Complications with the tissue transferred to the breast
Any surgical procedure is associated with possible risks and complications. These include: bleeding, infection (fig. 1, 2), haematomas (large collections of blood), delayed wound healing, deep vein thrombosis and more rarely pulmonary embolism.
|Fig. 1||Fig. 2|
Microsurgery carries its own particular set of complications and these apply to any tissue that is transferred to the breast for reconstruction. The most important microsurgical complication is a blood clot at the site where the vessels have been reconnected (fig. 3a-c). This may occur due to problems with the vessel wall (e.g. atherosclerosis), clotting abnormalities, post-operative compression of the vessels or rarely, a technical error.
|Fig. 3a||Fig. 3b||Fig. 3c|
Microsurgical complications almost always present within the first 72 hours following surgery. Once a free flap passes through this time frame, the vessels are permanently healed and the tissue should survive. Therefore within this early post-operative period, nurses regularly monitor the flap, initially every hour and then every two hours, to check the blood flow. This monitoring starts in recovery and continues when a patient is back on the ward. The medical staff and your surgeon are immediately informed if there is any change. A decision may be taken to return to theatre, remove any clot and restore blood flow (revascularisation). We currently have a re-exploration rate of approximately 3%.
Rarely, in approximately 0.7% of the flaps, it is not possible to restore blood flow and total flap loss occurs (fig. 4). However, over 99% of our patients do have a successful outcome and have a breast reconstruction that will last a lifetime. In the unusual event of complete flap failure, a future consultation can be arranged, in which other methods of breast reconstruction can be discussed.
Fig. 4: total flap necrosis
Partial flap necrosis, due to poor tissue perfusion or anatomical variations in blood supply, is seen in 7% of free DIEAP flaps (fig. 5). Isolated fat necrosis is seen in 6% of cases but this figure can be higher in smokers or patients who receive post-operative radiotherapy. Fat necrosis is felt as a firm nodule in the breast. The majority of areas soften over time and radiological imaging can be used to differentiate them from recurrent breast cancer. In cases that persist for more than one year or if there is any oncological doubt, the fat necrosis can be surgically excised.
Fig. 5: partial flap necrosis
Complications at the donor site
The same general complications apply to the donor site (fig. 6). Delayed wound healing occurs in up to 6% of patients but is often associated with smoking. A seroma, which is a collection of clear wound fluid, develops in about 2% of DIEAP flaps but it is much more common following SIEA flaps because of the more extensive dissection required in the inguinal region. Finally, lower abdominal bulging after DIEAP flap harvest is seen in less than 1% of patients. We have never encountered a true incisional hernia. This represents a major improvement over the TRAM flap and is a clear demonstration of how donor site morbidity is reduced by perforator flaps. Following TRAM flap reconstruction the lower abdominal wall may be weakened, leading to hernia formation but this can be surgically corrected.
Possible complications of autologous free flap breast reconstruction:
|Return to theatre||2|
|Partial flap necrosis||11.1|
|Total flap loss||1.3|