Tertiary Breast Reconstruction for Salvage of the Failed Implant-Based Reconstruction Using the Deep Inferior Epigastric Perforator Flap

A Multicenter Analysis Examining Patients Undergoing Conversion of Implant-based Breast Reconstruction to Abdominally based Free Tissue Transfer

We have read, with great pleasure, the recent article by Zhao et al entitled “A Multicenter Analysis Examining Patients Undergoing Conversion of Implant-Based Breast Reconstruction to Abdominally Based Free Tissue Transfer.”[1] The authors conclude that abdominal free tissue transfer remains a safe and effective salvage modality for implant-based reconstruction (IBR) failure and that a history of radiation is common in patients presenting with severe implant failure.

It is clear that while immediate IBR is portrayed as an attractive option for young patients, this study highlights the limited longevity and durability of IBR, with many patients developing complications and seeking alternative reconstruction. It is concerning that 35.4% of their referrals experienced tissue expander failure before exchange to implant despite a failure rate of 64.6% after exchange. However, the authors do not report on length of follow-up, number of ancillary or salvage procedures performed prior to referral—were these data collected? It is important these aspects are reported on, as patients can be subjected to multiple failed salvage operations.

We recently performed a 10-year retrospective analysis of our single institution's experience with tertiary reconstruction in 151 patients. Our median follow-up was 20 months (range: 4 months–7 years). During this time, 34% of patients had additional ipsilateral procedures to salvage a failed IBR prior to referral for tertiary reconstruction with a deep inferior epigastric perforator (DIEP) flap.[2] Of these, a median number of two additional procedures (range: 1–10) were performed prior to referral. In those who received radiotherapy, the number of salvage attempts was significantly less, in keeping with a lower threshold for referral in the setting of irradiated skin— 48.7% versus 29% (p = 0.0278). This is burdensome for patients and costly for health care provision. The primary reason for additional surgery in our series was infection salvage, capsulectomies, size adjustment, and patient dissatisfaction. As shown in this study by Zhao et al, we also found that radiotherapy is a significant risk factor for implant failure. In view of this, we advocate prompt referral for consideration of autologous reconstruction in all cases of failed reconstruction, prior to consideration to adjuvant salvage attempts and caution against the use of IBR when radiotherapy is planned. We share the authors reticence of adjuvant fat transfer for radiation fibrosis in the context of IBR which may preclude the abdomen as a donor and thus limit tertiary options.

The authors state in their introduction that failed IBR has deleterious physical and psychosocial effects on patients; however, no patient reported outcome measures (PROM's) was reported. We have compared PROM's following tertiary reconstruction versus delayed DIEP using the Breast-Q and have found that the preoperative scores for the failed implant group are similar to those with mastectomy only across all four domains ([Fig. 1]). At 3 months, we show that the tertiary reconstruction offers improved scores across the domain of breast satisfaction, psychosocial wellbeing, sexual wellbeing, and physical wellbeing but not as high as those who elect to have delayed reconstruction.[3] In the era of shared decision making it is important this information is communicated to patients.

Fig. 1 Bar charts demonstrating the difference between the Breast-Q scores in (A) tertiary and (B) delayed reconstruction groups with 95% confidence intervals displayed. Significant improvement across the four domains that is maintained at 3 months. postop, postoperative; preop, preoperative.

• References

• 1 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
• 2 Holmes W, Quinn M, Emam A, Ali S, Prousskaia E, Wilson S. Salvage of the failed implant breast reconstruction using the deep inferior epigastric perforator flap. A single centre experience with tertiary breast reconstruction. Paper presented at: Association of Breast Surgery Conference 2018 Annual Meeting; June 18–19, 2018; Birmingham. Available at: https://www.ejso.com/article/S0748-7983(18)30712-1/fulltext . Accessed November 21, 2018
• 3 Holmes W, Quinn M, Ali S. , et al. A comparison of PROMS following tertiary (salvage) DIEP breast reconstruction vs delayed DIEP breast reconstruction using the Breast-Q. Paper presented at: Association of Breast Surgery Conference 2018 Annual Meeting; June 18–19, 2018; Birmingham. Available at: https://www.ejso.com/article/S0748-7983(18)30713-3/fulltext . Accessed November 21, 2018