Autologous Breast Reconstruction in a Patient With End-Stage Renal Disease and Systemic Lupus Erythematosus

Patients with end-stage renal disease (ESRD) secondary to systemic lupus erythematosus (SLE) have historically been deterred from free flap breast reconstruction due to perceived complication risks. Numerous studies examining patients with ESRD have cited free flap complications including increased incidences of infection and wound breakdown, with some  surgeons suggesting ESRD is an independent risk factor for flap failure.^1-5 Notwithstanding the risks of operating on patients with ESRD, the increasing prevalence of the disease makes optimizing reconstructive options, such as free flaps, critical. SLE and other connective tissue diseases have also been recognized as potentially problematic comorbidities when considering autologous reconstruction.^6-8 While SLE alone is known to increase such surgical complications as flap vessel thrombosis and infection, there are reports of autologous breast reconstruction in patients with SLE.⁷ To the authors’ knowledge, there are currently no published reports of successful free flap breast reconstruction in patients with ESRD due to SLE.

Here, this case report describes a patient requiring hemodialysis for ESRD caused by SLE who underwent left mastectomy and immediate autologous breast reconstruction using deep inferior epigastric perforators (DIEP) flaps. This case report suggests the use of free flaps should be considered as a feasible option for oncologic breast reconstruction in patients on hemodialysis for ESRD secondary to SLE.

A 52-year-old woman presented with multifocal stage I T1N0M0 ERBB2 (formerly HER2/neu)-negative carcinoma of the left breast (Figure, left); immunohistochemical staining revealed 95% and 100% of cells were positive for estrogen and progesterone receptors, respectively, and oral tamoxifen was begun. Her medical history was significant for hypertension, asthma, SLE, and ESRD managed with hemodialysis. The patient was scheduled to undergo a left mastectomy with sentinel lymph node biopsy and requested immediate reconstruction. She expressed that she did not want a tissue expander placed with delayed reconstruction, even with the outlined risks to a longer surgery. 

After being presented with the option to undergo either implant-based or autologous reconstruction, the patient opted for autologous reconstruction. It was explained in detail that due to the estimated breast volume, autologous reconstruction would require a double-barrel deep-inferior-epigastric perforator (DIEP) flap. The patient acknowledged the increased risk of flap failure due to her comorbid conditions of ESRD and SLE. She underwent dialysis the evening before surgery to mitigate the anticipated electrolyte imbalances secondary to the procedure.  

The procedure began with both teams working simultaneously; the breast surgery team performed a left-side skin-sparing mastectomy with sentinel lymph node biopsy while the plastic surgery team harvested the DIEP flap. On the right abdomen, the surgical team was able to identify a type II system with 3 perforators, including a medial periumbilical and 2 midrectus perforators. On the left abdomen, a type II system was similarly outlined and 2 large perforators were identified. 

After the mastectomy and sentinel lymph node biopsy were complete, the plastic surgery team prepared the flap recipient site by removing part of the third rib and identifying the internal mammary artery (IMA) and a single internal mammary vein. An intravenous infusion of 3000 U of heparin was administered, the right and left DIEP flap pedicles were ligated at their takeoff from the iliac, and both flaps were brought to the left chest as separate units. The right flap was positioned cephalad, and the anastomosis was performed to the IMA in retrograde fashion using a 9-0 running nylon suture. The deep inferior epigastric vein anastomosis was performed using a 2.0-mm venous coupler. The left flap was placed caudal to the right flap, and anastomosis to the left IMA was performed in anterograde fashion, again using a running 9-0 nylon with a 2.5-mm venous coupler for the venous anastomosis. The distal aspects of the flaps were trimmed and found to have excellent perfusion. Both flaps were appropriately positioned such that a skin paddle representing each flap was easily visible, and the flaps were sutured to the chest wall with 2-0 polyglactin 910 fascial stitches. 

The final mastectomy weight was 1017 g, and the combined weight of the 2 DIEP flaps was 1050 g. Intraoperative laser angiography confirmed adequate perfusion throughout the flap. Strong triphasic Doppler signals were found in both skin paddles, which facilitated postoperative monitoring. Fluid balance for the procedure was net positive with 150 µL of estimated blood loss, 10 µL of urine output, and 750 µL of balanced multi-electrolyte crystalloid administered. Low urine output was anticipated as the patient was oliguric at baseline. The patient remained hemodynamically stable throughout the procedure, there were no complications during the surgery, and the patient awoke with no difficulty at the end of surgery. Total procedure time was 7 hours and 56 minutes.

The patient was transferred to the surgical intensive care unit per hospital free flap protocol for routine hourly flap checks. The patient was started on subcutaneous heparin 3 times daily in the evening of postoperative day 0 per usual DIEP flap protocol. On postoperative day 1, the patient was found to be hyperkalemic (serum potassium of 6.8 mEq/L) requiring hemodialysis to reduce her potassium to 4.3 mEq/L. Following dialysis, the patient became hypotensive (systolic blood pressure of 70-80 mm Hg) and required administration of albumin and midodrine with the initiation of norepinephrine continuous infusion. The patient also received a singular transfusion of 1 unit of packed red blood cells after her hematocrit volume percentage was found to be trending downward.

After these interventions, the patient was hemodynamically stable, alert, and interactive. She was weaned off norepinephrine within 24 hours and was downgraded to a stepdown unit on postoperative day 2. She reported excellent pain control throughout her postoperative course and remained asymptomatic with the exception of the aforementioned aberrant laboratory values and hypotension following dialysis. She was followed by the renal medicine team throughout her hospitalization and experienced no further complications for the duration of her treatment course. After the postoperative dialysis session in the surgical ICU, she returned to her normal Monday-Wednesday-Friday dialysis schedule; she underwent 3 total dialysis sessions while admitted. She was discharged home on postoperative day 7.

         The patient’s follow-up course has remained uneventful with a successful free flap reconstruction. Four months after surgery, the patient underwent a minor left breast revision with creation of a neo-nipple, excision of redundant mastectomy skin, and shaping of the underlying flap tissue for added projection. The patient also underwent a simultaneous right breast symmetrizing reduction. Now, 6 months since her initial autologous reconstruction, the flap remains a viable flap with no concerns (Figure 1, right). She is pleased with her overall cosmetic outcome and has no plans for future elective breast surgery.

Due to perceived risks, autologous breast reconstruction has not been extensively explored as an option in patients with ESRD on hemodialysis who have comorbid connective tissue/autoimmune disorders, such as SLE. Patients with both ESRD and SLE manifest local and systemic manifestations that create unique challenges to free flap reconstruction. Local factors that may impede free flap success include an elevated risk of infection, tissue hypoxia, local toxins, and vascular insufficiency.^9-12 Systemic comorbidities, such as malnutrition, peripheral vascular disease, chronic venous insufficiency, diabetes, uremia, and chronic corticosteroid usage, also plague this specific population.^9,13 Any of these conditions individually increases a patient’s risk of complications when considering autologous breast reconstruction.  

While there are a few studies suggesting the potential safety of free tissue transfers in ESRD patients, there does not appear to be any reports of attempted autologous breast reconstruction in patients with ESRD. In a retrospective review, Chien et al demonstrated 95% immediate free flap survival in 20 ESRD patients undergoing lower extremity free flap reconstruction.² Similarly, Moran et al highlighted an immediate free flap success rate of 94% in a retrospective review of 33 lower extremity reconstructions.¹ Both Chien and Moran had issues with long-term lower extremity salvage, with Chien citing a total limb salvage rate of 80% and Moran reporting only 55% reconstructive success at 1 year. Importantly, however, the overall success of free tissue flaps in lower extremity reconstruction is influenced by functional outcomes, which differs from measures of success in breast reconstruction. Lastly, Manrique et al evaluated outcomes in patients with ESRD who underwent free flap reconstruction for head and neck cancer, concluding that there were no significant differences in rates of flap failure between patients with ESRD and those with no identified renal disease.³ Taken together, these studies suggest that autologous breast reconstruction in patients with ESRD is possible.

The patient in the current study expressed her satisfaction with her overall reconstruction, and both free flaps remain viable throughout her 6-month postoperative course, even following a revision procedure. The patient experienced notable hyperkalemia in the immediate postoperative period; however, this resolved quickly with hemodialysis. Additionally, the patient required less than 24 hours of vasopressor therapy following a sudden drop in her blood pressure while receiving hemodialysis. The laboratory findings were not unexpected considering the patient’s kidney disease, and the drop in blood pressure was likely related both to the ESRD and the intraoperative fluid shifts that required more aggressive postoperative resuscitation. 

Importantly, due to the patient’s oliguria at baseline, the surgical and anesthesia teams agreed to limit the volume of intraoperative fluid. It is likely that the patient was underresuscitated and hypovolemic in the immediate postoperative period. It is worth acknowledging that the challenges of fluid resuscitation and metabolic derangements were not unexpected and were easily corrected in this patient. The authors recommend that surgeons with patients who have ESRD and are preparing to undergo free flap reconstruction should consider scheduling hemodialysis within 24 hours of surgery as a routine postoperative intervention.

Following the success of free flap breast reconstruction in a patient with both ESRD and SLE, the authors believe that further investigation is warranted to evaluate the safety of autologous breast reconstruction as an option for patients with either comorbidity. While considerable literature has highlighted the risks of performing free flap procedures in these populations, these patients may be successfully treated if appropriate caution is taken—with particular attention to intraoperative fluid management and electrolyte monitoring in the postoperative period. While ESRD and SLE are not explicit contraindications to free flap reconstruction, the authors stress the importance of careful patient selection, appropriate indication, and skilled surgical technique for immediate surgical and long-term reconstructive success. 

Affiliations: ¹Division of Plastic and Reconstructive Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY; ²Florida International University, Herbert Wertheim College of Medicine, Miami, FL

Correspondence: Philip Torina, MD; philip.torina@mountsinai.org

Ethics: No Institutional Review Board was required for submission of this case. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent: Informed consent was obtained by the patient, who agreed to allow the details of her case along with select preoperative and postoperative photos to be included for purposes of this research study and report.

Disclosures: The authors declare that they have no conflicts of interest to disclose.