Annals of the Royal College of Surgeons of Englanld (1976) vol 58 ASPECTS OF TREATMENT*
Repair of chest wall defects after irradiation for breast cancer L E Hughes
FRCS FRACS
Professor of Surgery, Welsh National School of Medicine, Cardiff
Summary A simple technique using a contralateral deltopectoral flap is described for the immediate repair of defects of the chest wall resulting from excision of radionecrosis or persistent tumour after radiotherapy. Successful use in 3 consecutive cases has shown that the deltopectoral flap may be r otated through a full I8o0o without compromise of blood supply and that primary healing may be obtained.
Introduction Surgery to the chest wall after high-dosage radiotherapy has always been fraught with problems, the most serious ones being poor blood supply and resultant failure of healing and the fact that the process usually involves the whole thickness of the chest wall. Such lesions must be repaired with tissue of substantial thickness to lessen the effects of paradoxical chest movement and with tissue that brings its own blood supply to ensure healing. Local tissues cannot be used for this purpose since the whole area has usually been subjected to irradiation, with resulting interference with healing and blood supply. Ulcers due to radionecrosis will not only fail to heal spontaneously but are frequently associated with severe intractable pain and persistent, sometimes offensive, discharge. The need to repair the chest wall after maximal radiotherapy for breast cancer arises in two situations. Occasionally resection is called for for persistent or recurrent tumour. Korlof et al.' have shown that with careful selection of cases good palliation is frequently obtained for 2-3 years and occasional longterm survival is seen. More commonly resec-
tion is required because of radionecrosis, though fortunately this is becoming rare as techniques of radiotherapy improve. Many techniques of repair have been described in the past and these have been reviewed by Rees and Converse2, though these authors do not give any results of the various methods. Most commonly complicated flaps have been used, either delayed, from the abdominal wall, or carried from the wrist, but such procedures are time-consuming and of uncertain outcome. The opposite breast may be used if it is of adequate size and mobility, but the cosmetic and psychological results of the midline breast are such that this should be used only as a last resort. The most satisfactory technique so far developed is that of omental transposition described by Kiricuta3. After mobilization of the greater omentum on a right- or left-based pedicle the omentum is brought up through a subcutaneous tunnel and used as a base for split skin grafting. Kiricuta has had excellent results with this technique, but it is a major procedure which carries the complications of laparotomy in addition to those of a chest procedure. More recently Cort and Collis4 have described a single case in which they modified Kiricuta's technique by transposing the origin of the diaphragm to above the defect to lessen the effects of paradoxical respiration. The deltopectoral flap was first described by Aymard in I9I75 as a means of reconstructing the nose, but its present-day place in reconstructive surgery stems from the work of Bakamjian6. Personal experience of the excellent blood supply carried by this flap when used in the surgery of oral cancer suggested that it should be possible to turn this flap completely
*Fellows and Members interested in submitting articles for to publication in this series should first write to the Editor
conisideration
with a view
Repair of chest wall defects after irradiation for breast cancer on itself, rotating it through I 8o0, without conmpromising the blood supply. Such has proved to be the case and the flap has been used successfully in 3 consecutive cases.
The operation Principles The aims of excision and repair of radionecrotic lesions are to provide an airtight repair which will heal primarily and will provide sufficient rigidity to minimize paradoxical movement of the affected chest wall. Since a large area of the chest wall is likely to have been irradiated total excision of the irradiated tissues is not practicable. This means that the transposed tissue should itself carry an excellent blood supply if primary healing is to be obtained. Thus tissues which have a good intrinsic blood supply, such as omentum or deltopectoral flap, are more likely to be successful than pedicle flaps that require a delaying procedure to ensure an adequate blood supply. With modern radiation techniques radionecrosis is likely to occur in the medial portion of the chest wall, where the costal cartilages are directly under the skin whose blood supply has been interrupted by division during mastectomy of the perforating branches of the internal mammary artery. Such lesions are usually localized (Fig. i) and skin and subcutaneous tissue need be excised only until good bleeding from the tissues is seen. However, it is necessary to excise totally the affected costal cartilages since with their poor blood supply they are unlikely to heal. Paradoxical movement is not a major problem with relatively small defects and is minimized if the parietal pleura is preserved, since in the irradiated area this is a tough, thickened layer. Replacement with a good thickness of subcutaneous fat is also desirable.
Careful attention to technique if is important satisfactory results are to be obtained. The area of radionecrosis is excised sufficiently widely to ensure that the cut edges bleed freely. Any affected costal cartilage must be excised in toto by resecting back to the cancellous bone of rib laterally and sternum
Technique
medially. It is important that the parietal pleura remain intact both because it provides a firm base for the deltopectoral flap and because its
14I
rigidity lessens paradoxical movement. At first it appears to be densely adherent to the necrotic costal cartilage, but in each case it has proved possible to separate it from the cartilage by careful blunt dissection. The pleura may be punctured during this procedure, but small defects can be closed with a catgut suture reinforced with a piece of absorbable sponge. This procedure has been satisfactory in each of the 3 cases reported here, but should the pleura have to be sacrificed it may be replaced by fascia lata or ox fascia or the visceral pleura of the lung may be sutured round the edges of the defect. The deltopectoral flap, based on at least 3 perforating branches of the internal mammary artery (2nd, 3rd, and 4th) is raised in nornal fashion and nmobilized as far medially as possible while still ensuring that the perforating arteries are preserved. The flap should be taken right down to the fascia over the deltoid and pectoral muscles to utilize the full thickness of subcutaneous tissue. It has not been found necessary to delay the deltopectoral flap. The flap is then turned across the midline and sewn into the 3 sides of the defect (Fig. 3). On the medial aspect an airtight closure is obtained by a continuous subcutaneous suture between the deep aspect of the flap and the medial edge of the defect. A suction drain is placed between the flap and the parietal pleura. The donor area of the deltopectoral flap is covered by a split skin graft applied by the open method at 48 h (Fig. 3). Two weeks later the flap is partially divided, a quarter of its width on each side, and then completely divided a week later. The excess flap is returned to its original site and the patient is able to leave hospital during the 4th week.
Case histories Case I A woman aged 64 years underwent radical mastectomy followed by postoperative radiotherapy in I947. In I964 she developed an ulcer over the medial ends of the 3rd and 4th ribs and the tumour showed no response to local treatment. From 1970 to 1973 the ulcer became increasingly painful and associated with offensive purulent discharge (Fig. i). She wvas referred for consideration of excision and this was carried out in February 1974, removing the ulcer en bloc with the underlying costal cartilages and with immediate repair by a contralateral deltopectoral flap. The donor area was covered with a split skin graft applied by the delayed exposed meiliod
142
L E Hughes
FIG. 3 Delto pectoral flap in Case 2, showing direct suture of flap to portion of old split FIG. I
Radionecrotic ulcer, Case i.
skin graft.
FIG. 2 Final result, Case i. until the free portion of the flap was returned. Primary healing occurred and the patient remains symptom-free at the present time (Fig. 2). Case 2 A woman aged 6i years presented with a Stage T3NoMo growth of the right breast which was treated by radical radiotherapy. As incomplete regression of the tumour occurred this was followed 3 months later by radical mastectomy with skin graft. Six months later a 3-cm ulcer appeared in the medial end of the skin graft, with involvement of the underlying costal cartilages. Pain was severe, so excision of the ulcer, with a 2-cm margin and the whole of the 2 involved costal cartilages, was carried out and immediate repair effected with a contralateral deltopectoral flap. The lateral half of the skin graft overlying ribs was left in situ and the lateral margin of the deltopectoral flap sewn to the skin graft (Fig. 3). Primary healing was obtained. The patient remains well I8 months later and has since undergone uneventful cholecystectomy for acute cholecystitis. Case 3 A patient aged 5' years presented in i969 with a TN,Mo carcinoma of the left breast treated
FIG. 4 Recurrent carcinoma of breast, Case 3.
FIG. 5 Deltopectoral flap repair, Case
3.
Repair of chest wall defects after irradiation for breast cancer
I43
costal cartilages, and in view of the heavy irradiation to the area, it was treated by wide local excision of the tumour and underlying chest wall in continuity with immediate repair by contralateral deltopectoral flap (Fig. 5). The lateral portion of the donor area was treated by a split skin graft applied by the delayed exposed method, and the medial portion of the donor area was left open until the free portion of the flap was retumed at 3 weeks. Primary healing was obtained (Fig. 6). The patient remained well for one year, when involved lymph nodes became evident in the ipsilateral axilla, for which axillary block dissection was performed. The patient has no clinical evidence of residual disease at the present time.
FIG. 6 Final result in Case 3
References i
initially by oophorectomy. One ovary contained metastatic tumour. Over the next 4 years the local tumour was controlled by 2 courses of radiotherapy, one radical and the second, 3 years later, to the tumour only (total 7500 rads) and cyclophosphamide. In 1973 the growth began to progress again (Fig. 4) and as no evidence of further distant spread was found on bone scan and X-ray surveys the patient was referred for consideration of radical local surgery. As the tumour was attached to the underlying
2
3 4 5 6
Korlof, B, Nylen, B, Olsson, T, Skoogt, T, and Strombeck, J (I973) British Journal of Plastic Surgery, 26, 322. Rees, T M, and Converse, J M (I965) Surgery, Gynecology and Obstetrics, 12I, io66. Kiricuta, I (i963) Presse Medicale, 71, 15. Cort, D F, and Collis, J L (I973) British Journal of Surgery, 6o, 582. Aymard, J L (I917) Lancet, 2, 888. Bakamjian, D Y (I965) Plastic and Reconstructive Surgery, 36, 173.
Repair of chest wall defects after irradiation for breast cancer L E Hughes
FRCS FRACS
Professor of Surgery, Welsh National School of Medicine, Cardiff
Summary A simple technique using a contralateral deltopectoral flap is described for the immediate repair of defects of the chest wall resulting from excision of radionecrosis or persistent tumour after radiotherapy. Successful use in 3 consecutive cases has shown that the deltopectoral flap may be r otated through a full I8o0o without compromise of blood supply and that primary healing may be obtained.
Introduction Surgery to the chest wall after high-dosage radiotherapy has always been fraught with problems, the most serious ones being poor blood supply and resultant failure of healing and the fact that the process usually involves the whole thickness of the chest wall. Such lesions must be repaired with tissue of substantial thickness to lessen the effects of paradoxical chest movement and with tissue that brings its own blood supply to ensure healing. Local tissues cannot be used for this purpose since the whole area has usually been subjected to irradiation, with resulting interference with healing and blood supply. Ulcers due to radionecrosis will not only fail to heal spontaneously but are frequently associated with severe intractable pain and persistent, sometimes offensive, discharge. The need to repair the chest wall after maximal radiotherapy for breast cancer arises in two situations. Occasionally resection is called for for persistent or recurrent tumour. Korlof et al.' have shown that with careful selection of cases good palliation is frequently obtained for 2-3 years and occasional longterm survival is seen. More commonly resec-
tion is required because of radionecrosis, though fortunately this is becoming rare as techniques of radiotherapy improve. Many techniques of repair have been described in the past and these have been reviewed by Rees and Converse2, though these authors do not give any results of the various methods. Most commonly complicated flaps have been used, either delayed, from the abdominal wall, or carried from the wrist, but such procedures are time-consuming and of uncertain outcome. The opposite breast may be used if it is of adequate size and mobility, but the cosmetic and psychological results of the midline breast are such that this should be used only as a last resort. The most satisfactory technique so far developed is that of omental transposition described by Kiricuta3. After mobilization of the greater omentum on a right- or left-based pedicle the omentum is brought up through a subcutaneous tunnel and used as a base for split skin grafting. Kiricuta has had excellent results with this technique, but it is a major procedure which carries the complications of laparotomy in addition to those of a chest procedure. More recently Cort and Collis4 have described a single case in which they modified Kiricuta's technique by transposing the origin of the diaphragm to above the defect to lessen the effects of paradoxical respiration. The deltopectoral flap was first described by Aymard in I9I75 as a means of reconstructing the nose, but its present-day place in reconstructive surgery stems from the work of Bakamjian6. Personal experience of the excellent blood supply carried by this flap when used in the surgery of oral cancer suggested that it should be possible to turn this flap completely
*Fellows and Members interested in submitting articles for to publication in this series should first write to the Editor
conisideration
with a view
Repair of chest wall defects after irradiation for breast cancer on itself, rotating it through I 8o0, without conmpromising the blood supply. Such has proved to be the case and the flap has been used successfully in 3 consecutive cases.
The operation Principles The aims of excision and repair of radionecrotic lesions are to provide an airtight repair which will heal primarily and will provide sufficient rigidity to minimize paradoxical movement of the affected chest wall. Since a large area of the chest wall is likely to have been irradiated total excision of the irradiated tissues is not practicable. This means that the transposed tissue should itself carry an excellent blood supply if primary healing is to be obtained. Thus tissues which have a good intrinsic blood supply, such as omentum or deltopectoral flap, are more likely to be successful than pedicle flaps that require a delaying procedure to ensure an adequate blood supply. With modern radiation techniques radionecrosis is likely to occur in the medial portion of the chest wall, where the costal cartilages are directly under the skin whose blood supply has been interrupted by division during mastectomy of the perforating branches of the internal mammary artery. Such lesions are usually localized (Fig. i) and skin and subcutaneous tissue need be excised only until good bleeding from the tissues is seen. However, it is necessary to excise totally the affected costal cartilages since with their poor blood supply they are unlikely to heal. Paradoxical movement is not a major problem with relatively small defects and is minimized if the parietal pleura is preserved, since in the irradiated area this is a tough, thickened layer. Replacement with a good thickness of subcutaneous fat is also desirable.
Careful attention to technique if is important satisfactory results are to be obtained. The area of radionecrosis is excised sufficiently widely to ensure that the cut edges bleed freely. Any affected costal cartilage must be excised in toto by resecting back to the cancellous bone of rib laterally and sternum
Technique
medially. It is important that the parietal pleura remain intact both because it provides a firm base for the deltopectoral flap and because its
14I
rigidity lessens paradoxical movement. At first it appears to be densely adherent to the necrotic costal cartilage, but in each case it has proved possible to separate it from the cartilage by careful blunt dissection. The pleura may be punctured during this procedure, but small defects can be closed with a catgut suture reinforced with a piece of absorbable sponge. This procedure has been satisfactory in each of the 3 cases reported here, but should the pleura have to be sacrificed it may be replaced by fascia lata or ox fascia or the visceral pleura of the lung may be sutured round the edges of the defect. The deltopectoral flap, based on at least 3 perforating branches of the internal mammary artery (2nd, 3rd, and 4th) is raised in nornal fashion and nmobilized as far medially as possible while still ensuring that the perforating arteries are preserved. The flap should be taken right down to the fascia over the deltoid and pectoral muscles to utilize the full thickness of subcutaneous tissue. It has not been found necessary to delay the deltopectoral flap. The flap is then turned across the midline and sewn into the 3 sides of the defect (Fig. 3). On the medial aspect an airtight closure is obtained by a continuous subcutaneous suture between the deep aspect of the flap and the medial edge of the defect. A suction drain is placed between the flap and the parietal pleura. The donor area of the deltopectoral flap is covered by a split skin graft applied by the open method at 48 h (Fig. 3). Two weeks later the flap is partially divided, a quarter of its width on each side, and then completely divided a week later. The excess flap is returned to its original site and the patient is able to leave hospital during the 4th week.
Case histories Case I A woman aged 64 years underwent radical mastectomy followed by postoperative radiotherapy in I947. In I964 she developed an ulcer over the medial ends of the 3rd and 4th ribs and the tumour showed no response to local treatment. From 1970 to 1973 the ulcer became increasingly painful and associated with offensive purulent discharge (Fig. i). She wvas referred for consideration of excision and this was carried out in February 1974, removing the ulcer en bloc with the underlying costal cartilages and with immediate repair by a contralateral deltopectoral flap. The donor area was covered with a split skin graft applied by the delayed exposed meiliod
142
L E Hughes
FIG. 3 Delto pectoral flap in Case 2, showing direct suture of flap to portion of old split FIG. I
Radionecrotic ulcer, Case i.
skin graft.
FIG. 2 Final result, Case i. until the free portion of the flap was returned. Primary healing occurred and the patient remains symptom-free at the present time (Fig. 2). Case 2 A woman aged 6i years presented with a Stage T3NoMo growth of the right breast which was treated by radical radiotherapy. As incomplete regression of the tumour occurred this was followed 3 months later by radical mastectomy with skin graft. Six months later a 3-cm ulcer appeared in the medial end of the skin graft, with involvement of the underlying costal cartilages. Pain was severe, so excision of the ulcer, with a 2-cm margin and the whole of the 2 involved costal cartilages, was carried out and immediate repair effected with a contralateral deltopectoral flap. The lateral half of the skin graft overlying ribs was left in situ and the lateral margin of the deltopectoral flap sewn to the skin graft (Fig. 3). Primary healing was obtained. The patient remains well I8 months later and has since undergone uneventful cholecystectomy for acute cholecystitis. Case 3 A patient aged 5' years presented in i969 with a TN,Mo carcinoma of the left breast treated
FIG. 4 Recurrent carcinoma of breast, Case 3.
FIG. 5 Deltopectoral flap repair, Case
3.
Repair of chest wall defects after irradiation for breast cancer
I43
costal cartilages, and in view of the heavy irradiation to the area, it was treated by wide local excision of the tumour and underlying chest wall in continuity with immediate repair by contralateral deltopectoral flap (Fig. 5). The lateral portion of the donor area was treated by a split skin graft applied by the delayed exposed method, and the medial portion of the donor area was left open until the free portion of the flap was retumed at 3 weeks. Primary healing was obtained (Fig. 6). The patient remained well for one year, when involved lymph nodes became evident in the ipsilateral axilla, for which axillary block dissection was performed. The patient has no clinical evidence of residual disease at the present time.
FIG. 6 Final result in Case 3
References i
initially by oophorectomy. One ovary contained metastatic tumour. Over the next 4 years the local tumour was controlled by 2 courses of radiotherapy, one radical and the second, 3 years later, to the tumour only (total 7500 rads) and cyclophosphamide. In 1973 the growth began to progress again (Fig. 4) and as no evidence of further distant spread was found on bone scan and X-ray surveys the patient was referred for consideration of radical local surgery. As the tumour was attached to the underlying
2
3 4 5 6
Korlof, B, Nylen, B, Olsson, T, Skoogt, T, and Strombeck, J (I973) British Journal of Plastic Surgery, 26, 322. Rees, T M, and Converse, J M (I965) Surgery, Gynecology and Obstetrics, 12I, io66. Kiricuta, I (i963) Presse Medicale, 71, 15. Cort, D F, and Collis, J L (I973) British Journal of Surgery, 6o, 582. Aymard, J L (I917) Lancet, 2, 888. Bakamjian, D Y (I965) Plastic and Reconstructive Surgery, 36, 173.
![[Interdisciplinary treatment of extensive chest wall defects due to irradiation].](/assets/img/hold.png)
