Patient diagnosed at 38 years of age with multifocal infiltrating ductal carcinoma of the left breast. She underwent surgery at our institution, a second level hospital, with modified left radical mastectomy on reduction pattern, homolateral axillary lymphadenectomy and immediate reconstruction with latissimus dorsi flap and 475cc textured anatomical prosthesis (model 20636 Polytech®, Polytech Healthand Aesthetics, Dieburg, Germany) in retromuscular position in a pocket formed by the junction of the pectoralis muscle with the latissimus dorsi. A right reduction mammoplasty designed in the same pattern with inferior pedicle for the nipple-areola complex was also performed for symmetry.

As postoperative adjuvant treatment she underwent chemotherapy, as planned at the time of diagnosis of the carcinoma, and radiotherapy as 3 metastatic axillary lymph nodes were found during surgery. The patient completed radiotherapy 8 months after surgery and 2 months later, the radiation received led to severe radiodermatitis and a spontaneous seroma which, after several attempts at drainage, led to explantation of the prosthesis one year after the initial surgery. The genetic counselling diagnosis recommended prophylactic right mastectomy as it was considered a high risk because the biopsy of the reduction specimen showed ductal hyperplasia with atypia.

Due to the impossibility of using the latissimus dorsi flap and the sequelae of radiotherapy, after assessing the reconstructive possibilities, we referred the patient to a tertiary hospital as our second level institution is not qualified for vascular microsurgery techniques. The indication was to perform breast reconstruction with a bilateral DIEP microsurgical flap. One year after the explantation, the indicated prophylactic mastectomy of the right breast and microsurgical reconstruction with bilateral DIEP flap was performed. The evolution, after a postoperative pulmonary infection that required admission to the Intensive Care Unit, was unfavourable, and total necrosis of both DIEP flaps occurred.
After a year had passed and the scars had stabilised, we assessed whether there was really any possibility of reconstruction given the patient's age and the severity of the sequelae (radiodermatitis and skin adhesions to the ribcage). We decided to try to improve the skin cover with an autotransplant of fat in order to be able to support tissue expanders in the future and achieve moderate-sized breasts.

Two sessions of autologous fat grafting were performed at an interval of 6 months and on an outpatient basis. In the first session, fat was obtained from the abdomen and after processing with centrifugation, 240cc of autologous fat was injected in the right thoracic region and 200cc in the left thoracic region. In the second session, fat was obtained from the flanks and crotch and 160cc. was transferred to the left breast. We achieved clinical improvement in terms of tissue thickness, release of soft tissue adhesions of the left thoracic radiodermatitis and, at the same time, we achieved a discreet increase in volume.

At 6 months we decided to place tissue expanders. We chose anatomically shaped tissue expanders (Mentor®, Johnson & Johnson, New Jersey, USA), 350cc. In the right hemithorax, the expander was implanted in a retropectoral plane without any technical difficulties. We had the additional problem of the precariousness of the tissues and the previous radiodermatitis in the left hemithorax. To prevent extrusion, we proceeded with the surgery by suturing with Vycril® 3/0 a sheet of Strattice® dermal matrix 8 x 16cm from a fibrous remnant found at the site of the inferior border of the pectoralis major to the submammary sulcus. The role of the matrix was to protect the lower pole of the expander which was located in a subpectoral plane in the upper part and covered by the Strattice® sheet in the lower half. The postoperative period was uneventful. Filling sessions of the expanders occurred normally from 2 weeks postoperatively. The amount of filling per session ranged from 20 to 60cc per expander to a total volume of 360cc spread over 7 sessions and with an average interval of 3 weeks. The great elasticity and the low resistance to expansion of the left breast, contrary to what was expected due to the previous radiotherapy, should be highlighted, so that after 4 months the process had been satisfactorily completed.

At 5 months we proceeded to replace the expanders with definitive 380cc, anatomical, textured prostheses (Polytech® model 20737). We observed a total integration of the dermal matrix which contributed to the thickening of the soft tissue.
Three months later, given the favourable evolution of the patient, with no evidence of capsular contracture, we reconstructed the nipples with local fleur de Lys flaps. The flap of the breast that had previously undergone radiotherapy suffered partial necrosis. At the time of writing this article, we are performing micropigmentation technique for the areola. Eight months after the last intervention the patient is satisfied with the result and has been able to fully reincorporate into her social and working life.