Microflaps for Breast Reconstruction
Over the past two decades I’ve been involved in a great deal of research dealing with reconstructive microsurgeries that employ “flaps.” Since I have performed and continue to perform many, many breast reconstruction surgeries, I believe the need to educate patients is of great importance. The literature is rife with all the needed information, but it’s medical literature, and it is full of terms that are not easy to understand unless you’re a medical person.
So, I’ve decided to “blog” this information in layman’s terms. Since breast surgeries are on the rise I’ve decided to start with my own published articles and bring you up to speed on the great advances being made and used today. The following is a breakdown of information from: Microvascular Free Flap Failure Caused by Unrecognized Hypercoagulability; which I co-authored with Craig M. Kessler,M.D. and Ali Al-Attar, M.D., Ph.D from the Department of Plastic Surgery and the Division of Coagulation, Georgetown University Hospital.
In this literature we give you a roadmap to follow as such: 1) Background – a mini-overview of the history of free flap techniques over the past two decades with the focus on failure rates and causes. 2) Methods: tells you how we got our information – in this case we studied 4 patients with major free flap microvascular complications who were later diagnosed with hypercoagulability and biochemical abnormalities. 3) Results: in this case revealed that hypercoagulability was a problem for all four patients, and 4) Conclusions: we restate what we found, we clarify the associated problems and we offer diagnostic and treatment recommendations to improve future success rates for patients with these problems.
In doing our “background” search we discovered that microsurgical reconstruction has become progressively more successful coming up from a low of 63% success rate to a high of 98.8% at centers of excellence over the last few years. But in spite of this: greater experience; improved technology and development of anastomotic devices, surgeons could not get that 1-3% failure rate to drop further, except in cases where DIEP flap procedure was used.
Our Method involved 4 patients all with major free flap microvascular complications. One of the four patients was a 38 year old woman who had bilateral mastectomy for treatment of cancer of the right breast. The other patients included: a 29 year old woman with a cheek cancer, a 42 year old woman with recurring mouth cancer and the 4th was a 43 year old woman with a tumor history and treatment that encompassed the cheek, orbital and sinus areas.
All four of these patients were treated using “flap” procedures. The importance of this is that microsurgery today relies heavily upon flap usage for successful reconstruction. The flap procedure involves using living tissue, taken from a donor site on the body and bringing it to the recipient site (the damaged site), to reconstruct that area so that it functions normally and looks as natural as possible.
Normal function and natural looking is always my primary goal as a surgeon.
Since free flap complications were present in all four patients – even though they were treated for different reasons – we were concerned with finding the cause(s) for the flap failures. Since our method involved 4 different cases with flap failures – there had to be similarities in all four.
We discovered a “hidden” contributing factor: the patient was that factor. The Results: Each patient had undiagnosed coagulopathy that was the direct cause for the flap failures. Coagulopathy means there is a problem with “blood clotting.” In these types of patients there appears to be a hidden predisposition to developing hypercoagulability complications during an operation. Coagulation is the process of the blood changing from a fluid to a solid (blood clot). In order for a “flap” to take hold, the blood must remain free flowing to bring life to that area. In each of these cases, clotting caused flap failure.
We were able to draw valuable conclusions that have enabled surgeons to overcome this problem and reduce the flap failure rate. The conclusions: in spite of careful patient selection, advanced and refined procedures and technology, we know that in certain patients this “hidden” factor can occur unexpectedly.
We underscored the following:
1) There are certain genetic and acquired causes for hypercoagulability that are not rare in the general population. Some patients develop diseases e.g. cancers or autoimmune disorders that can produce a hypercoagulable state.
2) Some medications can promote a procoagulapathic state.
3) The medical history is probably the most important tool used to reveal a genetic tendency for hypercoagulability.
4) If there is any suspicion of this problem – the only testing that can possibly identify those potentially at risk for hypercoagulability is screeing for deep venous thrombosis. However, the majority of patients at risk at not detected before surgery as the problem develops during the surgery.
5) All four of the patients studied had these things in common:
- All had locally advanced cancers of the head, neck or breast
- The cancers were recurrences for most of them
- They all had been treated for their cancer with irradiation
- All four had extensive histories of tobacco and alcohol usage
- All suffered with nutritional deficiency common with poor diets
- All had surgical removal of their tumors which involved more than 10 hours in surgery
- Each had at least one genetic hypercoagulable mutation and some had 2-3 of these events
Steven P. Davison, MD