INTRODUCTION
The reconstruction of chest wall defects is challenging and involves shape and
function restoration as well as vital structure coverage and protection1,2. Advances in surgical techniques, mechanical ventilation,
intensive therapy support, broad-spectrum antibiotics, and anesthesia allowed
broader resections with acceptable morbidity and mortality rates, improving
patient prognosis. An increased understanding and management of the ventilatory
dynamics is a determinant of the evolution of related procedures3.
The main indications for large thoracic wall resections include
radiotherapy-induced necrosis, congenital defects, trauma, osteomyelitis,
sarcomas, and advanced lung and breast neoplasms4.
Breast cancer is the most common cancer among women worldwide and after non-
melanoma skin cancer in Brazil, accounting for about 28% of new cases each year.
An increase in its incidence is reported in developed and developing countries.
In Brazil, the estimate is 59,700 new cases in 2018 according to the National
Cancer Institute and in 2013 there were 14388 registered deaths due to breast
cancer5.
Locally advanced breast cancer is considered clinical stage IIIb or IV. Its
occurrence comprises 20-25% of all cases and is characterized by a high local
recurrence rate and heterogeneous behavior6,7. Stage IIIB
involves T4 tumors classification that represents a tumor of any size with a
direct extension to the chest wall or skin presenting as ulceration or cutaneous
nodules. Clinical stage IV includes patients with any T, any N (lymph node
status), and M1, which means metastatic disease, including the skin. Treatment
with adjuvant chemotherapy is often considered in this clinical presentation
before surgery, as well as radiotherapy7.
Tansini was the first surgeon to use a musculocutaneous flap to reconstruct the
soft tissues of the anterior chest wall. The first case of closure of the defect
resulting from a radical mastectomy with a latissimus dorsi flap was reported in
19068. There were other descriptions
of flap transposition in the 40s9 and
50s10 for reconstruction of the chest
wall2. The technique only started
being widely used when the concept of myocutaneous flaps was revived and
perfected in the 70s, securing its routine use to date1,2.
The main muscles used for chest wall reconstruction include the latissimus dorsi
(LD), pectoralis major, and rectus abdominis; each has its advantages and
disadvantages, yet all are robust, reliable, and versatile, with a consistent
vascular anatomy and the possibility of using an associated skin island1,11.
Local and fasciocutaneous thoracoabdominal flaps are also useful in selected
cases12. In some cases, use of the
large omentum is described as a framework for chest wall reconstruction as
demonstrated initially by Kiricuta13 and
then by Tavares et al.14.
Researchers have attempted to develop algorithms11,15 for the
reconstruction of the soft tissues of the chest wall; however, in practice, a
great complexity and variety of defects is observed. The reconstructive surgeon
must be prepared to change the surgical plan to meet the intraoperative
findings1.
The choice of technique depends on defect location, donor area location and
availability, previous surgical approaches in the thoracic and abdominal
regions, and radiotherapy1,2.
OBJECTIVE
To evaluate the results of chest wall reconstructions using musculocutaneous and
fasciocutaneous flaps in patients with locally advanced breast cancer at a
referral hospital.
METHODS
This retrospective observational descriptive study was performed in a single
center by the same surgeon. The studied population is composed of patients who
underwent the resection of oncological lesions in the chest wall at the A. C.
Camargo Cancer Center and reconstructed using musculocutaneous and
fasciocutaneous flaps by the author from January 1, 2016 to December 31,
2017.
The study received approval from the institution’s ethics and research committee
(code EC 51/18). All patients were informed of the procedures and signed an
informed consent form.
The variables studied were age, sex, histology, defect size, myocutaneous flap
type, flap dimensions, presence of cutaneous and visceral metastasis,
postoperative evolution, and immediate and late complications.
To evaluate the postoperative complications, patients were divided into four
groups by flap type: 1) vertical rectus abdominis myocutaneous flap (VRAM), 2)
latissimus dorsi with VY skin island conformation (LDVY), 3) thoracoabdominal
flap (TA), and 4) latissimus dorsi associated with the thoracoabdominal flap
(LDVYTA).
The technique used to create the flaps is described below.
LD with VY skin island
The patients were placed in the lateral decubitus position. On the side
opposite the mastectomy, a VY-skin island was demarcated over the LD muscle
from the lateral margin of the mastectomy defect. A skin clamping test was
used to evaluate the tension at the donor area closure. Next, infiltration
with a 1:250,000 solution of adrenaline and 10 mg/mL ropivacaine was
performed.
The thoracodorsal artery was dissected and the tendon in the intertubercular
groove of the humerus was disinserted. The flap was transposed to the area
of the mastectomy defect followed by the confection of 10 adhesion stitches
with Vicryl 2.0. The donor area was closed in a “Y” shape after drainage
with Blake drain no. 19.
The patient was then moved to the horizontal position, the flap distribution
was performed on the mastectomy defect, a vacuum drain (Blake no. 19) was
placed, and closure by planes was performed. When necessary, LDVYTA was used
to complement the closure due to insufficient coverage of the LD flap.
The dressings of the donor area and reconstructed area were performed with
Adaptic gauze and Opsite film.
VRAM flap
With the patient in the horizontal decubitus position, the skin island on the
longitudinal axis of the contralateral monopediculate rectus abdominis
muscle was demarcated to the defect of the mastectomy.
A 1:250,000 solution of adrenaline and 10 mg/mL ropivacaine was infused.
Dissection by planes to the sheath of the rectus abdominis muscle with its
opening was performed. The distal third of the rectus abdominis muscle was
then incised in the projection of the semilunar line after ligation of the
inferior epigastric artery and corresponding veins with Vicryl 2.0 knots.
The flap was mobilized to the defect area and the donor area was closed with
reconstitution of the anterior sheath of the rectus abdominis muscle with
separate 0.0 nylon stitches. At this time, the need for reinforcement with
an Ultrapro screen (Johnson & Johnson) was evaluated according to the
closure tension. Vacuum drainage (Blake no. 19) was then performed and the
donor area closed by planes.
The mobilized flap was then accommodated on the defect resulting from the
mastectomy; vacuum drainage was performed with Blake’s drain no. 19 and
closure by planes. The dressings of the donor area and the reconstructed
area consisted of Adaptic gauze and Opsite film.
Thoracoabdominal flaps
After evaluation of the defect resulting from the mastectomy, fasciocutaneous
flaps of thoracic and abdominal advancement were created. Flap size was
proportional to the resulting defect and the donor area skin elasticity was
the criterion for its use. After the advancement of the flap, adhesion
stitches were performed with Vicryl 2.0 sutures, drainage of the dead space
with a Blake drain no. 19, and closure by planes.
The dressings of the donor area and the reconstructed area consisted of
Adaptic gauze and Opsite film.
The statistical analysis was performed using SPSS software version 24.0
(Chicago, IL, USA).
Differences were considered statistically significant when the
p values were <0.05. The descriptive analysis was
performed using frequencies and percentages for the characteristics of the
various categorical variables and for obtaining measures of central tendency
(average and median) for the quantitative variables.
The Kaplan-Meier method was used to evaluate patient survival.
RESULTS
We selected 11 patients with the chosen criteria (Table 1). Considering the descriptive variables, the age range was
28-63 years (mean, 49 years) and all patients were female with advanced clinical
stage IIIB or IV breast cancer. The left side was the most commonly affected
(6/11 patients). There were no cases of bilateral involvement.
Table 1 - Patient Data.
| Patient |
Age (years) |
Flap |
Clinical presentation |
Side |
Skin Metastases |
Visceral Metastases |
Size of lesion (cm2)
|
Size of Flap (cm2)
|
Death |
| 1 |
38 |
VRAM |
Mass |
Left |
Yes |
No |
240 |
200 |
Yes |
| 2 |
53 |
LDVY |
Ulcerated mass |
Right |
No |
Yes |
450 |
240 |
Yes |
| 3 |
60 |
VRAM |
Mass and hyperemia |
Left |
No |
Yes |
600 |
350 |
No |
| 4 |
51 |
LDVYTA |
Mass and hyperemia |
Left |
Yes |
No |
119 |
198 |
No |
| 5 |
50 |
LDVYTA |
Ulcerated mass |
Right |
Yes |
No |
144 |
684 |
Yes |
| 6 |
42 |
TA |
Mass and hyperemia |
Left |
No |
Yes |
595 |
800 |
No |
| 7 |
47 |
TA |
Mass |
Left |
Yes |
Yes |
63 |
800 |
Yes |
| 8 |
28 |
LDVY |
Mass and hyperemia |
Right |
No |
Yes |
625 |
171 |
No |
| 9 |
52 |
VRAM |
Ulcerated mass |
Right |
Yes |
Yes |
600 |
720 |
Yes |
| 10 |
63 |
TA |
Ulcerated mass |
Right |
No |
Yes |
336 |
425 |
No |
| 11 |
59 |
VRAM |
Ulcerated mass |
Left |
Yes |
No |
300 |
375 |
Yes |
The most common tumor type was invasive ductal carcinoma (9 cases), representing
81% of the sample. The other two cases were one of invasive lobular carcinoma
and one of metaplastic tumor. Of the 11 patients, four underwent a Halsted
mastectomy; the others underwent modified radical mastectomy.
The following flaps were used: LDVY in two, LDVYTA in two (Figures 1 and 2),
VRAM in four (Figures 3 and 4), and TA in three (Figure 5). The abdominal wall reinforcement mesh was used
in two patients for whom the VRAM technique was selected to repair the defect.
Defect sizes ranged from 17 × 7 to 45 × 10 cm (mean area, 421.72 cm2)
and flap sizes ranged from 19 × 9 to 40 × 20 cm (mean area, 451
cm2).
Figure 1 - Reconstruction with a latissimus dorsi muscle flap combined with
a thoracoabdominal flap. A: Defect; B:
Immediate postoperative aspect; C: Appearance 6 months
after surgery (post radiotherapy).
Figure 1 - Reconstruction with a latissimus dorsi muscle flap combined with
a thoracoabdominal flap. A: Defect; B:
Immediate postoperative aspect; C: Appearance 6 months
after surgery (post radiotherapy).
Figura 2 - Reconstruction with a latissimus dorsi muscle flap combined with
a thoracoabdominal flap. A: Initial lesion;
B: 3 weeks after surgery; C:
Appearance 4 months after surgery (extensive local
recurrence).
Figura 2 - Reconstruction with a latissimus dorsi muscle flap combined with
a thoracoabdominal flap. A: Initial lesion;
B: 3 weeks after surgery; C:
Appearance 4 months after surgery (extensive local
recurrence).
Figure 3 - Reconstruction with a vertical rectus abdominis myocutaneous
(VRAM) flap with a vertical skin island. A: Initial
lesion; B: Defect; C: Six months after
surgery.
Figure 3 - Reconstruction with a vertical rectus abdominis myocutaneous
(VRAM) flap with a vertical skin island. A: Initial
lesion; B: Defect; C: Six months after
surgery.
Figure 4 - Reconstruction with a vertical rectus abdominis myocutaneous
(VRAM) flap. Complications: A: Necrosis and partial
dehiscence 2 weeks after surgery, B: Mobilization of
the parascapular fasciocutaneous flap, and C: Local
relapse 3 weeks after surgery.
Figure 4 - Reconstruction with a vertical rectus abdominis myocutaneous
(VRAM) flap. Complications: A: Necrosis and partial
dehiscence 2 weeks after surgery, B: Mobilization of
the parascapular fasciocutaneous flap, and C: Local
relapse 3 weeks after surgery.
Figure 5 - Reconstruction with a thoracoabdominal flap. A:
Initial lesion; B: Defect; C: Immediate
postoperative aspect; D: Three months after
surgery.
Figure 5 - Reconstruction with a thoracoabdominal flap. A:
Initial lesion; B: Defect; C: Immediate
postoperative aspect; D: Three months after
surgery.
The initial clinical presentation was a massive mammary mass in two patients,
mass with diffuse cutaneous hyperemia in four patients, and mass with ulceration
in five patients (Figure 6). Hemorrhage
was present in four of the patients, one of whom required hemostatic
radiotherapy before surgery to control the symptoms.
Figure 6 - Clinical presentation.
Figure 6 - Clinical presentation.
Of the 11 patients, four had cutaneous metastasis during the follow-up period,
four had visceral metastases, and three had concomitant visceral and cutaneous
metastases (Figure 7). Four patients
previously underwent quadrantectomies and returned with recurrent disease for
locoregional neoplastic control.
Figure 7 - Distribution of metastases.
Figure 7 - Distribution of metastases.
The mean hospitalization was 4 days (range, 1-15 days). Only one patient required
postoperative follow-up in an intensive care unit (ICU) with a 1-day stay.
Four patients received complementary radiotherapy after surgical treatment. Of
the 11 patients, 10 were treated with neoadjuvant chemotherapy and ten patients
with adjuvant chemotherapy. Of the 11 patients, three presented comorbidities:
one with systemic arterial hypertension and two with associated diabetes and
hypertension.
The most frequent complication was partial dehiscence (seven patients; six were
managed conservatively and one required reoperation in order to enable the
patient to undergo adjuvant chemotherapy), followed by epitheliolysis in three,
abscess in two, and seroma in one patient (Figure 8).
Figure 8 - Complications by flap type.
Figure 8 - Complications by flap type.
A diabetic and hypertensive patient presented with a surgical wound abscess in
the presence of adjuvant chemotherapy evolving to septic shock and death 32 days
postoperatively. In a patient with breast cancer and previous radiotherapy who
underwent reconstruction with a VRAM flap, partial necrosis of the flap and skin
of the receptor area in the axillary region caused exposure of the axillary
vessels. Extensive surgical debridement and local reconstruction with a
fasciocutaneous parascapular flap showed a good evolution, although the patient
presented locoregional recurrence of the disease 3 weeks later and died 3 months
later of relapse.
At the time of data acquisition, six patients in the series had died. Of the four
groups evaluated the reconstruction with a VRAM flap presented the greatest
number of complications, while the thoracoabdominal flap group showed the lowest
number.
Regarding survival, the Kaplan-Meier test and stratifying by flap used resulted
in the following (Figure 9, Table 2): VRAM, survival at 12 and 28
months, 75% and 37.5%; LDVYTA, 50% survival in 18 months; TA: Survival of 66.7%
in 13 months. The mean survival of the VRAM flap was 25.5 months, that of LDVY
flap was 17 months, that of TA was 17 months, and that of LDVYTA was 20.5
months.
Figure 9 - Survival plot.
Figure 9 - Survival plot.
Table 2 - Survival Table.
| Survival Table |
| |
|
|
Cumulative Proportion |
Number of Cumulative Events |
Number of Remaining Cases |
| |
|
|
Survival at the Time |
| Flap |
Time (months) |
Status |
Estimate |
Std. Error |
| VRAM |
1 |
12 |
Yes |
0.750 |
0.217 |
1 |
3 |
| |
2 |
22 |
No |
. |
. |
1 |
2 |
| |
3 |
28 |
Yes |
0.375 |
0.286 |
2 |
1 |
| |
4 |
32 |
Yes |
0 |
0 |
3 |
0 |
| LDVY |
1 |
16 |
No |
. |
. |
0 |
1 |
| |
2 |
17 |
Yes |
0 |
0 |
1 |
0 |
| TA |
1 |
13 |
Yes |
0.667 |
0.272 |
1 |
2 |
| |
2 |
14 |
No |
. |
. |
1 |
1 |
| |
3 |
19 |
No |
. |
. |
1 |
0 |
| LDVYTA |
1 |
18 |
Yes |
0.500 |
0.354 |
1 |
1 |
| |
2 |
23 |
No |
. |
. |
1 |
0 |
Table 2 - Survival Table.
A log-rank test was applied to verify if there were statistical differences
between treatment types (p = 0.87). Thus, with a significance
level of 5%, there was no statistically significant survival difference among
flap types.
DISCUSSION
Wide surgical resection with free margins and defect closure using myocutaneous
or fasciocutaneous flaps is considered the approach of choice for locally
advanced breast cancer (stages IIIB and IV). This treatment provided a free time
of disease progression, improved quality of life, and increased overall
survival16-28.
The LD flap plays a leading role in chest and breast reconstructions because it
has a consistent vascular pedicle and a good rotational arc as a Dutra advocate.
The flap was made with the patient in the lateral decubitus position, a modality
that was adopted in all cases in this study29,30. In 2015,
Andrade et al.31 described flap
mobilization in the dorsal decubitus position and reported decreased operative
time.
Due to the need for large tissue quantities to cover the defects, variations in
the composition of the skin island were described as proposed by Micali et
al.32 in 2001 with a skin island of
an LDVY flap. Its usefulness as the first-choice flap in breast reconstructions
was confirmed by Woo et al.33 in 2006,
Luz et al.34 in 2010, and the present
study.
Adequate patient selection, coordinated planning with a mastologist, and careful
intraoperative manipulation of the involved tissues are essential to
reconstruction successful reconstruction using an LDVY flap35,36.
The extension of the skin outside the topography of the muscle and thus with
random vascularization plays an important factor in the occurrence of
complications such as dehiscence and partial necrosis. VRAM use is considered
for extensive defects or when there is contraindication to LD flap use23.
Silva et al.12, in a study similar to
ours, reported a resection area of 259.2 cm2, smaller than ours
(421.72 cm2) which may explain the greater use of VRAM flaps in our
study. In this same work, the most frequent complication was epitheliolysis,
followed by partial flap necrosis.
The use of myocutaneous and fasciocutaneous flaps does not interfere in the
diagnosis and treatment of a locoregional recurrence of breast cancer. In the
literature, the recurrence rate was 10.6%, ranging from 2 weeks to 3.8
years20. In our study, we found a
63.3% local recurrence rate. This is attributed to the profile of the operated
patients, all of whom had locally aggressive disease.
When only cutaneous metastases are present, the median survival is 42.1 months.
When visceral metastases are also present, the median survival is 12.08
months37. The six patients who died
had cutaneous and visceral metastasis and presented a median survival of 15
months.
CONCLUSION
Myocutaneous and fasciocutaneous flaps remain predominant choices for chest wall
reconstructions and enable the extensive resections necessary to ensure
oncologically adequate margins with acceptable complication rates.
COLLABORATIONS
|
JAJ
|
Analysis and/or data interpretation; conception and design study;
conceptualization; data curation; final manuscript approval; formal
analysis; methodology; project administration; realization of
operations and/or trials; supervision; visualization; writing -
original draft preparation; writing - review & editing.
|
|
AKD
|
Supervision.
|
|
MCD
|
Writing - review & editing.
|
|
EKY
|
Writing - review & editing.
|
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1. A. C. Camargo Cancer Center, Núcleo de Cirurgia
Plástica Reparadora, São Paulo, SP, Brazil.
Corresponding author: Joel Abdala Junior, Rua Prof. Antônio
Prudente, nº 211 - Liberdade, São Paulo, SP, Brazil, Zip Code 01509-010. E-mail:
drjoelabdala@gmail.com
Article received: July 31, 2018.
Article accepted: November 11, 2018.
Conflicts of interest: none.
