Management of massive mastectomy skin flap necrosis following autologous breast reconstruction

Background: The optimal management of severe mastectomy skin flap necrosis continues to remain a challenge. Following autologous reconstruction, small or minor areas of ischemia/tissue necrosis can result in multiple office visits, increased expenses due to dressing supplies and nursing care, and revisional operations. The purpose of this study is to describe outcomes of a common management strategy for surgeons when confronted with a patient with extensive mastectomy skin flap necrosis. Methods: Between 1997 and 2010, autologous breast reconstructions were performed in 805 women and 1076 breasts. Of these, 12 patients (15 breasts) were identified who met the criteria for massive skin flap loss (>30%). Patient photographs and wound measurements were used to estimate areas of necrosis. All patients were managed initially with local wound care followed by delayed scar excision. Results: Wound closure was ultimately achieved in all patients. Of the patients, 40% were active smokers in the perioperative period. The average patient age was 49.6 (range, 28-59) years with a body mass index of 30.9. The average mastectomy weight was 959.5 g (range, 223-1520). In-office soft-tissue debridement and local wound care was performed until wound closure was complete, which took place at a mean of 120 days (range, 30-300) after initial surgery. The average patient had a mean of 10 office visits before scar revision. There was an average of 1.7 types of dressing changes needed before wound closure. Topical wound therapy included moisturizing gels, wet-to-dry dressing, and antibiotic ointment. Oral antibiotic therapy was used in 60% of patients. Late scar revision was performed in 87% of the patients at an average of 8.9 months (range, 1-14) after initial surgery. After the initial flap surgery, no patient required skin grafting or hospitalization. Conclusions: Early conservative management followed by late scar revision produced excellent results in patients with massive mastectomy skin flap loss. The outcomes described may help clinicians and patients in the decision-making process when confronted with this difficult problem.