Outcomes of Take-Back Operations in Breast Reconstruction with Free Lower Abdominal Flaps

Abstract

BackgroundMicrovascular complications after free-flap breast reconstructions are potentially devastating problems that can increase patient morbidity and lead to flap loss. To date, no comprehensive study has examined the rates of salvage and the methods of microvascular revision in breast reconstruction. We reviewed the treatment of microvascular complications of free-flap breast reconstruction procedures over a seven-year period.MethodsA retrospective review of all patients who underwent microvascular breast reconstruction at our institution between April 2006 and December 2013 was conducted. Based on their surgical records, all patients who required emergency re-exploration were identified, the rate of flap salvage was determined, the factors associated with flap salvage were evaluated, and the causes and methods of revision were reviewed.ResultsDuring the review period, 605 breast reconstruction procedures with a free lower abdominal flap were performed. Seventeen of these flaps were compromised by microvascular complications, and three flaps were lost. The overall salvage rate was 82.35%. No significant differences between the salvaged group and the failed group were observed with regard to age, BMI, axillary dissection, number of anastomotic arteries and veins, recipient vessel types, or use of the superficial inferior epigastric vein in the revision operation. Successful salvage of the flap was associated with a shorter time period between recognizing the signs of flap compromise and the take-back operation.ConclusionsThe salvage rate of compromised lower abdominal flaps was high enough to warrant attempting re-exploration. Immediate intervention after the onset of flap compromise signs is as important as vigilant postoperative monitoring.

Reducing Length of Stay after Microsurgical Breast Reconstruction with a Standardized Postoperative Protocol

“…We noted a flap salvage rate of 33%, with earlier identification of flap compromise being associated with higher rates of flap salvage. 20,22,80,85,93,102,103 The incidence of hematomas requiring operative intervention was also comparable to other studies: chest hematomas occurred at a rate of 1.86% and abdominal hematomas at a rate of 0.62%. 84,91,94,96,104 Protocol Success There is no single "key" element of our protocol which is the source of its success.…”

“…20,[79][80][81][82][83] In large-scale studies, rates of postoperative vascular complications requiring unplanned reoperation vary significantly from 1.8 to 9.1%. 78,[84][85][86][87][88][89][90][91][92][93][94] Experienced microvascular surgeons report free flap failure rates between 0.7 and 2.9%. 84,[86][87][88][89][91][92][93][94][95][96][97][98][99][100][101] The present study demonstrated similar incidences of 1.86 and 0.69%, respectively.…”

Lessons Learned from 30 Years of Transverse Myocutaneous Gracilis Flap Breast Reconstruction: Historical Appraisal and Review of the Present Literature and 300 Cases

“…Flap take-backs to theatre due to venous or arterial insufficiency were recorded in 14.0% of patients (42/300) and were successful in 55.8% of patients. This confirms lower rates of successful flap salvage in TMG flaps compared to DIEP flaps [24]. A potential reduction of fat necrosis in PAP flaps due to a more centralized perforator in the skin island is still discussed but exact perfusion studies to quantify the blood flow through the individual angiosome have not been conducted so far [22].…”

The Outpatient DIEP: Safety and Viability following a Modified Recovery Protocol

“…Even in the event that a failing flap is salvaged, we feel and have found in our experience that there is a critical amount of ischemia and reperfusion injury resulting in significant fat necrosis and unacceptable aesthetic and functional results, thus raising the question of the value of delayed flap salvage past the 23-hour window. 21 It is due to this fact that we believe routine monitoring is not necessary after 23 hours.…”