Curious to learn about flap surgery? Dr. Lin discusses his experience with flap surgery and tips for patients considering this procedure for breast reconstruction.
1) Tell me a little about your experience performing flap surgery. It appears you’ve used flaps for breast reconstruction. Have you used them in any other ways? What types of breast reconstructive flaps have you performed?
I have been performing flap surgery as an attending plastic surgeon since 2007, although I was increasingly more exposed to the procedure starting in 2003 as a resident physician. Apart from using flaps for breast reconstruction, I have used them for head and neck, as well as facial, reconstruction, abdominal reconstruction, and extremity reconstruction. I largely use deep inferior epigastric perforator (DIEP) flaps for breast reconstruction, although I have also used other flaps, such as the latissimus dorsi, superior gluteal artery perforator (SGAP), superficial inferior epigastric artery (SIEA), profunda artery perforator (PAP) and transverse rectus abdominis myocutaneous flaps.
2) In performing these surgeries, what complications or risks do you warn your patients about?
In performing these surgeries, common complications are similar to those of other surgical procedures, such as wound infection, wound dehiscence, fluid collections, and bleeding. Some more flap specific complications include flap necrosis, flap failure, and vascular compromise. In addition, for breast reconstruction, other complications may consist of fat necrosis, abdominal bulge, or hernia. There are a number of risk factors for complications, with primary ones I warn my patients about including the radiation, smoking, obesity, and diabetes mellitus. There is continued research investigating other risk factors, with recent reports of potential risk factors such as connective tissue diseases.
3) What postoperative instructions do you send patients home with?
Postoperatively, following breast reconstruction, I instruct my patients to get plenty of rest with a balanced diet. Pain medications are prescribed, which they should take needed. Patients should remain active and walk to help reduce swelling and prevent blood clots. Use of arms for daily living is permitted, but I do not recommend for them to push their arms above their head until a few weeks post-op. By the same token, heavy lifting is prohibited for a number of weeks. Alcohol and tobacco are not to be consumed/used. Regarding the incisions, I would recommend my patients to keep the steri-strips on until they start peeling off and to keep the incisions clean and inspect them daily. Most importantly, patients should call in the event that any irregularities are noted, such as increased swelling or bruising, persisting redness, severe or increased pain, fever, or bleeding or draining incisions. These instructions would also extend to other flap reconstructions for different areas, except instead restricting aggressive movements near the respective flap site.
4) Have you ever had a patient deal with flap necrosis? How was it resolved?
Yes, I have had to deal with flap necrosis in patients. In a patient with flap necrosis, it would depend on whether it was partial or full. In partial flap necrosis, I would manage it with local wound care, whereas for full-thickness necrosis, debridement may be necessary. I would then manage the problem by allowing the wound to heal itself, replacing missing tissue with grafts or flaps, or converting to another reconstruction depending on the severity of the tissue loss. Application of nitroglycerin ointment may also aid in reducing necrosis rates. In addition, there may also be potential uses for hyperbaric oxygen therapy.
5) Finally, what tips do you have for patients looking to get flap surgery for breast reconstruction (or any other kind if you perform them)?
I would advise patients looking for flap surgery to first and foremost find a board certified plastic surgeon who routinely performs these procedures. Discussion with the surgeon is paramount to decide the best management plan moving forward, whether or not it may be flap reconstruction. The availability of flaps would be highly dependent on the defect, as well as the patient’s baseline characteristics. I would also stress that the reconstructive process is a combination of efforts from both the patient and the healthcare team. Controlling risk factors and the postoperative care period to optimize outcomes definitely requires the patient and their support system and caregivers!