Breast Reconstruction - LD Flap w/ Implant After Expander Infection?
- Asked by timetimetime in Los Angeles
- 3 years ago
I had radiation on left breast 2 years ago. Now I had mastactomy and reconstruction with expander , and have infection.2 weeks I have picc line with anibiotic, infection still there. Quation - if expender must be taken off,I was told , I can have LD Flap with implant ( My right breast has an implan long time ago. size C, I want to match. )But ,I do not understand, if I have infection with implan (expander) now, why LD Flap with implant can be better ? Thank you , Nataliya.
LD with implant after infection
Based on your history of radiation, you run an unacceptably high chance of implant related complications without bringing in some healthy non-radiated tissue. This tissue brings a healthy blood supply to protect against infection and capsular contracture (scar formation). I am unsure about the nature of your infection, but here are my thoughts:
1. LD with Implant: consider only if your problem was a threatened tissue expander exposure, not an active infection.
2. Tissue Expander Removal: If you have an aggressive infection (purulent drainage, high fever, etc), I would recommend removal of the expander and a reconstruction holiday until the tissues are free of infection and healed.
3. LD with Tissue Expander Reconstruction: If your surgeon thinks that you have an active infection, but the reconstruction can be saved, I would recommend this option. It would be important to culture the wound, perform a capsule removal, place a new tissue expander, and consult with an infectious disease specialist.
hope this helps and I wish you a safe recovery.
Paul S. GIll, M.D.
Gill Plastic Surgery
Houston Double Board Certified Plastic Surgeon
LD Flap with Implant
Unfortunately, the risks of implant reconstruction after radiation therapy are much higher than for those who have not previously been radiated. It is difficult to eradicate an implant infection and the infection often will lead to the removal of the implant. This does not mean that you can not be offered reconstruction. After an infection has resolved, a secondary reconstruction can be considered, and a LD flap with an implant may be an appropriate option. This procedure adds fresh, non-radiated soft tissue to the area. If sufficient tissue is available, an abdominal flap may also be an option.
Breast Reconstruction with LD Flap after Infection
If your expander is infected, it will need to be removed and your body will need some time to clear away the infection. When the infection resolves, the tissues will be more fibrous and stiff as a result of the scar tissue tissue that will form. Also, because of your history of radiation, you will already have firm, scarred tissue there. The LD flap will provide new, healthy soft tissue coverage that will expand easily and fight off infection much better than the tissue that is there now.
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Latissimus Flap Breast Reconstruction After Irradiation
I am sorry to hear about your complications. There are a couple reasons I believe a latissimus flap + an expander as the first stage of your reconstruction would be beneficial.
1. You have had irradiation to that side of your chest which reduces the circulation to that area. This can make you more prone to poor healing and infection
2. Irradiated skin does not stretch well enough to produce an aesthetically acceptable breast
3. Irradiated skin has more of a tendency to produce a firm scar capsule around the final implant.
For these reasons I prefer use of a Latissimus flap and an expander as the first step in reconstruction of the breast when a patient has received irradiation. The flap has the rich circulation of the muscle in conjunction with the soft pliable skin.
I hope this was helpful.
If you have an expander infection, you have to have it removed and then you should wait several months before attempting further reconstruction.
Radiation and breast reconstruction
Radiation and expansion are a bad combination, increased risk of infection, poor healing and capsular contracture. Adding non radiated tissue from the LD flap helps all of this.
Breast reconstruction and infected expander
It is very difficult to cure an infected prosthesis in an irradiated field with antibiotics. You might get a solution quicker if you remove the implant for a couple of weeks and then start over either with a new expander or the LD flap. I do not know what your specific situation is with your residual post-mastectomy tissue or the extent of your expansion so I cannot give a specific recommendation. A LD flap is commonly used to salvage or supplement the soft tissues of an irradiated reconstruction since it normalizes the soft tissue coverage and improves blood flow to the area allowing increased tolerance to an implant. While you might need antibiotic treatment anyways, a full course of antibiotics to try and salvage an expander in a field of irradiated tissue is probably prolonging your rehabilitation since you will have to go through explantation of the expander at any case.
Reconstruction with only implant after radiation have a large percentage of failure and problem rates. Radiated tissue is an injured tissue and can get infection easy.
When you bring the Latismus Dorsi Flap, you are bringing skin, muscle and fat. The muscle brings a well vascularized tissue to the area of radiation, this helps the radiation injury, and the implant is put under the well vascular Latismus Dorsi Muscle. Success rate is high, and achieving symmetry is much easier.
Breast Reconstruction After Infected Expander
Your question expresses a very valid point. The presence of a breast implant under the latissimus dorsi LD flap, still presents a risk of infection.
I feel that a better option is to do a flap-only breast reconstruction such as a TRAM flap or a DIEP flap which eliminates the need for a breast implant and its attentant risks.
The first priority is to control and resolve the infection. This requires that the infected implants be removed, that you receive antibiotics and that the breast reconstruction be postponed until the skin is fully healed, soft and flexible.
Then, using a flap-only technique, the breast could be reconstructed with your own tissues which have their own circulation and are more resistant to repeat infection than those that use breast implants.
Breast Reconstruction After Infection and Radiation
When radiation is used in the treatment of breast cancer, non-cancerous tissues in the path of the radiation are also affected. Radiation is especially problematic for women who undergo implant reconstructions, and failure of an implant reconstruction in the setting of radiation is not uncommon.
Natural-tissue reconstruction has the benefit of bringing non-radiated, healthy, well-vascularized tissue to the mastectomy site, and this can actually aid in the healing process. While the LD flap may improve the chances of success with an implant, avoiding the use of an implant altogether is generally a better option.
These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.