Reconstructive Management of

Advanced Breast Cancer

Bernardo Rivas, MD*
Jos F. Carrillo, MD
Gustavo Escobar, MD

To evaluate morbidity, quality of life, and oncological outcomes of

patients with advanced breast cancer, recurrence, or sequelae
secondary to radiotherapy, the authors present their experience
with 21 patients at the Instituto Nacional de Cancerologa in
Mexico City, who underwent resection of the lesion and reconstruction using thoracoepigastric fasciocutaneous, rectus abdominis, or latissimus dorsi musculocutaneous flaps. Complications
included partial flap necrosis and bronchopleural fistulae in 2 of
7 patients with whole-thickness chest wall resection. The remaining patients progressed nicely, with a short recovery period. The
patients and the surgical team evaluated results in terms of
aesthetics and function using questionnaires. The results were
from fair to good according to Sneeuws scale. Pedicled musculocutaneous and fasciocutaneous flaps are an excellent reconstructive option in patients with advanced, recurrent breast
cancer and in those with radionecrotic complications, which
sometimes require resection of the whole-thickness chest wall.
Rivas B, Carrillo JF, Escobar G. Reconstructive management of advanced
breast cancer. Ann Plast Surg 2001;47:234 239.
From the *Plastic and Reconstructive Section and the Breast Tumors
Section, Instituto Nacional de Cancerologa, Mxico City, Mxico.
Received Nov 17, 2000, and in revised form Mar 14, 2001. Accepted for
publication Mar 14, 2001.
Address correspondence and reprint requests to Dr Rivas, Plastic and
Reconstructive Section, Av. San Fernando No. 22, Delegacin Tlalpan,
Mxico City, Mxico.

There is a group of patients with advanced

breast cancer or recurrence who require complex
reconstructive procedures after chest wall resections to obtain local control of the lesions and a
better quality of life.1 Reconstruction requires
evaluation of the type of defect, and status of the
pleural cavity, the osseous support requirements
of the chest wall, and the soft tissues available to
complete the reconstruction.2
Partial chest wall resections require advancement of local tissue or harvest of pedicled
flaps.3,4 Conversely, procedures that involve
whole-thickness chest wall resections require
complex reconstructive techniques to obtain stable thoracic function as well as adequate coverage to protect deep structures with low morbidity
234

Copyright 2001 by Lippincott Williams & Wilkins, Inc.

and a short recovery period. We present reconstruction of partial- or whole-thickness chest wall
defects after surgery for advanced or recurrent
breast cancer, as well as reconstruction of the
defects that result from oncological treatments
(i.e., radiotherapy), focusing on morbidity, mortality, and functional and aesthetic issues. A brief
analysis of oncological results is made to evaluate
the impact of these therapeutic interventions in
the final outcome of this select group of patients.

Material and Methods

Twenty-one consecutive female patients underwent
partial- or whole-thickness resection of the chest wall
from May 1995 to June 1999 in the Instituto Nacional
de Cancerologa, Mexico City. Patients had a diagnosis of advanced or recurrent breast cancer, or had
radionecrotic sequelae. All patients were subjected to
a workup that included liver function tests, bone
scans, liver and spleen scans, and preoperative computed tomographic scans to evaluate infiltration
of the chest wall and intrathoracic structures. The
TNM staging system was used according to the
American Joint Committee on Cancer classification from 1997.
Reconstructive techniques used included latissimus dorsi and rectus abdominis pedicled flaps,
which have been described previously.4 Patients
who had involvement of the thoracodorsal and
epigastric vascular systems had reconstruction performed with a thoracoabdominal fasciocutaneous
flap. This flap has been described previously by
Baroudi and colleagues,5 and we use it with modifications of our own, as we will describe. Briefly,
the flap is designed on the thoracoabdominal wall,
with a rectangular shape, extending from the middle sternal line to the contralateral anterior axillary
line. The flap has its width limited by two lines:
The upper line is located on the inframammary
fold, and the lower one is a parallel line that runs
approximately 15 cm below it, depending on the

Rivas et al: Advanced Breast Cancer Reconstruction

Fig 1. Schematic representation of the surgical highlights of the fasciocutaneous flap with variations of our own.

width of the defect. When it reaches the midline, it

turns down in a perpendicular vertical line that
ends up at the middle point between the navel and
the pubis. The length of the flap is determined by
the upper line of the defect, and it is raised distal to
proximal, maintaining the fascial plane of the rectus abdominis and the serratus muscles. The flap
ends at the ipsilateral axillary line, is rotated 90
deg, and is advanced, leaving a small excess of
tissue that is corrected at the end of the procedure.
The abdominal flap is elevated in the same plane
and is advanced for closure of the donor area. (Fig
1). Hemostasis is completed and a negative-suction
drainage tube is applied. Wide spectrum antibiotics
are started because this is usually a highly contaminated area as a result of the advanced nature of the
breast lesions and the presence of severely necrotic
tissue (in some patients) secondary to radiation
therapy (Fig 2).
For reconstruction of whole-thickness defects
of the chest wall, Gore-Tex or Marlex mesh was
applied before flap harvest on the thoracic wall
defect and was fixed under tension with nylon
sutures to provide stability (Fig 3). A chest tube is
inserted and a latissimus dorsi pedicled flap,

detached from its humeral insertions to provide

mobility, is set in place. Valsalva maneuvers are
performed to ensure no air leaks exist, and
wounds are closed in the standard fashion.
After chest wall reconstruction, patients were
kept in the intensive care unit for 24 hours, and if
no respiratory complications ensued, they were
moved to another floor. Questionnaires were given
to two members of the surgical team as well as to
patients at the 3-month follow-up to answer questions regarding aesthetics, which was graded as
poor, fair, good, or excellent. Function was evaluated in the same manner, and grades were given
regarding respiratory functions as oxygen dependent, dyspnea at rest, dyspnea on exercise, or no
respiratory disability. Arm mobility was evaluated
as poor, fair, or good. Scales were modified and
adapted to our population according to the one
published by Sneeuw and associates.6

Results
Twenty-one patients underwent chest wall reconstruction with the aforementioned flaps. Pa235

Annals of Plastic Surgery

Volume 47 / Number 3 / September 2001

Fig 2. (A) Preoperative lateral chest radiograph shows a patient with advanced breast cancer, affecting only the
tissues of the right chest wall. (B) The soft-tissue defect and the thoracoepigastric fasciocutaneous flap is outlined. (C)
The flap is rotated to cover the chest wall. Here, the defect is closed. (D) Appearance 2 months after surgery.

Fig 3. (A) Left-side whole-thickness defect of chest wall. (B) The defect was closed with Gore-Tex mesh, which was
covered with a musculocutaneous latissimus dorsi island flap. (C) Appearance 1 month after surgery.
Table 1. Distribution According to Clinical Stage

tient age ranged from 24 to 67 years (mean age, 45

years). Size of the tumor or necrotic area ranged
from 5 to 20 cm (mean, 12 cm).
TNM classification of the lesions is depicted in
Table 1. Local recurrence occurred in 6 patients
after a diagnosis of stage IIIa breast cancer. Eight
patients had recurrent stage IIIb breast cancer and
7 patients had a severely radionecrotic area that
required excision and reconstruction of the defect (Table 2). Excision involved the full thickness of the chest wall in 7 patients, with a range
of two to six ribs resected and an average of four
ribs excised. Coverage of soft tissue only was
required in the rest of the patients.
Flaps used to reconstruct soft-tissue defects
only were the rectus abdominis flap (N 7), the
latissimus dorsi musculocutaneous flap (N 2),
and 5 patients were reconstructed with a thoracoabdominal fasciocutaneous flap because of severe damage to the thoracodorsal and internal
mammary vascular systems either by tumor or
236

Diagnosis
Clinical stage IIIa recurrence
Clinical stage IIIb advanced lesion
Radionecrosis
Total

No. of
Patients

Percent

6
8
7

28.57
38.09
33.33

21

99.99

radiation. A latissimus dorsi flap was used for

reconstruction in all patients with a whole-thickness defect of the chest wall.
One patient with partial necrosis was treated
with an application of a dermal graft. Two patients from the group that underwent reconstruction of the whole thickness of the chest wall had
bronchopleural fistulae secondary to partial dehiscence of the flap. In 1 patient, primary closure
was carried out, with muscle reinforcement performed with a rectus abdominis musculocutaneous flap. The second patient was treated
conservatively, with thoracostomy tube drainage
left in place for 10 days.

Rivas et al: Advanced Breast Cancer Reconstruction

Table 2. Type of Resection and Reconstructive Technique

Type of Resection

Latissimus Dorsi
Musculocutaneous
Flap, N

Rectus Abdominis
Musculocutaneous Flap, N

Thoracoepigastric
Fasciocutaneous Flap, N

Limited to soft tissues

Chest wall resection

2
7

7
0

5
0

Total

Hospitalization ranged from 3 to 15 days

(mean, 7 days). There was no operative mortality.
Evaluation of aesthetics and function is shown
in Table 3. Results in terms of function were good
to excellent (measured in terms of arm mobility
in the entire group), whereas aesthetics was rated
as good (47.61%). Regarding patients who underwent whole-thickness resection of the chest wall,
aesthetics were evaluated as fair, and respiratory
function (which is a major issue in this subgroup
of patients) was rated as good (71% of patients
with no respiratory disability) in most of the
patients (Table 4).
Patient follow-up ranged from 6 to 60 months
(mean follow-up, 24 months). Median survival
time was 75% at 25 months, and the current
status of the patients is shown in Table 5.

Discussion
Reconstructive management after resection of recurrent or advanced breast cancer, especially
when it affects the chest wall is complex. A strong
trend toward the use of autologous tissues exists.79 The current series illustrates a group of
patients who had advanced or recurrent lesions
and in whom an expeditious and low-morbidity
method was imperative to attain palliation and in
some cases an improvement in survival.
Very often, the involvement of critical vascular
structures like the thoracodorsal and epigastric
systems of vessels as well as morbidity and the

postoperative recovery period preclude the use of

free flaps such as the latissimus dorsi and the
rectus abdominis. Besides, many of these patients
have clinical deterioration that could make the
use of a free flap impractical. In this setting, we
use pedicled flaps. Because of our anatomic
knowledge of the vascularity of these flaps as
well as their geometry, latissimus dorsi, rectus
abdominis, and thoracoabdominal flaps allow the
coverage of extensive areas of chest wall, as
demonstrated by the mean size of the defects
reconstructed in the current study, with low
morbidity and a short recovery period. Several
patients in our series had involvement of the
thoracodorsal and epigastric system of vessels. In
these patients, Matsuo10 described a long latissimus dorsi musculocutaneous flap to reconstruct
the contralateral chest wall. However, changes in
position of the patient during surgery are complicated, and vascularity is at risk because of the
length of excursion of the flap, which receives its
vascularity through the posterior intercostal and
perforating arteries from the anterior serratus
muscle. This flap is easy to harvest, with no
complications in our hands and, as evidenced in
Table 3, function and aesthetics are good as
qualified by patients and surgeons.
When radionecrosis is present, the omental
flap11,12 with its rich vascularity, is an option.
However, it requires an abdominal operation, and
peritoneal contamination is very often present,
aside from the meticulous postoperative local

Table 3. Evaluation of Aesthetics and Functional Results of the Entire Cohort

Aesthetic Rating

N (%)

Arm Mobility Rating

N (%)

Poora
Good
Excellent

3 (14.28)
10 (47.61)
8 (38.09)

Poor
Good
Excellent

1 (4.76)
4 (19.04)
16 (76.19)

a
There was partial necrosis in 1 patient, which required a dermal graft, 1 patient required a second flap, and 1 patient presented with
partial necrosis and spontaneous closure.

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Annals of Plastic Surgery

Volume 47 / Number 3 / September 2001

Table 4. Evaluation of Aesthetics and Functional Results in Patient Who Underwent Whole-Thickness Resection of
the Chest Wall
Aesthetic Rating

N (%)

Poor
Good
Excellent

1 (14.28)
5 (71.42)
1 (14.28)

care required and the possibility of future hernias. We consider the omental flap as a secondchoice procedure in cases of failure.
When whole-thickness resection of the chest
wall is performed,13 we prefer to reconstruct the
defect with a latissimus dorsi flap, which is set on
top of Gore-Tex mesh. Only 2 patients developed
bronchopleural fistulas, probably secondary to
previous irradiation of the tissues involved in the
suture lines.
When extensive rib resection is performed, our
technique of using Gore-Tex mesh set in place with
adequate tension, and a pedicled latissimus dorsi
flap, has allowed us to achieve excellent stability.
When we analyzed these patients we found good
results in aesthetics and no respiratory disability in
71% of patients (see Table 4), which stresses the
importance of the reconstructive procedures, even
under these adverse circumstances.
Of note is the fact that we did not have any
patients who experienced locoregional failure,
and the survival analysis of our series shows that
many patients are alive at 3 years of follow-up,
with 14 alive with no evidence of disease (as
described in Table 5), which underscores the
possible role of locoregional control in the survival of these patients, especially when treatment
is early, as has been pointed out by others.14,15 Of
paramount importance is that most of the patients in the current study had good functional
and aesthetic results (76%) and excellent mobility of the arm, and good to excellent results in
terms of aesthetics (85%). Although we didnt
apply the psychosocial part of the evaluation by
Sneeuw and colleagues6 in our questionnaires
because of the wide variations in the psychosocial history of individuals in our country, we
think that performance of these extensive reconstructive procedures is justified, because quality
of life is good, and there is an acceptable survival
period in our patients, although most other series
238

Respiratory Function
Rating

N (%)

Oxygen dependent
Dyspnea at rest
Dyspnea on exercise
No respiratory disability

0 (0)
0 (0)
2 (28.57)
5 (71.42)

report very limited survival periods in this specific situation.

We administered wide-spectrum antibiotics to
these patients because they are immunocompromised, and some tumor lesions or radionecrotic
areas may be contaminated by aerobic and anaerobic bacteria. This treatment could be another
explanation for the low morbidity observed.
Pedicled flaps are an excellent reconstructive
option in patients with recurrent breast cancer or
with severe radionecrotic sequelae, given the low
morbidity, no mortality, and good functional and
aesthetic results attained. Quality of life is improved dramatically in this subgroup of patients
despite a probably short survival period because
of the biological nature of the disease. When
whole-thickness chest wall resection is required,
a latissimus dorsi pedicle flap combined with
Table 5. Diagnosis and Outcome of Patients After
Resection and Reconstruccion
Patient No.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21

Diagnosis

DFI, mo

Status

Recurrence
Radionecrosis
Radionecrosis
Radionecrosis
Recurrence
Advanced
Advanced
Advanced
Radionecrosis
Radionecrosis
Advanced
Advanced
Radionecrosis
Recurrence
Advanced
Recurrence
Advanced
Recurrence
Recurrence
Radionecrosis
Advanced

18
45
57
45
26
18
8
12
24
60
31
22
35
29
9
24
20
26
19
24
23

DOD
NED
NED
NED
NED
DOD
DOD
DOD
NED
NED
NED
NED
NED
DOD
DOD
NED
NED
NED
DOD
NED
NED

DFI disease-free interval; DOD dead of disease; NED no

evidence of disease.

Rivas et al: Advanced Breast Cancer Reconstruction

Gore-Tex or Marlex mesh is our reconstructive

method of choice. Good palliation is obtained
under these circumstances.

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5

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