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|Year : 1987 | Volume
| Issue : 1 | Page : 37-8
Chest wall reconstruction by latissimus dorsi myocutaneous flap for breast cancer (a case report).
Bhathena HM, Shinde SR
|How to cite this article:|
Bhathena H M, Shinde S R. Chest wall reconstruction by latissimus dorsi myocutaneous flap for breast cancer (a case report). J Postgrad Med 1987;33:37
|How to cite this URL:|
Bhathena H M, Shinde S R. Chest wall reconstruction by latissimus dorsi myocutaneous flap for breast cancer (a case report). J Postgrad Med [serial online] 1987 [cited 2020 Jan 24];33:37. Available from: http://www.jpgmonline.com/text.asp?1987/33/1/37/5303
Local recurrence in breast cancer is not uncommon after primary surgery. The local disease is extremely painful to the patient especially when it has fungated out. One such case treated by excision of the chest wall and reconstruction using latissimus dorsi composite myocutaneous flap is presented.
ABC, a 30 year old unmarried young lady, underwent simple mastectomy in August 1979 for cancer of the left breast elsewhere. Following this, she was put on cyclophosphamide methotrexate and 5-fluorouracil (CMF) regimen of which she received 7 cycles. While she was on CMF, she developed local recurrence in the form of small nodules. Following this, she was given radiation therapy to the chest wall and peripheral glandular areas totalling 4500 rads. Following this, she was given one dose of cyclophosphamide-adriaycin and 5-fluorouracil (CAF) in the month of June 1980. After that, the patient was without any treatment till January 1984, at which time she had a huge fungating recurrent growth involving the whole of the chest wall [Fig. 1]. This growth was fixed to the ribs. She was given 3 cycles of CAF. In March 1984, a total skeletal survey, liver scintigraphy and lung tomograms were done. Having confirmed the fact that the disease was still localised to the chest wall, we decided to do a wide excision of the disease involving full thickness chest wall which resulted into a skin defect of 24 cm x 24 cm and a chest wall defect of 15 cm x 15 cm [Fig. 1C]. Defect in the bony cage was bridged with the help of a fascia lata free graft from the left thigh. Latissimus dorsi myocutaneous flap was raised and rotated to cover the defect [Fig. 1EF]. Two drains were kept and wound closed. The patient was followed up for one year. The results at this time are shown in [Fig. 2].
Inadequate local treatment leads to a higher percentage of local recurrence in breast cancer. In fact, the aim of any local treatment either in the form of surgery or radiotherapy is to get a good loco-regional control than a longer survival. Since the concept of micrometastases came into work, the adjuvant treatment in the form of chemotherapy took its roots. Very often physicians mistake chemotherapy as a substitute for an inadequate local therapy and the results are as disastrous as this. No doubt, a local recurrence usually heralds a bad prognosis but not necessarily in all cases. In the absence of any evidence of a widespread disease, aggressive local treatment is justified, especially more so when the growing concept of quality of life is considered.
In this particular case, we have decided to use autogenous material especially because of the high chances of rejection of a foreign material. Review of the literature suggests that chest wall reconstruction has been a difficult problem. The respiratory movements coupled with the need for stability make the problem more difficult. Use of bone flaps from the sternum, strips of ribs sutured in place with wire and periosteal flaps from the adjacent ribs are described. Winkel and Watson and James had reported use of fascia lata grafts. Campbell had combined the free fascia lata graft with transposed latissimus dorsi muscle and obtained skin over with a split skin graft.
Rigid foreign bodies such as tantalum plates and stainless steel mesh, were used unsuccessfully in the past as they loosen with respiratory movements, get infected and ultimately rejected. Metal mesh guaze is abandoned because of its tendency to fracture or disintegrate. Rigid support is important to prevent herniation of the lung and paradoxical movements. Case like this, following local radiation injury,[1-3] demands support and coverage by a well vascularized bulky flap to avoid paradoxical respiratory movements. This was provided by a latissimus dorsi myocutaneous flap with fascia lata graft. The bulk of the flap itself was enough to prevent the paradoxical movement.
|1.||Campbell, D. A.: Reconstruction of the anterior thoracic wall. J. Thoracic Surg., 19: 456-461, 1950. |
|2.||Mandelson, B. C. and Masson, J. K.: Treatment of chronic radiation injury over the shoulder with a latissimus dorsi myocutaneous flap. Plast. and Reconstruct. Surg., 60: 681-691, 1977. |
|3.||May, J. W., Toth, B. A. and Cohen, A. M.: Teres major latissimus dorsi skin muscle flap for chest wall reconstruction. Plast. and Reconstr. Surg., 69: 326-328, 1982. |
|4.||Stephenson, K. L. and Mosley, J. M.: Reconstructive problems of the chest and breast. Amer: J. Surg., 92: 26 36, 1956. |
|5.||Watson, W. L. and James, A. G.: Fascia lata grafts for chest wall defects. J. Thorac. Surg., 16: 399-406, 1947. |
|6.||Winkel, A. Ff.: Hernia of lung; Report of a case, outlining mode of fascia lata repair, J. Thoracic Surg., 4: 627-634, 1935. |