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EL-Sabawi et al. Restoration of failed breast reconstruction

INTRODUCTION autologous breast reconstruction are lacking and
further add to the confusion regarding its potential
Breast reconstruction has consistently been shown benefit.
to enhance body image and quality of life in breast
cancer patients undergoing mastectomy [1-4] . Despite Due to the infrequency of failed or unsatisfactory
this, patients suffering reconstructive failures or breast reconstruction, management of this group of
unsatisfactory outcomes are not negligible [5,6] . patients in the literature is primarily limited to several
Previously failed breast reconstruction provides small case series from a few centers [7,8,16] . As a result,
multifaceted and unique challenges for plastic the indications, methods, and expected outcomes of
surgeons. Following evaluation of the causes of tertiary reconstruction are poorly defined. The purpose
failure and reassessment of patient goals, autologous of this systematic review is to assimilate the relevant
tissue transfer to salvage breast reconstruction has literature to evaluate surgical and aesthetic outcomes
been shown to be an effective strategy to optimize following tertiary reconstruction. The goal is to provide
outcomes [6-8] . Also termed tertiary reconstruction surgeons with a foundation of knowledge to assess the
by previous studies, autologous salvage has been risks and benefits associated with autologous salvage
reported as a means of breast restoration following of a previously unsuccessful breast reconstruction.
both failed prosthetic breast reconstruction and
previously failed autologous reconstruction [7,8] .
METHODS
The majority of the literature pertaining to tertiary
reconstruction describes autologous conversion A systematic search of the literature published
following complications with prosthetic reconstruc- from January 1, 1980 to December 29, 2016 was
tion [7,9-11] . Prosthetic reconstruction is the most common performed using search terms “salvage”, “tertiary”,
method of breast reconstruction and has increased at “restoration” and “breast reconstruction” to identify
a rate of 5% a year [12] . Despite its increasing popularity, all relevant articles on Pubmed/MEDLINE. Inclusion
complications leading to poor aesthetics, persistent criteria included studies that reported surgical
pain, and implant loss are not uncommon, particularly outcomes, aesthetic outcomes, or patient satisfaction
in the setting of adjuvant radiotherapy [13,14] . In addition of autologous breast reconstruction following failed or
to alleviating implant-related complications, autologous unsatisfactory breast reconstruction. The reference
conversion may provide a more natural appearance lists of all included studies were reviewed to identify
and improve longevity of the reconstructed breast. relevant articles that may have not been captured in
However, the impact of a prior complicated prosthetic the search. Exclusion criteria included studies that
reconstruction on outcomes of autologous conversion reported relevant outcomes of less than 5 patients,
remains unclear. A recent study has suggested non-English language articles, reviews, and studies
that patients with unsatisfactory prior prosthetic reporting previously published data. Studies reporting
reconstruction have increased recipient vessel scarring management of patients with complicated or failed
and major complications with autologous conversion as reconstruction that did not adequately describe
compared to patients that undergo de novo autologous outcomes of the autologous salvage procedure were
reconstruction [10] . excluded. One reviewer performed the search protocol
and article selection (B.E.), and two reviewers (K.M.P.
Tertiary reconstruction following failed autologous and A.C.H.) reconciled any discrepancies.
reconstruction by utilization of a second flap has also
[8]
been described . Although uncommon, flap failure Adherence to the standardized methodologic prin ciples
in autologous breast reconstruction is a stressful of Preferred Reporting Items for Systematic Reviews
and demanding situation for the patient and the and Meta-Analyses for reporting of systematic
surgeon [15] . Use of an additional flap to salvage breast reviews guided the analysis [17] . Study characteristics,
reconstruction may provide a means to still obtain patient demographics and comorbidities, oncologic
an acceptable reconstructive result and mitigate treatment characteristics, and details regarding the
patient distress associated with flap failure. Despite initial failed breast reconstruction were extracted.
demonstrating success in previous reports, questions Primary outcomes included flap choice for autologous
concerning the risk of reattempting autologous salvage, total complications, microsurgical revisions,
reconstruction with a different flap exist as risk factors total flap loss, and revision procedures associated with
that contributed to the initial flap failure and sequelae of tertiary reconstruction. Secondary outcomes of tertiary
the previous surgery may compromise its survival [8,16] . reconstruction included hematoma, seroma, infection,
In addition, data evaluating aesthetic outcome and fat necrosis, partial flap loss/skin necrosis, and
quality of life following tertiary reconstruction of failed measures of aesthetic outcome or patient satisfaction.
196 Plastic and Aesthetic Research ¦ Volume 4 ¦ October 31, 2017