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EL-Sabawi et al. Restoration of failed breast reconstruction

420 titles identified through 28 additional titles identified through
Pubmed/MEDLINE search cross-referencing
Included Eligibility Screening Identification

429 titles after duplicates removed

264 titles excluded
165 abstracts screened

92 abstracts excluded

73 full text records
assessed for eligibility

54 full text records excluded

19 studies included in qualitative synthesis

Figure 1: Flowchart of article selection process

Data analysis was completed using simple means contracture was the most commonly cited implant
allocating weight to each study by sample size. If only related complication with modified Baker grade III-
the median was reported, then a Gaussian distribution IV contracture occurring in 168 breasts (23.4%),
was assumed and the medians were equated to modified Baker grade I-II contracture in 137 breasts
means. Outcomes were stratified by method of failed/ (19.1%), and uncharacterized capsular contracture
unsatisfactory initial breast reconstruction. Qualitative reported in 144 breasts (20.0%). Other commonly
analysis of aesthetic outcome/patient satisfaction is reported indications for autologous conversion were
described due to the heterogeneity of included studies. poor cosmesis or asymmetry in 102 breasts (14.1%),
Statistical significance was defined as P < 0.05. pain/discomfort in 72 breasts (10.0%), infection/
exposure in 71 breasts (9.9%), implant rupture
RESULTS in 25 breasts (3.5%), or recurrence in 12 breasts
(1.6%). Neoadjuvant or adjuvant radiotherapy prior to
autologous conversion was reported in 231 patients
Results from the initial search yielded 420 titles. (48.8%). The deep inferior epigastric perforator
Screening yielded 165 studies for abstract review, of (DIEP) flap was the most commonly utilized flap
which 73 were selected for full text review. Ultimately, for autologous conversion and was reported in
19 studies met inclusion criteria and were included 398 breasts (51.1%). Other common flaps choices
in this review [Figure 1]. There were no randomized included a free transverse abdominis myocutaneous
clinical trials, 17 studies (89.5%) were retrospective, (fTRAM) flap in 89 breasts (11.4%), superior
and 2 studies (10.5%) were prospective. Study gluteal artery perforator (SGAP) flap in 67 breasts
characteristics and patient demographics and (8.6%), transverse upper gracilis flap or transverse
comorbidities within included studies are described in myocutanous gracilis (TMG) flap in 65 breasts (8.4%),
Table 1. superficial inferior epigastric artery (SIEA) flap in 53
breasts (6.8%), inferior gluteal artery perforator flap
Autologous salvage of unsuccessful in 35 breasts (4.5%), latissimus dorsi (LD) flap with
prosthetic breast reconstruction or without implant in 27 breasts (3.5%), or other or
Fifteen studies evaluated outcomes following undescribed flaps in the remaining 29 breasts (3.7%).
autologous conversion of failed or unsatisfactory
prosthetic reconstruction including a total of 564 Thirteen studies (n = 748 flaps) reported complications
patients (778 breasts) [6,7,9-11,18-27] . Study size weighted following autologous salvage of complicated prosthetic
mean age was 49.3 years and mean body mass reconstruction [Table 2] [6,7,9-11,18,20-24,26,27] . A total of 12
index (BMI) was 26.6 kg/m . Mean follow-up was total flap losses (1.6%; range 0-6.9%) were reported,
2
23.5 months. Thirteen of these studies (719 breasts) including 3 DIEP flap loss, 3 SGAP flap loss, 2 fTRAM
reported implant related complications occurring prior flap loss, and flap loss in 4 breasts that were not
to autologous conversion [6,7,9-11,18,19,21-24,26,27] . Capsular described. Microsurgical revisions were reported in 20

Plastic and Aesthetic Research ¦ Volume 4 ¦ October 31, 2017 197