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American Association of Plastic Surgeons
89th Annual Meeting Abstracts

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Unilateral Failures in Bilateral Microvascular Breast Reconstruction
Samir S. Rao, M.D., Pranay M. Parikh, M.D., Jesse A. Goldstein, M.D., Maurice Y. Nahabedian, M.D..
Georgetown University Hospital, Washington, DC, USA.

Purpose: As rates of bilateral prophylactic mastectomy and contralateral prophylactic mastectomy have increased over the past decade, bilateral microvascular breast reconstruction has played an increasing role in breast cancer care. Data on unilateral flap failure in bilateral microvascular breast reconstructions has been lacking, and strategies to address the challenges encountered in this situation are needed.
Methods: A retrospective review of all simultaneous bilateral microvascular breast reconstructions performed by the senior author from July1999-July 2008 was performed. Flap failures were identified and reviewed for operative parameters, causes of flap loss, and techniques used for secondary reconstruction.
Results: We identified 557 consecutive patients who underwent 728 microvascular breast reconstructions between July 1999 and July 2008. Bilateral reconstructions were performed in 171 patients (30.7%) and unilateral reconstructions were performed in 386 patients (69.3%). The mean age of our sample was 46 years (range 34 - 59), and mean follow-up was 32.1 months (range 5 - 127 months).
Flap failure occurred in 20 of 728 flaps, yielding an overall failure rate of 2.7%. Flap failure occurred in 8 of 386 flaps (2.1%) performed in the setting of unilateral reconstructions, and in 12 of 342 flaps (3.5%) performed in the setting of bilateral reconstruction. No significant difference in the incidence of flap failure was observed between unilateral and bilateral reconstructions (p = 0.24).
There was a 3.8% failure rate (8/212) for immediate reconstructions compared to a 3.4% failure rate (4/118) for delayed reconstructions, revealing no statistical difference between flap failure rates as a function of timing (p = 0.56)
When bilateral reconstructions and flap failures were stratified by flap type, we noted that 1 of 108 (0.9%) MS-TRAM flaps failed, and 11 of 228 (4.8%) DIEP flaps failed. No failures were observed in SGAP reconstructions. There was no statistical difference between rates of free flap failure as a function of flap type performed, but DIEP did approach significance (p=0.067) for increased odds of failure.
Causes of flap failure included venous insufficiency (6/12, 50%), lack of adequate perforator anatomy (3/12, 25%) and perforator injury during dissection (2/12, 17%), and late flap necrosis (1/12, 8%). Secondary reconstruction with tissue expanders and implants was performed in 11/12 patients who underwent an average of 2.25 additional procedures to complete reconstruction.
Conclusions: Bilateral autologous breast reconstruction can be performed with an acceptably low failure rate in both the immediate and delayed settings. The higher rate of flap failure amongst bilateral reconstructions is largely secondary to the obligation to use both sides of the abdominal donor tissue, compared to unilateral reconstructions in which the ideal side may be chosen. When failure does occur, prosthetic reconstruction to replace the failed flap is an excellent option. When the situation permits, the prosthetic reconstruction should be performed prior to the microvascular reconstruction, as the autologous tissue can be better shaped and modified to match the prosthetic side than vice versa. Employing these techniques can ultimately result in successful bilateral reconstructions despite free flap failure.


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