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Management of Mastectomy Skin Flap Necrosis Following Immediate Implant-Based Reconstruction: An Early Intervention Strategy Improves Salvage
Alexey Markelov, Sameer Shakir, Jr., Wendy Chen, Kenneth Shestak.
University of Pittsburgh Medical Center, Pittsburgh, PA, USA.

Implant-based breast reconstruction remains a popular and effective reconstructive technique following mastectomy for treatment or prophylaxis of breast cancer. Mastectomy flap necrosis remains one of the most frequent complications of this technique often leading to an early failure of tissue expander-implant reconstruction plan. This study compares the outcomes of different management strategies for addressing mastectomy skin loss as a function of time after the mastectomy and tissue expander insertion, which we have used at our institution.
This is a retrospective cohort study. We reviewed single surgeon experience in the last 6 years, with 251 consecutive patients who underwent immediate implant-based reconstruction. Pre-operative co-morbidities including smoking habits, diabetes, previous radiation therapy, and any history of previous breast surgery were recorded for each patient along with outcomes (salvage vs. non-salvage of tissue expander) following immediate (< 10 days post-op) vs. delayed intervention (> 10 days post-op) were recorded for each patient.
9.1% of the patients (N=23) developed mastectomy skin flap necrosis. The overall implant salvage rate in our cohort was 65%. Surgical intervention performed within 10 days from the initial operation resulted in salvage in 15/16 or 94 %. Delay in operative management lead to significantly higher rates of implant loss 6/7 of 85.8%. In 17.4% or 4/23 of patients the extent of the skin loss mandated a tissue added strategy and reconstruction and in these patients the reconstruction was salvaged with a latissimus dorsi flap musculo-cutaneous flap. Our individual case analysis reveals that new tissue introduction is essential in cases with skin tissue necrosis more than 6 cm in vertical dimension.
Tissue expander salvage is the best option to preserve the form and size of the existing skin envelope following skin-sparing mastectomy and immediate tissue placement. Our data strongly suggest that early intervention is the key to implant salvage especially in a face of impending biological tissue matrix or expander exposure. Furthermore delay in surgical intervention in patients with mastectomy skin flap necrosis appears to increase expander loss and reconstruction failure. In cases of extensive skin necrosis measuring greater than 6 cm the introduction of new tissue in the form of a vascularized flap increases the success rate of implant salvage.

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