Managing locoregional breast cancer recurrence after autologous free flap reconstruction: A retrospective review of 2,734 procedures.

[INTRODUCTION] The 5-year incidence of locoregional recurrence (LRR) after mastectomy is 3-8 %. This study examines the incidence, modes of detection, and reconstructive options after loss of index reconstruction in the largest series of autologous free flap patients who subsequently developed LRR.

[METHODS] We identified patients undergoing muscle-sparing free transverse rectus abdominus muscle or deep inferior epigastric perforator flap reconstruction for breast cancer at our institution from 2005 to 2017 who subsequently developed LRR. The main outcomes were incidence of recurrence, primary mode of detection, surgical management, and patient and cancer-specific factors associated with surgical management and loss of index reconstruction.

[RESULTS] The incidence of LRR in this cohort was 3% (n=66 of 2240 flaps), and 71% (n=46) of recurrences were diagnosed on physical examination. 80% (n=53) of LRR required multidisciplinary management, whereas 56% (n=37) were managed surgically. Patients with postoperative radiation prior to recurrence, metastatic disease at diagnosis, nodal positivity, and chest wall involvement were less likely to be offered surgery (all p<0.05). Twelve patients lost their index reconstruction and five required subsequent advanced chest wall reconstruction. No differences were seen in terms of location of recurrence, detection of recurrence, or mortality between flap types (all p>0.05).

[CONCLUSION] Management of LRR is centered around early multidisciplinary involvement and often requires surgery. Removal of index reconstruction and/or advanced chest well reconstruction is indicated in select cases. Plastic surgeons should be aware of the indications and options that exist for management in these complex situations.