Microsurgical restoration of failed or unsatisfactory breast reconstruction: a systematic review and pooled-analysis of outcomes

Abstract

Aim: Autologous tissue transfer to salvage breast reconstruction following a previously failed or unsatisfactory reconstruction has been described by previous studies to be an effective strategy to optimize outcomes. The purpose of this systematic review is to assimilate the relevant literature to evaluate surgical and aesthetic outcomes following autologous breast reconstruction in the setting of a prior unsuccessful reconstruction. Methods: A systematic review of the English literature was performed on Pubmed/MEDLINE to identify all manuscripts reporting surgical outcomes, aesthetic outcomes, or patient satisfaction of autologous breast reconstruction in the setting of a previously failed or unsatisfactory breast reconstruction. Results: Nineteen studies met the criteria for inclusion. Of these, 15 studies reported outcomes following autologous conversion of unsuccessful prosthetic reconstruction (778 breasts). Pooled-analysis of these studies demonstrated total flap loss in 1.6%, microsurgical revision in 3.2%, total complications in 21.7%, and revision surgery in 26.5%. Review of these studies demonstrated high rates of positive aesthetic outcomes and patient satisfaction. Five studies (54 patients) evaluated outcomes following autologous salvage of prior unsuccessful autologous breast reconstruction. Pooled-analysis of these studies demonstrated no instances of microsurgical revision, total complications in 42.2%, and revision surgery in 70.0%. Total flap failure following tertiary reconstruction utilizing microsurgical free flaps occurred in 9.5%. Data describing aesthetic outcomes or patient satisfaction was lacking in these studies. Conclusion: Autologous conversion in the setting of unsuccessful prosthetic breast reconstruction appears to be valuable option to improve outcomes. There is little evidence to suggest that prior prosthetic reconstruction negatively impacts outcomes of autologous breast reconstruction. Data describing autologous breast reconstruction following prior flap loss is limited but suggests it is viable method to salvage breast reconstruction in appropriate patients. ABSTRACT

Topical Tranexamic Acid (TXA) Decreases Time to Drain Removal, Wound Healing Complications, and Postoperative Blood Loss in Autologous Breast Reconstruction: A Retrospective Study

“…With an overall total flap loss of 2.0% in our cohorts, this continues to be consistent with the reported 1% to 2% within the breast reconstruction literature. 45,46 These findings are supported by Valerio et al, 47 who looked at lower extremity reconstruction in combat injuries following TXA use and did not observe any increase in total flap complications or total flap loss. Similar results are reported in Lardi et al, 19 where 98 microsurgical flaps were studied with no increased risk of thrombosis associated with TXA use.…”

A comparison of presentations and outcomes of salvage versus non-salvage abdominal free flap breast reconstructions—Results of a 15-year tertiary referral centre review

“…In cases where implant reconstruction is unsuccessful, suboptimal or ridden with intractable complications, a conversion to autologous tissue (usually a free flap) can be performed; this is termed salvage (or as originally described tertiary), breast reconstruction [ 4 , 8 , 9 , 13 , 16 ]. Salvage breast reconstruction has been deemed challenging for reasons mainly related to patient presentation and intra-operative challenges [ 7 , 9 ].…”

“…Patients referred for salvage breast reconstruction also present with more complex issues such as irradiated scarred skin and soft tissues, severe capsular contracture (CC), silicone lymphadenopathy and scarred internal mammary recipient vessels [ 2 , 9 , 14 , 15 ]. The intraoperative challenges include bleeding from partial or total capsulectomies, scarring interfering with the anastomoses, skin shortage and the need to manage both soft and hard capsules [ 16 , 17 ]. Further problems include management of the pectoralis major muscle, repair of the often-disrupted inframammary fold as well as the correction of poor shape of the breast mound in the context of stiff distorted tissues [ 18 ].…”