Salvage of Tissue Expander in the Setting of Mastectomy Flap Necrosis (MFN): A 13-year Experience Using Timed Excision with Continued Expansion
Anuja K. Antony, MD, Babak Mehrara, MD, Colleen McCarthy, MD, Nina Kropf, MD, Joseph Disa, MD, Andrea Pusic, MD, Peter Cordeiro, MD.
Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
BACKGROUND: The development of mastectomy flap necrosis (MFN) after immediate tissue expander (TE) placement can have profound implications. Not only can the presence of MFN lead to a peri-prosthetic infection necessitating subsequent TE removal, but it can also delay the administration of adjuvant oncologic therapies. Thus, the management of MFN and the timing of expansion are of concern to the reconstructive surgeon. The purpose of this investigation was to evaluate the safety and efficacy of timed, surgical excision during continued serial expansion in the setting of MFN.
METHODS: Consecutive patients in whom documented mastectomy flap necrosis developed following immediate tissue expander (ITE) placement from 1995 to 2008 were identified. Patient demographic, reconstructive and complication data were obtained from a prospectively-maintained clinical database. Medical records were then retrospectively reviewed to further characterize the extent of MFN and its management.
RESULTS: Over the 13-year study period, 182 patients in whom significant MFN developed following ITE placement were identified. 16%(N=30) of patients had a history of prior irradiation. 14% (N=26) of patients had a history of neoadjuvant chemotherapy; and, 37% (N=68) received adjuvant chemotherapy during expansion or after excision.
In all 182 patients, eschar formation was monitored during which time weekly expansions were performed. In 58 (32%) patients, once the MFN had fully demarcated, surgical excision of the eschar was performed. Indications for excision included the extent of eschar formation, the adequacy of surrounding expanded healthy tissue, and the relative timing and type of adjuvant oncologic therapy. Surgical excision occurred at a mean of 36 days (range: 8-153 days) following TE placement. Mean surface area of eschar excised was 42.5 cm 2 (range: 2.5-240 cm2). Mean expander volume achieved prior to excision was 371 cc (range: 60-920 cc). At the time of surgical excision, a mean volume of 204 cc (range: 0-420 cc) of fluid was removed from the TE in order to facilitate primary wound closure.
In 9 (15%) patients, resection of such an extensive area of MFN necessitated explantation of the TE and subsequent flap closure (local advancement flaps (n=8); latissimus flap (n=1)). Of the remaining patients, only 3 (6%) developed a subsequent infection necessitating the premature removal of a TE. In the majority of patients (46 of 49 patients or 94%), the timed excision of MFN facilitated the timely completion of expansion and the exchange of a temporary expander for a permanent implant.
CONCLUSIONS: Early timed excision is a straightforward procedure which allows continued expansion in the setting of mastectomy flap necrosis. Excision of necrotic tissue can allow for salvage of a tissue expander and may prevent delays in the administration of adjuvant oncologic therapy such as chemotherapy or radiation.