A 38-year-old patient diagnosed with multifocal ductal carcinoma of the left breast.
She underwent surgery in our institution, a second level hospital, performing left modified radical mastectomy on reduction pattern, ipsilateral axillary lymphadenectomy and immediate reconstruction with Polytechtics broadband Dorsal prosthesis 436
Right reduction mammoplasty with the same pattern was also performed for the asymmetry, and if it was designed for the nipple-areola complex.
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As adjuvant postoperative treatment, she underwent chemotherapy, as expected at the time of diagnosis of carcinoma, and radiotherapy for finding 3 metastatic axillary lymph nodes during surgery.
The patient finished radiotherapy 8 months after surgery and 2 months later, the radiation emitted a severe radiodermitis and a spontaneous seroma after several attempts to drain the prosthesis at the year e.g., the radiotherapy received.
On the other hand, the diagnosis of genetic counseling recommended the right prophylactic mastectomy for considering a high risk when the biopsy of the reduction specimen showed ductal hyperplasia with atypia.
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Due to the impossibility of using the latissimus dorsi flap and the sequelae of radiotherapy, after assessing the reconstructive possibilities, we refer the patient to a tertiary hospital because our second level institution is not enabled for vascular microsurgery.
The indication was to perform breast reconstruction with bilateral DIEP microsurgical flap.
One year after the explantation, the indicated prophylactic mastectomy of the right breast and microsurgical reconstruction with bilateral DIEP flap were performed.
The evolution after a postoperative pulmonary infection that required admission to the Intensive Care Unit was unfavorable, and there was total necrosis of both DIEP flaps.
After one year and after the stabilization of trics, it was evaluated if there really existed some reconstructive possibility given the age of the patient and the severity of cutaneous sequelae (dermitis and costal adherence).
We chose to try to improve the skin cover with a fat autotransplantation in order to support tissue expanders in the future and achieve moderate breast size.
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Two sessions of autologous fat grafts were performed with an interval of 6 months and in an outpatient setting.
In the first session, the abdomen was obtained and after processing with centrifugation autologous fat 240cc. in the right thoracic region and 200cc. in the left.
In the second session, fat was obtained from the flanks and the legs, transferring 160cc. in the left breast.
There was clinical improvement in tissue thickness, release of adhesions of soft parts of the left thoracic radiodermitis and, at the same time, we achieved a slight increase in volume.
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At 6 months we place tissue expanders.
We chose anatomically breast tissue expanders (Mentor®, Johnson & Johnson, New Jersey, USA) of 350cc.
In the right hemithorax, the expander was implanted in a retropectoral plane without any technical difficulty.
We had the overwhelmed problem of tissue precariousness and previous radiodermitis of the left hemithorax.
To prevent the extrusion to the greater jaw, we sutured a 8 x 16cm Strattice® dermal matrix sheet from a remaining fibrous edge found in the surgical specimen with Vycril® 3/0.
The role of the matrix was to protect the lower pole of the expander that was located in a subpectoral plane in the upper part and covered by the Strattice® plate in the lower half.
The postoperative course was uneventful.
The expander filling sessions were normal after 2 weeks postoperatively.
The amount of filling per session ranged from 20 to 60cc per expander to reach a total volume of 360cc.
The great elasticity and the low resistance to the expansion of the left breast were underlined, contrary to what was expected by previous radiotherapy, so that at 4 months the process had been satisfactorily completed.
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5 months later we added the dermal matrix to the replacement of expanders by definitive prosthesis of 380cc., anatomical, (Polytech® model 20737)
Three months later, due to the favorable evolution of the patient, without evidence of contracture, nipple reconstruction was performed with local Lys flower flaps.
The breast flap previously submitted to radiotherapy suffered partial necrosis.
At the time of writing this article, we are performing micropigmentation technique for the areola.
Eight months after the last intervention, the patient is satisfied with the result and has been able to fully return to his social and labor life.
