I had a prophylactic mastectomy with tissue exp and alloderm. My skin opened 8 wks post op and I drained from open wounds on the bottom of each breast. My ps removed the expanders. No infection. Drainage continued. A 2nd surgery removed alloderm and stitches. My wounds healed. What are my reconstruction options since the 1st failed? PS is not sure what caused all the problems I am healthy, 30 yrs, no medical conditions, do not smoke Drains were used all 3 surgeries w/ less than 10ml before removal
Failed Reconstruction After Mastectomy Due to Persistant Drainage. What Are my Options?
Doctor Answers (12)
Failed tissue expander reconstruction, DIEP flap, latissimus flap,
Essentially I had just answered this question but I would use your own tissue using either a DIEP flap. If you are to this or not a good candidate for a DIEP flap then I perform bilateral latissimus flaps in one stage and then at a later date perform fat grafting to improve the size of the breast reconstruction.
Sometimes you just have to start over. More than likely the alloderm or expander became infected. You can try again with the tissue expander or you can consider autologous reconstruction.
Alternative Breast Reconstruction Techniques
It seems that there may have been a seroma/fluid collection that was retained or possibly the alloderm did not incorporate into your tissues. You still have multiple options to choose from. The best choice will be based on a detailed physical exam by a breast reconstruction surgeon to determine what you are a candidate for, followed by a detailed history of your goals and expectations. Typical options are flaps from the back (latissimus dorsi), abdomen (TRAM or DIEP), buttock (S-GAP or I-GAP), or inner thigh (TUG)
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Alternative breast reconstruction techniques
Sorry you have had these troubles as a failed reconstruction can feel like another mastectomy to many patients.
Your "uninfected" persistent fluid issue sounds mysterious and it may be that there was an infection that was just not caught on the cultures or that it was a kind of infection that they didn't test for. Either way, if you have some extra tissue, you could look into doing a microsurgical breast reconstruction using that tissue. These are always the better one-sided breast reconstructions because they can be made to look more like your opposite breast, feel more natural, and can be trimmed and revised to get as close to the other side as possible. These are much more complicated operations than implants but have the advantage of no implant. Only go to somebody who has done very many of these to get the best result. These are usually in major institutions not in solo private practices.
Failed reconstruction after mastectomy due to persistent drainage. What are my options?
There are many options to breast reconstruction including implant-based and flap-based procedures. The complication rate with implants following radiation is reported as high as 60-70% in some studies. Flap reconstruction is usually recommended, but there are several centers who perform implants following radiation with great success and results. I typically prefer flaps, such as the DIEP flap. Other flaps are the conventional TRAM, latissimus flap, SGAP/IGAP, and, TUG.
You are a candidate for other procedures, if you are willing to continue with your journey for a reconstructed breast. Flaps such as those above, including others, are available. The decision to continue with this will be your decision and what you are willing to go through. There are risks and benefits with everything that we do in Surgery - discuss the various options with a board certified plastic surgeon who will educate you on all of the options and help you to decided if breast reconstruction or which procedure will be best for you. Hope that this helps and best wishes!
Salvage Breast Reconstruction Procedures
What you have described in your question is unfortunately not uncommon. There is a high rate of re-operation for a variety of problems following implant expander breast reconstruction.
For this reason, although longer and more complex, autologous tissue breast reconstructions such as TRAM flaps, DIEP flaps actually have lower complication rates and lower re-operation rate. Of course, any operation can have complications, so there are no guarantees.
In the situation you describe, one approach is to remove the AlloDerm, rinse out and drain the wound thoroughly, and allow the tissues to heal and soften. Then a flap breast reconstruction can be carried out.
Because the autologous flap breast reconstruction has only your tissues your breast is more likely to be warm, soft, and natural than your initial reconstruction.
See nybreastreconstruction.com for more information.
Options for reconstruction
You are a candidate for delayed reconstruction. After several months and once completely healed with no signs of infection, you may consider implant reconstruction again. However, you may want to consider an autologous reconstructive modality using your own tissue such as a DIEP or muscle sparing TRAM flap. To be a candidate, you must be in good health and have enough excess tissue in your lower tummy area. Another option would be to consider a latissimus dorsi flap + implant.
Options after failed reconstruction.
Persistent drainage despite negative cultures often means contamination of the expander or Alloderm with a bacteria producing a biofilm. This is a protective coating the bacteria create which allows them to persist and often does not grow in culture mediums used routinely to identify bacteria. The cure for this is often removal of the tissue or device to which this biofilm is attached. Once the area is cleared, it is appropriate to wait at least 3-6 months before attempting replacement of an expander. Most patients do well following the removal and the 6 month wait time, allowing for replacement of the tissue expanders and a completion of the reconstruction. Also available to you are the use of your abdomen or back tissues for breast reconstruction.
Breast Reconstruction Options
Options for failed first attempt at reconstruction with alloderm and expander
You could try another course of expanders without alloderm. Alternatively you could consider using a variety of flaps ranging from Latissimus or Tram (pedicled or free) or a DIEP flap among others. Alternatively you could try a staged course of fat grafting.
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.