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Reconstruction: Complications

 
MANAGEMENT OF COMPLICATIONS
 
 

EXPANDER/IMPLANT COMPLICATIONS

  • Hematoma

In case of hematoma formation, operative exploration of the surgical site and evacuation of the hematoma are required. To maximize sterility and minimize potential injury to the expander or implant, evacuation of the fluid is performed in an operating room.

  • Infection

If infection occurs, the entire expander or implant must be removed and the implant pocket drained. A Jackson-Pratt no. 10 fully perforated drain is used. The drain is placed into the implant pocket once the expander/implant is removed and remains in position until the output is less than 30 cc during a 24-hour period. Perioperative, broad-spectrum antibiotics are given preoperatively to the patient and continued until all inflammation has subsided. Prior to surgery, cefazolin is given intravenously, followed by oral doses of cephalexin for ten days. The selection of antibiotics may change based upon cultures obtained during implant removal. Following a six month interval, reconstruction using the expander/implant technique can again be attempted.

  • Capsular Contraction

The fibrous capsule surrounding the implant can contract to such a degree that may result in deformity of the shape of the breast mound as well as pain. In symptomatic patients, the only option is to perform a capsulectomy (removal of the implant capsule) and replace the implant.

TRAM FLAP COMPLICATIONS

  • Hematoma

Hematoma formation requires immediate operative evacuation and exploration of the surgical sites to control any ongoing bleeding. The procedure is performed in an operating room to maximize sterility and minimize risk of infection.

  • Wound Healing Difficulties

Wound healing difficulties are most commonly the result of necrosis of the mastectomy flap edges and/or the abdominal wound closure edges. If tissues appear necrotic the patient is immediately brought to the operating room, the necrotic portions excised, and the wound re-closed. It is vital that the tissue is removed promptly in order to avoid bacterial colonization or infection.

  • Loss of Umbilicus

Poor perfusion can lead to loss of the umbilicus. If the umbilicus becomes necrotic, the tissue is excised and the abdominal wall is closed. Again, excision of the necrotic tissue is performed immediately to avoid bacterial colonization or infection. Reconstruction of the umbilicus can be attempted after six months.

  • Incisional Hernia

Abdominal wall laxity may occur in the area from which the rectus abdominus has been harvested. Treatment requires repair of the abdominal wall laxity using marlex mesh.

  • Partial/Complete Flap Loss

Partial flap loss is rare. Should it occur, excision of necrotic portions is required, followed by wound closure.

Complete flap loss is very rare and typically occurs during elevation. If the flap is not viable, it is discarded. The abdominal incision is closed using the method described in the TRAM donor site closure section, whereas the mastectomy wound is closed without reconstruction. Reconstructive alternatives are then discussed with the patient after recovery from surgery.


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