Failed Reconstruction After Mastectomy Due to Persistant Drainage. What Are my Options?

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

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.

Failed 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.

Steven Wallach, MD
Manhattan Plastic Surgeon
4.5 out of 5 stars 18 reviews

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)

Paul S. Gill, MD
Houston Plastic Surgeon
5.0 out of 5 stars 55 reviews

Failed Implant Reconstruction After Mastectomy- What Are the Options

I'm sorry to hear that you are having trouble following Alloderm/expander breast reconstruction. Unfortunately, complications from breast reconstruction with implants are very common. In fact, there is some emerging evidence that shows that reconstructions that utilize Alloderm may be at especially high risk of complications from seroma formation. It is not clear from the limited information in your description whether the drainage you experienced was related to infection or seroma (or both), however, in the end, finding a way to reconstruct your breast with a high degree of success is your present goal.

While implant reconstructions generally require the shortest initial hospitalization of all the possible methods of breast reconstruction—and some women find implant reconstructions appealing for this and other reasons—many patients and many doctors are troubled by the high rate of unplanned re-operation associated with this method of reconstruction. Common consequences of implant reconstruction include re-operation and the need to remove implants, according to the U.S. Food and Drug Administration. Large studies of women who had breast reconstruction using implants have found that:

  • Approximately 40% of women will require unplanned re-operation within 5 years, and approximately 50% will require unplanned reoperation within 7 years 
  • One or more times over the course of the patient’s life, she will probably need to have her implants removed because of rupture or other complications
  • Once a woman has required a reoperation for an implant related complication, she has about a 1 in 3 chance of needing another unplanned surgery within just 3 years to address additional complication

Women who have trouble with implant reconstructions frequently do very well and go on to have sucessful breast reconstruction using their body's own tissue. Your own tissue is likely to provide the best option for a long-term success. You may want to explore  the possibility of natural-tissue reconstruction with your plastic surgeon. The most sophisticated approaches to natural-tissue breast reconstruction use perforator flaps.

In addition to giving you excellent cosmetic results without compromising important functional muscles, perforator-flap breast reconstruction, using flaps such as the DIEP, SGAP, and LAP, offers several unique advantages:

  • A more natural look and feel to reconstructed breasts than can typically be obtained with implants
  • Less postoperative pain than is typically associated with reconstruction using flaps that include muscle
  • Reconstructed breasts that will grow and shrink naturally as one’s weight changes, thereby keeping your reconstructed breast in proportion to your body
  • Possible connection of sensory nerves in a perforator flap to nerves at the mastectomy site to help restore sensation to the reconstructed breast
  • More rapid return to work and other activities than typically occurs following reconstruction with flaps that include muscle
  • A significantly lower rate of unplanned reoperation (only 5%), as compared to the approximately 50% rate reported for implants 7 years after reconstruction
  • Ability to reconstruct a breast after failure of an implant or other natural-tissue reconstruction, even after radiation

I hope this was helpful.

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?

Hello!  Thank you for your question.   You could still consider implant-based breast reconstruction with tissue expanders again.  This will carry the same risks as your previous procedure, but is a reasonable decision.  If you experience issues again, you may consider reconstruction with a flap - he flap, which is skin, fat, and sometimes muscle, will serve to bring in healthy, well-vascularized tissue to the chest/breast area that will significantly ameliorate the radiation or infection issues compounding the problem.  Microsurgical perforator flaps (such as the DIEP flap and SGAP/IGAP flap) are the newest and most-innovative procedures in breast reconstruction today.  As these are muscle-sparing flaps, the pain, morbidity, and complications such as those above, of these procedures are much less.  They are highly-complex procedures that few plastic surgeons performed and consult with one who is well-versed, trained, and skilled in these procedures if you are interested.  

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!

Lewis Albert Andres, MD
Scottsdale Plastic Surgeon
5.0 out of 5 stars 14 reviews

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.

 

 

 

 

 

Fredrick A. Valauri, MD
New York Plastic Surgeon

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.

David Bogue, MD
Boca Raton Plastic Surgeon
5.0 out of 5 stars 13 reviews

Breast Reconstruction Options

There are many options available for breast reconstruction, with the main decision focusing on whether to use one's own tissue (skin and fat). Most reconstruction today is done with tissue expanders and implants. More recent techniques have incorporated the use of acellular dermis implants in addition. Choosing the right surgery for you is based on both personal choice and consultation with your surgeon. Though you may be hesitant to try implants again, that is still a viable option as are the other choices. The only other consideration is radiation therapy and whether you have had or will need it as that may impact your recovery.

Asaad H. Samra, MD
New Jersey Plastic Surgeon
5.0 out of 5 stars 29 reviews

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.