I have seen several patients over the last months that highlight the risk of inappropriate use of compression. One patient had scrotal edema. He had non-Hodgkin's lymphoma and developed edema of the lower extremities and as this became worse, he developed edema of the scrotum. The edema was initially treated with diuretics, which temporarily resulted in decreased lower extremity edema but had very little effect on the edema of the scrotum. Unfortunately, the patient applied a compressive wrap. The scrotal skin is very thin and delicate and the edema further stretched the skin. The compressive garment did not help and caused area of skin breakdown leading to a severe infection. The proper treatment for this patient was to treat the cancer causing the problem, not applying compression of the swollen scrotum. The infection complicated the management of this patient since the infection had to be treated before the chemotherapy could be started. Fortunately, non-Hodgkin's lymphoma is a very treatable cancer and once the patient received the proper treatment with chemotherapy, the cancer decreased significantly in size and the scrotal edema resolved. For additional information on scrotal edema see the Dr. Reid's Corner article here.
Post Reconstructive Breast Surgery
Dr. Reid's Corner
I frequently get questions from my patients concerning the use of compression following reconstructive breast surgery. Most patients develop swelling and edema following reconstructive surgery. However, this edema and swelling subsides following the surgery and I do not recommend the use of compressive garments for the management of edema for these patients. In fact, the use of compression can be harmful. Just like the case of the scrotal edema above, the tissue following reconstruction is delicate. To perform the reconstruction a section of skin with the muscle and blood supply is moved from the abdomen to the chest wall. This section of tissue needs time to securely grow in place. The application of compression can cause diminished blood flow and the graft may complicate the procedure. Common complications include blood clots in the vessels, partial or complete loss of the tissue flap, skin necrosis, and local wound-healing problems. The use of compression could increase the risk of blood clots and increase the risk of loss or necrosis of the reconstructed breast. The expected complication rate for this type of surgery is in the range of 2 to 6% but can be significantly higher. Recent studies demonstrate that smokers and patients who are significantly over weight have a higher complication rate. In addition, recent studies have shown that smoking and obesity, which impair normal blood flow and tissue healing, significantly contribute to complications from reconstruction (see abstracts below). Since most swelling and edema following reconstructive surgery will resolve as the tissues heals, the use of compression to reduce edema is of limited value and can cause complications. Only your doctor will be able to evaluate your particular condition and determine if there is any role for compression following reconstructive surgery. For additional information on reconstruction see the Dr. Reid's Corner article here.
Tony Reid MD Ph.D
Complications of post-mastectomy breast reconstruction in smokers, ex-smokers, and nonsmokers. Padubidri AN, Yetman R, Browne E, Lucas A, Papay F, Larive B, Zins J. Plast Reconstr Surg 2001 Feb;107(2):342-9 Department of Plastic Surgery, Cleveland Clinic Foundation, Ohio, USA. firstname.lastname@example.org Smoking results in impaired wound healing and poor surgical results. In this retrospective study, we compared outcomes in 155 smokers, 76 ex-smokers, and 517 nonsmokers who received postmastectomy breast reconstructions during a 10-year period. Ex-smokers were defined as those who had quit smoking at least 3 weeks before surgery. Transverse rectus abdominis musculocutaneous (TRAM) flap surgery was performed significantly less often in smokers (24.5 percent) than in ex-smokers (30.3 percent) or nonsmokers (39.1 percent) (p < 0.001). Tissue expansion followed by implant was performed in 112 smokers (72.3 percent), 50 (65.8 percent) ex-smokers, and 304 nonsmokers (58.8 percent) (p = 0.002). The overall complication rate in smokers was 39.4 percent, compared with 25 percent in ex-smokers and 25.9 percent in nonsmokers, which is statistically significant (p = 0.002). Mastectomy flap necrosis developed in 12 smokers (7.7 percent), 2 ex-smokers (2.6 percent), and 8 nonsmokers (1.5 percent) (p < 0.001). Among patients receiving TR4AM flaps, fat necrosis developed in 10 smokers (26.3 percent), 2 ex-smokers (8.7 percent), and 17 nonsmokers (8.4 percent). Abdominal wall necrosis was more common in smokers (7.9 percent) than in ex-smokers (4.3 percent) or nonsmokers (1.0 percent). In this large series, tissue expansion was performed more often in smokers than was autogenous reconstruction. Complications were significantly more frequent in smokers. Mastectomy flap necrosis was significantly more frequent in smokers, regardless of the type of reconstruction. Breast reconstruction should be done with caution in smokers. Ex-smokers had complication rates similar to those of nonsmokers. Smokers undergoing reconstruction should be strongly urged to stop smoking at least 3 weeks before their surgery.
Complications in postmastectomy breast reconstruction: two-year results of the Michigan Breast Reconstruction Outcome Study. Alderman AK, Wilkins EG, Kim HM, Lowery JC. Plast Reconstr Surg 2002 Jun;109(7):2265-74 Robert Wood Johnson Clinical Scholars Program, The University of Michigan Medical Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-0340, USA. In this study, the effects of procedure type, timing, and other clinical variables on complication rates in mastectomy reconstruction were prospectively evaluated. Using a prospective cohort design, women undergoing first-time, immediate or delayed breast reconstruction were recruited from 12 centers and 23 plastic surgeons. Complication data for expander/implant, pedicle transverse rectus abdominis musculocutaneous (TRAM) flap, and free TRAM flap procedures were evaluated 2 years after surgery in 326 patients. For each patient, the total number of complications was recorded and the complication data were dichotomized in two ways: (1) total complications and (2) major complications (those requiring reoperation, rehospitalization, or nonperioperative intravenous antibiotic treatment). The effects of procedure type, timing, radiotherapy, chemotherapy, age, smoking, and body mass index on complication rates were analyzed using logistic regression. Immediate reconstructions had significantly higher total as well as major complication rates, compared with delayed procedures (p = 0.011 and 0.005, respectively). Furthermore, higher body mass indexes were associated with significantly higher total and major complication rates (p = 0.005 and p < 0.001, respectively). No significant effects on complication rates were noted for procedure type or for the other independent variables, although there was evidence of trends for higher total and major complication rates in implant patients who received radiotherapy and a trend for higher major complication rates in TRAM flap patients who received chemotherapy. It was concluded that (1) immediate reconstructions were associated with significantly higher complication rates than delayed procedures, and (2) procedure type had no significant effect on complication rates.
Immediate versus delayed free TRAM breast reconstruction: an analysis of perioperative factors and complications. DeBono R, Thompson A, Stevenson JH. Br J Plast Surg 2002 Mar;55(2):111-6 Department of Plastic Surgery, Ninewells Hospital and Medical School, Dundee, UK. Immediate breast reconstruction provides superior psychological benefit to the patient compared with delayed reconstruction, and has a financial advantage. Smokers undergoing immediate free TRAM breast reconstruction have a higher incidence of flap necrosis than smokers undergoing delayed free TRAM reconstruction. Whereas the differences in psychological benefit, effects of smoking and cost are well addressed in the literature, the differences in morbidity between immediate and delayed free TRAM breast reconstruction are still unknown. Knowledge of any differences would help to determine the best timing for reconstruction, and would support surgical decision making and preoperative patient advice. We present a retrospective review of 105 consecutive free TRAM breast reconstructions performed in 97 patients (89 unilateral and eight bilateral reconstructions). There were 48 immediate reconstructions and 57 delayed reconstructions. In the immediate-reconstruction group six flaps required revision of the anastomosis, and three flaps (6%) were lost. In the delayed-reconstruction group five flaps required revision of the anastomosis, and only one flap (2%) could not be salvaged. Delayed healing of the chest-wall skin flaps only occurred in immediate reconstructions (16%, P = 0.017). Copyright 2002 The British Association of Plastic Surgeons.
Comparison of immediate and delayed free TRAM flap breast reconstruction in patients receiving postmastectomy radiation therapy. Tran NV, Chang DW, Gupta A, Kroll SS, Robb GL. Plast Reconstr Surg 2001 Jul;108(1):78-82 Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA. Tumor pathologic features and the extent of nodal involvement dictate whether radiation therapy is given after mastectomy for breast cancer. It is generally well accepted that radiation negatively influences the outcome of implant-based breast reconstruction. However, the long-term effect of radiation therapy on the outcome of breast reconstruction with the free transverse rectus abdominis myocutaneous (TRAM) flap is still unclear. For patients who need postmastectomy radiation therapy, the optimal timing of TRAM flap reconstruction is controversial. This study compares the outcome of immediate and delayed free TRAM flap breast reconstruction in patients who received postmastectomy radiation therapy.All patients at The University of Texas M. D. Anderson Cancer Center who received postmastectomy radiation therapy and who also underwent free TRAM flap breast reconstruction between January of 1988 and December of 1998 were included in the study. Patients who received radiation therapy before delayed TRAM flap reconstruction were compared with patients who underwent immediate TRAM flap reconstruction before radiation therapy. Early and late complications were compared between the two groups. Early complications included vessel thrombosis, partial or total flap loss, mastectomy skin flap necrosis, and local wound-healing problems, whereas late complications included fat necrosis, volume loss, and flap contracture of free TRAM breast mounds. Late complications were evaluated at least 1 year after the completion of radiation therapy for patients who had delayed reconstruction and at least 1 year after reconstruction for patients who had immediate reconstruction.During the study period, 32 patients had immediate TRAM flap reconstruction before radiation therapy and 70 patients had radiation therapy before TRAM flap reconstruction. Mean follow-up times for the immediate reconstruction and delayed reconstruction groups were 3 and 5 years, respectively. The mean radiation dose was 50 Gy in the immediate reconstruction group and 51 Gy in the delayed reconstruction group.One complete flap loss occurred in the delayed reconstruction group, and no flap loss occurred in the immediate reconstruction group. The incidence of early complications did not differ significantly between the two groups. However, the incidence of late complications was significantly higher in the immediate reconstruction group than in the delayed reconstruction group (87.5 percent versus 8.6 percent; p = 0.000). Nine patients (28 percent) in the immediate reconstruction group required an additional flap to correct the distorted contour from flap shrinkage and severe flap contraction. These findings indicate that, in patients who are candidates for free TRAM flap breast reconstruction and need post-mastectomy radiation therapy, reconstruction should be delayed until radiation therapy is complete.