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EL-Sabawi et al. Restoration of failed breast reconstruction

may increase the complexity of autologous breast (volume, contour, placement, and inframammary
reconstruction. It has previously been reported that fold) in 18 patients with autologous conversion after
recipient vessel scarring was 5.23 times more likely complicated implant reconstruction as compared to 136
in patients with prior prosthestic reconstruction at the patients with uncomplicated prosthetic reconstruction.
time of autologous conversion as compared to those Spear and Onyewu [25] compared aesthetic scores of
with de novo autologous reconstruction [10] . However, patients with autologous conversion after irradiated
the impact of prior implant reconstruction on outcomes prosthetic reconstruction to patients with non-irradiated
of autologous conversion remains unclear. Planned prosthetic reconstruction and reported similar aesthetic
autologous conversion after immediate tissue expander means of 3.25 and 3.28 (4-point scale), respectively.
reconstruction and adjuvant radiotherapy, termed In this review, all 5 included studies demonstrated
delayed-immediate reconstruction, has been described acceptable rates of positive aesthetic results and patient
by several studies as a method of preserving the satisfaction following tertiary reconstruction in the setting
tissue envelope while avoiding deleterious effects of of unsuccessful prosthetic reconstruction [11,19,20,25,27] .
radiation on the flap [31-33] . In a series of 16 delayed- This suggests that improved aesthetic result associated
[31]
immediate reconstructions, Kronowitz et al. reported with autologous breast reconstruction may be attained
intra-arterial thrombosis in 12.5% of breasts following even in patients with prior unsuccessful prosthetic
autologous conversion, however, no patients suffered reconstruction.
a flap loss. In a larger study, Patel et al. [33] compared
outcomes of autologous conversion as a part of the Studies reporting outcomes following restoration of
delayed-immediate protocol in 74 reconstructions to a previously failed autologous breast reconstruction
118 delayed autologous reconstructions after radiation utilizing a second flap are limited and make it difficult
with no prior prosthesis insertion. They reported no to draw any definitive conclusions. In this review, all
difference in anastomotic revisions (6.8% vs. 5.9%; P 5 studies that met inclusion criteria retrospectively
= 1.0) or rate of flap failure (4.1% vs. 2.5%; P = 0.68). assessed outcomes of less than 15 patients [8,16,20,28,29] .
The literature pertaining to unplanned autologous Of these, 4 studies reported outcomes of unsuccessful
conversion secondary to implant-related complications autologous reconstruction by utilizing a pedicle
has suggested similar success but is limited. Only LD flap [8,20,28,29] . Overall, no partial or total flap loss
one study included in this review provided a head- was observed in these patients. Only 2 included
to-head comparison between autologous conversion studies evaluated the utility of microsurgical free flap
after unsuccessful prosthetic reconstruction to reconstruction in the setting of previous total flap
[8]
patients with de novo autologous reconstruction [10] . loss. Hamdi et al. assessed outcomes following
Roostaeian et al. [10] reported no difference in rates second free flap reconstruction after prior flap loss
of flap loss or operative take back between the two and noted total flap loss in 2 of 9 patients (22.5%). In
groups, but did note an increase in major complications another series, Munhoz et al. [16] evaluated outcomes
in the group with a prior prosthesis (17.4% vs. 8.1%; P following the use of a contralateral free LD flap to
= 0.035). Consistent with these studies, pooled-analysis salvage breast reconstruction after previous LD breast
in this review demonstrated a low incidence of total reconstruction failure. They reported 1 partial flap loss
flap loss or microsurgical revisions in 1.6% and 3.2%, (8.3%) but no total flap loss. Overall, the available
respectively. Overall, there is little evidence to suggest data suggests that a second free flap after prior free
that prior prosthetic reconstruction negatively impacts flap failure is a feasible technique to salvage breast
later autologous reconstruction in the setting of tertiary reconstruction in select patients. However, future
reconstruction or the delayed-immediate protocol. studies with significantly increased sample sizes
However, future prospective studies are required with are required in order to better define outcomes and
larger sample sizes to fully understand the impact of determine the optimal approach to managing patients
unsuccessful prosthetic reconstruction on autologous with unsuccessful autologous breast reconstruction.
conversion. In addition, data evaluating aesthetic outcomes,
patient satisfaction, or quality of life are lacking and
In addition to salvaging breast reconstruction, is necessary to evaluate the potential benefits that
autologous conversion in the setting of tertiary tertiary reconstruction may provide.
reconstruction may provide an improved long-term
aesthetic result and satisfaction [30] . In this review, 2 Tertiary reconstruction in the setting of prior failed
studies compared aesthetic outcomes of patients with autologous breast reconstruction brings several
autologous conversion to patients that completed challenges that need to be addressed to ensure
prosthetic reconstruction [19,25] . Mioton et al. [19] reported its success. The previous failure must be analyzed
superior scores across 4 out of 5 domains evaluated in order to adjust strategy and eliminate potential

Plastic and Aesthetic Research ¦ Volume 4 ¦ October 31, 2017 201