antibiotics, implant removal, and delayed prosthesis replacement leading to multiple operations, with a negative impact on patient's clinical, economical, and psychological outcomes. There is little information published in the literature on the management of periprosthetic infection following pre-pectoral reconstructions. Capsule's removal from a pre-pectoral plane brings the risk of excessive tissue thinning and the compromise of skin flaps viability. In this preliminary multi-center case series, eight patients diagnosed with implant infection following oncological mastectomy and two-stage heterologous pre-pectoral breast reconstruction underwent the same protocol, consisting in tissue expander removal and conservative surgical revision supplemented by an antibiotate pulse lavage of the pocket surface. All patients achieved a successful infection resolution with immediate prosthesis replacement switching the temporary expander to definitive implant. No additional surgical revision was registered during follow-up. The intermittent irrigation is meant to disrupt the biofilm structure and restore antibiotic susceptibility. Moreover, pulse lavage allows the cleansing of the prosthetic capsule, thus avoiding the vascular stress associated with subcutaneous capsulectomy. To the best of our knowledge, this is the first series reporting on the use of Pulsavac in periprosthetic infection following pre-pectoral breast reconstruction, in an attempt to set the basis for an alternative conservative protocol to manage breast implant infection. A thorough literature review on pulse lavage in breast surgery was carried out.
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Affiliation(s)
- Marco Marcasciano
- Unità di Oncologia Chirurgica Ricostruttiva della Mammella, "Spedali Riuniti" di Livorno, "Breast Unit Integrata di Livorno, Cecina, Piombino, Elba, Azienda USL Toscana Nord Ovest", Livorno, Italy.
| | - Juste Kaciulyte
- Sapienza University of Rome, Policlinico Umberto I, Department of Surgery "P. Valdoni", Unit of Plastic and Reconstructive Surgery, Roma, Italy; Unit of Plastic and Reconstructive Surgery, Department of Surgery, Ospedale Santa Maria Della, Misericordia, Perugia, Italy
| | - Riccardo Di Giuli
- Unit of Plastic and Reconstructive Surgery, Department of Surgery, Ospedale Santa Maria Della, Misericordia, Perugia, Italy
| | - Fabio Marcasciano
- UOC Chirurgia Plastica e Ricostruttiva, Azienda Ospedaliera San Camillo - Forlanini, Roma, Italy
| | - Federico Lo Torto
- Sapienza University of Rome, Policlinico Umberto I, Department of Surgery "P. Valdoni", Unit of Plastic and Reconstructive Surgery, Roma, Italy
| | - Maristella Guerra
- Unità di Chirurgia Plastica, Polo Ospedaliero Santo Spirito ASL/RME, Roma, Italy
| | - Giovanni Dal Prà
- Unità di Chirurgia Plastica, Polo Ospedaliero Santo Spirito ASL/RME, Roma, Italy
| | - Leonardo Barellini
- Unità di Oncologia Chirurgica Ricostruttiva della Mammella, "Spedali Riuniti" di Livorno, "Breast Unit Integrata di Livorno, Cecina, Piombino, Elba, Azienda USL Toscana Nord Ovest", Livorno, Italy
| | - Marco Mazzocchi
- Unit of Plastic and Reconstructive Surgery, Department of Surgery, Ospedale Santa Maria Della, Misericordia, Perugia, Italy
| | - Donato Casella
- UOC Chirurgia Oncologica della Mammella, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Diego Ribuffo
- Sapienza University of Rome, Policlinico Umberto I, Department of Surgery "P. Valdoni", Unit of Plastic and Reconstructive Surgery, Roma, Italy
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Haque S, Kanapathy M, Bollen E, Mosahebi A, Younis I. Patient-reported outcome and cost implication of acute salvage of infected implant-based breast reconstruction with negative pressure wound therapy with Instillation (NPWTi) compared to standard care. J Plast Reconstr Aesthet Surg 2021; 74:3300-3306. [PMID: 34217644 DOI: 10.1016/j.bjps.2021.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 03/04/2021] [Accepted: 05/24/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Implant loss due to infection is the most devastating complication of implant-based breast reconstruction. The use of negative pressure wound therapy with instillation(NPWTi) for salvage of infected implant-based breast reconstructions has shown promising results allowing early reinsertion of a new implant as an alternative to the current management with delayed reinsertion. This study compares the patient-reported outcome and cost implication of NPWTi to the current management. METHODS Twenty cases of infected breast implants treated with NPWTi(V.A.C. VERAFLO™ Therapy), followed by early reinsertion of new implants were compared to 20 cases that had delayed reinsertion(non-NPWTi). Patient satisfaction was evaluated using the BREAST-Q questionnaire. The average cost per patient was calculated using total operative expense, cost of inpatient stay, investigations, antibiotics, and outpatient visits. RESULTS Treatment with NPWTi allowed earlier reinsertion of a new implant (NPWTi: 10.3 ± 2.77days vs. non-NPWTi: 247.45±111.28days, p<0.001). Patients in the NPWTi group reported higher satisfaction. The average cost per patient for NPWTi and non-NPWTi was £14,343.13±£2,786.70 and £8,920.31±£3,005.73, respectively(p<0.001). All patients treated with NPWTi had one admission and spent 11.9 ± 4.1days as inpatients, while non-NPWTi patients had 2.1 ± 0.3 admissions(p<0.001) and spent 7.1 ± 5.8days(p<0.004) as inpatients. Patients treated with NPWTi had more procedures (NPWTi:3.35±0.81 Vs. non-NPWTi:2.2 ± 0.41, p = 0.006); however, three non-NPWTi cases required flap reconstruction. CONCLUSION Patients treated with NPWTi reported higher satisfaction, received a new and earlier implant, and had fewer admissions and outpatient visits; however, they incurred higher average costs, longer inpatient stays, and underwent more procedures. Early implant reinsertion preserves skin envelope; hence avoiding additional cost and stress related to further major autologous reconstruction.
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Affiliation(s)
- Shameem Haque
- Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London NW3 2QG, United Kingdom
| | - Muholan Kanapathy
- Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London NW3 2QG, United Kingdom; Division of Surgery & Interventional Science, University College London, London, United Kingdom.
| | - Edward Bollen
- UCL Medical School, University College London, London, United Kingdom
| | - Afshin Mosahebi
- Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London NW3 2QG, United Kingdom; Division of Surgery & Interventional Science, University College London, London, United Kingdom
| | - Ibby Younis
- Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London NW3 2QG, United Kingdom
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Patel AA, Arquette CP, Rowley MA, Borrelli MR, Lee GK, Nazerali RS. Comparing Outcomes of Flap-Based Salvage Reconstructions in the Radiated Breast. Ann Plast Surg 2021; 86:S403-S408. [PMID: 33976069 DOI: 10.1097/sap.0000000000002761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Chest wall irradiation significantly decreases the strength and quality of breast tissue supporting prostheses, increasing the risk of skin breakdown and implant or tissue expander extrusion. Autologous tissue, including the latissimus dorsi (LD) or abdominal-based flaps, including the muscle-sparing transverse rectus abdominis myocutaneous or deep inferior epigastric perforator flaps, may be used to salvage reconstructions. However, data comparing outcomes of the two flap options remains limited. We compare postoperative outcomes from both flap types after autologous salvage reconstruction in irradiated breasts. METHODS Charts were retrospectively reviewed from patients who underwent either chest wall radiation or postmastectomy radiation therapy followed by salvage autologous reconstruction with either a LD and an implant or an abdominal-based flap (muscle-sparing transverse rectus abdominis myocutaneous or deep inferior epigastric perforator flaps). Patients with a history of tissue expander or implant failure requiring autologous salvage as part of 2-staged or delayed-immediate breast reconstruction that were operated on between January 2005 and November 2015 were included. Basic demographics, comorbidities, and recipient site complications (infection, wound dehiscence, seroma, hematoma, fat necrosis, and flap failure) were collected. RESULTS A total of 72 patients met the inclusion criteria which included 72 flaps; 35 LD and 37 abdominally based flaps. Demographics and comorbidities did not vary significantly between patient groups. Mean follow-up was 767.6 weeks, and all reconstructions were unilateral. Nineteen (26.4%) patients had at least one complication, most commonly minor infections (9.7%). Overall complication rates were not significantly different between flap groups (P = 0.083). Wound dehiscence was significantly higher in the abdominal group (P = 0.045), and fat necrosis also trended higher in this group (P = 0.085). Major infection trended higher in the latissimus group (P = 0.069). CONCLUSIONS When comparing outcomes of salvage flap-based reconstruction in radiated breast tissue, overall complication rates were similar when comparing postoperative outcomes between the LD- and abdominal-based flaps. Wound dehiscence was significantly higher when salvage reconstruction used an abdominal flap. Understanding the complications after salvage procedures can help inform decision making and optimize patient care to improve outcomes after breast reconstruction in the radiated breast.
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Affiliation(s)
| | - Connor P Arquette
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Mallory A Rowley
- From the College of Medicine, SUNY Upstate Medical University, Syracuse, NY
| | - Mimi R Borrelli
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Gordon K Lee
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Rahim S Nazerali
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, Stanford, CA
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10
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Bijkerk E, Lopez Penha TR, van der Hulst RRWJ, Tuinder SMH. Rerouting of the pectoralis major muscle for breast animation deformity in sub-pectoral autologous breast reconstruction: A case report and review of the literature. Int J Surg Case Rep 2020; 77:28-31. [PMID: 33137667 PMCID: PMC7610019 DOI: 10.1016/j.ijscr.2020.10.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 10/09/2020] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Breast animation deformity (BAD) is a known complication of sub-pectoral implant placement that is usually corrected by simply repositioning the implant to a pre-pectoral position. However, when this complication occurs in the case of a sub-pectorally placed free-flap, the solution becomes a lot less straightforward: repositioning of the flap carries the risk of possible damage to the pedicle. In order to avoid having to re-do the anastomoses we opted for a rerouting of the pectoralis major muscle around the vascular anastomoses. PRESENTATION OF CASE We present a 26-year old patient with unsatisfactory aesthetic outcomes of her bilateral deep inferior epigastric perforator (DIEP) flap breast reconstruction. The flaps were placed sub-pectorally, in the already existing pocket that was created during her first breast reconstruction with silicone implants, resulting in severe BAD. Repositioning the free flap from the sub-pectoral to the pre-pectoral plane allowed for reinsertion of the pectoralis major muscle to its anatomical position without jeopardizing the vascular anastomoses. The patient was satisfied with the increased projection of the breasts. DISCUSSION Changing the plane from sub-pectoral to pre-pectoral remains the best treatment option for patients experiencing BAD. In combination with an acellular dermal matrix, this would have been a good option for our patient. However, when choosing to perform autologous breast reconstruction instead, our recommendation would be to always place the flap in the pre-pectoral plane to avoid BAD. CONCLUSION The report shows that the plane of a flap can be successfully changed without jeopardizing the pedicle of the flap.
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Affiliation(s)
- Ennie Bijkerk
- Department of Plastic and Reconstructive Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
| | - Tiara R Lopez Penha
- Department of Plastic and Reconstructive Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - René R W J van der Hulst
- Department of Plastic and Reconstructive Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
| | - Stefania M H Tuinder
- Department of Plastic and Reconstructive Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands.
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11
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Marquez MDLP, Fernandez-Riera R, Cardona HV, Flores JMR. Immediate implant replacement with DIEP flap: a single-stage salvage option in failed implant-based breast reconstruction. World J Surg Oncol 2018; 16:80. [PMID: 29665804 PMCID: PMC5905049 DOI: 10.1186/s12957-018-1387-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 04/10/2018] [Indexed: 11/23/2022] Open
Abstract
Background Implant-based immediate breast reconstruction after skin-sparing mastectomy has shown a significant improvement in patients’ quality of life, making the procedure steadily more popular year after year. However, this technique has a high morbidity rate, including skin necrosis and implant exposure. Methods A retrospective review of a prospectively held database for autologous breast reconstruction in our institution of the last 5 years found eight cases with exposed implants after nipple-sparing mastectomy and immediate reconstruction. A single-stage procedure consisting on implant removal and immediate replacement with a deepithelialized DIEP flap was performed in all cases (10 DIEP flaps). Results All flaps were successful. Patients’ mean age was 45 years old. Three patients developed seroma (5, 7, and 14 days after surgery, respectively). No infections were detected in up to 24 months of follow-up. Conclusions Nipple-sparing mastectomy with immediate implant-based reconstruction is considered oncologically safe. However, it has a high rate of complications that could require implant removal. Immediate free flap reconstruction is a feasible and safe option to replace the missing volume with low risk of complications that result in a soft and natural-shaped breast.
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Affiliation(s)
- Miguel De La Parra Marquez
- Division of Plastic and Reconstructive Surgery, Mexican Institute of Social Security (IMSS), No. 21 Pino Suárez y 15 de Mayo, Av. Hidalgo 2480 pte, col. Obispado. C.p.64060. Cons. 212, Monterrey Nuevo León, Mexico.
| | - Ricardo Fernandez-Riera
- Department of Plastic and Reconstructive Surgery, Hospital General Dr. Ruben Leñero, Plan de San Luis esq Salvador Díaz Mirón SN, Col. Santo Tomás. Deleg. Miguel Hidalgo. Cp. 11340. CDMX, Mexico City, Mexico
| | - Hector Vela Cardona
- Division of Plastic and Reconstructive Surgery, Mexican Institute of Social Security (IMSS), No. 21 Pino Suárez y 15 de Mayo, Av. Hidalgo 2480 pte, col. Obispado. C.p.64060. Cons. 212, Monterrey Nuevo León, Mexico
| | - Jesus María Rangel Flores
- Division of Plastic and Reconstructive Surgery, Mexican Institute of Social Security (IMSS), No. 21 Pino Suárez y 15 de Mayo, Av. Hidalgo 2480 pte, col. Obispado. C.p.64060. Cons. 212, Monterrey Nuevo León, Mexico
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