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Page 8 of 13 Myers et al. Plast Aesthet Res 2023;10:38 https://dx.doi.org/10.20517/2347-9264.2022.150

prior radiation result in increased rates of major complications such as implant extrusion, capsular
[61]
contracture, and reconstruction failure compared to similar reconstructions in non-irradiated breasts . As
such, many reconstructive surgeons opt to use autologous reconstruction in these patients. The latissimus
[62]
dorsi flap (LD) is the most common pedicled flap option for autologous tissue salvage following free flap
failure, as it does not require microsurgery and has a reliable anatomy with a versatile skin paddle that
results in a high reconstructive success rate [13,63] [Figure 4]. Though first described for postmastectomy
reconstruction by D’Este in 1912 , it was popularized in the late 1970s as a method of autologous breast
[63]
reconstruction. The latissimus dorsi flap allows for the harvest of a large skin paddle, useful in situations
where there was a loss of skin from the prior failed free flap.

Aesthetic results are often excellent, and the LD flap permits the use of healthy, non-radiated tissue to cover
[64]
an implant if one is needed to achieve a size match . If greater volume is required, an implant or tissue
expander can be placed under the flap, in one or two stages, either above or below the pectoralis muscle .
[65]
In appropriate candidates, autologous fat grafting at the initial time of the LD flap can provide significant
volume enhancement as needed [66,67] . This is known as the Latissimus Dorsi and Immediate Fat Transfer
(LIFT) procedure, where upwards of 500 cc of fat can be added for increased volume. When considering
this option, ensure the thoracodorsal pedicle has not been injured from previous interventions, such as an
[68]
axillary lymph node dissection or radiation . A recent retrospective review of 248 patients by Wattoo et al.
[69]
showed long-term overall patient satisfaction from latissimus flap reconstruction . While minor
complication rates were high in the short term (seroma 58% and wound infection 13%), chronic
complications were low (shoulder stiffness 1.9%, pain 11.5%), highlighting the utility of this procedure.
These results are consistent with another retrospective review of 277 patients by Yezhelyev et al., with
[70]
higher short-term complications (seroma 19.5%), but overall low risk in the long term .

CONVERSION TO ALLOPLASTIC
Alloplastic or implant-based reconstruction is another effective option for salvage, particularly in non-
radiated breasts. When contemplating conversion to implant-based reconstruction, the psychological and
emotional toll experienced after free flap failure should be considered, especially in women who specifically
chose autologous tissue to avoid implants [71,72] . The benefits of conversion to prosthetic reconstruction
[73]
include a shorter hospital stay and a lower complication rate in the short term [Figure 5] . Factors that
influence the decision to choose alloplastic reconstruction include the amount and quality of mastectomy
skin available, the desired size of the breast and ultimately the patient’s wishes. Decisions about implant
pocket placement (prepectoral or subpectoral) and use of a biologic mesh (coverage and support with or
without acellular dermal matrix) need to be made. A history of radiation must be considered if choosing
alloplastic reconstruction.

The timing of initiation of expansion in the outpatient clinic is variable, depending upon surgeon
preference and healing of the incision. The timing of adjuvant therapies must also be considered. If initial
flap failure occurs in the immediate postoperative setting with several days to weeks of complications, a full
course of tissue expansion may not allow for timely receipt of adjuvant radiation or chemotherapy.
[74]
Expansion can begin as quickly as 10-14 days without an increase in complications , though a common
protocol is to begin expansion 3-4 weeks after tissue expander placement with exchange to permanent
implants 3-6 months from tissue expander placement. Patients can then undergo revisions including fat
grafting as needed to achieve optimal aesthetic results.

CONCLUSION/RECOMMENDATIONS
While less common in high-volume centers , autologous free tissue transfer failures can be devastating in
[75]