Turning failure into form: autologous solution to salvage a severely compromised breast following partial mastectomy and radiation - a case report

Patient information

We report the case of a 40-year-old woman who presented with an aesthetically unsatisfactory breast appearance following treatment for breast carcinoma of the left breast. In addition to pain, the patient reported substantial impairment of superficial sensation of the affected breast, functional impairment, and considerable psychosocial reduction in quality of life. The primary tumor was a tubulolobular carcinoma (pT2, pN0, M0, G2, ER 100%, PR 95%, HER2-negative, Ki-67 30%). Treatment included neoadjuvant chemotherapy (12 cycles of nab-paclitaxel followed by four cycles of epirubicin and cyclophosphamide), breast-conserving therapy with two re-excisions, adjuvant chemotherapy (11 cycles of paclitaxel), radiotherapy, and endocrine therapy (tamoxifen). Preoperative and postoperative interventions are summarized in a timeline [Figure 1]. After completion of radiotherapy (30 Gy), a left-sided epipectoral implant was placed to address the volume deficiency resulting from the previous interventions. At the patient’s request, a contralateral implant was inserted simultaneously to achieve symmetry between the breasts. On the left side, the initial 360 cc implant was removed three months after implantation due to wound-healing complications. Reimplantation with a 360-cc implant subsequently failed because of recurrent infections after 7 and 8 months, necessitating definitive explantation.

Figure 1. Timeline of the patient’s treatment course from initial diagnosis to final follow-up.

At presentation to our center, the patient’s height was 1.65 m with a body weight of 70 kg [body mass index (BMI) 25.7 kg/m²]. No relevant comorbidities were reported; Sapporo criteria were negative. She had a 20 pack-year smoking history. Family history was positive for breast cancer; no genetic predisposition was identified. Apart from a prior cesarean section, there were no additional abdominal surgeries. The patient’s only regular medication was adjuvant endocrine therapy with tamoxifen.

Clinical findings

Four weeks after explantation of the left implant, the patient presented to our department. Clinical examination revealed an unremarkable right breast, whereas the left breast exhibited loss of the medial and lateral lower pole, pronounced scar adhesions at the thoracic wall, and an inverted nipple-areola complex. There were no signs of active infection. Overall, the diagnosis of a secondary breast and nipple-areola complex deformity following recurrent wound healing disorders and infections after alloplastic augmentation was established [Figure 2]. Clinical photographs from the period before implant-based reconstruction were not available.

Figure 2. We present examples of three-dimensional photographic documentation at different time points. (A) Preoperative; (B) 2 weeks postoperative; (C) 25 months postoperative.

Preoperative volumetric analysis revealed a pronounced volume deficiency of the left breast, with a volume of 179.7 cc compared with 654.3 cc on the right (Δ 474.6 cc). Anthropometry confirmed breast asymmetry, with both the sternal notch-to-nipple and nipple-to-inframammary fold distances greater on the right side (differences of 4.5 and 8.3 cm). All measurements and photographic documentation were obtained using the VECTRA System (Canfield Scientific, NJ, USA). [Table 1 and Figure 2].

Additionally, the validated BREAST-Q questionnaire was administered pre- and postoperatively [Table 2]. Responses were converted into domain scores ranging from 0 to 100 according to the developer’s guidelines, with higher scores indicating better outcomes. “Satisfaction with abdomen” items were analyzed as stand-alone measures. Preoperative assessment revealed low scores, particularly in “Satisfaction with breast” (0) and “Psychosocial well-being” (0).

Diagnostic assessment

Sonographic examination demonstrated a seroma in the left breast with no residual breast glandular tissue, while the right breast showed an intact implant. Preoperative contrast-enhanced axial computed tomography angiography demonstrated adequate subcutaneous abdominal fat thickness (28.3 mm), enabled perforator mapping of the deep inferior epigastric vessels, and confirmed normal internal mammary vessel anatomy without anatomical variations. Laboratory testing showed no evidence of infection and no abnormalities in coagulation parameters.

Therapeutic intervention

Following the previously performed external procedures, approximately 100 g of residual breast tissue remained on the left side. After interdisciplinary gynecological evaluation at our center, no further gynecological surgical intervention was indicated. After shared decision-making, the patient expressed a clear preference for autologous reconstruction and declined further implant-based procedures. The abdomen was considered the most suitable donor site, as it provided sufficient skin and soft tissue to restore the required breast volume while simultaneously replacing the deficient skin envelope [Figure 3]. Immediate smoking cessation was implemented preoperatively.

Figure 3. Lateral view showing postoperative abdominal contour enhancement at different time points. (A) Preoperative; (B) 2 weeks postoperative; (C) 25 months postoperative.

Preoperatively, the patient was marked in both supine and standing positions; the planned flap dimensions measured 14 cm × 46 cm. The procedure was performed by two surgical teams and lasted 8 h and 39 min. Flap dissection followed a standardized approach^[7] with identification and intramuscular dissection of the abdominal perforators in a muscle-sparing fashion to the deep inferior epigastric vessels. Although a deep inferior epigastric perforator (DIEP) flap was initially planned, a small cuff of rectus muscle was intentionally left around the vascular pedicle to prevent pedicle kinking. Consequently, the reconstruction was formally classified as an muscle-sparing type II transverse rectus abdominis myocutaneous (MS-2 TRAM). Concurrently, the internal mammary vessels were prepared as recipient vessels, including partial resection of the fourth rib and release of scar adhesions. Based on intraoperative indocyanine green fluorescence angiography, the flap was limited to its right hemi-abdominal component to ensure sufficient tissue perfusion. Microsurgical anastomosis was performed, with venous coupling using a 2.5 mm device and arterial suturing using the open-book technique. Repeated indocyanine green fluorescence angiography confirmed adequate perfusion of the free flap tissue. Total ischemia time was 1 h and 23 min. The flap was inset in a semi-upright position with reconstruction of the lower breast pole by a skin island (15 cm × 6 cm). Donor-site closure was performed as an abdominoplasty with mesh reinforcement of the anterior rectus sheath in a sublay technique and rectus diastasis plication.

At 3 months postoperatively, 80 mL of autologous fat was injected into the upper pole to improve upper pole fullness. At 11 months, 170 mL was grafted into the upper medial quadrant (50 mL), lateral breast (70 mL), and lower pole (50 mL). At 19 months, an additional 110 mL was injected into the left breast to further refine breast contour. The bilateral flanks were infiltrated with Klein tumescent solution, followed by vacuum-assisted liposuction. After decantation, the processed fat was reinjected using a multilayered, multichannel technique.

Follow-up and outcomes

Discussion

Breast cancer incidence has increased in recent years, with diagnoses occurring at progressively younger ages^[8]. Consequently, expectations regarding the long-term stability and aesthetic outcomes of breast reconstruction have risen. Autologous reconstruction has therefore gained importance as a durable reconstructive option.

In the present case, marked breast asymmetry (right > left) developed following previous treatments. To correct this asymmetry, several attempts at implant placement were performed, each resulting in implant failure. Implant-based procedures are known to be associated with higher complication rates, particularly in previously treated tissue, as in the present case with prior surgery and radiotherapy. In such settings, complication rates have been reported to be up to eightfold higher compared with reconstructions using autologous tissue^[9]. Reported complications include capsular contracture, reconstruction failure, seroma formation and infection^[10], several of which occurred during the clinical course of our patient. The effect of radiotherapy on tissue, resulting for example in fibrosis and microangiopathy, increase the likelihood of implant-related complications, which may be up to twice as high in irradiated compared with non-irradiated tissue^[11,12]. In our patient, prior treatments, including radiotherapy, and resulting repeated implant-related complications led to severe compromise of the left breast with loss of the lower pole. In contrast, the contralateral breast, which had not undergone prior surgery or radiotherapy, remained free of implant-related complications, consistent with the lower complication rates reported in untreated tissue. Alternative reconstructive options for the left-sided defect, including repeat implant-based reconstruction, serial lipofilling or pedicled flap reconstruction, were considered. However, given the irradiated breast, previous implant failures, the substantial volume deficit and the patient’s preference for an autologous abdominal-based reconstruction, a microsurgical approach was favored.

The transfer of autologous tissue introduces well-vascularized, non-irradiated tissue into the compromised recipient site and thereby improves local perfusion and tissue quality. In our case, the flap not only restored breast volume but also functioned as a biological replacement for damaged skin and soft tissue, providing improved structural and functional properties. These findings align with the established benefits of autologous tissue transfer^[13]. The improved tissue characteristics create favorable conditions for wound healing and long-term tissue stability, which was reflected in the absence of flap-related complications such as flap loss, skin necrosis, wound-healing disorders, or infection at the recipient site. Furthermore, sensory recovery after autologous breast reconstruction has been described in the literature in a subset of patients^[14]. In our patient, sensation was present within the flap but absent in the native tissue of the upper pole, further supporting the functional restoration achieved by autologous tissue transfer.

Abdominally based autologous breast reconstruction has also been associated with donor-site benefits such as improved abdominal contour and simultaneous reconstruction or correction of abdominal wall defects, which may contribute to higher patient satisfaction^[15]. In our case, simultaneous correction of rectus diastasis combined with abdominoplasty resulted in both functional stabilization and aesthetic improvement of the abdominal wall [Figure 3]. This was reflected by maximum BREAST-Q scores in the categories “Satisfaction with abdomen” and “Physical well-being with abdomen” at final follow-up [Table 2]. (A limitation of this case report is the differing follow-up schedules for VECTRA and BREAST-Q assessments, which limited direct comparison of objective and patient-reported outcomes at corresponding postoperative time points). Smoking is a recognized risk factor for postoperative complications such as wound-healing disorders and may have contributed to the donor-site wound-healing disturbance observed in this case. Therefore, a smoking cessation period of at least four weeks before autologous breast reconstruction should be recommended in future cases.

Once successfully integrated, autologous breast reconstruction is considered a stable reconstructive solution that allows for durable breast symmetry^[16]. This observation was reflected in our patient by stable anthropometric measurements and sustained improvement in breast symmetry throughout the 25-month follow-up period. Serial VECTRA assessments demonstrated stable breast volume following reconstruction and adjunctive lipofilling procedures [Table 1]. Although a residual volumetric difference remained at final follow-up, the patient reported high satisfaction with the reconstructive outcome, indicating that subjective aesthetic satisfaction may be achieved despite measurable residual volumetric asymmetry. Representative VECTRA 3D images demonstrate a consistent aesthetic outcome [Figures 2 and 3]. Long-term patient satisfaction has been reported to be higher following autologous tissue-based breast reconstruction compared with implant-based reconstruction^[17]. One reason may be that autologous tissue adapts to physiological aging processes, weight fluctuations, and gravitational forces, resulting in a body perception that closely resembles that of natural breast tissue. In the present case, this was reflected by increasing BREAST-Q scores over time in “Satisfaction with breast,” including items such as “Perception of the breast as a natural body part” (rated as “very satisfied”) and “Psychosocial well-being,” reaching high values at final follow-up [Table 2]. In the “Satisfaction with breast” domain, a marked early postoperative increase was observed, followed by a slight decline between 6 weeks and 6 months, likely reflecting initial improvement relative to baseline and subsequent normalization of expectations. In the present case, high final scores were achieved, indicating a favorable aesthetic outcome from the patient’s perspective. Lipofilling can support this outcome by addressing minor secondary contour irregularities that may occur following breast reconstruction. Autologous fat grafting represents a commonly used adjunctive technique for this purpose, offering low morbidity and relative ease of use. Given partial graft resorption, repeat procedures are often required and performed at individualized time points^[18]. In this case as well, lipofilling achieved progressive contour refinement, contributing to high patient satisfaction. Given the variable degree of fat graft resorption, volumetric changes following lipofilling should be interpreted within the context of the overall reconstructive process. Future studies may provide further insight into fat graft retention at different postoperative time points.