Reconstructive options after cancer surgery of the breast

Breast cancer is now treated either by conservative therapy or by mastectomy. In the first case, no reconstruction is usually necessary, although some patients require additional surgery for asymmetry, distortion or even severe damage, by surgery or radiotherapy, of the treated breast. In these cases, reconstructive surgery should be performed very carefully, taking full account of the risk of operating in irradiated tissues. Minor procedures are usually adequate, but major surgery, reconstruction with abdominal flap, is sometimes the only solution to solve difficult postradiotherapy disasters. When a mastectomy is the choice of the patient and the surgeon, immediate reconstruction is now performed more often than before, as expansive prostheses are now available, allowing immediate implantation without endangering the skin flaps. In most cases of mastectomy, however, reconstruction is performed as a secondary procedure, in two stages if possible (volume and symmetry after the first, areola after the second). Most of the reconstructions are done by simple implantation of a prosthesis. When local conditions require a flap, the latissimus dorsi musculocutaneous has been the best choice for years, but the lower rectus flap is now taking over, as it gives the advantage of reconstructing a breast with autologous tissue.     

Rectus abdominis myocutaneous flap in radical oncopelvic surgery: A safe and useful procedure

AIMS: The aim of this retrospective study was to evaluate the usefulness of rectus abdominis myocutaneous (RAM) flaps to treat locally advanced pelvic gynaecological or digestive tumours. METHODS: We reviewed 46 patients, who received RAM flaps after radical oncopelvic surgery, including: (a) total vaginal reconstruction (TVR); (b) partial vaginal reconstruction (PVR); (c) perineal reconstruction (PR). RESULTS: Between 1989 and 1998, 46 patients underwent pelvi-perineal reconstruction with RAM flaps after radical pelvic surgery for carcinoma of the cervix (n=22), anal carcinoma (n=11), rectal carcinoma (n=7), or other pelvic tumours types (n=6). There were two post-operative deaths. Overall surgical morbidity was 45, 6% (n=21). Specific morbidity of the RAM flap was 21, 7% (n=10). Global re-intervention rate was 13% (n=6). CONCLUSION: Rectus abdominis myocutaneous flap in radical oncopelvic surgery is useful for vaginal or perineal reconstruction and prevention of pelvic collections after extended resections with a low rate of associated morbidity.     

Reconstruction of oncologic torso defects: emphasis on microvascular reconstruction

A large variety of pedicle flaps centered at the shoulder girdle or pelvic girdle, or derived from the epigastric axis, are generally available to reconstruct defects of the torso. However, microvascular free flap reconstruction may occasionally be required for: 1) locations that are difficult to reach with pedicle flaps (the posterolateral iliac crest region, epigastrium, lower lumbar and sacral, and upper back and lower central); 2) locations in which muscles or their vascular pedicles have been destroyed by surgical ablation or irradiation; 3) a large-volume "dead space" or a large surface area that may be inadequately covered by available regional flaps; and 4) a combination of factors. Whether using a pedicle or free flaps, the reconstructive requirements of torso reconstruction must be met: 1) to restore chest wall or abdominal wall integrity, 2) to fill "dead space," 3) to cover vital exposed structures, 4) to maintain skeletal stability of the thoracic cage and minimize respiratory compromise, and 5) to buttress visceral repairs. Semin. Surg. Oncol. 19:255-263, 2000.     

Pelvic exenteration and reconstruction

For the past six decades, pelvic extenteration has been utilized in the treatment of localized central pelvic recurrences after chemo/radiotherapy. The radicality of the procedure that includes resection of the bladder, vulva/vagina, and rectum, although with curative intent, results in comprehensive changes for the patient. For this reason, all patients should undergo extensive psychosocial counseling to prepare them for the changes in body image and lifestyle. Extirpation of the pelvic viscera has undergone a number of modifications since Brunschwig first described it in 1948 to maximize survivability and minimized anatomical distortion. Most of the advancements have been focused on the reconstructive phase after pelvic exenteration. A few select patients can be free of any external appliances such as a colostomy bag with utilization of a low colorectal anastomosis, and can maintain sexual intimacy with creation of a neovagina. In addition, reconstruction of the pelvic floor with omental flaps, dura mater grafts and myocutaneous flaps have decreased postoperative morbidity. In this article, we provide a review of pelvic exenteration in gynecologic oncology, emphasizing preoperative evaluation, surgical techniques and their postoperative management.     

The preauricular tubed pedicle flap

Tubed pedicle flaps find limited application for the cutaneous surgeon, but the preauricular area offers particular advantages in reconstructing certain congenital or acquired defects on the pinnae. These flaps are two-staged procedures, the utmost care being required in presurgical assessment and careful handling of the transposing pedicles. The attached vascular pedicle virtually guarantees success in transferring thicker portions of preauricular tissue into deep defects on the auricle. The reconstructive surgeon will find the challenges rewarding in achievement of aesthetic results with difficult problems. To date we have performed 36 two-staged pedicled auricular reconstructive procedures with no untoward complications or sequelae.     

Oncoplastic and reconstructive breast surgeon performance and impact on breast reconstructions: Clinical outcomes,learning curve,and patients’ satisfaction

BackgroundCompared to mastectomy alone, the addition of breast reconstruction could improve quality of life and it is usually performed by two-team approach, which consisted of both breast surgeons and plastic surgeons. This study aims to illustrate the positive impacts of the dual-trained oncoplastic reconstructive breast surgeon (ORBS) and reveal the factors influencing reconstruction rates.MethodsThis retrospective study enrolled 542 breast cancer patients who undergone mastectomy with reconstruction performed by a particular ORBS between January 2011 and December 2021 at a single institution. Clinical and oncological outcomes, impact of case accumulation on performance and patient-reported aesthetic satisfactions were analyzed and reported. Furthermore, in this study 1851 breast cancer patients treated with mastectomy combined with or without breast reconstructions, which included 542 performed by ORBS, were reviewed to identify factors affecting breast reconstructions.ResultsAmong the 524 breast reconstructions performed by the ORBS, 73.6% were gel implant reconstructions, 2.7% were tissue expanders, 19.5% were transverse rectus abdominal myocutaneous (TRAM) flaps, 2.7% were latissimus dorsi (LD) flaps, 0.8% were omentum flaps, and 0.8% involved LD flaps and implants. There was no total flap loss in the 124 autologous reconstructions, and the implant loss rate was 1.2% (5/403). Patient-reported aesthetic evaluations showed that 95% of the patients were satisfied. As the ORBS's accumulated case experiences, the implant loss rate decreased, and the overall satisfaction rate increased. According to the cumulative sum plot learning curve analysis, it took 58 procedures for the ORBS to shorten the operative time. In multivariate analysis, younger age, MRI, nipple sparing mastectomy, ORBS, and high-volume surgeon were factors related to breast reconstruction.ConclusionThe current study demonstrated that a breast surgeon after adequate training could become an ORBS and perform mastectomies with various types of breast reconstruction with acceptable clinical and oncological outcomes for breast cancer patients. ORBSs could increase breast reconstruction rates, which remain low worldwide.     

Conservative surgery and restoration after pelvic exenteration

Pelvic exenteration can be proposed to non-metastatic patients with advanced or recurrent pelvic cancer and remains frequently the only potentially curative option in combination with others therapies. Colorectal function preservation and reconstructive procedures are useful to decrease functional and psychologic impact and postoperative morbidity. Technical procedures including urinary diversion, colorectal function preservation, vaginal reconstruction and pelvic filling are described and commented. Specific morbidity is analysed.     

Chinese flap in head and neck surgery

Twenty patients underwent resections for head and neck cancer. The reconstructive procedure used was the free forearm flap with microsurgical technique on 22 occasions. The free forearm flap was used in its simple or composite form, with double or manifold islands, with a segment of the radius for mandible reconstruction or with two islands joined solely by the vascular pedicle, constituting what the authors call "tandem flap", with excellent results. The procedure does not replace conventional ones, but the authors believe it should be regarded as one of the choice flaps by surgeons dedicated to this special field.     

Aesthetic and Functional Evaluation of Total Nasal Reconstructions

The loss of a portion or the totality of the nose has great relevance on the perception of the beauty of a face and can result in a catastrophic quality of life impairment. Several surgical techniques are currently available for the reconstruction of the nasal pyramid. However, there are very few nasal reconstruction quality evaluation protocols that allow the surgeon to choose objectively the best technique for each kind of defects. Six total nasal reconstruction performed in University of Sassari Maxillofacial Unit were evaluated with a protocol that investigate objectively and subjectively the surgical aesthetic and functional outcome. Sensitivity recovery on the reconstructive flaps was also assessed. Patients reported a satisfactory nasal reconstruction both functionally and aesthetically. Sensitivity recovery on the forehead flap was always present even after pedicle resection or in case of traumatic section of the infraorbital nerve. The use of a three layer reconstruction has proved a viable technique both aesthetically and functionally. In particular the use of the forehead flap to reconstruct the outer layer of the nose allows to carry a tissue with very similar characteristics to the original with a recovery of the sensitivity almost complete.     

Issues related to choice of breast reconstruction in early-stage breast cancer

Opinion statement Reconstructive surgeons focus their efforts on refining and developing techniques that optimize oncologic outcome and recreate the most natural breast mound possible. The introduction of perforator flaps offers the potential for faster and more complete recovery, while increasing technical complexity and the risks associated with microsurgical reconstruction. Despite appealing long-lasting results, autologous reconstruction is not the ideal reconstructive choice for every patient. Tissue/expander reconstruction can produce a satisfactory aesthetic outcome and is the reconstruction of choice for most women undergoing breast reconstruction. Immediate autologous reconstruction at the time of mastectomy best resembles the lost breast and favorably withstands radiation, compared with other reconstructive methods. However, the best method for integrating reconstruction and radiation is being actively debated. Placing a tissue expander at the time of mastectomy allows a skin-sparing approach and gives the patient a chance to see how she will feel with an implant. This approach avoids radiation damage to tissue reconstruction flaps, saving them for use later if necessary. This approach, using a tissue expander as a first step, is growing in popularity.     

Functional surgery for head and neck squamous cell carcinoma

Surgery for head and neck squamous cell carcinoma can alter speech, swallowing, and cosmoses. Recent tendency is to avoid mutilating surgery unless the tumour is aggressive or resistant to chemotherapy and or radiotherapy. Functional surgery is being widely employed, and for example it may vary between conventional partial surgery and endoscopic laser surgery for small sized vocal cord cancers. Various new reconstructive procedures have been developed to help early functional restoration. Loco-regional flaps can be used to replace gums and avoid dental extractions. Free flaps with micro-vascular anastomosis can be employed for immediate reconstruction of extensive surgical defects involving pharyngeal wall, tongue, mandible and mid-face to restore better function and cosmoses. Few recently developed techniques can be also employed in selected cases of laryngo-pharyngeal cancers to avoid permanent laryngeal mutilation. Another goal of functional surgery is to decrease the postoperative radiotherapy or chemo-radiotherapy sequelae, and obtain successful postoperative functional rehabilitation.     

The evolution of oncovascular pelvic surgery: A historical perspective

Pelvic exenteration surgery has evolved dramatically in recent decades and now represents the standard of care for many patients with advanced pelvic malignancy. Most recently the use of complex vascular resection and reconstructive techniques have been applied in advanced pelvic oncology surgery at specialist units and these oncovascular techniques are considered one of the frontiers in this field. This article summaries the historical evolution of oncovascular surgery in the pelvis and sets the scene for where this treatment is going. The role of vascular resection and reconstruction in curative treatment of advanced pelvic malignancy is an evolving area that is redefining the boundaries of what was historically thought possible.     

Mandible reconstruction with microvascular surgery

Microvascular surgery has become the preferred method for mandible reconstruction. Whenever possible, immediate reconstruction at the time of segmental mandible resection will provide the best aesthetic and functional result. Four donor sites (fibula, iliac crest, radial forearm, and scapula) have become the primary sources of vascularized bone and soft tissue for the reconstruction. The fibula has multiple advantages, including bone length and thickness, donor site location permitting flap harvest simultaneously with tumor resection, and minimal donor site morbidity. The fibula donor site should be the first choice for most defects, particularly those with anterior or large bony defects requiring multiple osteotomies. Use of an alternative donor site is best reserved for cases with large soft tissue and minimal bone requirements. Dental rehabilitation through the use of prostheses and osseointegrated dental implants is an important part of the reconstructive process to optimize aesthetics and function. An algorithm for mandible reconstruction with microvascular osseous flaps is presented. Semin. Surg. Oncol. 19:226-234, 2000.     

Influence of irradiation and oncologic surgery on head and neck microsurgical reconstructions

Despite the refinement of microsurgical techniques, microsurgical free flap transfer in patients with a history of previous radiotherapy, neck dissection or free flaps remains a challenge in oncologic reconstructive surgery. Previous studies on the prognostic factors for postoperative complications have been largely retrospective and shown conflicting results. Our aim was to design a prospective study to identify negative outcome predictors of free flap surgery in previously treated oral cancer patients. Prospective study including all patients who required microsurgical free flap transfer for reconstruction of the oral cavity between July of 2007 and June of 2010 with subset analysis of those cases in whom previous surgical or nonsurgical oncological treatment for head and neck cancer had been carried out. A total of 360 free flaps were performed in 358 patients, of whom 61 had previous neck dissection and 58 had undergone radiation therapy. Operation time was significantly found to be longer in irradiated patients. The need for microsurgical revision, postoperative wound infection and free flap loss were significantly associated with the ASA score and a previous neck dissection. Wound infection was seen significantly more often after radiotherapy. Previous neck dissections and radiotherapy as well as the ASA score are significant negative predictors for success in free flap transfer. For patients with prior oncologic treatments in their medical history, we recommend detailed preoperative assessment of the vascular status and an intensified postoperative care to reduce complication rates to improve outcome in oncologic reconstructive surgery.     

Vaginal reconstruction after pelvic exenteration: when and which techniques?

Pelvic exenterations are commonly performed to treat locally advanced or recurrent tumours of the pelvic organs to achieve long-term survival. Those procedures may present complications. Reconstructive procedures have become an important part of radical pelvic surgery to improve quality of life. Various surgical procedure of vaginal reconstruction have been describe. Myocutaneous flaps are effective in the prevention of major morbidity with pelvic filling and physiological neovagina. Vertical rectus abdominis myocutaneous flap is the technique of choice with simple harvesting and large pelvic filling. Gracilis and gluteal thight flaps are particularly adapted in pelvectomy with perineal resection. Enteroclpoplasty and omental flap must be used in radical colpectomie or difficulty pelvic access.     

The pectoralis major myocutaneous flap in head and neck reconstruction

The pectoralis major myocutaneous flap (PMMC flap) represents a landmark in the development of head and neck reconstructive surgery. After Stephan Ariyan first described its use for head and neck reconstruction in 1979, it has become tremendously popular and has revolutionised head and neck cancer surgery. Here, we present our initial experience with fourteen PMMC flaps in head and neck reconstruction. In most of the instances it was used for oral or oropharyngeal reconstruction. It was used for five other reconstructive tasks as well. Wound infection was the most common complication. There was no case of total flap loss. It has proven to be a reliable method of reconstuction in the head and neck.     

Selective reconstructive options for the anterior skull base

Carcinomas of the ethmoid, frontal, or maxillary sinuses sometimes invade the anterior skull base. It is necessary to perform en-bloc resection for this invasive carcinoma according to the concepts of surgical treatment for head and neck cancer. The anterior skull base consists of two parts, the orbital roof as the lateral portion and the roofs of the frontal sinus, ethmoid sinus, and/or sphenoid sinus as the central portion. Selective reconstructive options for the anterior skull base depend on the size of the defect of the skull base. A dural defect is repaired by a fascia lata or a pericranial flap. After the dura has been tacked up, reconstruction of the anterior skull base is performed simultaneously with augmentation of the defect of extracranial structures. Larger defects that consist of both central and lateral portions with orbitomaxillary structures are reconstructed by a bulky musculocutaneous flap such as a rectus abdominis or latissimus dorsi flap. The bony reconstruction of supraorbital structures is also to be considered esthetically. On the other hand, intraorbital tissues are basically preserved in cases of central defects of the anterior skull base. These defects are reconstructed by a free forearm flap or a local flap such as a de-epithelialized midline forehead flap or a pericranial flap. We have selected and applied these flaps in 37 patients as reconstructive options for the anterior skull base since 1989. Eleven of the 37 patients had larger defects and 26 had central defects. De-epithelialized midline forehead flaps were used in 20 patients and were recognized to be a very useful and reliable reconstructive option for central defects of the anterior skull base.     

Reconstruction of the perineum

Defects of the perineal area commonly occur following ablative procedures for gynecological, urological, and colorectal malignancies. A coordinated approach between the surgical oncologist and the reconstructive surgeon is necessary in order to achieve appropriate results in these patients. Consideration of both form and function is essential and must be planned for. A variety of reconstructive procedures, including skin grafts, local skin flaps, various myocutaneous and fasciocutaneous flaps and, in rare situations, free tissue transfers, are used in the closure of these wounds. An algorithm for the selection of these various procedures is presented so that uncomplicated wound healing can be achieved and functional results can be optimized. Semin. Surg. Oncol. 19:282-293, 2000.     

Urologic complications of major pelvic surgery

The close proximity of pelvic organs makes the genitourinary system susceptible to injury during major pelvic surgery. Iatrogenic injury remains the most common cause of lower urinary tract trauma. Recent modifications in surgical technique, such as sharp mesorectal incision and nerve-sparing radical prostatectomy, have decreased the incidence of many of these complications. Genitourinary complications due to pelvic surgery remain common, however, and as new surgical advancements are made, new complications may present. An understanding of the prevention, recognition, and treatment of urologic complications is important for every surgeon performing major pelvic surgery.     

Vulvovaginal reconstruction for neoplastic disease

Current treatment of neoplastic disease that involves the external female genitalia aims to achieve local disease control, but not to restore form and function of these organs. Despite a growing trend to reduce the extent of surgical resection, impaired quality of life after surgery due to severe sexual dysfunction and disturbed body image is common. We postulate that the integration of surgical techniques for vulvar and vaginal reconstruction into primary treatment would improve aesthetic and functional results and therefore quality of life. We systematically searched the literature for surgical procedures designed and validated for vulvovaginal reconstruction. Various skin flaps, both with random vascularisation and those based on vascular territories (ie, axial pattern, fasciocutaneous, musculocutaneous, and bowel flaps), can restore important parts of vulvovaginal form and function with acceptable morbidity at the donor and recipient sites. Appropriate vulvovaginal reconstruction cannot be achieved by doing a few standardised procedures; rather, it necessitates specialists who are familiar with general principles of reconstructive surgery to master many techniques to select the optimum procedure for the individual patient. Vulvovaginal reconstructive surgery has limitations, particularly achievement of functional restoration in irradiated tissue. Physicians who treat women with neoplastic disease of the external genitalia should be aware of the current state of vulvovaginal reconstructive surgery. Prospective controlled clinical trials are warranted to assess the effect of vulvovaginal reconstruction on morbidity and quality of life after treatment.