Outcomes of Autologous Free Flap Reconstruction Following Infected Device Explantation

 

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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.

Publication History

Received: 18 February 2021

Accepted: 29 May 2022

Article published online:
21 August 2022

© 2022. Thieme. All rights reserved.

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• References

• 1 American Society of Plastics Surgeons. Plastic surgery statistics report. Am Soc Plast Surg 2014; 2014: 1-23
  PubMedGoogle Scholar
• 2 Sigurdson L, Lalonde DH. MOC-PSSM CME article: breast reconstruction. Plast Reconstr Surg 2008; 121 (1, Suppl): 1-12
  CrossrefPubMedGoogle Scholar
• 3 Serletti JM, Fosnot J, Nelson JA, Disa JJ, Bucky LP. Breast reconstruction after breast cancer. Plast Reconstr Surg 2011; 127 (06) 124e-135e
  CrossrefPubMedGoogle Scholar
• 4 Spear SL, Mardini S, Ganz JC. Resource cost comparison of implant-based breast reconstruction versus TRAM flap breast reconstruction. Plast Reconstr Surg 2003; 112 (01) 101-105
  CrossrefPubMedGoogle Scholar
• 5 Lagares-Borrego A, Gacto-Sanchez P, Infante-Cossio P, Barrera-Pulido F, Sicilia-Castro D, Gomez-Cia T. A comparison of long-term cost and clinical outcomes between the two-stage sequence expander/prosthesis and autologous deep inferior epigastric flap methods for breast reconstruction in a public hospital. J Plast Reconstr Aesthet Surg 2016; 69 (02) 196-205
  CrossrefPubMedGoogle Scholar
• 6 Liu C, Momeni A, Zhuang Y. et al. Outcome analysis of expander/implant versus microsurgical abdominal flap breast reconstruction: a critical study of 254 cases. Ann Surg Oncol 2014; 21 (06) 2074-2082
  CrossrefPubMedGoogle Scholar
• 7 Gabriel SE, Woods JE, O'Fallon WM, Beard CM, Kurland LT, Melton III LJ. Complications leading to surgery after breast implantation. N Engl J Med 1997; 336 (10) 677-682
  CrossrefPubMedGoogle Scholar
• 8 Selber JC, Wren JH, Garvey PB. et al. Critical evaluation of risk factors and early complications in 564 consecutive two-stage implant-based breast reconstructions using acellular dermal matrix at a single center. Plast Reconstr Surg 2015; 136 (01) 10-20
  CrossrefPubMedGoogle Scholar
• 9 Ibrahim AMS, Shuster M, Koolen PGL. et al. Analysis of the National Surgical Quality Improvement Program database in 19,100 patients undergoing implant-based breast reconstruction: complication rates with acellular dermal matrix. Plast Reconstr Surg 2013; 132 (05) 1057-1066
  CrossrefPubMedGoogle Scholar
• 10 Coroneos CJ, Selber JC, Offodile II AC, Butler CE, Clemens MW. FDA breast implant post-approval studies: long term outcomes in 99,993 patients. Ann Surg 2019; 269 (01) 30-36
  CrossrefPubMedGoogle Scholar
• 11 Banuelos J, Esquer-Garrigos Z, Sohail MR. et al. Diagnosis of infectious fluid collections in implant-based breast reconstruction: the role of ultrasound. J Breast Imaging 2019; 1 (04) 310-315
  CrossrefPubMedGoogle Scholar
• 12 Banuelos J, Abu-Ghname A, Asaad M, Vyas K, Sohail MR, Sharaf B. Microbiology of implant-based breast reconstruction infections: a systematic review. Ann Plast Surg 2020; 85 (02) 194-201
  CrossrefPubMedGoogle Scholar
• 13 Halvorson EG, Disa JJ, Mehrara BJ, Burkey BA, Pusic AL, Cordeiro PG. Outcome following removal of infected tissue expanders in breast reconstruction: a 10-year experience. Ann Plast Surg 2007; 59 (02) 131-136
  CrossrefPubMedGoogle Scholar
• 14 Reish RG, Damjanovic B, Austen Jr WG. et al. Infection following implant-based reconstruction in 1952 consecutive breast reconstructions: salvage rates and predictors of success. Plast Reconstr Surg 2013; 131 (06) 1223-1230
  CrossrefPubMedGoogle Scholar
• 15 Bennett KG, Qi J, Kim HM, Hamill JB, Pusic AL, Wilkins EG. Comparison of 2-year complication rates among common techniques for postmastectomy breast reconstruction. JAMA Surg 2018; 153 (10) 901-908
  CrossrefPubMedGoogle Scholar
• 16 Tsoi B, Ziolkowski NI, Thoma A, Campbell K, O'Reilly D, Goeree R. Safety of tissue expander/implant versus autologous abdominal tissue breast reconstruction in postmastectomy breast cancer patients: a systematic review and meta-analysis. Plast Reconstr Surg 2014; 133 (02) 234-249
  CrossrefPubMedGoogle Scholar
• 17 Poppler LH, Mundschenk MB, Linkugel A, Zubovic E, Dolen UC, Myckatyn TM. Tissue expander complications do not preclude a second successful implant-based breast reconstruction. Plast Reconstr Surg 2019; 143 (01) 24-34
  CrossrefPubMedGoogle Scholar
• 18 Levine SM, Lester ME, Fontenot B, Allen Sr RJ. Perforator flap breast reconstruction after unsatisfactory implant reconstruction. Ann Plast Surg 2011; 66 (05) 513-517
  CrossrefPubMedGoogle Scholar
• 19 Mohan AT, Al-Ajam Y, Mosahebi A. Trends in tertiary breast reconstruction: literature review and single centre experience. Breast 2013; 22 (02) 173-178
  CrossrefPubMedGoogle Scholar
• 20 Visser NJ, Damen THC, Timman R, Hofer SOP, Mureau MAM. Surgical results, aesthetic outcome, and patient satisfaction after microsurgical autologous breast reconstruction following failed implant reconstruction. Plast Reconstr Surg 2010; 126 (01) 26-36
  CrossrefPubMedGoogle Scholar
• 21 Holmes WJM, Quinn M, Emam AT, Ali SR, Prousskaia E, Wilson SM. Salvage of the failed implant-based breast reconstruction using the deep inferior epigastric perforator flap: a single centre experience with tertiary breast reconstruction. J Plast Reconstr Aesthet Surg 2019; 72 (07) 1075-1083
  CrossrefPubMedGoogle Scholar
• 22 Bramhall RJ, Hernan I, Harris PA. A single-centre, retrospective proof-of-concept review of salvage of infected or exposed implant breast reconstructions with explantation and one-stage free flap replacement. J Plast Reconstr Aesthet Surg 2018; 71 (02) 194-200
  CrossrefPubMedGoogle Scholar
• 23 CDC, Ncezid. DHQP. CDC/NHSN Surveillance Definitions for Specific Types of Infections. Published 2020. Accessed August 13, 2020 at: https://www.cdc.gov/nhsn/pdfs/pscmanual/17pscnosinfdef_current.pdf
  PubMedGoogle Scholar
• 24 Gill PS, Hunt JP, Guerra AB. et al. A 10-year retrospective review of 758 DIEP flaps for breast reconstruction. Plast Reconstr Surg 2004; 113 (04) 1153-1160
  CrossrefPubMedGoogle Scholar
• 25 Knox ADC, Ho AL, Leung L. et al. Comparison of outcomes following autologous breast reconstruction using the DIEP and pedicled TRAM flaps: a 12-year clinical retrospective study and literature review. Plast Reconstr Surg 2016; 138 (01) 16-28
  CrossrefPubMedGoogle Scholar
• 26 Fischer JP, Nelson JA, Cleveland E. et al. Breast reconstruction modality outcome study: a comparison of expander/implants and free flaps in select patients. Plast Reconstr Surg 2013; 131 (05) 928-934
  CrossrefPubMedGoogle Scholar
• 27 Hamdi M, Casaer B, Andrades P. et al. Salvage (tertiary) breast reconstruction after implant failure. J Plast Reconstr Aesthet Surg 2011; 64 (03) 353-359
  CrossrefPubMedGoogle Scholar
• 28 Zhao R, Tran BNN, Doval AF. et al. A multicenter analysis examining patients undergoing conversion of implant-based breast reconstruction to abdominally based free tissue transfer. J Reconstr Microsurg 2018; 34 (09) 685-691
  Article in Thieme ConnectPubMedGoogle Scholar
• 29 Roostaeian J, Yoon AP, Ordon S. et al. Impact of prior tissue expander/implant on postmastectomy free flap breast reconstruction. Plast Reconstr Surg 2016; 137 (04) 1083-1091
  CrossrefPubMedGoogle Scholar
• 30 Lee K-T, Mun G-H. Prosthetic breast reconstruction in previously irradiated breasts: a meta-analysis. J Surg Oncol 2015; 112 (05) 468-475
  CrossrefPubMedGoogle Scholar
• 31 Tallet AV, Salem N, Moutardier V. et al. Radiotherapy and immediate two-stage breast reconstruction with a tissue expander and implant: complications and esthetic results. Int J Radiat Oncol Biol Phys 2003; 57 (01) 136-142
  CrossrefPubMedGoogle Scholar
• 32 Chen TA, Momeni A, Lee GK. Clinical outcomes in breast cancer expander-implant reconstructive patients with radiation therapy. J Plast Reconstr Aesthet Surg 2016; 69 (01) 14-22
  CrossrefPubMedGoogle Scholar
• 33 Brooks S, Djohan R, Tendulkar R, Nutter B, Lyons J, Dietz J. Risk factors for complications of radiation therapy on tissue expander breast reconstructions. Breast J 2012; 18 (01) 28-34
  CrossrefPubMedGoogle Scholar
• 34 Garvey P, Clemens M, Hoy A, Kronowitz S, Butler C. Designing a breast reconstruction as a MS FTRAMrather than a DIEP is not protective against radiation damage. Plast Reconstr Surg 2013; 132 (02) 509
  CrossrefPubMedGoogle Scholar
• 35 Evans GRD, Schusterman MA, Kroll SS. et al. Reconstruction and the radiated breast: is there a role for implants?. Plast Reconstr Surg 1995; 96 (05) 1111-1115 , discussion, 1116–1118
  CrossrefPubMedGoogle Scholar
• 36 Clemens MW, Kronowitz SJ. Current perspectives on radiation therapy in autologous and prosthetic breast reconstruction. Gland Surg 2015; 4 (03) 222-231
  PubMedGoogle Scholar
• 37 Fracol ME, Basta MN, Nelson JA. et al. Bilateral free flap breast reconstruction after unilateral radiation comparing intraoperative vascular complications and postoperative outcomes in radiated versus nonradiated breasts. Ann Plast Surg 2016; 76 (03) 311-314
  CrossrefPubMedGoogle Scholar
• 38 Fosnot J, Fischer JP, Smartt Jr JM. et al. Does previous chest wall irradiation increase vascular complications in free autologous breast reconstruction?. Plast Reconstr Surg 2011; 127 (02) 496-504
  CrossrefPubMedGoogle Scholar
• 39 Halle M, Ekström M, Farnebo F, Tornvall P. Endothelial activation with prothrombotic response in irradiated microvascular recipient veins. J Plast Reconstr Aesthet Surg 2010; 63 (11) 1910-1916
  CrossrefPubMedGoogle Scholar
• 40 Clemens MW, Evans KK, Mardini S, Arnold PG. Introduction to chest wall reconstruction: anatomy and physiology of the chest and indications for chest wall reconstruction. Semin Plast Surg 2011; 25 (01) 5-15
  Article in Thieme ConnectPubMedGoogle Scholar
• 41 Clemens M, Evans K, Mardini S, Salgado C. In: Levine P, Wei F. eds. Fasciocutaneous Versus Muscle Flap in Soft Tissue Reconstruction of the Lower Extremity. Elsevier; 2013