Local recurrent mammary carcinoma failing multimodality therapy. A solution.

Chest wall recurrence following radiation and hormonal therapy is an uncommon but serious and disabling condition. A chest wall ulcer secondary to treatment for recurrence also presents the same dilemma. Over the past 35 years, the Thoracic Service at our institution has treated 35 patients for these problems by surgical resection and reconstruction. Eight patients were seen after the first recurrence, six after the second, ten after the third, and ten after the fourth. One patient had chest wall resection with mastectomy when recurrence followed radiation therapy. Following resection of the tumor, 21 patients had reconstruction using mesh or a mesh "sandwich." There were no operative deaths and no respirator need. Twenty patients are alive from five to 120 months, with a median of 50 months. One of 35 patients had chest wall recurrence. Surgical resection of recurrent mammary carcinoma resistant to all other therapy is a viable alternative for both palliation and cure.

Resection and debridement of chest-wall tumors and general aspects of reconstruction.

The main criterion for adequate local control of a chest-wall malignancy remains wide excision. With the available techniques of skeletal and soft-tissue reconstruction, even large lesions can be resected with safe margins. The primary purpose is to achieve a curative resection, although a significant number of symptomatic patients can benefit from palliative resection provided by such procedures. A key element in the success in treating chest-wall tumors is a multidisciplinary approach by all participating physicians, namely the thoracic surgeon, the plastic and reconstructive surgeon, the radiotherapist, and the medical oncologist.

External oblique myocutaneous flap coverage of large chest-wall defects following resection of breast tumors.

Defects resulting from resection of advanced breast tumors can be quite large, posing a difficult reconstructive challenge. A significant number of such patients present with local recurrences after receiving external beam radiation and/or chemotherapy treatments. Pectoralis major, latissimus dorsi, rectus abdominis, and omental flaps with split-thickness skin grafts have been recommended for closure of chest-wall defects. What is often excluded from the list of reconstructive options is the external oblique myocutaneous flap. In our series of 20 consecutive patients treated at Memorial Sloan-Kettering Cancer Center, an external oblique myocutaneous flap was used to cover these large chest-wall defects successfully. The median age of our patient population was 54.5 years, and 68 percent of them presented with local recurrence. Fifty percent had external beam radiation, and fifty percent had received chemotherapy. Twenty-five percent of our study group had had both treatments. The mean chest-wall defect measured 326 cm2, corresponding to a 20 x 16 cm area. We believe that the external oblique myocutaneous flap should be considered a safe and reliable option when reconstruction of large chest-wall defects is contemplated.

The use of a preoperative pattern in chest wall reconstruction with the latissimus dorsi musculocutaneous flap.

To use the entire muscle for breast reconstruction with the latissimus dorsi musculocutaneous flap, the location of the skin ellipse on the back is planned with a cloth pattern. The technique as used in two patients is described and illustrated.

The use of cross-leg flap in malignancy: realization of a potential complication.

We present a case of recurrent myxoid fibrosarcoma presumed to have spread to the contralateral leg by means of cross-leg flap procedure. In the era of free flap transfer, musculocutaneous flaps and the recent cross-leg musculocutaneous flap, the cross-leg flap remains a valuable technique for the reconstructive plastic surgeon. However, it should not be considered in reconstruction after resection of a malignant tumor.

Breast reconstruction after mastectomy: who seeks it, who refuses?

Recent Food and Drug Administration hearings on silicone gel implants have drawn attention to the paucity of information about women who seek reconstruction after mastectomy compared with those who do not. New analyses of data gathered in the early 1980s address this issue. Three groups of mastectomy patients were compared: 117 women who sought and obtained delayed reconstruction, 26 who sought but decided against delayed reconstruction, and a comparison group of 53 who were not seeking reconstruction. Results indicated that although younger and more knowledgeable about reconstruction, patients in the reconstruction group were similar to those in the comparison group. However, the women who sought but chose not to proceed with reconstruction appear to have been at greater risk for physical and emotional disappointment with the results of reconstruction, which suggests that poor candidates for reconstruction may select themselves out at the time of consultation.

Breast reconstruction after mastectomy.

Breast reconstruction after mastectomy is discussed with emphasis on present surgical techniques and results achieved. The deformity is defined and the goals outlined. Contra-indications, indications, evaluation of the patient and proper choice of reconstructive procedures and implantable materials are reviewed as well as complications and restrictions. Selective illustrations demonstrate some of the clinical experience of patients treated at Memorial-Sloan Kettering Cancer Center.

Neurovascular flap repair of the foot for sarcoma.

Wide excision of soft tissues of the foot for sarcoma invariably creates a large defect requiring closure in a way that will withstand the trauma of bearing weight. Neurovascular flap reconstruction provides a thick, well-vascularized cover with good sensation, functional durability, and brief immobilization.

A method of breast reconstruction with a deepithelialized TRAM flap via the abdominal approach for failed implant salvage in postmastectomy patients.

Postmastectomy reconstruction of breasts is one of the most commonly performed procedures of the plastic surgeon today. Tissue expansion with subsequent implant placement, transverse rectus abdominis musculocutaneous (TRAM) flaps, latissimus dorsi flaps, gluteal flaps, Ruben's fat pad flaps, and free flaps from other areas have all been utilized with consistently good aesthetic results. One special class of patient is the woman who has undergone breast reconstruction with tissue expansion, with or without subsequent implant placement, who than receives external beam radiation therapy. Capsular contraction frequently complicates this therapy. In the past, women have undergone capsulotomy or capsulectomy with replacement of the implant. Recently, women are more reluctant to have foreign tissue in their bodies and are opting for autologous tissue reconstructions. TRAM reconstruction following removal of implants has been previously reported. A new approach to the placement of the TRAM flap after implant reconstruction via the abdominal approach, with avoidance of any incision on the breast itself, is presented. This is especially important in a patient who has evidence of radiation damage to the skin, placing any incision through the treated tissue at risk.

Cervical apron flap reconstruction: a technique for second-stage revision.

A technique for second-stage revision of a cervical apron flap is described. Food particle retention and pocketing in hair-bearing recesses can be minimized by accurately trimming and contouring the flap to fit smoothly into the oral defect.

A simple geometric flap for the closure of skin defects.

The Limberg flap is a useful method of closing defects anywhere on the body which are too large for simple closure but where skin grafting is not desirable. It is an easy flap to perform, and it is reliable and safe to use. It must not, however, be used indiscriminately or by rote. Care must be taken in planning both the excision and the flap so that the points which must move farthest are placed where the skin is maximally extensible. With such planning, accurate and precise designing and careful surgical technique, the Limberg flap can be used successfully to solve a number of otherwise extremely difficult problems.

Polyester as a bioimplantable material.

In response to the recent controversy over silicone gel implants, alternative substances are being sought to offer new options in bioimplantable materials. Polyester is a Food and Drug Administration-approved prosthetic material utilized in vascular grafts for decades without significant problems in body tolerance. Working with textile scientists, polyester (both in its woven and fibrous forms) was engineered to influence differential fibrous ingrowth. Implants of medical-grade polyester were constructed in a 3-cm2 diskette configuration. Four combinations of material with varying layers of weave and fiber were created to influence tissue ingrowth differentially. Four implants were placed in separate dorsal pockets beneath the panniculus carnosus of each of 12 adult female New Zealand White rabbits. Care was taken to sort the implant types equally among the four quadrants such that a similar distribution of implants existed between animals. Implants with intact capsules were harvested at 1, 3, and 6 months, and were analyzed for histology, capsular thickness, and tissue ingrowth. A phantom mammogram was taken through the implant material that did not obscure interpretation. The materials were further tested to determine fiber fill-to-wet implant weight ratios to determine postimplantation weight predictably. Tensile strength was also determined.

Mammography after prosthesis placement for augmentation or reconstructive mammoplasty.

Mammograms of 59 women who underwent placement of a prosthesis for augmentation or reconstructive mammoplasty were retrospectively reviewed. Free silicone was used in five women, retroglandular prostheses in 40, and subpectoral implants in 14. Abnormalities of prosthesis contour were seen only in eight women with retroglandular implants. In another four women, retroglandular prostheses became calcified. In women who received free-silicone injections, coarse calcifications developed in three, and gross nodularity with calcified silicone granulomas developed in one. Five palpable masses developed, three of which were malignant; four masses were in breasts augmented with a retroglandular prosthesis, and they could not be detected with mammography. The mass that developed in a woman with a subpectoral prosthesis could be seen at mammography. The only nonpalpable malignancy detected with mammography was in a breast with a retroglandular prosthesis and contained microcalcifications. The authors conclude that in women with retroglandular prostheses, masses may often be obscured on mammograms by compressed, dense glandular tissue.

Abdominal wall reconstruction.

Patients with abdominal wall reconstruction present a difficult management problem to the oncological surgeon. There were 36 patients treated for abdominal wall primary and secondary tumors between the years 1973 and 1982 at the Memorial Hospital. There were 25 abdominal wall sarcomas, 6 recurrent colon cancers, 2 recurrent bladder cancers, 1 cervical cancer, 1 recurrent endometrial cancer and 3 complications of radiotherapy treated by excision and reconstruction of the defect. The desmoid tumors were closed primarily. The recurrent sarcomas after radical excision, were reconstructed with Marlex mesh and local mobilization of skin and subcutaneous tissue. The recurrent colon bladder and endometrial cancers had been treated with over 5,000 cGy each. Three patients had significant full thickness skin loss secondary to radiotherapy. These patients comprised the group that required a myocutaneous flap to provide full thickness skin and fascia. The tensor fascia lata flap was used in eight patients. This group of patients did extremely well in contrast to the group of radiated patients with Marlex mesh reconstruction. There were less complications in the TFL group. We recommended the TFL flap for a large abdominal wall defect and for a previously radiated abdominal wall.

Variation of latissimus dorsi skin island design for postmastectomy reconstruction.

The latissimus dorsi myocutaneous flap has proved valuable in breast reconstruction after radical mastectomy. The procedure has been used often and successfully at the Breast Reconstruction Center of Memorial Sloan-Kettering Cancer Center. Since the axis of the mastectomy scar often varies, we have found that adjusting the orientation and location of the skin islands is necessary to achieve maximal coverage on the chest wall and to place the transposed skin without tension precisely where it is most needed. These different skin island designs may necessitate a scar on the back that is not covered by a brassiere. This paper discusses and illustrates with clinical examples modifications that produce superior reconstructive results.

Psychological response to breast reconstruction. Expectations for and impact on postmastectomy functioning.

Breast reconstruction is being considered by increasing numbers of breast cancer patients. Recent controversy over the relative risk to benefit of breast implants suggests a need for more information about who seeks reconstruction, why, and its impact on postmastectomy functioning. Eighty-three women undergoing reconstructive surgery were assessed with respect to surgical and psychological status. Evaluations were made at the time of consultation for breast reconstruction and repeated 2 months or more postsurgery. Findings highlight the overwhelmingly positive effects of postmastectomy breast reconstruction and provide information useful to those counseling or following breast cancer patients who pursue this option.

Prediction of skin viability following en bloc resection for osteogenic sarcoma with fluorescein.

Intravenous fluorescein dye was applied as a test of skin viability in 11 en bloc resections for osteogenic sarcoma about the knee. Intravenous fluorescein dye is an easy, safe, efficient, and inexpensive method that helps to predict the viability of surgically created skin flaps. When patchy fluorescence is observed, primary debridement is recommended to prevent immediately postoperative skin necrosis. This test proved to be an accurate, significant indicator of nonviable skin, in both location and dimension. All flaps that were patchy by the fluorescein test consisted of nonviable skin. Conversely, flaps that took up the dye evenly went on to uneventful wound healing. The fluorescein test should be considered for further application in orthopedic surgical procedures when skin viability is uncertain, e.g., in cases of trauma and complicated reconstructions about the knee and elbow.

Radiation therapy after breast augmentation or reconstruction in early or recurrent breast cancer.

Fourteen patients whose augmented or reconstructed breasts were treated with radiation therapy were analyzed. Silicone gel implants were used in 13 patients and free-injected silicone in one patient. The total radiation dose ranged from 4400 to 6200 cGy using tangential photon fields or an en face electron field by megavoltage equipment. In several cases, electron boost radiation was added to the tumor bed. The majority of the patients tolerated therapy well with minimal transient skin reactions; only three patients required a treatment break secondary to moist desquamation. Three patients developed documented implant encapsulation, although the majority retained good to excellent cosmesis. In summary, when breast carcinoma arises in the augmented or reconstructed breast, conservative management (i.e., limited surgery and definitive irradiation) is feasible without compromising the therapy or the cosmetic result. Thus, conservative management should be offered as an option to patients who are interested in breast prosthesis conservation.

Myocutaneous flaps in genitourinary oncology.

Between January 1983 and September 1992, 32 myocutaneous flaps were fashioned in 28 patients for reconstruction following treatment of genitourinary malignancies or complex pelvic fistulas. Of the myocutaneous flaps 14 were used to obtain primary soft tissue coverage of large but otherwise uncomplicated wounds and 10 were used to cover previously irradiated resection sites. Four myocutaneous flaps were used to repair complex radiation-induced fistulas involving the bladder, vagina, urethra and rectum. Flaps were used to cover infected or nonhealing open wounds in 8 cases, 4 of which also had been previously irradiated. Myocutaneous flap donor sites were the tensor fascia lata in 11 cases, gracilis in 9, rectus abdominis in 10 and rectus femoris in 2. There was 1 major complication (flap loss) and 9 minor complications. There were no perioperative deaths. Myocutaneous flaps are an effective means of covering large groin, perineal and lower abdominal surgical defects after radical surgery.