Which of the following is the most appropriate reconstructive option in this patient?

(A) Reconstruction with a latissimus dorsi flap and a saline-filled implant
(B) Reconstruction with a TRAM flap
(C) One-stage reconstruction with a silicone gel-filled implant
(D) Two-stage reconstruction with a tissue expander and a saline-filled implant
(E) Two-stage reconstruction with a tissue expander and a silicone gel-filled implant

The correct response is Option B.

Reconstruction with a TRAM flap is the most appropriate choice for this 36-year-old woman. Transfer of autologous tissue alone is the best method in any patient who has previously undergone radiation therapy. Use of an implant, whether saline- or silicone gel-filled, is associated with a significant increase in capsular contracture and other complications in previously irradiated patients. The latissimus dorsi flap is reserved for those patients who are not good candidates for TRAM flap reconstruction or as a salvage technique following periprosthetic contracture in patients who underwent implant reconstruction following radiation therapy.

References
1. Evans GR, Schusterman MA, Kroll SS, et al. Reconstruction and the radiated breast: is there a role for implants? Plast Reconstr Surg. 1995;96:1111.
2. Spear SL, Onyewu C. Staged breast reconstruction with saline-filled implants in the irradiated breast: recent trends and therapeutic implications. Plast Reconstr Surg. 2000;105:930.

A 55-year-old woman is scheduled to undergo right mastectomy for management of breast carcinoma. She has a 30 pack/year history of cigarette smoking. She would like to undergo breast reconstruction using a free TRAM flap at the time of the mastectomy procedure.

This patient would be at significantly increased risk for development of which of the following complications?

(A) Anastomotic thrombosis
(B) Fat necrosis
(C) Mastectomy skin flap necrosis
(D) Partial TRAM flap loss
(E) Wound infection

The correct response is Option C.

When compared with nonsmokers, patients who smoke are at increased risk for necrosis of the mastectomy skin flap or abdominal flap and hernia development after breast reconstruction using a TRAM flap. Patients who have a smoking history of greater than 10 pack/years are at particularly high risk for the development of these complications. However, the risk can be decreased significantly if a delay procedure is performed or if the patient stops smoking at least four weeks before the procedure.

TRAM flap reconstruction is not associated with an increased risk for vessel thrombosis, fat necrosis, TRAM flap loss, or wound infection in patients who smoke.

References
1. Chang DW, Reece GP, Wang B, et al. Effect of smoking on complications in patients undergoing free TRAM flap breast reconstruction. Plast Reconstr Surg. 2000;105:2374.
2. Reus WF III, Colen LB, Straker DJ. Tobacco smoking and complications in elective microsurgery. Plast Reconstr Surg. 1992;89:490.