Which patients are suitable for consideration for free flap breast reconstruction?

Whilst age is just a number, the physiological age of the patient is important. We work closely with our anaesthetic colleagues to make sure that our patients will cope with the length and complexity of the surgery. We have had patients well into their 70’s who have benefited from these procedures.

Body mass index, is a medical tool to aid clinicians when assessing suitability for complex surgery. We know from studies that the risk of complications are unacceptably high when operating on someone with a BMI of greater than 35.

The nicotine contained with cigarettes, vapes and e-cigarettes can have detrimental effects on the blood supply to a healing wound and cause significant problems in the healing phase after surgery. It has also been shown to increase the risk of chest infection in the postoperative period. We do not perform reconstruction of this type on smokers as the risk is just too high.

There are reversible and irreversible effects of radiotherapy. The effects that can improve over time, do so over 12 months. We therefore want to wait a year after the radiotherapy has stopped before performing a delayed reconstruction. If it is likely that radiotherapy is needed after your mastectomy then on the whole we tend not to perform an immediate free flap reconstruction at the same time. This is because it can cause the transferred tissue to become a little firm.

Tamoxifen is stopped 3 weeks before and 2 weeks after delayed reconstruction. There should not be a detrimental effect from this gap and it is likely that this will reduce the risk of blood clots around the time of surgery.

A recent review of world literature has shown that NACT does not increase the risk of failure for free flap breast reconstruction. We will of course liaise with your clinicians to determine the safe period to come off these medications around the time of surgery.

Some medications such as Herceptin and some neoadjuvant chemotherapeutic agents can have an effect on cardiac function. We liaise with our anaesthetic colleagues and will require a recent echocardiogram to make sure the ejection fraction is within normal range.