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Flap Revisions

Autogeneous breast reconstruction requires a second surgery to achieve the final breast contour, and create the nipple areola. During this second stage of reconstruction, the surgeon will have the opportunity to address any issues on the new breast mound, in order to enhance the quality of the aesthetic appearance created during the initial operation. This operation is generally performed after the initial swelling from the first surgery has settled, allowing the breast mound time to heal. If the patient has chemotherapy after the first stage of reconstruction, she can usually have the second surgery performed about one month after completing her treatments. If a patient is undergoing radiation therapy, it is best to wait several months. Generally done as outpatient surgery, the level of anesthesia and the amount of time for recovery will vary depending on what revisions the patient requires.

Contour Abnormalities

The most common revisions in flap reconstruction are corrections of flap fullness, or contour abnormalities. If the flap is too large, it can be corrected with liposuction or excision of skin. If there is a dent in the soft tissue, it may be possible to improve it with fat injections. In this procedure, fat is removed from other parts of the body with liposuction, and is then prepared for injection into the soft tissue of the reconstructed breast. It is not always predictable as to how much fat will “take” or be accepted by the body. It is not unusual to need more than one procedure to get the desired final outcome. The fat that does survive should last forever.

Photos and Doctor Commentary
 

Pre-operative markings

Final reconstruction

Flap Revisions

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This patient underwent right mastectomy and TRAM free flap reconstruction. The right reconstructed breast is fuller than her left breast. To improve symmetry, she underwent liposuction of the reconstructed breast at the time of her nipple areola reconstruction.

Fat Necrosis

Another area of concern that may require revision is fat necrosis. Fat necrosis is an area of firm tissue that can form in the reconstructed breast as a result of inadequate blood supply. Although typically not visible, fat necrosis can present like a lump, and may be painful. This can cause some degree of oncologic concern, and ultrasound or biopsy can be used to rule out cancer. The degree of firmness from fat necrosis usually improves with time. In some cases, areas of necrosis will need to be excised. Fat necrosis is more common in patients who have had radiation after the initial flap surgery, and in patients who have had pedicled TRAM flaps rather then abdominal free flaps.

Abdominal Bulge

Harvesting of an abdominal flap for breast reconstruction can result in donor site weakness, bulging, or hernia. The risk of this is greatest with the pedicled TRAM flap. It is much less likely when the abdominal tissue is transferred as a microvascular free flap. If fullness develops in the abdominal site, surgical options are available to correct the problem. Abdominal bulges or hernias that are not addressed may become larger or more difficult to repair with time. Repair can be done by reopening the abdominal scar and using a mesh material to reinforce the bulge. Newer techniques also utilize the external oblique muscles as part of the repair. Minor cosmetic problems in the abdominal area can corrected with simple scar revisions.

Once the revisions are done, the nipple areola will be created. Most autogeneous tissue reconstruction is completed after two procedures, although some will require a third operation to make additional contouring changes where necessary.

Photos and Doctor Commentary
 

Post-operative abdominal bulge after bilateral TRAM flaps

After correction of abdominal bulge

Abdominal Bulge

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This patient underwent bilateral mastectomies and TRAM flap reconstruction. She developed abdominal wall weakness with a large visible lower abdominal bulge. This was corrected using a large prosthetic mesh reinforced with her external oblique muscles bilaterally.