Chest wall reconstruction and advanced disease

Abstract

Clinical experience supports a role for palliative procedures in patients with locally advanced or recurrent breast cancer, yet numerous challenges are entailed in both the extirpation and reconstruction of the chest wall in these cases. The defects may be profound and complicated by prior surgery, radiation therapy, or patient-related variables. The reconstructive techniques employed must neither encumber nor delay any necessary postoperative therapy and must not result in unacceptable morbidity or compromise quality of life. Our surgical approach to these cases incorporates a team of specialists from a broad spectrum of medical and surgical disciplines. Each operative plan is tailored to the specific needs and requirements of the individual patient.

Keywords: Chest wall reconstruction; advanced breast cancer.

Figure 1

Radiation damage to a free transverse rectus abdominis myocutaneous (TRAM) flap for breast reconstruction. A 54-year-old woman underwent bilateral mastectomies with immediate reconstruction utilizing free (TRAM) flaps. Unexpectedly, the patient's final pathology demonstrated significant axillary lymph node involvement, necessitating a course of postoperative radiation to the left breast reconstruction. The patient is seen (A) preoperatively and (B) 2 months postoperatively after her free TRAM. (C) The progressive effect of radiation on the reconstructed left breast TRAM flap can be noted a year following the completion of the radiation therapy. The patient subsequently required reduction of the right (nonirradiated) reconstruction to achieve symmetry.

Figure 2

The V.A.C.^™ for wound closure. (A) The V.A.C.^™ utilizing negative pressure to remove tissue fluid and edema and enhance wound healing. (B) A compressible porous foam sponge placed on the wound is sealed with an occlusive dressing and subjected to a prescribed level of suction (continuous or intermittent). (C) A 61-year-old morbidly obese woman with diabetes mellitus, hidradenitis suppurativa, chronic obstructive pulmonary disease (COPD), and severe coronary artery disease (CAD) presented with an infected painful breast due to recurrent breast cancer. The patient had initially been treated with conservation therapy, which was then followed with an additional 75 Gy of radiation for tumor control after her recurrence. (D) Palliative resection was performed but the patient's CAD precluded use of general anesthesia. (E) She achieved definitive wound closure with serial debridement, V.A.C.^™ dressing changes, allograft and split-thickness skin graft secured with the V.A.C.^™ all done under local anesthesia. (F) Patient is seen 4 months postoperatively with a healed wound.

Figure 3

Latissimus dorsi pedicled flap for chest wall reconstruction. (A) A 52-year-old woman presented with inflammatory breast cancer and underwent neoadjuvant chemotherapy and radiation therapy. (B) A radical mastectomy for local control was followed by immediate chest wall coverage with a pedicled latissimus dorsi myocutaneous flap, placing the skin paddle transversely on the back, thus limiting the donor scar to within the patient's brassiere line. (C) The patient had an uneventful postoperative course and is seen 10 months postoperatively.

Figure 4

Pedicled TRAM flap for chest wall coverage. (A) A 48-year-old woman with osteoradionecrosis of the sternum and recurrent breast cancer. A superiorly based pedicled TRAM flap based on the right superior epigastric vessels is planned, with the vascular zones of the TRAM illustrated. (B) The size of the defect necessitated skin grafting a portion of the rectus muscle at the inferior wound edge. Note the relatively smaller volume of abdominal TRAM flap tissue that may be transferred by pedicled in comparison to microvascular techniques (see Figs. 5 and 6). (Case courtesy of Dr. Robert Walton.) (From Bland KI, Copeland EM, eds. The Breast: Comprehensive Management of Benign and Malignant Disorders, 3rd ed. Harcourt Medical; 2003. Reprinted with permission of © Harcourt Medical.)

Figure 5

Free TRAM flap for chest wall reconstruction. (A) A 50-year-old woman presented with locally advanced recurrent breast cancer. (B) An extensive chest wall defect resulted after wide resection of the tumor. (C) This defect was reconstructed with a large unilateral free TRAM flap. The postoperative result demonstrates the size of a TRAM that may be transferred on a single pedicle and the flexibility of flap positioning with microsurgical transfer. (D) In this case harvest of the large TRAM flap required a skin graft to close the donor site.

Figure 6

Combination of free TRAM and latissimus flaps for chest wall reconstruction. (A) A 47-year-old woman presented with neglected locally advanced breast cancer, which was responsive to neoadjuvant chemotherapy. Negative surgical margins were achieved with an en bloc tumor resection inclusive of the sternum and six ribs. The chest wall defect was reconstructed with Marlex mesh and methylmethacrylate (B) The sternal defect is seen at the right hand side of the photograph. (C) Bilateral free TRAM flaps and an ipsilateral latissimus dorsi myocutaneous flap were used to close the wound, with complete closure of all donor sites. (D, E) Patient had an uneventful recovery and is seen 9 months after completion of radiation therapy, with healed wounds. (From Bland KI, Copeland EM, eds. The Breast: Comprehensive Management of Benign and Malignant Disorders, 3rd ed. Harcourt Medical; 2003. Reprinted with permission of © Harcourt Medical.)