Is a Second Free Flap Still an Option in a Failed Free Flap Breast Reconstruction?

BACKGROUND: Salvage of a failed autologous breast reconstruction is a complex and challenging problem. The purpose of this study was to analyze the indications, methods, and outcomes of tertiary surgery in patients with a failed autologous breast reconstruction. METHODS: A retrospective chart review was performed for all patients who underwent breast reconstruction with autologous tissue performed by the senior author (M.H.) between 2002 and 2009. Special emphasis was made to evaluate the first reconstruction performed, causes of failure, indications for tertiary reconstruction, and outcomes. A preoperative hematologic workout was performed. For patients who were classified within the highest group of thromboembolism, specific prophylactic measurements were taken for the tertiary surgery. RESULTS: Of 688 patients who underwent autologous breast reconstruction, a total of 14 patients required tertiary breast reconstruction. Hypercoagulability was found in three patients resulting from disorders such as lupus anticoagulant positivity and antiphospholipid syndrome. Six patients (43 percent) underwent a combination of local skin flaps and/or implant reconstructions. Eight patients (57 percent) underwent nine microvascular breast reconstructions: five superior gluteal artery perforator flaps, three transverse myocutaneous gracilis flaps, and one deep inferior epigastric artery perforator flap. Two of nine flaps (22 percent) required quaternary reconstructions because of a failure of the second free flap. Additional corrections such as revision lipofilling, scar revision, contralateral breast shaping, implant change, and capsulotomies were performed in 92.7 percent of the patients, with a mean follow-up of 37 months (range, 6 months to 7 years). CONCLUSIONS: Tertiary surgery after autologous breast reconstruction failure has limited options and further reoperations are often needed. Careful patient history and selective blood tests may reveal hidden coagulation disorders. When a second free flap is planned, primary and secondary antithrombotic therapy should be considered.