Surgical Closure of Chest Wall in Noninflammatory Locally Advanced Breast Carcinoma with Ulceration of the Skin¹

Abstract

Patients with noninflammatory locally advanced breast cancer with ulceration of skin or muscle or parietal wall infiltration, better named "extended locally advanced breast cancer," may require cancer surgery and plastic reconstruction of the chest wall after multidisciplinary evaluation. The decision is made to improve quality of life, independently of prognosis, and severity of the disease. The aim of this study is to evaluate the best method for surgical closure of the chest wall and to check whether ablative surgery is an appropriate procedure in regards to the treatment of cancer. From October 1997 to June 2006, 27 patients with noninflammatory extended locally advanced breast cancer with ulceration of the skin, who were not candidate or did not respond to a neo-adjuvant treatment, underwent radical mastectomy and reconstructive surgery. Sixteen patients (59%) were affected by primary tumors of the breast, and eleven patients (41%) had local recurrence after mastectomy or conservative breast surgery. Two main techniques were used for breast reconstruction: transverse rectus-abdominis musculo cutaneous flap in 19 patients (70%), and a fasciocutaneous flap in eight patients (30%). The best procedure in each patient was chosen according to the extent of skin loss or previous radiotherapy to the chest wall. Fourteen patients (52%) died during the follow-up and the median length of survival was 16 months (range 3-79) in transverse rectus-abdominis musculo cutaneous group and 4 months (range 2-23) in fasciocutaneous flap group. The median length of follow-up after treatment for patients still alive was 32.5 months (range 0-96) in transverse rectus-abdominis musculo cutaneous flap group, and 18 months (range 8-41) in fasciocutaneous flap group. At the end of the follow-up, 10 patients were alive without evidence of disease and three patients developed metastatic lesion or local recurrence. The longest recorded disease free interval for a patient still alive and tumor free was 96 months. Only three patients (11%) had local complications: two wound infections and one partial necrosis of the transverse rectus-abdominis musculo cutaneous flap. Median hospital stay was 7 days (range 3-13) for transverse rectus-abdominis musculo cutaneous and 6 days (range 3-13) for fasciocutaneous flap. Our results confirmed that transverse rectus-abdominis musculo cutaneous group and fasciocutaneous flap flaps are good reconstructive options in patients with extended locally advanced breast cancer. Quality of life has improved in this group of patients, with acceptable survival periods and in some cases very important survival rates.

ITADE flap after mastectomy for locally advanced breast cancer: A good choice for mid‐sized defects of the chest wall, based on a systematic review of thoracoabdominal flaps

“…Figure illustrates the dermofat flaps and fasciocutaneous flaps observed in the literature, with the main findings described in Table . Table summarizes the results of the flaps, providing data to evaluate the possibility of an association between flap type and the presence of necrosis.…”

“…Thus, prior to neoadjuvant chemotherapy with intent to cure, a skin graft is suggested, which can be annotated in the medical records or in the form of a dermal tattoo. Resection of the entire tumor area prior to adjuvant therapy is advisable, but much has been discussed regarding this point, and studies with extensive resection typically describe the technical details, with few describing the survival and recurrence . In the clinic, there is a tendency to maintain the tumor area prior to chemotherapy, with the lesion outlined prior to therapy by sizing on medical records (17/23) or the skin tattoo (1/23), preferably resecting the entire area, as the present flap is associated with acceptable morbidity.…”

“…The vertical rectus‐abdominus myocutaneous (VRAM) flap or transverse rectus‐abdominis myocutaneous (TRAM) flap is associated with a weakening of the abdominal wall; an abdominal screen is required, and the procedure is associated with the possibility of abdominal hernia and a greater necrosis rate (range of 5.2‐12.8%). This procedure is typically described using VRAM due to the greater ease of the technique and the non‐aesthetic component of the treatment. The oblique abdominal flap has the advantage of not weakening the abdominal wall, presenting an acceptable rate of distal flap necrosis (range of 5.0‐16.7%), but it has been described only rarely .…”

“…In LABC, chemotherapy and radiotherapy can be used as neoadjuvants aimed at decreasing tumor size and increasing resectability . However, because of local extension, it is often necessary to combine flaps with mastectomy aimed at primary closing, which can be accomplished with myocutaneous, fasciocutaneous, or dermofat flaps aimed at rapid healing and an early start for adjuvant therapy …”

Application of a rhomboid flap for the coverage of defects after malignant breast tumor resection: A case report

“…Deo et al (19) reported that fasciocutaneous flaps are more successful compared with myocutaneous flap due to decreased blood loss during the surgery, a shorter length of the surgery and a shorter hospital stay. Conversely, Martella et al (20) suggested that there is no difference between myocutaneous and fasciocutaneous flaps in regards to local complications and the length of hospital stay required. Typically, myocutaneous flaps provide enough tissue volume to cover the skin defect and have a good blood supply (2,21).…”