Omental transposition in the treatment of locally advanced and recurrent breast cancer

Robotic omental flap harvest for near-total anterior chest wall coverage: a potential application of robotic techniques in plastic and reconstructive surgery

We present the robotic harvest of a pedicled omentum flap for reconstruction of a near-total anterior chest wall defect. The patient was a 68-year-old woman with recurrent secondary chest wall angiosarcoma after previous mastectomy and radiation therapy. She underwent neoadjuvant chemotherapy and radiation, followed by wide radical chest wall resection with a final defect size of 15×35 cm. A one-stage reconstruction was performed with an omentum flap harvested by robotic technique and split-thickness skin grafts from thigh donor sites. The patient healed with minimal complications. Our case supports more widespread application of robotics in plastic and reconstructive surgery.

Use of Extended Pedicled Transverse Rectus Abdominis Myocutaneous Flap for Extensive Chest Wall Defect Reconstruction After Mastectomy for Locally Advanced Breast Cancer

BACKGROUND

The reconstruction of a large postmastectomy chest wall defect for patients with stage III/IV breast cancer is a challenge for plastic surgeons. In this study, we present the application of an extended transverse rectus abdominis myocutaneous (TRAM) flap to easily and safely reconstruct these defects.

PATIENTS AND METHODS

A retrospective review from November 1997 to November 2016 revealed that 65 patients with stage III/IV breast cancer immediately underwent postmastectomy TRAM flap reconstruction. In total, 16 patients were enrolled in this study based on the inclusion criteria of a postmastectomy chest skin defect size of greater than or equal to 100 cm and a TRAM flap size of greater than or equal to 80% of the lower abdominal area for reconstruction.

RESULTS

Eleven (68.9%) and 5 patients (31.3%) were diagnosed with stage III and stage IV breast cancer, respectively. The chest wall skin defects ranged from 135 to 440 cm. All flap areas exceeded 80% of the lower abdominal area. Overall, 100% of the harvested flaps were used in 3 patients, and only 1 patient had marginal necrosis in zone IV. No total flap loss was observed. The average length of hospital stay was 5.8 days, and the mean follow-up duration was 46.6 months (range, 4.5-117.7 months). On a Likert scale, the mean follow-up satisfaction score of 10 patients was 4.7.

CONCLUSIONS

Even when the flap area exceeded 80% of the lower abdominal area, the extended TRAM flap proved an effective and viable method for the immediate reconstruction of extensive postmastectomy chest wall skin defects, resulting in few minor complications and high follow-up satisfaction scores.

Thoracoabdominal Flap: a Simple Flap for Covering Large Post-mastectomy Soft Tissue Defects in Locally Advanced Breast Cancer

Locally advanced breast cancer (LABC) constitutes 40-50% of breast cancer in developing countries. Large soft tissue defects after mastectomy often require some additional cover. The primary aim of reconstruction in this group should be an expeditious and simple closure with good-quality skin cover, early recovery, and short hospital stay so that the patients can receive early post-operative radio-chemotherapy. Thoracoabdominal (TA) flap is a type-c fasciocutaneous flap and the skin and fat of the upper abdomen are used, based on medial or lateral perforating vessels. We present our experience of TA flap cover for large post-mastectomy defects. A retrospective analysis of prospectively maintained breast cancer database in the Department of Surgical Oncology from January 1994 to December 2017 at All India Institute of Medical Sciences, New Delhi, was performed. The medical records of patients undergoing TA flap cover were analyzed to assess operative duration, blood loss, post-operative morbidity, hospital stay, adjuvant treatment, recurrence patterns, and survival outcome. A total of 3142 breast cancer patients underwent surgery, of which 1840 were LABC and 88 patients (4.13%) of LABC required flap cover for the closure of mastectomy defect. TA flap was used in majority of these patients 72/83 (86.7%) for cover. Majority was stage IIIB (54 out of 72) and we could achieveR0 resection in all patients. TA flap was done following MRM in 60 patients and RM in 12 patients. Upfront primary surgery was performed in 27 patients and 45 underwent surgery after neoadjuvant chemotherapy. Most commonly laterally based flaps were done, except 4 medially based flaps. The mean operating time was 30 min and blood loss was 45 ml. Mean hospital stay was 4.45 days. Superficial flap necrosis occurred in 6 and wound infection in 4 patients, all managed conservatively. Only 2 patients had major flap loss and required debridement and skin grafting. Planned post-operative radiation could be delivered in most of the patients in time. At a mean follow-up of 24 months, only 9 out of 72 (12.5%) patients had a loco-regional recurrence. Results of our experience show that TA flap is a simple, cost-effective procedure for managing large post-mastectomy soft tissue defects in LABC. It has huge potential in developing countries dealing with a large number of LABC because of simplicity and short learning curve.

Omentum for Mammary Disorders: A 30-Year Systematic Review

PURPOSE

Although the safety of applying omentum to the female breast for total breast reconstruction is controversial, it has recently been used to treat certain mammary disorders as well. A systematic review was therefore conducted to analyze and establish the suitability and safety of applying omentum to the breast.

METHODS

Covereing the interval from January 1984 to December 2013, we performed searches in MEDLINE, Embase, SciELO, and Google-Scholar for original articles describing the applicability of greater omentum to the breast and its clinical complications.

RESULTS

Sixty observational articles with 985 women were chosen. The main clinical indications were total breast reconstruction after mastectomy due to breast cancer (45 studies), radiation damage (23 studies), and congenital Poland syndrome (4 studies). Altogether, 273 complications were identified among the 985 women treated. The most frequent was flap necrosis (26.74 %). The most serious was injury to the digestive system (1.10 %). There was a 35.48 % incidence of local breast cancer recurrence in eight observational studies on oncological risk. Seven of the eight included only women with advanced cancer. One of these studies reported the incidence and relapse time predominantly according to the primary tumor size.

CONCLUSIONS

Although the oncological risk remains unclear, there was a high volume of complications that affected the digestive system. These findings suggest that omentum has well established applicability, but only for total breast reconstruction of huge defects, where muscular/myocutaneous or perforator flaps may be unsuitable.

Immediate locally advanced breast cancer and chest wall reconstruction: surgical planning and reconstruction strategies with extended V-Y latissimus dorsi myocutaneous flap

BACKGROUND

Surgical resection in locally advanced breast cancer produces large defects that may not be suitable for primary closure. Immediate reconstruction is controversial and presents a complicated scenario for breast surgeons and plastic surgeons.

METHODS

In this study, a different design was planned for the latissimus dorsi musculocutaneous flap with primary closure in V-Y for the correction of major lesions in the anterior chest wall. Twenty-five patients underwent immediate locally advanced breast cancer reconstruction with a V-Y latissimus dorsi musculocutaneous flap. This flap was raised from adjacent tissue located on the lateral and posterior thoracic region and presented a triangular shape whose base was the lateral aspect of the mastectomy wound. The technique was indicated in patients with large thoracic wounds.

RESULTS

Mean follow-up time was 16 months. Closure was obtained in the donor and recipient sites without the use of skin grafts or other more major procedures. Complications occurred in nine patients (36 percent), including dorsal wound dehiscence in five patients and seroma in three. All cases except one were treated by a conservative approach with a good result. No total flap loss was reported. All patients achieved a satisfactory thoracic reconstruction and adequate wound care.

CONCLUSIONS

The V-Y latissimus dorsi musculocutaneous flap is a reliable technique for immediate locally advanced breast cancer reconstruction. The technique is advantageous because the V-Y design allows primary closure of the chest wound and donor defect. Success depends on patient selection, coordinated planning with the breast cancer surgeon, and careful intraoperative management.

Resection of sternal tumors and reconstruction of the thorax: a review of 15 patients

PURPOSE

We report our experience of resecting sternal tumors, followed by reconstruction of the skeletal and soft-tissue defects, and discuss the usefulness of sandwiched Marlex and stainless-steel mesh.

METHODS

Fifteen patients underwent resection of a sternal tumor and chest wall reconstruction with autologous bone grafts, sandwiched Marlex and stainless-steel mesh or a titanium plate, and musculocutaneous flaps. The sternal tumors were from locally recurrent breast carcinoma in ten patients, metastasis from other organs in three, and primary chondrosarcoma in two.

RESULTS

All patients were extubated without paradoxical respiration just after surgery. There was no operative mortality. A wound infection developed in the acute phase after a sandwiched Marlex and stainless-steel mesh reconstruction in one patient. A second repair with Marlex and stainless-steel mesh was required in two patients; for flail chest after an autologous bone graft in one; and following re-recurrence of breast carcinoma in another patient who had undergone a musculocutaneous flap repair. No signs of breakdown, dislodgment, severe depression, or deformity were seen in any of the six patients who underwent reconstruction with Marlex and stainless-steel mesh during a median follow-up period of 56 months.

CONCLUSIONS

Wide resection of sternal tumors provides good local control. Reconstruction with Marlex and stainless-steel mesh seems to be the most effective technique for repairing a wide anterior chest wall defect.

Recycling spare tissues: splitting a bipedicled TRAM flap for reconstruction of the contralateral breast

A new method of bipedicled transverse rectus abdominis myocutaneous flap splitting to reconstruct the contralateral breast 1 year after the first breast reconstruction is presented. This technique can be useful in cases of large salvage mastectomy for asynchronous breast cancers allowing a bilateral thoracic closure.

Myocutaneous versus thoraco-abdominal flap cover for soft tissue defects following surgery for locally advanced and recurrent breast cancer

BACKGROUND AND OBJECTIVES

Radical surgical extirpation in advanced breast cancer patients produces large defects that may not be suitable for primary closure. The primary aim in such cases is to achieve an adequate soft tissue cover expeditiously. Various methods, including skin graft, omentum, random flaps, and myocutaneous (MC) flaps, have been tried in the past; however, there is no consensus regarding the method of choice in such patients.

METHODS

A retrospective analysis of the breast cancer database of a single surgical unit was performed to find out the incidence of advanced breast cancer patients requiring an additional surgical procedure for soft tissue cover. A comparative analysis of two major groups, "MC flaps" and "thoraco-abdominal (TA) flaps," was performed in relation to operative time, blood loss, morbidity, hospital stay, and final outcome.

RESULTS

Forty (12.7%) out of 315 advanced breast cancer patients undergoing surgery required additional surgical procedures for soft tissue cover. MC flaps were used in 18 patients and TA flaps were used in 22 patients. The mean blood loss (192 +/- 77 ml vs. 40 +/- 19 ml), operating time (110 +/- 20 minutes vs. 35 +/- 7 minutes), and hospital stay (10 +/- 4 days vs. 5 +/- 2 days) were significantly less in the TA flap group.

CONCLUSIONS

The results of the current study show a significant difference in the blood loss, operating time, and hospital stay between patients requiring TA and MC flap for soft tissue cover following mastectomy. In view of its simplicity and better results, we recommend that the TA flap should be used as a first option flap in advanced breast cancer patients requiring skin cover.

Radical surgery with omental flap for uncontrolled locally recurrent breast cancer

BACKGROUND

Uncontrolled chest wall disease due to breast cancer is a highly morbid condition causing pain, ulceration, malodour and the need for frequent dressings. Aggressive surgical approaches are rarely justified because most patients will succumb to metastatic breast cancer within a short period. A highly selected group of patients with minimal or no evidence of metastatic disease and good performance status may benefit from radical chest wall surgery. Omental transposition flaps are ideal for reconstructing extensive surgical defects following chest wall surgery.

METHODS

A retrospective review was carried out of 61 female patients treated consecutively between 1980 and 1995. The surgical technique is described herein.

RESULTS

All patients were symptomatic preoperatively. Symptoms included ulceration (80%), pain (44%) and malodour (40%). Twenty-nine patients had uncontrolled local recurrence following initial treatment for locally advanced breast cancer and 32 patients developed uncontrolled recurrence after treatment for operable breast cancer by mastectomy or conservation surgery. Median survival following chest wall surgery was 21 months and the median local recurrence-free interval was 20 months. Morbidity was -limited. There were no cases of major flap loss. Twenty-nine patients (48%) had no further local disease. Eighteen patients (30%) developed soft-tissue recurrence at the edge of the omental flap or in surrounding skin and 14 (23%) developed recurrence beneath the flap.

CONCLUSION

In a highly selected group of patients with symptomatic uncontrolled chest wall recurrence who are fit and have an expectation of at least moderate-term survival, radical chest wall surgery and omental flap transposition offers excellent palliation and local control in the majority of patients

Ulcerative breast cancer: case report and review of management

In the literature, there is an astonishingly small amount of information on specific treatment modalities of locally advanced, ulcerated breast cancer. Here we present a case report and a literature review on ulceration in breast cancer. An older, so far untreated woman with complete ulcerative destruction of her right breast was inoperable because of the extent of the tumor. Primary anthracycline-based chemotherapy and hormonal therapy led to major tumor shrinkage with complete ulcer healing, which was maintained for nearly 2 years. There is increasing evidence from the literature that primary chemotherapy may particularly benefit patients with inoperable ulceration, as also illustrated by our case.

Use of omentum pedicled graft to protect great vessels in gastric transposition for pharyngoesophageal cancer

BACKGROUND AND OBJECTIVES

Transmediastinal gastric transposition and pharyngogastric anastomosis is perhaps one of the most widely accepted methods for restoration of the alimentary continuity after pharyngoesophageal resection. The need of neck dissection, mediastinal tracheostomy, and previous radiotherapy may favor exposure and rupture of major vessels. Protection with omentum may prevent this complication. A comprehensive review of omentum flap use in surgery was undertaken.

METHODS

A modified omentum pedicled flap was used in 6 out of 36 patients submitted to total pharyngolaryngoesophagectomy and gastric transposition (PLE&GT).

RESULTS

None of the patients had major vessel rupture as compared with a 13% carotid and innominate artery rupture of a series of 30 patients previously operated on without omentum pedicled flap protection.

CONCLUSIONS

The omental pedicled flap, performed as described, may provide reliable protection for carotid and innominate artery exposure, adding little time to the procedure.

Lower back coverage with endoscopically harvested pedicled greater omental flap

An alternative surgical treatment is proposed here for radionecrosis of the lower back. A 78-year-old patient was treated successfully for a nonhealing ulcer with a pedicled omental flap. The omentum was harvested endoscopically and brought out of abdominal cavity through a limited incision on lateral left side of abdominal wall. The omentum was then tunneled to the back for coverage the lower back. The combination of an endoscopic harvest of an omental flap performed by a general surgeon and wound debridement and skin grafting of the omentum by a plastic surgeon allows minimal donor-site morbidity and avoids the use of delicate microsurgical technique. Additionally, omentum is an ideal flap for the treatment of radionecrosis.

Primary reconstruction after extensive chest wall resection

BACKGROUND

Chest wall resection and reconstruction has been proven to be a safe surgical procedure. This is particularly useful for breast cancer patients with chest wall recurrences or for those who first present with locally advanced cancer in the chest wall where there is both a large soft tissue and bony defect that need repair. In addition, many of these patients have had irradiation or chemotherapy, which can significantly impair wound healing.

METHODS

Thirty-four patients underwent chest wall resection and primary reconstruction over an 8-year period.

RESULTS

Twenty-three patients had breast carcinomas and six had breast and chest wall sarcomas. Of the breast carcinoma patients, 12 had local recurrences and 11 presented with locally advanced primary disease. Bony resection of the chest wall was required in 16 (47%) cases. Thirty myocutaneous flaps (18 rectus abdominis, four pectoralis major, eight latissimus dorsi) and three omental flaps were used for reconstruction. One required a deltovertebral skin flap. Skeletal reconstruction was necessary in four cases. All except one (97%) achieved primary wound healing. There was one mortality (3%) and three patients required further surgery for complications that were related to the reconstruction. Post-resection metastases occurred in 13 (42%) patients and only 2 (6%) had local recurrences. The 2-year survival rate was 78% with a mean survival time of 25.5 months.

CONCLUSIONS

Primary reconstruction for curative or palliative purposes is a useful and safe surgical procedure for patients with recurrent or locally advanced chest malignancies after extensive chest wall resection. Pedicled myocutaneous flap is the preferred option for skeletal and soft-tissue coverage.

Omental transposition flap for gross locally recurrent breast cancer

BACKGROUND

The omentum has been employed to cover the defect produced after resection of gross breast cancer recurrence for nearly three decades.

METHODS

A series of 11 patients undergoing omental transposition flap for very wide resection of gross local recurrence (LR) of breast cancer is reported. The median age was 39 years, with a short interval (median = 21 months) from the treatment of the primary tumour to LR. Local recurrence was gross and predominantly inflammatory.

RESULTS

All except one patient had lymphovascular invasion in the recurrent tumour. The omental graft was 100% viable but one patient required re-application of further split-thickness skin graft. The mean hospital stay was 16 days. Two cases of seroma formation were encountered. New recurrence developed around the periphery of the flap in eight patients after a median duration of local control of only 2.5 months. Eight patients died with metastatic disease after a median period of 6 months, six patients with uncontrolled local disease. Five patients were free from LR in over half of their remaining period of life.

CONCLUSION

Omentoplasty is a safe and reliable procedure but the length of palliation achieved is often far from satisfactory.

Chest-wall reconstruction: an account of 500 consecutive patients

Our experience with 500 consecutive chest-wall reconstructions over the past 18 years is reviewed. Of the 500 patients, 286 were male and 214 were female. Their ages ranged from 1 day to 85 years (average 55 years). Among the patients, 275 had chest-wall tumors, 142 had infected median sternotomies, 119 had radiation necrosis, and 121 had combinations of the three. Skeletal resection of the chest wall was done in 443 patients. An average of 3.9 ribs were resected in 241 patients. Total or partial sternectomies were performed in 231 patients. Four-hundred and seven patients underwent 611 muscle flaps: 355 pectoralis major, 141 latissimus dorsi, and 115 others, including serratus anterior, rectus abdominis, and external oblique. The omentum was transposed in 51 patients. Chest-wall skeletal defects were closed with polytetrafluoroethylene soft-tissue patch in 116 patients, polypropylene mesh in 55, and autogenous rib in 13. The 500 patients underwent an average of 2.3 operations. Hospitalization averaged 21 days. There were 15 perioperative deaths. Twenty-three patients required tracheostomy. The average duration of follow-up was 57 months. There were 229 late deaths; the cause of death was cancer in 147 patients, cardiac in 49, pulmonary in 7, and other in 26. Four-hundred and three of the 485 patients (83.1 percent) who were alive 30 days after the operation had excellent results and had a healed, asymptomatic chest wall at the time of death or last follow-up. We conclude that chest-wall reconstruction is safe, durable, and associated with long-term survival.

The pedicled omentoplasty and split skin graft (POSSG) for reconstruction of large chest wall defects. A validity study of 34 patients

The aim of this study was to evaluate retrospectively the results of pedicled omentoplasty and split skin graft (POSSG) in reconstructing (full thickness) chest wall defects, and to define its role as a palliative procedure for local symptom control. Thirty-four patients with recurrent breast cancer (n = 25), radiation-induced necrosis (n = 5) or sarcoma (n = 4) of the chest wall were selected for the study. All patients underwent curative or palliative chest wall resection with reconstruction by pedicled omentoplasty and split skin graft (POSSG), between 1986 and 1994. Reconstructive outcome, complications, local tumour and symptom control following surgery was measured. The most common complication was shown to be partial necrosis of the omental flap (35%), followed by respiratory problems (26%), facial hernia (26%) and thoracic wound problems (15%), which were mostly treated in a conservative way (68%). The 3-year local tumour-free interval after POSSG in patients curatively treated for breast cancer is 16%. Seventy per cent of the patients who underwent palliative resection had longstanding relief of local pain, bleeding or foetor due to local tumour growth. It can be concluded that large (full thickness) chest wall defects after resection of local recurrence, primary malignancy or osteoradionecrosis of the chest wall can successfully be reconstructed by POSSG. Chest wall resection in patients treated with palliative intention is effective in local symptom control.