Verschlu\ von Thoraxwanddefekten nach Resektion von Mammacarcinom-Rezidiven
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The treatment of local recurrences in breast carcinoma involving the thoracic wall
Summary
- 1)
Because of the first operation there is invariably not enough skin.
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In the vast majority of cases the chest wall has received heavy X-ray treatment.
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The thoracic wall must be removed to ensure radical surgical excision.
To overcome these difficulties our technique, developed in the last 10 years, has been:
After ascertaining the possibility of radical operation by local inspection of pleura and lungs, the thoracic wall is resected in its full thickness, giving the tumor a safety margin of five centimeters all around. To close the thoracic defect and insure the stability of the chest-wall, autologous dermis grafts have proven successful. They can be taken either from the lower abdomen and the flank, or from the inside of the thigh. Both these regions are fairly hairless, which minimizes the danger of postoperative epithelial-cyst-development. As donor-sites we prefer the thighs for large, and the lower abdomen for smaller, defects. The carefully de-epithelialized and de-fatted dermis graft is stitched under high tension snugly into the thoracic wall (Fig. 1) and should have its de-epithelialized side turned towards the better blood-supply, which in these cases usually is the lung.
- 1)
Sickel-flaps (Figs. 2 and 3) and rotation-flaps (Figs. 4 and 5) taken from the upper abdomen of the contralateral side have the advantage of giving large areas of good skin. They have to be designed very carefully, since circulatory difficulties may occur at their margin (Table 2).
- 2)
Hammer-head-flaps (Figs. 6 and 7), a combination of rotation-flap with Z-plasty are very useful in long, narrow defects, but should only be used for fairly small ones or in combination with other flaps.
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Rotation-flaps from the other breast: The advantages are the possibility of mastectomy on the second side and that they provide large amounts of excellent skin. The aesthetic results however are disappointing.
- 4)
Epaulette-flaps from the shoulder: They are efficient for covering the otherwise difficult areas in the axilla and close to the clavicle. They do not interfere with the lymphatic drainage from the arm.
In 44 patients, 55 flaps were used. Tables 1 and 2 give the data of the results of these various flaps. In doubt, combinations of flaps should be used rather than undully large single flaps, because their complication rate is significantly lower.
If a large part of a flap is lost, secondary operations should not be postponed longer than 5 days.
In most cases, however, the losses were marginal and could be managed with split-thickness grafting.
Fig. 13 shows the survival time of the 26 patients who have died and Fig. 14 the surviving time of our 18 living patients.
These curves suggest, that fatalities from local recurrences are practically all due to the original disease, and not to the recurrence as such.
A comparison between 44 local recurrences and 39 extremely large primary carcinomas (Table 3) shows that the chances of survival in cases of recurrence are no worse than for the other group of primaries.
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Literatur
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