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Complications in Delayed Breast Reconstruction after Irradiation: A Comparison of Abdominal flaps and Latissimus flaps with tissue expanders
Steven M. Levine, M.D.1, Nima Patel, M.D.2, Joseph J. Disa, M.D.2.
1NYU Langone Medical Center, New York, NY, USA, 2Memoral Sloan-Kettering Cancer Center, New York, NY, USA.
Mastectomy after breast conservation therapy and post mastectomy radiation without immediate reconstruction result in the need for delayed reconstruction in the setting of a previously irradiated chest wall. Though multiple methods of reconstruction are possible in this scenario, it is generally agreed that autologous reconstruction provides the most reliable results. The goal of the authors' study was to compare complications in delayed abdominal-based (TRAM/DIEP) reconstruction with delayed latissimus dorsi plus tissue expander-based reconstruction in this setting.
The authors reviewed 133 consecutive delayed breast reconstructions performed in patients who received either whole-breast irradiation or post mastectomy irradiation. Reconstructive techniques were abdominal-based methods (single-pedicle TRAM, super-charged pedicle TRAM, muscle-sparing TRAM free flap, DIEP flap, and SIEA flap) or a pedicled latissimus dorsi flap plus tissue expander. Complications for donor and recipient sites were recorded including infection, seroma, hematoma, and partial flap loss. Abdominal-based reconstructions were considered to have failed if the flap had to be removed and replaced with an alternative reconstruction. Latissimus dorsi flaps plus implant reconstructions were considered to have failed if an implant was lost because of extrusion, infection, or rupture or if implant exchange was required because of a severe capsular contracture.
Seventy-five patients were reconstructed with abdominal-based flaps (37 muscle-sparing free TRAMs, 19 pedicled TRAMs, 12 DIEPs, 6 super-charged pedicled TRAMs, 1 SIEA). Their median age was 50 years and mean follow-up was 22.7 months. Three patients (4.0%) (2 MS-free TRAMs, 1 single-pedicle TRAM) required re-operation during the same hospital visit for vascular compromise, which resulted in 2 (2.7%) (1 MS-free TRAM, 1 single-pedicle TRAM) flap failures. Three patients (4.0%) (1 MS-TRAM, 2 single-pedicle TRAMs) had partial flap loss that ultimately required debridement and primary closure. Seventeen patients (22.7%) had minor complications including seroma, small hematoma, cellulitis, and abdominal bulge.
Fifty-six patients were reconstructed with latissimus dorsi flaps plus tissue expanders. Their median age was 47 years and mean follow-up was 32 months. Three patients developed infections that resulted in expander loss (5.4%). Four patients (7.1%) had partial flap loss that required debridement and primary closure. Thirteen patients (23.2%) had minor complications including seroma (12 patients) and hematoma (1 patient) that required drainage. Fisher’s exact test was used to determine statistical significance of complication and failure rates between the two types of reconstruction. In patients who had undergone preoperative irradiation, patients with abdominal-based reconstructions had fewer complications compared with latissimus dorsi flap plus tissue expander reconstructions (28.0% percent versus 30.4% percent, p = .846). Also, fewer reconstructions failed in patients with abdominal-based reconstruction (2.7% versus 5.4 percent, p =.650).
Abdominal-based autologous reconstruction had fewer complications and fewer reconstruction failures than latissimus dorsi flap plus tissue expander reconstructions in patients with previously irradiated breasts in our series; however these rates were not statistically significant. Both methods appear to be effective strategies for delayed breast reconstruction in the setting of prior irradiation.
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