Closure of The
Primary Radical Mastectomy A New Method Adrian A transverse incision is
Lambert,
MD
reported with an oblique counterincision to satisfy all Halstedian criteria for tissue removal and to allow as little as possible skin incision to approach the clavicular area. Closure is planned so that there is no tenting of skin or limitation of shoulder motion. performed in such
purpose of this article is to emphasize a method of closure following radical mastectomy that will avoid the complications attending the Halsted type of in¬ cision and the disadvantages usually associated with pri¬ mary closure of radical mastectomy wounds. This approach has been evolved in the last ten years, during which time I have used the transverse incision for all my radical mastectomies, with various types of Zplasty or T-plastic modifications. The last three radical mastectomies have been successfully performed in the manner described below, which has proved by far the most satisfactory method.
TECHNIQUE
a manner as
The
procedure includes
an
open
biopsy examination through
a
transverse incision over the mass to establish the diagnosis. A transverse incision (Fig 1) is then performed to include the closed biopsy incision at its center, 7.5 cm above and below, lateral and medial to the first incision.
The incision is then deepened through the deep layer of super¬ ficial fascia that is used as the limit of the depth of the incision. The breast remains attached to the chest wall, until it is later re¬ moved with pectoral muscles. Staying in this plane, the skin is then flayed up to the clavicle much in the manner of Handley,1 from manubrium to axilla, deep¬ ened above to the axillary vein, and radical mastectomy per¬ formed (Fig 2). With the breast and axillary contents removed, skin flaps are modified by using a short upper oblique counterincision. In addition, the skin flap posteriorly is mobilized to a line approximately 7.5 cm posterior to the posterior axillary line over the latissimus dorsi muscle (Fig 3) from axilla to the costal mar¬
gin.
This enables an effective skin closure that not only allows full motion in all directions without tension but affords an ax¬ illary flap of viable skin and subcutaneous tissue that responds to arm motion by emptying the axilla of its underlying serum, rather than the tenting that attends the usual skin incision. There are two principles that should be observed during this dissection. The first is that wide flaps of skin including the subcu¬ taneous tissues may be formed without imperiling the blood sup¬ ply of the skin, provided that this layer is strictly preserved. Blood supply to the skin is lost when it is separated by too thin a layer of fat and fascia over the extrathoracic muscles. The second point is that by mobilizing the chest wall skin and subcutaneous tissues 7.5 cm behind the latissimus, it is possible to bring this whole skin flap forward up toward the clavicle to fill the axilla. arm
REPORT OF A CASE A
65-year-old woman, on whom I had performed a right radical 15 years previously, at present admission had a 2-cm
mastectomy
in the outer aspect of the left breast. No nodes were felt and excisional biopsy examination revealed a primary carcinoma of the breast. mass an
Accepted
publication Dec 11, 1974. Department of Surgery, Roosevelt Hospital, New York. Reprint requests to 768 Park Ave, New York, NY 10021 (Dr. Lambert). for
From the
Downloaded From: http://archsurg.jamanetwork.com/ by a Western University User on 06/06/2015
Fig 1.—Defect of chest wall to be closed following removal of breast. Incision ex¬ tends from point AB beyond midline to pos¬ terior axillary line H. Counterincision ex¬ tends from point J at midclavicular line halfway between clavicle and upper edge of skin incision to point IL at junction of outer
Fig 2.—Extent of mobilization of skin and deep subcutaneous fat that is made around centrally placed 15-cm squared skin defect (shaded area).
Fig 3.—Lateral view showing extent (shaded area) of skin mobilization from chest wall that is made 7.5 cm posterior to
Fig 5.—Newly sutured wound illustrates position of various points in skin clo¬ sure. There is no tension on lower flaps
Fig 6.—Arm abducted at 90° shows lack of tension and absence of fluid accumula¬ tion under arm on fifth postoperative day.
anterior border of latissimus dorsi muscle downward toward costal margin.
and middle third of upper aspect of incision.
D
\
Fig 4.—Reconstruction of chest wall skin flaps after full mobilization. Point AB is ap¬ proximated to establish medial point of
transverse incision. Points CD and EF are approximated as shown to allow DF to ad¬
join and thus form downward arm DFM. Flap of viable skin and subcutaneous tissue is then formed, KLH, and swung around an¬ terior border of scapula and up into axilla, so as to reapproximate skin points as indi¬ cated: H joins I, L joins J, and is brought up to inner portion of arm.
new
FJDM and MFG because of mobilization of skin and subcutaneous tissues anteriorly and laterally down to costal margin.
She underwent radical mastectomy utilizing the transverse inci¬ sion with the oblique counterincision as outlined (Fig 4 and 5) and closed with a single layer of through-and-through 2-0 silk sutures. A large 0.5-cm plastic drain was placed laterally toward but not into the axilla and brought out to suction. The patient, while under anesthesia, was supported upright by a wide powdered board pos¬ teriorly that was included in the 15-cm isoadhesive circular elastic bandage and removed after the dressing was in place. The arm was not incorporated, and early motion was encouraged on the second postoperative day. About 150 ml was drained on the first day, 25 ml on the second, and the drain was removed on the third postoperative day (Fig 6); sutures were removed on the 14th day. Her course was uneventful with no postoperative infection or
lymphedema.
COMMENT It is to be stressed that use of this incision in no way violates the principles of adequate radical cancer surgery as laid down by Halsted. Rather, it calls attention to an al¬ ternate method of closure that accomplishes the same re¬ sults without tenting of the axilla and allows early full arm motion with minimum serum accumulation without ne¬
crosis, infection,
or
lymphedema. Reference
1. Handley WS: Cancer of the Breast. London, John Murray, 1906, p 180.
Downloaded From: http://archsurg.jamanetwork.com/ by a Western University User on 06/06/2015
Primary Radical Mastectomy A New Method Adrian A transverse incision is
Lambert,
MD
reported with an oblique counterincision to satisfy all Halstedian criteria for tissue removal and to allow as little as possible skin incision to approach the clavicular area. Closure is planned so that there is no tenting of skin or limitation of shoulder motion. performed in such
purpose of this article is to emphasize a method of closure following radical mastectomy that will avoid the complications attending the Halsted type of in¬ cision and the disadvantages usually associated with pri¬ mary closure of radical mastectomy wounds. This approach has been evolved in the last ten years, during which time I have used the transverse incision for all my radical mastectomies, with various types of Zplasty or T-plastic modifications. The last three radical mastectomies have been successfully performed in the manner described below, which has proved by far the most satisfactory method.
TECHNIQUE
a manner as
The
procedure includes
an
open
biopsy examination through
a
transverse incision over the mass to establish the diagnosis. A transverse incision (Fig 1) is then performed to include the closed biopsy incision at its center, 7.5 cm above and below, lateral and medial to the first incision.
The incision is then deepened through the deep layer of super¬ ficial fascia that is used as the limit of the depth of the incision. The breast remains attached to the chest wall, until it is later re¬ moved with pectoral muscles. Staying in this plane, the skin is then flayed up to the clavicle much in the manner of Handley,1 from manubrium to axilla, deep¬ ened above to the axillary vein, and radical mastectomy per¬ formed (Fig 2). With the breast and axillary contents removed, skin flaps are modified by using a short upper oblique counterincision. In addition, the skin flap posteriorly is mobilized to a line approximately 7.5 cm posterior to the posterior axillary line over the latissimus dorsi muscle (Fig 3) from axilla to the costal mar¬
gin.
This enables an effective skin closure that not only allows full motion in all directions without tension but affords an ax¬ illary flap of viable skin and subcutaneous tissue that responds to arm motion by emptying the axilla of its underlying serum, rather than the tenting that attends the usual skin incision. There are two principles that should be observed during this dissection. The first is that wide flaps of skin including the subcu¬ taneous tissues may be formed without imperiling the blood sup¬ ply of the skin, provided that this layer is strictly preserved. Blood supply to the skin is lost when it is separated by too thin a layer of fat and fascia over the extrathoracic muscles. The second point is that by mobilizing the chest wall skin and subcutaneous tissues 7.5 cm behind the latissimus, it is possible to bring this whole skin flap forward up toward the clavicle to fill the axilla. arm
REPORT OF A CASE A
65-year-old woman, on whom I had performed a right radical 15 years previously, at present admission had a 2-cm
mastectomy
in the outer aspect of the left breast. No nodes were felt and excisional biopsy examination revealed a primary carcinoma of the breast. mass an
Accepted
publication Dec 11, 1974. Department of Surgery, Roosevelt Hospital, New York. Reprint requests to 768 Park Ave, New York, NY 10021 (Dr. Lambert). for
From the
Downloaded From: http://archsurg.jamanetwork.com/ by a Western University User on 06/06/2015
Fig 1.—Defect of chest wall to be closed following removal of breast. Incision ex¬ tends from point AB beyond midline to pos¬ terior axillary line H. Counterincision ex¬ tends from point J at midclavicular line halfway between clavicle and upper edge of skin incision to point IL at junction of outer
Fig 2.—Extent of mobilization of skin and deep subcutaneous fat that is made around centrally placed 15-cm squared skin defect (shaded area).
Fig 3.—Lateral view showing extent (shaded area) of skin mobilization from chest wall that is made 7.5 cm posterior to
Fig 5.—Newly sutured wound illustrates position of various points in skin clo¬ sure. There is no tension on lower flaps
Fig 6.—Arm abducted at 90° shows lack of tension and absence of fluid accumula¬ tion under arm on fifth postoperative day.
anterior border of latissimus dorsi muscle downward toward costal margin.
and middle third of upper aspect of incision.
D
\
Fig 4.—Reconstruction of chest wall skin flaps after full mobilization. Point AB is ap¬ proximated to establish medial point of
transverse incision. Points CD and EF are approximated as shown to allow DF to ad¬
join and thus form downward arm DFM. Flap of viable skin and subcutaneous tissue is then formed, KLH, and swung around an¬ terior border of scapula and up into axilla, so as to reapproximate skin points as indi¬ cated: H joins I, L joins J, and is brought up to inner portion of arm.
new
FJDM and MFG because of mobilization of skin and subcutaneous tissues anteriorly and laterally down to costal margin.
She underwent radical mastectomy utilizing the transverse inci¬ sion with the oblique counterincision as outlined (Fig 4 and 5) and closed with a single layer of through-and-through 2-0 silk sutures. A large 0.5-cm plastic drain was placed laterally toward but not into the axilla and brought out to suction. The patient, while under anesthesia, was supported upright by a wide powdered board pos¬ teriorly that was included in the 15-cm isoadhesive circular elastic bandage and removed after the dressing was in place. The arm was not incorporated, and early motion was encouraged on the second postoperative day. About 150 ml was drained on the first day, 25 ml on the second, and the drain was removed on the third postoperative day (Fig 6); sutures were removed on the 14th day. Her course was uneventful with no postoperative infection or
lymphedema.
COMMENT It is to be stressed that use of this incision in no way violates the principles of adequate radical cancer surgery as laid down by Halsted. Rather, it calls attention to an al¬ ternate method of closure that accomplishes the same re¬ sults without tenting of the axilla and allows early full arm motion with minimum serum accumulation without ne¬
crosis, infection,
or
lymphedema. Reference
1. Handley WS: Cancer of the Breast. London, John Murray, 1906, p 180.
Downloaded From: http://archsurg.jamanetwork.com/ by a Western University User on 06/06/2015
