Breast Reconstruction after Mastectomy Harvey A. Zarem, MD, Los Angeles, California Wiley F. Barker, Jr, MD, Los Angeles, California Harold S. Gewirtz, MD, Los Angeles, California

The majority of women who have undergone mastectomy for carcinoma of the breast are grateful for the hope of a cure. When questioned, many patients are quite specific about complaints relating to the operative procedure. The consequences of the operative procedure are seen by the patients as an absence of a breast, a noticeable scar, the loss of the anterior axillary fold, and’infraclavicular depression. (Figure 1.) The scar is acceptable to patients when it does not extend to the sternum medially or to the shoulder laterally. Loss of the anterior axillary fold and the infraclavicular depression after removal of the pectoralis muscle in classic radical mastectomy specifically limit the patient’s ability to wear certain common types of clothing. Although the majority of patients have not expressed discontent and have not sought any form of reconstruction after modified or radical mastectomy, there is an increasing number of women who have raised the question as to whether reconstructive procedures are feasible. Material Forty-eight women were seen in consultation, seeking advice as to the advisability of reconstruction after having undergone modified or radical mastectomy for carcinoma of the breast. Thirty-two patients underwent various operative procedures to reconstruct the chest, including Silastic@ breast prosthetic implants, dermal-fat grafts, areolar-nipple grafts, and contralateral simple mastectomy or reduction mammoplasty. Patients who had adequate pectorahs muscle bulk underwent Silastic breast prosthesis and nipple reconstruction using either the labia as a free skin graft designed to simulate the nipple or nipple reconstruction from the contralateral nipple which is shared. Patients who had undergone radical mastectomy with remova1 of the pectoralis muscle underwent dermal-fat grafts from the gluteal region to augment the soft tissues of the chest above the breast area prior to implants with Silastic

From the Department of Surgery, UCLA School of Medicine, Los Angeles, California. Reprint requests should be addressed to Harvey A. Zarem. MD, Division of Plastic Surgery. UCLA School of Medicine, Los Angeles, California 90024. Presented at the F&y-Eighth Annual Meeting of the Pacific Coast Surgical Association, Palm Springs, California, February 20-23, 1977.

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breast prostheses. All patients who underwent any form of reconstruction did so after correspondence with the treating surgeon and after complete operative records and pathology reports were obtained. In no instance did a patient undergo any operative procedure without the consent and approval of her surgeon. Postoperative radiation treatment has not been considered a contraindication to reconstruction if the tissues appear satisfactory to tolerate the operative procedure.

Comments

Of the thirty-two patients who underwent reconstruction, one had a postoperative wound infection. That patient had undergone a dermal-fat graft to restore the soft tissue contour of the upper chest after radical mastectomy and removal of the pectoralis muscle. The dermal-fat graft became infected and was partially removed. The primary problems in reconstruction after mastectomy have been related to placement of the implant. It is difficult to achieve symmetry when the chest wall is asymmetric, and it is not possible to duplicate the size and shape of the normal contralateral breast. Details of technic allow for some compensation, and the patients are told that the

Figwrs 1. cfhStdefol7nity secondary to radkal mastectomy, illustrating unsightly scar, loas of anterior axillary fold, and pendulous contralateral breast.

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Figure 3. lnferoiaterai border of intact pectoraiis muscle dissects area of intended breast implant, illustrating potential hazard of placing fmpfant retropectoralfy.

Figure 2. Top, patient fourteen months after modified radical mastectomy with preservation of the pectoralis muscle. Middle, patient eight months after Siiastic breast implant and areolar reconstruction with free labial transplant. Battom, secondary “nippie” reconstwtfon by modification of the labial graft.

breast contour is approximated in wearing underclothing as the standard. Scar formation around the Silastic implant can cause a firm and unsightly implant due to contracture of the scar capsule. This occurred in less than 20 per cent of the patients and can be improved with subsequent operative release of the capsule. In selected patients, steroids (triamcinolone acetonide, 40 mg) were placed in the breast pocket at the time of reconstruction to minimize capsule formation. Care must be taken to avoid

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pooling of this steroid in the inferior breast because of potential atrophy of the tissues. The Silastic breast implant has been successfully used as a subcutaneous foreign body to restore the breast mound [I--51. (Figure 2.) In the presence of a contralateral normal breast, the inframammary fold of that breast is the guideline to placement of the Silastic implant. The development of the subcutaneous pocket can he accomplished either superficial to or deep to the pectoralis muscle through a 6 cm incision that will define the inframammary fold. When the pectoralis muscle is thin, the implant may be placed behind the pectoralis muscle to supply additional soft tissue over the implant. When the pectoralis muscle is well developed, the retropectoral position is undesirable because the inferior border of the pectoralis muscle transects the implant (Figure 3), and the implant attaches to the pectoralis muscle. If the contralateral breast is pendulous and if the nipple of that breast is below the inframammary fold (Figure 4, top), reconstruction of the resected breast will not be satisfactory unless the normal breast is reduced. (Figure 4, bottom.) In the patient with the pendulous contralateral breast, reduction mammoplasty designed to position the nipple above the inframammary fold will be required either at the time of or prior to reconstruction of the resected breast. An increasing number of surgeons and patients express concern for the possibility of breast cancer in the contralateral breast. In some instances, family history and pathologic condition warranted simple mastectomy on the contralateral breast. (Figure 5.) In these patients, the nipple can be removed and used by a halving technic to restore the areolar-nipple complex. The pathologic features beneath the nipple

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Figure 4. Top, patient with modified radical mastectomy scar and pendulous contralateral breast. Bottom, patient after breast reconstruction (right) and reduction mam( left ). moptasty

Figure 5. Top, patient after modified radical mastectomy (left) and simp/e mastectomy (right). Bottom, bilateral breast Silastic implants and free labial grafts were done at one operative procedure.

must be carefully examined to rule out the possibility that a carcinoma of the breast extending to the nipple was present in the specimen. Replacing the fullness of the chest in the region of the pectoralis muscle is important to restore appearance. If the patient has had very thin skin flaps developed at the time of mastectomy and if the skin is adherent to the chest wall, it has been advisable to place dermal-fat grafts under the skin prior to the Silastic breast implant. The fate of transplanted fat is unpredictable. In contrast, dermis is collagen, which is predictable in its transplantability [6]. The combination of dermis and fat as a composite graft appears to be more effective than a fat graft alone. The thickness of the dermal-fat grafts has been limited to 1 cm. The most popular donor site for dermal-fat grafts has been the buttocks and the lower abdomen in patients who wish at the same time to have an abdominal lipectomy. The type of incisions used by the tumor surgeon has not significantly affected our ability to reconstruct the breast. The patient prefers scars that do not extend up to the clavicle or on to the shoulder.

The implant is placed through an incision comparable to the inframammary fold. The previous mastectomy scar is not a desirable site for the incision because of tension on the wound. After reconstruction of the breast with the Silastic implant, most patients desire a simulated areola. When patients are undergoing reduction mammoplasty or simple mastectomy on the contralateral side, half of the nipple of the normal side can be shared and used as a free graft to reconstruct the areola on the mastectomy side [7]. When this is not feasible, a free graft from the labia minora is effective [8]. The texture and pigmentation of the labia skin simulates an areola. Secondarily, under local anesthesia, the grafted labial skin can be alt,ered to simulate a nipple [9]. The decision as to which patient might be a candidate for breast reconstruction in the face of possible residual disease is very difficult. When the breast has been adequately removed, when there is no evidence of any distant metastases, and when the surgeon has every reason to think that all of the tumor has been removed, there seems to be little contraindication to undertaking breast reconstruction. There remains

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the remote possibility that nests of tumor cells lie dormant in the chest wound and subsequent reconstructive procedure could stimulate tumor growth. The incidence of chest wall tumor in patients after mastectomy is reported to be 9 to 30 per cent [IO-131. The prognosis of a patient who has been discovered to have chest wall recurrence is poor, and it has been reported that in all instances patients with chest wall recurrence have evidence of distant metastases as well [14]. Some surgeons have recommended that the nipple be salvaged at the time of mastectomy and used to reconstruct the breast. Reports have indicated involvement of the nipple by carcinoma in as many as 11 per cent of the patients [15]. However, it appears that if the tumor is not grossly in the region of the areolai the areola can be salvaged at the time of mastectomy and transplanted to the groin for later use in reconstruction. This remains controversial, and the decision must remain with the treating surgeon at the time of mastectomy. We have not attempted reconstruction at the time of mastectomy. Reconstructive procedures have been deferred until the wounds have matured and the tissues softened. Ongoing chemotherapy for the patient after mastectomy for carcinoma of the breast need not be a contraindication to breast reconstruction. Despite the expectation that antineoplastic agents would have profound effects on wound healing, the results have been inconclusive [16-231. All of the drugs that have been used as adjuvants for breast cancer therapy have been studied in the laboratory. Vincristine has been shown to have minimal long-range effects on experimental wounds. Methotrexate has been shown experimentally to have minimal effects on wound healing after the drug is discontinued; it has an effect on early healing in experimental wounds, but the effect is reversed when leucovorin is administered. Five-fluorouracil (5-FU) has been shown to have no effect on experimental wounds and no effect clinically when used as an adjuvant for carcinoma of the colon. However, a significant effect on wound healing has been demonstrated when 5-FU has been used as an adjuvant for breast cancer patients and experimentally on rat intestinal wounds. Adriamycin has had no effect on experimental wounds. Cytoxan has been reported to have a dose-related effect on wound healing that is significant at the late stages of healing; others have found no effect on wound healing when it is used as an adjuvant in breast cancer patients. Despite these studies, most surgeons understandably prefer to have patients await completion of chemotherapy before breast reconstruction is begun.

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Rehabilitation of the mastectomy patient by restoration of resected pectoralis muscle mass by dermal-fat grafts, restoration of the breast mound by Silastic implants, and simulation of the areolarnipple complex by grafting has resulted in high levels of satisfaction for women who have undergone previous mastectomy. Summary

Reconstruction of the breast contour and areolanipple complex can be undertaken in patients who have had mastectomy for carcinoma of the breast. Although the reconstructed breast is not normal, the restored contour and simulation is gratifying for those patients who have sought this procedure. References 1. Alexander JE, Block LI: Breast reconstruction following radical mastectomy. Plast Reconstr Surg 40: 175, 1967. 2. Freeman BS: Reconstruction of the breast form by Silastic gel from breast prostheses. Br J Plast Surg 27: 264, 1974. 3. Guthrie RI: Breast reconstruction after radical mastectomy. P&t Reconstr Surg 57: 14, 1976. 4. Hartwell SW, Anderson R, Hall MD, Esselstyn C: Reconstruction of the breast after mastectomy for cancer. Plast Reconstr Surg57: 152, 1976. 5. Snyderman RK, Guther RH: Reconstruction of the female breast following radical mastectomy. Plast Reconstr Surg 47: 565, 1971. 6. Leaf N, Zarem HA: Correction of contour defects of the face with dermal and dermal-fat grafts. Arch Surg 105: 715, 1972. 7. Wexler MR. Oneal RM: Areolar sharing to reconstruct the absent nipple. Plast Reconstr Surg 51: 176, 1973. 6. Adams WM: Labial transplant for correction of the loss of the nipple. Plast Reconstr Surg 4: 295, 1949. 9. Silsby JJ: Nipple reconstruction. P&t Reconstr Surg 57: 667, 1976. 10. Dao TL, Nemoto T: The clinical significance of skin recurrence after radical mastectomy in women with carcinoma of the breast. Surg Gynecol Obstet 117: 447, 1963. 11. Donegan WL, Perez-Mesa CM, Watson FR, Francis R: A biostatistical study of locally recurrent breast cancer. Surg Gynecol Obstet 122: 529, 1966. 12. Snyder AF, Farrow GM, Masson JK, Payne WS: Chest wall resection with a locally recurrent breast cancer. Arch Surg 97: 246, 1966. 13. Papaioannou AN, Tanz FJ, Volk H: Fate of patients with recurrent carcinoma of the breast. Cancer 20: 37 1, 1967. 14. Fisher El?, Gregorio RM, Fisher B: The pathology of invasive breast cancer; a syllabus derived from findingsof the national surgical adjuvant breast project (protocol no. 4). Cancer 36: 1, 1975. 15. Smith J, Payne WS, Carney JA: Involvement of the nipple and areola in carcinoma of the breast. Surg Gynecol Obstet 143: 546, 1976. 16. Cohen SC, Gabelnick HL, Johnson RK, Golding A: Effects of antineoplastic agents on wound healing in mice. Surgery 76: 238, 1975. 17. Calnan J, Davies A: The effects of methotrexate (Amethopterin) on wound healing: an experimental study. Br J Surg 19: 505, 1965. 16. Goldman LI, Lowe S. Al-Saleem T: The effect of fluorouracil on intestinal anastomoses in the rat. Arch Surg 96: 303. 1969.

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19. Higgins GA, Dwight RW, Smith JV, Keehn RJ: Fluorouracil as an adjuvant to surgery in carcinoma of the colon. Arch Surg 102: 339, 1971. 20. Cohn I, Slack NH, Fisher B: Complications and toxic manifestations of surgical adjuvant chemotherapy for breast cancer. SurgGynecolObsfet 127: 1201, 1966. 21. Desprez JD, Kiehn CL: the effects of cytoxan on wound healing. Plast Reconstr Surg 26: 301, 1960. 22. Finney R: Adjuvant chemotherapy in the radical treatment of carcinoma of the breast: a clinical trial. Am J Roentgenol 111: 137,197l. 23. Cohen SC, Gabelnick HL, Johnson RK, Randall KJ, Goldin A: Effects of cyclophosphamide and adriamycin on the healing of surgical wounds in mice. Cancer 36: 1277. 1975.

Discussion Arthur J. Donovan (Mobile, AL): With regard to the departure from the traditional approach to treatment of mammary cancer discussed herein, Doctor Halsted said, “As to the closure of the wound, I would not care to say. . , ‘Beware of the man with the plastic operation’ ” (Ann Surg 25: 75,1907) and “. . . the operator whose duty it is to close the wound should not be entrusted with the planning of the skin incision. . . .” Doctor Halsted made it clear that basic oncologic principles must be followed and must take precedence over the plastic operation. Next, when chest wall recrudescence develops in a patient who has undergone mammary reconstruction, the ultimate outcome may not be affected, but treatment will certainly be complicated. Reconstruction should be performed in cases with the least likelihood of chest wall recrudescence. Halsted defined two types of chest wall recrudescence: local recurrence, defined as “. . . a return of disease in any part of the explored region . . . ,” and regionary recurrence, which included “. . . skin metastases at a greater or less distance from the scar. . .” (Ann Surg 20: 513,1894). With respect to avoidance of local recurrence, he emphasized wide extirpation and quarantine of the wound from shed cancer cells. Regarding regionary recurrence, he stated that “ . . . for the eradication of the so-called lenticular and apparently discrete metastases of the skin we have no guide,”

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but cited that Billroth “assumes a cancer diathesis, or that conditions favorable to the development of cancer have been furnished by the scar” (Ann Surg 20: 513, 1894). Halsted rejected this apparent reference by Billroth to the concept of locus resistentiae minoris. I accept the experimental and clinical evidence that supports this concept. Could a foreign body used in mammary reconstruction create a locus resistentiae minoris and perhaps accelerate the time of appearance of otherwise dormant tumor? As increasing numbers of mammary reconstructions are performed, the time of appearance, location, and incidence of chest wall recrudescence will require precise documentation. Wiley F. Barker (closing): The reconstructive procedure is still in an exploratory stage. It is not appropriate for all patients, and yet almost every patient does wish for some kind of reconstruction. The procedure can be done on almost any woman despite her original anatomy and the type of operation performed. It is certain that one must not in any way compromise the mastectomy with forethought to making the reconstruction easier. We do not believe that the reconstruction as described herein will obscure a recurrence in the skin or that it will in any way enhance a recurrence of tumor locally. It is probably wise to delay reconstruction to be sure that there is no flagrant, rapid recurrence. It is more important, however, to wait long enough to have the skin sufficiently pliable and soft for the best possible results. The postponement also allows the patient time to be sure she wants the operation. In other words, if she realizes how badly she misses the lost breast, she may be happier with the reconstruction that provides her with a breast that is somewhat less than the original model. I have been less concerned about the necessity for the creation of a new nipple, and the indications for this are not so well defined as is the need for restoration of the major contour of the breast. If, however, Doctor Zarem’s technics for reconstructing the nipple continue to be as successful as they are, this may become an integral part of the procedure.

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Breast reconstruction after mastectomy.

Breast Reconstruction after Mastectomy Harvey A. Zarem, MD, Los Angeles, California Wiley F. Barker, Jr, MD, Los Angeles, California Harold S. Gewirtz...
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