title: Management of mastectomy skin flap necrosis in autologous breast reconstruction.
abstract: BACKGROUND
  Mastectomy skin flap necrosis is a significant problem in the autologous breast reconstruction. The necrosis may create unsightly scarring, produce contour irregularities, and deform the breast mound. This may lead to a poor reconstruction and patient satisfaction. Most importantly, the development and treatment of mastectomy skin flap necrosis can delay further oncologic treatment.We performed a retrospective chart review of all patients undergoing autologous breast reconstruction in the past 5 years to examine our incidence and treatment of mastectomy skin flap necrosis. We then used these data to create a management algorithm for mastectomy skin flap necrosis. The goals of this algorithm were as follows: (1) to not delay further oncologic treatment, (2) to expedite the healing time while minimizing patient risk, and (3) to create an aesthetically pleasing breast reconstruction.
  
  
  METHODS
  A retrospective chart review from 2008 to 2013 was performed of all autologous breast reconstruction at our institution. We then analyzed our data and patient outcomes and developed a treatment algorithm.
  
  
  RESULTS
  We identified 204 patients who underwent autologous free flap breast reconstruction that was performed by the senior author (G.K.L.). Our incidence of mastectomy skin necrosis was 30%. There was no delay in adjuvant oncologic treatment for any of our patients. The development of mastectomy skin necrosis was significant for patients with diabetes (P=0.03), current tobacco use (P=0.04), and body mass index (P=0.01). The time for wound healing was prolonged in patients with a high body mass index (P=0.04). Regression analysis of wound size showed full-thickness wounds greater than 6 cm benefited from operative closure.
  
  
  CONCLUSIONS
  Our incidence of mastectomy skin necrosis was 30%. Despite our high incidence mastectomy skin necrosis, we had no delays in adjuvant oncologic treatment. Retrospective data analysis allowed us to then develop a management algorithm for mastectomy skin necrosis. We feel it is advantageous to the patient and the reconstructive outcome to heal the breast wounds in the acute phase (within 3 weeks); and with regression analysis, we found full-thickness wounds greater than 6 cm benefit from operative intervention. Finally, patients requiring adjuvant oncologic treatment should be healed as quickly as possible so they may continue on with their oncologic care.
authors.affiliation: From the Division of Plastic Surgery, Stanford University, Stanford, CA.
authors.forename: Matthew
authors.initials: M
authors.lastname: Nykiel
authors.forename: Zahra
authors.initials: Z
authors.lastname: Sayid
authors.forename: Ryan
authors.initials: R
authors.lastname: Wong
authors.forename: Gordon K
authors.initials: GK
authors.lastname: Lee
mesh_terms: D000328:Adult; D000465:Algorithms; D001940:Breast / Q000473:pathology* / Q000601:surgery; D001943:Breast Neoplasms / Q000601:surgery*; D003646:Debridement; D003661:Decision Support Techniques; D005260:Female; D058752:Free Tissue Flaps / Q000637:transplantation*; D006801:Humans; D016462:Mammaplasty / Q000379:methods*; D008408:Mastectomy; D008875:Middle Aged; D009336:Necrosis / Q000453:epidemiology / Q000209:etiology / Q000601:surgery; D011183:Postoperative Complications / Q000453:epidemiology / Q000601:surgery*; D012189:Retrospective Studies; D016038:Skin Transplantation; D014182:Transplantation, Autologous; D016896:Treatment Outcome; D058106:Wound Closure Techniques