title: Breast reconstruction in the high risk patient with systemic connective tissue disease: a case series.
abstract: BACKGROUND
  The presence of severe underlying connective tissue disease may restrict the reconstructive options offered to a woman in the event of mastectomy. Putative concerns about reconstructive surgery include the effects of connective tissue disease and immunosuppression on wound healing and donor site morbidity, and increased risks of deranged clotting and thrombophilia after free tissue transfer. There is also the possibility of an unpredictable tissue reaction after oncological resection surgery and adjuvant radiotherapy.
  
  
  METHODS
  Here we present a review of the current sparse evidence regarding reconstructive breast surgery in this challenging group of patients. In addition we present a series of six consecutive patients with a spectrum of connective tissue disorders including combinations of longstanding Systemic Lupus Erythematosis (SLE), Rheumatoid arthritis and Raynaud's Disease who underwent successful post-mastectomy reconstruction with an extended autologous latissimus dorsi flap, along with subsequent successful correction of asymmetry and/or nipple reconstruction.
  
  
  RESULTS
  There is a paucity of literature on this subject perhaps suggesting that surgeons are reluctant to offer reconstruction or that uptake is poor in this group. Complications related to radiotherapy and free tissue transfer in patients with severe CTD is less than may be expected. The most common complications experienced by our patients with CTD after extended ALD breast reconstruction were persistent donor site seroma, wound dehiscence and delayed haematoma formation, reflecting the abnormal inflammatory response and deranged haemostatic cascade common to connective tissue disease. However, all six patients made a full recovery from surgery without residual donor site morbidity and with an acceptable aesthetic breast reconstruction.
  
  
  CONCLUSIONS
  Careful peri-operative management is crucial in this group of patients, but good outcomes are possible using a variety of reconstructive techniques. This is the first reported series of patients with severe connective tissue disease who have been managed with extended ALD breast reconstruction. The majority of complications relate to the donor site but the favourable outcomes demonstrate that the extended ALD flap remains a reliable reconstructive option for this group.
authors.affiliation: Burns and Plastic Surgery, Canniesburn Unit, Glasgow Royal Infirmary, Glasgow G4 0SF, UK. andycky@doctors.org.uk
authors.forename: K Y
authors.initials: KY
authors.lastname: Chin
authors.forename: C R
authors.initials: CR
authors.lastname: Chalmers
authors.forename: A V
authors.initials: AV
authors.lastname: Bryson
authors.forename: E M
authors.initials: EM
authors.lastname: Weiler-Mithoff
mesh_terms: D000328:Adult; D001172:Arthritis, Rheumatoid / Q000150:complications; D001943:Breast Neoplasms / Q000601:surgery*; D018270:Carcinoma, Ductal, Breast / Q000601:surgery*; D003240:Connective Tissue Diseases / Q000150:complications*; D005260:Female; D006801:Humans; D008180:Lupus Erythematosus, Systemic / Q000150:complications; D016462:Mammaplasty / Q000009:adverse effects / Q000379:methods; D008408:Mastectomy; D008875:Middle Aged; D018482:Muscle, Skeletal / Q000601:surgery; D011928:Raynaud Disease / Q000150:complications; D012307:Risk Factors; D013524:Surgical Flaps / Q000009:adverse effects