Catastrophic rhabdomyolysis following breast reconstruction operation using an abdominal flap: a case report

Abstract

Background: Rhabdomyolysis is a potentially fatal clinical syndrome resulting from the damage or breakdown of skeletal muscle, which can also lead to permanent disabilities. Based on our review of studies on rhabdomyolysis after prolonged surgeries, no other cases of rhabdomyolysis caused by muscle injury in the buttock area following breast reconstruction have been reported, making the current report the first to share information related to patient conditions and treatment progress in such cases.

Case description: Here, we present the case of a 57-year-old Asian patient with left breast cancer. We performed immediate breast reconstruction using a deep inferior epigastric perforator (DIEP) flap anastomosed to the internal mammary vessels after a skin-sparing mastectomy with sentinel lymph node biopsy. The surgery exceeded the estimated time because, after anastomosis, severe congestion was observed in the flap and because of the need to perform re-anastomosis and the reconstruction of the internal mammary vein twice. The surgical team eventually re-performed the breast reconstruction using a contralateral pedicled transverse rectus abdominis myocutaneous (TRAM) flap. The patient underwent breast reconstruction in a sitting position to ensure a symmetrical and natural breast shape resembling its original state. Additionally, a brown splint was placed underneath both legs to keep the hip and knees flexed to ensure donor-site closure when using an abdominal-based flap. The patient was closely monitored in the early postoperative period. On postoperative day (POD) 3, patient developed hypotension and was deemed to have experienced a hypovolemic shock. A complete laboratory workup was performed, and a rhabdomyolysis diagnosis was made based on the laboratory results. We believe that rhabdomyolysis resulted from prolonged pressure on the large gluteus maximus muscle located below the site of the pressure sore in the present patient.

Conclusions: Postoperative rhabdomyolysis often results from prolonged surgery. Given the possibility of prolonged procedure time in patients undergoing breast reconstruction, the current case emphasizes the need to identify each patient's risk factors for rhabdomyolysis and prepare for possible rhabdomyolysis to prevent ischemic injuries and reduce the risk of complications such as hypovolemic shock.

Keywords: Rhabdomyolysis; abdominal flap; breast cancer; breast reconstruction; case report.

Figure 1

Operation position during immediate total breast reconstruction using an abdominal flap. A sponge layer with sufficient cushioning was placed on top of the operating table and covered with fabric. The patient was then placed in the supine position. The upper body was elevated by 30–45 degrees to facilitate abdominal flap elevation and donor site closure. However, this position resulted in high pressure on the buttocks. After spreading her arms and gently fixing them in place, a brown splint was placed underneath the legs to keep the knees flexed.

Figure 2

Serum biochemistry and pressure sore on the buttocks area. The patient’s condition improved starting on POD 3 of the ICU care and CRRT (blue red arrow). The patient was transferred to the general ward on POD 8. The changes and healing patterns of the sore wounds were examined throughout the postoperative period. LDH, lactate dehydrogenase; BUN, blood urea nitrogen; eGFR, estimated glomerular filtration rate; CRRT, continuous renal replacement therapy; ICU, intensive care unit; POD, postoperative day.

Figure 3

Pressure sore on buttock area. Pressure sores were observed on both buttocks following prolonged surgery (POD 3). Widespread stage II pressure sores were observed throughout the coccygeal area subjected to the highest pressure. Pressure sore care was provided by applying foam dressing and changing the patient’s position every 3 h. It was observed that the wound gradually heals from margin after the demarcation process (POW 1, POW 2). Focal debridement for the necrotic tissue was performed and the wound has almost healed after 3 months (POM 3). POD, postoperative day; POW, postoperative week; POM, postoperative month.

Figure 4

Patient photographs. (A) Preoperative findings, AP view. The preoperative volume for the right and left breasts was 560 cc each. (B) Postoperative findings. The photo was taken from the bedside at the time of ICU admission, as the patient experienced severe delirium. (C) Findings 3 months postoperatively. The patient underwent chemotherapy. The breast reconstruction outcome was highly satisfactory. The patient is planning to undergo nipple-areolar complex reconstruction in the future. AP, anterior–posterior; ICU, intensive care unit.