Multiple Infections - Should I Remove the Expander or Continue w/ LD Flap Surgery?

I was diagnosed with breast cancer in 2009; had a bilateral mastectomy and LN dissection with reconstruction done during this surgery (expanders placed). Underwent chemo and had radiation to the left breast. In December developed a cellulitis to the left breast took about a month of augmentin and was fine until a few days ago. Again I have pain and redness to the left breast and a fever. Is it time to say this cannot be saved and have the expander removed and go ahead with a LD flap in May?

Doctor Answers (9)

Infection, Radiation and Breast Reconstruction

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When radiation is used in the treatment of breast cancer, non-cancerous tissues in the path of the radiation are also affected. Radiation therapy can mean a significant loss of skin elasticity, which can profoundly affect the aesthetic results of breast reconstruction. And because the body’s wound-healing mechanisms are altered by exposure to radiation, complications from all types of reconstructive breast surgery occur at a higher rate.

Radiation is especially problematic for women who undergo implant reconstructions, regardless of whether the radiation is administered before or after the implant is placed. 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.

Because of the potential complications associated with implants, breast reconstruction using natural tissue is generally considered the best method for women who will require or have already had radiation. Based upon the brief description you provided, consideration should be given to removing the implant and then proceeding with a natural tissue reconstruction a few months later (when the infection has fully cleared). Most women do not have nough tissue to reconstruct a breast using an LD flap without an implant, but other locations on the body frequently do have enough tissue to reconstruct a breast in proportion to a woman's body. The buttocks, thighs, abdomen and love-handle areas are all possible options for donor site for tissue for breast reconstruction.

While radiation therapy can complicate breast reconstruction surgery, with proper preparation most women can achieve a satisfactory reconstruction even if radiation therapy is part of their treatment plan. Perforator flaps including the DIEP flap, SIEA flap and SGAP flap are all used routinely with excellent results to reconstruct patients who have required radiation therapy.


New York Plastic Surgeon

Implant Complication in Irradiated Breast

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Based on your history of radiation to the left breast and recurrent infection, I recommend that you consider a tissue reconstruction.   Either a latissimus flap or abdominal tissue transfer would be suitable, depending on what you prefer and are a candidate for.    

As far as the immediate issue, it seems that it will be necessary to at least remove the implant and all the capsule.   An informed discussion between you and your surgeon is necessary to chose the safest way to treat your infection and then proceed with reconstruction of your breast.

My safest recommendation would be that you have the left implant and ALL capsule removed, followed by a 4-6 month recovery period.   At this point, I would proceed with tissue reconstruction.   If you choose a latissimus flap, I would place a tissue expander again and expand until the desired volume and symmetry are achieved.   Subsequent, implant exchange would then be necessary.  

I wish you a safe and healthy recovery.

Paul S. Gill, MD
Houston Plastic Surgeon
5.0 out of 5 stars 38 reviews

Breast reconstruction and infection

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If you have a recurrent infection, you  may have to bite the bullet and have the expander removed and then come back at a later time for a different type of reconstruction or a restart of the TE.

Steven Wallach, MD
Manhattan Plastic Surgeon
4.5 out of 5 stars 17 reviews

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Multiple infections - should I remove the expander or continue w LD flap surgery?

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Hello!  Thank you for your question.   After radiation, you have an increased rate of complications including wound problems, infections, thinning of the tissue, and decreased vascularity to the skin/tissue of the area.  The best method to reconstruct a breast following radiation therapy is with a flap.  The 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 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 12 reviews

Breast Reconstruction After Radiation and Infection

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Based on the information you provided, your best option is to have the breast implant removed, the pocket cultured, and the infection aggressively treated.  Once the infection has resolved, and your tissues are soft, then a flap breast reconstruction should be considered. 

The choice of flap technique will depend on size of the breast that is appropriate for your body and other considerations that will be discussed by the reconstructive plastic surgeon.

Flap techniques include the latissimus dorsi flap, TRAM flap, and DIEP flap to name a few.  

The Latissimus dorsi flap alone is useful for reconstruction of small sized breasts, whereas other flap choices provide more tissue and, thus can create larger breasts without need for breast implants.

 

Fredrick A. Valauri, MD
New York Plastic Surgeon

Post radiation breast reconstruction.

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If you are experiencing a recurrence of your infection, then you may want to consider some form of autologous breast reconstruction (tissue reconstruction without implants).   In addition, you are experiencing these problems on your radiated side.  Remember, your history of radiation will significantly increase your risk of scar tissue formation around your implant. I generally do not recommend placement of final implants after radiation because of an increased risk of scar tissue formation around you implant (also known as capsular contracture).  I would evaluate you to see if you are a candidate for a muscle sparing TRAM/DIEP Free flap procedure.   Please  visit our website to learn more about your reconstructive options.

C. Bob Basu, MD, FACS
Houston Plastic Surgeon
4.5 out of 5 stars 123 reviews

Autologous reconstruction following failed implant reconstruction

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Once you have failed expander placement, you are limited to undergoing your reconstruction with autologous tissue. these include local flaps such as LD, but also distant flaps, and even less invasive fat grafting.

Arian Mowlavi, MD
Laguna Beach Plastic Surgeon
5.0 out of 5 stars 9 reviews

Infections after breast reconstruction

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This is a choice you should discuss with your plastic surgeon. If the radiation has changed your skin and it is becoming infected, then you should consider the latissimus dorsi flap or TRAM flap. Long-term, breast reconstructions with implants after radiation do tend to have more problems.

Karol A. Gutowski, MD, FACS
Chicago Plastic Surgeon
5.0 out of 5 stars 19 reviews

Breast Reconstruction

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Most failed implant reconstruction is due to the effect of radiation.

Two episodes of cellulitis is enough to take the expander out and the capsule, treat the infection then discuss the timing and the options of breast reconstruction.

1: Latismus Dorsi flap with or without implant

2: TRAM flap

3: diep flap or other free flap reconstruction.

4: In some cases fat transfer

Samir Shureih, MD
Baltimore Plastic Surgeon

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.