Introduction
Large, sloughing, painful, ulcerated or bleeding breast tumours can frequently only
be treated by means
of extended resections. Radiotherapy and chemotherapy alone do not usually lead to
sufficient
containment of the local situation, leaving patients with pain or open wounds, which
involve a
significant restriction of quality of life, at the mercy of the progression of the
local finding. On the
one hand, patients dread an intervention like this and, on the other hand, doctors
dissuade them from
surgical treatment, so progression is accepted as being inevitable. This is a common
occurrence when
people are not aware of the plastic-surgery reconstruction options.
On the one hand, plastic surgery reconstructive procedures enable oncological tumour
resection and, on
the other hand, could make radiotherapy possible by improving the local tissue situation,
or alleviate
pre-existing radiotherapy effects [1 ], [2 ], [3 ]. Full-thickness defects can also be covered using relatively simple
procedures. However, there are barely any long-term results for this procedure [4 ], [5 ], [6 ] and those which are
available are usually restricted to survival, relapse and metastasis frequency [7 ], [8 ], while reports on patient satisfaction, quality of life or
pulmonary function are rare [9 ], [10 ].
So, in the following, the options for defect coverage and reconstruction in advanced
breast tumours are
to be discussed using selected case studies and weighted in the context of the references.
Tumour Resection and Reconstruction of the Thoracic Wall
The scale of the final resection size depends primarily on the treatment approach.
While rather radical
resections can also make sense if the intention is curative, a careful weighing up
of the radicality of
the surgery and the affliction of the patient must take place, particularly when it
comes to palliative
situations.
However, in the case of advanced breast tumours, when it comes to an invasion of the
thoracic wall, both
cases frequently require not just a soft tissue excision, but also a (partial) thoracic
wall resection.
When it comes to the resection of a tumour, particularly if the intention is to cure,
no compromise may
be made on radicality to the benefit of the emerging defect. Follow-up resections
do not necessarily
worsen the outcome, but the aim is always the direct and full resection of the tumour
[11 ]. Only a sufficient tumour resection like this enables containment of the
local situation and thus adequate treatment [12 ]. Furthermore, the
established criteria of oncological surgery apply as a matter of course, e.g. with
regard to the use and
positioning of drains [13 ].
The resulting defect can be safely closed using the techniques described in the following,
by which means
these also enable the resection of extensive findings.
Synthetic nets are used to reconstruct the resulting thoracic wall defect for the
purposes of avoiding a
herniation of the intra-thoracic organs and improving the stability of the thorax.
These nets should be
both robust and pliable at the same time. There are a variety of materials available
but, similar to the
situation with implant-based reconstruction, thus far none [14 ] have proven
significantly superior [9 ], [15 ], [16 ]. We have had good experience with non-absorbable prolene nets in our
institution. No bony chest wall reconstruction takes place, nor even stabilisation
using rigid metal or
artificial ribs/sternal replacement. In the case of extensive wound infections, the
synthetic net may
need to be avoided at first, this may be brought in subsequently if need be and once
the wound has
finished healing. If the wound healing process is disrupted, an exposed net does not
have to be fully
resected anyway. If the infection is contained and the discharge guaranteed, overgranulation
can be
waited for and split skin transplanted [17 ].
Synthetic nets, exposed ribs or the sternum must be covered with well-perfused tissue
of sufficient
thickness and good skin condition. A local tissue shift in the sense of a transposition-rotation
flap
can close smaller defects, however, to prevent disruptions to the wound healing process,
it should only
take place if the tissue to be transplanted has not been pre-irradiated. In the case
of larger defects
and following irradiation, regional pedicled or free flap-plasties must be used to
gain tissue on the
irradiated region. On the torso there are several secure local flap-plasties available,
which are
supplied via defined blood vessels and dispose of a rotational radius suitable for
reaching the upper
anterior and lateral thorax.
Flap-Plasties
Thoracoepigastric flap
This fascio-cutaneous flap is lifted pedicled to the perforators coming out at the
proximity of the
midline of the fascia of the musculus rectus abdominis and is capable of closing-up
smaller defects.
It can be safely lifted to the lateral clavicular line and then reaches the 3rd rib
when cranially
transposed. In order to improve the supply security of this flap, after localising
the relevant
perforator vessel using Doppler imaging, the flap can be planned and lifted based
on this
perforasome [18 ].
[Figs. 1 ] to [3 ] show a thoracoepigastric flap
graft being carried out in a patient with recurrent breast cancer following an ablation.
Fig. 1 Preoperative situs of a patient with recurrent breast cancer following an
ablation.
Fig. 2 Intraoperative situs following the resection of the finding and planning of a
thoracoepigastric flap.
Fig. 3 Postoperative finding with fully healed flap-plasty and stable defect coverage.
Pectoralis major flap
In principle, the pectoralis major flap can be used as a myocutaneous flap or simply
as a muscular
flap. In the case of a myocutaneous flap, a skin graft is also taken from the region
of the lower
breast fold, this graft remains pedicled to the muscle and can be transposed into
the head/neck
region [19 ]. As a result of prior operations or radiotherapy, this flap
is only seldom used for ipsilateral defect coverage on the thorax. Its area of application
is
primarily in the field of head and neck reconstruction (myocutaneous flap) [19 ] or in the reconstruction of defects in the cranial portion of the sternum (muscular
flap) [20 ]. Smaller contralateral defects may be easily reached but one
constraint that must be mentioned is that while the skin graft lifted from the lower
breast fold
region does leave behind a donor site which is good in terms of aesthetics, it has
an insecure blood
supply and partial flap necrosis could result from venous insufficiency, which is
why we only use it
in certain cases. As a flap which is simply muscular, the pectoralis major can be
removed from the
thoracic wall as a “sliding pectoralis flap” and, to gain more rotational freedom,
it can be removed
from the clavicle and the humerus too. In this case, it remains pedicled to the pectoral
branches of
the arteria thoracoacromialis and can thus be transposed to the defect requiring coverage
[21 ], [22 ]. Upon lifting the muscle, there is
only a moderate loss of strength [20 ].
Pectoralis major flaps are, however, only used in the reconstruction of the thoracic
wall following
tumour resection under certain circumstances. Firstly, the size of the skin graft
is very limited in
the case of a myocutaneous flap and, secondly, the vascular structure of the flap
is often impaired
by prior operations, the progression of infections and radiotherapy because of where
it is
located.
VRAM flap
The vertical rectus abdominis muscle flap (VRAM) is best suited to longitudinal defects
due to its
shape and coverage [23 ]. Because the VRAM is primarily supplied by the
caudal continuation of the arteria epigastrica superior, the planning should take
into account any
possible removal of the arteria mammaria interna (usually the left) in previous coronary
artery
bypass operations, and the flap should be lifted contralaterally to the place of removal.
An
incision along the edge of the costal arch also usually involves the sectioning of
the underlying
superior epigastric vessels, making ipsilateral flap lifting obsolete. On rare occasions,
insufficient venous outflow via the superior epigastric vessels can occur. In order
to be able to
react appropriately, it is advisable when lifting a flap to prepare the inferior epigastric
vessels
too in order to then be able to connect these parasternally to the mammaria interna
vessels in the
sense of “vessel supercharging”. Our own follow-up studies on the VRAM flap in oncological
patients
showed the formation of an abdominal hernia or bulging in 13 % in the long-term. All
patients would
choose the surgical procedure again. No flap loss was observed and the loss of strength
was moderate
with a slight restriction of endurance without decreased maximum strength [24 ].
[Figs. 4 ] and [5 ] show the case of a patient
with full-thickness sternal infiltration by a CUP (cancer of unknown primary). Following
radical
resectioning involving the sternum, the defect was covered using a pedicled VRAM-flap.
Fig. 4 Intraoperative situs following radical resectioning involving the sternum.
Fig. 5 Coverage of the defect using a pedicled VRAM-flap.
Anchor flap
If larger defects require to be closed up which also affects the lateral thorax, the
flap can be
extended to include a transversal graft from the lower abdomen (transverse rectus
abdominis muscle
flap: TRAM). The thus resulting anchor flap can close up defects of up to 40 cm in
diameter. In the
majority of cases, the cutaneous donor site should primarily be closed by means of
an abdominoplasty
with umbilical repositioning where possible. The closure of the abdominal wall wound
can, depending
on the resulting fascia defect, be reinforced with a mesh insert in order to avoid
the formation of
a hernia.
In the case of this flap-plasty, the perfusion also takes place via the superior epigastric
vessels
which are, however, weaker in comparison to the inferior epigastric vessels. So, in
the case of a
cranially pedicled flap from the lower abdomen, perfusion disorders and partial necrosis
can occur,
particularly in the lateral portions.
Because free flap-plasties can be performed with the same or even a higher degree
of safety than
local flap-plasties as a result of the increasing improvement of microsurgical techniques,
the trend
with regard to flap-plasties from the lower abdomen is towards using free grafts based
on the
inferior epigastric vessels (see also TRAM/DIEP in the section on free flap-plasties).
Nevertheless,
this form of flap-plasty remains a good option for defect coverage, especially in
the case of very
expansive findings.
A case report of a patient with ulcerated breast carcinoma and defect coverage with
an anchor flap is
shown in [Figs. 6 ] to [9 ].
Fig. 6 Preoperative ulcerated breast carcinoma finding.
Fig. 7 Intraoperative planning of an anchor flap.
Fig. 8 Situs following resection of the tumour and lifted anchor flap.
Fig. 9 Situs after anchor flap is sewn in and donor site has been closed by means of an
abdominoplasty with umbilical repositioning.
Latissimus dorsi muscular flap
The myocutaneous latissimus dorsi flap is lifted pedicled to its thoracodorsal vessels
while in a
lateral position. It may be lifted simply as a muscular flap or as a myocutaneous
flap [25 ], [26 ]. One further modification is the
lifting of the skin graft above the anterior rim of the latissimus and the dissection
of the
perforator vessels running through the muscle up to the outlet from the arteria subscapularis
(thoraco-dorsal artery perforator flap; TAP-flap). This way the muscle and its innervation
are
preserved, however only smaller grafts can be lifted [27 ]. If muscles and
overlying skin grafts are lifted, it is advisable to lift a graft of sufficient size
or to subject
the perforator vessels to Doppler imaging beforehand so that a secure blood supply
is guaranteed for
the skin graft. Due to its reliable vascular supply, its proportions, the relatively
simple
dissection and the moderate donor site defect, the latissimus flap has proven itself
in the coverage
of defects of the thoracic cage [28 ]. As a result of its volume, it can
also seal intra-thoracic defects. Flap losses rarely occur with pedicled flap-plasties
provided
there is careful dissection. However, in case of any doubt, particularly following
axilla
dissections, the presence of the supplying vessel must be examined, e.g. using Doppler
imaging. In
order to guarantee as much supply security as possible, the flap can also be lifted
as a
transposition-rotation flap. In this case, the parascapular vessel is included via
the remaining
cutaneous pedicle. The resulting donor site defect can undergo a split skin graft.
While this does
mean a compromise in terms of aesthetics, a larger flap can, however, be lifted and
close up the
relevant defects if the anchor flap is not an option ([Figs. 10 ] to
[12 ]).
Fig. 10 Preoperative situs of a patient with ulcerated breast carcinoma.
Fig. 11 Postoperative situs after pedicled latissimus flap-plasty with complete healing of
the skin graft.
Fig. 12 Donor site of the latissimus flap which required split skin graft due to the size.
There are wound healing complications cranially and caudally which underwent conservative
treatment.
Omentum majus flap
The omentum majus is a reserve option for closing defects in the anterior throracic
wall. Pedicled to
the unilateral or bilateral gastro-omental vessels, it can be lifted by means of a
paramedian
incision from the xiphoid process to beneath the umbilicus [29 ]. Whether
or not the omentum is the desired size cannot be determined until after opening up
the abdominal
region. Occasionally, adhesions must be painstakingly removed and the net raised from
the stomach in
order to achieve the appropriate rotational radius. Furthermore, a gap must remain
in the abdominal
wall so that the pedicle can be guided outwardly through it in the direction of the
thoracic wall.
Even though such a fear of a “two-cavity-operation” is over-exaggerated, this flap
should only be
lifted with the relevant experience and any potential complications such as intestinal
perforations
and bleeding can be contained. Due to its great plasticity, the omentum is well placed
for
obliterating dead space. It must, however, always be covered by split skin and achieves
only modest
aesthetic results following secretion which often lasts a while and frequent partial
secondary
healing.
A meta-analysis [30 ] demonstrated that the overall complication rates of
myoplasty and omentoplasty are comparable and can still be improved through laparoscopic
exposure of
the omentum or microsurgical omental transplantation. Due to the relatively high epigastric
hernia
rate [31 ], [32 ], [33 ] and the disadvantages mentioned, it remains as nothing more than a fallback option
in
special cases in our view.
Free flap-plasties
In the event that pedicled flap-plasties are not an option on account of prior operations
or
radiotherapy, free flap-plasties may be used. These techniques also make a useful
addition to the
reconstructive armamentarium as a fall-back procedure in the event of failed coverage
attempts using
local options. Fasciocutaneous or myocutaneous flap-plasties from the back for example
(parascapular
flap) or the thigh (anterior lateral thigh [ALT] ([Figs. 13 ] to [15 ]); Tensor-fasciae-latae-[TFL-]flap). One frequently used donor area is
the abdominal region with the transverse rectus abdominus myocutaneous flap (TRAM)
or its
muscle-preserving variation (ms-TRAM) as well as the perforator-based deep inferior
epigastric
artery perforator flap (DIEP). These flaps also have a certain volume depending on
the constitution
of the patient, so breast reconstruction beyond simple defect coverage can also be
achieved or
sufficient tissue is available to improve the local situation. [Figs. 16 ] and [17 ] show a patient with ulcerated axillary
breast carcinoma metastasis. Due to significantly reduced arm mobility in the case
of scar
contractures, the emphasis here was placed on the improvement of the local situation
after a
detailed explanation of the treatment options. By means of a DIEP flap-plasty, connected
to the
mammaria interna vessels, the existing scarred cords were able to be dispersed and
the mobility of
the shoulder significantly improved. Because the patient expressly refused the formation
of a breast
mound, but was however in a very good general condition, this flap-plasty was able
to be selected
with minimal donor site morbidity.
Fig. 13 Wound healing disorder following ablation of the breast in the case of carcinoma
and defect coverage by means of VRAM and pedicled latissimus dorsi flap-plasty. In
this the
flaps were lifted simply as muscular flaps without a skin paddle, something which
we advise
against on account of the higher complication rate and the smaller size of the flaps.
Fig. 14 Lifting of an anterior-lateral-thigh-flap (ALT) with view of the supply perforator
vessel (the colour and texture change is caused by a prior split skin removal).
Fig. 15 Postoperative situs with well-supplied ALT flap-plasty and successful defect
closure.
Fig. 16 Preoperative situs of a patient, condition after ablation of the right breast for
carcinoma and ulcerated axillary metastasis.
Fig. 17 Postoperative situs after defect closure with DIEP.
The mammaria interna vessels are the primary connecting vessels, depending on the
finding, the
thoraco-dorsal vessels can also act as connectors. In the event that these are not
available, an
arteriovenous loop between the cephalic vein and the thoracoacromial artery, where
the vena
cephalica is dissected from the upper arm in a distal direction, stripped to the required
length and
anastomosed with the arteria thoracoacromialis, can constitute an effort-intensive
solution [34 ].
The donor site morbidity of free flap-plasties is comparatively low, especially if
the donor site can
be closed primarily [35 ], [36 ]. It is not
unusual for free flap-plasties to require operation times of over 6 hours and they
are not suitable
for all patients, particularly those at an advanced stage of progression. They also
require the
relevant microsurgical expertise and intensive monitoring in order to quickly detect
any perforation
disorders and, if need be, to guarantee an emergency anastomosis revision.
Discussion
The indication for operation in patients with an advanced tumour affecting the thoracic
wall often comes
into being on account of pain, ulceration, haemorrhage or odour nuisance resulting
from sloughing
tumours. Their general condition is usually restricted, a long history of illness
preceded and mental
capacity is also reduced. With this in mind, larger interventions must be viewed critically.
Reduced
life expectancy is also frequently used as an argument against intervention, in palliative
situations in
particular. Experience in our own patient population and further studies do however
show a high degree
of patient satisfaction following these interventions because social participation
is made possible for
patients again. If we weigh up the average 3-week hospital stay against the remaining
life expectancy
following thoracic wall resectioning, intervention seems justified if the level of
suffering is reduced
and the remaining time can be made worth living [28 ]. The low 30-day
mortality rates and the limited effects on the lung function parameters back up the
concern about the
negative consequences of thoracic wall resectioning and reconstruction at least partially
[10 ], [28 ], [37 ], [38 ], [39 ], [40 ].
In international references there is a complication rate of almost 30 % which reflects
both the severity
of the underlying disease and the reduced condition of the patients as well as the
complexity of these
interventions [4 ], [6 ], [41 ].
Such disruptions to the wound healing process cause the period of hospitalization
to be extended and
quality of life to deteriorate. Adjuvant radiotherapy or chemotherapy can also be
delayed. Secure
pedicles flap-plasties are sufficiently available for most thoracic wall defects and
should be preferred
owing to the simple and quick dissection as well as their low complication rate [2 ], [4 ], [41 ], [42 ]. Small defects qualify for a pectoralis or thoracoepigastric flap, for larger vertical
defects we prefer the VRAM-flap, large central defects are best suited to an anchor
flap, lateral for an
anchor or latissimus flap. We prefer free flap-plasties over the omentum as a reserve
option due to the
lower donor site morbidity. On account of the size of the flap and the potential back
position and thus
the better possibility of connecting to the mammaria interna vessels, here it is primarily
the anterior
lateral thigh flap (ALT) which is used [43 ]. A recapitulatory therapy
algorithm is depicted in [Fig. 18 ].
Fig. 18 Therapy algorithm for defect coverage of the thoracic wall.
Conclusions
Advanced breast tumours can also be adequately treated by plastic surgery reconstruction
procedures.
Defects which result from radical resection, sometimes involving the thoracic wall
sections, can usually
be safely covered using a pedicled flap-plasty from the torso.
Free flap-plasties as well as the omentum majus remain as fall-back options.
These techniques may be applied not only when aiming to cure, but also in palliative
situations where,
e.g. in the case of ulcerated, painful or sloughing tumours, the patientʼs quality
of life can be
significantly improved. Because, even in the case of partial thoracic wall resection,
the impact on the
respiratory mechanism remains easy to compensate and the donor site morbidity of flap-plasties
is
moderate, a practical treatment option can be offered even in the case of advanced
tumours.
In addition to forming the right indication, under consideration of the individual
patient profile and
the relevant surgical techniques, an interdisciplinary cooperation of all disciplines
involved is
required above all.
Only by doing so can patients with such extensive tumours be cared for optimally.
