Mastectomy Flap Necrosis – an Article Review

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

This study (full reference below) comes out of Memorial Sloan-Kettering Cancer Center.  Flap necrosis following mastectomy and reconstruction using a tissue expander has always concerned me.  I will never (due to the size of my practice) have the numbers they have or experience.  They state their purpose as

The purpose of this study was to assess the outcomes of our approach to mastectomy flap necrosis and to establish an algorithm that may be useful to other surgeons faced with this complication.

They were able to use the “prospectively maintained database” of all patients treated at Memorial Sloan-Kettering Cancer Center to identify patients with documented mastectomy flap necrosis following immediate tissue expander placement between January of 1995 and March of 2008.  A total of 178 patients were identified (4.3% of 4158 pts who had immediate tissue expander placement).

Of these 178, 29 patients (16%) had a history of prior irradiation. Twenty-five patients (14%) had a history of neoadjuvant chemotherapy, and 68 patients (38%) received adjuvant chemotherapy during expansion or after excision. 

Most healed with local wound care, but 58 (33% of 178) needed surgical excision of the eschar once the flap necrosis was fully demarcated.   Of these, five patients (9%) had prior irradiation, eight (14%) had prior chemotherapy, and 29 (50%) had chemotherapy during expansion or after excision.

In nine patients (15.5% of the 58 who need surgical excision), extensive mastectomy flap necrosis necessitated explantation of the tissue expander and subsequent flap closure. 

I appreciate the authors sharing their treatment algorithm which led to their low incidence of failure.

….a more conservative approach that consists of a period of observation during which time the mastectomy flap necrosis is observed clinically over the initial 2 weeks.

Local wound care such as alcohol or Betadine swabbing may be utilized during these first 2 weeks, particularly to manage partial-thickness wounds to keep the necrotic skin clean and dry.

Expansion continues as the full-thickness demarcation becomes more evident over the next 3 to 4 weeks.

Antibiotics are not routinely administered, other than the typical oral course used for the duration that closed-suction drains remain in the breast pocket. However, if significant erythema surrounding the mastectomy flap necrosis is present and there is a clinical suspicion of infection, a more aggressive strategy using antibiotics and earlier excision may be implemented.

At about 4 to 6 weeks, full-thickness excision and closure are performed, typically in the clinic setting, with sterile removal of expander fluid to allow closure without tension.

Re-expansion is then carried out after closure approximately 2 weeks later

REFERENCE

Salvage of Tissue Expander in the Setting of Mastectomy Flap Necrosis: A 13-Year Experience Using Timed Excision with Continued Expansion; Plastic and Reconstructive Surgery. 124(2):356-363, August 2009; Antony, Anuja K.; Mehrara, Babak M.; McCarthy, Colleen M.; Zhong, Toni; Kropf, Nina; Disa, Joseph J.; Pusic, Andrea; Cordeiro, Peter G.