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Leach et al. Plast Aesthet Res 2023;10:39 https://dx.doi.org/10.20517/2347-9264.2023.32 Page 7 of 11

Several treatment algorithms have been published for the management of suspected pneumothorax intra-
operatively [55,56] . The first step is to perform a bubble test by filling the cavity with saline followed by a breath
hold by anesthesia. In a series of four pneumothoraces during free flap breast reconstruction identified at a
single institution, this test was only noted to be positive in one patient diagnosed with pneumothorax based
on postoperative chest X-ray . If the bubble test is negative, then no additional intervention is required. If
[55]
the bubble test is positive, the injury should be repaired by direct suture of the pleural tear, fascial graft or
muscle/fascia flap, or fat plug as needed [55,56] . Repair should be performed over a catheter which is removed
during positive pressure breath hold as the last suture is tied down. Bubble test should then be repeated to
confirm the repair. Postoperative chest X-ray and clinical monitoring for signs of pneumothorax should be
performed. If clinically significant pneumothorax develops postoperatively, the patient will require a chest
tube. Careful coordination with the team placing the chest tube is vital as placement of a postoperative
intercostal drain for pneumothorax was reported to occur immediately adjacent to the internal mammary
[56]
vascular pedicle and vascular anastomosis .

Intraoperative concern for pneumothorax should prompt a bubble test and repair as needed. Venous
[54]
congestion in a flap may be a sign of pneumothorax in an otherwise healthy flap and is considered during
the evaluation for the cause of venous congestion. Patients with concern for intra-operative pneumothorax
should have postoperative chest x-ray completed. If chest tube placement is needed postoperatively, the
microsurgical reconstruction team needs to carefully coordinate the placement of the chest tube to
minimize potential injury to the flap and/or vascular pedicle.

CHYLE LEAK
With dissection of the internal mammary vessels, identified lymph nodes are typically removed. Removal of
these lymph nodes interrupts the lymphatic channels, and in 2019, Long et al. reported a case of a chyle leak
after delayed-immediate bilateral DIEP flaps . The patient had a history of invasive ductal carcinoma of
[57]
the right breast and was treated with a right modified radical mastectomy and left simple mastectomy with
immediate placement of acellular dermal matrix wrapped tissue expanders followed by adjuvant radiation.
On postoperative day five following the DIEP flaps, the left breast drain changed to cloudy but low volume
output and she was discharged home. The next day, she had significant swelling of the left breast surgical
site, which improved after 600 mL of milky fluid spontaneously decompressed through the left-sided drain.
Chyle leak was suspected and confirmed after testing the fluid for triglycerides and chylomicrons
(> 1300 mg/dL and present). She had foam tape applied to the area to try to compress the leak and was
started on a low-fat, high-protein diet with resolution of the milky drainage on postoperative day 12. Her
drain was subsequently removed on postoperative day 16 and she remained on a low-fat diet for 3 weeks.
Their recommendation is to deal with lymphatic vessels and nodes deliberately with the use of clips as
opposed to cautery or sharp dissection during internal mammary vessel dissection .
[57]

For a patient who is otherwise clinically doing well without evidence of infection but experiences milky
output from a drain after starting a regular diet, chyle leak should be suspected and evaluated with fluid
testing for triglycerides and chylomicrons (> 110 mg/dL and presence is confirmatory) as was done in this
case. Treatment may start with a diet low in long-chain triglycerides with supplementation of medium-
chain triglycerides as well as the addition of somatostatin or octreotide. If the leak persists beyond 2 weeks
[58]
or the volume is greater than 500 to 100 mL per day, more aggressive measures may be required, such as a
percutaneous approach with coiling of the thoracic duct or surgical intervention to identify the leak and
ligate the offending vessels.