POST-MASTECTOMY BREAST RECONSTRUCTION

JAMES ET ALll

THE EVOLUTION OF BREAST R E C O N S T R U C T I O N A F T E R MASTECTOMY FOR CANCER

J. T. HUESTON

Melbourne See Editorial Comment, this issue.

RECTUS ABDOMlNlS MYOCUTANEOUS FLAP FOR BREAST RECONSTRUCTION THOMAS H. ROBBINS

Melbourne A method of breast reconstruction for the post-mastectomy patient, using a rectus abdominis myocutaneous island flap as a one-stage procedure, is presented. It Is considered that this method produces improved results.

THE utilization of breast reconstruction for the post-mastectomy patient has been retarded by the ignorance of the patient, perhaps by the prejudice of the ablative surgeon, and certainly by the dissatisfaction of the reconstructive surgeon with earlier results. These earlier attempts at breast reconstruction following mastectomy involved timeconsuming multistaged pedicled skin flaps. They produced multiple areas of scarring at various sites and gave poor aesthetic results. Later the subcutaneous placement of silastic implants provided a one-stage procedure, but r e s u l t s have o f t e n b e e n g r o t e s q u e a n d embarrassing. The rectus abdominis myocutaneous island flap to augment bulk and introduce additional skin cover in breast reconstruction overcomes these problems. Reprints: Consultants Suite, Southland Centre, Cheltenham, Victoria 31 92

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METHOD The proposed flap (Figures l a , b) is marked before operation with the patient in the erect position. The outline of the rectus abdominis muscle of the same side as the defect is marked from its upper limits above the costal margin to just beyond the level of the umbilicus. A line is drawn laterally from the base of this flap over the mastectomydefect. It represents the incision into which the myocutaneous flap is to be transposed. It can be varied, and its exact siting is dictated by the previous mastectomy scar and other scars. The flap is incised around its periphery (Figures 2a, b). The proximal part of this overlies the thoracic cage. This protects the superior epigastric vessels which enter the rectus abdominis muscle from below the costal margin. Below the costal margin the incision is carried down to the muscle layer.The anterior sheath of the rectus abdominis muscle is divided vertically along its lateral and medial edges, 527

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The myocutaneous flap is transposed (Figures3a, b) through 90" into the transverse defect. The subcutaneous fat of the flap and the rectus abdominis muscle are buried under the upper and lower edges of the transverse incision. Both ends of the flap are de-epithelialized and buried under the skin of the chest wall to improve breast contour and bulk. The buried lateral end simulates theaxillary tail of the breast, and the buried medial end improves

FIGURE 1: (a) view of the defect to be reconstructed. The patient has had a Patey mastectomy with tight skin closure and fonowed by radiotherapy. The mulitple scars represent previous local skin flaps in an attempt to accommodate a silastic implant; (b) this illustrates the site and size of the myocutansous flap to be raised. The dotted lines and the full transverse line mark scarring from previous surgery. The flap will be transposed into a transverse incision placed along one of these scars. The proximal limit of the island skin flap is not marked. It extends as a triangle two inches proximal to the scar marked b y the interrupted lines. The costal margin and the surface markings of the superior epigastric vessels are indicated.

and then transversely at the distal limit of the flap. The rectus abdominis muscle is transected at the level of the distal limit of the flap and mobilized by digital separation from the posteror rectus sheath. The axial (superior epigastric) vessels entering the muscle from beneath the costal margin can be clearly seen and easily avoided. The muscle is then freed on its deep surface from the underlying costal cage. T h e superior epigastric vessels are consciously respected while this is being done. The transverse lateral incision (Figure 2b) is made down to the muscle layer, and the chest wall skin is undermined both above and below.

FIGURE2: (a) the myocutaneous flap of the rectus abdominis muscle and the overlying skin has been raised. The vessels of supply can be seen entering the muscle from beneath the costal margin: (b) the flap has been replaced in its bed and its upper limits defined by incision through the skin and muscle down to the thoracic cage. The underlying rectus abdominis muscle is separated from the thoracic cage The vessels at this level are protected behind the thoracic cage. A transverse incision into which the flap will be transposed has been madeand theskinof the chest wall above and below undermined.

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ROBBINS

RECTUS ABDOMlNlS FLAP FOR BREAST RECONSTRUCTION

3: (a) the myocutaneous flap has been transposed into position and the donor site closed directly. Both ends of the flap have FIGURE been de-epithelialized and buried to increase bulk and produce a midlinecleavage mediallyand an axillary tail laterally. The superior epigastric vessels are easily identified and respected. The "dog-ear" produced medially on transposition of the flap has been de-epithelialized over a small triangular area. This will be buried and closed directly to increase bulk and improve contour; (b) this shows the flap in position and suturing completed. The photograph was take\ at the first postoperative dressing on the first postoperative day. The vertical suture line within the area of the flap shows where the de-epithelialized "dog-ear" was buried; (c, d) oblique postoperative views showing the final result.

the breast cleavage. This transposition produces a dog-ear close to the medial end of the transposed flap. This dog-ear is de-epithelialized over a triangular area and buried by direct approximation of the wound edges. The flap donor site is closed directly in one layer, using 3/0 nylon and suturing the skin and the edges of the rectus abdominis sheath together so that muscle continuity of the upper abdomen is restored. A gauze and Elastoplast dressing is applied. The dressing is changed the following day to check for viability of the skin and to exclude haematoma. The patient is usually discharged from hospital on the third postoperative day, wearing a brassiere over a gauze dressing. The sutures are AUST. N.Z. J. SURG.VOL. 49-No.

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removed at two weeks. The final result is shown in Figure 3, a, b. aMMENT

This method of reconstruction has been used on four occasions. It is considered that operative and postoperative management has been simplified and superior results produced. The bulk of the muscle and subcutaneous fat has been sufficient to produce a satisfactory breast size and shape, and silastic implants were not necessary. This is considered a further advantage. In each case the viability of the flap was never in doubt. The distal end of the transected rectus abdominis muscle had to be oversewn because of 529

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profuse bleeding, and where the flap was deepithelialized at each end and at the site of the dogear copious bleeding confirmed the viability of the flap. The patient illustrated had put on one stone in weight over a short time before operation. At the operation the abdominal subcutaneous fat was two inches thick and separated the skin from the rectus abdominis muscle by this distance, but the viability of the muscle and the skin of the flap was never in doubt. The length of the flap taken was more than adequate for reconstruction of the breast, and allowed for the ends of the flap to be buried for reconstruction of an axillary tail laterally and improved cleavage medially. Clearly the length of the flap taken was adequately supplied by the superior epigastric artery. The distal part of the rectus abdominis muscle was not needed, and in any case its use is considered unreliable because of its axial blood flow from the inferior epigastric vessels. Further, the distal portion of the rectus abdominis muscle has no posterior sheath, and it isconsidered that this would be a relative contra-indication to the use of this part of the muscle. ’ The donor site scar represented by an upper paramedian abdominal scar is considered acceptable. Direct closure of the donor site defect has been effected without tension, and patients have

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expressed satisfaction with their improved abdominal contour. Skin sensation to touch has been retained on the flap except at its extreme lateral (distal) part. This has added to the satisfaction of the patient, and would tend to confirm that the muscle has not been completely denervated and should therefore not atrophy completely. Even if it should a silastic implant could be inserted later. A delayed p r i m a r y o r early secondary reconstruction was used in each case. It is felt that there is no need for women to suffer the torment resulting from an amputated breast for long periods of time in view of the fact that any local recurrence following radical mastectomy is usually not susceptible of surgical treatment and indicates a very poor prognosis. It was felt, however, that the patient should see the effect of the ablative surgery and the problem that the reconstructivesurgeon has to deal with, so that she can appreciate more the efforts of the reconstructive surgeon. Further, it should be stressed to the ablative surgeon that the patient should not be reassured in such a way that her expectations from reconstructive surgery become unrealistic. Discussion with respect to this should be left to the reconstructive surgeon, who can speak to the patient in realistic terms.

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Rectus abdominis myocutaneous flap for breast reconstruction.

POST-MASTECTOMY BREAST RECONSTRUCTION JAMES ET ALll THE EVOLUTION OF BREAST R E C O N S T R U C T I O N A F T E R MASTECTOMY FOR CANCER J. T. HUEST...
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