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Citation: Bojanic C, Di Pace B, Ghorra DT, Fopp LJ,
Rabey NG, Malata CM (2023) A comparison of
presentations and outcomes of salvage versus
non-salvage abdominal free flap breast
reconstructions—Results of a 15-year tertiary
referral centre review. PLoS ONE 18(11):
e0288364. https://doi.org/10.1371/journal.
pone.0288364
Editor: Fabio Santanelli, di Pompeo d’Illasi,
Universita degli Studi di Roma La Sapienza Facolta
di Medicina e Psicologia, ITALY
Received: January 2, 2023
Accepted: June 24, 2023
Published: November 1, 2023
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https://doi.org/10.1371/journal.pone.0288364
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PLOS ONE | https://doi.org/10.1371/journal.pone.0288364 November 1, 2023
A comparison of presentations and outcomes
of salvage versus non-salvage abdominal free
flap breast reconstructions—Results of a 15-
year tertiary referral centre review
Christine Bojanic ID1*, Bruno Di Pace ID2,3, Dina T. Ghorra ID1,4, Laura J. Fopp1, Nicholas
G. Rabey1, Charles M. Malata1,3,5
1 Plastic & Reconstructive Surgery Department, Addenbrooke’s Hospital, Cambridge University Hospitals
NHS Foundation Trust, Cambridge, United Kingdom, 2 Scuola Superiore Meridionale, University of Naples
“Federico II”, Naples, Italy, 3 School of Medicine, Anglia Ruskin University, Cambridge and Chelmsford,
United Kingdom, 4 Department of Plastic Surgery, University of Alexandria, Alexandria, Egypt, 5 Cambridge
Breast Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge,
United Kingdom
* cb2097@cam.ac.uk
Abstract
Introduction
Salvage breast reconstruction with autologous tissue is becoming more prevalent due to a
resurgence in implant-based procedures. The latter has caused a commensurate rise in
failed or treatment-resistant prosthetic cases requiring conversion to free tissue transfers.
Salvage reconstruction is often considered more challenging, owing to patient presentation,
prior treatments and intraoperative difficulties. The aim of the study was to test this hypothe-
sis by comparing outcomes of salvage versus non-salvage autologous microsurgical breast
reconstructions in a retrospective matched cohort study.
Methods
The demographics, risk factors, operative details and outcomes of patients who underwent
free flap salvage of implant-based reconstructions by a single operator (2005–2019) were
retrospectively evaluated. For each salvage reconstruction, the consecutive non-salvage
abdominal free flap reconstruction was selected for comparison. The clinical outcomes
including intraoperative blood loss, operative time, flap survival and complication rates were
compared.
Results
Of 442 microsurgical patients, 35 (8.0%) had salvage reconstruction comprising 41 flap
transfers (29 unilateral, 6 bilateral) and 42 flaps (28 unilateral, 7 bilateral) in nonsalvage
reconstruction. Deep inferior epigastric perforator (DIEP) flaps comprised the commonest
autologous tissue used in both groups at 74% and 71% respectively. Most patients (83%)
underwent salvage reconstruction for severe capsular contractures. There was a significant
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Data Availability Statement: All relevant data are
within the paper and its Supporting information
files.
Funding: The author(s) received no specific
funding for this work.
Competing interests: The authors have declared
that no competing interests exist.
PLOS ONE | https://doi.org/10.1371/journal.pone.0288364 November 1, 2023
Salvage breast reconstruction 15-year review of outcomes
difference in radiation exposure between groups (salvage reconstruction 89%, non-salvage
reconstruction 26%; p<0.00001). All 83 flaps were successful with similar reoperation rates
and intraoperative blood losses. Unilateral salvage reconstruction took on average two
hours longer than non-salvage reconstruction (p = 0.008). Overall complication rates were
similar (p>0.05).
Conclusion
This 15-year study shows that despite salvage autologous free flap breast reconstruction
requiring longer operation times, its intra and postoperative outcomes are generally compa-
rable to non-salvage cases. Therefore, salvage breast reconstruction with free flaps pro-
vides a reliable option for failed or suboptimal implant-based reconstructions.
Introduction
Breast cancer is the most common malignancy in women, with over 2 million new cases each
year worldwide [1]. Around 40% of these women will require a mastectomy as part of their
treatment [2]. Following mastectomy, 21% of women in the UK and 43% of women in the US
choose to undergo breast reconstruction [3–5]. Implant-based breast reconstruction is the
most commonly performed type of breast reconstruction across the globe [6–8]. However,
although reconstruction with prostheses is considered to be “simple” and has distinct advan-
tages in certain patients, its limited lifespan and frequent unsatisfactory long-term patient out-
comes (especially in the context of adjuvant radiotherapy) have resulted in a significant
proportion of patients requiring multiple revision surgeries [7–9]. The number of patient
referrals for failed implant-based cases or those with recalcitrant complications has been
steadily increasing with implant removal now being the third most commonly performed
breast reconstruction procedure in the US after implant-based reconstruction and breast
reduction [10–12].
In cases where implant reconstruction is unsuccessful, suboptimal or ridden with intracta-
ble complications, a conversion to autologous tissue (usually a free flap) can be performed; this
is termed salvage (or as originally described tertiary), breast reconstruction [4, 8, 9, 13, 16]. Sal-
vage breast reconstruction has been deemed challenging for reasons mainly related to patient
presentation and intra-operative challenges [7, 9]. These include an older patient demographic
with increased co-morbidities, chronic or persistent implant-related pain, and frustration with
their suboptimal or symptomatic reconstructions [3, 9]. Patients referred for salvage breast
reconstruction also present with more complex issues such as irradiated scarred skin and soft
tissues, severe capsular contracture (CC), silicone lymphadenopathy and scarred internal
mammary recipient vessels [2, 9, 14, 15]. The intraoperative challenges include bleeding from
partial or total capsulectomies, scarring interfering with the anastomoses, skin shortage and
the need to manage both soft and hard capsules [16, 17]. Further problems include manage-
ment of the pectoralis major muscle, repair of the often-disrupted inframammary fold as well
as the correction of poor shape of the breast mound in the context of stiff distorted tissues
[18]. More recently surgeons also have had to contend with extra scarring caused by previous
acellular dermal matrix (ADM) incorporation into soft tissues where this was used as an
adjunct to implant reconstruction [11, 18]. This can be in the context of ruptured or failed
implants with silicone “extravasation” outside the capsules which create additional challenges
[19]. It is interesting that extracapsular rupture has been estimated to be about 25.8% and
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PLOS ONE Salvage breast reconstruction 15-year review of outcomes

therefore this is a common practical problem [20]. In these complex salvage breast reconstruc-
tion cases, autologous free flap conversion has been the favoured method [2, 7, 15].
The objective of this study was to compare the presentation and outcomes of patients
undergoing autologous free flap salvage of previous implant-based breast reconstruction to
those of non-salvage free flap breast reconstruction performed over a cumulative period of 15
years by a single operator. To our knowledge, this is the first 15-year retrospective study that
compares each salvage free flap breast reconstruction (SR hereafter) with a chronologically
consecutive non-salvage autologous free flap breast reconstruction (NSR hereafter).

Materials and methods

A retrospective review of all free flap breast reconstruction patients who underwent salvage of
their previous prosthetic reconstructions by a single operator (CMM) at Cambridge University
Hospital (Addenbrookes) between January 2005 and September 2019 was undertaken.
Patients were identified from a prospective departmental free flap register cross-referenced
with the senior author’s logbook. There were no patient exclusions and, in design, this was a
retrospective matched cohort study. Data were retrospectively collected and anonymised from
archived patient records, electronic Epic™ production software patient records and supporting
correspondence. A total of 442 patient cases were studied, including 35 salvage reconstructions
(SR) and 35 chronologically consecutive non-salvage reconstructions (NSR). The SR group
consisted of patients who underwent free flap breast reconstruction following previous
implant-based breast reconstruction. Patients undergoing free flap breast reconstruction for
the first time comprised the control group (NSR). These patients had not undergone any type
of breast reconstruction previously. Due to the long timeframe of the study, it was important
to exclude any learning curve and surgical technology advances, and this also completely
avoided selection bias. Therefore, for each SR, the control was selected as the chronologically
consecutive NSR, occurring between 2 and 23 days after each SR.
The study design was assessed by the Ethics Committee of the Research & Development
Department of Cambridge University Hospitals NHS Foundation Trust and it waived the
requirement for Ethics Approval.

Surgical data
Patient demographics including age, body mass index (BMI), smoking status, and co-morbidi-
ties were recorded. In both groups, detailed oncological background was examined, such as
whether the patient received post-mastectomy radiotherapy (PMRT).
Details about the patient’s initial breast reconstruction were recorded such as age at that
surgery, time elapsed and number of revisions prior to SR. Indications for SR were catego-
rized as either objective or subjective. Objective indications included implant rupture,
severe CC (Baker III/IV), post-radiotherapy skin and soft tissue changes as well as infection.
Subjective indications entailed patient-reported symptoms such as pain, tightness and/or
perceived poor cosmesis. The free flap operative details comprised specific flap type, flap
weight, operative time, estimated blood loss, intra-operative haemoglobin changes, need for
transfusion, flap ischemia time, number of venous anastomoses performed and venous cou-
pler sizes.
Post-operative complications were classed as either major or minor. Major complications
denoted operative intervention such as return to theatre for flap exploration, flap loss/necrosis
or readmission to hospital. Minor complications were those treated conservatively e.g. seroma
aspiration, wound breakdown, oedema and cellulitis, etc.

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PLOS ONE Salvage breast reconstruction 15-year review of outcomes

Statistical analyses
Statistical analysis was carried out using R3.5.2 software whereby a p-value of <0.05 was
deemed to be statistically significant. Data were analysed using unpaired student’s t-test and
one-way ANOVA for continuous variables or χ2 test for categorical variables.

Results
Patient demographics
Between January 2005 and September 2019, a total of 442 patients underwent abdominal free
flap breast reconstructions, 35 (7.9%) of these were SR. Of these 35 SR patients six had bilateral
(see example in Fig 1) whilst 29 underwent unilateral (see example in Figs 2 and 3) procedures
making a total of 41 free flap reconstructions (Table 1). The numbers of patients with the co-
morbidities of diabetes, body mass index (BMI) over 30, smoking and hypertension are given
in Table 1. Mastectomy pattern and breast cancer type are also described as well as initial
breast reconstruction type and any operative history at the donor site (Table 1). The most
notable difference between the two groups was in the radiotherapy exposure prior to the

Fig 1. 55-year-old with bilateral SIEA flap salvage breast reconstruction. A 55-year-old patient with bilateral SIEA
flap salvage breast reconstruction shown before (Fig 1A and 1C) and 2 years post-operatively (Fig 1B and 1D) with
natural breast shapes restored, improved positions of the breast mounds and clearly defined inframammary folds. The
indications for salvage surgery were grade IV capsular contracture, ruptured silicone implant and poor cosmesis (Fig
1A and 1C).
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PLOS ONE Salvage breast reconstruction 15-year review of outcomes

Fig 2. 46-year-old with left unilateral salvage breast reconstruction with DIEP. This 46-year-old patient underwent
a left unilateral salvage breast reconstruction with a DIEP flap 6 years after an immediate breast reconstruction with
implant-only technique. The indications for salvage were grade III capsular contracture with significant pain, poor
cosmesis, and a very high-riding implant (status post-radiotherapy) (Fig 2A and 2C). Appearance at 2 years post-
operatively showing the reconstructed breast to be lower, wider and more natural (Fig 2B). The inframammary fold
has been recreated and is now clearly defined enabled by skin replacement (Fig 2D). The patient was pain-free and
very satisfied with the outcome declining further nipple reconstruction.
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reconstruction. Notably, almost 90% of (n = 31) of patients in the SR group had received chest
wall radiotherapy before their reconstruction, compared to only a quarter (n = 9) in the NSR
group (p<0.00001). In the SR group, 42.8% had had immediate breast reconstruction (with
implants) at the time of the mastectomy whilst 28.6% had had delayed implant breast recon-
struction prior to SR. The comparable figures in the NSR group for the timing of the recon-
struction were 68.6% and 20.0% respectively (Table 1). Operative history at the donor site was
not significantly different in both groups; 51.4% of patients in both groups had abdominal
scars from previous operations.

Salvage breast reconstruction patient presentation

The mean age of patients at initial breast reconstruction was 45.7±3.0 years and the salvage
reconstruction was carried out an average of 7.4±1.9 years later (Table 2). Most patients under-
going SR had had one prior revision of their implant reconstructions. A permanent fixed vol-
ume implant had been utilised in 57.1% of patients at the initial reconstruction. Notably,
almost 90% of salvage patients had received prior postmastectomy radiotherapy (PMRT)
before the SR in contrast to only one quarter of non-salvage patients. Indication was salvage
was collected, with most patient sharing two or more indications (Table 2). In 29 patients
(83%), the objective indication for the salvage reconstruction was severe CC and most patients

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PLOS ONE Salvage breast reconstruction 15-year review of outcomes

Fig 3. 73-year-old with left unilateral salvage breast reconstruction with DIEP flap. This 73-year-old patient
underwent a left unilateral DIEP salvage of a previous latissimus dorsi flap-implant reconstruction on account of poor
cosmetic results and persistent pain. She is shown before (Fig 3A and 3C) and 9 months following surgery with a better
shape of her breast mound and a much better location of her neo-skin paddle (Fig 3B and 3D). The patient declined
nipple reconstruction. The indications for salvage were capsular contracture, poor cosmesis (rippling and lateralised
skin paddle containing a reconstructed nipple) (Fig 3A and 3C).
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cited poor cosmesis and pain as subjective indications for requesting SR (Table 2). 37.1% of
patients were documented to have significant post-radiotherapy skin changes, 22.8% of
patients had ruptured implants (Table 2) while the implant infection was the cause of the sal-
vage in 8.5%. The operative history at the recipient site prior to SR is shown in Table 2.

Patient outcomes
The flap types used in both groups were similar with over 70% of all flap types used in each
group being the deep inferior epigastric perforator (DIEP) (Table 3). Flap weights (grams
±SEM) were comparable in both groups (Table 3). Unilateral SR took significantly longer to
perform that NSR (652±63.45 minutes) and NSR (544±41.48 minutes; p = 0.008) (Fig 4) by
almost two hours. This relationship did not hold true for bilateral reconstructions due to the
small patient numbers in this subcategory. Contrary to expectation, the average intraoperative
blood loss was identical for the two groups. Graphic analysis of estimated blood loss (EBL)
(Fig 5) revealed no difference between SR and NSR (p = 0.99) in both unilateral and bilateral
reconstructions (Table 3). EBL, however showed a positive Pearson correlation coefficient
with duration of surgery (r = 0.4056). Interestingly only one in 20 SR patients (5.7%) required
transfusion compared to one in 10 of NSR patients (11.4%). Flap ischaemia times, and vein

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PLOS ONE Salvage breast reconstruction 15-year review of outcomes

Table 1. Patient demographics for salvage and non-salvage breast reconstructions.

Characteristics Salvage (n = 35) Non-salvage (n = 35) p-value
Total flap number 41 (100%) 42 (100%)
Unilateral 29 (70.7%) 28 (66.6%)
Bilateral 6 (29.3%) 7 (33.3%)
Age at operation (years) 53 ± 3.2 50.7 ± 3.1 0.32
BMI at operation (kg/m2) 26.3 ± 0.8 26.4 ± 1.1 0.93
BMI >30 4 (11.4%) 6 (17.1%)
Co-morbidities
Diabetes 2 (5.7%) 1 (2.9%)
Smoking status
Never 31 (88.6%) 28 (80%)
Current smoker 1 (2.9%) 4 (11.4%)
Ex-smoker 3 (8.6%) 3 (8.6%)
Hypertension 7 (20.0%) 5 (14.3%)
PMRT 31 (88.6%) 9 (25.7%)
Neoadjuvant chemotherapy 20 (57.1%) 17 (48.5%)
Breast cancer type
Ductal carcinoma in situ (DCIS) 16 (45.7%) 16 (45.7%)
Invasive ductal carcinoma (IDC) 9 (25.7%) 7 (20.0%)
Invasive lobular carcinoma (ILC) 2 (5.7%) 6 (17.1%)
Prophylactic 2 (5.7%) 3 (8.6%)
Unknown 6 (17.1%) 2 (5.7%)
Mastectomy pattern
Standard 11 (31.4%) 17 (48.6%)
Skin sparing 9 (25.7%) 5 (14.3%)
Wise pattern 7 (20%) 6 (17.1%)
Unknown 8 (22.9%) 7 (20%)
Initial breast reconstruction timing
Immediate 15 (42.8%) 24 (68.6%)
Delayed 13 (37.1%) 7 (20.0%)
Unknown 7 (20.0%) 4 (11.4%)
Operative history at donor site 18 (51.4%) 18 (51.4%)
Pfannenstiel incision 9 (25.7%) 12 (34.3%)
Midline laparotomy incision 5 (14.3%) 1 (2.9%)
Open appendicectomy incision 4 (11.4%) 2 (5.7%)
No abdominal scars 17 (48.6%) 17 (48.6%)
Unknown 0 2 (5.7%)
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coupler sizes were not significantly different in either group. The additional operative steps
unique to SR are summarised in Table 4.
Post-operative complications were classified as either minor or major and shown in
Table 3. The difference in overall complication rates between groups was not significant and
this was the case for the incidence of complications requiring reoperation (Table 3). The recip-
ient and donor site complications and second touch procedures are further summarised in
Table 3. All 83 flap transfers were successful with no total or partial flap losses. A return to the-
atre was required for two patients following SR and three patients after NSR for flap re-
exploration.

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PLOS ONE Salvage breast reconstruction 15-year review of outcomes

Table 2. Patient presentation in salvage breast reconstruction.

Characteristics Salvage (n = 35)
Age at initial breast reconstruction (mean ± SD) 45.7 ± 3.0 years
Time elapsed since initial reconstruction (mean ± SD) 7.4 ± 1.9 years
Number of surgical reinterventions prior to salvage Patients
0 4 (11.4%)
1 23 (65.7%)
2 6 (17.1%)
3 3 (8.6%)
4 0
5 1 (2.9%)
Initial breast reconstruction
Permanent implant 20 (57.1%)
ADM & implant 7 (20.0%)
LD & implant 5 (14.3%)
Expander & implant 3 (8.5%)
Objective indications
Capsular contracture (Baker III/IV) 29 (82.8%)
Post radiotherapy skin changes 13 (37.1%)
Implant rupture 8 (22.8%)
Implant infection 3 (8.5%)
Subjective indications
Poor cosmesis (patient & others) 32 (91.4%)
Pain 30 (85.7%)
Operative history at the recipient site
Capsulectomy (often more than once) 26 (74.2%)
Implant exchange 11 (31.4%)
Fat grafting 5 (14.3%)
Other 2 (5.7%)
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The recipient and donor site complications are summarised in Table 3. Intra-operative
anastomotic revision was required in 4 flaps (9.8%) in the SR and 3 flaps (7.1%) in the NSR
group (p>0.05). Donor site haematomas were encountered in 2.4% and 7.1% of SR and NSR
flaps, respectively. Donor-site wound dehiscence was comparable in the two groups (7.3% SR
and 4.8% NSR).

Discussion
The present study provides the first direct head-to-head comparison of salvage reconstruction
(SR) and non-salvage reconstruction (NSR). Previous studies have described series of salvage
breast reconstructions with patient numbers ranging from 8 to 191 patients [7, 9, 11, 13, 17].
However, none of these undertook a direct comparison with NSR. Despite the retrospective
study design the comparison with NSR cases undertaken over a 15-year period provides an
evaluation that can better ascertain the relevant patient risk factors and specific complications
attributable to salvage reconstruction. Interestingly, there were few differences in intra-opera-
tive and post-operative outcomes between the groups.
Unlike when free flaps are performed during immediate or delayed breast reconstruction,
SR have been largely thought of as more technically challenging, taking longer, and beset with
greater intra-operative difficulties and post-operative morbidity [13]. The procedure specific

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PLOS ONE Salvage breast reconstruction 15-year review of outcomes

Table 3. Operative details in salvage and non-salvage breast reconstructions.

Parameter Salvage (n = 35) Non-salvage (n = 35) p-value
Free flap type
Deep inferior epigastric perforator (DIEP) 26 (74.2%) 25 (71.4%)
Superficial inferior epigastric artery (SIEA) 2 (5.7%) 3 (8.6%)
a)
MS-TRAM 4 (11.5%) 2 (5.7%)
DIEP & SIEA bipedicled 3 (8.6%) 3 (8.6%)
Flap weight (g) (n = 29) 740.50±51 812.44±66 0.36
Operation time (min) 659 ±59 587 ±49 0.07
Unilateral reconstruction (min) 652 ±63.45 544 ±41 0.008
Bilateral reconstruction (min) 778 ±317 1,055 ±284 0.27
Estimated blood loss (EBL) (ml) 557 ±132 556 ±132 0.99
Pearson correlation with operation time r = 0.43 (p = 0.0108) r = 0.56 (p = 0.0004)
% Haemoglobin (Hb) change b) (g/dL) 18.5 ±2.8 18.5 ±3.7 0.99
Unilateral % Hb change 17.3 ±2.9 18.3 ±4.3 0.069
Bilateral % Hb change 22.9 ±6.32 20.3 ±6.5 0.065
Intraoperative transfusion (patients) 2 (5.7%) 4 (11.4%)
Flap ischaemia time (min) 97.6 ±12.4 97.5 ±8.14 0.49
Unilateral flap 94.4 ±12.3 96.3 ±11.1 0.41
Bilateral flap 115.1 ±25.93 97.1 ±11.3 0.29
Vein coupler size (mm) (n = 29) 2.8 ±0.2 3.0 ±0.2 0.08
Characteristic Salvage total flap number (n = 41) Non-salvage total flap number (n = 42)
Complication total number 20 (48.8%) 18 (42.9%)
Minor–conservative 13 (31.7%) 8 (19%)
Major–surgical 7 (17%) 10 (23.8%)
Returns to theatre 2 (4.9%) 3 (7.1%)
Flap-related complication
Haematoma 1 (2.4%) 3 (7.1%)
Anastomotic revision 4 (9.8%) 3 (7.1%)
Re-exploration 2 (4.9%) 2 (4.8%)
Fat necrosis 0 0
Partial flap loss 0 0
Flap loss 0 0
Donor-site related complication
Wound dehiscence 3 (7.3%) 2 (4.8%)
Seroma aspiration 8 (19.5%) 4 (9.5%)
Dog ear correction 2 (4.9%) 2 (4.8%)
Second touch procedures number 10 (24.4%) 6 (14.3%)
Seroma aspiration 8 (19.5%) 4 (9.5%)
Lipofilling 2 (4.8%) 2 (4.8%)
a)
MS-TRAM: Muscle Sparing Transverse Rectus Abdominis Myocutaneous flap
b)
Post-operative Hb subtracted by pre-operative Hb divided by pre-operative Hb

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operative manoeuvres which contribute to this are summarised in Table 4. Notable amongst
these are the capsulectomy, with its attendant bleeding problems, and refashioning of the IMF,
both unavoidable parts of improving the cosmetic outcome (a frequent indication for surgery).
These two are interrelated since the procedure of excising the tight peri-implant scar tissue fur-
ther damages (often lowering) the IMF. While certain co-morbidities may be viewed as

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PLOS ONE Salvage breast reconstruction 15-year review of outcomes

Fig 4. Operation time for unilateral free flap salvage and non-salvage breast reconstruction.
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contraindications for treatment, our patients were not excluded from operative consideration
based on modifiable risk factors. Still, lifestyle advice and smoking cessation guidance was
offered pre-operatively to optimise operative fitness. Although it has been postulated that
patients undergoing SR are likely to have higher BMIs primarily because of older age at

Fig 5. Estimated blood loss (ml) in salvage and non-salvage breast reconstruction.
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PLOS ONE Salvage breast reconstruction 15-year review of outcomes

Table 4. Additional surgical steps undertaken during salvage breast reconstruction.

Intraoperative Manoeuvre Salvage (n = 35)
Creation of subcutaneous pocket (from previous subpectoral) 32 (100%)
Capsulectomy 32 (100%)
Excision of irradiated skin and soft tissue 27 (84.4%)
Repositioning of pectoralis major 26 (81.3%)
Internal mammary lymph node excision (to enable IMV exposure) 25 (78.1%)
Refashioning of inframammary fold (recreating the IMF) 22 (68.8%)
Removal of infected breast implant 8 (25%)
Nibbling of rib cartilage to improve access 8 (25%)
Unspecified (no specific detail provided) 3 (8.5%)
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operation, our study showed no statistical difference in BMI between the groups [13]. Another
expectation is that the patients undergoing SR are older as this is often undertaken almost a
decade later, our findings support those of others who reported similar results [15].
A notable finding was the significant difference in the prevalence of PMRT; this result par-
allels that of several studies [7, 21, 22]. Radiotherapy has a two-fold contributory effect to the
likelihood of needing SR in the future. Firstly, PMRT after implant-based reconstruction is
associated with increased risk of complications in a dose-dependent manner [23]. A meta-
analysis of 2348 patients by Ricci et al. suggested that PMRT has greater effect on certain forms
of implants over others [24]. Secondly it has also been associated with an increased capsular
contracture (CC) risk in all implants [25]. Congruently, in our study, one of the chief reasons
for referral for SR following implant-based reconstruction was symptomatic CC. This may
explain why, when PMRT is required, autologous reconstruction is considered more favour-
able than implant-based reconstruction [26].
Other studies have also reported that patients undergoing SR are more likely to have under-
gone delayed as opposed to immediate reconstruction. Although they have some similarities
related to PMRT and its sequelae–namely overall shrinkage of the soft tissue envelope–delayed
and SR differ in many respects, as elaborated on in Tables 4 and 5. Subjective indications for
SR were reported by the majority of patients, in line with other studies that investigated patient
reported outcome measures (PROM) [11, 26]. Although our study did not include assessment
of PROMs, evaluating patient satisfaction could be informative. A useful comparison could be
with salvage using non-free flap methods such as implant removal combined with serial fat
grafting or pedicled latissimus dorsi or perforator flaps.
Consistent with previous studies, our group found the DIEP flap to be the most commonly
used in our SR cohort [9, 11, 13]. The DIEP flap has been favoured due to lower donor-site
complications, reliability (reduced flap loss) and superior long-term aesthetic outcome as com-
pared with the TRAM flap [26]. Changing the pocket for flap inset entails managing the pec-
toralis major by suturing it back to the chest wall. This is said to reduce pain associated with
the CC as now the muscle has been replaced back to its original position and is no longer
under tension. PMRT also causes problems with internal mammary vessel (IMV) exposure,
but it remains our preferential recipient site [27]. Whilst this is not unique to SR more of these
patients have had PMRT compared to the NSRs. A notable finding was that a significant pro-
portion of SR patients underwent incidental internal mammary lymph node biopsy to expose
the recipient IMVs as these nodes were fibrosed from previous surgery and PMRT and become
entangled with the surrounding vessels which thus could not be adequately prepared for
microanastomoses without removing the lymph nodes [28, 29]. Furthermore, we found a

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significant correlation between estimated blood loss (EBL) and operation time (Table 3), indi-
cating that longer operations lead to increased EBL. This reinforces the complexity argument
for SR and hence the challenge to obtain good flap outcomes. To achieve this we recommend,
amongst other measures, that adequate theatre time is allocated in order to account for these
complexities (Tables 4 and 5).
Flap ischaemia is strongly correlated to extent of flap necrosis and post-operative complica-
tions, and flap ischaemia time greater than 120 minutes is thought to significantly increase
complication risk [30]. There was no significant difference in flap ischaemia and the average
time for both groups was under 120minutes. A venous coupler size of less than 2.0mm is
known to be related to increased complication risk [31]. Both groups in our study had an aver-
age venous coupler size greater than 2.0mm (Table 3). Whilst both groups had a similar flap-
related complication rates, the SRs had a proportionately greater rate of donor-site related
complications. Although this could be related to flap choice this is unlikely as the was a similar
flap distribution in both groups. A possible cause of discrepancy in donor-site morbidity could
be due to longer operative time in SR, during which the donor-site may be unattended or open
and exposed to the theatre environment for greater durations. Our incidence of major compli-
cations was however higher than the 7% reported by Carnevale et al. from La Sapienza in their
series of 46 patients in which postmastectomy radiotherapy was found to cause complications
perhaps reflecting the complexity of our patients as a tertiary referral centre [32].

Limitations of our study

Our study cohort size was not sufficient to conduct linear regression analysis, and this may
therefore limit transferability of our findings to larger populations. It is also acknowledged
that the senior author’s experience may attract a specific self-selecting patient cohort seeking
SR. Furthermore, the interventions in this study were performed by a single operator which
may mean the given results may not be reproducible by other operators. There may also have
been an inherent risk of bias in the study design for selection of “controls”. However, the
sequential consecutive patient selection, whilst not random or matched, aimed to eliminate
operator-dependent and team-related improvement of outcomes with experience. Whilst dif-
ficult to apply to such research, prospective, blinded randomised studies remain the gold stan-
dard. Coriddi et al. collected PROMs for 34 patients out of 137 who underwent SR at six-
month follow-up and found statistically significant positive outcomes overall [33]. It may also
have been informative to investigate other forms of outcomes such as length of hospital stay,
readmission rate and long-term larger population PROMs in future studies. Likewise patient
factors (e.g. nulliparity) and hospital stay related factors (e.g. type of intravenous fluid admin-
istered) and their role in DIEP flap necrosis would be helpful to investigate in future studies
[34]. The retrospective nature of the study also limited in-depth analysis of time dependent
factors in DIEP flap reconstruction, the relation to perforator flap anatomy and superficial
versus deep venous drainage predominance which have been shown to be important factors
in operative time [35].
With the mounting disease burden of breast cancer and commensurate rise in implant-
based reconstruction following mastectomy, it is increasingly important to understand the
outcomes of SR. Here, we show that SR whilst considered more challenging, can broadly pro-
vide similar outcomes to NSR. This is all the more imperative as more operations of this nature
will be needed in the years to come. A list of the critical considerations and potential solutions
the surgeon should consider is given in Table 5.
Although it is generally held that SR is technically demanding and takes longer, as shown in
our study for unilateral cases, its intra- and postoperative outcomes are, however, comparable

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PLOS ONE Salvage breast reconstruction 15-year review of outcomes

Table 5. Considerations and potential solutions in salvage breast reconstruction.

Consideration Issue(s)
Previous • Delayed breast
reconstruction reconstruction procedure
• Previous lymph node
clearance
• Subpectoral / Subcutaneous
implant
• Prior use of Acellular
Dermal Matrix (ADM)
Previous adjuvant • Irradiated tissue within
therapy operative field
Presenting • Unfavourable aesthetic
complaints appearance
• Chronic pain
• Multiple failed operations
• Previous complications
• No inframammary fold
(IMF)
• Breasts too high
Older age • ⇩ Cardiorespiratory reserve
demographic • ⇧ Thromboembolism risk
• Worse healing outcomes
• Comorbidities: diabetes,
hypertension, cardiac
Consequences
• Diffuse tissue scarring / incorporation of
ADM
• Pectoral fibrosis / contracture
• Implant capsular contracture
• Lymphoedema
• Internal Mammary (IMLN) silicone
lymphadenopathy
• Risk of cancer recurrence / Breast implant
associated lymphoma
• Skin changes: variable including ulceration
• Capsular contracture
• Other soft tissue fibrosis
• Poor tissue planes
• Fat necrosis / cysts / seroma
• Chest wall osteonecrosis
• Friable internal mammary recipient vessels
• Delayed healing / wound dehiscence
• Skin: contracted / puckered / adherent
atrophy
• Disrupted anatomical landmarks e.g. IMF
• Poor tissue planes
• Skin and tissue volume shortage
• Fat necrosis / cysts / seroma
• Gross breast asymmetry and deformity
• Neuromas and neuropathic pain
• Increased operative time
• Increased anaesthetic risk
• Higher risk of post-operative complications
e.g. delirium, pulmonary embolism,
pneumonia
• Increased hospital stay duration
Solutions
• Accurate documentation of surgical history and examination
• Pre-operative oncology review
• Pre-operative management of lymphoedema
Preoperative scans: Computerised tomography (CT)/
Magnetic resonance imaging (MRI) chest and axilla /
contralateral mammogram
• Pre-operative CT Angiogram of internal mammary vessels
• Meticulous resection of fibrotic tissue
Introduce new skin–carefully preserve skin flaps
• Total capsulectomy, IMLN biopsy, ± rib sacrifice
• Plan for additional autologous volume and skin needs e.g.
bipedicled / stacked flap design.
• Have “plan B” for microvascular anastomoses / vein grafts /
alternate free flap recipient sites
• Experienced microsurgeon participation
• Manage realistic patient expectations
• Pre-operative photography: standardized
• Pectoralis muscle repositioning
• Careful planning of repositioned landmarks
• Plan for additional autologous volume needs e.g. bipedicled /
stacked arrangement
• Consider contralateral balancing procedures
• Pain service involvement
• Book for adequate theatre time
• Recreate IMF with sutures
• Medical optimisation and preassessment
• Consider high dependency post-operative care
• Plan for increased nursing and physiotherapy demands
• Strict diabetic / thromboprophylaxis control

https://doi.org/10.1371/journal.pone.0288364.t005

to NSR. SR and NSR were all successful with a similar complication profile. Therefore, SR with
free flaps provides a reliable salvage option following failed implant-based reconstructions and
should be actively considered when faced with this patient group.

Supporting information
S1 Dataset.
(XLSX)

Author Contributions
Conceptualization: Charles M. Malata.
Data curation: Christine Bojanic, Laura J. Fopp.
Formal analysis: Christine Bojanic.

PLOS ONE | https://doi.org/10.1371/journal.pone.0288364 November 1, 2023 13 / 16

PLOS ONE Salvage breast reconstruction 15-year review of outcomes

Investigation: Christine Bojanic.

Methodology: Christine Bojanic.
Project administration: Bruno Di Pace, Dina T. Ghorra.
Supervision: Charles M. Malata.
Validation: Charles M. Malata.
Writing – original draft: Christine Bojanic.
Writing – review & editing: Bruno Di Pace, Dina T. Ghorra, Laura J. Fopp, Nicholas G.
Rabey, Charles M. Malata.

References
1. Ferlay J, Colombet M, Soerjomataram I, Mathers C, Parkin DM, Piñeros M, et al. Estimating the global
cancer incidence and mortality in 2018: GLOBOCAN sources and methods. Int J Cancer. 2019 Apr 15;
144(8):1941–53. https://doi.org/10.1002/ijc.31937 PMID: 30350310
2. Malata CM, McIntosh SA, Purushotham AD. Immediate breast reconstruction after mastectomy for can-
cer. Vol. 87, Br J Surg. 2000 Nov; 87(11): 1455–72. https://doi.org/10.1046/j.1365-2168.2000.01593.x
PMID: 11091232
3. Ilonzo N, Tsang A, Tsantes S, Estabrook A, Thu Ma AM. Breast reconstruction after mastectomy: A
ten-year analysis of trends and immediate postoperative outcomes. Breast. 2017 April; 32: 7–12.
https://doi.org/10.1016/j.breast.2016.11.023 PMID: 27988412
4. Jeevan R, Cromwell DA, Browne JP, Caddy CM, Pereira J, Sheppard C, et al. Findings of a national
comparative audit of mastectomy and breast reconstruction surgery in England. J Plast Reconstr Aes-
thetic Surg. 2014 Oct; 67(10):1333–44. https://doi.org/10.1016/j.bjps.2014.04.022 PMID: 24908545
5. Jeevan R, Mennie JC, Mohanna PN, O’Donoghue JM, Rainsbury RM, Cromwell DA. National trends
and regional variation in immediate breast reconstruction rates. Br J Surg. 2016 Aug; 103(9): 1147–56.
https://doi.org/10.1002/bjs.10161 PMID: 27324317
6. Frey JD, Salibian AA, Karp NS, Choi M. Implant-Based Breast Reconstruction: Hot Topics, Controver-
sies, and New Directions. Plast Reconstr Surg. 2019 Feb 1; 143(2): 404e–416e. https://doi.org/10.
1097/PRS.0000000000005290 PMID: 30688910
7. Rabey NG, Lie KH, Kumiponjera D, Erel E, Simcock JW, Malata CM. Salvage of Failed Prosthetic
Breast Reconstructions by Autologous Conversion With Free Tissue Transfers. Eplasty 2013 Jun 20;
13:e32. Print 2013 PMID: 23814635
8. Santosa KB, Qi J, Kim HM, Hamill JB, Wilkins EG, Pusic AL. Long-term Patient-Reported Outcomes in
Postmastectomy Breast Reconstruction. JAMA Surg. 2018 Oct 1; 153(10): 891–9. https://doi.org/10.
1001/jamasurg.2018.1677 PMID: 29926096
9. Levine SM, Lester ME, Fontenot B, Allen RJ Sr. Perforator flap breast reconstruction after unsatisfac-
tory implant reconstruction. Ann Plast Surg. 2011 May; 66(5): 513–7. https://doi.org/10.1097/SAP.
0b013e3182012597 PMID: 21301299
10. Statistics P. American Society of Plastic Surgeons. 2018 Plastic Surgery Statistics Report. https://www.
plasticsurgery.org/documents/News/Statistics/2018/plastic-surgery-statistics-full-report-2018.pdf.
Accessed Sept 27, 2019. Plast Surg. 2017; 25.
11. Visser NJ, Damen THC, Timman R, Hofer SOP, Mureau MAM. Surgical results, aesthetic outcome,
and patient satisfaction after microsurgical autologous breast reconstruction following failed implant
reconstruction. Plast Reconstr Surg. 2010 Jul; 126(1):26–36. https://doi.org/10.1097/PRS.
0b013e3181da87a6 PMID: 20595835
12. Mennie JC, Mohanna PN, O’Donoghue JM, Rainsbury R, Cromwell DA. National trends in immediate
and delayed post-mastectomy reconstruction procedures in England: A seven-year population-based
cohort study. Eur J Surg Oncol [Internet]. 2017 Jan; 43(1):52–61. https://doi.org/10.1016/j.ejso.2016.
09.019 PMID: 27776942
13. Hamdi M, Casaer B, Andrades P, Thiessen F, Dancey A, D’Arpa S, et al. Salvage (tertiary) breast
reconstruction after implant failure. J Plast Reconstr Aesthetic Surg. 2011 Mar; 64(3): 353–9. https://
doi.org/10.1016/j.bjps.2010.05.019 PMID: 20576480
14. Woerdeman LAE, Hage JJ, Hofland MM, Rutgers EJ. A prospective assessment of surgical risk factors
in 400 cases of skin-sparing mastectomy and immediate breast reconstruction with implants to establish

PLOS ONE | https://doi.org/10.1371/journal.pone.0288364 November 1, 2023 14 / 16

PLOS ONE Salvage breast reconstruction 15-year review of outcomes

selection criteria. Plast Reconstr Surg. 2007 Feb; 119(2): 455–63. https://doi.org/10.1097/01.prs.
0000246379.99318.74 PMID: 17230076
15. McCarthy CM, Mehrara BJ, Riedel E, Davidge K, Hinson A, Disa JJ, et al. Predicting complications fol-
lowing expander/implant breast reconstruction: An outcomes analysis based on preoperative clinical
risk. Plast Reconstr Surg. 2008 Jun; 121(6): 1886–92. https://doi.org/10.1097/PRS.
0b013e31817151c4 PMID: 18520873
16. EL-Sabawi B, Howell AC, Patel KM. Microsurgical restoration of failed or unsatisfactory breast recon-
struction: a systematic review and pooled-analysis of outcomes. Plast Aesthet Res. 2017 Oct 31; 4(10):
195.
17. Marquez MD, Fernandez-Riera R, Cardona HV, Flores JMR. Immediate implant replacement with DIEP
flap: A single-stage salvage option in failed implant-based breast reconstruction. World J Surg Oncol.
2018 Apr 17; 16(1): 80. https://doi.org/10.1186/s12957-018-1387-5 PMID: 29665804
18. Cordeiro PG, Jazayeri L. Two-stage implant-based breast reconstruction: An evolution of the concep-
tual and technical approach over a two-decade period. Plast Reconstr Surg. 2016 Jul; 138(1):1–11.
https://doi.org/10.1097/PRS.0000000000002243 PMID: 27348635
19. Juanpere S, Perez E, Huc O, Motos N, Pont J, Pedraza S. Imaging of breast implants—a pictorial
review. Insights Imaging. 2011 Dec; 2(6):653–70. https://doi.org/10.1007/s13244-011-0122-3 PMID:
22347984
20. Paolini G, Firmani G, Briganti F, Macino M, Nigrelli S, Sorotos M, et al. Assessment of Risk Factors for
Rupture in Breast Reconstruction Patients with Macrotextured Breast Implants. Aesthetic Plast Surg.
2022 Oct; 13. Epub ahead of print. https://doi.org/10.1007/s00266-022-03118-9 PMID: 36229658
21. Pu Y, Mao TC, Zhang YM, Wang SL, Fan DL. The role of postmastectomy radiation therapy in patients
with immediate prosthetic breast reconstruction: A meta-analysis. Medicine (Baltimore). 2018 Feb; 97
(6): e9548. https://doi.org/10.1097/MD.0000000000009548 PMID: 29419662
22. Cordeiro PG, Albornoz CR, McCormick B, Hu Q, Van Zee K. The impact of postmastectomy radiother-
apy on two-stage implant breast reconstruction: An analysis of long-term surgical outcomes, aesthetic
results, and satisfaction over 13 years. Plast Reconstr Surg. 2014 Oct; 134(4):588–95. https://doi.org/
10.1097/PRS.0000000000000523 PMID: 25357021
23. Chang JS, Song SY, Oh JH, Lew DH, Roh TS, Kim SY, et al. Influence of Radiation Dose to Recon-
structed Breast Following Mastectomy on Complication in Breast Cancer Patients Undergoing Two-
Stage Prosthetic Breast Reconstruction. Front Oncol. 2019 Apr 9; 9: 243. https://doi.org/10.3389/fonc.
2019.00243 PMID: 31024845
24. Ricci JA, Epstein S, Momoh AO, Lin SJ, Singhal D, Lee BT. A meta-analysis of implant-based breast
reconstruction and timing of adjuvant radiation therapy. J Surg Res. 2017 Oct; 218: 108–16. https://doi.
org/10.1016/j.jss.2017.05.072 PMID: 28985836
25. Barry M, Kell MR. Radiotherapy and breast reconstruction: A meta-analysis. Breast Cancer Res Treat.
2011 May; 127(1): 15–22. https://doi.org/10.1007/s10549-011-1401-x PMID: 21336948
26. Mohan AT, Al-Ajam Y, Mosahebi A. Trends in tertiary breast reconstruction: Literature review and single
centre experience. Breast. 2013 April; 22(2): 173–8. https://doi.org/10.1016/j.breast.2012.06.004
PMID: 22795362
27. Sasaki Y, Madada-Nyakauru RN, Samaras S, Oni G, Di Candia M, Malata CM. The ideal intercostal
space for internal mammary vessel exposure during total rib-sparing microvascular breast reconstruc-
tion: A critical evaluation. J Plast Reconstr Aesthet Surg. 2019; 72(6):1000–1006. https://doi.org/10.
1016/j.bjps.2019.01.008 PMID: 30824382
28. Lindenblatt N, Gruenherz L, Farhadi J. A systematic review of donor site aesthetic and complications
after deep inferior epigastric perforator flap breast reconstruction. Gland Surg. 2019 Aug; 8(4): 389–98.
https://doi.org/10.21037/gs.2019.06.05 PMID: 31538064
29. Yu JTS, Provenzano E, Forouhi P, Malata CM. An evaluation of incidental metastases to internal mam-
mary lymph nodes detected during microvascular abdominal free flap breast reconstruction. J Plast
Reconstr Aesthet Surg; 2011 Jun; 64(6): 716–21. https://doi.org/10.1016/j.bjps.2010.10.003 PMID:
21051303
30. Marre D, Hontanilla B. Increments in ischaemia time induces microvascular complications in the DIEP
flap for breast reconstruction. J Plast Reconstr Aesthetic Surg. 2013 Jan; 66(1):80–6. https://doi.org/10.
1016/j.bjps.2012.08.024 PMID: 22981497
31. Broer PN, Weichman KE, Tanna N, Wilson S, Ng R, Ahn C, et al. Venous coupler size in autologous
breast reconstruction—Does it matter? Microsurgery. 2013 Oct; 33(7): 514–8. https://doi.org/10.1002/
micr.22169 PMID: 24038542
32. Carnevale A, Scaringi C, Scalabrino G, Campanella B, Osti MF, De Sanctis V, et al. Radiation therapy
after breast reconstruction: outcomes, complications, and patient satisfaction. Radiol Med. 2013 Oct;
118(7):1240–50. https://doi.org/10.1007/s11547-013-0947-6 PMID: 23801395

PLOS ONE | https://doi.org/10.1371/journal.pone.0288364 November 1, 2023 15 / 16

PLOS ONE Salvage breast reconstruction 15-year review of outcomes

33. Coriddi M, Shenaq D, Kenworthy E, Mbabuike J, Nelson J, Pusic A, et al. Autologous Breast Recon-
struction after Failed Implant-Based Reconstruction: Evaluation of Surgical and Patient-Reported Out-
comes and Quality of Life. Plast Reconstr Surg. 2019 Feb; 143(2): 373–9. https://doi.org/10.1097/PRS.
0000000000005197 PMID: 30688876
34. Santanelli F, Longo B, Cagli B, Pugliese P, Sorotos M, Paolini G. Predictive and protective factors for
partial necrosis in DIEP flap breast reconstruction: does nulliparity bias flap viability? Ann Plast Surg.
2015 Jan; 74(1):47–51. https://doi.org/10.1097/SAP.0b013e31828d994d PMID: 23851375
35. Laporta R, Longo B, Sorotos M, Farcomeni A, Amorosi V, Santanelli di Pompeo F. Time-dependent fac-
tors in DIEP flap breast reconstruction. Microsurgery. 2017 Oct; 37(7):793–799. https://doi.org/10.
1002/micr.30203 PMID: 28758229

PLOS ONE | https://doi.org/10.1371/journal.pone.0288364 November 1, 2023 16 / 16