IMMEDIATE BREAST RECONSTRUCTION AFTER …



LATE RESULTS OF THORAC-AXILLAR FLAP FOR IMMEDIATE BREAST RECONSTRUCTION AFTER QUADRANTECTOMY

Elvio B. Garcia MD,PHD, Miguel Sabino MD,PHD, Luis Eduardo F. Abla MD,PhD, Lydia M. Ferreira MD,PHD.

INTRODUCTION: The high incidence of breast cancer, associated with psychological and physical trauma and the consequences of this treatment, were the main reasons that stimulated the medical community to search for the most conservative treatment and solution for this reparation, 1, 2, 3.

The aesthetic results obtained with the primary closing, in the conservative treatment with quadrantectomies, were fair or even bad, as emphasized by Berrino 4.

To achieve better aesthetic results, several local flaps have been employed in breast reconstruction after quadrantectomy, Cooperman & Dinner 5 and Carramaschi 6.

The sequels of conservative treatment and the difficulties of this kind of reparation, encouraged us to search for a local flap and we propose the use of the lateral thorac-axillar flap for the immediate reconstruction of the upper lateral quadrantectomies, with the objective to minimize and prevent the deformities by quadrantectomies.

METHOD: The skin resection is marked by the oncologist and after we plan the thorac-axillar flap (7,5 x 13cm. width / length in range), some schemes, below, fig. 1.

Surgical Technique

Figura 1. Schemes from the planning of the flap.

After tumoral resection, (quadrantectomy), the flap was carefully elevated, preserving the miocutaneous perforators of the anterior serratus, and the transposition is complete including the fascia, and the donor area is sutured by

primary closure fig. 2.

Figure 2 . Intra-operative tissue loss and flap elevation.

Sixty four patients with breast cancer (Clinical Stage I -II) located in the upper lateral quadrant were submitted to quadrantectomies with local skin resection and axillary limphoadenectomy by the same incision and immediate mammary reconstruction with the lateral thorac-axilar flap, in the Federal University of São Paulo UNIFESP.

The age of the patients ranged from 29 to 81 years. Respecting a clinical trial that (85%) of these patients had been treated previously with chemotherapy (5-fluoracil, ciclophospahamide and epirubicin).

The diameter of the tumors ranged from 0 to 3.0 cm (one patient was operated on because of malignant microcalcifications and had no palpable tumor). The tumors were classified as T1NoMo (40 cases) , T2NoMo (22 cases), and TxNoMo (2 case).

Evaluation of aesthetic results was carried out at the twelve month of postoperative follow-up and was based on the opinion of the patient and objective evaluation was based on three criteria: asymmetry of nipples, loss of volume, and retraction, estimated by the surgeon and the other medical team assistants.

All of these patients were submitted to radiotherapy

The follow-up ranged from 1 to 9 years.

RESULTS: Fifty two patients(82%)rated themselves excellent and 3 (4%) good, and in our objective evaluation we rated 59 (93%) excellent and 3 (10%) good aesthetic outcomes.

Figure 3 . pre and 3 years of postoperative, shows the restoration of size and shape.

The histological diagnose were (83%) ductal carcinoma; (10%) lobular carcinoma and (7%) mucinoso carcinoma.

The tumor size ranged from 0.5 to 3.0 cm at the moment of surgery.

Two patients had a local recurrence, and two patients (3%) had a fat necrosis tumor.

The flap size ranged 5 and 10 (base) x 9 and 16 cm (length), ranged 7.5 x 12.5 cm.

Viability was present in 100% of the flaps.

The duration of surgery performed by the plastic surgery team ranged from 40 to 65 minutes ( 57.5 mean).

Two patients had a seroma, 3 patients had an epedermolise of scars.

Twenty two patients(34%)had other diseases such as (hypertension, diabetes, etc).

Three patients underwent a mastectomy because of a local reocurrence, margins jeaopardized, presence of a new tumor in same the breast at a diferent location.

DISCUSSION:Conservative treatment of breast cancer with quadrantectomies does not always guarantee good aesthetic results when compared to radical treatments with mastectomies and breast reconstruction.

Results also depend on tumor location and size, extension of skin resection and breast size, results can be even worse. This is why every attempt for immediate reconstruction must be considered, in order to prevent breast deformities.

Several techniques have been employed for breast reconstruction after quadrantectomy, such as: “Z” plasties, local and flaps from de other areas distance flaps 4, 6, 7.

The thorac-axillar flap can be employed in the immediate repair of any sized breast, small, medium or large. However patients with small sized breasts can be considered a challenge for this kind of reconstruction and the thorac-axillar flap has been showing good solutions without the necessity of implants, which increases the possibilities and facilitates the immediate repair in all types of breasts.

To accomplish this study, we based our work on the studies of Cooperman & Dinner 5 and Holmström & Lossing 8.

In 2000, we proposed the thorac-axillar flap which receives its blood supply from the miocutaneous perfurators by anterior serratus and classified it as a randomized flap.

The aesthetic results do not change in the late postoperative period and no distortion or retraction of the breast was observed after the adjuvant therapy as mentioned by some authors 9, 10, Munhos.

We believe that the good results and low incidence of complications are determined by the presence of new tissue transported with a good blood supply to the area of loss, bringing enough tissue necessary for no distortion or retraction.

Some advantages of the lateral thorac-axillar flap are: fast and easy execution, about the thirty minute range, it can be used on the majority of patients, it facilitates the approach in axillary dissection, there is an absence of scar in other regions of the body and there is no need for contralateral breast symmetrization in the majority of the cases and no interference with adjuvant therapy .

Due to the facility and quickness of its execution, it can be used in patients with a greater surgical risk (elderly, hypertension, diabetes, etc.).

In conclusion the thorac-axillar flap after upper lateral quadrantectomy, permits immediate mammary repair through an easy technique, and breast restoration of form and volume and expands the possibilities of immediate breast repair after quadrantectomies.

REFERENCES

1.Goes, J.C.S. & Garcia, E.B. – Immediate reconstruction with tissue expander after mastectomy by periareolar approach. Breast J. 2(1): 71 – 6, 1996.

2.Garcia, E.B., Sabino, M., Ferreira, L.M. et al. Implantes na Reconstrução Mamaria: Comparação de três métodos. In Tournieux, B. A. A. Atualização em Cirurgia Plástica . Sociedade Brasileira de Cirurgia Plástica Eds. 1 Ed. 209 – 11, São Paulo, 1998.

3.Garcia, E.B., Ferreira, L.M. Deformidades do Tronco. In Ferreira, L.M. Manual de Cirurgia Plástica. Atheneu (Eds.), Pp.183 – 96, Vol. 1, 1 Ed. São Paulo, 1995.

4.Berrino, P., Campora, E., Santi, P. Postquadrantectomy breast deformities: classification and techniques of surgical correction. Plast. Reconstr. Surg. 79: 567, 1987.

5.Cooperman, A. M. & Dinner, M. - The rhomboid flap and partial mastectomy. Surg. Clin. North America 58: 869 – 73, 1978.

6.Carramaschi, F., Yamaguchi, C., Herson, M., Alonso, N., et al. Immediate Breast Reconstruction After Quadrantectomy. Rev Soc Bras Cir Plast. 6(3): 73 - 77, 1991.

7.Garcia, E. B., Sabino, M., Ferreira, L. M., Castilho, H. T., Calil, J. A., and Carramaschi, F. R. Retalho tóraco-axilar na reparação imediata da quadrantectomia supero-lateral da mama. Rev. Bras. Mastol. 10: 185, 2000.

8.Munhoz, A.M., Montag, E., Arruda E.G., Aldrighi C., Gemperli R., Aldrighi J.M., Ferreira M.C. Plast Reconstr Surg. 117(4):1091-103, 2006.

9.Clough, K.B., Nos, C., Salmon, R. J., Soussaline, M. Durand J.C. Conservative treatment of breast cancers by mammaplasty and irradiation: A new approach to lower quadrant tumors. Plast. Reconstr. Surg. 96(2): 363,

10.Holmström, H., Lossing, C. The lateral thoracodorsal flap in breast reconstruction. Plast. Reconstr. Surg. 77(6): partial mastectomy. Ann. R. Coll. Surg. Engl. 67: 245 - 7, 1985.

11.Clarke, D., Martinez, A., Cox, R. S. Analysis of cosmetic results and compications in patients with stage I and II breast cancer treated by biopsy and irradiation. Int. J. Radiat. Oncol. Biol. Phys. 9: 1807, 1983.

12.Levitt, S. H.: Primary treatment of early breast cancer with conservation surgery and radiation therapy, the effect of adjuvant chemotherapy. Cancer 55: 2140 - 48, 1985.

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