Salvage anastomosis in free PAP-flap breast reconstruction: What about free flap neovascularization?

Since the emergence of microsurgery in reconstructive surgery, free flaps have become a key tool in the management of patients with breast cancer. One such flap is the profunda artery perforator (PAP) flap. To date, there is no scientific consensus on whether voluminous free flaps remain dependent on their vascular pedicle throughout their lifespan. Therefore, the pedicle should always be carefully protected during revision surgery. In this article, we review the case of a middle-aged woman who suffered a pedicle transection needing re-anastomosis during revision surgery six months after free-flap breast reconstruction. A 52-year-old woman who noticed a firm nodule in her right breast and armpit was referred to our department for surgical management. The Caucasian woman presented with no significant medical history or symptoms at the first consultation. Ultrasound-guided biopsy confirmed an invasive grade III lobular carcinoma. Following staging, the patient underwent neoadjuvant chemotherapy before a right mastectomy with a complete homolateral axillary lymph node dissection and postoperative radiotherapy. One year after completing radiotherapy, free flap reconstruction with a PAP flap was performed, and six months later, revision surgery was required to enhance the volume of the reconstructed breast with a tissue expander and later an implant. Unfortunately, pedicle transection occurred during revision surgery, causing complete devascularization of the flap, which was confirmed by intraoperative Indocyanine Green imaging. The authors elected to perform salvage re-anastomosis during the surgery. In keeping with the author’s 23-year experience with free flaps, the vascular pedicle should always be preserved in voluminous free flaps, as neovascularization alone may not ensure whole flap survival. The authors suggest always attempting re-anastomosis if vessels are compromised during revision surgery.