Postmastectomy breast reconstruction

POSTMASTECTOMY BREAST RECONSTRUCTION mm

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FRANCIS E. ROSATO, M.D. CHARLES E. HORTON, M.D. G. PATRICK MAXWELL, M.D.

0011-3840/80/11-0585-629-$05.00 ((') 1980, Year Book Medical Publishers, In('.

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SELF-ASSESSMENT QUESTIONS . INTRODUCTION

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EVOLUTION OF SURGICAL PROCEDURES FOR ABLATION Of

BREAST CANCER

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HISTORY OF BREAST RECONSTRUCTION . . . . . . . . . . .

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GENERAL SURGICAL CONSIDERATIONS AT THE TIME OF MASTECTOMY .

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RECONSTRUCTION FOLLOWING MASTECTOMY FOR CANCER . . . .

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PROPHYLACTIC MASTECTOMY

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ONCOLOGIC CONSIDERATIONS IN BREAST RECONSTRUCTION SUMMARY AND PROJECTIONS .

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SELF-ASSESSMENT ANSWERS

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SELF-AS~JESSMENT QUESTIONS 1. Which of the following s t a t e m e n t s regarding epidemiology of breast cancer is true? a. It 7Is presently estimated t h a t 9% of women reaching age 70 will develop breast cancer. b. The incidence of b r e a s t cancer is h i g h e r in E a s t e r n and F~r-Eastern countries t h a n in Western countries. c. About 20% of women, when first diagnosed to have breast cancer, will have evidence clinically of nodal involvement. d. Larger ~umors, in general, indicate a poorer prognosis thar~ s m a l l e r ,~,umors. 2. Little is k,vov, n about the exact causative a g e n t in breast cmlcer. Which one of the following s t a t e m e n t s is true? a. V~rus-;i~e particles found in milk can produce breast cancer ~in bo:~h rats and h u m a n s . b. The use of e~ogenous estrogens definitely causes an increase in the rate of breast cancer. c. E a r l y me~opause results in a lower rate of subsequent development of b r e a s t cancer. d. Women who undergo surgical castration prior to menopause have the same incidence of cancer as those who do not. 3. Which one of the following findings derived from psychologic studies on women undergoing mastectomy is true? a. Few women experience any significant depression following mastectomy. b. Women are very likely to express a n x i e t y related to previous mastectomy. c. Psychologic changes following mastectomy are almost never present in older women. d. P a t i e n t s are g e n e r a l l y more satisfied with reconstructive efforts t h a n ,are men or surgeons asked to judge the cosmetic results. 4. In comparing a modified radical mastecomy to the s t a n d a r d (Halsted) radical mastectomy, which of the following is not true? a. There are m u l t i p l e review studies a t t e s t i n g to s i m i l a r survival figures for those treated with the modified mastectomy as opposed to the standard classical radical mastectomy. b. There are multiple studies attesting to the completion of axillary dissection employing the modified mastectomy as compared with the s t a n d a r d radical mastectomy. c. The NSABP s t u d y - a prospective randomized and strat587

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ified s t u d y - c o m p a r i n g various modalities for t r e a t i n g p r i m a r y breast cancer clearly showed an a d v a n t a g e of Halsted radical mastectomy over other modalities. d. It is i m p o r t a n t at this time to perform as complete an axillary dissection as possible in order to accurately stage and choose optimal a d j u v a n t programs. In subclinical (minimal) breast cancer the incidence o f m u l t i c e n t r i c i t y - t h a t is, a second cancerous lesion in a q u a d r a n t of the breast other t h a n t h a t in which the p r i m a r y is f o u n d - is: a. 25% b. 6% c. 35% d. 50% All of the following are possible complications to the subcutaneou s placement of silicone prosthesis except: a. Displacement of the prosthesis. b. Capsular contracture. c. Skin necrosis. d. Allergic reactions. Which of the following is an inevitable consequence of total excision of the pectoralis minor muscle in a modified mastectomy? a. There results a denervation with eventual atrophy and t h i n n i n g of the lower pectoralis major muscle. b. There is loss of a r m adduction. c. There is a g r e a t e r tendency to edema of the ipsilateral arm. d. There is a higher incidence of wound infection. Regarding the thoracodorsal vessels and nerve t h a t supply the latissimus dorsi muscle, which of the following is correct? a. If possible, they should be preserved in order to m a i n t a i n blood supply and function to the latissimus dorsi muscle should a future myocutaneous flap be required. b. They should always be routinely divided to effect a more complete axillary dissection. c. If they are sacrificed, it will be impossible in the future to utilize a latissimus myocutaneous flap. In patients who have undergone a radical mastectomy, which of the following is most satisfactory in most situations to provide chest wall coverage prior to prosthesis placement? a. Latissimus dorsi myocutaneous flap. b. Rectus abdominis myocutaneous flap. c. S e r r a t u s anterior flap. d. An abdominal pedicle flap. A demonstrated functional disability following use of latiso simus dorsi muscle as a myocutaneous flap is: a. Weakness in a r m abduction. b. Slight weakness elicited when the a r m is passed behind the back in an adducting fashion.

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c. Limitation o f c i r c u l a r ' a r m motion. d. Weakness of arm extension. Which of" the following is not true regarding nipple-areolar reconstruction in a postmastectomy setting? a. Nipple-areolar s h a r i n g procedures, utilizing the contralateral nipple, are not necessary in this reconstruction today. b. If possible, at the time of mastectomy, it is always desirable for the general surgeon to preserve a nipple-areolar complex by autografting. c. The donor tissue to construct the areolar complex is selected on the basis of the color skin needed to match the c o n t r a l a t e r a l areola,: tissue, the usual site being the upper inner thigh area. d. Labial autografts will produce a d a r k l y pigmented areola. Which ones of the following can be considered contraindications to breast reconstruction? a. I n f l a m m a t o r y breast cancer. b. Multiple positive lymph nodes. c. Inner q u a d r a n t lesions. d. Lesions g r e a t e r t h a n 3 cm and centrally located in the breast. Which of the following is not considered a significant risk factor in d e t e r m i n i n g whether an individual is a candidate for prophylactic mastectomy? a. Positive family history of breast cancer. b. Florid fibrocystic disease with mastodynia. c. Previous contralateral mastectomy for breast cancer. d. Nulliparity. Subcutaneous mastectomy with immediate subcutaneous prosthesis placement as a form of prophylaxis against cancer in a high-risk group is not recommended because: a. It does not remove all breast tissue because of limited access. b. There are m a n y complications specifically as a result of placing Lhe prosthesis in a subcutaneous position. c. There is a higher rate of capsular contracture. d. There is a higher rate of allergic reactions when the prosthesis is in this position as opposed to the subr~uscular position.

Answers are listed at the end of the article.

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is the Samuel D. Gross Professor of Surgery and Chairman of the Department of Surgery of Jefferson Medical College, Thomas Jefferson University, Philadelphia. Dr. Rosato completed his surgical training at the Hospital of the University of Pennsylvania and served for 10 years on its staff. His principal research interests then were the biologic markers in tumor systems and immunotherapy of human tumors. The first Chairman of the Eastern Virginia Medical School in Norfblk, Virginia, Dr. Rosato has collaborated with its Department of Plastic Surgery on reconstruction of the breast since 1978.

is a graduate of the University of Virginia. He completed his general surgery and plastic surgery training at George Washington University and Duke University Medical Center. He is Professor of Plastic Surgery, Eastern Virginia Medical School, Director, Eastern Virginia Graduate School of Medicine and Assistant Dean of Continuing Medical Education, Eastern Virginia Medical School. Doctor Horton was recently selected to receive a Fellowship in the Royal College of Surgeons, Glasgow, Scotland.

is a graduate of Vanderbilt University and Vanderbilt University Medical School. He completed his general surgery and plastic surgery training at the Johns Hopkins Hospital and currently is Assistant Professor of Plastic Surgery at the Eastern Virginia Medical School. Dr. Maxwell devotes a major portion of his clinical practice to reconstructive breast surgery. His other research and clinical interests center around axial arid myocutaneous flaps, microvascular surgery and esthetic surgery.

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INTRODUCTION THIS WORK is not a definitive treatise on the subject of breast cancer. We have avoided discussion of selecting surgical treatment and a d j u v a n t measures in the m a n a g e m e n t of breast cancer, as excellent monographs and m a n y books on these subjects have recently been published, i. ,., Rather, we will review herein our own experience in the specific area of breast reconstruction and the role it plays in the mana g e m e n t of breast disease. We c a n n o t overemphasize t h a t such an effort requires the conjoint p l a n n i n g and complementary techniques of plastic and general surgery. Although the m a n a g e m e n t of the p a t i e n t with breast problems, particularly breast cancer, will dictate certain therapeutic decisions, both doctor and p a t i e n t should be involved as much as possible. This r e l a t i o n s h i p between physicians and patient should r u n the course of her medical m a n a g e m e n t , from diagnosis to the end of t r e a t m e n t . The patient, needless to say, is the cornerstone of the decision-making process and is the third party in all decisions. It would be a retrogressive step should either the general surgeon or the plastic surgeon, whose combined efforts are essential for a most satisfactory outcome, i n t r u d e too aggressively in the other's area of expertise. While e x t i r p a t i o n of disease r e m a i n s the most i m p o r t a n t aspect of breast cancer t r e a t m e n t , we m u s t r e m a i n cognizant of the final objective, which is to r e t u r n the p a t i e n t to as normal a life as possible. SCOPE AND EPIDEMIOLOGY

Breast cancer r e m a i n s at the present time the n u m b e r one cause of cancer mortality a m o n g women (Fig 1). Approximately 22% of all cancer d e a t h s in women are directly related to breast cancer. It had previously been e s t i m a t e d t h a t 7% of women reaching age 70 would develop breast cancer. The American Cancer Society has recently revised this figure and now states t h a t about one in 11 (9%) women who reach age 70 will develop b r e a s t cancer. T h e r e are geographic differences in the incidence of b r e a s t cancer; it is notably lower in Middle and Far Eastern countries t h a n in Western countries. An e a r l y hypothesis related this statistical difference to the a m o u n t of breast tissue at risk, which is considered smaller in Far E a s t e r n women. It has recently been observed, however, t h a t first-generation female descendants of E a s t e r n women who migrate to Western cultures acquire the same incidence of breast cancer as t h a t of Western women, a fact t h a t stresses the importance of e n v i r o n m e n t in causing the disease. In W e s t e r n countries b r e a s t cancer is, after n o n m e l a n o t i c skin cancers, the type of cancer most frequently found in women. :~ At the t i m e of discovery of breast tumors, approximately 50% of 591

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9 % Lung 21% Breost

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15% Colon & rectum -

13% Other digest,re 7 % Uterus

IO%Leukemia 25% Other

Fig 1 . - S o u r c e s of cancer deaths in women. (Redrawn from the American Cancer Society's epidemiology report).

women will show evidence of clinical nodal involvement. However, there r e m a i n s a 2 5 - 33% rate of error in clinically judging nodal involvement. Interestingly, there seems to be no correlation between the size of the initial tumor and the u l t i m a t e or/tcome of the patient. In fact, large tumors tend to be present tbr a longer period of time and probably carry a somewhat better prognosis t h a n small tumors, which d e m a n d doctors' a t t e n t i o n earlier t h a n large tumors. To date, no known causative a g e n t has been specifically implicated in the genesis of breast cancer. In studies on mice, viruslike particles have been described in milk t h a t can produce breast cancer. No study has confirmed an analogous situation in man. A l t h o u g h it is recognized 4 t h a t the use of exogenous estrogens does cause an increase in the rates of endometrial cancer, there is no convincing evidence t h a t the use of such estrogens promotes the development of breast cancer. It has been observed t h a t early menopause r e s u l t s in a lower rate of subsequent development of breast cancer, and t h a t women who undergo surgical castration prior to menopause have a lesser incidence of breast cancer. The a d m i n i s t r a t i o n of estrogens in e i t h e r of the above settings simply vitiates this conferred protective effect but does not result 592

in a n y cancer in t h e has yet

increased incidence of breast cancer. In summary, breast r e m a i n s a m a j o r h e a l t h p r o b l e m for w o m e n , p a r t i c u l a r l y Western hemisphere, and no clearcut identifiable cause been implicated.

PSYCHOLOGICAL CONSIDERATIONS T h e w o r k o f McGuire=' h a s c l e a r l y d o c u m e n t e d a n a l m o s t u n i versal onset of depression followihg mastectomy. This depression u s u a l l y affects s e x u a l f u n c t i o n , a t e n d e n c y t h a t t h e w o r k o f J a m i s o n et al." ( T a b l e 1) c o n f i r m s . In m o r e t h a n h a l f o f t h e s e p a t i e n t s , s u c h a n x i e t y w a s n o t v e r b a l l y e x p r e s s e d . T h e p r o b l e m s go f a r b e y o n d t h e s e x u a l r a n g e , i n c l u d i n g d i f f i c u l t i e s in d r e s s , b o d i l y image, and self-esteemJA sense oflos~ persists even among older women. A most interesting outgrowth of several reported psychologic TABLE

1.--PERCEIVED EFFECTS OF MASTECTOMY

ON SEXUAL ADJUSTMENT* VARIABLE

Rating of spouse's reaction Extremely understanding Very understanding Somewhat understanding Not very understanding Not at all understanding Women seen naked by spouse after mastectomy Yes No Intercourse with spouse after mastectomy Yes No

Effect on coital orgasm Made it impossible or more difficult No difference Made it easier Sexual satisfaction in relationship No change Worse Better Frequency of intercourse No change Less often More often No. of extramarital affairs No change Increase Decrease

NO.

e.~,

18 7 5 2 3

51.4 20.0 14.3 5.7 8.6

27 8

77.0 23.0

30 5

85.7

7 22 1

23.3 73.3 3.3

21 8 4

63.6 24.2 12.1

27 2 1

75.8 21.2 3.0

31 3 4

81.6 7.9 10.5

14.3

*From Jamison R.R., Wellisch D.K., Pasnau R.O.: Am. J.

Psychol. 135:432, 1978.

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studies concerns the patient's appreciation of the reconstructive effort. Patients judge the results of reconstruction quite differently t h a n do surgeons or men in general. P a t i e n t s are more satisfied t h a n their surgeons or a group of laymen asked to judge the cosmetic results might expect. In addition, the commitment to reconstruction indicates to the patient a better prognosis and highlights an expected positive result in the m a n a g e m e n t of her breast cancer. This in itself offsets the depression t h a t is an inexorable a f t e r m a t h of mastectomy. In s u m m a r y , although women are slow to verbalize their feelings after loss of a breast, emerging studies clearly document t h a t a serious psychologic i m p a i r m e n t is the inevitable result of mastectomy done for cancer, and t h a t breast reconstruction offsets this feeling at several different levels.

EVOLUTION OF SURGICAL PROCEDURES FOR ABLATION OF BREAST CANCER The g r e a t contribution of William S t e w a r t Halsted in the mana g e m e n t of breast cancer remains evident to all practitioners today. His classically described radical mastectomy, which resulted in the removal of all breast tissue, an a b u n d a n t overlying portion of skin, the entire pectoraIis major and minor muscles, and all o$ the fibro-fatty tissue beneath the axillary vein, including nodes, is still called a Halsted mastectomy. An analysis of d a t a before and after the Halsted mastectomy attests to the efficacy of this t r e a t m e n t as the most definitive step in the m a n a g e m e n t of breast cancer. ~1'' Interestingly, until the advent of adjuv a n t chemotherapy no improvement in survival figures for patients with breast cancer had been documented, as witness survival figures for 1 9 1 0 - 1960 from the National Cancer Institute. Within decades of the general acceptance'of the Halsted mastectomy, a t t e m p t s were made to shorten the procedure in the hopes of m a i n t a i n i n g similar survival figures. All surgeons are familiar with the initial McWhirter procedure, which involved total mastectomy (previously termed simple mastectomy) in combination with radiotherapy as a proposed modality for the control of breast cancer. ~1 The modified mastectomy, which involves removal of the breast, overlying skin and axillary nodes but spares the pectoralis major muscle, has recently been established as an entirely satisfactory operation for breast cancer. I'' The work of Dahl-Iverson H has documented a similar survival p a t t e r n with this approach as compared to the classic radical mastectomy. Other articles have attested to the completion of axillary dissection with this technique as contrasted with the standard radical mastectomy, j'1 Finally, these differing therapeutic modalities were tested in a prospective random594

ized stratified study under the direction of Dr. B e r n a r d Fisher, ~-' which concluded t h a t radical mastectomy, modified radical mastectomy, or total mastectomy combined with radiation t h e r a p y all produce comparative results when applied to a large population of critically analyzed patients, i, Nevertheless, the American Cancer Society and National Cancer Institute recently published a position paper recommending t h a t either radical or modified mastectomy is the procedure of choice, since an axillary dissection with careful analysis of the m a x i m u m n u m b e r of nodes is critical for prognosis as well as all-important decisions about adj u v a n t therapy. At the moment, therefore, the general surgical consensus is t h a t both the Halsted radical m a s t e c m m y and modified mastectomy are acceptable procedures. In most hospitals, the latter is by far the most commonly performed procedure for resectable breast cancer. In 1970, 51% of breast cancer patients were treated by radical mastectomy, while in 1976, only 25% received this operation. I~ The increasing use of operations t h a t spare the pectoral muscle have set the stage in the promotion of breast reconstruction. Recently, there has been a revived interest in the use o f " l u m pectomy" combined with axillary sampling with or without radiation t h e r a p y as an a l t e r n a t i v e to the procedures previously described in which all breast tissue has been removed. Multiple studies a t t e s t to an incidence of multicentricity of breast cancer in the neighborhood of 40% when tumors are grossly appreciable. Even where the disease is subclinical, the incidence of multicentricity is still reportedly 25%. We define multicentricity as the presence of a second lesion in a q u a d r a n t of the breast other t h a n t h a t in which the p r i m a r y lesion is found. Schwartz et al TM have demonstrated t h a t even in subclinical breast cancer there is still a 24% incidence of multicentricity. The need to t r e a t any remaining breast tissue is therefore critical. Proponents of lumpectomy and radiation t h e r a p y assume t h a t any additional foci in t h e breast are neutralized by radiologic therapy. Their u l t i m a t e aim in such an approach is to assure satisfactory cosmetic results by leaving the majority~of breast tissue, which they feel is adequately protected by a dose of radiation therapy. The efficacy of radiation t h e r a p y in curing additional foci of breast cancer r e m a i n s to be proved. W h e t h e r in fact it is an acceptable method for m a n a g ing breast cancer awaits the completion of prospective statified and randomized studies now under way. However, since the cosmetic results obtained by the procedures listed in the r e m a i n d e r of this monograph are constantly improving, we feel t h a t the cosmetic justification for p r i m a r y radiation t h e r a p y is a moot point. More doctors t h a n ever agree about the timing of procedures related'to the diagnosis of breast cancer. It was formerly routine to perform a biopsy and, if necessary, radical mastectomy in one 595

Survival After Radical Mastectomy 100.

80 ~..,....A~ "~'~@ Portsmouthlocal biopsy "'"""A ColumbiaStageA'

-6 •? -~ 60 E u

40

20

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Years Following Masleclomy Fig 2.-Survival after radical mastectomy. Asterisk indicates data based on a group of Columbia Stage A patients at Ellis Fischel State Cancer Hospital who underwent biopsy with immediate mastectomy. The Portsmouth group underwent local biopsy with mastectomy performedseveral days later, after review of permanent sections. (Courtesy of Knapp, R.W., et al.: Am. J. Surg. 131:626, 1976.)

stage and under a single anesthetic. Presently, it is far more common that the biopsy procedure be done as an initial separate undertaking and usually under local anesthesia. Many studies, including that of Knapp and Mullen I" document the safeness of such a two-stage approach with a delayed mastectomy. In gen"eral, as long as mastectomy was performed within four weeks of the biopsy procedure, the overall survival rates were not adversely affected (Fig 2). Therefore, women can safely undergo excisional biopsy and have the opportunity to discuss therapeutic implications with the surgeon prior to mastectomy. There is also an opportunity to selectively study and accurately stage such patients with positive biopsy procedures before proceeding with mastectomy. This approach also allows time to include the plastic surgeon in the total m a n a g e m e n t of the patient. A talk with the plastic surgeon prior to mastectomy comforts the patient simply by letting her know that reconstruction is possible. The patient also appreciates the thoughtfulness of her general surgeon in asking for this plastic surgical consultation to provide better overall patient information and care. In summary, there has been a shift i n breast cancer surgery toward less extensive procedures and the acceptance of a two-step approach in the management of breast lesions. Changes such as these facilitate collaboration with plastic surgeons in planning for reconstruction and an ultimately satisfactory result. 596

HISTORY OF BREAST RECONSTRUCTION Reconstruction of the breast has been attempted for m a n y years. The first article about it, published by Czerny in 1895,"" concerned the t r a n s p l a n t a t i o n of a large lipoma to replace a breast removed for benign disease. Since then, the search for body tissues to re-form a breast has continued with enthusiasm. Fat grafts from the buttock and abdomen were used, but it was soon noted that they s h r u n k so that adequate a u g m e n t a t i o n of the breast mound was not feasible. Fat and d e r m a l grafts'-" with the epidermis removed were then used, and less s h r i n k a g e occurred. These, too, proved inadequate to produce a normal-size breast. In 1924 Kleinschmidt"'-' advocated the reconstruction of a surgically removed breast with a lateral local skin flap. A y e a r later, Sauerbruch '':~ suggested a contralateral total breast flap for chest wall coverage, and in 1932 Reinhard'-'" suggested breast reconstruction by a flap s h a r i n g of the contralateral breast. In 1953, Longacre":' recommended the use of adjacent local pedicle flaps with the epidermis removed to reconstruct breasts after mastectomy for benign disease. These small local flaps did not have sufficient bulk to produce good results. Since the development of the tubed pedicle by Filatov"" and Gilles, '-'7 it has been demonstrated that tubes of skin can be developed on the abdomen or the lower chest for transfer via multiple operative procedures to the breast area. These procedures were prolonged, somewhat hazardous, often unsuccessful. The tubes were used in reconstructing patients who were determined to have their breast rebuilt, although the surgical methods offered to them yielded results that would be unacceptable today. In m a n y of these operative techniques, reconstruction required more t h a n a year to complete and the r e s u l t a n t breast frequently bore little resemblance to its normal counterpart. It is no wonder that general surgeons decried attempts at breast reconstruction and advised their patients against it. Various foreign m a t e r i a l s have been used for breast reconstruction. Paraffin injections were proposed by Gersuny in 1899. ''~ These early attempts resulted in total failure. In 1954, Pangman'-':' used Ivalon to enlarge the breast. Ivalon became firm, s h r u n k and proved totally unsatisfactory when observed over a long period of time. It was not until Cronin and Gerow:"' introduced the silicone breast prosthesis in 1963 t h a t a satisfactory foreign material was available to the surgeon for use in breast reconstruction. Breast a u g m e n t a t i o n for the hypoplastic breast soon became popular and m a n y types of silicone prostheses were developed, including custom i m p l a n t s for breast and chest wall deformities. Since silicone was well tolerated by the body, m a n y of these prostheses were used in early attempts at breast reconstruction. Unfortunately, when silicone is implanted b e n e a t h thin skin 597

there are very often complications. These complications include 1) displacement of the prosthesis, 2) capsular contraction (a strong fibrous tissue capsule fbrms al~und the breast prosthesis, causing excessive firmness), and 3) necrosis of skin over the; prosthesis. While plastic surgeons were trying to reconstruct the breast after radical extirpation for cancer, general surgeons were approaching the problem of the premalignant breast. Subcutaneous mastectomy in which the majority of the breast tissue was removed through an inframammary incision became fashionable. Many of these reconstructions were performed by placing silicone prostheses subcutaneously beneath the thin skin covering. An unacceptably high incidence of capsular contraction and skin necrosis was noted. Because total glandular removal could not be accomplished while retaining skin and nipple viability, and because there were too many complications of subcutaneous mastectomy, the popularity of the subcutaneous mastectomy has declined. In a cooperative venture of the Departments of Plastic Surgery and General Surgery at the Eastern Virginia Medical School in the early 1970s, the technique of total breast glandular extirpation and submuscular prosthesis implantation was developed for the control of difficult, premalignant, benign disease of the breast. The term simple mastectomy was felt not to be descriptive of the surgery performed, and the word total mastectomy was preferred for the procedure. :~I It was found that implantation of a prosthesis beneath the pectoralis muscles, rectus fascia and the serratus fascia provided a cushion that allowed the breast to remain supple and soft. If capsules still developed around the prosthesis, the muscle cover more or less prevented them from becoming clinically detectable. Problems of cutaneous erosion and implant extrusion, so frequent with subcutaneous prostheses, were virtually eliminated. Even cutaneous flap viability became much less of an issue, for total muscle coverage of the prosthesis allowed small areas of flap loss without progressing to a disastrous complication. ~The evolution of the submuscular placement of the prosthesis h a s h a d many ramifications. The placement of implants beneath the pectoral muscles in routine augmentation mammoplasties has greatly diminished the problems of capsule contracture once encountered. Subcutaneous mastectomies have fewer complications when the implant is placed submuscularly. Immediate breast reconstruction can be performed much more predictably with submuscular prostheses. The popularization of myocutaneous flaps, especially the latissimus dorsi, in breast reconstruction has allowed total muscle coverage of prostheses, even after radical mastectomy. This concept, which stresses the importance of muscle in supplying overlying skin, was documented by Iginio 598

Tansini of Pavia, Italy. "~'-'In 1906 he actually described latissimus dorsi myocutaneous flap breast reconstruction performed at the time of radical mastectomy. Unfortunately, his work was not accepted, and until McCraw and Dibbell :r~,:u repopularized the concept of myocutaneous flaps in 1977 and Olivari, :~-,M u h l b a u e r and Olbrisch, :~" Bostwick :~. :~. "~J and Maxwell '~j0j~, 4.., refined its use in breast reconstruction, this i m p o r t a n t technique in reconstructive breast surgery lay dormant.

GENERAL SURGICAL CONSIDERATIONS AT THE TIME OF MASTECTOMY The principle established at the beginning of this monograph m u s t be reemphasized: the general surgeon and plastic surgeon m u s t work in unison with the patient. It is the responsibility of the general surgeon, however, to m a k e all decisions concerning tumor ablation. Although the ablative cancer procedure should never be compromised, there are acceptable variables within these guidelines t h a t would improve the likelihood of a better reconstructive result. Our attention in the next section is directed to such variables, with the u n d e r s t a n d i n g t h a t they in no way interfere with complete en bloc t u m o r resection. SKIN I N C I S I O N . - In general, we prefer incisions t h a t are slightly oblique off the transverse line and t h a t extend more laterally t h a n medially. Such an incision is most suited to the dress and evening-clothes styles t h a t predominate today (Fig 3). Since the Fig 3 . - A slightly obliqued mastectomy incision generally allows the best reconstructive result. If the breast is not too large, the medial extent of this incision may be limited, which ultimately may allow a more acceptable selection in clothing without visualizing a chest scar.

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/

599

prosthesis will be placed in a s u b m u s c u l a r position, there is less concern with the thickness of the skin flap for coverage, and the standard flaps should be developed, as'is generally recommended for extirpative surgery for cancer. The a m o u n t of skin to be included with the en bloc resection should follow the usual precepts and include at least 3 cm in all directions from the m a r g i n s of a tumor when palpable. "De novo" nipple-areola reconstruction has produced results that no longer m a n d a t e preservation or b a n k i n g of the original nipple areolar complex. (This is discussed below.) In addition, there have been several reports of tumor developm e n t at the site of an autotransplanted nipple-areola complex..,:~. 44 Anderson and Palleseu '~ have shown that ifcareful multiple horizontal sectioning is done, tl,ere is about 33% involvem e n t of nipple-areola with cancer. PECTORALIS MAJOR I N N E R V A T I O N . - A s mentioned previously, the overall results of cancer surgery using modified mastectomy are comparable to those of standard radical mastectomy whether or not the pectoralis minor muscle has been removed. However, m a n y surgeons feel that an adequate axillary dissection requires removal of the pectoralis minor muscle. In such a situation, m a n y of the nerves i n n e r v a t i n g the lower reaches of the pectoralis major muscle are divided, and t h a t s e g m e n t of muscle is denervated, and atrophy and t h i n n i n g of the lower pectoralis major muscle e v e n t u a l l y occur. Wherever possible, therefore, one should try to preserve the pectoralis major innervation. This is rel.~tively easy if the pectoralis minor is mobilized by detaching its medial and inferior origin and performing the axillary dissection beneath the raised lower reaches of the muscle, leaving its insertion near the coracoid process intact. When the muscle is completely removed, inevitable denervation results, which m a y require additional soft tissue cover at the time of reconstruction. The innervation of the upper reaches of both pectoral muscles derives from medial branches of the intercostal nerves, which are generally left intact despite m a n i p u l a t i o n and dissection around the pectoralis minor muscle. THORACODORSAL VESSELS AND N E R V E . - Since Halsted's original descriptions of radical mastectomy and axillary dissection, attention has focused on preservation of the thoracodorsal nerve in order to m a i n t a i n the function of the l a t i s s i m u s dorsi muscle. The thoracodorsal artery and vein t h a t run along the nerve in the posterior axilla have generally been sacrificed. If clinically significant l y m p h nodes are seen in the posterior axilla, all of these structures should unquestionably be sacrificed. If, on the other hand, no nodes are encountered, and one considers selectively preserving the thoracodorsal nerve, one should also strive to preserve the thoracodorsal vessels. These vessels m a y be extremely i m p o r t a n t in later reconstruction if a latissimus dorsi myocuta6oo

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neous flap is used.-~" Since the edge of the Iatissimus muscle is the posterior extent of axillary dissection, it is generally acceptable to preserve these structures without compromising the axiIlary dissection. The location of these structures is shown in Figure 4.

RECONSTRUCTION FOLLOWING MASTECTOMY FOR CANCER MODIFIED MASTECTOMY Selection of the exact technique to be used in the reconstruction of the female breast following mastectomy must be carefully individualized. One should always seek to perform the simplest procedure possible. But one must also use that procedure which will give a functionally acceptable as well as an aesthetically pleasing result. As stated previously, muscular coverage of the implant is, in our practice, a prerequisite.

Submuscular Implantation The patient in whom a modified mastectomy has previously been performed with preservation of the pectoralis major muscle in its entirety and an adequate amount of overlying skin laxity is the optimal candidate for submuscular implant placement. The pectoralis muscle.must also remain innervated in its inferior portion to allow for adequate muscle cover. This is the simplest form of reconstruction we use and encompasses the placement of an 6ol

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Fig 5 . - A , defect following modified radical mastectomy with full preservation of a fully innervated pectoralis major muscle and ample cutaneous laxity. El, submuscular pocket for insertion of prosthesis is beneath pectoralis major, rectus abdominis, and serratus anterior muscles. C, totat muscle coverage of prosthesis is achieved. D, diagrammatic resuJt with concomitant nipple-areola reconstruction.

implant beneath a solid muscle-skin cover. Since the lower edge of pectoralis muscle will not cover the entire implant, it is necessary to use the adjoining m u s c l e s - t h e rectus abdominis and serratus a n t e r i o r - t o achieve this result. One need not worry about the blood supply to the overlying skin, since the elevation of the muscle does not alter the musculocutaneous perforators now present. A small incision is made either in the new inframammary fold or in the old incision. Through this access to the sub602

muscular plane beneath the pectoralis muscle, muscle coverage :is achieved. It is generally easier to enter the subpectoral plane higher on the lateral side, As the plane is developed inferiorly, it is important to stay on the periosteum of the ribs in the area of the pectoralis muscle. As this dissection is continued inferiorly, it allows the elevation of the continuous rectus abdominis fascia inferiorly. Continuing this dissection laterally, one elevates the anterior fibers and overlying fascia of the serratus musculature. Thus the muscular pocket into which the implant will be placed is composed primarily of lower pectoralis major muscle, augmented by the upper rectus abdominis fascia and a portion ofthe serratus anterior muscle (Fig 5). If additional muscle coverage is neeeded in the superior lateral portion, you can use one of two techniques. If the pectoralis minor muscle is still present, the origin of the muscle may be elevated from the ribs and rotated superolaterally. This small muscle may then be sutured to the overlying pectoralis major muscle and the underlying serratus musculature to give lateral upper muscular coverage. Alternatively, the anterior edge of the latissimus dorsi muscle can be dissected free and rotated to cover this lateral area. If more muscle is needed inferiorly, the entire latissimus muscle can be used. A closed suction drain is used. When the mastectomy scar is restricting, we perform Z-plasties before closing the wound. Nipple reconstruction may be performed at this time or in a delayed fashion. When there is marked skin tension, we generally delay nipple reconstruction"' (Fig 6).

Latissimus Dorsi Myocutaneous Flap Plus Pectoral Muscle In patients who have previously undergone a modified mastectomy when either the lower portion of the pectoralis major muscle was removed, or when the pectoral nerves were severed with resultant denervation of the inferior portion of the pectoralis major muscle, or when inadequate skin cover is present, latissimus dorsi myocutaneous flap reconstruction is used. Any patient in whom the pectoralis minor muscle was removed at time of mastectomy will lose the innervation to the pectoralis major. The innervation to this muscle is var!able; in some patients the entire lower section will be defunctionalized by this procedure. In others this denervatien will be of less clinical importance. Patients with tight overlying skin or skin grafts also need the enhancement of the anterior soft tissue with the latissimus dorsi myocutaneous flap. When the latissimus dorsi flap is used to enhance the overlying pectoral muscle and its skin cover, a less extensive procedure is required. In addition, the location of the skin island on the back differs from that required for the patient in whom a radical mastectomy has been performed. The skin island is positioned in the inferior lateral portion of the back overlying the anterior edge of the latissimus muscle. It is elevated with the majority of the latis6o3

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both the back donor site and the anterior chest pocket. Nipple reconstruction can be carried out primarily without hesitancy, as there is no question of the blood supply to the skin overlying the latissimus muscular segment. We have been very accurate in determining the location of the nipple areola primarily. If one is unable to do this, secondary nipple reconstruction is preferable (Figs 8 and 9). RADICAL MASTECTOMY

In patients who have undergone a radical mastectomy, the latissimus dorsi muscle is the primary reconstructive modality.

Latissimus Dorsi Myocutaneous Flap Reconstruction In patients in whom the entire pectoralis major muscle has been removed, an additional prime reconstructive problem is fill of the infraclavicular hollow and the fullness of the anterior axil605

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Fig 8 . - A , defect following left modified mastectomy with denervated lower pectoral muscle. B, result following single-stage right latissimus dorsi myocutaneous flap reconstruction.

lary fold. The l a t i s s i m u s dorsi myocutaneous flap a d m i r a b l y accomplishes these ends. In this situation, the cutaneous island is situated in a more superior fashion on the back. This allows elevation of the entire l a t i s s i m u s dorsi muscle, based on its proximal thoracodorsal pedicle with an island of skin, and can be located in a more inferior position when rotated over the chest wall. The positioning of the major portion of the l a t i s s i m u s muscle superiorly allows the rotated muscle to be sutured to the clavicle superiorly, the periosteum of the sternum medially, and to the chest wall inferiorly to recreate the i n f r a m a m m a r y fold. The remaining portion of the procedure is s i m i l a r to that previously described (Figs 1 0 - 13). An additional concern in e v a l u a t i n g patients postmastectomy prior to performing the latissimus dorsi flap procedure is the 606

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question of previous sacrifice of the thoracodorsal neurovascular stalk. Although it has been shown in laboratory and clinical studies t h a t sacrifice of the thoracodorsal nerve and vessels does not prohibit use of the flap, 41~previous muscle denervation significantly reduces the bulk of the latissimus muscle and does not allow as satisfactory a reconstruction. Preoperative a r t e r i o g r a m s are not indicated. To assess the status of the thoracodorsal nerve, have the patient press her hip with her hand. An innervated latissimus muscle will clearly stand out in its t a u t position. This establishes continuity of the nerve. It does not necessarily m e a n a vascular stalk is intact, however, and one should be careful in the elevation of the flap not to carry the dissection too high into the axilla unless the thoracodorsal vascular a r t e r y is m a i n t a i n e d either through collateral circulation from the branches of the scapula circumflex a r t e r y or from retrograde flow via the s e r r a t u s branch. Another consideration in the use of the ]atissimus dorsi muscle is possible functional disability. We have now performed over 300 latissimus dorsi flap transpositions in patients for breast reconstruction, chest wall defects, 4". 47 shoulder coverage, 4" head and neck reconstruction, ~:',~" and free flap transfer.:'" ~"'~:~ Careful evaluation of these patients has shown t h a t minimal functional 607

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Fig . I O . - A , design of skin island for radical mastectomy latissimus dorsi reconstruction is slightly different than for modified mastectomy reconstruction. B, flap elevation. C, flap is transferred to the chest and sutured to clavicle above, sternum medially, and chest wall inferioi'ly. If the anterior axillary fold is not adequately filled by this measure, the tendinous insertion of the humerus may be transferred anteriorly as well. D, result of one stage reconstruction is similar to that of modified mastectomy reconstruction.

defects occur after t r a n s f e r of this flap. Adjacent muscles compensate for its absence. There is a slight weakness t h a t can be elicited when the a r m is passed behind the back adductively. This, however, is not an i m p o r t a n t motion in the normal activity of most persons.

Other Methods Although the latissimus dorsi myocutaneous flap procedure is far and a w a y our first choice for radical mastectomy reconstruc608

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p u e j j o pauanl oae tuooa ~uDeaedo aql u! s~q~.q eq~ 'aele I se~nu.ttu gI XpleuaTxoaddv "lua!led otI1 ol disnouoAealu! u!ooseaonlj po :~ni!p3o tu~ oral o~ ouo ae:~s!u!tupe no X :~,,'injdioq s! oanpoooad oh!l -~un[pe ue se u!o~soaonlJ snOUOAea]u.t 3o osn ot~q~ 'Xi~u!paoo~ v "Xlddns p o o r q l ! ~ -~1 -Ina!jj!p ~mseoaou! aoluno~uo .Zeua ouo '~p~q oql o~uo pue o p s n t a !saop sntu!ss.tle[ oql3 o o~po ao!aolue oq~ ssoao~ d~g s!ql s u o q l ~ u o l ouo s V "ou!i ~aeli!x,~p~.tu oql ol XlIno~!p l n o q l ! ~ po!aa~o oq Xem delJ oql 3 o luolxo Iels!p eq& "iieta lsoq~ ao!aolu,e oql ol upIs ~u!ppe 30 poqlotu oiqeTioa pue ~sea ue s! delj s!q-I ~,~'~eaDOIAI pue SlAe(I fig pau!joa pu~ ~,.u!uoa o Xq poz.ta~[ndo d "delj o!a~se~.Tdoo~ -eaoql oql osn ol s! ~soqo oq~ ol aonoo onss!~ ~3os o~uequo ol .~e~ ou O "uo!le!peaa! .ZaeIi!Xe .ZAeoq pue o p s n t u s n u q s s ! l e I poleAaouop ql!~, l u o ! l e d oql u! sdeqaed ao oiosnta oql ~u.tloossueal potuaoj -aod uaoq s e q .~uaolooeaoql IeaOlel!sd! ue t u o q ~ u! l u o ! l e d oql u~ ano'~o X~m s.tq,T, "d~lj s.tql osn o~, oiq!ssodm.t A'ii~uo.Is~o~o st ~,t. 'uop, •AlSeldOWWeW uo!lonpeJ llal e ql!M luel!wo3 .uoo lno pe!JJl~O seM uoo, onJ),Suooaj !$Jop snw!ss!lel lqB!J e qo!qM u! eJnpa3oJd )^!leJedo elfiU!S 6u!MOllOl llnseJ '8 'peaJaseJd seM elosnw Jolew S!leJoloed o d!ts Jeddn IteUJ£ V "/(woloalsew leo!peJ lqfi!J 6u!~aOllOj ;oejep 'V--'LL 8!4

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a. Wood's light is used to assess fluorescence. All viable cutaneous areas will fluoresce brightly, while questio.nable areas will show minimal, or mottled fluorescence, and areas of skin destined to necrose will show no evidence of fluorescence. Using this adjunctive procedure, the thoracoepigastric flap can be carried past the midaxillary line to whatever extent it is determined viable. The flap is simply rotated superiorly on to the chest wall; primary closuite of the donor site in a reverse abdominoplasty type underlays the procedure. Another way to reconstruct the breast when the latissimus dorsi muscle is unavailable is to use one of the rectus abdominis muscles and its overlying skin. :,7 This muscle, based on its superior epigastric vascular pedicle, may be transposed through the breast area for soft tissue coverage. Although this leaves a verticle abdominal scar and generally does not allow adequate muscle coverage for the entire area, it may be a useful procedure in certain individuals. 610

Fig 13.-Top, severe defect following right radical mastectomy with total pectoral muscle removal and split thickness skin graft. Bottom, result following latissirnus dorsi reconstruction.

611

B i r n b a u m and Olsen :',~ advocate custom-made prostheses to fill out the infraclavicular hollow. They. also suggest dermal graft coverage beneath the mastectomy scar. We rarely use these techniques, which require several procedures and employ subcutaneous prosthesis placement, but B i r n b a u m and Olsen have demonstrated admirable results. Rarely, other techniques such as microvascular free tissue transfer:"' m a y be used. The situation in which this technique m i g h t be necessary, however, is exceptional. We have scarcely mentioned subcutaneous insertion of a prosthesis, for reasons cited previously. Some do advocate this type of breast reconstruction. Good results can be achieved with it. In our opinion, however, its disadvantages far outweigh its advantages.

NIPPLE-AREOLA RECONSTRUCTION Although the evolution of nipple-areola reconstruction has frequently employed s h a r i n g procedures from the contralateral areola complex, this is generally not necessary in nipple-areola reconstruction today. F o r m e r techniques of contralateral splitthickness and full-thickness skin grafts, either spiraled or halved, are generally not used. Nor are b a n k e d nipple-areola complexes, used nowadays, for they have tended to lose pigmentation or projection in their multiple transfers. An especially difficult situation arises when the general surgeon preserves the nipple and b a n k s it on the chest, as the site is usually incorrect, and repositioning is not easily accomplished. Donor tissue to construct the areolar complex is selected on the basis of the color of skin needed to match the contralateral areola tissue. The usual donor site is the upper inner thigh. A split thickness g r a f t t a k e n from this area and placed in the location of the areola will give a t a n to light brown color once it matures. To m a t c h a . c o n t r a l a t e r a l pink areolar complex, the postauricular area is used. The labia is the preferred donor site to m a t c h a d a r k brown- to black-pigmented areola complex. A skin g r a f t between 20 and 30 one t h o u s a n d t h s of an inch thick is taken. The upper inner thigh donor a r e a can be closed primarily, and the scar rem a i n s insignificant in appearance. The nipple tissue itself m a y also be obtained from one of several sites. The preferred site is h a l f of the contralateral nipple. This can be used only when there are no pathological contraindications. The lower h a l f of the contralateral nipple is a m p u t a t e d and the r e m a i n i n g nipple sutured onto itself. A specimen at the base of the nipple is shaved and sent for frozen section evaluation. The nipple is then sutured to itself to form a conical composite graft. This composite nipple g r a f t is sutured to the de-epithelialized site on the reconstructed mound. One may also t a k e a segment ofcostochondral cartilage with its overlying perichondrium from the 612

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,@. Fig 14.-Nipple areola reconstruction. A, the new nipple areola site is deepithelialized leaving a smalt epithelial ring in the center. B, the lower half of the contralateral nipple is molded into a mound and sutured to the epithelial ring. C, a thick split graft from the upper inner thigh forms the areola. D, diced costochondral cartilage with overlying perichondrium is placed beneath the graft to simulate Montgomery's glands.

rib area where the submuscular pocket is dissected. These diced portions of cartilage and perichondrium are placed b e n e a t h the graft to give the resemblance of Montgomery's glands and prevent the appearance of a slick skin graft (Fig 14). Another location t h a t m a y be used for the nipple graft when the contralateral nipple is u n a v a i l a b l e is the lobule of the ear. A bolster dressing is placed over the reconstructed nipple-areola complex and removed on the fifth day. This technique of nipple-areola reconstruction has consistently produced a reconstructed complex s i m u l a t i n g normal and superior in its esthetic appearance to the banked nipple. 4t, "" (Fig 15). THE OPPOSITE BREAST

In the t)atient who has undergone mastectomy for cancer, there r e m a i n i m p o r t a n t considerations regarding the opposite breast. The first of these concerns the question of development of cancer in the r e m a i n i n g breast. It has been estimated t h a t among women surviving mastectomy, 1% will develop cancer each year, so that by ten years, approximately 10% of survivors will have developed a m a l i g n a n t lesion in the contralateral breast. U r b a n et al. "j followed up their patients and found a 9% ten-year involvement of the contralateral breast, which represented a 15% incidence of cancer in the contralateral breast of those who survive original mastectomy. Leis"'-' followed closely a group of Stage 1 patients who were at high risk for development of cancer, and had a positive family 613

q

Fig 15.-Nipple areola reconstruction. A, de-epithelialized area on reconstructed breast. B, the lower half of the contralateral nipple is taken as a composite graft. C, the halved nipple is sutured to itself and then anchored to the epidermal ring. D, a split thickness graft from the upper inner thigh forms the areola. Diced costochondral cartilage with overlying perichondrium is placed beneath the graft to resemble Montgomery's glands.

history, evidence of multifocal disease, or any component of in situ or invasive lobular cancer associated with the original lesion. After three years, these patients had a prophylactic mastectomy of the r e m a i n i n g breast and were found to have tumor involvement, two thirds of which were in situ lesions and one third of which were invasive. The c o n t r a l a t e r a l breast is a decided higher risk for the development of subsequent cancer. A second consideration relates to the cosmetic disparity between the reconstructed and the r e m a i n i n g breast. The reconstructed breast retains a tight configuration, is less movable and lacks the ptotic appearance of a large normal breast of a middleaged woman. This lack of s y m m e t r y when the contralateral b r e a s t is large generally calls for operative intervention on the r e m a i n i n g breast. Such patients, therefore, are ideal candidates for prophylactic mastectomy, a subject treated below. Because it provides maxim u m cosmetic s y m m e t r y and protects the patient from the welldocumented high incidence of contralateral cancer, such an approach has appealed to a large n u m b e r of women. 614

In those situations where prophylactic mastectomy is not opted for (and m a n y women prefer to r e t a i n their e x t a n t breast), close clinical observation of the r e m a i n i n g breast is necessary. Physical e x a m i n a t i o n at least once every three months, yearly mammograms, and even a blind biopsy of where invasive lobular cancer was involved in the mirror-image contralateral breast are all reasonable approaches. For those women who prefer to retain their normal breast but want better symmetry, there are several possible alternatives. If the r e m a i n i n g breast is not so large t h a t it can be matched with reconstruction, nothing need be done. For large breasts, a reduction m a m m o p l a s t y m a y be done. For sagging breast, a mastopexy m a y be done. An a u g m e n t a t i o n m a m m o p l a s t y m a y be done on a small breast. There are no data to support the possibility that augmented breasts in such a high risk population m i g h t lead to the development of new growths. However, there r e m a i n s the problem of fibrous capsule formation and scar tissue in either a u g m e n t a t i o n or reduction mammoplasty, which may necessitate biopsy and have more fearful connotations. Patients must be apprised of the possibility and, with the surgeon, m a k e the decision as to the most appropriate m a n a g e m e n t of the opposite breast. Again, from the point of view of cancer prophylaxis, a total mastectomy is the most desirable option presently available. One would not hesitate to perform a colon resection for a villous adenoma with a 20% risk of colon cancer, nor hesitate to perform a limited gastric resection for multiple polyps with a 12% incidence of gastric cancer. Thus, a strictly n u m e r i c a l consideration would support the notion of a contralateral prophylactic mastectomy. COMPLICATIONS AND THEIR MANAGEMENT

Formerly t h e r e were m a n y complications of subcutaneous insertion of a silicone prosthesis. Capsule contracture, cutaneous erosion, and i m p l a n t extrusion headed the list. In an effort to control capsule contract-ure, steroid solutions were introduced into the subcutaneous pocket or the inside of inflatable prostheses. The use of these steroids was f r a u g h t with m a n y complications, including total dermal atrophy resulting in paper-thin cutaneous envelopes. There were also m a n y problems with random skin-flap rotation, including ischemia, infection and necrosis. With the current techniques described in this monograph, complications have been few. Our knowledge of cutaneous blood supply from u n d e r l y i n ~ m u s c l e has v i r t u a l l y e l i m i n a t e d problems with flap viabilitY'~ Even with l a t i s s i m u s dorsi flap rotation, it is extremely / rare to .have flap circulatory problems. Submuscular prostheses have greatly d i m i n i s h e d the problems of capsule formation. Implant extrusion is almost nonexistent. H e m a t o m a or infection is 615

rarely encountered. In over 200 latissimus dorsi reconstructions (tHe operation may t a k e as long as fo.ur hours) with extensive soft tissue, dissection, flap elevation, and insertion of a silicone prosthesis, we have had only two infections t h a t required removal of the prosthesis. Our most fi'equent complication is the collection of a seroma in the back donor area, which m a y require aspiration. We have not encountered any serious sequelae of these seromas. Other complications relate to s y m m e t r y . It is not uncommon for one b r e a s t to be slightly larger or slightly higher than the other. Nipple-areola location m a y be slightly off'. The reconstructed breast has scars and does not have normal sensation. In reconstruction of severe infraclavicular depression in radical mastectow y patients, the entire infraclavicular fullness may not be restored. Any of these problems, if severe enough, can be corrected by minor secondary procedures. TIMING AND SEQUENCE

Reconstruction following mastectomy m a y be done p r i m a r i l y at the time of mastectomy, in the delayed p r i m a r y s e t t i n g - d u r ing hospitalization fbr mastectomy, in an intermediate fashion, or secondarily.

Immediate The general surgeon will occasionally encounter a patient who refuses to have necessary breast surgery unless immediate reconstruction can be performed. The n u m b e r of patients having immediate breast reconstruction is too small to be evaluated to date; however, it is now technically feasible to consider this alternative. The techniques used for total mastectomy with immediate reconstruction and latissimus dorsi reconstruction in secondary setting can be used for the patient who demands immediate breast restoration. Many patients who require this type of reconstruction are young, . intelligent women who place great importance on their beauty and on the significance of their breasts It is essential t h a t these patients receive proper preoperative counseling as to the imperfections of all breast reconstructive surgery. M a n y surgeons feel t h a t the patient who h a s immediate reconstruction and has never suffered the disaster of loss of a breast fails to appreciate the severity of the deformfty caused by mastectomy and will not accept a reconstructed breast as readily as the w o m a n who has suffered this loss. It is essential also t h a t the plastic surgeon and general surgeon confer in detail with the patient preoperatively. This is a difficult time (after one learns t h a t the biopsy sample is positive) to m a k e rational decisions, and the patient m u s t h a v e t~ll the sound medical advice she needs. She m u s t also be a w a r e of the possibility of not proceeding with the immediate reconstruction if the extent of the tumor is found intraoperatively to be much greater t h a n expected. 615

Psychological t r a u m a is inevitable in these patients whose planned procedures prove impractical. For these and other reasons, patients eligible fbr i m m e d i a t e reconstruction must be very carefully selected and all details carefully explained before the general surgeon and the plastic surgeon make a c o m m i t m e n t to attempt reconstruction. The principle that the general surgeon performs that resection which in his j u d g m e n t is required to best treat the patient i~ inviolable. Following resection of those structures necessary to cure the patient, the plastic surgeon assesses the defect. If the pectoral muscle is unharmed, a submuscular, subfascial implantation of a silicone prosthesis can restore the breast mound. If skin is adequate, p r i m a r y closure of the skin flaps and nipple reconstruction can be performed. If the pectoral muscle is resected either partially or totally, a primary l a t i s s i m u s muscle or myocutaneous flap reconstruction can be performed. It must be explained that the dissection for breast extirpation should best be altered and that care of the patient is paramount. Prolongation of the operation is not necessarily an aspect of the surgery, since the defect created by the general surgeon is s i m i l a r to the first part of the operation for later reconstruction.

Delayed Primary Reconstruction Aside from psychological considerations, there have been two basic a r g u m e n t s against primary breast reconstruction: technical concerns with viability of skin flaps, hematomas, seromas, etc.; and lack of knowledge of the stage of disease. Delayed p r i m a r y reconstruction has been felt by some to resolve these issues. The term delayed p r i m a r y reconstruction is used to refer to reconstruction performed during hospitalization for m a s t e c t o m y - p e r formed, usually, three to five days after mastectomy. When prostheses were placed subcutaneously, total skin-flap viability was critical to successful reconstruction. Three to five days following mastectomy, skin flaps could be carefully assessed, and if they are healthy, a prosthesis could be placed b e n e a t h them. Drainage from the raw tissue surfaces would also have d i m i n i s h e d by that point. S u b m u s c u l a r prosthesis placement has obviated the need for consideration of delayed primary reconstruction on technical grounds. Since total muscle coverage of the prosthesis is achieved, minor skin-flap problems can be tolerated with little concern. The use of intravenous fluorescein:'" also has taken the guesswork out of d e t e r m i n i n g the fate of the skin flaps. Staging of the cancer is a more valid a r g u m e n t for delayed p r i m a r y reconstruction. When p e r m a n e n t sections are back on the tumor and the nodal status, further t r e a t m e n t considerations can be made. Knowledge of the staging m i g h t help to d e t e r m i n e whether reconstruction should be done at t h a t time or postponed. On the other hand. if reconstruction is carried out p r i m a r i l y and 617

permanent-section information requires chemotherapy or radiotherapy, either t h e r a p y could be carried out after reconstruction without any problem. "7

Intermediate Reconstruction I n t e r m e d i a t e reconstruction should be considered for some patients. Soft tissue coverage in the form of a flap should be performed primarily. The r e m a i n i n g portion of the reconstruction (insertion of a prosthesis and nipple reconstruction) can be done later, depending on the patient's interest and h e r state of disease. Where the extent of the cutaneous resection will not allow prim a r y skin closure, we recommend flap coverage of the chest wall instead of placement of a split thickness skin graft. E i t h e r a latissimus dorsi myocutaneous flap or a thoracoepigastric skin flap m a y be used primarily, with minimal addition to the operative time. The use of these flaps with p r i m a r y donor site closure will allow the chest deformity to be covered with pliable soft skin, which can be used later for definitive recolmtruction. Even if the patient does not w a n t a reconstruction in the future, better soft tissue coverage with a more functional chest and axilla results. In addition, wound healing is less complicated and more predictable t h a n it is with a skin graft. There is also the occasional patient who needs extended cutaneous resection, followed by immediate aggressive adjunctive therapy, usually irradiation. In this type of patient, especially when her entire overlying m u s c u l a t u r e and skin have been resected, the immediate employment o f a latissimus dorsi myocutaneous flap will allow a well-healed soft tissue coverage of the chest wall to undergo early irradiation. Those patients in whom reconstruction is not anticipated will occasionally show no sign of r e c u r r e n t disease and m a y in fact undergo the completion of their reconstruction in a secondary fashion. They profit from an immediate wound coverage, earlier irradiation, and the chance to have a future simplified reconstruction.

Secondary Reconstruction

TECHNIQUE.-When implants are placed beneath skin flaps, it is necessary to allow an extended period of time to pass for the wound to mature. When a s u b m u s c u l a r implant is used, two to six months m a y be necessary for the same reason. When a latissimus dorsi breast reconstruction is employed, skin m a t u r a t i o n is unnecessary. ' Accordingly, from a technical standpoint, submuscular i m p l a n t a t i o n could generally be carried out from two or three months later on. L a t i s s i m u s dorsi reconstruction could be carried out from as early as several weeks following mastectomy. PATHOLOaV. -- Given improved techniques, more sophisticated 618

prostheses, and shortened hospital stays, there are few it' any absolute contraindications to breast reconstruction. The major contraindications, however, relate to those patients who run an exceedingly high risk of recurrence, particularly those whose chance for recurrence is associated with an extremely poor survival pattern. First and foremost among this group are those with inflammatory carcinoma, which is defined as any cancer presenting with inflammatory signs and with the usual histopathologic accompaniment of dermal lymphatic invasion. It is known that approximately 3% of such patients will survive for two years or longer but virtually none for five years. One must carefully expend any additional time, financial resources, or other effort toward reconstruction in this group of patients. However, flap coverage following total mastectomy may be desirable to prevent the locally offensive complications that attend this type of tumor. The second major pathologic consideration leading to delayed reconstruction concerns the number of lymph nodes present. The chance of recurrence is almost linearly related to the number of axillary nodes involved with cancer. Delayed reconstruction in this setting should be considered, less for the reason of a greater chance of recurrence than for the adjuvant considerations that such positive nodes often require. Such patients will be prime candidates for x-ray therapy and/or chemotherapy. In either of these settings it may be more prudent to delay reconstruction until completion of adjuvant programs. Even in this group of multiple positive nodal patients, the risk of recurrence is greatest in the first two years, during which time about 80% of all recurrences manifest themselves. Therefore, patients in poor risk groups who are alive and well beyond two years again become prime candidates for reconstruction. One must carefully weigh reconstruction because postmastectomy chemotherapy is attended by periods of suppressed immunity and decreased resistance to infection. We have carried out a number of reconstructions in patients on chemotherapy when the hematological parameters have been acceptable. Chemotherapy is usually stopped for a~ten-day postoperative period. To date, we have had no untoward complications in these patients. It is obvious that considerations of secondary reconstruction should be preceded by communication between surgeon, plastic surgeon, chemotherapist, radiotherapist and patient. We must remember that anticipated immortality is no prerequisite to decisions in favor of reconstructive surgery. In selected patients with poor prognoses, a judicious attempt at reconstruction not requiring excessive hospitalization or expenditure of time would certainly be in order to improve the quality of even a contracted lifespan: 619

PROPHYLACTIC MASTECTOMY RISK FACTORS AND INDICATIONS

It is obvious t h a t all physicians w a n t to prevent breast cancer whenever possible and practical. Unfortunately, no single test or e x a m i n a t i o n is able to identify those patients certain to develop breast cancer. Because no scientific test is available, the selection of patients for prophylactic mastectomy requires the practice of the true " a r t " of medicine. The conscientious physician must have a total u n d e r s t a n d i n g of the intelligent patient and consider the a g g r e g a t e of factors presently i m p o r t a n t in the assessment of this problem. Certain factors are i m p o r t a n t in predicting the patient with high risk for malignancy. The occurrence of a malignancy in one breast increases the chance for a n o t h e r breast cancer, as we have emphasized above. The patient with florid fibrocystic disease with a histologic v a r i a n t of proliferative ductal epithelium appears at the m o m e n t to run a high r i s k of developing a breast malignancy. The most i m p o r t a n t factor is probably t h a t of family history. Statistics now s u b s t a n t i a t e t h a t the patient with a maternal aunt, mother, g r a n d m o t h e r , or sister has three times a g r e a t e r risk of developing cancer, and if these family members have developed their cancer premenopausally, the risk is increased eightfold. O t h e r conditions are of concern to the conscientious general surgeon: a suspicious m a m m o g r a m , silicone injections in the breast, mastodynia, certain congenital syndromes (such as Cowden's syndrome), excessive radiati}51~-tb-the-b-r~a-~, late child bearing, and a type of wet-ear cerumen are all risk factors in breast cancer. The patient with m a s t o d y n i a m a y pose such a severe problem to the conscientious physician t h a t he will ultimately recommend prophylactic m a s t e c t o m y if her pain cannot be controlled with medication. Conservative m e a s u r e s should be attempted with potential candidates for prophylactic mastectomy; surgery should be offered to these patients only after all other efforts are exhausted. The conscientious general surgeon m a y have several patients who will have had multiple excision of benign tumors and in whose minds the fear of cancer assumes a proportion such t h a t it wrecks their lives. It is recognized t h a t there m a y be no other recourse left for this particular patient other t h a n t h a t of b r e a s t extirpation to restore her to a useful and valuable life. We t h i n k it likely t h a t too m a n y prophylactic mastectomies are now being done in the United States for obscure reasons. Unfortunately, we cannot give an absolute list of indications for prophylactic m a s t e c t o m y but m u s t rest on the s u m m a t i o n of the high risk factors e n u m e r a t e d above, a s k i n g the conscientious general surgeon to t r e a t the patient in her best interest with the least possible h a r m . W h e n e v e r total mastectomy is indicated under 620

these circumstances, the general surgeon is obligated to perform an operation prophylactic for cancer and not a partial extirpation of breast tissue. As risk factors aggregate, the indications for prophylactic mastectomy become clearer. In our series "'~ the following indications have been used: f a m i l y history, cancer in opposite breast, florid fibrocystic disease, mastodynia, cancerphobia, silicone injections, radiation injury and Cowden's syndrome. C. TECHNIQUES

General Surgeon's Role The general surgeon should plan to totally excise all visible and identifiable breast tissue. To allow easy access to all breast tissue, we recommend a transverse oblique or gently oblique incision extending around the nipple laterally and slightly upward. Superior and inferior skin flaps are elevated to expose the entire extent of the breast field. The breast tissue is raised from the pectoral fascia. All identifiable breast tissue is removed by the general surgeon, and the nipple-areolar complex is excised with the breast specimen. Skin flaps should be as thin as necessary in the surgeon's j u d g m e n t to remove all breast tissue. The operation should be the standard operation employed for total mastectomy whether reconstruction is contemplated or not. In well over 100 patients with benign disease who underwent prophylactic mastectomy performed by the authors, no recurrence of breast disease was noted after an observation period of up to ten years. ":~ In the 1 2 patients upon whom the authors operated for mastodynia, none had a recurrence of breast pain postoperatively. In 15 successive patients having biopsies of the surgical field after extirpation of the breast proper, no residual breast tissue was identified histologically (Fig 16).

Plastic Surgeon's Role After the general surgeon has completely extirpated the breast tissue, the plastic surgeon begins reconstruction. Entrance under the pectoral muscle is exactly the same as previously described. The s u b m u s c u l a r pdcket is produced in the same fashion and the i m p l a n t is placed using the technique already described. The skin flaps are t h e n closed using subcutaneous and skin sutures. Fluorescein dye is used to assess viability of skin circulation to the flaps. Any evidence of flap avascularity is considered to be an indication for excision of the involved portion; if necessary, further m o v e m e n t of distant skin tissue into the area may be performed at this time. If the viability of the flaps is questionable but is such that the flaps should not be discarded, it is prudent to store the nipples for 24 hours in a cold sterile saline container. These can be plaeed on the breast mound the next day if the skin is satisfactory. We prefer, however, the technique of nipple reconstruction 621

• A

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D J

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Fig 1 6 . - A , design of incmion for total mastectomy, which is essentially the same as for a modified mastectomy. B, resection of all detectable breast tissue just as in a modified mastectomy. An axillary dissection is not done. (3, submuscular placement of a silicone prosthesis. D, skin closure and nipple areola reconstruction.

described previously, and since these nipple grafts are t a k e n from an a r e a some distance from the surgical field, it would not be necessary to store these grafts if nipple reconstruction is not completed during the p r i m a r y procedure. Closed suction d r a i n a g e is used within the b r e a s t pocket, as previously described (see Fig 16). SUBCUTANEOUS VS. TOTAL MASTECTOMY

Subcutaneous m a s t e c t o m y has become very popular in the United States in recent years, despite the fact t h a t m a n y authors have reported catastrophic results with such surgery. The operation has been touted as a cancer-preventive operation when in fact it does not remove all of the breast tissue because of the limited access from a s u b m a m m a r y incision and because of the impossibility of r e t a i n i n g blood supply to the nipple areola complex if all breast tissue is removed from b e n e a t h it. There are m a n y 622

complications of subcutaneous mastectomy, particularly when the prosthesis is implanted subcutaneously. The prosthesis may displace and produce asymmetry of the breasts. The skin flaps, which are thin and have tenuous blood supply, may necrose because of pressure of the prosthesis. The nipple, in particular, has a precarious circulation and depends on underlying.breast tissue to give vascularity to the central portion of the breast. Late complications consist of erosion of the prosthesis through the skin with loss of the prosthesis; capsular contracture with hard, firm, and painful breasts; and recurrence of pathology in breast tissue not removed at the primary surgery. Because of the high complication rate of subcutaneous mastectomy, we abandoned this technique many years ago. Some authors have promoted the technique of subcutaneous mastectomy and implantation of the prosthesis beneath the pectoral muscle. This technique helps correct the problems of erosion of the prosthesis and diminishes t h e rate of capsule formation around the prosthesis, but it does nbt answer the objection to lea~ingJn-situ ~ breast tissue that can later become cance!:ous.:The-operation~of subcutaneous mastectomy with subpectoral augmentation could conceivably be used in cases of mastodynia and in the siliconeinjection patient, where apparent malignancy is not a threat. However, in patients with true premalignant potential, it would seem to raise false hopes to offer patients this operation as a cancer-preventive measure. Total mastectomy, on the other hand, allows the general surgeon to remove all vestiges of breast tissue, although it may admittedly be impossible ever to totally remove the breast. It is, however, a surgical procedure as extensive as could ever be contemplated for removal of t h e b r e a s t under any circumstances. It also allows subpectoral implantation of the prosthesis and reconstruction of the nipple-areola complex with an acceptable cosmetic result and gives the best current prophylaxis for the patient who has the premalignant potential to develop breast malignancy (Fig 17).

ONCOLOGIC CONSIDERATIONS IN BREAST RECONSTRUCTION PROSTHESIS AND IMMUNITY. -- Some have objected that the placement of breast prostheses may interfere with the immune response as foreign bodies. Schuler, Rosato, and Miller ~;4 used a mouse model to demonstrate that immune function, as defined by specified tests of lymphocyte capability, is in no way impaired by the placement of polyurethane-covered silicone prostheses in conjunction with removal of a transplantable mammary tumor. MANAGEMENT

O F T H E P A T I E N T W I T H A R E C O N S T R U C T E D BREAST.

The patient who has undergone breast reconstruction subse623

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Fig 17.-To~, patient with family history of breast cancer and florid fibrocystic disease. Bottom, same patient shown following bilateral total mastectomy with immediate reconstruction.

quent to breast cancer is to be considered in exactly the same fashion as all patients who have undergone mastectomy for cancer. Physical examination every three months with careful attention to the reconstructed breast as well as the remaining breast is in order. In general, local recurrence in the overlying muscle and skin would possibly be more easily detected."-' Bone scans can be done without a problem in the presence of prostheses; chest films to document pulmonary recurrence are in no way compromised 624

by the placement of a prosthesis. Mammographic e x a m i n a t i o n of" r e m a i n i n g chest wall tissue devoid of any breast tissue fbllowing reconstruction will show soft tissue detail without compromise in the presence of a prosthesis."" Should further surgery be required for palpable lesions in a reconstructed breast, an electrocautery should be used rather t h a n knife dissection to protect the underlying prosthesis, which is impervious to heat but easily punctured by pointed instruments. Any lesion can be removed this way, and because of the overlying muscle, primary healing can be anticipated. Should local recurrence be documented, radiation therapy could be performed even in the presence of a prosthesis. "7

SUMMARY AND PROJECTIONS MULTIDISCIPLINARY EFFORT As has been emphasized throughout this monograph, the patient can only benefit by the open-minded approach of" a team of general and plastic surgeons. The overall m a n a g e m e n t team is, of course, not limited to these two specialties. F a m i l y practitioners, medical oncologists, radiotherapists and psychiatrists are also fYequently involved in m a n a g i n g the patient. All of these specialties must be knowledgeable about breast reconstruction and the importance it has in the lives of m a n y women. No longer should a w o m a n be told: "You should be happy to be alive after your mastectomy; don't worry about how you look" or ~'Reconstruction is meddlesome; I don't advise it." The modern approach to breast cancer demands that physicians listen to their patients, that all modalities of cancer t r e a t m e n t be considered, and that, when a mastectomy is contemplated or performed, reconstruction be offered as a further extension in the overall m a n a g e m e n t of' the patient. PATIENT SUPPORT GROUPS J u s t as Reach to Recovery has played an important role in the lives of m a n y women who have undergone mastectomy, support groups have evolved for women contemplating or undergoing breast reconstruction following mastectomy. These volunteer women have undergone reconstructions and want to provide education and support to other women fbllowing in their paths. One such group, called A.W.E.A.R. (A Woman Educating About Reconstruction) is a pilot project of the Virginia Division of The American Cancer Society. A.W.E.A.R. volunteers meet with women who are considering reconstruction, visit them in the hospital during the operative stay, and offer them postoperative 625

support and guidance. Working in conjunction with Reach to Recovery, they have provided a critical link in fulfilling the patient's needs. FINANCIAL CONSIDERATIONS

Until a few years ago, most insurance carriers considered reconstructive surgery following mastectomy to be "cosmetic" in nature. This, of course, m a k e s little sense, as all other forms of defects arising from cancer ablation were reconstructed under insurance coverage. In the past several years, however, most insurance companies have reversed their decisions, so t h a t it is now exceptional to find a carrier who does not cover reconstructive breast surgery. This battle, however, has t a k e n much time and energy and continues today. We look to the future with hope for enlightened concern from all health insurance companies. PATIENT'S OUTLOOK

The cure for breast cancer r e m a i n s elusive. The hope for women, however, m u s t be significantly improved. While the medical field will never rest until the cure is discovered, advances made in overall patient m a n a g e m e n t in recent years have been dramatic. Women can look to a diminishing number of radical mastectomies and an increasing n u m b e r of lesser operative procedures combined with other adjunctive forms of therapy. When mastectomies are required, women can look to breast reconstruction to restore a close resemblance of normalcy to the shape of their bodies and their psychological self-image. REFERENCES 1. Henderson I.C., Canellos G.P.: Cancer of the b r e a s t - the past decade. N. Engl. J. Med. 302:78, 1980. 2. Stehlin J.S., et al.: Treatment of carcinoma of the breast. Surg. Gynecol. Obstet. 149:911, 1979. 3. Saracci R., Repetto F.: Epidemiology of breast cancer. Semin. Oncol. 5:342, 1978. 4. Lipsett M.B.: Estrogen use in cancer risks. J.A.M.A. 237:112, 1977. 5. McGuire P.: The psychologic and social sequelae of mastectomy, in Howell J.G. (ed.): Modern Perspectives in the Psychiatric Aspects of Surgery. New York: Brunner and Mazel, 1976. 6. Jamison R.R., Wellisch D.K., Pasnau R.O.: Psychological aspects ofmastectomy: I. The women's perspective. Am. J. Psychol. 135:432, 1978. 7. Ervin C.V. Jr.: Psychologic adjustment to mastectomy. Med. Asp. Human Sex. 7:42, 1973. 8. Halsted W.S.: The results of operations for the cure of cancer of the breast performed at Johns Hopkins Hospital from June 1889 to J a n u a r y 1894. Ann. Surg. 20:497, 1894. 9. Halsted W.S.: The results of radical operations for the cure ofcarcinoma of the breast. Ann. Surg. 46:1, 1907. 626

10, Anglem T.J., Leber R.E.: Characteristics of survivors after radical mastectomy. Am. J. Surg. 121:363, 1971. l 1. McWhirter R.: Treatment of cancer of the breast by simple mastectomy and roentgenotherapy. Arch. Sarg. 59:830, 1949. 12. Handley R.S.: The conservative radical mastectomy of Patey: 10-year results in 425 patients' breasts. Dis. Breast 2:16, 1976. 13. Dahl-lverson E., Tobiassen T.: Radical mastectomy with parasternal and supraclavicular dissection for mammary carcinoma. Am. Surg. 157:170, 1963. 14. Nemoto T., Dao T.L.: Is modified mastectomy adequate for axillary lymph node dissection?An:l. Sur~,~. 182:722, 1975. 15. Progress report of the sixteenth semi-annunl meeting of the National Surgical Adjurant Project for breast and bowel cancers (NSABP), spring meeting, Tucson, Arizona, March 28-31, 1979. 16. Fisher B.: United States trials of conservative surgery. Worhl d. Surg. 1:327, 1977. 17. Robinson G. N., et al., The primary surgical treatment of carcinoma of the breast: A changing trend toward modified radical mastectomy. Mayo Clin. Proc. 51:433, 1976. 18. Schwartz et al., Clinically occult breast cancer. Ann. S,rg. 191:1, 1980. 19. Knapp R.W., Mullen J.T.: Triage for the breast biopsy. Am. J. Surg. 131:626, 1976. 20. Czerny V.: Plastic replacement of the breast with a lipoma. Chir. Kong. Verhandl. 2:216, 1895. 21. Maliniac J.W.: Use of pedicle dermo-fat flap in mammoplasty. Plast. Reconst. Surg. 12:110, 1953. 22. Kleinschmidt O.: Mammary plastics. Zentralbl. F. Chir. 51:653, 1924. 23. Cocke W.M.: Breast Reconstruction. Boston: Little, Brown & Co., 1977. 24. Reinhard W.: Total mastoneoplasty following amputation of the breast. Dtsch. Z. Chir. 236:309, 1932. 25. Longacre J.J.: The use of local pedicle flaps for reconstruction of the breast after sub-total extirpation of the mammary gland and for the correction of distortion and atrophy of the breast due to excessive scar. Plast. Reconst. Surg. 2:380, 1953. 26. Filatov V.P.: Plastic procedure using a round pedicle (in Russian). Vestn. Oftal. (Moscow) 34:149, 1917. 27. Gilles H.D.: The tubed pedicle in plastic surgery. N.Y. Med. J. 111:1, 1920. 28. Gersuny R.: Cited by Thorek, 1942. 29. Pangman W.J., Wallace R.M.: The use of plastic prosthesis in breast plastic and other soft tissue surgery. Read before the 6th Congress of Pan-Pacific Surgical Association, Oct. 7, 1954. 30. Cronin T.D., Gerow F.J.: Augmentation mammoplasty: A new "natural t~el" prosthesis. Plast. Reconstr. Surg. 1:46, 1970. 31. Horton C.E., Carraway J.H.: Total mastectomy with immediate reconstruction for premalignant disease, in Goldwyn R.M. (ed.): Plastic and Reconstrzlctire Surgery of the Breast. Boston: Little, Brown & Co., 1976, p. 459. 32. Tansini I.: Sopra il mio nuovo processo di amputazione della mamella. Gazzetta Med. Ital. 57:141, 1906. 33. McCraw J.B., Dibbell D.G.: Experimental definition of independent myocutaneous vascular territories. Plast. Reconstr. Surg. 60:212, 1977. 34. McCraw J.B., Dibbell D.G., Carraway J.H.: Clinical definition of independent myocutaneous vascular territories. Plast. Reconstr. Surg. 60:341, 1977. 35. Olivari N.: The latissimus flap. Br. J. Plast. Surg. 29:126, 1976. 36. Muhlbauer W., Olbrisch R.: The latissimus dorsi myocutaneous flap for breast reconstruction. Chir. Plast. 4:27, 1977. 37. Bostwick J., Vasconez L.D., Jurk'iewicz M.J.: Breast reconstruction after radical mastectomy. Plast. Reconstr. Surg. 61:682, 1978. 38. Bostwick J., Nahai F., Wallace J.G., et al.: Sixty latissimus dorsi flaps. Plast. Reconstr. Surg. 63:113, 1978. 627

39. Bestwick J., Schellein M.: The latissimus dorsi musculocutaneous tlap: A one stage breast reconstruct.ion. Clin. Phlst. St~,'g. 7:71, 1980. 40. Maxwell G. P., McGibbon B.M., Hoopes.J.E.: Vascular considerations in the use of tile latissimus dorsi myocutaneous flap following mastectomy with axillary dissection. Phtst. Reconslr. SItrA~. 64:771, 1979. 41. Maxwell G.P., McCraw J.B., Horton C.E.: Post-mastectomy rehabilitati~m: A comprehensive appraisal. Part 11: Operative considerations. Presented at the annual meeting, American Society of Aesthetic Plastic Surgery, Orlando, Florida, May 19, 1980. 42. Maxwell G.P.: Post-mastectomy breast reconstruction utilizing the latissimus dorsi myocutaneous flap breast cancer, in Lewison E.F. (eds.): Post-Mclstectomy Reconstruclion. Baltimore: Williams and Wilkins Co., 1980. 43. Allison A.B., Howorth M.B.: Carcinoma in a nipple preserved by heterotopic auto-implantation. N. Engl. d. Med. 298:1132, 1978. 44. Surg. d. Attst. 2:937, 1977. 45. Anderson J., Palleseu R.M.: Spread to the nipple and areolar in carcinoma of the breast, Ann. Surg. 189:367, 1979. 46. McCraw J.B., Penix J.O., Baker J.W.: Repair of major defects of the chest wall and spine with the latissimus dorsi myocutaneous flap. Mast. Reconstr. Surg. 62:197, 1978. 47. Maxwell G.P., Bosley J.H., Myocutaneous flaps. J. Hopkins Mcd. ,1. 141:258, 1977. 48. Dowden R.V., McCraw J.B.: Muscle flap coverage of shoulder defects. J. Hand Surg. 5:382, 1980. 49. Quillen C.G.: Latissimus dorsi myocutaneous flaps in head and neck reconstruction. Plast. Reconslr. Sarg. 63:664, 1979. 50. Maxwell G.P., et al.: CraniofaciaI coverageutilizing the latissimus dorsi myocutaneous island flap. Ann. Plast. Surg. 4:410, 1980. 51. Maxwell G.P., Stueber K., Hoopes J.E.: A free latissimus dorsi myocutaneous flap. Plast. Reconstr. Surg. 62:462, 1978. 52. Maxwell G.P., Manson P.N., Hoopes J.E.: Experience with thirteen free latissimus dorsi myocutaneous flaps. Plast. Reconstr. Surg. 64:1, 1979. 53. Maxwell G.P.: M usculocu taneous free flaps. Clin. Pl~lst. Surg. 7:111, 1980. 54. Cronin T.D., Upton d., McDonough J.M.: Reconstruction of the breast after mastectomy. Plast. Reconstr. Surg. 59:1, 1977. 55. Davis W.M., McCraw J.B., Carraway J.H.: Use of a direct thoracoabdominal flap to close difficult wounds of the thorax and upper extremities. Plast. Reconstr. Surg. 60:526, 1977. 56. McCraw J.B., Myers B., Shanklin K.: The value of fluorescein in predicting the viability ofarterialized flaps. Plast. Reconstr.. Surg. 60:710, 1977. 57. Houston J.T.: The evolution of breast reconstruction after mastectomy [br cancer. Aust. N.Z. J. Surg. 49:527, 1979. 58. Birnbaum L., Olsen J.A.: Breast reconstruction following radical mastectomy using custom designed implants. Plast. Reconstr. Surg. 61:355, 1978. 59. Serafin D., Georgiade N.G., Given K.S.: Transfer offi'ee flaps to provide wellvascularized, thick cover for breast reconstructions after radical mastectomy. Plast. Reconstr. Sllrg., 62:527, 1978. 60. Brent B.: Nipple-areola reconstruction following mastectomy: An alternative to the use of labial and contralatera] nipple areola tissues. Clin. Plast. St~rg. 6: 85, 1979. 61. Urban J.A., Papachristou D., Taylor J.: Bilateral" breast cancer. Cancer 40: 1968, 1977., 62. Leis H.P., Mersheimer W.L., Black N.N.: The second breast. N.Y.J. Med. 62: 2460, 1965. 63. Horton C.E., Rosato F.E., Schuler F.F., et al.: Post-mastectomy reconstruction. Ann. Surg. 188:773, 1978. 64. Schuler F.A., Rosato F.E., Miller E., et al.: Silicone prostheses and anti-tumor immunity. Plast Reconstr. Surg. 61:762, May, 1978. 628

65. Bandian J., Horton C.E., Rosato F.E.: Evaluation of patients after augmentation mammoplasty, Surg. GynecoLObslel. 147:596, 1978. 66. Youngkin J., Minagi R.: Roentgen appearance of injected silicone in the breast. Radiology 90:57, 1968. 67. Shedbalkar A.R., Devata A., Padenalam T.: A study of effects of radiation on silicone prostheses. Plast. Reconstr. Sur~. 65:805, 1980.

SELF-ASSESSMENT ANSWERS 1. a

2. 3. 4. 5. 6. 7.

c d c a d a

8, a

9. 10. ll.b 12. 13. 14.

a b

a,b d

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