Unilateral failures in bilateral microvascular breast reconstruction

As rates of bilateral prophylactic mastectomy and contralateral prophylactic mastectomy have increased over the past decade, bilateral microvascular breast reconstruction has played an increasing role in breast cancer care. Data on unilateral flap failure in bilateral microvascular breast reconstructions have been lacking, and strategies to address the challenges encountered in this situation are needed.

A retrospective review of all simultaneous bilateral microvascular breast reconstructions performed by the senior author (M.Y.N.) from July of 1999 to July of 2008 was conducted. Flap failures were identified and reviewed for operative parameters, causes of flap loss, and techniques used for secondary reconstruction.

The authors identified 171 consecutive patients who underwent bilateral microvascular breast reconstruction between July of 1999 and July of 2008. In these patients, 342 flaps were attempted, including 108 free transverse rectus abdominis musculocutaneous flaps, 228 deep inferior epigastric artery perforator flaps, and six superior gluteal artery perforator flaps. Twelve flaps failed or were aborted intraoperatively, yielding an overall failure rate of 3.5 percent. The authors' unilateral microsurgical breast reconstruction failure rate over this period was 2.1 percent (eight of 386). No bilateral failures occurred. Causes of flap failure included venous insufficiency (six of 12), lack of adequate perforator anatomy (three of 12), and perforator injury during dissection (two of 12). Secondary reconstruction with tissue expanders and implants was performed in 11 of 12 patients who underwent an average of 2.25 additional procedures to complete reconstruction.

Flap failure is more common in bilateral reconstructions than in unilateral reconstructions, largely secondary to the obligation to use both sides of the abdominal donor tissue. When flap failure does occur, techniques to optimize prosthetic reconstruction can ultimately result in successful bilateral reconstructions despite free flap failure.