Management of Mastectomy Skin Flap Necrosis in Autologous Breast Reconstruction

Nykiel, Matthew; Sayid, Zahra; Wong, Ryan; Lee, Gordon K.

doi:10.1097/sap.0000000000000174

Cited by 40 publications

(23 citation statements)

References 14 publications

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“…The risk of further operation in order to expedite wound healing must be weighed up against a protracted course of wound healing, requiring long-term dressing care. Some feel that patients at a higher risk of MSFN, or with full-thickness defects, should be treated more aggressively 9. Patients awaiting the timely administration of adjuvant therapy may benefit from operative management to try and expedite wound healing 101…”

Section: Resultsmentioning

confidence: 99%

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Mastectomy skin flap necrosis: challenges and solutions

Robertson¹,

Jeevaratnam²,

Agrawal³

et al. 2017

BCTT

102

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IntroductionMastectomy skin flap necrosis (MSFN) has a reported incidence of 5%–30% in the literature. It is often a significant and underappreciated problem. The aim of this article was to review the associated challenges and possible solutions.MethodsA MEDLINE search was performed using the search term “mastectomy skin flap necrosis”. Titles and abstracts from peer-reviewed publications were screened for relevance.ResultsMSFN is a common complication and may present as partial- or full-thickness necrosis. Predictive patient risk factors include smoking, diabetes, obesity, radiotherapy, previous scars and severe medical comorbidity. MSFN leads to a number of challenges, including wound management problems, delays to adjuvant therapy, esthetic compromise, implant extrusion, patient distress and financial loss. Careful preoperative planning and meticulous surgical technique may reduce the incidence of MSFN. A number of intraoperative techniques are available to try and predict skin flaps at risk of MSFN. MSFN may be managed operatively or nonoperatively. Early intervention may reduce the morbidity of MSFN in selected cases. Topical nitroglycerin ointment may be beneficial in reducing MSFN following immediate reconstruction, but the evidence base is still limited.ConclusionMSFN can result in considerable challenges for the patient and the health care service. This review discusses the management options for this problem.

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Section: Resultsmentioning

confidence: 99%

“…Where the risk of MSFN is considered to be very high during mastectomy, other operative management strategies may involve the use of skin banking104 or skin grafts, which may be split or full thickness, using redundant abdominal dog ear tissue, for example 9…”

Section: Resultsmentioning

confidence: 99%

Mastectomy skin flap necrosis: challenges and solutions

Robertson¹,

Jeevaratnam²,

Agrawal³

et al. 2017

BCTT

102

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show abstract

“…We previously reported a mastectomy skin necrosis rate of 21.7% following immediate hybrid breast reconstruction . It is noteworthy, however, that the notion that the hybrid approach might have contributed to an increased rate of mastectomy skin necrosis does not seem warranted, particularly in light of reports of mastectomy skin necrosis rates of up to 30% following conventional autologous breast reconstruction . While mastectomy skin necrosis following hybrid reconstruction can be managed expectantly as the implant is covered by vascularized tissue and, thus, separated from the area of necrosis, the cosmetic outcome may be compromised.…”

Section: Discussionmentioning

confidence: 99%

“…This challenge is further compounded in those desiring larger breasts postreconstruction. In addition to the challenge of estimating how much larger the patient desires to be, anatomic limitations exist as stretch of the mastectomy skin flap beyond its preoperative boundaries is likely to increase the incidence of mastectomy skin necrosis, which is reported to occur in up to 30% of cases, even after conventional autologous reconstruction …”

Section: Introductionmentioning

confidence: 99%

Delayed‐immediate hybrid breast reconstruction—Increasing patient input and precision in breast reconstruction

Momeni

Kanchwala

2019

Breast J

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The benefits of breast reconstruction via free tissue transfer with simultaneous implant placement, that is, hybrid breast reconstruction, in select patients are well‐known. Challenges exist, however, and are related to proper implant selection as well as postoperative mastectomy skin necrosis. Here, the authors present an approach that increases reconstructive precision while minimizing postoperative mastectomy skin necrosis. A retrospective analysis of patients who underwent immediate prepectoral tissue expander placement (stage 1) followed by delayed‐immediate hybrid breast reconstruction (stage 2) was performed. Parameters of interest included patient demographics, postoperative complications, and revision rates. A total of 31 patients with a mean age of 48.7 years (range, 30‐67 years) and a mean BMI of 26.3 kg/m2 (range, 21.0‐35.3 kg/m2) who underwent bilateral breast reconstruction were included. Of the 62 free abdominal flaps, 45 (72.6%) and 17 (27.4%) were MS‐TRAM and DIEP flaps, respectively. The most common implant volume was 240 cc (range, 140‐445 cc). Following stage 1, minor and major complications were observed in nine (29%) and one (3.2%) patients, respectively. No major complications were noted after stage 2. Of note, no patient developed mastectomy skin necrosis or requested a change in implant size following stage 2. Delayed‐immediate hybrid breast reconstruction improves the ability to more precisely match patient expectations related to breast size and is associated with a reduction in the rate of mastectomy skin necrosis following the critical second stage of reconstruction.

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“…One potential complication from NSM is mastectomy flap necrosis, which occurs when the overlying breast skin does not have sufficient bloody supply to survive. The rate of mastectomy flap necrosis is reported to be approximately 15.8%; this number increases to 30% if partial‐thickness skin necrosis is included as well . Risk factors for developing necrosis include smoking, obesity, advanced age, history of radiation, and greater breast volumes .…”

Section: Introductionmentioning

confidence: 99%

Mastectomy flap necrosis after nipple‐sparing mastectomy and immediate implant‐based reconstruction: An evaluation of tumescence and sharp dissection technique on surgical outcomes

Knowles

Brackstone

et al. 2019

Breast J

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Nipple‐sparing mastectomy (NSM) with immediate implant‐based reconstruction has better esthetic outcomes and improved patient satisfaction, in addition to being oncologically safe. A known complication of NSM is skin flap necrosis. The use of tumescence and sharp dissection may decrease this complication compared to the standard NSM technique using electrocautery. This is a retrospective review of patients who underwent a NSM between 2014 and 2017 at a regional cancer center. Tumescence with sharp dissection was compared to electrocautery. The primary outcome was skin flap necrosis. The secondary outcomes were operative time and management of the complication. A total of 62 patients underwent a NSM with 116 breasts being operated on. Full‐thickness necrosis occurred more frequently in the standard electrocautery group (12.8%) compared to the tumescence and sharp dissection group (1.3%; P = 0.02). Partial‐thickness necrosis also occurred more frequently in the standard group (33.3%) compared to the sharp dissection group (13.0%; P = 0.01). The operative time was significantly shorter in the sharp dissection group with the mean (SD) time being 183.5 (48.9) minutes compared to the standard electrocautery group at 202.9 (33.8) minutes (P = 0.03). NSM using tumescence and sharp dissection have a lower rate of the complications of partial‐ and full‐thickness necrosis. Shorter operative time was also seen with the tumescent technique.

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Management of Mastectomy Skin Flap Necrosis in Autologous Breast Reconstruction

Cited by 40 publications

References 14 publications

Mastectomy skin flap necrosis: challenges and solutions

Mastectomy skin flap necrosis: challenges and solutions

Delayed‐immediate hybrid breast reconstruction—Increasing patient input and precision in breast reconstruction

Mastectomy flap necrosis after nipple‐sparing mastectomy and immediate implant‐based reconstruction: An evaluation of tumescence and sharp dissection technique on surgical outcomes

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