master degree in plastic surgery thesis
TRANSCRIPT
Thesis For Master Degree in Plastic Surgery
Different Modalities of Breast Reconstruction after Mastectomy
Doctor Mohamed Ahmed El Rouby
Consultant of Plastic & Reconstructive Surgery
Ain Shams University – Cairo – Egypt
+2 0101556023
+2 0126531265
http://www.elroubyegypt.com
http://tajmeel.ohost.de
محمد أحمد الروبي. د
مصر –القاهرة - معة عين شمسمدرس جراحات التجميل واالصالح بجا
CONTENTS
Page Subject A ---------------------------------------------------- Contents B -------------------------------------- List of Abbreviation C ---------------------------------------------- List of Tables D ------------------------------- List of Figures and Photos 1 -------------------- Introduction and aim of the work Review of literature
3 ------------------ Anatomy of normal female breast 20 ---------------------------- Pathology of breast cancer 29 ----------------------------------- Breast examination 34 ---------------------------------- Types of mastectomy 38 ----------- Goals & timing of breast reconstruction 43 ------ Different modalities of breast reconstruction 44 ----------------- Prosthetic breast reconstruction: 44 ----------------------------------- Breast implants 49 ---------------------------------- Tissue expanders 63 ----------------- Autologous breast reconstruction: 65 -------------------- Latissimus Dorsi muscle flap 79 ----------------- Rectus Abdominis muscle flap 100 ------------------------- Microsurgical free flaps 111 ------ Shaping of Autologous reconstructed breast 118 ------------ Nipple-Areola complex reconstruction 125 ------------------------------------- Patients and Methods 137 ----------------------------------------------------- Results 147 ------------------------------------------------- Discussion 153 ------------------------------- Summary and Conclusion 157 ------------------------------------------------- References
Arabic Summary ----------------------------------------- أ
LIST OF ABBREVIATIONS
Abbreviation Meaning
LCIS Lobular carcinoma in situ
IDC Invasive duct carcinoma
UICC International Union Against Cancer
AJC American Joint Commission
BSE Breast self examination
MCP mid-clavicular point
IMF Inframammary fold
LDMF Latissimus dorsi muscle flap
TRAM Transversus rectus abdominis muscle flap
VRAM Vertical rectus abdominis muscle flap
DIEP Deep inferior epigastric perforator vessels
SGAP Superior gluteal artery perforator
ASIS Anterior superior iliac spine
SSN Suprasternal notch
Ni Nipple
Ac Acromium
AFIP Armed Forces Institute of Pathology
WHO World Health Organization
NAC Nipple-areola complex
INTRODUCTION
The breast is considered a significant component of feminine health. A woman’s reaction
to any actual or suspected disease of the breast may include fear of disfigurement, fear of
loss of sexual attractiveness and fear of death. Men have similar fear regarding personal
experience with breast disease of that of a loved one, (Pujato, 1987).
Therefore, while many women undergoing mastectomies eventually adjust to their
deformity, some never do so, and suffer morbidity related to self-esteem, interpersonal
relationships, discomforts and embarrassments related to the use of external prosthesis.
The lives of these women can be transformed by reconstruction of the breast. Hence, the
possibility of breast reconstruction needs to be considered for all women requiring
mastectomies for whatever reason, (Bostwick, 1990).
Breast reconstruction either can be immediate at the time of mastectomy, delayed after
six months or late up to five years after mastectomy, (Kroll, 1997).
There are many modalities for breast reconstruction: 1. External prostheses e.g. breast cup.
2. Internal prostheses e.g. tissue expanders with or without subsequent breast
implants.
3. Autologous tissue such as transversus rectus abdominis muscle (TRAM) flaps,
latissimus dorsi flaps (LDMF), superior and inferior gluteal flaps, either pedicled
or free flaps, (Franchelli et al, 1998).
Reconstruction usually entails a series of long hospitalization during which pedicled flaps
and subcutaneous tissue are transferred from the abdomen, flanks or both to reconstruct
the breast mound. The nipple-areola complex can be reconstructed later using a free graft
from the contralateral nipple-areola complex, labia, inner aspect of thighs or toes,
(Kincaid, 1984).
It is the duty of plastic surgeons not only to restore the breast mound anatomically but to
reassure the patients that breast reconstruction is an integral part of treating their disease,
(Kroll et al., 1998).
Reconstruction of the breast after mastectomy is predominantly a demand of women in
the western world and the well-developed countries. Nevertheless, in the developing
countries, the women hardly demand breast reconstruction after mastectomy unless
offered or motivated. The causes of these facts are not clearly understood, (Vyas, 1998).
In this thesis, we will try to investigate these causes and to spread the idea of breast
reconstruction after mastectomy between Egyptian females.
AIM OF THE WORK The aims of this thesis are:
1. To review the different modalities of breast reconstruction after mastectomy
with thorough analysis of cases being operated upon during this year 1999-2000.
2. To identify the causes of refusal of Egyptian women to reconstruct their
breasts after mastectomy and to evaluate their compliance for breast reconstruction.
ANATOMY OF THE NORMAL FEMALE BREAST
The female breast is one of the signs of femininity that consists of a group
of highly specialized cutaneous glands.
Shape: The transverse shape of the young adult female breast can be
represented best as a cone with a spherical surface contour, an arched base
and an eccentrically situated top deviated fifteen degrees laterally. Using the
nipple as a reference point, each breast is divided into four quadrants,
superolateral, superomedial, inferolateral and inferomedial. In addition, there
is a retroareolar area and axillary tail, (Peck, 1951).
Extension: The breast tissue extends from the second to the sixth ribs and
from the para-sternum to the mid-axillary lines. However, the glandular
tissue extends upwards to the clavicle, downwards below the costal arch,
medially to the midline and in about 95% of women, laterally to the axillary
fossa as the axillary tail of Spence. The axillary tail of Spence passes
through a foramen in the axillary fascia known as the foramen of Langer,
(Monsen, 1992).
The breast parenchyma lies between the deep layer of the superficial
fascia and the fascial investment of the pectoralis major muscle (about two
thirds of breast tissues). The other one third is related to the serratus anterior
muscle and the aponeurosis of the external oblique muscle, (Skandalakis et al.,
1995).
The retromammary space is a bloodless plane containing some loose
areolar tissue, small blood vessels and lymphatics. Thickenings called
posterior suspensory ligaments, extend from the deep surface of breast to the
deep pectoral fascia. So, in mastectomy, the correct plane is under the
pectoral fascia and includes the retromammary space, (Iglehart, 1991).
Another bloodless plane lies just deep to the dermis, in thin individuals.
This plane is 2-3 mm deep to the skin. Fibrous tissue strands extend from the
deep fascia to the skin. These are called the ligaments of Asteley Cooper,
which are responsible for the protuberant appearance of the young female
breast. With age, they become atrophic and allow the breast to drop. Also, in
cases of carcinoma of the breast dimpling of the skin occur when it involves
these ligaments, (McVay, 1984).
Size and weight: There is a tremendous variation in the size and the
weight of the female breast. At maturity, the glandular portion has a
distinctive protuberant conical form. The base of the cone is roughly
circular, measuring 10-12cm in diameter and 5-7cm in thickness, (Peck, 1951)
The nulliparous females have typical hemispherical configuration,
whereas the multiparous females, who experienced hormonal stimulation
associated with pregnancy and lactation, have pendulous and larger breasts.
Postmenopausal, the breast usually decreases in volume, (Cody et al, 1984).
The typical non-lactating breast weights between 150-225gm, whereas the
lactating one exceeds 500gm, (Cody et al, 1984).
The areola is a circular area of skin around the nipple, variable in size,
pink white in nulliparous and dark brown in multiparous women. The areola
contains numerous sebaceous glands, Montgomery glands, which secrete an
oily material for lubrication of areola, (Moore, 1992).
The nipple is a conical or cylindrical prominence that is located in the
center of the areola. In nulliparous females, the nipples are usually situated
at the level of the fourth intercostal spaces. However, the position of the
nipples varies even in the same woman. The tip of the nipple is formed of a
circulatory arranged smooth muscle fibers that compress the lactiferous
ducts and erect the nipple when they contract, (Moore, 1992).
Consistency: The breast is composed of acini, which together make
lobules and lobes of the gland. The lobes are arranged in a radiating fashion,
converging towards the nipple where each lobe is drained by a duct. There
are 15 main ducts, where each one is dilated into an ampulla beneath the
areola forming lactiferous sinuses, where they open separately on the
summit of the nipple, (Last, 1996).
Blood Supply of the Breast:
Arterial blood supply (Figure 3):
Blood supply of the breast comes from many sources and within the
breast arterial interconnection leads to collateralization of flow, (Russell,
1983).
(1) Lateral Thoracic Artery:
The lateral thoracic artery is a branch from the second part of the
axillary artery. It is the main source of blood supply for the lateral part
of the mammary gland. In the absence of this artery, the thoracodorsal
artery, which is the continuation of the subscapular artery from the
third part of the axillary artery, becomes the main source of blood
supply, (Monsen, 1992).
(2) Internal Mammary Arteries:
The internal mammary arteries are branches from the first part of
the subclavian artery. They course downwards along the lateral border
of the sternum, sending branches through the intercostal spaces, to
supply the medial part of the breast, (McMinn, 1990).
(3) Intercostal Perforators:
The intercostal perforators are the lateral branches of the second,
third and fourth posterior intercostal arteries, which supply the inferior
and lateral parts of the breast, (McMinn, 1990).
Venous drainage (Figure 4):
The venous drainage of the breast is important not only because the veins
are the route of hematogenous metastases but also because the lymphatic
vessels generally follow the same course. It can be classified into the
superficial subcutaneous veins and the deep veins, (Haagensen, 1986).
A. The Superficial Subcutaneous Veins:
Around the nipple the superficial subcutaneous veins form the
anastomatic circle, the circulus venosus. The superficial veins radiate
from this circle to the periphery of the breast then unite into vessels,
which join the internal mammary, axillary and posterior intercostal
veins. The majority of these veins drain into the internal mammary
vein, (Haagensen, 1986).
B. The Deep Veins:
The deep veins drain along routes roughly corresponding to the
arterial blood supply, (Rush, 1989).
1- The perforating branches of the internal mammary veins: These are the
largest veins draining the breast. They end finally into the innominate veins,
then to the pulmonary capillary network.
2- Multiple tributaries to the axillary vein.
3- The intercostal veins: They are one of the most important routes of
venous drainage from the breast. They travel posteriorly to the vertebral
veins and hence to the azygos veins and superior vena cava. They are the
third pathway from the breast to the lungs, (McVay, 1984).
C. The Vertebral System of Veins:
This is a separate system paralleling the caval system. They drain not only
the vertebrae but also the bones of the pelvis, upper ends of the femur, the
shoulder girdle, upper end of the humerus and the skull, (McVay, 1984).
The anastomosis of the deep veins of the breast with vertebral veins
through the intercostal veins is the explanation for the metastasis of breast
cancer to the vertebral bodies or even the sacrum or pelvis without presence
of metastatic deposits in the lungs, (Rush, 1989).
Innervation of the Breast (Figure 5):
The breast, has a segmental sensory innervation that follows the
distribution of the intercostal nerves, which are subdivided into an anterior
and posterior nerve rami. The anterior ramus courses laterally in the
intercostal space to about the level of the anterior axillary line, where, after
piercing the serratus anterior, it gives rise to a lateral cutaneous branch. The
main ramus then continues anteriorly where it terminates in the midline as
the anterior cutaneous branch, (Rush, 1989).
The smooth muscles present in blood vessels and the nipple-areola
complex receive their innervation via the sympathetic nervous system,
(Serafin, 1976).
Lymphatic Drainage of the Breast (Figure 6):
The lymphatic drainage of the breast is extremely important because
breast cancer spreads along such channels, (McVay, 1984).
In the subareolar area, there is a particularly numerous meshwork of
lymphatics that widens peripherally to form a dense circumareolar plexus
(Retroareolar plexus of Sappy). From this, enormous external and internal
trunks are the main routes of lymphatic drainage from the breast to axilla:
1. The External Trunk:
Passes from the subareolar plexus to the outer border of the pectoralis
major and receives collaterals from the upper half of the breast.
2. The Internal Trunk:
From the medial edge of subareolar plexus to the outer border of the
pectoralis major and receives tributaries from the lower half of the breast.
Both these trunks pass around the outer edge of the pectoralis major
muscle, then penetrate the costo-coracoid fascia and terminate in the axillary
lymph nodes, (McVay, 1984).
There are two accessory routes of lymphatic drainage from the breast to
the nodes at the apex of the axilla, these are:
a. The Transpectoral route:
Begins as a retromammary plexus of lymphatics. Then, they
perforate the pectoralis major and following the course of the pectoral
branch of the thoracoacromial artery, empties into the subclavicular
group of axillary lymph nodes.
b. The Retropectoral route:
It is a lymphatic pathway found in about one third of subjects and
drains the upper internal portion of the breast. It runs laterally to rotate
around the outer edge of pectoralis major and then runs upward on its
under surface or under the pectoralis minor to the apex of the axilla
where it empties into the subclavicular group of axillary lymph nodes.
This group is a more direct pathway to the subclavicular nodes than
the main lymphatic route, (Rush, 1989).
Lymphatic Drainage to the Internal Mammary Nodes:
The central and medial lymphatics of the breast pass medially along the
course of the blood vessels perforating down through the pectoralis major
muscle and empty into the internal mammary chain of nodes situated in the
interspaces between the costal cartilages within 3 cm of the sternal edge,
(McVay, 1984).
Lymphatic Drainage to the Contralateral Axillary lymph nodes:
The crossing of skin lymphatics from one breast area to the opposite side
provides one explanation for metastasis reaching the opposite axilla in breast
cancer. A second route for such contralateral spread is along the deep
pectoral fascia lymphatics from one side to the other, (McVay, 1984).
Lymphatic Drainage of the Muscles of the Chest Wall:
These follow the general course of their blood supply. The lymphatics of
the medial portion of pectoralis major and pectoralis minor muscles empty
into the internal mammary lymph nodes, while the lateral portions drain to
the axillary lymph nodes, (Rush, 1989).
Lymph nodes:
I) The Axillary Lymph Nodes (Figure 7):
They are of large size and vary from twenty to thirty in number. There are
five principle groups that lie beneath the coracoid fascia along with the
axillary blood vessels, nerves, connective tissue and fat and which are held
together by strong fascial network making dissection in one mass easy,
(McVay, 1984).
1. The external Mammary group (Anterior group): lies along the medial
wall of the axilla, outside the fascia covering the digitations of serratus
anterior muscle from the sixth rib to the axillary vein following the
course of the lateral thoracic vein.
2. The Subscapular group (Posterior group): lies along the subscapular and
thoracodorsal blood vessels and extend from the lateral thoracic wall to
the axillary vein.
3. Axillary Vein group (Lateral group): is the most numerous, and lies along
the lateral portion of the axillary vein.
4. The Central group: is the second most numerous, as well as being the
largest of the axillary nodes. They are also the most frequently felt
axillary lymph nodes. They lie embedded in the fat in the center of the
axilla.
5. The Subclavicular group (Apical group): lies at the apex of the axilla
where the subclavian vein disappears beneath the subclavius muscle. The
collecting trunks from all other axillary groups of nodes end into this
group, (Rush, 1989).
Drainage of the axillary lymph nodes:
Large efferent lymph vessels from the subclavicular group pass upward
beneath the clavicle for 3cm to terminate in one of three pathways:
a) Directly into the venous system at the junction of the subclavian and
jugular veins.
b) With the jugular and bronchomediastinal lymphatic trunks to form a
common duct ends in the jugular-subclavian venous confluence.
c) Into the Sentine nodes of supraclavicular (inferior deep cervical) group
close to the jugular-subclavian venous confluence, (McVay, 1984).
For surgical purposes, the axillary lymph nodes are divided into three
levels according to their relationship with the pectoralis minor muscle.
1. Nodes lying lateral to pectoralis minor are termed level I.
2. Nodes lying deep to pectoralis minor are termed level II.
3. Nodes lying medial to pectoralis minor are termed level III , (Haagensen, 1986).
Level I and II lymph nodes are removed in an extended total mastectomy
(mastectomy with axillary dissection). Removal of the level III lymph nodes
requires excision or division of the pectoralis minor muscle, as in radical
mastectomy or Patey’s radical mastectomy where the pectoralis minor
muscle is preserved, (Haagensen, 1986).
Involvement of the supraclavicular lymph nodes, unlike involvement of
lymph nodes of the axillary chain is considered as a distant metastasis
because it occurs in a retrograde fashion, from the lymph nodes at the
jugular-subclavian venous confluence, (McMinn, 1994).
II) The Internal Mammary lymph Nodes:
They are situated in the interspaces between the costal cartilages within
3cm of the sternal edge. They are small nodes about 5mm in diameter and
their average number is 6 per subject with the greatest concentration in the
upper three interspaces. Sometimes, there are retromanubrial nodes at the
level of the first interspace connecting the right and left internal mammary
chains, (Haagensen, 1986).
Efferent lymphatics of these nodes empty into the thoracic duct on the left
side and the right lymphatic duct on the right side or they may empty
directly into the jugular-subclavian venous confluence, (McVay, 1984).
III) The Posterior Intercostal Lymph Nodes:
They are one to three nodes in each interspace lying upon the inner aspect
of thoracic wall, close to the head of the ribs. These nodes also receive
tributaries from the parietal pleura, the vertebrae and the spinal muscles and
provide a retrograde route where-by carcinomatous emboli from the breast
may reach the pleura or the vertebrae. The normal efferent channel from
these posterior intercostal lymph nodes is to the thoracic duct, (McVay, 1984).
ANTHROPOMORPHIC BREAST MEASUREMENT
The breast is an organ with varied volume, width, height, projection,
tissue density, composition, shape and position on the chest wall, (Penn,
1955).
The aesthetically perfect breast was defined as a non-ptotic breast in
which no common aesthetic procedure would be considered appropriate to
enhance the breast’s form, (Melvyn, 1997).
Although the results of the measurements indicate the range and variance
in the aesthetically perfect breast, there still was a statistically significant
correlation of some of the parameters of the breast and torso shape to breast
volume. This correlation can be used preoperatively to predict the desired
breast shape and volume in breast reconstruction, (Melvyn, 1997).
The parameters that should be recorded are shape, volume, relative
position to the trunk and the other breast, ptosis and projection, (Melvyn,
1997).
Measurements to the nipple were made to the center of the nipple.
Measurements to the umbilicus and pubis were to the superior border of
each. The clavicular point is defined as a point on the upper border of the
clavicle 5 cm lateral to the clavicular-manubrial joint, (Smith, 1986).
Definitions of parameters measured to determine the aesthetically perfect
breast include:
1. Suprasternal notch (SSN)- inframammary fold (IMF): the vertical
midline measurement from SSN to the point level with the most inferior
point of the inframammary fold.
2. SSN- Xiphoid, (16.73~17.4 cm).
3. SSN-Umbilicus, (33.51~34.9 cm).
4. SSN-Pubis, (47.6~48.9 cm).
5. SSN-center of the nipple (Ni), (18.6~19.3 cm).
6. SSN-Point of maximal lateral prominence of Acromion (Ac), (18.3~19.1
cm).
7. Nipple-Clavicle: the vertical measurement from a point 5 cm lateral to
the clavicular-manubrial joint, (18.6~23 cm).
Nipple
SSN Acromion
IMF
1 432
6
11 7 5
12
8 13
17
9
Fig 8:Anthropomorphic breast measurements, (Melvyn, 1997).
14
BP
17
18
8. Nipple to nipple: the horizontal measurement of the center of both
nipples, (19.35~20.76 cm).
9. Areola-IMF: the vertical measurement of the inferior areolar edge to the
lowest point of IMF, (5.1~6.1 cm).
10. Areola-Low: the vertical measurement of the inferior areolar edge to the
most dependant point of the breast, (5.1~6.1 cm).
11. Nipple-Acromion, (21~23 cm).
12. Nipple width, (3.49~4 cm).
13. Nipple height, (3.69~4.2 cm).
14. Breast projection (BP): it is measured at 90 degrees to the chest wall just
beneath the breast, (12~16).
15. Infra right: the circumlinear measurement of the inferior 180 degrees
about the nipple on the right IMF, (16.86~18.6 cm).
16. Chest circumference: this is measured at the level of the most inferior
point of IMF, (71.94~75 cm).
17. Chest width: this is measured at the level of the most inferior point of
IMF, (25.1~27.4 cm).
18. Chest depth: this is measured at the level of the most inferior point of
IMF, (17.1~19.2 cm).
19. Volume: the volume of the breast, (260~340 cm3), (Melvyn, 1997).
By definition, the areola-low, item 10, equal the distance from areola to
IMF, item 9. So, if there is a discrepancy between the two, it would indicate
ptosis, (Melvyn, 1997).
There is a formula to calculate the volume of the breast:
On average, the sizes desired are between 1~2 standard deviations above
the predicted volume, (Melvyn, 1997).
The ideal nipple plane is 1defined as a line level to the midpoint on the
shaft of the humerus, (Maliniac, 1950).
Another important consideration in female breast surgery is that
the higher the breast, the smaller is the volume necessary to obtain an appropriate volume, (Melvyn, 1997).
Volume = (SSN-Ni)1.103x(Ni-Ni)0.811
PATHOLOGY OF THE BREAST CANCER
I-CARCINOMA OF THE BREAST
Pathological examination is considered to be the backbone in the
diagnosis as well as the treatment decision of the breast cancer.
Histopathology is not only essential in the diagnosis of breast carcinoma and
its differentiation from benign conditions, but also, it is very important now
to select the proper treatment so as to get the best results. The
histopathological features of the disease will determine its aggressiveness
and accordingly the mode of treatment and prognosis, (Kumar et al, 1992).
Currently about one in ten women develop breast cancer during their
lifetime, and breast carcinoma causes about 20% of cancer deaths among
women, (Robbins et al, 1995).
Incidence / Epidemiology of Breast Cancer:
It rarely develops before the age of 25 years with a peak incidence during
perimenopausal years.
A greater risk in women who have an early menarche and late menopause.
More common in nulliparous than in multiparous women.
Obesity is associated with increased risk attributed to synthesis of
estrogens in fat depots.
Exogenous estrogens for menopausal symptoms are associated with
moderately increased risk of breast carcinoma.
More common in patients with a family history of breast carcinoma,
(Robbins et al, 1995).
Distribution and Incidences:
Fifty percent of breast carcinomas arise in the upper outer
quadrant, 10% in each of the remaining quadrants and 20% in
the central and sub-areolar region.
Lesions are multifocal in about one third of patients and not
infrequently bilateral, especially lobular carcinoma of the
breast, (Robbins et al, 1995).
Risk factors High risk group Low risk group
Age Old Young
Race America, Europe Asia, Africa
Socioeconomic state High Low
Marital state Never married Ever married
Place of residence Urban Rural
Race > 45 years White Black
<45 years Black White
Nulliparity Yes No
Age of menopause Late Early
Age of menarche Early Late
Weight Obese Thin
+ve Past history Yes No
+ve Family history Yes No
Classification of Breast Carcinomas:
Several pathologic classifications of mammary carcinomas
are in use. The most commonly used are those presented by the
Armed Forces Institute of pathology (AFIP) and the World
Health Organization (WHO), (Harris et al, 1993).
A perfect classification system would ideally correlate both
clinical manifestation and histological features with the
prognosis, (Iglehari, 1991).
The WHO system, which has the definite advantage of
worldwide distribution and which, with minor modifications,
Table 1: Risk Factors of breast cancer
(Schwartz, 1989)
represents a decent compromise among different opinions is
widely used, (Silverberg, 1983).
Types of Breast carcinoma:-
I. In situ carcinoma : A. Intraduct Carcinoma:
1st. Benign mammary dysplasia :
A. Cysts:
One) Simple cyst
Two) Papillary cyst B. Adenosis
C. Typical, regular epithelial proliferation of the lactiferous ducts
or the lobules.
D. Duct ectasia
E. Fibrosis
F. Gynecomastia
G. Other non-cancerous proliferative lesions.
2nd. Benign or apparently benign tumours :
A. Breast adenoma
B. Nipple adenoma
C. Lactiferous duct papilloma
D. Fibroadenoma: One) Pericanalicular fibroadenoma
Two) Intracanalicular fibroadenoma
1. Simple type
2. Cellular type (cystosarcoma phyllodes)
E. Benign soft tissue tumors
3rd. Carcinomas: A. Intracanalicular and non infiltrating interlobular carcinoma
B. Infiltrating carcinoma
C. Specific histological types of carcinoma:
One) Medullary carcinoma
Two) Papillary carcinoma
Three) Adenoid cystic (cribirform) carcinoma
Four) Mucoid carcinoma
Five) Lobular carcinoma
Six) Squamous carcinoma
Seven) Paget’s disease
Eight) Carcinoma arising from cystosarcoma phyllodes
4th. Sarcomas: A. Sarcoma arising in cystosarcoma phylloides
B. Other sarcomas
5th. Carcino-sarcoma
6th. Unclassified tumors
Table 2: World Health Organization histological classification
of proliferative and tumoral lesions of the breast
(Iglehari, 1991).
Characterized by pleomorphic carcinoma cells that fill the ducts
and ductules with carcinoma cells but remain confined within the
basement membrane. Various patterns are present such as solid,
cribriform, papillary, micropapillary and comedo-carcinoma
variants.
Poorly differentiated, pleomorphic in situ tumors often show
central necrosis, with recurrence rate up to 40% after lumpectomy.
Well-differentiated variants exhibit very little necrosis with
recurrence rate 0% to 10% of cases, (Robbins et al, 1995).
B. Lobular Carcinoma in Situ (LCIS):
Characterized by a proliferation of small, uniform cells, which fill
and distend at least 50% of the acinar units of a single lobule.
Invasive carcinoma develops in about 30% of cases of LCIS if
untreated with mastectomy, (Robbins et al, 1995).
II. Invasive Breast Cancer :
A. Invasive Duct Carcinoma (IDC):
(schirrous carcinoma) (94%):
It is the most prevalent form of invasive carcinoma, which is
characterized by infiltration of the stroma by malignant epithelial
cells that are usually arranged in nests, (Robbins et al, 1995).
B. Invasive Lobular Carcinoma (5%):
It tends to be multifocal and bilateral compared with other breast
carcinomas. It has about the same prognosis as invasive duct
carcinoma but tends to be bilateral or multicentric (20%), (Robbins et
al, 1995).
C. Medullary Carcinoma (1-5%):
The paradox of medullary carcinoma is that, inspite of the highly
anaplastic cytological appearance of its cells and despite the
presence of axillary lymph node metastasis at the time of diagnosis
in many cases, it is associated with a very good prognosis, (Ridolfi et
al, 1977).
D. Mucinous Carcinoma:
It characterized by a very good prognosis in their pure form.
E. Paget’s Disease of the Nipple
Paget’s disease of the nipple is not so much a separate type of
mammary carcinoma as it is a highly specialized manifestation of
ductal carcinoma.
Grossly, the skin of the nipple and areola is frequently ulcerated
and fissured. Histologically, the duct carcinoma cells appear as large
pale somewhat vacuolated cells located within the overlying
keratinizing squamous epithelium. Paget’s disease has been
associated with a high incidence of nodal metastasis at the time of
diagnosis, (David, 1996).
F. Tubular Carcinoma:
A very well differentiated variant of invasive ductal carcinoma.
G. Papillary Carcinoma:
Papillary carcinomas are defined by the presence of fibrovascular
cores that support the overlying abnormal epithelium. However,
these tumors still behave in a relatively benign fashion, about 90%
of patients are alive 5 years after their modified radical
mastectomies, (Fisher, 1980).
H. Adenoid Cystic Carcinoma:
This rare variant has an excellent prognosis and often does not
have lymph node metastasis, (Silverman, 1991).
I. Apocrine Carcinoma:
Apocrine carcinoma is an unusual variant of breast carcinoma
possibly of sweat duct, (Kline, 1988) or ductal origin, (Frable et al,
1980). The biologic behavior is similar to that of the common
invasive ductal carcinoma , (Silverman, 1991).
J. Inflammatory Carcinoma
It is characteristized clinically by erythema, peau d’orange and skin ridging
with or without the presence of a palpable mass, (Brustein S, 1987).
Staging of breast carcinoma
The most widely used staging system is one adopted by the
International Union Against Cancer (UICC) and the American
Joint Commission on cancer staging and end results reporting
(AJC) and is based on TNM system. UICC-AJC clinical staging
system is used for preoperative assessment of the patient. For better
staging pathological criteria may be used hence UICC-AJC
pathological staging system was designed (PTNM), (Kirbty et al,
1991).
TNM breast cancer classification system:
Primary tumor:
TX Primary tumor cannot be assessed.
T0 No evidence of primary tumor. It is carcinoma in situ: intraductal
carcinoma, lobular carcinoma in situ, or Paget’s disease of the nipple with
no tumor.
T1 Tumor is 2 cm or less in greatest dimension.
T1a < 0.5 cm in greatest dimension.
T1b 0.5 ~ 1 cm in greatest dimension.
T1c 1 ~ 2 cm in greatest dimension.
T2 2 ~ 5 cm in greatest dimension.
T3 > 5 cm in greatest dimension.
T4 Tumor of any size with direct extension to chest wall or skin.
T4a Extension to chest wall
T4b Edema (including peaud’orange) or ulceration of the skin of the
breast or satellite skin nodules confined to the same breast.
T4c Both (T4a and T4b)
Regional lymph node
NX Regional lymph nodes cannot be assessed or previously removed.
N0 No regional lymph node metastasis.
N1 Metastasis to moveable ipsilateral axillary lymph nodes.
N2 Metastasis to ipsilateral axillary lymph nodes fixed to one another or
to other structures.
N3 Metastasis to ipsilateral internal mammary lymph nodes.
Distant metastasis
M
X
Presence of distant metastasis can not
be assessed
M
0
No distant metastasis
M
1
Distant metastasis (includes
metastasis to ipsilateral supraclavicular
lymph nodes)
Stage grouping:
Table3: Staging of Breast Cancer, (Anderson, 1989).
Stage 0 T0 N0 M0
Stage I T1 N0 M0
Stage IIA T0 N1 M0
T1 N1 M0
T2 N0 M0
Stage IIB T2 N1 M0
T3 N0 M0
Stage IIIA T0 N2 M0
T1 N2 M0
T2 N2 M0
T3 N1, N2 M0
Stage IIIB T4 Any N M0
Any T N3 M0
Stage IV Any T Any N M1
Pathological classification (PN)
Regional lymph nodes can not be assessed (e.g., previously
removed or not removed for pathological study).
PNX
Regional lymph nodes can not be assessed (e.g., previously removed
for pathological study or not).
PN0 No regional lymph node metastasis
PN1 Metastasis to moveable ipsilateral axillary lymph nodes
PN1a Only micrometastasis (none larger than 0.2 cm)
PN1b Metastasis to lymph nodes, any larger than 0.2 cm
PN1bi Metastasis in 1 to 3 lymph nodes,
0.2 ~ 2 cm in greatest dimension.
PN1bii Metastasis to 4 or more lymph nodes,
0.2 ~ 2 cm in greatest dimension.
PN1biii Extension of tumor beyond the capsule of a lymph
node metastasis,
< 2 cm in greatest dimension.
PN1biv Metastasis to a lymph nodes > 2 cm in greatest dimension
PN2 Metastasis to ipsilateral axillary lymph that are fixed to one
another or to other structures
PN3 Metastasis to ipsilateral internal mammary lymph nodes
II- SARCOMA OF THE BREAST
They are a heterogeneous group of lesions which include
fibromatosis, fibrosarcoma, malignant fibrous histiocytoma,
liposarcoma, leiomyosarcoma, osteogenic sarcoma, and
chondrosarcoma, (Gutman H, 1994).
III- LYMPHOMA OF THE BREAST
Primary lymphomas of the breast are rare. Presentation is
that of a large lesion (mean size 4 cm) in the postmenopausal
patient. Mammary lymphomas are identical to other malignant
lymphomas, with tumor cells that are densely infiltrative
throughout the breast parenchyma. There is a predominance of
diffuse histiocytic lymphomas, (Brustein S, 1987).
BREAST EXAMINATION BREAST SELF-EXAMINATION (BSE):
The routine BSE is based on the following beliefs:
1. Cancer detected by BSE is likely to be of smaller size than that
found accidentally.
2. Survival rates after treatment are better for patients with small
tumours and no lymph nodes metastasis than those with large tumours
and lymph nodes metastasis.
3. Small tumours enlarge progressively if left without treatment.
4. Large lesions are more frequently associated with axillary node
metastases than small lesions.
5. Prognosis is directly related to the presence and extent of lymph
node metastases, (O'Higgins, 1991).
BSE has three primary components:
1. Manual examination in the shower
2. Visual examination in the mirror
3. Manual examination when laying flat.
All women should complete all these maneuvers 5 to 7 days
after the last day of their menstrual period. The instructions for
a breast self examination are as follows:
In the shower
Raise one arm, with fingers flat, touch every part of each
breast, gently feeling for a lump or thickening.
In front of a mirror
With arms at your sides, then raised above your head, look
carefully for changes in the size, shape, and contour of each
breast. Look for puckering, dimpling, or changes in skin
texture. Gently squeeze both nipples and look for discharge.
Lying down
With fingers flat press gently in small circles, starting at the
outermost top edge of your breast and spirally in toward the
nipple. Examine every part of the breast. Repeat with left
breast.
With your arm resting on a firm surface, use the same circular motion to
examine the underarm area, (O'Higgins, 1991).
CLINICAL EXAMINATION:
Inspection:
Inspection of the breast is an important part of the physical
examination, as many lesions can be detected by inspection.
The breasts should be looked at directly from infront and
from the side of the examiner. The patient should be examined
with her arms by her side and while she is asked to raise her
arms fully above the head.
During this movement, minor degrees of asymmetry,
dimpling or tethering of the skin can be detected and movement
of the breast on the pectoral muscles and chest wall can be
identified. Abnormalities of the nipple such as retraction,
discharge, ulceration or encrustation are noted. The skin over
the breast is examined for signs of thickening, edema,
erythema, ulceration or prominent veins, (Rush, 1988).
Palpation:
Palpation should be carried out with the patient in the upright and the
supine positions, using the volar aspect and tips of the fingers.
If a lump is detected in the breast, the relation of the mass to the breast
substance is determined by holding the breast with one hand and trying to
move the mass by the other hand.
The mobility of the lesion on the pectoralis major muscle from side to
side and from above downwards is then assessed. The mobility of the lump
Fig 9: Breast Self Examination, (O'Higgins, 1991).
should be checked when the muscle is both contracted and relaxed, (Rush,
1988).
Physical examination of the regional lymph nodes is a routine during the
time of examination of the breast. The medial, anterior, posterior and lateral
walls of the axilla are first examined followed by the examination of the
apical area and supraclavicualr lymph nodes, (Rush, 1988).
CLINICAL EXAMINATION OF THE MASTECTOMIZED PATIENTS:
In the first consultation, the following must be determined:
Whether the patient is a good candidate for autologous reconstruction.
Whether she is willing to undergo the additional surgery required.
Special considerations in the patients’ history include existing medical
problems such as diabetes mellitus, lupus, cardiac disease, pulmonary
problems, and peripheral vascular disease.
A previous mastectomy or radiation therapy to the chest or axilla may
affect local skin quality and tightness.
Other considerations include past or current smoking, and the patients’
occupation and lifestyle. The patients’ height, weight, and bra size are
recorded, (Bernard, 1998).
Physical examination consists of careful assessment of the affected and
the normal breast. The anthropomorphic breast measurements are recorded,
(Bernard, 1998).
We should be minded by four important items that will help us to decide
the options for breast reconstruction, and those suitable for a particular
patient. These four items are:
Fig 10: Breast Clinical
Examination, (Schwartz,
1991)
Palpation
Inspection
1. The location of previous incisions and scars should be made with
attention to the most recent biopsy site to incorporate the biopsy
incision with the nipple-areola complex in the mastectomy incision
2. The skin quality and vascularity.
3. The amount of subcutaneous fat.
4. The pectoralis muscle: if it is present or not and if it is atrophied or
not, (Heinz, 1997).
Donor site considerations include the adequacy of sufficient vascularized
tissue in the various donor sites and patient preference, (Bernard, 1998).
The contralateral breast should be examined also, as other procedures can
be considered if the opposite breast is large or ptotic, and may be performed
at the initial operation or with secondary nipple reconstruction, (Bernard,
1998).
During general examination we should consider:
The general built of the patient.
The chest shape.
The state of the abdominal wall and the presence of other abdominal
scars, (Heinz, 1997).
TYPES OF MASTECTOMY I) Halsted (Radical) Mastectomy:
As classically described by Halsted (1894-1907), radical
mastectomy involves enbloc removal of all breast tissue and an
abundant overlying portion of skin, the entire pectoralis major
and minor muscles, and all of the fibrous and fatty tissue
beneath the axillary vein including the axillary lymph nodes.
II) Modified Radical Mastectomy:
It was described by Patey and Dyson in 1948 and
subsequently by Richard Handley. This operation involves
resection of the breast, pectoralis major fascia, pectoralis minor
muscle and the axillary lymph nodes where the pectoralis major
muscle is preserved. Further modification by Auchincloss
preserved the pectoralis minor muscle as well.
III) Extended (Radical) Mastectomy:
In this type of mastectomy, the skin incision incorporates the
nipple and may be either oblique or transverse, depending upon
whether the pectoralis major is removed or not. The radical
mastectomy portion of the procedure removes all breast tissue
in conjunction with an axillary dissection, (Veronsei, 1981).
IV) Super Radical Mastectomy:
The super-radical mastectomy goes beyond the Halsted
radical mastectomy to include removal of all breast tissue and
both pectoral muscles and dissection of the axillary, internal
mammary and supraclavicular lymph nodes, (Veronsei, 1981).
V) Total (Simple) Mastectomy:
In this approach, the entire breast with a safety margin of
skin at least 4cm around the tumor is removed with the
underlying pectoral fascia and the nipple-areola complex. Both
pectoralis major and minor muscles are preserved. Less
extensive skin margins are acceptable when the procedure is
done for early cancer (lesions less than 1cm diameter) or for in-
situ or premalignant lesions. The axillary tail of Spence is
included in the en-bloc specimen. In general, no axillary
dissection is employed, (Rosato, 1986).
VI) Breast Conservation Surgeries:
Breast conservation surgeries involve removal of the primary
tumor and a variable safety margin of surrounding normal
breast tissue. There are various terms to describe these approaches. They
include lumpectomy, tumorectomy, segmental mastectomy, local
excision, partial mastectomy and quadrantectomy, (Harris, 1993).
In 1990, the National institute of Health published the consensus
development conference statement of “The patients with early stage
breast cancer”. It states that "breast conservation treatment is an
appropriate method of primary therapy for the majority of women
with stage I and II breast cancer and is preferable because it provides
survival equivalent to total mastectomy and also preserves much of
the breast tissues", (Osborne et al., 1990).
The primary goals of this therapy are:
1. Tumor control
2. An acceptable appearance of the breast.
If both goals are not obtained, then the treatment has failed,
(Osborne et al., 1990).
Selection criteria for breast conservative treatment:
The tumor size is less than 5cm.
A motivated patient.
A solitary lesion that can be completely excised.
Focal not diffuse microcalcifications.
Contraindications for breast conservative treatment:
Absolute contraindications:
The presence of multiple primaries.
The tumor size is more than 5cm.
Pregnancy.
Collagen vascular disease.
Diffuse microcalcifications.
Relative contra indications:
Extensive ductal carcinoma in-situ.
Very young patients, (Wells, 1993).
VII) Subcutaneous Mastectomy:
Subcutaneous mastectomy removes only the major portion of
the breast tissue, preserving the nipple, both the pectoral
muscles and the axillary lymph nodes. The skin is
subcutaneously dissected off the underlying breast tissue,
leaving a skin flap 4~8mm in thickness, (Shone and Press, 1983).
VIII) Prophylactic Mastectomy:
Some women have a high risk of developing breast cancer.
Prophylactic mastectomy is an operation designed to reduce
this risk by removing a high percentage of the breast tissue.
This option has become more attractive for the woman at high
risk since the development of satisfactory methods of im-
mediate breast reconstruction, (Jarrett, 1978; Woods, 1980).
Surgeons differ in their opinions in the most suitable
operation for each patient, varying from extensive preventive
surgeries, as simple or total mastectomy, to subcutaneous
mastectomy for aesthetic results, (Heinz, 1997).
Indications:
1. Histological diagnosis: The premalignant lesions and
preinvasive carcinoma are the most urgent
2. Age: The younger the woman, the better to perform a
subcutaneous mastectomy.
3. Personality and Mental state: play important roles.
4. Family History: of breast cancer, especially if the mother
and/or one of the patient’s sisters had a past history of breast
cancer, (Heinz, 1997).
Technically, after excision of most of the breast tissue, simple methods of
breast reconstruction should be used if possible. However, selection of the
breast reconstruction procedure must be chosen individually depending on
various conditions:
1) Implantation of silicone implants.
2) Latissimus dorsi musculocutaneous flap.
3) The TRAM flap can be used to avoid the disadvantages of
alloplastic materials.
4) The muscular fascial turnover flaps from the external oblique
muscle and parts of rectus fascia or rectus abdominis muscle
improve the muscular coverage of the implant at the medial
inferior area, (Heinz, 1997).
THE GOALS OF BREAST RECONSTRUCTION
Regardless the timing of the breast reconstruction and the
nature of mastectomy procedure, the goals of reconstruction
still the same, which are:
1) To restore the breast mound and contour.
2) To achieve symmetry between the reconstructed breast and
the remaining natural breast.
3) Reconstruction of the anterior axillary folds in case of
pectoralis muscle loss.
4) Reconstruction of the nipple-areola complex.
5) Psychological benefits of breast reconstruction, (Heinz, 1997).
Reconstruction was clearly associated with reducing the
psychological trauma generally attributed to amputation of the
breast. Also, reconstruction improves the women's sense of
femininity, elevates her self-esteem and encourages sexual
expressiveness.
It has been approved that immediate breast reconstruction
has additional benefits:
1. The patients can expect the restored physical state from the
beginning of treatment.
2. She does not have to grieve the loss of the breast.
3. She dose not experience psychological disturbance or loss
of the general daily activities of life, (McDonald, 1988).
THE TIMING OF BREAST RECONSTRUCTION
There are two important considerations in breast reconstruction after
mastectomy, the timing and the choice of technique.
The timing of breast reconstruction has usually been delayed
until primary treatment and adjuvant therapies have been
carried out, (Bostwick, 1990).
However, oncologically, there is no reason preventing
immediate breast reconstruction unless the patient refuses the
operation or has a poor prognosis, (Kroll, 1997).
Whether to undergo immediate or delayed breast
reconstruction, this will not by any means affect the decision
regarding the type of mastectomy to be performed, (Dinner,
1984).
Patients vary in their reactions and response to the necessity
for mastectomy. Some refuses to undergo the primary treatment
without the knowledge that the breast can be reconstructed
immediately. Other patients, however, prefer the removal of the
cancerous breast before they can contemplate the physical and
psychological implication of breast reconstruction.
Close cooperation between the patient, the general surgeon,
and the reconstructive surgeon is mandatory, for patient to
make a well-informed intelligent decision, (Dinner, 1984).
A. IMMEDIATE BREAST RECONSTRUCTION:
Indications:
The ideal patient for immediate reconstruction is a young
female with a small non-ptotic opposite breast. Her tumor is
small (less than 1 cm in diameter); her biopsy indicates a
minimal or intraductal breast carcinoma, with other social,
emotional or personal problems that can be aggravated by this
surgery, (Patrizi et al, 1993).
Advantages:
Some women find it difficult simultaneously to face the
specter of breast cancer and to loose the primary symbol of
their femininity. This leads some women to delay or refuse the
mastectomy. With immediate reconstruction, there is no fear of
mutilation or loss of breast thus avoiding the postoperative
psychological trauma, (Bostwick, 1990).
Disadvantages:
I. The patient must understand that immediate breast
reconstruction is the initial procedure after mastectomy
and other operations are required.
II. The operation takes a long time; so, it needs two
operative teams (general surgeons and plastic surgeons).
III. There is a higher rate of postoperative complications,
(Heinz, 1997).
Technique:
The simplest approach is usually selected for reconstruction
at the time of mastectomy:
If there is a small non-ptosed breast on the opposite side one
can place a small implant at the time of mastectomy.
In case of a moderate-sized non-ptosed breast on the
opposite side or a relative shortage of tissue to cover an
appropriate-sized prosthesis, another technique may be
more suitable.
When a relative lack of tissue is noted, an esthetic match to
the opposite side can be achieved by placing a tissue
expander at the same time of mastectomy and after the
surgical wound has healed, gradually expanding the
prosthesis, so that there will be adequate tissue coverage.
Alternatively, a latissimus dorsi flap or rectus abdominis
flap may be immediately performed for reconstruction, (Mc
Donald, 1988).
B. DELAYED BREAST RECONSTRUCTION:
Time:
Delayed reconstruction can be performed at any time from
few days to years after mastectomy. It is usually considered
three to six months after mastectomy, as by this time, the soft
tissues will have recovered from the operative trauma. Also,
adjuvant chemotherapy treatment is usually ended, (Heinz, 1997).
Advantages:
1. Permits histopathological study of specimens to determine
the exact nature of the tumour and the margins of resection
and to ascertain the status of the axillary lymph nodes.
2. In cases of breast reconstruction with prosthesis, delayed
breast reconstruction is better than immediate breast
reconstruction to avoid hazards of radiation as
hypoperfusion and fibrosis.
3. Allows the wound to heal and mature so as to evaluate the
skin deficit after mastectomy
4. Less postoperative complications than the immediate breast
reconstruction (less incidence of haematoma or seroma).
5. The patient experiences living with the deformity for
sometimes, thus accepting any possible outcomes of breast
reconstruction.
6. Provides both patient and plastic surgeon the time to decide
the best method of reconstruction, (Mc Donald, 1988).
Disadvantages:
1. Pre-mastectomy anxiety and fear from loss of this symbol of
femininity which may lead some women to delay or to
refuse mastectomy.
2. Post-mastectomy psychological trauma, (Bostwick, 1990).
Technique:
It is usually done in two stages:
The first to reconstruct the mastectomized breast and the
chest wall.
The second one is to correct the opposite breast if in need to
do that and to perform the nipple-areola reconstruction.
There may be another stage if tissue expansion technique is
used by placing the permanent implant prior to
reconstruction of the nipple-areola complex, (Radovan, 1982).
(I) PROSTHETIC BREAST RECONSTRUCTION
A) RECONSTRUCTION WITH AVAILABLE TISSUE AND
BREAST IMPLANT (SILICONE-GEL BREAST IMPLANTS)
This is the simplest and quickest reconstruction technique if skin and
muscle have been well preserved, (Bardsley, 1991).
History of Breast Implants:
In 1963, Dow Corning introduced the first generation implants which were
composed of a thick gel and a thick elastomeric wall, (Peters, 1994).
In 1970, Don McGhan joined Heyer-Schulte and subsequently developed the
first soft “Cohesive” silicone-gel with a high degree of softness, (Peters, 1994).
Throughout the 1970s, saline inflatable implants were also marketed by many
implant manufacturers with high rate of spontaneous deflation, (Gruber, 1978).
As the failure properties of the “soft second generation” implants became more
apparent, further studies demonstrated measurable levels of silicone in the
capsules surrounding implants, (Peters, 1994).
In 1974, the third generation implant was introduced, which had a stronger shell
(High Performance [HP] elastomer), and an inner surface which was coated with a
barrier layer to reduce the diffusion of silicone. In 1979, it had a biphenyl barrier
layer of proprietary composition, between an inner and outer layer of HP
elastomer. The new Dow Corning (Silastic II) implant had a fluorosilicone layer to
restrict silicone bleed. The corresponding Surgitek implant (Strong Cohesive Low-
Bleed [SCL]) also had a biphenyl barrier layer, (Peters, 1994).
In the early 1980s, The newest evolution was the change from smooth-surfaced
to textured-surface envelopes, which seem to have minimized the incidence of
unwanted firmness from capsular contracture, (Garry, 1998).
Types and Contents of Breast Implants:
There were several types of devices but the basic to all implants is a
silicone rubber shell, which can be single or double, smooth or textured or
covered with polyurethane foam.
The contents are either factory filled with silicone gel of various
consistencies or filled at surgery with normal saline (inflatable). There have,
and continue to be, other fill materials used or proposed, but these were
either short lived or are still considered experimental. The double-lumen
devices contain the silicone in one chamber and the saline in the other. The
original envelopes were made of thick, smooth-walled silicone rubber
(elastomer) containing the silicone gel material, (Garry, 1998).
Silicone products are especially well tolerated by the body, and in general
the patient’s body has a mild fibroblastic reaction resulting in a thin
encapsulation. There is almost no adherence of living tissue to the silicone
rubber envelop and there have been no substantial reports of cancer caused
by implantation of silicone in humans in over 30 years of experience using
silicone prosthesis. Also WHO permits a silicone-serum level up to 1mg/cm2
of barrel surface, (Garry, 1998).
Various hydrogels and a pure form of triglycerides are the two main fill
formulations. The major advantage of the triglycerides material is a Z-
number that is similar to fat, therefore compromising mammography little or
none. All currently considered substances are designed to be harmlessly
absorbed and excreted if the shell breaks, (Garry, 1998).
Autoclaving and physical characters of the implants:
Gel -Fill Implants
Autoclave by one of the following gravity displacement 1-Standard cycle: 30 minutes at 250F (121 3C) and 15psi (1kg/cm
2).
2-Alternative cycle: 15 minutes at 273F (134 4C) and 30psi (2kg/cm2).
Saline-Gel Implants. Sterilize with fill tube in situ in the valve. Use a syringe to
instill 5-10 cc sterile normal saline through tube into the outer
lumen. Disconnect syringe, leaving fill tube in place. Remove
as much air as possible from the outer lumen through the fill
tube. 1-Standard cycle: 55 minutes at 250F (121 3C) and 15psi (1kg/cm2).
2-Alternative cycle: 40 minutes at 273F (134 4C) and 30psi
(2kg/cm2), (Mentor H/S, 1992).
Indications:
1. For delayed breast reconstruction, this method of breast reconstruction
is used if there is:
An adequate quality and vascularity of the local skin.
An adequate amount of subcutaneous tissues.
A muscle to cover the breast implant.
2. For immediate breast reconstruction, it is ideal in the patient with a
round, pubescent-like breast with no glandular or nipple ptosis,
(Bostwick, 1983).
Advantages:
1. It can be carried out through the existing scars, so that no new scars are
created.
2. It is a relatively short and uncomplicated operative procedure compared
with other reconstructive procedures of the breast.
3. It does not mask local recurrence of diseases, because the prosthesis is
placed in the plane under the muscle on the anterior chest wall, below
the plane of mastectomy, (Bostwick, 1990).
4. There are many variables to achieve the best result and patient
satisfaction:
1. Timing of reconstruction.
2. Size of the reconstructed breast.
3. Placement of the implant subcutaneously or submuscularly (partial
or complete muscle coverage)
4. The methods of application of the implants, include placement of a
permanent implant, placement of a permanent expander or serial
expansion with permanent implant exchange, (Francel et al., 1993).
Contraindications and Disadvantages:
1. The technique is generally not suitable if:
a) There is inadequate skin, subcutaneous tissue and muscle as after
Halsted Radical Mastectomy.
b) There is a skin graft.
c) The pectoralis major muscle is denervated.
d) The patient has glandular or nipple ptosis.
2. Failure to match the symmetry with the opposite breast.
3. Saline implants have always tendency to wrinkle more than gel-
filled implants, especially, in thin-skin women and in the lower lateral
quadrant where the muscle coverage may be deficient.
4. By using the thick-wall textured implants, the prostheses become
palpable, visible or both, (Bostwick, 1994).
Techniques:
In choosing the suitable implant, the width (base diameter), height,
projection, shape and estimated weight or volume of the breast are the key
factors. So round implants match women with small flat breasts, (Scott, 1998).
After mastectomy, the skin flaps and under lying muscle should be
inspected for signs of excessive damage or impending necrosis and then,
start the reconstructive procedure by suturing the lateral edge of the
pectorals major muscle to the serratus anterior muscle with 3/0 chromic
catgut. This will secure the lateral portion of the muscular layer, which will
cover the implant, (Scott, 1998).
In cases of delayed reconstruction after mastectomy, the reconstruction is
begun by reopening of a small segment in the old mastectomy scar. Then, an
incision is made using the cutting cautery parallel to the line of direction of
lateral fibers of pectoralis major muscle in the mid-zone of the muscle
(others prefer incision through lateral part of pectoralis major muscle using
the blunt or the sharp dissection). An extensive pocket is created under
pectoral muscles, serratus anterior and the upper portion of rectus
abdominis, (Jackson, 1989).
After haemostasis, the breast implant should be fit easily into the pocket.
Then a suction drain is placed in the sub-muscular pocket and the skin is
closed without tension or tightness.
A dressing of gauze and strapping is used to hold the implant in the
allowed position in the pocket and inframammary fold, (Jackson, 1989).
Fig 11: Selection of proper implant by measuring the three
dimensions, (Scott, 1998)
B) RECONSTRUCTION USING TISSUE EXPANDERS The concept of tissue expansion in plastic surgery was introduced by
Neuman in 1957. In 1979, it was adapted for use in breast reconstruction. The
method’s apparent simplicity and versatility made it popular, since it seemed to
obviate the need for distant flaps in many cases, (Gibney, 1989).
Principles of tissue expansion:
A tissue expander is simply an empty silicone bag that is placed
through the mastectomy incision beneath the musculofascial layer. It has
either a contained valve or a small tubing and a filling valve, placed
beneath the skin of the lateral chest wall, (Gibney, 1987).
After the wound has healed, the tissue expander is gradually inflated by
injections of 50 to 200 ml of saline. Many surgeons slightly over-inflate the
expander in relation to the opposite breast to decrease the likelihood of scar
capsule contracture. Once the local tissues are expanded to the surgeon’s
satisfaction, the tissue expander is removed under local or general
anesthesia and the permanent breast implant is placed in the subpectoral
muscle pocket, (Bostwick, 1990).
The breast reconstruction can not be considered successful unless
acceptable symmetry with the opposite breast is achieved. The expanders
provide larger reconstructed breasts, therefore minimizing the number of
reductions of the natural opposite breast, (Radovan, 1982).
Types of Breast expanders:
There are two distinctly different types of breast expansion devices: 1. Radovan type: which is expanded with saline, (Cohen et al, 1987).
2. Becker style implant: double-lumen permanent expander implant, (Becker,
1986).
Recent advances in expander design include improvements in shape,
the development of textured surfaces, and alterations in valve design. Taken
together, these changes have enhanced the aesthetic results of tissue
expander breast reconstruction and decreased the number of complications,
(Fisher et a1, 1994).
Becker Expander/Mammary Prostheses
The Becker expander/mammary prostheses are a family of devices that
have low-bleed, gel-filled outer lumens and an adjustable saline-filled inner
lumens. The resulting device has combined some of the advantages of tissue
expanders with the feel of a gel-filled mammary implant. The outer and
inner shells are made with successive crossed-linked layers of silicone
elastomer. The standard Becker prosthesis is produced with either an outer
shell or a Siltex shell to provide disruptive surface for collagen interface,
(Mentor H/S, 1992).
Both the standard smooth Becker expander and the Siltex Becker
expander are designed with a silicone gel volume of 25% of normal implant
size. Both are designed to tolerate temporary over expansion. However, The
Siltex Becker-50 prosthesis has a gel volume that is 50% of the normal
implant size. It is not indicated for temporary over expansion and therefore
is best classified as an adjustable implant rather than an expansion device,
(Mentor H/S, 1992).
Each prosthesis is supplied with a connector system, (Mentor H/S True-
Lock connector) and a choice of two injection domes:
1. The microinjection dome, which may be used in thin patients.
2. The standard injection dome is larger in diameter, (Mentor H/S, 1992).
The standard Heyer-Schulte type inflatable breast implant has been
modified to enable a reservoir to be attached and detached at a side-filling
valve. The breast implant, therefore, functions initially as a tissue expander
and then remains in position as a permanent implant once the reservoir is
removed, (Becker, 1984).
Shape:
The original Radovan tissue expander has a circular base diameter and
a contour that is spherically symmetric. It creates a breast with a wide
base and an unaesthetic fullness in the upper pole of the breast.
With the development of shaped expanders, it becomes possible to
decrease the amount of upper pole fullness and lower the most projecting
point of the expander to create a more ptotic appearance of the breast,
(Hammond et al, 1993).
Textured Surface:
The advantages of the textured expander over the smooth walled
expander:
1. Creating an irregular surface texture has dramatically decreased the
incidence of capsular contracture, (Fisher et al, 1994).
2. Textured expanders remain immobile at the site of original
positioning to tissue ingrowth into the interstices of the texture, whether
by tissue ingrowth or simple friction, (Fisher et al, 1994).
3. Easy and less painful expansion.
4. The collagen in the surrounding capsule is non-linear.
5. The dimensionally correct expander with an appropriate base
diameter allows the inframammary fold to be created passively in many
patients by the expansion process alone.
25% gel
6. Incidences of infection with the textured expanders are less than
that of the smooth walled expanders.
7. Theoretically, no need to remove the textured expander in second
operation, (Maxwell et al, 1992).
Incorporated valve:
Previous valve designs incorporated a remote port connected to the
body of the expander by silicone tubing. New generations developed by
fixing the valve into the body of the expander, to eliminate the
complication of remote valves like flipping and infection, (Fisher et al,
1994).
Indications:
Tissue expanders are valuable when the local tissues remaining after
total mastectomy are inadequate for breast implant, (Cohen, 1987).
There are two indications for use of expander/prostheses:
1. If the opposite breast is non-ptotic or if the patient agrees to do
mastopexy to the opposite breast, a Becker device can be used that has
size adjustment without removal.
2. If the opposite breast is ptotic or if the patient refuses to do
mastopexy to the opposite breast, then a simple expander such as the
Radovan is used and positioned low down on the chest wall, (Cohen,
1987).
Advantages:
1. Less surgical procedure with minimal hospital stay.
2. A shorter postoperative recovery time.
3. An improved aesthetic result achieved by means of non-operative
volumetric adjustments, (Maxwell et al, 1992).
Tissue expanders have many advantages over the use of flaps for
breast reconstruction as:
a) The skin color and texture are identical.
b) There is maximum control over the size adjustment of the
prosthesis.
c) Avoidance of the debilitating problems caused by the removal of
muscle and tissue at the site of donor flaps.
d) In some sense, the woman sometimes feels that she is regrowing
her missing breast, (Bostwick, 1990).
e) With expanders, the opposite breast can be matched without the
need for additional scars, (Gibney, 1987).
However, tissue expansion does not eliminate the use of other
methods of breast reconstruction and if there is a less adequate or
unsatisfactory result with this method, the TRAM flap and latissimus
dorsi muscle flap should be used, (Gibney, 1987).
Disadvantages:
1. Placement of an expander frequently necessitates a second operation
for exchange with a permanent prosthesis, however, use of permanent
expander/implant device may reduce the need for this second
procedure.
2. Although textured surfaces have decreased the rate of capsular
contracture, this still remains troublesome, resulting in firm and
sometimes-painful breast.
3. Prosthetic devices are subjected to failure with leakage of gel or saline.
4. Saline devices may exhibit wrinkling, particularly when the soft tissue
cover is thin, (Fisher, 1994).
5. For inflation of the device, multiple visits to the doctor’s clinic are
required. This can be avoided by teaching the patients to inflate the
device by herself, (Gibney, 1987).
Technique:
I. First stage:
Using local or general anesthesia, the position of the temporary
subcutaneous tissue expander is outlined on the chest. A 5 cm subaxillary
incision either through the lateral tail of the old mastectomy scar or through
a new oblique incision. It is important to place the inframammary border of
the pocket on the same line as the opposite breast, (Radovan, 1982).
The pocket is developed mainly by a blunt scissors or finger dissection
and preferably about 3 cm wider in circumference than the base of the
expander. A small subcutaneous pocket is developed posterior to the incision
for placement of the reservoir dome, (Radovan, 1982).
The expander is initially filled with 50 to 100 cc of normal saline and any
remaining air in the expelled. The lower edge of the expander should reach
the inframammary line, (Radovan, 1982).
The reservoir dome is placed posterior to the incision, which is then
closed in two layers. It is important to approximate the subcutaneous tissues
between the expander and the reservoir to prevent sliding of the reservoir
toward the expander, (Radovan, 1982).
Subsequent normal saline injections are preformed according to the
expansion protocol, (Scott, 1998).
The expansion protocol:
The expansion process usually begins within 2 weeks after insertion of
the expander depending on the local wound condition. If there are any
concerns regarding the wound healing or the skin flap viability,
expansion should be delayed, (Scott, 1998).
The skin overlying the injection site is carefully prepared with
betadiene before insertion of a 21-gauge needle. Saline is then added
(about 50cc) to the expander to reach the end-point of moderate soft-
tissue tension, (Scott, 1998).
Expansion continues every 2 weeks until:
The desired maximum point of projection is obtained.
Passive creation of a new inframammary fold (IMF) occurs.
Fig 14: The pocket is developed mainly by blunt scissors or finger dissection, (Scott, 1998).
Fig 15:The position of the reservoir dome, (Scott, 1998).
3 inches at
least
Final volume within the expander should closely match the size of the
opposite breast, limiting over-expansion to approximately 10% to
15%, (Scott, 1998).
Once full expansion is obtained, the expander should remain in place
for 4 to 6 months. This allows time for tissue adherence with the surface
of the expander to develop, producing a mature, pliable capsule.
This period of maximum expansion also prevents any recoil of the
soft-tissue envelope once the expander is removed, (Scott, 1998).
II. Second stage:
Through the same subaxillary approach, the expander and the reservoir
can be removed. The old scar is excised, and electrocautery can be used for
dissection around the expander or reservoir dome, as the device is heat
resistant. If necessary, readjustment of the pocket should be performed by
partial capsulotomy at the desired corners. The amount of normal saline in
the expander should be calculated, and a smaller implant should be placed in
the pocket, to allow mobility and flexibility of the reconstructed breast. The
incision should then be closed in two or three layers, (Radovan, 1982).
Operative technique for application of Becker prosthesis:
The size of the prosthesis is determined, then the filling valve is attached
to the valve of the implant and the deflated implant is then placed in
position. Saline is now added through the filling tube until some pressure is
exerted on the overlying skin.
The prosthesis is placed beneath the muscle rather than subcutaneously.
The muscle and skin are, therefore expanded in this procedure. The reservoir
is fixed to a subcutaneous pocket. The skin incision is approximated in the
usual fashion. Once the viability of the skin flaps is ensured, the implant is
further filled by saline (A volume of 50 cc is injected twice weekly until the
desired volume is achieved).
At this stage, the reservoir is removed through a small opening in the
original incision, detaching the filling tube at the self-sealing valve, (Becker,
1984).
Complications of prosthetic breast reconstruction:
A. Intra-operative complications :
1- Muscular tears:
If the pectoralis major muscle is traumatized at the time of mastectomy
or during pocket dissection, the implant may herniate through the defect
that may lead to skin erosion and implant exposure, (Jackson, 1989).
Management:
If the defect is small, repair may be sufficient by direct closure.
If the defect is medium or large, a TRAM flap with its overlying sheath
based superiorly is turned up to cover the deficient muscles.
If there is extensive muscle tears, a tissue expander is placed and not
inflated until it is considered safe 10-24 days later, (Jackson, 1989).
2- Deficient skin flaps to close the wound:
As long as the implant has a complete musculofascial coverage, there is
no concern regarding inferior migration of the implant resulting from this
maneuver.
Management:
If there is excess tension on skin flaps following approximation the
abdominal skin and subcutaneous tissues are undermined off the abdominal
wall for a distance sufficient to allow advancement of the inferior flap and
closure., (Jackson, 1989).
3- Skin flaps circulatory compromise:
The patient is given intravenous fluorescen and the skin flaps are
examined under the Wood's lamp.
Management:
If there is still cause for concern, the implant is completely deflated to
its gel component and nitropaste is applied. Intravenous corticosteroids are
given to help protect against the effect of ischaemia on the skin flaps,
(Jackson, 1989).
4- Haematoma:
Management:
If acute intraoperative haematoma occurs, the sutures must be removed
and the haematoma is promptly evacuated and the bleeder could be
managed before replacement of the implant, then proceed toward closure,
(Jackson, 1989).
5- Pleural tear:
This is more likely to occur if a curved scissors is used with the points
towards the chest wall.
Management:
If a small tear occurs sutures are initially placed and left untied. A small
drain is inserted into the pleural space and placed on suction and removed
while the suture is air tied. The adequacy of the repair can be tested also by
filling the field with sterile saline and observing for bubbles during several
inspiratory cycles, (Shaw, 1992).
B. Early postoperative complications:
1- Hematoma:
This is unusual but may occur within the first 24 to 48 hours.
Management:
There should be immediate exploration with control of bleeding,
copious irrigation with dilute betadine and reinsertion of the implant,
(Jackson, 1989).
2- Infection:
The most common site of infection is the wound.
Management:
Drainage is indicated. Since the implant is under the muscle, it is rarely
involved.
If there is infection in relation to the implant the latter is removed and
the pocket is irrigated and drained. In this situation, it is probably wise not
to implant another prosthesis for six months. Early replacement may result
in another infection, (Jackson, 1989).
3- Wound breakdown:
This is usually due to ischaemia of the wound edges due to either
prolonged forcible retraction at surgery or closure under tension.
Management:
Debridment then either secondary sutures or frequent dressing to
inforce healing by secondary intension. Once the expander is exposed, it
should be removed, (Jackson, 1989).
4- Implant displacement:
This occurs most frequently in a cranial direction but may caudal or
lateral.
Management:
The pocket is reopened surgically and enlarged by incising the capsule
with a cutting cautery in the direction of the desired implant positioning. In
large displacements a portion of the pocket may have to be obliterated with
non-absorbable sutures to prevent redisplacement, (Jackson, 1989).
5- Postoperative pain:
A significant number of patients have complained of shoulder, arm and
chest wall pain after immediate reconstruction and this may persist for
many months. It is important in the preoperative interview to stress that the
postoperative symptoms of pain, paraesthesia may be painful because of
dissection to form the pocket, but this is short lived, in a few patients long
term pain may occur, because of capsular contraction, (Jackson, 1989).
6- Rupture of implant:
The ruptured implant is an uncommon complication. The symptoms
and signs are frequently vague, the diagnosis is usually difficult. Patient
with ruptured breast implant do not necessarily have a history of trauma. A
number of changes in the breast texture, symmetry and size imply breast
implant rupture. Mammography is a good screening test and is very,
accurate when silicone has migrated away from the implant.
Management:
A number of procedures have been used to remove silicone from soft
tissue
These procedures include:
Suction assisted removal.
Wide local excision of soft tissue and excisional biopsy of silicon
granuloma, (Anderson et al, 1989).
7- Mondor’s disease:
Thrombophlebitis of some part of the superficial mammary venous
plexus may result in a tender cord-like lesion. Extending out of the breast
into the thoraco-epigastric vein.
Management:
Supportive measures with warm, moist compresses and salicylates.
Spontaneous resolution usually occurs, (Woods, 1994).
C. Delayed postoperative complications:
1- Capsular contracture:
The formation of a postoperative fibrous tissue capsule around a
mammary prosthesis occurs in all patients in varying degrees. However,
there is no clinical significance unless the capsule contracts, causing pain,
excess breast tissue firmness, a misshapen breast, increased palpability of
the implant, wrinkling of the implant, or displacement of the prosthesis.
Capsular contracture in implants with the Siltex surface has been a far less
common occurrence than seen with smooth-walled implants of any variety
either gel-filled or saline-filled. When tissue expansion is the goal, the
development of capsular contracture during inflation is less frequent with
the Siltex Becker expander implant than with the smooth-walled Radovan
expander. The latter is frequently accompanied by scar contracture during
expansion, and the contracted capsule must be addressed during the second
stage of the expansion procedure then the Radovan expander is removed
and is replaced by a permanent implant, (Woods, 1994).
2- Recurrence of cancer:
This is uncommon. Fortunately, it will usually occur in the skin and can
be resected without disturbing the implant. If the underlying muscles are
involved, it is usually necessary to remove the implant. The presence of an
implant does not negate the use of chemotherapy or Radiotherapy, (Jackson,
1989).
3- Rupture of implant or deflation of the expander:
Deflation of the expander may also occur spontaneously or if punctured
with a needle at the inflation time or ruptured by direct trauma.
Management:
Once it is ruptured it should be removed and replaced by either another
expander or by an implant, (Anderson et al, 1989).
Postoperative care of prosthetic breast reconstruction:
1. The patient is advised to do massage of the breasts after 12 hours
postoperatively and to wear a sling for 12-24 hours to give gentle
pressure against the prosthesis and help control oozing of serum into the
cavity.
2. The dressing and brassiere are retained unchanged for 2 weeks.
3. The patient should not raise the upper arm above the horizontal
plane during this period, but gentle use of the arm is recommended.
4. At the end of this time, the dressing is removed although the
patient is advised to retain a brassiere day and night for the next 6
weeks.
The type and shape of the brassiere chosen by the patient will
determine the shape of ensuring mound to a great extend, (Watts, 1982).
A- RECONSTRUCTION WITH LATISSIMUS DORSI
MUSCLE FLAP (LDMF) The latissimus dorsi muscle flap is an excellent choice for myocutaneous
flaps for breast reconstruction after mastectomy. Also, it is the flap of choice
to replace the missing pectoralis major muscle from the upper breast area
and axilla. It is a muscle flap type V with a major vessel and segmental
arteries on the other side, (Bostwick, 1990).
Anatomy:
The latissimus dorsi muscle is a flat, fan-shaped back and shoulder
muscle, which forms the posterior wall of axilla. Deep to the latissimus dorsi
lie the erector spinae, serratus posterior, inferior and the serratus anterior
muscle.
Origin: The muscle arises from the spine of the lower six thoracic
vertebrae, the posterior iliac crest, small muscular slips from the lower
four ribs, interdigitating with the slips of origin of the external oblique
muscle of the abdomen.
Insertion: Into the intertubercular groove of humerus, (Mathes and Nahai,
1981).
Blood Supply: The blood supply to the latissimus dorsi muscle is constant
and exhibits no significant anatomic variations that prevent muscle
transposition, (Scott, 1998).
Fig 17: Surface of
Latissimus Dorsi muscle,
(Ward, 1986)
Trapezius
muscle
latissimus Dorsi Muscle
The primary blood supply to the latissimus dorsi is from the thoracodorsal
artery, a branch of the subscapular artery that arises from the axillary artery.
The thoracodorsal vessels enter the muscle on the deep surface
approximately 10 cm from the origin where the muscle forms the posterior
axillary fold. The thoracodorsal artery is accompanied by the thoracodorsal
nerve and two veins into the muscle.
The serratus branch extends from the thoracodorsal and enters the
latissimus dorsi muscle to the outer surface of the serratus anterior muscle.
Normally blood flows from the thoracodorsal artery into the serratus
branch. However, in cases where the thoracodorsal pedicle has been divided,
reversal of flow through the serratus branch provides adequate blood flow to
the flap, allowing it to be safely transposed, (Bostwick, 1983).
There are numerous musculocutaneous perforators, that allow skin islands
to be safely designed anywhere within the margins of the muscle, although
the most reliable location is over the lateral aspect of the muscle
corresponding to the course of the lateral branch of the thoracodorsal artery,
(Bostwick, 1983).
Nerve Supply:
The motor nerve supply is the thoracodorsal nerve which arises
from C6, 7, 8 roots of the posterior cord of the brachial plexus. It runs
with the thoracodorsal vessels on the deep surface of the muscle,
(Romanes, 1976).
Axillary A. Brachial
A.
Subscapular A. Circumflex Scap.
A. Serratus Collateral A.
Latissimus Dorsi M.
Serratus Ant. M.
Lateral Thoracic Artery
Fig 18: Blood Supply of LDM, (Scott, 1998).
The sensory nerves of the skin of the back are segmental, they are
divided when the latissimus dorsi muscle is elevated. Reinnervation of
the flap is possible by suture of the fourth intercostal nerve to the sensory
nerve supply to the latissimus dorsi skin island, (Bostwick, 1987).
Actions of the Latissimus Dorsi muscle:
It is an adductor and medial rotator of the humerus.
It also assists in securing the tip of the scapula against the posterior
chest wall.
Transposition of this muscle anteriorly has been shown to be well toler-
ated by patients and results in only a minimal functional deficit, although
dynamic weakness in shoulder extension and adduction may occur, (Fraulin
et al., 1995)
Shape of the muscle:
The shape of the muscle flap to be used depends primarily on the shape of
the patient's latissimus dorsi muscle and secondarily on the specific
pectoralis muscle and subcutaneous defect under the chest skin after
mastectomy.
For testing of the latissimus muscle function and innervation, there are
three simple tests, which are helpful:
a) Resistance test.
b) Scapular test.
c) Cough test.
One) The resistance test: the surgeon supports the abducted arm,
palpates the latissimus dorsi laterally, and asks the patient to push down.
When the muscle is denervated, the scapula tip pulls upwards and
appears "winged".
Two) The Scapular test: To check for winging of the scapula the patient
should place her hands on her hips and push inwards, the surgeon looks
and feels for the latissimus dorsi function.
There is usually an apparent asymmetry after latissimus dorsi denervation
Three) The cough test: by having the patient inhale and then cough, the
surgeon can confirm contraction of the latissimus muscle, (Kendall, 1983).
The mastectomy scar dictates the shape of the flap so:
The low transverse scar confined to the inframammary line is ideal and
the flat “pie-wedge” skin island will probably be chosen to give the best
projection at the nipple.
The lateral oblique scar that runs from the axilla into the inframammary
line will need a skin island shape, like a half-moon with one tip cut-off
to produce the ideal breast projection.
A mid-oblique scar if not placed too medially will need a similar half-
moon with a blunt end.
In the high transverse mastectomy scar, a simple elliptical skin island
may be the first choice if the scar itself is not acceptable. If projection is
desired, a diamond-shaped skin will be beneficial, (Millard, 1982).
Technique of elevation of the flap:
Elevation and anterior transposition of the Latissimus Dorsi muscle flap is
easy once surrounding landmarks have been identified, (Dennis, 1998).
Accurate preoperative markings are vital to properly position the skin is-
land and should always be made with the patient upright.
The superior margin: is identified by locating the tip of the scapula
and drawing a curved line across this landmark up into the axilla over the
top of the posterior axillary fold.
The lateral margin: is identified by drawing a straight line along
the anterior margin of the posterior border of the axilla down to the iliac
crest.
Between these lines, the posterior border of the iliac crest and the midline
of the back, lies the latissimus dorsi muscle, (Dennis, 1998).
First of all, the entire dorsal region is perfused with adrenalinated serum
(1 mg of adrenaline in 200 ml of physiologic serum). The infiltration is
achieved in the subcutaneous fat in the plane of the fascia superficialis. This
perfusion has two objectives:
a. It is hemostatic.
b. It helps with the lifting of cutaneous flaps, (Emmanuel et al., 1998)
There are three methods to harvest the LDM flap:
1. Open method.
2. Balloon assisted endoscopic method.
3. Vascularized Latissimus Dorsi musculocutaneous Free Flap.
1) OPEN METHOD After incising through the skin, dissection proceeds superiorly to identify
the superior border of the muscle. Medially the covering fibers of the
trapezius muscle are identified and elevated away from the underlying
latissimus muscle. After identifying the superior border of the latissimus,
dissection is carried superolaterally towards the axilla, separating away the
fibers of the teres major muscle that fuse with those of the latissimus,
(Dennis, 1998).
The superior, portion of the muscle is then elevated away from the chest
wall, working inferiorly. Once the proper plane has been identified, the
medial fascial attachments to the paraspinous fascia can be released. Care
must be taken to avoid incising through the paraspinous fascia as this makes
the proper plane of dissection difficult. The dense fascial attachment of the
lower border of the serratus to the latissimus can be easily identified and
divided, to avoid elevation of the serratus anterior with the latissimus,
(Dennis, 1998).
Dissection then proceeds across the inferior origin of the muscle to the
inferolateral border, where muscle fibers fuse with those of the external
oblique and intercostals and must be sharply divided. The lateral border of
the muscle is then identified, and dissection is then carried toward the axilla.
The serratus branch is easily identified and left intact because it is not
necessary to divide this vessel to allow adequate anterior transposition of the
muscle. The latissimus muscle is fully detached from its attachments to the
teres major and the overlying fat, but it is not necessary to fully identify the
thoracodorsal pedicle at this point.
The muscle is then tucked into the axilla and the back wound closed over
a closed suction drain, (Dennis, 1998).
Further dissection then proceeds through the mastectomy wound. The
thoracodorsal pedicle is easily identified and protected.
It is not necessary to release the insertion of the muscle to achieve
adequate anterior transposition of the muscle, and this is done only in cases
where the tendon is to be reinserted anteriorly to recreate the anterior
axillary fold, (Dennis, 1998).
2) BALLOON ASSISTED ENDOSCOPIC METHOD The donor site scar of LDMF, is usually 15 to 25 cm in length. Although
the incision can be hidden in either the area of the bra strap or laterally, the
scar tends to be long and frequently widens and hypertrophies with time,
(Moore, 1992).
If the muscle is required alone for the reconstruction, endoscopic harvest
techniques have become valuable. As with abdominal and thoracic surgical
procedures, endoscopic techniques are likely to result in better aesthetic
results, shorter recovery time, and less pain than open procedures,
(Friedlander, 1994).
A standard endoscopic setup (similar to laparoscopic cholecystectomy) is
used for the dissection. This setup includes a light source, endoscopic video
camera, and video monitor. A high flow insufflator, using CO2 gas, may be
used during the procedure. Endoscopic instruments include 10-mm ports, 5-
mm ports, blunt and sharp forceps, clip appliers, and scissors. The endoscope
is a l0-mm; 30-degree angled laparoscope, (Nolan et al, 1996).
The balloons were custom made to approximate the size of the latissimus
dorsi muscle. The balloons measure 30.5 x 33 cm and are tillable to 2500 cc
using air or saline, (Nolan et al, 1996).
The incisions are three:
One of them is 5 to 6 cm axillary incision placed parallel to the lateral
edge of the latissimus dorsi muscle.
Another two incisions 1 cm or less in length.
One is at the midlateral edge of the muscle.
The other incision is at the superior-medial border of the muscle.
The pedicle is clearly defined and dissected distally onto the muscle and
then proximally beyond the serratus branch, The vessel is retracted and
protected with vessel loops. The undersurface of the muscle is always
dissected first, (Nolan et al, 1996).
When the dissection has gone as far distally as possible with the lighted
retractor, a balloon dissection device is inserted under the muscle. The
balloon is inflated until the required dissection is complete using either
saline or CO2, (Nolan et al, 1996).
There usually are attachments distally and medially that need to be
dissected sharply. Ports are inserted at the sites of the other smaller incisions.
The electric cautary or hemoclips could be used to control the bleeding
vessels.
It is critical, at this point, that all of the edges of the muscle be clearly and
completely dissected. In addition, the distal surface of the muscle should be
transected while freeing the undersurface of the muscle.
The pedicle dissection is then completed proximally, and the muscle flap
is ready for the appropriate transfer. One of the small incisions is used as the
site for a hemovac drain.
The average harvest time is 2.5-3 hours, (Nolan et al, 1996).
3) VASCULARIZED LATISSIMUS DORSI MUSCULOCUTANEOUS
FREE FLAP
The contralateral latissimus dorsi can be transplanted as a free flap, when
the ipsilateral latissimus dorsi is not available. During dissection, the entire
muscle is taken with a smaller elliptical cutaneous paddle.
An extensive amount of donor tissue is thus available to replace the
extirpated pectoralis major muscle. Thus the infraclavicular depression is
corrected and an anterior axillary fold is created.
Because wound closure is performed in two separate layers, muscle and
skin, augmentation with a prosthesis can be done safely during the initial
procedure.
A neural coaptation between the proximal recipient nerve to the latissimus
dorsi muscle and the corresponding donor nerve is done if dissection is not
too difficult or lengthy. Subjectively, there appears to be less muscle
atrophy. Therefore, capsular contracture and fibrosis are inhibited.
The lengthy vascular pedicle facilitates flap positioning and performance
of the vascular anastmosis. An attempt must be done to perform an end to
end vascular anastmosis to a branch of the axillary and to one of the axillary
vena comitants.
If the dissection is difficult because of excessive fibrosis, an end to side
arterial and/or venous anastmosis is performed.
The neuro-vascular pedicle is often of sufficient length to reach the more
distant recipient vessels. If not, an interpositional vein graft may be used
during this technique, (Serafin et al., 1982).
Risk Factors:
1. Smoking.
2. Insulin dependant diabetes mellitus.
3. Morbid obesity.
4. Irradiation to the base of the flap or to the mediastinum.
5. Previous transection of the thoraco-dorsal vessels or posterio-lateral
thoracotomy.
6. Old age more than 65 years old, (Emmanuel et al, 1998).
Indications:
1. Patients who have had a radical mastectomy if:
The pectoralis muscle has been excised.
The skin is of inadequate quality or quantity.
2. Patients who have had a modified radical mastectomy if:
The pectoralis muscle has been denervated secondary to the cancer
surgery.
Women who have received radiation.
Women with thin skin over the mastectomy site.
3. It is most useful for thin patients who are not good candidates for
transverse rectus abdominis myocutaneous flap e.g. hypertension,
diabetes, obesity, and smoking habits, (De Mey et al., 1991).
Contraindications:
1. The use of this flap is limited when the thoracodorsal pedicle has been cut
during the cancer surgery.
2. In-patients who have had a posterolateral thoracotomy, because the
incision cuts across the latissimus muscle, interrupting the blood supply to
the lower part of the muscle, (Mc Donald, 1988).
Advantages:
The advantages of the latissimus dorsi flap are:
1. It is a large flat muscle and when transferred to the front of the chest can
simulate the shape of the pectoralis muscle.
2. It can be used to replace the deficiency in the axillary fold by moving the
insertion from the back of the humerus to the front.
3. It may also carry skin with it to release tightness.
4. It is a hearty flap, which can usually be transferred without tissue loss, (Mc
Donald, 1988).
5. Advantages of LDMF over TRAM flap:
Minimal blood loss.
A very low complication rate.
A recovery period similar to mastectomy.
6. It is a one-stage procedure that is not possible with a tissue expander.
Therefore, in patients who desire a single-staged breast reconstruction at
the time of mastectomy and are not good candidates for a TRAM flap either
by choice or by medical condition, the latissimus flap remains a very good
option, (Corral, 1996).
Disadvantages:
1. It requires an implant, which induces the same rate of capsular
contracture.
2. It results in additional scars on the back, it may weaken the shoulder
girdle in a patient who already has some deficit secondary to mastectomy.
Patients may notice this type of weakness when they attempt to push
themselves up out of a chair.
3. It can result in a patch work appearance on the reconstructed breast. This
is because of the sun exposure and, therefore, the color of the skin of the
back is different from that on the front of chest, (De Mey, 1991).
Complications:
1. Injury to brachial plexus, (Maxwell et al, 1979).
2. Flap loss: The most common situation, in which flap loss occurs,
is following division of the thoracodorsal vessels as well as the serratus
branches.
Management:
Total flap loss: can be treated by excision of the flap and skin
grafting of the defect, which may be able to be reconstructed at a
later date by other means such as an abdominal flap.
Partial flap loss: managed by excision of the necrotic tissue and
direct closure, (Ward, 1986).
3. Seroma or hematoma of the donor site: is the most frequent
problem associated with a donor site area. The use of a drain for 4 to 5
days, help in minimizing this complication, (Bostwick, 1983).
Postoperative care:
a. The flap is kept under closed supervision by means of an aperture left in
the bandaging for 48 hours.
b. Some early mobilization is recommended (lateral supine position of
duration of 5 to 10 minutes, every 2 hours, on the contralateral side) to
avoid risk of marginal necrosis in the dorsal skin flaps.
c. The day after the operation, the patient gets out of bed and must pass the
greater part of the day in an armchair.
d. It is necessary to warn the patients not to take notice of contractions in the
breast during certain shoulder movements. These contractions decrease
progressively over time.
e. Three out of four drains are removed on the sixth postoperative day, and
the patient leaves the hospital with a dorsal drain that is left at least until
the fifteenth day, or sometimes for three weeks if it produces more than
30 ml per day.
f. A compressive dorsal belt is prescribed and is carried 24 hours a day,
especially for whom there is a continuing risk of dorsal seroma. We also
prescribe a hypolipidic regime.
g. Rehabilitation of the scapular region started after the first month. The best
is to practice swimming, as this helps in the recovery of normal scapular
and dorsal function, (Emmanuel et al., 1998).
B- RECONSTRUCTION WITH RECTUS ABDOMINIS
MUSCLE FLAP The transverse rectus abdominis myocutaneous (TRAM) flap has proven
itself over the years as the autogenous tissue of choice for breast
reconstruction. It is a muscle flap type III that has two predominant arterial
blood supply, (Hartrampf, 1991).
Several strategies have emerged to meet these goals. The surgeon usually
uses a single-pedicle or whole muscle technique while avoiding the use of a
bipedicle technique when possible.
Most importantly, we treat the abdomen as if it were the primary reason
for the procedure, and to that end, synthetic mesh is used in all cases.
In unusual circumstances, bipedicled and free TRAM flap techniques are
used, (Zienowicz, 1995).
Anatomy:
The rectus abdominis muscle is long and strap like, extending along the
entire anterior abdominal wall. It is attached:
Superiorly: to the lower and anterior border of the 5th, 6th and 7th ribs
and the xiphoid process as an insertion.
Inferiorly: it originates from the body of the pubis and symphysis.
Medial border: is separated from its fellow by the linea alba. Below the
umbilicus, the linea alba is narrow and the two recti are partially in
contact, but above the umbilicus it is almost 0.5 inch wide, (Dinner et al,
1982).
The rectus abdominis is enclosed in an aponeurotic sheath except on the
posterior aspect of its lower quarter below the arcuate line, where the sheath
is absent, and superiorly the muscle lies directly on the anterior surface of
the costal cartilage.
Blood Supply:
The epigastric vascular system is the primary supply to the muscle and
overlying musculocutaneous area of the anterior abdominal wall.
1st) The superior epigastric artery:
It nourishes the superiorly based TRAM flap. It originates at the
bifurcation of the internal mammary artery opposite the 6th costal cartilage.
It enters the abdominal wall beneath the lower costal arch through the
xiphocostal portion of the diaphragm 2 to 3 cm from the midline.
The superior epigastric pedicle is at first behind the rectus abdominis
muscle then enters the midportion of the upper rectus abdominis muscle and
courses inferiorly, (Bostwick, 1983).
2nd) The inferior epigastric artery :
Fig 22: Blood Supply of TRAM, (Scott, 1998)
Superior epigastric A&V.
Inferior epigastric A&V.
Arcuate line
It is a branch of the external iliac artery and approaches the deep lower
portion of the rectus abdominis muscle from below and laterally. It courses
upward behind the muscle until the region of arcuate line. It enters the deep
central portion of the rectus abdominis muscle and branches within the
rectus abdominis muscle, (Bostwick, 1983).
The deep inferior epigastric artery with its twin on the other side (the
arteriovenous system) provides the major supply to all the layers of the
anterior abdominal wall. With its paired venae comitantes it ascends within
the rectus sheath on the deep surface of the rectus muscle and divides
usually into two primary branches. This division generally occurs below the
umbilicus and the primary branches ascend within the muscle to connect
with the superior epigastric system above the umbilicus. During its course
the artery supplies peritoneal, muscular and cutaneous branches which
radiate in all directions from the main stem and its primary divisions like the
spokes of a wheel. The dominant branches fan from the para-umbilical
region in all layers of the abdominal wall to form a series of laminated
vascular planes. As these dominant branches radiate from the para-umbilical
region they link directly by reduced caliber arteries with:
(a) Cranially, the superior epigastric system,
(b) Laterally, the intercostal and lumbar vessels,
(c) Caudally, the superficial and deep vessels from the groin,
(d) Medially, with branches of the opposite deep inferior epigastric system.
These connections, which occur in all the layers of the anterior abdominal
wall, provide the anatomical basis for a versatile variety of tissue
combinations which can be harvested for local or distant flap transfer, (Taylor
et al., 1984).
The superior and inferior epigastric vessels converge within the substance
of the muscle and form a collateral vascular network, (Bostwick, 1983).
Nerve Supply:
The nerve supply is the segmental motor branches from the 6th through
12th intercostal nerves which innervate the muscle from its deep surface.
Actions of the rectus abdominis muscle:
The muscle flexes the vertebral column and tightens the abdominal wall;
it is a relatively expandable muscle, (Mathes and Nahai, 1979).
Shape of the muscle:
The rectus muscle is separated into four equal units by transverse
tendinous inscriptions. Each unit is individually nourished and innervated
from the thoracolumber vessels and nerves. These tendinous inscriptions are
densely adherent to the tough anterior rectus sheath, (Mc Gibbon, 1984).
Techniques and methods of elevation of the TRAM flap:
I. Pedicled Flaps:
1. Vertical rectus abdominis myocutaneous flap.
2. Lower transverse rectus abdominis myocutaneous flap.
3. Upper transverse rectus abdominis myocutaneous flap.
4. Double pedicle TRAM flap
II. Microvascular flaps:
1. Endoscopic harvesting of TRAM flap.
2. Free lower TRAM flap.
3. Deep inferior epigastric artery perforator flap (DIEP).
III. Combination of pedicled and microvascular flaps:
1. Extended TRAM flap,
2. Supercharged TRAM flap.
3. Turbocharged TRAM flaps.
Common goals for any breast reconstructive procedure are:
1) Safe and well-perfused volume of tissue
transferred.
2) Minimizing the donor site morbidity, (Zienawicz,
1995).
Vascular delay is a method used to improve the perfusion to rectus muscle
flaps This is accomplished by ligating collateral circulation to the flap 13
weeks before the reconstructive procedure, (Bostwick, 1992).
1) VERTICAL RECTUS ABDOMINIS MYOCUTANEOUS FLAP
(VRAM)
This may be the procedure of choice if the latissimus dorsi flap or the
lower TRAM flap can not be used. Women with excess tissue in the mid-
abdominal region are suitable for this procedure.
However, those with flat abdomens or athletes who count on abdominal
musculature integrity are not suitable candidates, neither are those women
who object to an abdominal scar especially if it extends above the umbilicus,
(Drever, 1984).
Operative Technique:
The skin ellipse up to 15 x 20 cm is designed over the muscle, dissection
is not extended below the linea arcuate. The flap is incised through skin and
subcutaneous tissue and through the underlying anterior rectus sheath. A 1
cm strip of the anterior rectus sheath is preserved near the midline for
closure, Finger dissection beneath the lateral margin separates the entire
muscle from the posterior sheath. The segmental nerves enter beneath this
lateral edge and must be divided.
The distal end of the muscle is transected at the linea arcuate, at which
level the posterior rectus sheath disappears. The inferior epigastric artery and
vein are ligated and cut, and the flap is raised from distal to proximal at the
costal margin. Care must be taken in isolating the superior epigastric artery
and vein because they emerge through the fascia of the seventh intercostal
space. The attachment of the muscle to ribs can be separated, allowing full
rotation of this island myocutaneous flap. The flap is rotated as needed into
the defect. The edge of the rectus muscle is sutured to the lateral border of
the remaining pectoralis major muscle. The other margin of the rectus
muscle is sutured to the predetermined level of the IMF. The anterior rectus
sheath is repaired by advancement of the external oblique muscle and
sutured to the remnants of medial rectus fascia. The skin portion of the flap
is then sutured in place, (Dinner et al., 1982).
2) LOWER TRANSVERSE RECTUS ABDOMINIS FLAP
(LOWER TRAM)
The TRAM myocutaneous flap is an ellipse of skin and fat from the lower
abdomen attached to the rectus muscle. The blood supply of the flap is
derived from the musculocutaneous perforators coursing through the rectus
abdominis fascia in the periumbilical area.
Breast reconstruction with the lower abdominal skin and fat provides an
abundant source of tissue for the patient who desires a reconstruction
without a silicone breast implant and who also wants an abdominoplasty,
(Bostwick, 1990).
Advantages of single-pedicled TRAM flap:
1. The other rectus muscle is left intact and the patient retains greater
abdominal length.
2. The operative procedure is less complicated.
3. The anterior abdominal wall defect easily re-approximated in a direct
manner without the need for prolene mesh, (Beasley, 1994).
4. The breast reconstruction by the TRAM flap is an attractive method as :
The use of generally unwanted abdominal wall tissue.
The scar is placed in a relatively hidden position on the body.
Fig 23: Distribution of
perforators along TRAM, (Heinz, 1997)
Contour changes often result in improvement, and the tissues can be readily
shaped into a variety of new breast configurations, (Elliott, 1994).
Pre-Operative Planning For Use of TRAM Flap:
With the patient erect, the exact limits of the mastectomy defect are
marked and the expected level of the inframammary crease is drawn. The
actual chest incision should be 2 or 3 cm above this level to compensate for
the downward pull of the abdominoplasty, (Hartrampf, 1984).
Pre-operative assessment of TRAM flap perforators:
Preoperative knowledge of the number, location, and flow characteristics
of TRAM flap perforators of 1 mm external diameter is possible with Color-
Low Duplex Scanning.
The preoperative detection of the perforators has a significant impact on
flap design and intraoperative elevation techniques in order to capture the
dominant vessels within the flap.
This information allows the surgeon to individualize the planning and
technical performance of TRAM flap surgery on the basis of each patient’s
specific vascular anatomy. In addition, preoperative knowledge of the
number and flow velocity characteristics of the perforators allows the
selection of single pedicled, double pedicled or free TRAM flap based on
each patient’s individual perfusion characteristics.
If robust perforators are detected, the single pedicled TRAM flap
procedure may be approached with confidence. Conversely, if the perfusion
appears marginal, a double pedicled or free TRAM flap should be selected,
(Rand, 1994).
Operative Technique:
A transverse infraumbilical skin island measuring up to 30x12cm, is
designed so as not to extend beyond either anterosuperior iliac spines. The
random contralateral extension is elevated above the external oblique and
anterior rectus fascia to the midline. The ipsilateral skin island is elevated
above the external oblique fascia to the lateral margin of the carrier rectus
muscle. The anterior rectus fascia beneath the skin island is incorporated
with the flap. The cut fascial edge is secured to the overlying dermis with
temporary stay sutures. The abdominal skin proximal to the rectus flap is
elevated above the abdominal wall fascia to the inferior costal margins. On
the mastectomy side, dissection continues above the costal margin to the
chest incision. The anterior rectus sheath of the carrier muscle is then opened
along its lateral border. The inferior epigastric pedicle is identified just
below the arcuate line and isolated. The rectus muscle with its attached skin
island is dissected from its sheath. Several arterial and venous branches will
be encountered piercing the posterior rectus sheath, which may be ligated
safely.
Caudal to the arcuate line, the muscle is dissected from fascia
transversalis. Following division of the inferior epigastric pedicle, the flap
unit is delivered into the recipient defect, (Bunkis et al., 1983).
With bilateral lower rectus breast reconstruction, the transverse lower
abdominal skin island is divided in the midline, and the dissection is
modified to allow each half of the skin island to be brought to the chest
defect with the underlying rectus muscle, (Bunkis et al., 1983).
3) TRANSVERSE UPPER RECTUS ABDOMINIS FLAP
(UPPER TRAM)
Operative Technique:
With the patient in a supine position and both arms abducted, the upper
abdominal ellipse is marked as a "reverse" abdominoplasty, extending from
the epigastrium to just below the umbilicus. The horizontal ellipse extended
to the anterior axillary line bilaterally and is elevated as an island pedicle
flap based on the ipsilateral rectus abdominis muscle.
The rectus sheath is entered just below the inferior border of the ellipse,
and the muscle and anterior rectus sheath are transected at this level. A wide
portion of the rectus sheath is elevated with the musculocutaneous flap. The
origin of the rectus muscle is carefully detached from the lower ribs, so as
not to injure the underlying deep epigastric vessels. A segment of the lower
two-costosternal cartilages is removed and the internal thoracic pedicle is
dissected free. The rectus abdominis myocutaneous flap is now attached
only by the internal thoracic pedicle. In preparation for the flap inset, the
chest-wall skin flaps are raised to the clavicle, to the sternum, and to the
suggested inframammary fold. The island myocutaneous flap is transposed
into the defect and sutured to the clavicle and margins of the pocket. Excess
skin is deepithelialized and the abdominal fat is shaped to simulate a breast.
The chest skin flaps are sutured to the edges of the skin island.
The "reverse" abdominoplasty is completed by mobilizing the lower
abdominal apron relocating the umbilicus, (Hartrampf et al., 1982).
4) DOUBLE-PEDICLE (TRAM) FLAP
Indication:
1) Large soft-tissue requirements.
2) Previous abdominal operation compromising the blood supply to
portions of the anterior abdominal wall.
3) Selected patients with suspected microvascular pathology e.g.
smoker, older patients and patients with past history of radiation
along the course of the internal mammary artery, (Ishii et al., 1985).
Advantages of double-pedicled TRAM flap:
It improves the arterial blood supply and venous drainage for a larger
volume of the abdominal tissues, which improves the flap safety, (Beasley,
1994).
Disadvantages of double-pedicled TRAM flap:
1. A more complicated pedicle dissection.
2. A more difficult abdominal wall closure that usually requires a
prolene mesh.
3. Increased abdominal wall morbidity, (Beasley, 1994).
Operative Technique
The skin island is marked preoperatively with the patient standing. The
skin is designed as low as possible so that the final transverse scar is just
above the pubis. The upper transverse limb of the skin island is just above
the umbilicus. The recti are transected just below the level of the arcuate
line, and mobilization of each rectus abdominis muscle pedicle is achieved
with preservation of the lateral third of the muscle. The island is supplied by
periumbilical perforators through an elliptical segment of anterior rectus
fascia that is elevated with the underlying muscle to help preservation of the
vascular network.
The skin island is divided in the midline to allow for independent, safe
manipulation of two islands of tissue in reconstruction. These islands can be
stocked to achieve greater projection of the breast mound. Abdominal wall
closure is achieved by the use of a prolene mesh and fascial plication, (Ishii,
1985).
5) THE EXTENDED (TRAM) FLAP
A (TRAM) flap based on one of the rectus abdominis muscles, can be
extended towards the contralateral side by including the superficial
epigastric vessels and the superficial circumflex iliac vessels, and
anastomosing either artery and vein of those to the recipient vessels. Thus,
the blood supply to this extended flap is derived from the superior epigastric
vessels of the same side and artery and vein of either the superficial
circumflex iliac vessels or superficial epigastric vessels of the other side.
By utilizing this technique, the random portion of the TRAM flap can be
extended and transferred with vigorous deepithelization of the flap safely
performed, (Takyangi, 1989).
6) SUPERCHARGED TRAM FLAP
The most important problem of the superiorly based TRAM flap for
breast reconstruction is distal necrosis or fat lysis due to poor circulation. In
order to utilize the entire TRAM flap tissue in extensive tissue defects the
contralateral rectus muscle is used as a pedicled carrier and the ipsilateral
superficial or deep inferior epigastric vessels are anastomosed with
appropriate recipient vessels in the axilla, (Harashina et al., 1987).
The supercharged TRAM flap has been presented as a method where the
single superiorly based pedicle can be augmented by additional flow by
means of the microvascular anastomosis of the vessels to recipient vessels in
the axilla, (Beegle, 1991).
The deep inferior epigastric artery, in fact, has been demonstrated to be
the dominant artery to the lower abdominal region, (Boyd et al., 1984). The
free TRAM flap exploits this principle and has evolved as a popular and
reliable choice in breast reconstruction, (Grotting et al., 1989 and Shaw, 1984).
The preferred recipient vessels for the supercharged flap as well as the
free TRAM flap, include:
One- The axillary vessel branches (e.g. the subscapular vessels
and its divisions).
Two- The internal mammary system which has also been
utilized successfully.
Vein grafts or turndown of the external jugular vein may be required to
establish venous drainage. The success of both the supercharged flap and the
free TRAM flap is totally dependent on the quality and availability of the
recipient vessels. A short pedicle may cause difficulty in shaping and
positioning the breast, requiring the use of interpositional vein grafts, (Beegle,
1991).
Radiation and previous extensive obliterative surgery may cause further
problems in finding reliable recipient vessels, (Bostwick, 1990).
Indications for the supercharged TRAM flap:
One- In patients in whom a large volume of lower abdominal skin is
required but there is a lower abdominal midline scar.
Two- It also provides an alternative to the double-pedicle TRAM flap
or as a method of salvage for a single-pedicle TRAM flap in trouble,
(Beegle, 1991).
7) TURBOCHARGING TRAM FLAP
A technique was presented with a modification of the single-pedicle
supercharge TRAM flap in which the random segment of the flap is
augmented.
The augmenting blood flow is provided in a retrograde fashion through
the distal aspect of the main pedicle into the opposite deep inferior epigastric
artery/vein system.
A contralateral single-pedicle TRAM flap is designed with special care
taken to preserve the deep inferior epigastric artery and vein through out its
entire length. Close to the external iliac vessels, the venae comitantes often
form a single large vein. On the ipsilateral side, a small patch of anterior
rectus fascia, and rectus muscle is taken, again preserving the deep inferior
epigastric artery and vein as long as possible. The ipsilateral and
contralateral vascular pedicles are then oriented for microvascular
anastmosis.
There are still clinical situations that challenge the surgeon even with the
available choices:
Previous abdominal surgery (midline scars) in patients requiring a
large volume of tissue or damaged
Absent recipient vessels in the axillae or chest area.
Following the anastomosis, the flow crosses the deep inferior epigastric
artery anastomosis and moves from a retrograde flow system into a
physiologic vascular tree with normal direction flow, low pressure and low
resistance. The venous outflow from the random segment is also physiologic
until it crosses back into the main rectus pedicle, where it becomes
retrograde. The venous anatomy of the deep inferior epigastric veins has
been well documented, (Taylor, 1988).
The increased volume of venous outflow from the random portion
heading into the retrograde system may help to overcome the valvular
obstruction and possibly quicken the realignment of physiologic axial flow
within the choke vessel system. The opening of arteriovenous shunts within
the muscle under different flow conditions also may result in adaptive
compensation in myocutaneous flaps, (Hjortdal et al., 1991).
Advantages of Turbocharged TRAM flap:
1. Augmented flow to the random portion of the flap with an intrinsic anastomosis
independent of the quality or quantity of recipient vessels in the axillae.
2. The recipient vessels are not in the axilla.
3. A large volume of tissue raised on a single-pedicle regardless of a midline scar.
4. Ease of breast mound, shaping and minimal epigastric mound.
5. Abdominal-wall donor morbidity similar to that of a single pedicle.
6. Recipient vessels intrinsic within the flap away from radiation damage and
scarring.
7. Augmented venous outflow from the random portion of the flap.
Disadvantages of Turbocharged TRAM flap:
1. Sufficient retrograde flow must be demonstrated and may be presented
only in a selected group of patients.
2. Violation of the opposite rectus muscle pedicle may occur.
8) ENDOSCOPIC HARVESTING OF TRAM FLAP Endoscopic techniques have the benefits of limiting scars and incisions
morbidity. They are safe, reliable, easily learned, and time and cost effective
when compared with traditional methods, (Peters, 1991).
Endoscopically, the rectus muscle can be harvested by two different ways:
A- The extraperitoneal dissection: from within the rectus sheath - with
balloon "optical space" dissecting devices.
B- The transperitoneal technique: approaches the muscle from the
posterior rectus sheath, (Miller, 1993).
As the initial step, the abdomen is insufflated with carbon dioxide through
the Hassan cannula. The video camera was then introduced so that the
remaining ports were placed under direct vision in a way to avoid any injury
to the underlying viscera.
Now, the rectus abdominis muscle can be easily seen through the
posterior rectus sheath, as well as the inferior epigastric vascular pedicle on
the undersurface of the muscle, traversing through the preperitoneal fat
towards the external iliac vessels
Muscle perforators that pierce the anterior sheath usually can be
cauterized or hemoclipped. When the dissection of the muscle within the
sheath goes below the entry point of the inferior epigastric vessel, the muscle
is transected and there are two options for muscle delivery:
1- From the low access port. That could be dilated by 30-mm Ethicon
Endosurgery port/ tissue extraction system.
2- A short 4-cm Pfanninstiel-type incision was made and the muscle
directly removed.
As the final step in the procedure, using the two high ports, a fascial-
stapling device is then used to reestablish the posterior sheath continuity
across the midline
By developing these muscle harvest techniques, it is possible for a single
surgeon to harvest the muscle with an assistant for camera control, (Miller,
1993).
9) FREE LOWER TRAM FLAP.
Free TRAM flap transfer for breast reconstruction following mastectomy
overcomes the shortcomings of the pedicled TRAM flap.
10) DEEP INFERIOR EPIGASTRIC ARTERY PERFORATOR
FLAP (DIEP)
This flap is a variation of the free TRAM flap in which the deep inferior
epigastric vessels are dissected away from the rectus abdominis muscle so
that no muscle is harvested with the flap to reduce donor site morbidity,
(Kroll et al., 1998).
Indications of rectus abdominis muscle flaps:
1. Patients with a moderate excess of tissue on the abdominal wall and no
desire for breast reconstruction with prosthesis.
2. Patients who had failure of other methods of reconstruction.
3. It is indicated when the latissimus dorsi muscle is denervated, divided or
atrophic.
4. It is also useful for the patient who has had a complication with the silicon
breast implant.
5. For patients with a radical mastectomy with a large tissue deficit in the
axillary and infraclavicular region.
6. For patients with a large breast as reconstruction with the silicone implant
is often disappointing in such patients, (Scheflan, 1983).
Risk Factors and Contraindications of TRAM flap:
The risk factors for elective TRAM flap for breast reconstruction are well
established and should be strictly reinforced. These were stated by
Hartrampf, 1988 as:
7. Smoking.
8. Insulin dependant diabetes mellitus.
9. Uncontrolled hypertension.
10. Morbid obesity.
11. Irradiation to the base of the flap or to the mediastinum.
12. Previous transection of the superior epigastric artery.
13. Previous disruption of the periumbilical perforators.
14. Old age more than 65 years old.
15. Sever cardiovascular diseases.
16. Chronic obstructive lung diseases.
Advantages:
1. The transferred tissue closely matches the color and texture of the
opposite breast.
2. It is associated with abdominoplasty.
3. It can be performed without the use of a prosthetic device.
4. The transferred tissue brought from the abdomen can simulate breast
ptosis and has movement and flow approximating the natural breast,
(Drever, 1984).
5. One stage breast reconstruction is performed with the patient in the supine
position throughout the operation.
6. The amount of transferred tissues and their arc of rotation are such that
the infraclavicular hollow and pectoral fold can be easily reconstructed,
(Hartrampf et al., 1982).
Disadvantages:
1. Time, magnitude and length of the procedure
2. Loss of blood, with a possible need for transfusion.
3. Transfer of the rectus abdominis muscle, thereby creating a potential for
hernia formation below the arcuate line.
4. Meticulous repair of this area and the use of a mesh will preclude
complications, (Dinner, 1984).
Complications:
1. Problems of the donor site:
Abdominal seroma is a frequent complication, it is decreased some what
by suction drains and abdominal support.
When a seroma occurs, aspiration is sometimes helpful, but it may be
necessary to open the incision and insert a drain, (Bostwick, 1983).
2. Injury of the lateral cutaneous nerve of the thigh:
In the course of dissection of the flap, it may lead to injury of the lateral
cutaneous nerve of the thigh, leading to dysanesthesia over the anterolateral
aspect of the thigh.
Management: This can be effectively treated by excision of any
neuroma, and allowing the proximal end of the nerve to retract into a
deeper and insulated retroperitoneal position, (Kalisman, 1984).
3. Problems of the flap viability:
Inadequate venous drainage with excessive hyperemia and very rapid
blanching and refill is a frequent problem of the transverse rectus abdominis
flap and attention should be directed to proper positioning of the flap in
relation to its pedicle, (Bostwick, 1983).
4. Fat necrosis:
Localized fat necrosis of the deepithelialized portion of the reconstructed
breast occurred in about 4.2% of patients.
Management: by local incision and drainage of the specific area,
(Bostwick, 1983).
5. Fat Fibrosis:
Fat fibrosis is one of the most serious complications usually occuring in
the post-operative period. It is manifested as a local indurated area in the
deepithelialized portion of the reconstructed breast.
Mammography and needle biopsy must be done to exclude the possibility
of recurrence. It is suggested that all indurated area should be removed to
avoid liquefaction and secondary infection, (Bostwick, 1983).
Postoperative care:
During her typical 3-day hospital stay:
1. The patient will remain on antibiotics, steroids, and calcium channel
blocker.
2. The ambient temperature of the hospital room will be increased to prevent
cold reflex.
3. The patient takes clear liquids the night of surgery and full diet the next
day.
4. The Foley catheter is removed the first postoperative day, and she beams
ambulation.
5. Pneumatic stockings are worn except when she is walking.
6. Hematocrite is monitored daily.
At discharge:
1. The axillary and large abdominal drains are removed, whereas the small
abdominal drain is retained.
2. She will continue antibiotics, analgesics, and iron supplement after
discharge.
3. The importance of frequent ambulation in elastic stockings is stressed
during the recovery period at home.
4. Exercise and activity is gradually resumed.
5. Abdominal exercises are forbidden for 6 weeks.
Fig 27: Zones of TRAM flap, (Scott, 1998).
IV II I
III
S-GAP flap
Superior gluteal A.
Gluteus Max. M. (splited)
Gluteus Med. M.
Fig 29: Superior Gluteal Myocutaneous flap (Scott,
1998).
Fig 38: Tetrapod-flap, (Elliot, 1990)
C- BREAST RECONSTRUCTION BY MICROVASCULAR
FREE FLAPS
Although various techniques produce satisfactory results, microvascular
techniques are of great value in the autologous breast reconstruction, (Serafin
et al., 1982).
Indications:
1) Marked deficiency of well-vascularized skin of the chest. Also, they
are used to replace radiated tissue, with its deficient cutaneous and
osseous blood supply.
2) Failure of other methods of breast reconstruction.
3) Restoration of form and contour with a minimal secondary donor
deformity.
4) Patient preference, (Shaw, 1987).
Advantages:
1. Surgeon can move a large block of tissue to its definitive location without
delay or staging.
2. The free flap allows the flap to undergo irradiation or additional surgery
either for the purpose of revision to improve contour or for local
recurrence.
3. Free flap procedures allow the surgeon to select the right kind of donor
tissue for specialized reconstruction.
4. It provides more selection in matching skin texture, skin color and tissue
volume.
5. Choice of donor tissue from a distance rather than a nearby source
minimizes donor site disfigurement.
6. The free flap is not depending on a fixed pedicle, one has more freedom
in designing the breast repair, (Shaw, 1987).
Recipient Vasculature:
In any free flap transfer, the surgeon must have recipient vessel of
suitable:
Size. Location.
Length. Expandability.
Undamaged and away from the injury of previous surgery, (Shaw,
1987).
The recipient arteries are:
The internal mammary artery.
The recipient veins are:
Internal mammary vein.
Thoraco-acromial artery.
Thoraco-dorsal artery.
Posterior humeral circumflex.
Vein graft to axillary artery.
Cephalic vein of the arm.
Branch of the axillary
vein.
Vein graft to axillary vein
The internal mammary artery provides excellent caliber (1.5 to 3mm). The
meticulous dissection after resection of the third or fifth costal cartilage
allows the flap to be situated in a comfortable position matching the other
side. If the internal mammary vein is small (less than 1.5mm), a conscious
choice is made to use vein grafts to the axillary or to mobilize the cephalic
vein from the middle of the upper arm through small incision, (Shaw, 1987).
Donor Sites:
Selection of donor site depends on:
The patients’ decisions to carry out the risks associated with free flaps in
comparison to other methods.
A careful assessment of the anatomical deformities and the suitable
methods of correction are then determined.
Examination of the opposite breast to determine the size, shape and the
location of the nipple and areola.
Another important factor is the surgeons’ experience.
Based on these factors the patient and the surgeon can establish a realistic
reconstructive plan, (Shaw, 1987).
A firm and conical breast can be reconstructed by gluteal or tensor flaps,
whereas a soft, highly ptotic breast is more ideally reconstructed by TRAM
flap.
In planning the chest incision, one must take into account the best access
to the recipient vessels, the manner of minimizing unsightly scars, and the
best way in setting and contouring the breast, (Shaw, 1987).
The presence of the extensive and deleterious effects of both surgery and
irradiation, indicate that the axillary dissection to isolate the recipient
vasculature would be hazardous. So, a branch of the internal carotid artery
and an adjacent fascial vein are selected and an end to end arterial and
venous anastomosis is performed.
There are specific types of donor tissue that have been successfully
employed in breast reconstruction:
1) The free lower transverse rectus abdominis flap (TRAM).
2) Deep inferior epigastric artery perforator flap (DIEP).
3) Vascularized superior gluteal musculocutaneous flap.
4) Vascularized inferior gluteal musculocutaneous flap.
5) Vascularized latissimus dorsi musculocutaneous flap (LDMF).
6) Tensor fascia latae.
7) Contralateral breast.
8) Ruben’s flap (Vascularized groin flap).
9) The lateral transverse thigh flap.
10) The medial transverse thigh flap.
11) Superficial inferior epigastric artery flap.
12) Omentum (Elliott LF, 1994, Heinz, 1997).
1) FREE LOWER TRAM FLAP
It ensures the perfusion of the entire flap via its dominant vascular pedicle
and allows flexibility in the design of the breast mound, (Arnez et al., 1988).
Dissection of the flap is very straightforward. The inferior epigastric
pedicle is both long (as much as 10cm in length) and large in caliber (2.5~
3mm). The length and caliber of these vessels allows the surgeon
considerable latitude in choosing recipient vessels. There is no need for vein
grafts or repositioning of the patient, (Friedman et al., 1985).
With two teams working, the chest team excises the mastectomy scar and
explores the axilla preparing the recipient vessels (the thoracodorsal axis is
preferred but if it is not available, the circumflex scapular or the circumflex
humeral vessels offer reliable alternatives).
Meanwhile, the abdominal team prepares a TRAM flap, which is raised in
the same way as the standard pedicled flap, with preservation of the peri-
umbilical perforators. At the lower margin of the muscle, the inferior
epigastric vessels are dissected to yield a vascular pedicle 8-10cm. The
muscle is divided just above the umbilical level and the TRAM flap is
delivered to the chest team for revascularisation. Either ipsilateral or
contralateral rectus abdominis may be used, (Arnez et al., 1988).
The abdominal wall is closed in the standard manner. The microvascular
anastomoses are then performed preferably using end to end anastomosis.
The final orientation of the flap is made to achieve the desired contour,
(Arnez et al., 1988).
2) DEEP INFERIOR EPIGASTRIC ARTERY PERFORATOR FLAP
(DIEP)
This flap is a variation of the free TRAM flap in which the deep inferior
epigastric vessels are dissected away from the rectus abdominis muscle so
that no muscle is harvested with the flap to reduce donor site morbidity.
Usually, dissection of two or three perforators is done and all others are
sacrificed. This flap often has a less robust blood supply than the
conventional free TRAM flap. Consequently, the perforator flap has a higher
incidence of fat necrosis than the standard free TRAM flap.
The surgeon also is less able to fold and aggressively shape the perforator
flap compared with the free TRAM flap.
The perforator flap is most useful in: 1. Patients who need only a small amount of tissue for breast reconstruction.
2. Patients who cannot tolerate a reduction in abdominal wall strength.
In most other patients, the surgeons prefer a free TRAM flap that harvests
only a small portion of the muscle so that the reduced morbidity of the
perforator flap is approached although, admittedly, not equaled, (Kroll et al.,
1998).
3) VASCULARIZED SUPERIOR GLUTEAL MUSCULOCUTANEOUS
FLAP The upper gluteus provides the best free tissue transfer source for breast
reconstruction since it supplies sufficient bulk with excellent skin texture
and color, so augmentation, particularly in moderately obese patients, may
not be necessary.
The gluteus maximus free flap has large dependable vessels the superior
gluteal artery, and it leaves minimal donor deformity. Advantageously, most
people and the patient herself rarely see or think about the superior gluteal
area, (Shaw, 1987).
In the operating room, the patient is placed into the lateral decubitus
position and the ipsilateral flap is used for reconstruction.
Two operating teams simultaneously work on the donor and recipient sites
when both sides are ready and haemostasis is completed in the donor site,
the flap is divided and brought into the chest. The donor site is then quickly
closed so that the patient can be brought into a more or less supine position
for the microvascular anastomosis on the chest, (Shaw, 1987).
4) VASCULARIZED INFERIOR GLUTEAL MUSCULOCUTANEOUS
FLAP The inferior gluteal musculocutaneous flap usually provides a sufficient
amount of autogenous tissue for breast reconstruction when adequate tissue
is not present in the lower abdomen or back.
Dissection of the inferior gluteal musculocutaneous free flap begins with a
transverse incision just beneath the inferior gluteal crease. The subcutaneous
tissue is dissected in such a way as to bevel inferiorly. The posterior
cutaneous nerve of the thigh is identified as it exits beneath the inferior
gluteal maximus muscle just lateral to the ischeal tuberosity, (Palett et al.,
1989).
The posterior cutaneous nerve of the thigh and its accompanying inferior
gluteal artery are then dissected superiorly beneath the lower portion of the
gluteal maximus muscle. Once these structures are identified, the superior
portion of the flap can be designed and incised with the upper portion of the
flap over the lower part of the gluteal maximus muscle. At and above the
ischeal tuberosity, the posterior cutaneous nerve of the thigh and inferior
gluteal artery are in close proximity, but superficial to the sciatic nerve,
which runs just to the lateral side. At its most proximal level, the inferior
gluteal artery has several anastomotic branches with the perineurium of the
sciatic nerve, and these are carefully ligated during the dissection, (Palett et
al., 1989).
One must dissect a (5x8cm) segment of inferior gluteal maximus muscle
adjacent and lateral to the inferior gluteal artery pedicle to ensure adequate
blood flow to the overlying soft tissue through the muscular perforators.
Proximal dissection permits an increased length of the pedicle for
microvascular transfer.
During this proximal dissection, two or three branches of the inferior
gluteal nerve are encountered and preserved in order to maintain nerve
supply to the remaining gluteus maximus muscle.
The flap must be carefully dissected away from the sciatic nerve. The
inferior gluteal vessels are anastomosed to the internal mammary or to the
thoracodorsal artery in the axilla, (Palett et al., 1989).
5) VASCULARIZED LATISSIMUS DORSI MUSCULOCUTANEOUS
FLAP
The contralateral latissimus dorsi can be transplanted as a free flap, when
the ipsilateral latissimus dorsi is not available. During dissection, the entire
muscle is taken with a smaller elliptical cutaneous paddle.
Because wound closure is performed in two separate layers, muscle and
skin, augmentation with a prosthesis can be done safely during the initial
procedure.
A neural coaptation between the proximal recipient nerve to the latissimus
dorsi muscle and the corresponding donor nerve is done if dissection is not
too difficult or lengthy. Subjectively, there appears to be less muscle
atrophy. Therefore, capsular contracture and fibrosis are inhibited.
The lengthy vascular pedicle facilitates flap positioning and performance
of the vascular anastomosis. An attempt must be done to perform an end to
end vascular anastomosis, but, if the dissection is difficult, an end to side
anastomosis is performed, (Serafin et al., 1982).
6) TENSOR FASCIA LATAE The tensor fascia latae musculocutaneous flap also may be employed in
reconstruction. The greatest usefulness of this composite tissue, however, is
the tough fascia latae, which can stabilize large thoracic defects and
minimize paradoxical respiration. Its lengthy vascular pedicle facilitates
placement and anastomosis.
Although the donor defect can be closed primarily, the resulting deformity
is significant. Aesthetic considerations are second to the functional
reconstruction with this donor tissue, (Serafin et al., 1982).
7) CONTRALATERAL BREAST In this method, the lateral half of the contralateral breast based on the
lateral thoracic artery and vein is used for free flap reconstruction, (La Quang,
1979).
Now it is restricted because of the increased risk for later cancer, however
the most disadvantageous point is the need to resect the original breast as
well as the reconstructed breast, (Shaw, 1987).
8) RUBEN’S FLAP (VASCULARIZED GROIN FLAP) The first Ruben’s flap transfer for breast reconstruction was performed in
1990.
This flap is supplied by the deep circumflex iliac system which perfuse
both the iliac crest as well as fat and skin overlying the crest, (Taylor, 1979).
The deep circumflex iliac vessels are located 1 cm to 2 cm deep to the
anterior superior iliac spine (ASIS) and travel along the inguinal ligament
and conjoint tendon in the plane just deep to the internal iliac musculature
and superficial to the transversus abdominis musculature, (Taylor, 1979).
Although, the superficial circumflex iliac artery also has been reported as
a main supply to the groin flap, however, this vessel is not reliable to
transfer the fat overlying the iliac crest, (Hester, 1984).
Operative Details:
Large segments of composite tissue usually can be obtained (11x27 cm)
and the donor site can be closed primarily.
There is a certain limitation to the vertical height of the skin island be-
cause tight closure leads to a widened unattractive scar.
The skin island generally starts at the ASIS, with the incision extending
medially toward the pubic tubercle. The fat harvest dimensions also should
be outlined based upon the width and height dimensions of the breasts,
(Elliott, 1998).
On the operation table, the patient is positioned essentially in the supine
manner, although the hip is lifted up with the support of a beanbag. In the
bilateral simultaneous operation, each hip can be propped and draped to an
adequate lateral extent. During the operation, first one side, and then the
other, is elevated and supported by the beanbag for sequential dissection,
(Elliott, 1998).
The skin island is harvested down in a cephalic direction to the external
oblique fascia, caudal to the gluteus maximum, and posteriorly to the
posterior iliac crest. The incision extends medially toward the pubic
Fig 30: Cross section of the
Ruben’s flap (Elliott, 1998).
Skin island
Fat
harvest Iliac creast
Deep circumflex iliac vessels
tubercle. An incision is made through the external oblique, internal oblique,
and transversus abdominis musculature about 1cm to 2cm cephalic to the
inguinal ligament. Once the transversus is split, the preperitoneal fat is
retracted cephalad, and the deep circumflex iliac vessels can be found along
the inguinal shelf, or near the origin of the deep inferior epigastric vessels.
The pedicle length is generally 6cm to 7cm , (Elliott, 1998).
A sterile Doppler can be helpful in locating the deep circumflex iliac
vessels, (Elliott, 1998).
The shaping of the breast is relatively uncomplicated because the breast
essentially has been shaped during flap harvest. It is tacked superiorly and
medially in the pocket to prevent its inferolateral migration, (Elliott, 1998).
9) THE LATERAL TRANSVERSE THIGH FLAP The lateral transverse thigh flap is a modification of the tensor fascia lata
musculocutaneous flap based on the terminal branch of the lateral
circumflex femoral artery. The residual scar will be obvious and a
significant contour deformity in the thigh results, (Elliott, 1989).
10) THE MEDIAL TRANSVERSE THIGH FLAP If there is significant medial thigh fatty excess, a medial transverse thigh
flap can be designed based on musculocutaneous perforators of the medial
circumflex femoral artery via gracilis muscle. Although pedicle length is
relatively short (4~5cm), the donor site is hidden and results in thigh lift, but
usually there is not enough tissue in this area to satisfy the volume
requirement, (Heinz, 1997).
11) SUPERFICIAL INFERIOR EPIGASTRIC ARTERY FLAP The lower abdominal panniculous may also be transferred on the
superficial inferior epigastric artery. However, there is an anatomical
variation of the vessels with absence in 20% of population, (Hartrampf, 1991).
12) OMENTUM It is rare nowadays to be done but it still indicated in cases with extensive
chest wall deformity and cases of radiation neuritis of the brachial plexus.
It can be also harvested endoscopically, so avoid risks of laparotomy and
donor site morbidities, (Hartrampf, 1991).
Disadvantages of reconstruction with microvascular free flap:
1. Increased complexity requiring specialized equipment and experience.
2. Long operation time due to the added time for microvascular
anastomosis of the artery and vein.
3. Fear of failure of the anastomosis resulting in total loss, (Shaw, 1987).
Complications:
The main complication with free tissue transfer is the failure of the
vascular anastomosis, resulting in loss of the tissue. In experienced hands,
however, this should not exceed 5% to 10%, (Mc Donald, 1988).
RECONSTRUCTION OF NIPPLE-AREOLA COMPLEX (NAC) For the nipple-areola complex (NAC) reconstruction, it is advisable to wait at least three
months until the breast mound has settled so that, the nipple-areola complex can be
symmetrically positioned, (Ward, 1986).
It can be performed under local anesthesia since sensation from the breast mound is either
entirely absent or diminished, (Bostwick, 1990).
Multiple techniques are available for reconstruction of the nipple and areola. The
patient’s native nipple-areola complex (NAC) serves as a template. When the two breasts
are nearly symmetric, the site of localization is measured from fixed points, the sternal
notch, midline, midclavicular line and inframammary crease, (Cronin, 1979).
In cases with breast asymmetry but symmetrical volume, so it is best to use the
disposable electro-cardiographic electrodes to be adjusted to the size of the normal areola
with the aid of scissors, (Kon, 1985).
Areola reconstruction:
If the normal contralateral areola is sufficiently large, it usually provides the best
result when shared with the reconstructed breast. It is rotated in a circular fashion on
the deepithelized bed of the reconstructed breast. The inner margin is sutured with 5/0
absorbable interrupted sutures, while the periphery is also closed with 5/0 silk sutures.
After the nipple graft is placed, the ends of the sutures are tied over a bolus dressing
which remain place for 7-10 days, (Schwartz, 1976).
A split thickness dermal graft may be taken from the normal breast by a drum
dermatome. The dermatome cement is carefully applied only to the areola and not to
surrounding skin or nipple, (Millard, 1972).
Full thickness grafts from the upper inner thigh or the non-hair bearing inguinal
crease are suitable for areolar reconstruction. The texture and color of these grafts are
usually similar to the patient’s areola and the skin graft will darken with time,
(Broadent et al., 1977).
Tattooing is a method to reconstruct the areola that may be a single procedure (four to
six months after nipple/areolar reconstruction) or it can be accomplished simply
under local anesthesia. Care is taken to use sufficient dark brown and red pigment in
the tattooed area (The Permark tattooing system). The mid-portion of the tattooed
area should be darker than the periphery to simulate a nipple, (Georgiade, 1976).
Dermabrasions: This technique is used in black females. It is safe, simple, and rapid
and there is no need for a donor site. It depends on the hyperpigmentation of skin
after split thickness removal in dark people, (Cohen, 1981).
Nipple Reconstruction:
1) Composite graft from:
a) Opposite nipple:
The opposite nipple is the first choice as a donor area. This approach provides for a better
symmetry and enables the surgeon to perform a biopsy from the opposite nipple. This is
done by excision of the distal 1/3 or 1/2 of the normal nipple. This portion is transferred
to the deepithelized recipient site in the center of the reconstructed areola, where it is
sutured with 5/0 absorbable interrupted sutures. The donor defect is allowed to epithelize,
(Bostwick, 1983).
b) Ear lobule:
The ear lobe is an excellent donor for the nipple projection and texture which are
reasonable when compared to the opposite protuberant nipple without the disadvantage of
violating the normal breast, (Rose, 1985).
In this method, a clover leaf-shaped auricular graft is harvested from the inferior pole of
the ear lobule. This composite graft is inserted into the deepithelized part of areola, where
it retains the pinkish appearance of the vascularized donor site. The donor site is closed
directly or with Z-plasty, (Rose, 1985).
c) Labial graft:
The composite free labial graft is a time-honored method. A wedge is excised and the
resulting defect is closed primarily with absorbable sutures. Any area around the labia
minora may be used, as it is usually brown. This is the method of choice in bilateral NAC
reconstruction, (Morgan, 1984).
d) Toe pulp:
It is done by using the pulp of the second to the fourth toe depending on the desired size.
The donor site is left for contraction and reepithelization, (Klastsky, 1981).
2) Reconstruction with local flap:
a) T-flap:
The T-shaped flap is based on the dermal plexus. The flap is elevated at the dermal fat
level, the remainder of the skin within the areolar marking is intradermally deepithelized.
In shaping the nipple, the T-flap is folded on itself and the horizontal limb of the T-flap is
warped around and sutured to the vertical limb along the lateral markings. The width of
the transverse limb of the flap is about three times the desired diameter of the nipple. The
nipple diameter is determined by the length of the vertical limb of the flap, (Chang,
1984).
b) Tetrapod flap:
This technique gives a well formed projecting nipple. The site of the areola is marked
with a No. 15 blade. Four opposing flaps are done based on a central disk forming a
modified cross form.
Once the four limbs are freed to the central disk, they are collectively lifted and the
dermis around the nipple margin is incised. With 6/0 absorbable sutures, the pods are
joined at their eight corners. A graft is applied to the donor site. A part of plastic syringe
barrel is used to protect the nipple from pressure exerted by the tie-over dressing, (Little
et al, 1983).
c) Dermal flap:
This technique result in a nipple of natural color and size with lasting projection.
The apex of this flap corresponds to the upper limit of the new areola. The length and
width is determined by the size of the other nipple. The amount of fat taken with the flap
is determined by the volume of the opposite nipple. Care must be taken during release of
fat for free projection to protect the delicate blood supply entering from the subdermal
plexus at the base of the flap. The donor is closed primarily. No compressing dressing is
used for three weeks, (Hartrampf, 1984).
Combined nipple and areola reconstruction:
1) The conjoined spiral technique:
In this technique, one can use the entire NAC as a full thickness skin graft. The comma-
shaped graft is removed and the spiral is closed on itself on the recipient bed. Each
complex has an area of 50% of the donor complex, thus no tissue is wasted, (Cronin,
1979).
2) Star flap:
This technique is a one-stage procedure using a local flap that is tattooed immediately
before its elevation in the same procedure. It has the advantages of being a reliable, safe
and low cost method of nipple areola reconstruction. High patients’ acceptance can be
achieved by sharing them in process of color selection and nipple location, (Eskenazi,
1993).
Several points should be emphasized about the modified “ Star flap” technique:
The nipple can be based inferiorly, superiorly or laterally as local scarring dictates, but
more natural projection appearance to the patient is obtained by basing the flap
superiorly.
The flap is primarily based on subdermal plexus but can be based reliably on a previous
incision line if the scar is six or more weeks old.
The "wings" of the flap will determine the nipple height, the height of the flap should be
150% the ultimate desired height allowing for 50% decrease in projection over time.
The nipple flap is tattooed with darker pigments before flap elevation and excess pigment
is removed with alcohol before incision.
The flap is incised through dermis, preserving a base equal to the diameter of the nipple.
The donor incisions are closed around the base of the nipple with 3/0 nylon to maintain
projection.
The "cap flap” is brought down and sutured loosely, and if the surgeon is satisfied with
the projection and contour of the nipple, the remaining donor incisions are closed with
interrupted 5-0 plain gut sutures.
Finally, a thick coat of polysporin and a layer of xeroform are applied, followed by a 4x4
gauze with a hole cut centrally for the nipple, (Eskenazi, 1993).
3) Skate technique:
Fig 40: Star flap, (Elliot, 1990)
X
Y
Two wings are elevated on each side of a central base. The wings are elevated at the level
of the deep dermis. The dermis at the base of each wing is incised into the subcutaneous
tissue and the two wings are drawn out at 90 to the surface. The wings are wrapped
around their base, and the donor wound is grafted to reconstruct an areola, (Elliott, 1990).
Fig 37: T-flap, (Chang, 1984)
PATIENTS AND METHODS The patients in this thesis were divided into two groups:
A. First group: it includes a group of 50 patients, who were subjected to a
questionnaire to evaluate the idea of breast reconstruction between
Egyptian females.
B. Second group: it includes all the patients who came for breast
reconstruction after mastectomy during this year (1999-2000).
A-First group:
A Questionnaire was applied for 50 patients with breast cancer in General
Surgery and Radiotherapy Departments (in El-Demrdash Hospital) during
September-1999 to September-2000 to evaluate their compliance for breast
reconstruction.
These fifty patients were classified into two subgroups:
Subgroup A: it includes ten cases presented before mastectomy.
Subgroup B: it includes forty cases presented after mastectomy. (25 cases
still under treatment and the other 15 cases finished their adjuvant chemo-
radiotherapy including two cases already had reconstructed by TRAM
flaps).
Each one analyzed for the following items:
Age.
Pregnancies and abortion.
Body weight.
Previous pathology.
Sexual life.
Past history of Chemotherapy, Radiotherapy or hormonal therapy.
Effect of the operation on their life (socially, physically and
psychologically).
Their opinion in breast reconstruction.
The causes of objection for breast reconstruction.
Their choice for method of breast reconstruction.
B-Second group:
It includes seven patients who underwent breast reconstruction
(immediate or delayed) in the plastic surgery department in El-Demrdash
Hospital during the period of September-1999 to September-2000.
This group was further subdivided into three subgroups:
Subgroup A: patients who came for immediate breast reconstruction
(one case).
Subgroup B: patients who came for delayed breast reconstruction (4
cases).
Questionnaire for Patients for Their Opinion
about Methods of Breast Reconstruction
انىشنانىشن:: انسهانسه:: االسماالسم:: انعىىانانعىىان:: عمم انصوجعمم انصوج:: انعممانعمم::
عدد مساث اإلجهبضعدد مساث اإلجهبض:: بىبثبىبث أوالدأوالد عدد عدد األوالداألوالد:: انحبنت االجخمبعٍتانحبنت االجخمبعٍت::
سبب اسخئصبل انثديسبب اسخئصبل انثدي::
اسم انجساحاسم انجساح:: مكبن انعمهٍتمكبن انعمهٍت: : حبزٌخ انعمهٍتحبزٌخ انعمهٍت::
مكبن انمخببعت بعد انعمهٍتمكبن انمخببعت بعد انعمهٍت:: مدة انمخببعت بعد انعمهٍتمدة انمخببعت بعد انعمهٍت::
ونمدةونمدة:: بدء بعد انعمهٍت بمدةبدء بعد انعمهٍت بمدة:: عالج كٍمبويعالج كٍمبوي::-- انىىعانىىع:: ونمدةونمدة:: بدء بعد انعمهٍت بمدةبدء بعد انعمهٍت بمدة:: عالج اإلشعبععالج اإلشعبع::--
::انىىعانىىع ونمدةونمدة:: بدء بعد انعمهٍت بمدةبدء بعد انعمهٍت بمدة:: عالج هسمىوىعالج هسمىوى::--
::انىىعانىىع ::كٍفكٍف الال وعموعم ::هم أثسث انعمهٍت عهى انحبنت االجخمبعٍتهم أثسث انعمهٍت عهى انحبنت االجخمبعٍت
::كٍفكٍف الال وعموعم : : هم أثسث انعمهٍت عهى انحبنت انىفسٍتهم أثسث انعمهٍت عهى انحبنت انىفسٍت ::كٍفكٍف الال وعموعم : : هم أثسث انعمهٍت عهى انحبنت انصحٍتهم أثسث انعمهٍت عهى انحبنت انصحٍت
::كٍفكٍف الال وعموعم ::هم أثسث انعمهٍت عهى انعالقت انصوجٍتهم أثسث انعمهٍت عهى انعالقت انصوجٍت ::كٍف حىصهخى نرنككٍف حىصهخى نرنك الال وعموعم ::هم حعهمٍه أن هىبك عمهٍبث إلصالح انثديهم حعهمٍه أن هىبك عمهٍبث إلصالح انثدي
::مب هًمب هً الال وعموعم ::هم حعهمٍه أوىاع عمهٍبث إصالح انثديهم حعهمٍه أوىاع عمهٍبث إصالح انثدي الال وعموعم ::هم حسغبٍه فً عمم عمهٍت إصالح نهثديهم حسغبٍه فً عمم عمهٍت إصالح نهثدي
::نمبذانمبذا: : إذا كبوج اإلجببت الإذا كبوج اإلجببت ال
::فأي األوىاع حسغبٍه فٍهفأي األوىاع حسغبٍه فٍه: : إذا كبوج اإلجببت وعمإذا كبوج اإلجببت وعم الال وعموعم ((بدون عمهٍتبدون عمهٍت))جهبش حعىٌضً خبزجً جهبش حعىٌضً خبزجً --11
((بىاسطت عمهٍتبىاسطت عمهٍت))جهبش حعىٌضً داخهً جهبش حعىٌضً داخهً --2 الال وعموعم عمهٍت شزع عضهت مه انجسم وفسهعمهٍت شزع عضهت مه انجسم وفسه --33 الال وعموعم
Subgroup C: patients who came for secondary procedures after breast
reconstruction (2 cases).
METHODS The choice of the breast reconstruction procedure chosen individually
according to following parameters:
a) The age of the patients.
b) The desires of the patients.
c) Histopathology results of cancer breast.
d) The conditions of the local tissues and the donor sites.
e) Bilaterality.
f) The experiences of the plastic surgeons.
g) The facilities.
Preoperative evaluation:
Clinical examination was done for all cases with thorough analysis of
medical problems if present as one of the patients was complaining of
diabetes mellitus, hypertension and obesity.
Preoperative Duplex was done for the patients those were candidates for
TRAM flaps to access the superior and inferior epigastric vessels.
Preoperative photography.
Preoperative instructions were given to all patients to: 1) Do not smoke and to be away from any smoker.
2) Donate Blood: two units of blood before surgery.
3) Preoperative Labs: include: blood picture, electrocardiogram, chest X-ray,
random blood sugar level, renal function tests and liver function tests were
done for all patients.
4) Preoperative visits a one day before surgery:
a) To go over the planning procedure.
b) To answer any question the patient may have.
c) To be evaluated by the anesthetist.
d) To apply some markings.
5) Patients were advised to prepare bra and binders to use them postoperatively.
Operative techniques:
Preoperative marking was done for all the patients.
All the patients were operated upon under general anesthesia.
Intraoperative photography.
Subgroup A (one case):
This case had unilateral infiltrative duct carcinoma grade II and was
operated upon by modified radical mastectomy with immediate breast
reconstruction by contralateral pedicled TRAM flap.
Subgroup B (four cases):
Two cases with unilateral mastectomy of 4 and 5 years ago came for
delayed breast reconstruction by contralateral pedicled TRAM flaps.
A case with bilateral mastectomy of 4 years ago underwent delayed
breast reconstruction by bilateral ipsilateral pedicled TRAM flaps.
A case with bilateral mastectomy of 6 years ago underwent delayed
breast reconstruction by bilateral prepectoral breast silicone-filled
implants. They were smooth in texture, rounded in shape and 250cc in
size.
Subgroup C (two cases):
two cases were previously reconstructed by pedicled TRAM flap of 1
and 2 years ago
One came for reconstruction of the nipple and the areola of the
reconstructed breast by local flap with graft from the other areola,
mastopexy of the other breast by inferior pedicled technique and
creation of umbilicus.
The other one came for refashioning and debulking of the
reconstructed breast and repair of the anterior abdominal wall bulge
by repair of the rectus sheath and application of a prolene mesh.
TRAM flaps were harvested by the usual technique and zone IV was
discarded in all cases.
In all, cases, TRAM flaps were inserted oblique to transverse, with
zone I medially situated and deepithelized zone II laterally situated.
All of them, had two or three blood units intraoperatively and early
postoperatively.
In two cases were breast reconstruction had been done by TRAM flaps
closure of abdominal defects were done by On-lay prolene mesh to
strengthen the repair, and by direct closure in the other two cases.
For all these cases, the portovacs were inserted for abdominal and chest
wounds ranging 3-6 days.
Operative time was ranging from three to eight hours by the end of this
work.
In case where bilateral prostheses where used for breast reconstruction
two portovacs were inserted for chest wounds for 3 days.
Postoperative instructions:
All the patients were advised to: 1) Do not smoke and to be away from any smoker for one month after surgery.
2) Good nutrition is important for healing.
3) There is a certain amount of “tightness' in the area where the flap was taken
from. This will slowly relax within a few months.
4) Start walking on the second day postoperatively.
5) Not lift anything heavier than five pounds for 10 days.
6) The patient may shower starting 3 days after surgery.
7) The patient may perform usual household duties three weeks after surgery.
8) Gentle massage is recommended in cases with prosthetic breast
reconstruction to avoid capsular contracture.
The case of the immediate breast reconstruction was transferred to radio-
chemotherapy department to complete here adjuvant chemo/radiotherapy.
Follow up was done for a period of 6-12 months for all the patients after
the breast reconstruction to detect tumour recurrence, flap changes and
donor site complications and to assess the satisfaction and psychological
state of the patient after reconstruction.
Also, the patients continued follow up with their oncologists and general
surgeons.
Postoperative photography was done for all patients after 3days, 2 weeks,
3 months and 6 months postoperatively.
Second stage breast reconstruction was discussed with all patients for the
following Procedures: 1. Reconstruction of the nipple and the areola.
2. Revision of the flap.
3. Revision of the donor site.
4. Surgery on opposite breast for symmetry, if indicated:
RESULTS A- First group:
A Questionnaire was applied for 50 patients with cancer breast:
Subgroup A (10): Ten cases before mastectomy.
Subgroup B (40): Forty cases after mastectomy:
Thirteen cases (13): finish their adjuvant chemo-radiotherapy.
Two cases (2) : finish their adjuvant chemo-radiotherapy and had
already breast reconstruction after mastectomy by TRAM flaps.
Twenty-five cases (25): still under adjuvant chemo-radiotherapy.
The results of this questionnaire were as follow:
All the patients were 20~60 years old.
All the patients’ body weights ranged from 70 to 90 Kgms.
All the patients of low to moderate social class
The histopathological examination of biopsies were stage II and III
breast cancer with 90% infiltrative duct carcinoma and 10% of other
types of breast cancer.
The patients with non-reconstructed breasts were frustrated and
depressed in comparison to the patients (seven cases) with
reconstructed breasts.
The sexual life after mastectomy was impaired.
In Subgroup A (10 cases):
Seven cases (7) (70%) know the concept of the breast reconstruction
after mastectomy. They know only one modality, which is the breast
reconstruction by the silicone-filled implants. In addition, three cases
(3) (30%) ignore any thing about the breast reconstruction.
By discussion of the other modalities of the breast reconstruction
with these patients, only one case (1) (10%) was content with the
idea of the breast reconstruction.
The nine cases (9) (90%) who refuse the concept of the breast
reconstruction:
Seven cases (7) (70%): refusal was due to fear of surgical
trauma.
Two cases (2) (20%): refusal was by their husbands.
in Subgroup B (40 cases):
Thirty-eight cases (38) (95%) know the concept of the breast
reconstruction after mastectomy. They know only one modality,
which is the breast reconstruction by the silicone-filled implants,
except two cases those were already reconstructed by TRAM flaps.
In addition, two cases (2) (5%) ignore any thing about the breast
reconstruction.
By discussion of the other modalities of the breast reconstruction
with these patients, only seven cases (7) (17.5%) were content with
the idea of the breast reconstruction but one case escape.
The thirty-four cases (34) (85%) refuse the concept of the breast
reconstruction:
Twenty-seven cases (27) (67.5%): refusal was due to fear of
surgical trauma.
Three cases (3) (7.5%): adapted their life for that and they do
not seek for any further beauty.
Three cases (3) (7.5%): refusal was by their husbands.
One case (1) (2.5%): the patient refused, as she knew a
complicated case after the breast reconstruction.
B- Second group: The second group was subdivided into three subgroups:
Subgroup A (one case): the patients who came for immediate
breast reconstruction.
Subgroup B (four cases): the patients who came for delayed
breast reconstruction.
Subgroup C (two cases): the patients who came for secondary
procedures of breast reconstruction.
Their ages rang from 20 to 60 years.
All of them were stage II cancer breast with full metastatic work up done
(chest X-ray, bone scan, tru-cut needle biopsy, abdominal
ultrasonography and tumour markers assay).
The patients in subgroup B,C have been finished their adjuvant
chemo/radiotherapy.
All of them have no medical problems except one of the subgroup B. she
had bilateral mastectomy and she was diabetic, hypertensive and obese.
She came for bilateral ipsilateral pedicled TRAM flaps.
The results of subgroup A (one case) were as follow:
This case was unilateral IDC grade II of the left breast.
She came for modified radical mastectomy with immediate breast
reconstruction by contralateral pedicled TRAM flap.
The flap survival rate was 100%.
During the follow up after 2 months, she presented by a small nodule
within the TRAM flap. Biopsy was taken and examined
histopathologically and had been proved that it was fat necrosis.
During the follow up after 6 months, she had a lump in the other
breast, tru-cut needle biopsy was done to detect any lesion in the
other breast, but histopathological examination was free.
Both breasts were nearly symmetrical.
The patient, here husband and the plastic surgeons were satisfied
form the aesthetic results.
The patient is willing to undergo the second stage of the breast
reconstruction to reconstruct here nipple and areola.
The results of subgroup B (4 cases) were as follow:
Two cases with unilateral mastectomy of 4 and 5 years ago were
candidates for delayed breast reconstruction by contralateral pedicled
TRAM flaps.
The flaps survival rates were 100% in the two cases.
During follow up after one month, the second case developed
abdominal bulge, which was due to laxity of the abdominal muscles.
Both breasts were nearly symmetrical in a one case and in the other
case ptosis of the normal breast was noted.
4th day postoperatively Preoperatively
A unilateral contralateral pedicled TRAM
flap: 1st- Preoperatively. 2nd- Two weeks postoperatively.
B A
The patients and the plastic surgeons were satisfied form the
aesthetic results.
The two patients are willing to undergo the second stage of the breast
reconstruction to reconstruct here nipple and areola and to complete
the reconstruction by mastopexy of the normal breast for the second
case.
A case with bilateral mastectomy of 4 years ago was a candidate
for delayed breast reconstruction by bilateral ipsilateral pedicled TRAM
flaps.
This case was diabetic, hypertensive and obese but the results of
duplex revealed no abnormalities in the inferior and superior
epigastric vessels and both were of normal diameters.
The flaps showed color changes in the form of mottling on the
second day postoperatively. 60% of right TRAM flap was lost and
80% of left flap was lost. Also, there was sloughing of a part of the
anterior abdominal wall with exposure of the mesh on the fourth day
postoperatively.
Debridment was done with application of split thickness skin graft
for raw areas.
The patient, here husband and the plastic surgeons were not satisfied
form the results.
The psychological state of the patient was very bad during the period
of hospitalization but she was getting better when she was
discharged from the hospital after 45 days.
The case with bilateral mastectomy of 6 years ago was a candidate
for delayed breast reconstruction by bilateral prepectoral breast silicone-
filled implants.
The patient and the plastic surgeons were satisfied form the aesthetic
results.
Both breasts were nearly symmetrical.
The patient is willing to undergo the second stage of the breast
reconstruction to reconstruct here nipple and areola.
The results of subgroup C (2 cases) were as follow:
The case was previously reconstructed by pedicled TRAM flap of
1 year ago and she was operated upon for the second procedure for
reconstruction of the nipple and the areola by Star-shape local flap and
reconstruction of the umbilicus.
The patient and the plastic surgeons were satisfied form the aesthetic
results.
Both breasts were nearly symmetrical so there was no need for
reconstruction of the normal breast.
Postmastectomy TRAM flap Nipple –areola complex reconstruction with umblicoplasty.
The case was previously reconstructed by pedicled TRAM flap of
2 years ago and she was operated upon for the second procedure for
refashioning and debulking of the reconstructed breast and repair of the
anterior abdominal wall bulge.
Both breasts were nearly symmetrical.
The patient and the plastic surgeons were satisfied form the aesthetic
results.
The patient refused to continue the second stage of the breast
reconstruction to reconstruct here nipple and areola.
In two cases were breast reconstruction had been done by TRAM flaps
closure of abdominal defects were done by On-lay prolene mesh to
strengthen the repair, and by direct closure in the other two cases.
In case where bilateral prostheses where used for breast reconstruction
two portovacs were inserted for chest wounds for 3 days.
Operative time was ranging from three to eight hours for TRAM flap and
ranging from one to two hours for application of mammary prosthesis.
All the patients were discharged from the hospital after 3-14 days with
follow up except for one case of bilateral pedicled TRAM flaps, the
patient was discharged after 45 days.
DISCUSSION Regardless the timing of the breast reconstruction and the
nature of mastectomy procedure, the goals of reconstruction
still the same, which are:
6) Restoration of the breast mound and contour.
7) Achievement of symmetry between the reconstructed
breast and the remaining natural breast.
8) Reconstruction of the nipple-areola complex, (Dinner,
1984).
However, Reconstruction of the breast after mastectomy is
predominantly a demand of women in the western world and the
well-developed countries. In addition, elective mastectomy with
immediate breast reconstruction is done for high risk females in
these countries. Nevertheless, in the developing countries, the
women hardly demand breast reconstruction after mastectomy
unless offered or motivated, (Vyas, 1998).
In this study, we try to recognize and analyze the causes of
these variations and to public the idea of breast reconstruction
after mastectomy between Egyptian females.
We were confronted with 16% of females (eight cases of fifty patients)
ignore any thing about the breast reconstruction. By analysis the causes of
this ignorance, lack of communication between the general surgeons,
oncologists and the plastic surgeons was the main cause. Another factor is
that, there is no publication of the idea of the breast reconstruction after
mastectomy through the audiovisual aids.
In 84% of females (forty-two cases of the fifty cases) who were
acquainted with the concept of the breast reconstruction after mastectomy,
they know only one modality, which is the use of silicone-filled implants.
This another important factor led to decrease the rate of breast
reconstruction after mastectomy in Egyptian females, as there is false belief
that these silicone implants are carcinogenic.
By talking to the patients, 86% of females (forty-three cases of fifty
patients) refused the concept of the breast reconstruction after mastectomy.
The causes of the refusal are:
About 79.8% of women (thirty-four cases of the forty-three cases) were
afraid to undergo any other operations.
1. About 11.7% of women (five cases of the forty-three cases), the refusal
was by their husbands.
2. About 7.2% of women (three cases of the forty-three cases) accepted the
result of mastectomy operation and they adapted their life for this
condition so they did not seek for any further beauty.
3. About 2.3% of women (one case of the forty-three cases), the refusal was
due to the occurrence of a complication in a similar case.
In this study, only seven cases (14%) out of fifty patients who had been
reconstructed.
In this study, seven cases underwent breast reconstruction, only one case
was reconstructed immediately, and six cases were reconstructed by delayed
methods.
Studies that deal with timing of the reconstruction have emphasized the
positive effects of immediate reconstruction on emotional and sexual state,
(Rowland et al, 1995).
In immediate reconstruction, the patient is already anesthetized, the defect
does not have to be recreated and the patient can recover from her breast
reconstruction at the same time that she is convalescing from the
mastectomy. Since then, immediate breast reconstruction after mastectomy
becomes more popular, (Elkowitz et al, 1993).
Kroll et al, 1995, have shown that the outcomes of immediate breast
reconstruction tend to be aesthetically better than those of delayed
reconstruction.
Other reports have also found that immediate breast reconstruction is
oncologically safe, (Noone et al, 1994) and does not mask tumour
recurrence, (Slavin et al., 1994). Hence, the use of immediate breast
reconstruction is considered the preferred approach in almost all cases in
which breast reconstruction is planned.
Despite all these advantages of immediate breast reconstruction, in addition
to, it is a mean of reducing both the morbidity and cost of staged surgery.
However, the Egyptian females still refuse the immediate breast
reconstruction as their main target is to get rid of breast cancer not to seek
for beauty.
The choice of the breast reconstruction procedure chosen individually
according to following parameters:
h) The age of the patients.
i) The desires of the patients.
j) Histopathology results of cancer breast.
k) The conditions of the local tissues and the donor sites.
l) The experiences of the plastic surgeons.
m) The facilities.
Also, during the choice of the technique one should concern that cases with
unilateral breast cancer that will be candidates for immediate breast
reconstruction, the other breast may be affected later on. Therefore, the
technique of reconstruction should safe other modalities that one of them
may be needed to reconstruct the other breast.
In this study, we try to adapt all these parameters to reach the ideal
procedure for every patient individually. So, four cases were reconstructed
by pedicled TRAM flaps. One case was reconstructed by bilateral silicone-
filled breast implants. In addition, two cases, who were already
reconstructed by delayed TRAM flaps, came for secondary procedures for
reconstruction of the nipple-areola complex and for refashioning of the
reconstructed breast.
Breast reconstruction can be achieved either by prostheses or by flaps those
may be pedicled or free flaps. However, prosthetic reconstruction has many
disadvantages like infection, extrusion, rupture, capsular contraction and
difficult to be used in post-radiated or tight scarred chest wall, (Fisher et al,
1992).
In this study, another two factors limited the use of the prosthetic breast
reconstruction. The financial state of the patients that make them unable to
buy the prosthesis. The second factor is the false belief among the patients
that these silicone-filled prostheses are carcinogenic. However, only one
case that was reconstructed by bilateral silicone-filled breast implants and
she did not have any of the previous complications.
The latissimus dorsi muscle flap can be used also for breast reconstruction
after mastectomy. However, this flap has many drawbacks. It is small; thus,
it may be insufficient to restore the volume of the reconstructed breast. The
subscapular vessels may be ligated during mastectomy or affected by
radiotherapy. In addition, the donor site scar of the latissimus muscle flap is
aesthetically bad, (Kroll, 1996).
Hence, the TRAM flap is the first option for most surgeons performing
autogenous tissue breast reconstruction, due to:
1. The use of generally unwanted abdominal wall tissue.
2. The scar that is placed in a relatively hidden position on the body.
3. The contour changes that often result in improvement.
4. The tissue that can be readily shaped into a variety of new breast
configurations, (Elliott, 1994).
However, the risk factors for TRAM flap are well established and should be
strictly reinforced. These risk factors include smoking, diabetes mellitus,
hypertension, obesity, radiation to the base of the flap, injury of the superior
epigastric artery, old age, cardiovascular diseases, chronic obstructive lung
diseases, (Hartrampf, 1988).
The nightmare of the unipedicled TRAM flap, used for breast reconstruction
after mastectomy, is the high incidence of flap ischemia especially affecting
zone IV. No doubt, this is due to the fact that the epigastric archade might be
deficient at the region of the umbilicus or the superior epigastric vessels
might be tenuous, (Millory et al, 1960).
In addition, the venous valves might prevent retrograde flow from the
inferior to the superior epigastric tributaries, (Costa et al, 1987).
In our study, six cases out of seven were reconstructed by TRAM flaps,
including two cases that were already reconstructed. Only one case that
suffered from flap complication.
In this case, bilateral pedicled ipsilateral TRAM flaps were done for delayed
breast reconstruction. This patient also had medical problems as she was
diabetic, hypertensive, and obese. In addition, she had post-radiation tight
scar of the chest wall.
All these factors contribute in the complications in the form of ischaemia
and sloughing of the flaps and disruption of the abdominal wound.
However, we selected this modality for breast reconstruction on the
following bases, the bilaterality, the desire of the patient as she refused to
has scar on her back, the scar of the chest wall was tight, the bulky abdomen
was a good donor site and the facilities.
To combat such ischemic complications augmentation of the blood supply of
the TRAM flaps was tried by:
Delaying of the flap, (Codner et al., 1995).
Inclusion of superior epigastric pedicles, (Wagner et al, 1991).
Free flap transfer, (Arnez, 1992).
Retrograde vascularization of the pedicled TRAM flap, (Pernia et al, 1991).
Delay of the flap has the limitation of being a staged procedure as well as it
might not be beneficial to improve the blood supply of the distal part of the
flap (the infra-umbilical portion) because the communication between the
superior and inferior epigastric vessels are grossly absent in 60% of people,
(Mathes and Nahai, 1997).
Meanwhile, bipedicled TRAM entails the sacrifice of both recti which
eventually, produce abdominal wall dysfunction and possibly an incisional
hernia in 25-45% of cases, (Kroll, 1992).
However, the presence of two pedicles may limit free rotation of the flap,
(Harashina et al, 1987).
Free flap does not ensure the viability of the whole the TRAM flap and it is
dependent on the integrity of a single vessel that might suffer from
anastmotic complication which may prove to be disastrous especially in high
risk patients, (Ishii et al, 1985).
The augmentation of blood supply to the TRAM flap may be either by:
A. Anastmosing of both inferior epigastric vessels together in unipedicled
TRAM flap "Turbocharging" TRAM flap, (Kind et al, 1997).
B. Anastmosing the inferior epigastric vessels with appropriate recipient
vessels in the axilla "Supercharging" TRAM flap, (Harashina et al, 1987).
SUMMARY AND CONCL USION
The female breast is one of the most important physical expressions of
femininity. Removal or deformity of this sexual organ can induce severe
psychological effects. Therefore, breast reconstruction is an element of
prime importance to mastectomized women.
The goals of breast reconstruction are creating a breast that looks and feels
like the normal breast, with achievement of symmetry by correction of the
contralateral side.
The aims of this thesis are to review the different modalities of breast
reconstruction after mastectomy and to identify the causes of refusal of
Egyptian women to reconstruct their breasts after mastectomy and to
evaluate their compliance for breast reconstruction.
Breast reconstruction either can be immediate at the time of mastectomy,
delayed (secondary breast reconstruction) after six months or late up to five
years after mastectomy.
Oncologically, there is no reason preventing immediate breast reconstruction
unless the patient refuses the operation or the prognosis is very poor.
Immediate breast reconstruction has many advantages. For the patient, it is
easier, less expensive and psychologically more convenient. For the surgeon,
it facilitates the reconstruction and improves aesthetic results.
Disadvantages of immediate breast reconstruction are minimal and consist of
prolongation of duration of the surgery, more severe postoperative pain and
a higher complication rate.
Delayed breast reconstruction is considered three to six months after
mastectomy as by this time the soft tissue will have recovered from the
operative trauma, also, adjuvant chemotherapy is usually finished. In
addition, the patient lived with the deformity for sometimes, which made her
accept any kind of breast reconstruction.
Technically, simple methods should be used if possible. However, selection
of the breast reconstruction procedure must be chosen individually
depending on various conditions:
Silicone implants should be used only in the case of locally abundant
soft tissue coverage.
By tissue expansion, soft tissue coverage can be expanded until the
desired volume with or without subsequent application of silicone
implants.
Local advancement flaps in combination with silicone implants are used
to replace lost skin.
The LDM flap enables the breast reconstruction of a thick soft tissue
with skin and muscle and with insufficient or irradiated soft tissue.
The TRAM flap is the standard way for the breast reconstruction but the
problem of distal necrosis and fat lysis (due to ischaemia of zone IV) has
produced trends to find different modalities to overcome this problems.
Generally, all methods are suitable for immediate as well as for delayed
breast reconstruction procedures.
The patients in this thesis were divided into two groups.
The First group, that included fifty patients, who were selected to evaluate
the breast reconstruction idea between Egyptian females. This was done in
General Surgery and Oncology Departments (in El-Demrdash Hospital)
during 1999-2000.
The Second group, this included the patients who underwent breast
reconstruction. This was done in Plastic Surgery Department (in El-
Demrdash Hospital) during 1999-2000.
The study, showed that 16% of Egyptian females ignore any thing about the
breast reconstruction. The most probable cause for this is the lack of
communication between the general surgeons, oncologists and the plastic
surgeons and the paucity of publications of the idea of the breast
reconstruction after mastectomy through the audiovisual aids.
The Egyptian females know only one modality for breast reconstruction,
which is the silicone-filled implants, that is known to be carcinogenic by
most of them.
In addition, 86% of Egyptian females refused the concept of the breast
reconstruction after mastectomy, due to, 79.8% of women were afraid to
undergo any other operations, 11.7% of women the refusal was by their
husbands and 7.2% of women adapted their life for their postmastectomy
condition.
Also, the Egyptian females still refuse the immediate breast reconstruction
as their main target is to get rid of breast cancer not to seek for beauty.
In this study, seven cases underwent breast reconstruction, one case was
reconstructed immediately, and six cases were reconstructed by delayed
methods.
The choice of the breast reconstruction procedure chosen individually
according to the age of the patient, bilaterality, the desire of the patient, the
condition of the local tissues and the donor sites, the experience of the
plastic surgeon and the facilities.
The TRAM flaps still the most commonly used modality for breast
reconstruction. As this modality was used in six cases out of the seven
reconstructed cases with good results, except in the patient that has some
risk factors. So, it is recommended to enhance the vascularity of the TRAM
flap.
The seventh case was reconstructed by bilateral silicone-filled implants. This
is not demanded by many cases for financial causes and false belief of
carcingenicity of the silicone.
By conclusion, we recommend the followings:
Enhance the communication between the general surgeons, oncologists
and the plastic surgeons to improve the quality of breast surgery for
Egyptian females.
Publishing of the breast reconstruction after mastectomy idea through the
audiovisual aids.
During mastectomy, the breast surgeons if possible should avoid injury or
ligation of the subscapular vessels as it is the arterial blood supply of the
LDMF and it can be used as recipient vessel for the free flaps.
After mastectomy, the patient should have a full operative details report to
help in choosing of the reconstructive method.
Immediate breast reconstruction is recommended as it reduces both the
morbidity and cost of staged surgery. Also, it avoids reconstruction in
irradiated tissues with its hazards.
TRAM flap should not be used for risky patients. But, To combat that
augmentation of the blood supply of the TRAM has to be done.
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