British Journal oj Plastic Surgery









By J. C. VANDERMEULEN,M.D. Lambertweg 40, Rotterdam, The Netherlands

THE outstanding results of Snyderman and Guthrie (1971) and recently Guthrie (1976), Cronin et al. (1977) and Birnbaum and Olsen (1978) have convinced many surgeons that the reconstruction of a breast after radical mastectomy does not necessarily result in one deformity being substituted by another. However, the reconstruction of a breast after a radical amputation is not an easy procedure and for the result to be satisfactory to both patient and surgeon, the following 3 requirements should be fulfilled: the reconstruction should produce a symmetrical result; the reconstruction should be completed in a minimum of time with a minimum of extra scarring; the reconstruction should not enhance the recurrence of the disease nor make it difficult to examine the patient for such a recurrence. In the past years it has become quite clear that symmetry cannOt be obtained by reconstruction of the amputated breast alone. In the majority of cases, it is necessary to remodel the other breast. Both reconstruction and remodelling can be executed in one operation. The reconstruction of a nipple is performed at the same time or deferred until a second operation. RECONSTRUCTION OF THE AMPUTATEDBREAST When the skin is freely movable over the chest wall, reconstruction of a prominence is, as a rule, fairly simple. Little skin surplus is needed to make the implantation of a prosthesis possible after adequate undermining and in the presence of normal skin. Using the lateral part of a transverse scar (Stewart incision) or the caudal part of an oblique one (Halsted incision), a pocket is created. As a precaution the inferior border of the pocket should be located I or 2 cm below the inframammary line of the second breast since there is always some contraction of the envelope surrounding the prosthesis which tends to push the implant in a cranial direction. In those cases in which the pectoralis major has been removed a low profile prosthesis is slipped directly under the skin. The ugly depression which is often found in the infraclavicular region can be corrected by the use of a custom designed implant. When the pectoralis major is still present, the implant can be placed under the muscle Partial freeing is necessary to prevent irregularities due to muscle action. However the skin on the chest wall following mastectomy is not always normal. There may be severe scarring or irradiation damage and different approaches are needed. Scarring. Extreme scarring is usually caused by a prolonged period of stretching It is symptomatic of a skin deficiency which must following closure under tension. first be replaced. When the direction of the scar is vertical the best method to supply extra skin is to use the medially based flap described by Haas and Bohmert (Fig. I). 226







FIG. I. A. Broad stretched vertical scar after radical mastectomy. B. A medially based flap to supply extra skin is outlined. C. The flap transposed. D and E. After reconstruction of the amputated breast and subtotal mastectomy and reconstruction of the second breast.

Extreme scarring seems to occur less often when a lateral incision has been used to amputate the breast, but when it does occur, it can probably best be corrected with the help of a U-shaped flap as shown in Figure 2. Irradiation damage. Implantation of a prosthesis under irradiated skin entails distinct risks. In the only case in which this procedure seemed justified, the apparently healthy skin suddenly broke down after several uneventful postoperative weeks (Fig. 3). Replacement of the irradiated skin by a well-vascularised flap should therefore precede



FIG. 2. FIG. 3.


The lateral U-shaped




Asp to supply extra skin when the scar is horizontal.

Spontaneous breakdown of irradiated skin some weeks after implantation of a prosthesis The second breast has been reduced in size. reconstruct the breast.


FIG. 4. A. Skin damage following postoperative irradiation after mastectomy. B. Creating a fold in the border of a latissimus C. Excision of irradiated skin and flap. transposition of the latissimus flap with the inframammary fold incorporated. D. After reconstruction of the amputated breast. No prosthesis was used. The second breast was reduced. Reconstruction of the amputated FIG. 5. breast and reduction of the second breast. Reconstruction of the areola by areolar sharing was planned for the second stage. An unsuspected cancer was found, however, in the removed tissue and the second breast was also amputated.



the reconstruction when any doubt as to the viability of the skin exists. Of the several procedures in the literature which can be used to provide this cover, the latissimus dorsi flap (Olivari, 1976) provides I excellent alternative (Fig. 4), the recently described thoraco-abdominal flap (Baroudi et al., 1978) another.

REMODELLINGTHE OTHERBREAST Reduction of the remaining breast should always be considered, not only to match the size of the reconstructed breast but also for prophylaxis. The observed incidence of cancer in the second breast in the under-50 age group is 17 times the normal incidence. In the over-50 group it is 6 times the normal incidence (Haagensen, 1972). Some, who feel that a cancer in the second breast constitutes a separate and additional risk to the patient, remove this breast prophylactically (Leis, 1959; Hubbard, 1953). Others (Donegan and Spratt, 1967; Haagensen, 1972) disagree both on scientific grounds (a second breast cancer does not lessen the chance of survival) as well as on humanitarian grounds (the second breast is of important emotional value to the patient). It seems to me that both parties should be satisfied with the compromise offered here, namely a subtotal mastectomy. This reduces the danger of a second cancer significantly and also makes it possible to discover a hitherto unsuspected cancer, remove it and thereby cure the patient (Fig. 5). Furthermore the body image is largely undisturbed. The decision to reduce the remaining breast or even remove it by a subtotal mastectomy should be made in agreement with a general surgeon, a pathologist and the patient. To match the size of the reconstructed breast and to create a firm breast which can withstand the force of gravity, the reduction should be fairly radical. This is especially important since, due to the lack of skin and the presence of a solid fibrotic envelope which is adherent to the chest wall, the reconstructed breast never shows any sagging. On the contrary it shows a tendency to migrate upwards in some cases.

RECONSTRUCTION OF AN AREOLA This goal is usually achieved with a graft taken from the areola of the opposite breast, or more recently, from the inner aspect of the upper thigh (Broadbent et al., 1977). A graft taken from the labia is too dark and the procedure is sometimes repugnant to the patient. Areolar sharing when possible (Fig. 6) seems to give the best results in our hands. The procedure, however, is not entirely without risk and the graft should therefore be examined for cancer using frozen sections. When the skin over the implant is too thin and it is felt that its viability may be jeopardised by the reconstruction of an areola, this step is postponed until a second stage. SECONDARYOPERATIONS To achieve the desired result in I stage is more than one can hope. The reconstruction of an areola presents an excellent opportunity to correct any flaws which may have been left. An implant which is too small can be replaced with a bigger one. A capsule contraction which has caused dislocation of the implant can be released and a breast which still shows some ptosis can be given a final lift.






A. After amputation of the left breast. Subtotal reduction of the second breast. da is transposed on a superoC. Verv little breast tissue remains: D. After subtotal reduction of the right breast and reconstruction of the left breast with a prosthesis. The areola is reconstructed from the half which was removed from the right breast. E, F and G. Postoperative result. FIG. 6.








SUMMARY Reconstruction majority

of cases.

with a subtotal

of the breast by implantation

of a prosthesis

For reasons of safety and symmetry


In some patients

or mastectomy

the reconstruction

of the second must

alone is possible

the procedure

be combined

by the transfer

of additional


be preceded


REFERENCES A transverse thoracoabdominal skin BAROUDI, R., PINOTTI, J. A. and KEPPKE, E. M. (1978). Plastic and Reconstructive Surgery, 61, 547. flap for closure after radical mastectomy. BIRNBAUM, L. and OLSEN J. A. (1978). Breast reconstruction following radical mastectomy, using custom designed implants. Plastic and Reconstructive Surgery, 61, 355. Restoring the mammary areola BROADBENT, T. R., WOOLF, R. M. and METZ, P. S. (1977). by a skin graft from the upper inner thigh. British Journal of Plastic Surgery, 30, 220. Reconstruction of the breast after CRONIN, T. D., UPTON, J. and MCDONOUGH, J. (1977). mastectomy. Plastic and Reconstructive Surgery, 59, I. DONEGAN,W. L. and SPRATT, J. S. Jr. (1967). Cancer of the second breast, in “Cancer of the Breast”. Philadelphia: W. B. Saunders Co., p. 179. GUTHRIE, R. H. (1976). Breast reconstruction after radical mastectomy. Hastic and Reconstructive Surgery, 57, 14. HAAGENSEN, C. D. (1972). “Diseases of the Breast”, 2nd edition. Philadelphia: W. B. Saunders Co. Mammaplastik, in “Indikation zur Operation”, edited HAAS, W. and BOHMERT, H. (1974). by Heberer, G. and Hegemann, G. Berlin: Springer. Surgery, 34, HUBBARD, T. D. (1953). Nonsimultaneous bilateral carcinoma of the breast. 706. LEIS, H. P. (1959). Bilateral mastectomy for carcinoma of the breast. Journal of the I?lteWZatiOd COhgt? Of SUrgeOnS, 31, 329. OLIVARI, N. (1976). The latissimus dorsi flap. British Journal of Plastic Surgery, 29, 126. SNYDERMAN, R. K. and GUTHRIE, R. H. (1971). Reconstruction of the female breast following radical mastectomy. Plastic and Recomtructive Surgery, 47, 565.


in the


Breast reconstruction after radical mastectomy.

British Journal oj Plastic Surgery BREAST (IQ~Q), 32, 226-231 RECONSTRUCTION AFTER RADICAL MASTECTOMY By J. C. VANDERMEULEN,M.D. Lambertweg 4...
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