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Delayed Division of the Thoracodorsal Nerve: a Useful Adjunct in Breast Reconstruction
percent), and hematoma (1.6 percent versus 1.9 percent), were comparable between the two groups, but the flap seroma rate was significantly higher in the thoracodorsal group (4.0 percent versus 0.7 percent; odds ratio, 4.2). Conclusion.—In the authors’ experience, use of internal mammary vessels is safe, with low rates of vessel conversion and flap-related complications. The internal mammary artery (IMA) and vein have become the preferred recipient vessels for microvascular breast reconstruction. Two important points merit discussion. The first is related to factors associated with anastomotic failure following microvascular breast reconstruction. Previous investigation has demonstrated that anastomotic failure is independent of the recipient vessel selected.1
Delayed Division of the Thoracodorsal Nerve: a Useful Adjunct in Breast Reconstruction Halperin TJ, Fox SE, Caterson SA, et al (Beth Israel Deaconess Med Ctr, Boston) Ann Plast Surg 59:23-25, 2007
Breast reconstruction utilizing the latissimus dorsi musculocutaneous flap with an underlying breast implant is a well-established technique. Postoperative shoulder limitation is usually limited if at all noticeable. The muscle itself may, however, remain active in the new anterior position. Many patients find the muscle twitches with extension of the humerus, despite the anterior translocation of the muscle. This leads to a disturbing contraction, superolaterally, of the entire reconstruction. In addition, the resting tone can lead to a sense of tightness, despite a lack of clinically obvious capsular contracture. Division of the thoracodorsal nerve during initial flap elevation can prevent this problem. When raising the rou-
The second point addresses the consequences of using the IMA as it relates to future coronary artery disease (CAD). Previous investigation has demonstrated the incidence of CAD in a population of women over 50 years of age with breast cancer to be 0.8%.2 Current trends in the management of CAD has shown that 72% of women are now managed with percutaneous transluminal coronary angioplasty or endovascular stenting.3 The percentage having coronary artery bypass grafting is 28%. Alternative conduits include the opposite IMA or the saphenous vein. In conclusion, the thoracodorsal artery and IMA are suitable recipient vessels; however, the IMAs have become the vessels of choice for the stated reasons.
References 1. Nahabedian MY, Momen B, Manson PN. Factors associated with anastomotic failure following microvascular reconstruction of the breast. Plast Reconstr Surg. 2004;114:74-82. 2. Nahabedian MY. The internal mammary artery and vein as recipient vessels for microvascular breast reconstruction: Are we burning a future bridge? Ann Plast Surg. 2004;53: 311-316. 3. American Heart Association: Heart Disease and Stroke Statistics-2006 Update. Available at: www.americanheart.org. Accessed: November 19, 2007.
M. Y. Nahabedian, MD
tine flap however, the pedicle itself is often not visualized and there is anxiety related to dividing the nerve and accidently injuring the vascular pedicle. In addition, many of the transferred muscles atrophy, thereby avoiding this potential problem. When the muscle remains active, delayed division of the thoracodorsal nerve via a 2.5-cm axillary incision will stop the active twitching, decrease the resting tone of the muscle, and in most patients offer significant relief from symptoms of tightness. During the past 2 1/2 years, 100 latissimus dorsi flap breast reconstructions in 80 patients were performed. Forty-one nerves in 28 patients have been divided, with successful denervation in 37 of the 41 reconstructions, for a success rate of 90%. Delayed division of the thoracodorsal nerve can offer relief to patients complaining of tightness and muscle activity post-latissimus flap breast reconstruction. In this paper, the authors reported that of 100 patients who underwent breast reconstruction with latissimus
dorsi flaps, 41 underwent thoracodorsal nerve division as a secondary procedure because of active twitching of the muscle and a feeling of tightness. I agree with the authors that when latissimus dorsi flaps are used for breast reconstructions, the thoracodorsal nerves should be divided to avoid these problems, which are due to the persistent activity of the innervated latissimus dorsi muscle. However, I disagree with the authors on the timing. Although they state that the division of the thoracodorsal nerve during the initial flap elevation can prevent nerve problems, they also state that during the flap harvest, the pedicle itself is often not visualized, and division of the nerve could result in accidental injury to the vascular pedicle. When raising the latissimus dorsi flap, it is important to identify the vascular pedicle, especially after sentinel node biopsy or axillary node dissection, to ensure that it is intact and not injured. Furthermore, it is not difficult to dissect and identify the vascular pedicle, at which time the thoracodorsal nerve, ®
Breast Diseases: A Year Book Quarterly Vol 19 No 1 2008
93 93
which courses with the vascular pedicle, can be divided. I believe that secondary division of the thoracodorsal nerve would be more difficult and risky because of scarring from the previous surgery.
Primary division of the nerve would eliminate this risky and unnecessary secondary procedure. However, I do agree with the authors that if the thoracodorsal nerve is not divided during the initial op-
eration and the patient is experiencing muscle twitching, a secondary procedure to divide the nerve is indicated.
Comparison of Local Recurrence and Distant Metastases Between Breast Cancer Patients After Postmastectomy Radiotherapy With and Without Immediate TRAM Flap Reconstruction
flap group) were as follows: grade I, 74 of 82 (90 percent) versus 93 of 109 (85 percent); grade II, seven of 82 (9 percent) versus 13 of 109 (12 percent); grade III, one of 82 (1 percent) versus three of 109 (3 percent) (p = 0.558). In the TRAM flap group, the increased percentage of fat necrosis was 8 percent. No flap loss was detected. Conclusions.—There were no significant differences in the incidences of complication, locoregional recurrence, and distant metastasis between the TRAM flap and non-TRAM flap patients. The authors’ results suggest that immediate TRAM flap reconstruction can be considered a feasible treatment for breast cancer patients requiring postmastectomy radiotherapy.
diation therapy is highly controversial and poorly understood and must be critically evaluated in terms of both oncologic and aesthetic outcomes. Immediate reconstruction preserves more native breast skin, which is aesthetically advantageous, provides a psychological benefit, and is associated with a lower rate of short-term operative complications.1-8 Although the resulting fibrosis appears to be more severe if the flap itself is irradiated, there is an increased rate of flaprelated complications in flaps placed in previously irradiated sites.1-8 Furthermore, a large number of reconstructive flaps that have been subjected to postoperative radiotherapy appear to exhibit acceptable results.1,3-6,9 There appears to be wide variability in the clinical response to irradiation, leading to relatively minor changes in some flaps and severe deformation in others, which unfortunately cannot be accurately predicted from patient variables or radiation dosing.3,4,6,8,10,11 Objective evaluation of reconstructive results is limited by both the number and quality of the existing data in the current study and others.1-9 Differences in outcomes may reflect patient variables, anatomy, surgical technique, experience, preference, and proficiency, all of which are problematic to control and assess. There are a number of technical nuances in the transfer of lower abdominal flaps for reconstruction with suggestions that one configuration, ie, microsurgically transferred flaps, may tolerate insult, including radiation, more favorably than do conventional (pedicled) flaps. Additionally, establishing aesthetic outcome is by nature a highly subjective process and essentially impossible to quantify. There is significant discordance between patients’and
Huang CJ, Hou MF, Lin SD, et al (Kaohsiung Med Univ Hosp, Taiwan, Republic of China) Plast Reconstr Surg 118:1079-1086, 2006
Background.—The purpose of this study was to compare the local recurrence and distant metastasis of postmastectomy radiotherapy for breast cancer patients with and without immediate transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction. Methods.—Between March of 1997 and October of 2001, 191 breast cancer patients received postmastectomy radiotherapy: 82 patients had TRAM flap reconstruction (TRAM flap group) and 109 patients did not (non-TRAM flap group). The mean radiation dose to the chest wall or entire TRAM flap, axillary area, and lower neck was 50 Gy (range, 48 to 54 Gy). The median follow-up period was 40 months. Results.—The percentages of chest wall recurrence were 3.7 percent (three of 82) in the TRAM flap group and 1.8 percent (two of 109) in the non-TRAM flap group (p = 0.653). The percentages of distant metastases were 12.2 percent (10 of 82) in the TRAM group and 15.6 percent (17 of 109) for the non-TRAM group (p = 0.67). The percentages of acute radiation dermatitis according to Radiation Therapy Oncology Group scoring criteria (TRAM flap group versus non-TRAM
94 94
®
This article evaluates the risk of local-regional recurrence and distant metastases for patients treated with adjuvant radiotherapy after mastectomy as a function of whether or not the patient underwent an immediate or delayed transverse rectus myocutaneous (TRAM) flap reconstruction. The authors noted a very low rate of local-regional recurrence in both groups and concluded that TRAM reconstruction does not adversely affect the therapeutic benefits of mastectomy with adjuvant local-regional radiation. There were no differences in acute skin toxicity and an 8% rate of fat necrosis in the patients who had a TRAM flap irradiated. Notably, 36% of patients had volume loss of their TRAM, and 36% had contracture of their TRAM. Cosmetic outcome was assessed by patient self report and considered to be excellent (16%) or good (54%) in the majority of cases. The management of patients seeking breast reconstruction in the setting of ra-
Breast Diseases: A Year Book Quarterly Vol 19 No 1 2008
D. W. Chang, MD
Delayed Division of the Thoracodorsal Nerve: a Useful Adjunct in Breast Reconstruction Halperin TJ, Fox SE, Caterson SA, et al (Beth Israel Deaconess Med Ctr, Boston) Ann Plast Surg 59:23-25, 2007
Breast reconstruction utilizing the latissimus dorsi musculocutaneous flap with an underlying breast implant is a well-established technique. Postoperative shoulder limitation is usually limited if at all noticeable. The muscle itself may, however, remain active in the new anterior position. Many patients find the muscle twitches with extension of the humerus, despite the anterior translocation of the muscle. This leads to a disturbing contraction, superolaterally, of the entire reconstruction. In addition, the resting tone can lead to a sense of tightness, despite a lack of clinically obvious capsular contracture. Division of the thoracodorsal nerve during initial flap elevation can prevent this problem. When raising the rou-
The second point addresses the consequences of using the IMA as it relates to future coronary artery disease (CAD). Previous investigation has demonstrated the incidence of CAD in a population of women over 50 years of age with breast cancer to be 0.8%.2 Current trends in the management of CAD has shown that 72% of women are now managed with percutaneous transluminal coronary angioplasty or endovascular stenting.3 The percentage having coronary artery bypass grafting is 28%. Alternative conduits include the opposite IMA or the saphenous vein. In conclusion, the thoracodorsal artery and IMA are suitable recipient vessels; however, the IMAs have become the vessels of choice for the stated reasons.
References 1. Nahabedian MY, Momen B, Manson PN. Factors associated with anastomotic failure following microvascular reconstruction of the breast. Plast Reconstr Surg. 2004;114:74-82. 2. Nahabedian MY. The internal mammary artery and vein as recipient vessels for microvascular breast reconstruction: Are we burning a future bridge? Ann Plast Surg. 2004;53: 311-316. 3. American Heart Association: Heart Disease and Stroke Statistics-2006 Update. Available at: www.americanheart.org. Accessed: November 19, 2007.
M. Y. Nahabedian, MD
tine flap however, the pedicle itself is often not visualized and there is anxiety related to dividing the nerve and accidently injuring the vascular pedicle. In addition, many of the transferred muscles atrophy, thereby avoiding this potential problem. When the muscle remains active, delayed division of the thoracodorsal nerve via a 2.5-cm axillary incision will stop the active twitching, decrease the resting tone of the muscle, and in most patients offer significant relief from symptoms of tightness. During the past 2 1/2 years, 100 latissimus dorsi flap breast reconstructions in 80 patients were performed. Forty-one nerves in 28 patients have been divided, with successful denervation in 37 of the 41 reconstructions, for a success rate of 90%. Delayed division of the thoracodorsal nerve can offer relief to patients complaining of tightness and muscle activity post-latissimus flap breast reconstruction. In this paper, the authors reported that of 100 patients who underwent breast reconstruction with latissimus
dorsi flaps, 41 underwent thoracodorsal nerve division as a secondary procedure because of active twitching of the muscle and a feeling of tightness. I agree with the authors that when latissimus dorsi flaps are used for breast reconstructions, the thoracodorsal nerves should be divided to avoid these problems, which are due to the persistent activity of the innervated latissimus dorsi muscle. However, I disagree with the authors on the timing. Although they state that the division of the thoracodorsal nerve during the initial flap elevation can prevent nerve problems, they also state that during the flap harvest, the pedicle itself is often not visualized, and division of the nerve could result in accidental injury to the vascular pedicle. When raising the latissimus dorsi flap, it is important to identify the vascular pedicle, especially after sentinel node biopsy or axillary node dissection, to ensure that it is intact and not injured. Furthermore, it is not difficult to dissect and identify the vascular pedicle, at which time the thoracodorsal nerve, ®
Breast Diseases: A Year Book Quarterly Vol 19 No 1 2008
93 93
which courses with the vascular pedicle, can be divided. I believe that secondary division of the thoracodorsal nerve would be more difficult and risky because of scarring from the previous surgery.
Primary division of the nerve would eliminate this risky and unnecessary secondary procedure. However, I do agree with the authors that if the thoracodorsal nerve is not divided during the initial op-
eration and the patient is experiencing muscle twitching, a secondary procedure to divide the nerve is indicated.
Comparison of Local Recurrence and Distant Metastases Between Breast Cancer Patients After Postmastectomy Radiotherapy With and Without Immediate TRAM Flap Reconstruction
flap group) were as follows: grade I, 74 of 82 (90 percent) versus 93 of 109 (85 percent); grade II, seven of 82 (9 percent) versus 13 of 109 (12 percent); grade III, one of 82 (1 percent) versus three of 109 (3 percent) (p = 0.558). In the TRAM flap group, the increased percentage of fat necrosis was 8 percent. No flap loss was detected. Conclusions.—There were no significant differences in the incidences of complication, locoregional recurrence, and distant metastasis between the TRAM flap and non-TRAM flap patients. The authors’ results suggest that immediate TRAM flap reconstruction can be considered a feasible treatment for breast cancer patients requiring postmastectomy radiotherapy.
diation therapy is highly controversial and poorly understood and must be critically evaluated in terms of both oncologic and aesthetic outcomes. Immediate reconstruction preserves more native breast skin, which is aesthetically advantageous, provides a psychological benefit, and is associated with a lower rate of short-term operative complications.1-8 Although the resulting fibrosis appears to be more severe if the flap itself is irradiated, there is an increased rate of flaprelated complications in flaps placed in previously irradiated sites.1-8 Furthermore, a large number of reconstructive flaps that have been subjected to postoperative radiotherapy appear to exhibit acceptable results.1,3-6,9 There appears to be wide variability in the clinical response to irradiation, leading to relatively minor changes in some flaps and severe deformation in others, which unfortunately cannot be accurately predicted from patient variables or radiation dosing.3,4,6,8,10,11 Objective evaluation of reconstructive results is limited by both the number and quality of the existing data in the current study and others.1-9 Differences in outcomes may reflect patient variables, anatomy, surgical technique, experience, preference, and proficiency, all of which are problematic to control and assess. There are a number of technical nuances in the transfer of lower abdominal flaps for reconstruction with suggestions that one configuration, ie, microsurgically transferred flaps, may tolerate insult, including radiation, more favorably than do conventional (pedicled) flaps. Additionally, establishing aesthetic outcome is by nature a highly subjective process and essentially impossible to quantify. There is significant discordance between patients’and
Huang CJ, Hou MF, Lin SD, et al (Kaohsiung Med Univ Hosp, Taiwan, Republic of China) Plast Reconstr Surg 118:1079-1086, 2006
Background.—The purpose of this study was to compare the local recurrence and distant metastasis of postmastectomy radiotherapy for breast cancer patients with and without immediate transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction. Methods.—Between March of 1997 and October of 2001, 191 breast cancer patients received postmastectomy radiotherapy: 82 patients had TRAM flap reconstruction (TRAM flap group) and 109 patients did not (non-TRAM flap group). The mean radiation dose to the chest wall or entire TRAM flap, axillary area, and lower neck was 50 Gy (range, 48 to 54 Gy). The median follow-up period was 40 months. Results.—The percentages of chest wall recurrence were 3.7 percent (three of 82) in the TRAM flap group and 1.8 percent (two of 109) in the non-TRAM flap group (p = 0.653). The percentages of distant metastases were 12.2 percent (10 of 82) in the TRAM group and 15.6 percent (17 of 109) for the non-TRAM group (p = 0.67). The percentages of acute radiation dermatitis according to Radiation Therapy Oncology Group scoring criteria (TRAM flap group versus non-TRAM
94 94
®
This article evaluates the risk of local-regional recurrence and distant metastases for patients treated with adjuvant radiotherapy after mastectomy as a function of whether or not the patient underwent an immediate or delayed transverse rectus myocutaneous (TRAM) flap reconstruction. The authors noted a very low rate of local-regional recurrence in both groups and concluded that TRAM reconstruction does not adversely affect the therapeutic benefits of mastectomy with adjuvant local-regional radiation. There were no differences in acute skin toxicity and an 8% rate of fat necrosis in the patients who had a TRAM flap irradiated. Notably, 36% of patients had volume loss of their TRAM, and 36% had contracture of their TRAM. Cosmetic outcome was assessed by patient self report and considered to be excellent (16%) or good (54%) in the majority of cases. The management of patients seeking breast reconstruction in the setting of ra-
Breast Diseases: A Year Book Quarterly Vol 19 No 1 2008
D. W. Chang, MD