Reconstruction Of The Partial Mastectomy Defect

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Breast conserving surgery combined with adjuvant radiation has been accepted as a regime equivalent to modified radical mastectomy for early stage (I and II) breast cancer. The technique is popular due to its ability to eradicate breast cancer while preserving a maximal volume of breast tissue.

Skin incisions are designed directly over the lesion, and skin and subcutaneous tissues are preserved unless involved in the lesion. Closure involves subcuticular closure only and the

Figure 11-10. Bilateral free TRAM reconstruction.

avoidance of drains. The resulting deformity after lumpectomy or quadrantectomy depends on initial breast size, tumor size and location, radiation dose, surgical technique, and adjuvant chemotherapy. The relative excision, in proportion to breast size, is perhaps the most important factor. Patients with large, pendulous breasts may easily accommodate a 4 cm lumpectomy. The same resection in a smaller-breasted woman may lead to an unacceptable cosmetic result. Radiation therapy exaggerates the tissue deficit in the form of ischemic fibrous contracture.

The treated breast is subject to edema, retraction, fibrosis, calcification, hyperpigmentation, depigmentation, telangiectasia formation, and atrophy. It is not until 24 to 36 months postradiation that radiation-induced changes stabilize. Initial edema camouflages the initial deficit and is replaced with fibrosis and contracture that tends to worsen with time. Deficits within the lower pole tend to retract upward. Deficits along the superomedial aspect of the breast are difficult to camouflage due to the paucity of available adjacent tissue and are, unfortunately, socially conspicuous. Centrally located lesions are more forgiving unless resection involves some aspect of the nipple-areolar complex.

An assessment of the patient's overall onco-logic risk for recurrence should be considered prior to any attempt at partial mastectomy reconstruction. Breast cancer history, the nature of the inciting lesion, and the patient's family history should be reviewed prior to an additional procedure that may further affect subsequent screening examinations. In any event, stabilization of the breast appearance is a prerequisite and occurs 1 to 3 years postradiation.

Investigators have attempted to classify the spectrum of partial mastectomy deficits and relate them to specific treatment options. Classification is based upon the localized deficit of skin and glandular tissue, malposition and/or distortion of the areola, and the extent of fibrous contracture of the breast.106 Local flap transposition is recommended for mild deformities, whereas myocutaneous flaps are reserved for more extensive defects.

Approximately 15 percent of patients treated with BCT are not content with the esthetic out-come.107 These patients often seek consultation to improve selfesteem and body image. Careful assessment of the actual and apparent tissue deficits are crucial in the selection of the appropriate reconstructive strategy. Contour deficits signify substantial parenchymal loss, whereas radiation contracture represents extensive cutaneous deficits. Nipple-areolar distortion necessitates a substantial increase in cutaneous replacement, as central areolar support requires dermal rather than subcutaneous support.

The majority of patients are poor candidates for implant reconstruction. Cutaneous fibrosis responds poorly to implant displacement, and implant radio-opacity impairs an already complex screening examination. Autologous tissues, conversely, are reliable, versatile, and provide all the components necessary for partial restoration. The inherent vascularity may actually improve the quality of the relatively ischemic and radiated recipient tissue.

Large central excisions involving the nipple-areolar complex and primary closure take on a flat, attenuated appearance, lacking projection. These defects may be reconstructed in one of two ways. It may be possible to mobilize a skin glandular flap based on inferolateral perforators from the underlying pectoral fascia, which is then mobilized into the defect. The curvilinear incision extends from the inferomedial aspect of the previous areola to the central inframammary fold. All but a central skin paddle, rotated into the areolar defect, is de-epithelialized. Primary skin closure is facilitated by undermining at the parenchymal interface. The second technique parallels conventional mastopexy and enables superior advancement of an inferior dermoglan-dular pedicle. It is performed through a Wise or keyhole pattern incision.106 108-109

Upper outer quadrant excisions are the most frequent and, fortunately, the most forgiv-ing.106,108-109 The great majority of these excisions do not require reconstruction. Occasionally, delayed augmentation, scar lengthening via Z-plasty, and areolar transposition are indicated. If a discrepancy between the medial and lateral breast quadrant is recognized due to a substantial superolateral resection, immediate centralization of the nipple-areolar complex over the point of maximal projection is warranted. This involves simple areolar transposition after release of the dermal attachments. Wide excisions may require transfer of regional or distant tissue. The latissimus dorsi myocuta-neous flap represents the ideal choice for these defects (Figure 11-11).

Partial inferior defects may be corrected on an immediate or delayed basis. The occasional patient, lacking significant radiation change, may benefit from delayed insertion of a small round or custom (one-third) implant for volume replacement. Most defects, however, benefit from a procedure that parallels a standard superior pedicle reduction mammoplasty.108-109 The resection and reconstruction are facilitated through a standard keyhole pattern. Medial and

Figure 11-11. Reconstruction of the partial mastectomy defect. Superolateral reconstruction with latissimus dorsi myocutaneous flap.

lateral parenchymal flaps are mobilized from the pectoralis fascia and inframammary fold and mobilized into the inferior defect, whether it be lateral, central, or medial.

Supra-areolar defects are socially conspicuous and necessitate local reconstruction due to the paucity of available adjacent tissue and the tendency to develop a visible and depressed scar. These defects are corrected by superior advancement of the areolar complex, based on an inferior pedicle, in a procedure similar to an inferior pedicle reduction mammoplasty.106 108-109

The latissimus dorsi myocutaneous flap represents the flap of choice for the majority of partial mastectomy defects. Its regional location, malleability, ease of dissection, and lack of donor site morbidity are ideally suited for this indication. All breast conservation defects should be reconstructed by overcorrecting the skin and soft tissue deficits. In general, twice the apparent tissue loss should be inset to compensate for normal wound contracture, continued retraction of the postradiation fibrosis, and anticipated muscle atrophy inherent in raising muscle flaps. The muscle may be folded and contoured to accommodate the most irregular defects. Although small skin paddles may be harvested to precisely accommodate the apparent skin deficit, a typical 4 x 6 cm skin paddle facilitates flap harvest and replacement of compromised or contracted radiated skin.

Although partial latissimus harvests are possible, the majority of partial mastectomy defects warrant total flap elevation. Preservation of the thoracodorsal nerve will maintain greater muscle bulk but lead to early postoperative contractions. Compulsive fixation at the recipient site is necessary to avoid disruption. Transection or resection of the muscular insertion will help avoid the typical bulge within the anterior axilla. Finally, supporting the radiated native breast skin with a de-epithelialized portion of the transposed skin paddle will improve ultimate wound contour.

The TRAM flap represents a flap of substantial bulk, typically incurring greater donor site morbidity and a longer recovery. It would appear less economic in restoration of limited tissue defects. It is indicated for the reconstruction of large inferior pole deficits in large-breasted women.

Continued surveillance for recurrent cancer after partial reconstruction should proceed unimpeded. Studies comparing pre- and postoperative mammograms after partial reconstruction have confirmed the radiolucency of these flaps. The development of new microcalcifications, fat necrosis, and new lesions are easily discernible. Some reports, interestingly, have noted improved mammographic visualization and resolution of breast density and fibro-sis as a result of improved local vascularity.

Immediate reconstruction of partial mastectomy defects is gaining popularity. The demand for these techniques has evolved due to a tendency toward more aggressive resection in BCT and accumulated experience with unfavorable tumors. Petit and colleagues reported that immediate reconstruction of the partial mastectomy defect was performed in 25 percent of cases. They advocated close preoperative collaboration to optimize cosmetic results and enable "improved radicality" of the surgical breast conservation.110 Thus, the potential for immediate partial mastectomy reconstruction facilitates a more aggressive resection or marginal clearance in BCT and may lessen the need and/or frequency of re-excision. Also, it may lessen the need for staged reconstruction following radiation-induced exaggeration of the defect.

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