Những Nguyên Tắc Thiết Yếu Trong Phẫu Thuật Tuyến Vú (Essentials of Breast Surgery)

area of each lymph node is examined because
subjecting each lymph node to a more meticu-
lous search, considering there may be from 10
to 30 lymph nodes in the specimen, is time
and
cost
prohibitive.
However,
with
SLN
biopsy, the pathologist typically has only 1 to
4 lymph nodes to examine. This allows for
serial sectioning for a more thorough examina-
tion of the nodes and the identification of
metastases that would have otherwise been
missed (Fig. 13–10). The nodes should be
examined by H&E at a minimum of 2-mm
intervals. With this technique, SLN biopsy is
more sensitive at finding lymph node metas-
tases than ALND.
A key feature of SLN biopsy is the detailed
pathologic review. By focusing on a few nodes,
rather than the entire axilla, a more thorough
examination of each node in the sentinel node
specimen is feasible (Fig. 13–11). As compared
with bivalving the SLN, several studies have
demonstrated the importance of obtaining
multiple sections in detecting axillary metas-
tases. Many centers also examine nodal sec-
tions with IHC, a more sensitive method of
detecting metastatic cells. The use of IHC stain-
ing will be discussed in further detail later in
the text.
With increased scrutiny of the SLN, smaller
and
smaller
metastases
can
be
identified.
Although it would seem quite reasonable to
presume that the discovery of any disease in
the lymph node would portend a worse prog-
nosis, this is not necessarily the case. Several
retrospective studies of patients with negative
ALND have involved reexamining the lymph
nodes by serial sectioning and IHC, and the
outcomes of patients with occult metastases
compared to those without. Although some
studies found a worse outcome associated with
micrometastases,
most
found
no
negative
impact on prognosis.
The significance of micrometastases detected
by IHC is further called into question by the
DCIS literature. Micrometastatic disease can
be detected in as many as 10% of patients
undergoing SLN biopsy for DCIS, which has
a nearly 99% survival and for which axillary
recurrences are extremely rare. In addition,
three studies have demonstrated that micro-
metastases detected by IHC correlate more
with the method of biopsy than with the
biology of the cancer, suggesting they may
be an artifact rather than a biologic pheno-
menon. Thus, the available evidence does
not support the routine use of IHC in the
evaluation of the SLN. IHC may be used
selectively, such as in the case of lobular
carcinoma, which may be difficult to identify
in the lymph node. If metastases are detected
by IHC, their presence should be confirmed
on H&E.
Patients
with
micrometastases
less
than
0.2 mm are considered node negative (current
American Joint Committee on Cancer [AJCC]
staging stages these patients as N0mic) and
should not be considered for completion dis-
section or adjuvant chemotherapy based solely
on their nodal status. Patients with metastases
greater than 0.2 mm should continue to be
treated as node positive. Pending data from
recent prospective trials will hopefully help
clarify these issues.
Figure 13–10. Micrometastases identified on senti-
nel lymph node biopsy. (Image courtesy of Dr. Maria
Braman, Department of Pathology, University of
Michigan.)
Figure 13–11. Step-sectioning the sentinel lymph
node as opposed to bisecting it, allows for evalua-
tion of a greater cross-sectional area of the lymph
node and improves the accuracy of axillary staging.
In this example, a micrometastasis would have been
missed by bisection (false-negative) but is detected
by step-sectioning.
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13—REGIONAL MANAGEMENT OF BREAST CANCER

Management of the Clinically
Positive Axilla
Axillary Lymph Node Dissection
Whether the disease was identified by physi-
cal examination, axillary ultrasound, or SLN
biopsy, ALND remains the standard of care
for patients with known involvement of the
axillary lymph nodes. The few patients in
whom a sentinel node cannot be identified,
even intraoperatively, are also candidates for
primary complete axillary lymphadenectomy
for staging purposes. The axillary dissection
for breast cancer involves en bloc resection of
the level I and level II lymph nodes. The axilla
is anatomically defined posteriorly by the
subscapularis and latissimus dorsi muscles,
medially by the chest wall and the overlying
serratus anterior muscle, laterally by the skin
and subcutaneous tissue of the underarm area,
and superiorly by the axillary vein. These ana-
tomic boundaries do not imply that lymph
nodes do not reside above the axillary vein,
and these nodes can be included in the speci-
men by pulling the fatty tissue above the vein
inferiorly with the specimen, taking care not
to injure the brachial plexus. However, aggres-
sive dissection above the vein exposes the bra-
chial plexus to injury. This area encompasses
the intercostobrachial nerve(s), thoracodorsal
bundle, and the long thoracic nerve, which
are often intimately involved with the soft
tissue and lymphatics of the surgical specimen.
The thoracodorsal bundle, consisting of a
nerve, artery, and vein, contains the major blood
supply and innervation to the latissimus dorsi.
Disruption of the thoracodorsal nerve results in
weakness during abduction and medial rotation
of the shoulder. The long thoracic nerve is the
sole motor nerve to the serratus anterior, a thin,
flat muscle primarily responsible for anchoring
the scapula to the posterior chest wall. Injury
to the long thoracic nerve results in “winging”
of the scapula, in which the medial edge of
scapula protrudes involuntarily and uncomfort-
ably from the posterior thorax.
Axillary dissection is accomplished in con-
cert with mastectomy (a MRM) via an oblique
elliptical mastectomy incision or in concert with
a lumpectomy using a separate curvilinear inci-
sion connecting the anterior and posterior axil-
lary lines, just inferior to the axillary hairline.
Technique
Patient Position
Before being brought back to the operating
room, the correct arm for dissection should
be marked in the preoperative area. This is
not only to avoid performing a lymph node
dissection on the wrong side, but also so that
the nurses and anesthesia team place all intra-
venous lines, blood pressure cuffs, and moni-
tors on the contralateral arm. Long-acting
muscle relaxants should be avoided so that
motor nerves can be identified during the pro-
cedure. Short-acting muscle relaxants during
intubation are okay because these typically
wear off before nerve identification.
The patient is positioned supine with the
arm out at 90 degrees (Fig. 13–12). The arm
should not be hyperextended at any point in
the operation. The armboard should be pad-
ded appropriately to avoid subluxation of the
shoulder because this can stretch the brachial
plexus. Standard skin prep is used, with the
entire arm prepped to the wrist. The shoulder
and lateral chest are prepped down to the table
because these will be exposed when the arm is
brought across the chest. The armboard is cov-
ered with a sterile drape and the arm sheathed
to above the elbow with a sterile impervious
Stockinette. The arm is brought through a lap
sheet, with the drapes underneath the shoul-
der so that the arm is within the operative
field.
Procedure
The surgeon stands below the arm with a first
assistant above the arm. If available, a second
assistant can be positioned on the contralat-
eral side. A curvilinear incision is made just
inferior to the hair-bearing area, extending
from just posterior to the pectoralis major
muscle and just anterior to the latissimus dorsi
Figure 13–12. The patient is positioned supine
with the arm out at 90 degrees, never hyperex-
tended. The entire arm prepped to the wrist and the
shoulder and lateral chest are prepped down to the
table. The armboard is covered with a sterile drape
and the arm sheathed to above the elbow with a
sterile impervious Stockinette, keeping it within the
sterile field. Bland KI, Copeland EM 111. The Breast,
3rd ed. Philadelphia: WB Saunders, 2004.
192
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

muscle. The first step is to raise superior and
inferior skin flaps. A common error is to make
these flaps too thin. This does not increase the
number of lymph nodes removed and can lead
to a more pronounced cosmetic defect in the
axilla. The incision should be carried straight
down to just above the axillary fascia and then
flaps created. Once the flaps are raised, the
next step is to identify three landmarks; the
pectoralis major and minor muscles, the axil-
lary vein, and the latissimus dorsi muscle
(Fig. 13–13). Although these can be identified
in any order, the pectoralis muscle is usually
the easiest to expose. Once identified, the lat-
eral aspect of the pectoralis major muscle is
exposed with electrocautery along its length.
With the pectoralis major muscle retracted
medially,
the
pectoralis
minor
muscle
is
exposed, and the investing fascia can be
opened in a similar manner. During the expo-
sure of the muscles, it is important to identify
and preserve the medial pectoral neurovascu-
lar bundle. There is typically a small vascular
branch coursing toward the axillary contents
that will need to be divided. However, cutting
the nerve will cause atrophy of a portion of
the
pectoralis
muscle
and
can
be
easily
avoided with careful surgical technique.
The latissimus dorsi muscle can then be
identified at the inferior aspect of the axilla
and then exposed superiorly, staying on the
anterior edge of the muscle to avoid injury to
the thoracodorsal bundle. The latissimus dorsi
muscle should be exposed to the point where
the axillary vein crosses it. During this dissec-
tion, the lateral aspect of the intercostobra-
chial nerves will be encountered. Preserving
these nerves, although adding time to the
procedure, will avoid numbness of the upper
inner arm.
Finally, the axillary vein needs to be ex-
posed. The vein is often encountered during
the exposure of the muscles. If it was not seen,
careful exploration and dissection should be
used to identify it. It is important not to dis-
sect superior to the level of the axillary vein
because an injury to the brachia plexus can
be one of the most debilitating complications
Figure 13–13. Superior and inferior flaps are raised, and the pectoralis major, latissimus dorsi, and axillary
vein are identified.
193
13—REGIONAL MANAGEMENT OF BREAST CANCER

of an ALND. Once the vein is identified, dis-
section should be on its inferior aspect. Skele-
tonizing the entire anterior surface of the
vein may increase the potential for lymph-
edema. This dissection is greatly facilitated by
retracting the axillary contents caudally. As
the fat is dissected from the vein, small super-
ficial branches of the axillary vein are divided
and ligated with 3-0 silk sutures. As the vein
is cleared laterally to medially, the next step
is to identify the thoracodorsal bundle. The
thoracodorsal vein is usually the first deep
branch off of the axillary vein as one moves
medially. The artery is often seen in close prox-
imity. At this point, the nerve is not typically
running with the vein, but rather located more
medially (Fig. 13–14). It will eventually join
the vein and artery as they course toward the
latissimus dorsi muscle. Once the entire bun-
dle is identified, the fibrofatty tissue can be
cleared from the neurovascular structures so
that they may be seen entering the latissimus
dorsi muscle. Although this portion of the dis-
section may be deferred until the end of the
case, with the optimal exposure it is worth
completing. During this dissection, it is impor-
tant not to divide this tissue to reveal the bun-
dle, but rather retract the tissue medially and
dissect it off of the underlying subscapularis,
sparing the thoracodorsal bundle. Otherwise
the node-bearing tissue between the latissimus
dorsi muscle and the thoracodorsal bundle is
left behind.
As
the
thoracodorsal
vein
is
cleared,
a
branch is noted heading toward the chest wall.
This “crossing branch” can often provide a
clue to the location of the long thoracic nerve.
Some
surgeons
will
routinely
follow
this
branch to the serratus anterior at this point
in the dissection to identify the long thoracic.
Others identify the long thoracic after the dis-
section of the level II nodes. Either way is
acceptable, but regardless of when the long
thoracic is identified, this crossing branch
should be preserved.
For a level I and II dissection, the pectoralis
minor muscle must be raised to allow access
to the level II nodes. Division of the fascia
and ligation of the external mammary vessels
found near the lateral border of the pectoralis
Intercostobrachial
nerve
Latissimus
dorsi m.
Teres major m.
Thoracodorsal
neurovascular
bundle
Subscapularis m.
Pectoralis major
and minor
mm.
Long
thoracic
nerve
Serratus
anterior m.
Figure 13–14. The thoracodorsal neurovascular bundle is seen laterally. Near the axillary vein, the thoraco-
dorsal nerve is more medial than the artery and vein. As they course toward the latissimus dorsi, they are in
closer proximity. (From Roses D. Breast cancer. Philadelphia: Elsevier, 2005.)
194
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

minor muscle allows for mobilization. Again,
care is taken not to injure the medial pectoral
nerve. The pectoralis minor is then retracted
upward and medially to allow removal of the
nodes beneath it. This is greatly facilitated by
rotation of the arm medially. The exposure of
the axillary vein can then be continued under
the pectoralis minor muscle with inclusion of
this fibrofatty tissue with the specimen. Dur-
ing this portion of the dissection, an aggressive
use of suture ligation should be employed to
avoid bleeding in a difficult to visualize area.
In the patient with grossly involved lymph
nodes, especially when level II involvement is
suspected, a level III dissection should be
included. This can be accomplished by divid-
ing the pectoralis minor muscle near its origin.
This should be done distal to the pectoral
nerve so that innervation to the pectoralis
major is preserved. With this added exposure,
the node-bearing tissue medial to the pectora-
lis minor
(the
level
III
nodes)
are easily
included in the specimen.
The axillary contents are now dissected from
medial to lateral off of the serratus anterior
muscle. During this portion of the dissection,
the medial aspect of the intercostobrachial
nerve is identified, and the entire nerve can
be freed from the specimen if the decision
was made to preserve it. The long thoracic
nerve is also identified. Unless disturbed by
previous axillary surgery or tumor, the long
thoracic nerve is in the same anteroposterior
plane as the thoracodorsal nerve (Fig. 13–15).
Knowing where the thoracodorsal nerve is will
help the surgeon identify the long thoracic.
The crossing branch of the thoracodorsal vein
will serve the same purpose. The most com-
mon mistake is to look for the nerve directly
on the serratus anterior, thus actually retract-
ing the nerve into the specimen. The nerve is
actually a few millimeters off of the muscle in
the encapsulating fascia. Once identified, it is
cleaned off along its length. With the intercos-
tobrachial, thoracodorsal, and long thoracic
nerves identified and cleared, all that remains
is to free the axillary contents from the under-
lying
subscapularis
muscle
between
the
nerves. With both nerves visualized, the tissue
between the nerves may be clamped at the
inferior margin of the vein and suture ligated.
The tissue may now be dissected free from
the muscle. It is important not to rush through
this portion because excessive retraction of the
Intercostobrachial
nerve
Long thoracic nerve
Thoracodorsal nerve
Thoracodorsal vein
Thoracodorsal artery
Latissimus dorsi m.
Teres major m.
Subscapularis m.
Serratus
anterior
mm.
Pectoralis
major and
minor mm.
Medial
pectoral
nerve
Figure 13–15. After completion of the axillary dissection, the relationship of the nerves can be seen. The
intercostobrachial nerve can be identified and preserved. The long thoracic nerve is identified slightly lateral
to the serratus anterior, in the encapsulating fascia. The long thoracic nerve is in the same anteroposterior
plane as the thoracodorsal nerve, so knowing where the thoracodorsal nerve is will help the surgeon identify
the long thoracic. (From Roses D. Breast cancer. Philadelphia: Elsevier, 2005.)
195
13—REGIONAL MANAGEMENT OF BREAST CANCER

specimen inferiorly can pull either the thora-
codorsal or long thoracic nerve into the speci-
men and lead to an inadvertent injury. The
nerves should be visualized throughout this
portion of the dissection.
Once the specimen is removed, hemostasis
is assured and a closed suction catheter is
placed through a separate incision lower on
the chest wall. Do not place this stab incision
too far posterior because this will inconve-
nience the patient. The drain is secured with
a Nylon suture and attached to a suction reser-
voir. The wound is closed with absorbable sub-
cutaneous
sutures
and
the
skin
may
be
reapproximated with a subcuticular stitch or
tissue adhesive.
Postoperative Care
The patient is discharged after being instructed
on drain management (Box 13-5). The patient
should be taught to care for the drain and to
record the amount of drainage. When the vol-
ume in the reservoir is less than 30 ml/24 hours,
the drain can be removed. All patients will have
some limited abduction of the shoulder after
ALND, but this will return to normal with rou-
tine exercises or physical therapy once the
wound is completely healed. Some patients will
completely avoid use of the arm or keep the arm
in a sling after the operation. This should be
strongly discouraged because this can result in
capsular contracture and a frozen shoulder.
Exercises are given to the patient to encourage
mobility; some are to be performed immedi-
ately, and others to be included after the drain
is removed. Physical therapy may be necessary
to return to a full range of motion. An orthopae-
dic consult may be needed in those rare cases in
which full range of motion does not return with
physical therapy.
Management of the Internal
Mammary Lymph Nodes
The breast drains predominantly to the axil-
lary lymph nodes, but also drains to the supra-
clavicular, infraclavicular, cervical, and IMNs.
Anatomically, 75% of the breast lymphatics
drain toward the axilla, and 25% drain into the
IMNs. Going back to the early part of the last
century, attempts to improve on the Halsted
radical mastectomy included attempts to include
the IMN with the resection (known as the
extended radical mastectomy [ERM]). This failed
to improve survival, and momentum shifted
toward less radical surgery, the MRM. The
ERM did, however, give us information on
the incidence of IMN metastases in breast
cancer.
Contrary
to
what
many
surgeons
believe, metastases to the IMN do not come
only from the inner quadrants of the breast,
but rather from all quadrants. The likelihood
of IMN drainage does decrease as one moves
from medial to lateral. Overall, there appears
to be a low risk of metastases to the IMN in
the absence of metastases in the axillary
lymph nodes. In a study of over 7000 patients
who had ERM, the overall incidence of IMN
metastases was 22%, but only 10% when the
axillary lymph nodes were negative. Of those
patients with negative axillary nodes, the risk
of IMN metastases for medial lesions was
14%, but only 6.5% for lateral lesions.
Given the morbidity of IMN dissection and
the low likelihood of finding disease in the
IMNs that would change adjuvant chemother-
apy decisions, few surgeons advocated routine
IMN biopsy for breast cancer. However, with
the advent of SLN biopsy, the question of
how to best handle the IMN has returned.
Lymphatic mapping with lymphoscintigra-
phy may identify IMN in as high as 25% of
cases, depending on the method of injection
of the Tc99. When Tc99 is injected peritumo-
rally, there will be drainage to the axilla in
99% of cases. In 76%, this is the only drainage.
In 10%, there is primary drainage to the axilla
with secondary drainage to the IMNs. In 5%
there was drainage to the IMNs primarily, with
secondary drainage to the axilla. The remain-
ing cases include combinations of drainage to
the
axillary,
IMNs,
and
clavicular
lymph
nodes. Other studies have shown slightly
higher rates of IMN-only drainage, as high as
4%. However, if the Tc99 is injected in a subar-
eolar or intradermal manner, drainage to the
IMNs is a relatively rare occurrence.
Studies of IMN metastases in the age of SLN
biopsy show patterns similar to that in the age
of the ERM, with metastases in the IMNs in
27% of patients who have axillary node metas-
tases but only in 7% of patients who are nega-
tive in the axilla. As one would expect, the
presence of disease in the IMNs is indepen-
dently prognostic. Patients tumor-free in both
basins have a higher survival than that of
patients with disease in either the axillary or
IMNs. The survival is the lowest for patients
with disease in both basins.
Whether or not to biopsy these nodes if they
light up on lymphoscintigraphy remains con-
troversial. Unidentified disease in the IMNs
196
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

BOX 13–5 PATIENT INSTRUCTIONS ON DRAIN MANAGEMENT
Care of Your Drain
After your surgery you will go home with a bulb drain in place. The drain will remove fluid that
builds up under your wound to promote healing. The drain generally does not cause pain.
1.
For the first 3 days, it is recommended that you clean the area where the drain tubing
enters your body and change the gauze. Clean the insertion site using cotton-tipped
swabs and a solution of one-half water and one-half peroxide.
2.
Apply a clean drain sponge around the insertion site daily. You may it more often if it
becomes heavily soiled.
3.
After 2 days you may shower or gently wash the area where the drain tubing enters
your body.
4.
You may use nonperfumed soaps (Ivory or Neutrogena).
5.
Always pat dry, never rub.
6.
Reapply gauze after cleansing.
7.
Women should continue to wear their bra.
Notify your doctor or the breast care center if:

The reservoir cannot be reactivated (it quickly reexpands).

The drain falls out or the stitch holding the drain tube comes out.

The drainage fluid in the reservoir becomes foul smelling.

You have a fever or there is any increased redness, swelling, or drainage from the site.

There is an air leak, fluid leak, or malfunction of the drain bulb.

Clots form in the tubing and block drainage and cannot be cleared by “milking” the drain
tubing.
Emptying the Drain (Reservoir)
You will need to empty and reactivate the drain bulb (reservoir). You will also need to record the
amount of fluid collected in the reservoir. Empty the reservoir as many times a day as directed by
your doctor or nurse or if full. Wash your hands before and after handling the reservoir. Empty the
reservoir into the measuring container when the fluid collected reaches the 100 ml mark or before.
Do not let the reservoir completely fill because the drainage will stop.
Keep a record of the amount of fluid collected in the reservoir. Record the date, time, and amount
of fluid that has accumulated from each reservoir. If the drainage stops within the first few days after
your surgery there may be a clot in the drain tubing. Try milking or “stripping” the drain if this is
the case.
Attach the reservoir (using the plastic strap) to your bra or shirt, usually with a safety pin. Do not
disconnect, kink, or puncture the tubing that is connected to the reservoir. You will notice the
amount of drainage decreasing over time. The color of the drainage will also lighten over time.
Milking or Stripping the Drain Tubing
To keep the drain working well you will be shown how to milk the drain tubing three times per day.
You should always wash your hands before handling the drain.

Grasp the tubing close to your body with one hand and pull toward your body.

With your other hand, grasp the tubing below the first hand.

Using an alcohol swab, pinch tubing tightly, sliding your fingers down the tubing and
away from your body, repeat this two or three times.

Be sure that the drainage is flowing into the bulb. It is okay if the tube becomes flat
from the suction. Never disconnect the tubing from the bulb at any time.
197
13—REGIONAL MANAGEMENT OF BREAST CANCER

could potentially account for the poor progno-
sis of patients falsely labeled as node negative
based on the axillary sentinel node. Identify-
ing disease in the IMNs could potentially
upstage patients and change adjuvant therapy
decisions, especially for patients with smaller
tumors who, based on T stage alone, would
not receive chemotherapy if their axillary
nodes were negative. In addition, the presence
of microscopic disease in the IMNs might
change the radiation fields to include the
internal mammary chain, although this is
associated with increased morbidity. Excising
sentinel nodes from the IMN that harbor
microscopic disease might also decrease the
risk of parasternal recurrences. For these rea-
sons, some surgeons advocate the routine
biopsy of these nodes when performing SLN
biopsy. If this is to be done, peritumoral injec-
tions of Tc99 are mandatory.
On the other hand, the increasing use of
chemotherapy for patients who are node nega-
tive and the availability of Oncotype DX to
make adjuvant therapy decisions (see Chapter
16) lessens the impact of a positive IMN on
decision making. The decision to radiate the
IMN is often made on the tumor size, location,
and presence of disease in the axillary nodes.
Recurrent disease in the IMN is not a common
occurrence. Given the additional morbidity of
excising an internal mammary SLN, including
the risk of pneumothorax, many surgeons opt
not to go after SLN in the IMN, and inject the
Tc99 in a manner that is unlikely to demon-
strate IMN drainage on lymphoscintigraphy.
Internal Mammary Sentinel Lymph
Node Biopsy
The internal mammary lymph node biopsy
often takes breast and general surgeons outside
their area of comfort. For surgeons who feel
that biopsy of the IMN should be performed
when the lymphoscintigraphy shows uptake,
but do not feel comfortable performing the
procedure themselves, it is not unreasonable
to do so in conjunction with a thoracic sur-
geon. The drawback to this approach is obvi-
ously that of scheduling because it is usually
not known whether the thoracic surgeon is
needed until the day of (or night before) the
surgery.
The internal mammary sentinel node can be
excised through the same incision as the mas-
tectomy, and in many cases, (because most
tumors that drain to the IMNs are medial)
the lumpectomy incision. In the rare case in
which a more lateral tumor drains to the
IMNs, a separate incision can be made parallel
to the sternum, approximately 3 cm from the
lateral sternal margin. The pectoralis muscle
needs to be exposed for approximately 2 to
3 cm over the interspace identified by the
gamma probe. When performing the biopsy
through a lumpectomy incision, this may
require raising the breast parenchyma off of
the underlying muscle.
The pectoralis major muscle fibers are split
to expose the superior intercostal space, expos-
ing the external and internal intercostals mus-
cles. These need to be divided transversely
from the sternal border for approximately 3
to 4 cm. The two potential injuries during this
part of the procedure are to the anterior inter-
costal vessels and to the inferior parietal
pleura, leading to pneumothorax. The vessels
course along the inferior aspect of each rib
and are avoided by dividing the muscles in
the middle. Care must be taken not to injure
the parietal pleura when dividing the internal
intercostals muscle. If it does occur, it can be
closed with a fine absorbable suture, and post-
operative chest tubes are rarely necessary.
After dividing the intercostals, the internal
mammary vessels should be identifiable. The
artery is approximately 1 to 1.5 cm from the
lateral sternal border. They are located in an
extrapleural space, surrounded by fibrofatty
tissue and lymphatics. This tissue is divided
and small vessels coagulated. A vessel loop
should be placed around the artery and vein
(either together or separately). This not only
helps keep the vessels in view, but it helps pre-
vent major bleeding in the case of accidental
transection. While encircling the vein, coagu-
lation
or
clipping
of
some
small
venous
branches might be needed.
If excessive bleeding from the vein occurs, it
can be ligated. The artery should be preserved
in case it is needed in the future for pedicled
transverse
rectus
abdominis
myocutaneous
(TRAM) flap reconstruction or coronary artery
bypass graft (CABG). However, if transection
does occur, the rib may need to be either disar-
ticulated or transected to obtain control.
Once the vessels are controlled, the probe is
used to identify the node within the surround-
ing adipose tissue. The SLN may be either
medial or lateral to the vessels. The node is
excised, taking care to clip or coagulate the
small surrounding vessels.
The wound is irrigated and on the final irri-
gation, the water left within the wound and
observed for small air bubbles that would be
198
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

indicative of an injury to the pleura. The fibers
of the pectoralis muscle are reapproximated
using 2-0 Vicryl sutures, although pulling
these too tightly will transect the muscle
fibers. If the procedure was performed through
a lumpectomy incision, the breast paren-
chyma can be reapproximated to restore the
shape of the breast.
In the recovery room, a chest x-ray should
be obtained to rule out a pneumothorax, if
there is any question regarding the pleura.
Internal Mammary Node Dissection
An internal mammary node dissection is an
extremely rare operation, typically done in con-
junction with a mastectomy when there are
grossly involved internal mammary lymph
nodes. The surgeon identifies the attachment
of the pectoralis major muscle to the sternum
and the first rib. In the first intercostals space,
the medial fibers of the pectoralis major are
split, and the intercostal muscles are identified
(Fig. 13–16). The intercostal muscles are divi-
ded from the sternal border to about 3 cm later-
ally. Underneath this, the internal mammary
vessels can be identified. These are ligated.
The fifth rib is then identified, and the intercos-
tal space between the fifth and sixth rib is
entered in a similar manner, identifying the
internal mammary vessels and ligating them.
A tunnel can be established underneath the
pectoralis major muscle. A sternal knife is
placed into the first interspace, directed medi-
ally to the mid sternum, and directed down
through the mid sternum to the level of the
fifth intercostal space, and then directed later-
ally to come out in the fifth intercostal space.
The chondral portion of the second, third,
fourth, and fifth ribs are transected lateral to
Internal
thoracic artery,
vein, and nodes
Figure 13–16. The internal mammary nodes. (From Bloom N, Beattie E, Harvey J. Atlas of cancer surgery.
Philadelphia: Elsevier, 2000.)
199
13—REGIONAL MANAGEMENT OF BREAST CANCER

the origin of the pectoralis muscle. When trans-
ecting the ribs, care is taken to secure the inter-
costal vessels at the lower margin of each rib.
The entire internal mammary lymph node
chain can be removed in this manner, along
with the pleura underneath. Chest tubes are
placed through the skin distal to the lower skin
flap and within the chest wall defect to manage
the pneumothorax.
Is Axillary Lymph Node Dissection
Necessary for a Positive Sentinel Lymph
Node Biopsy?
Just as lumpectomy greatly minimized the mor-
bidity of breast surgery compared to mastec-
tomy, SLN biopsy has done the same for
axillary surgery compared to ALND. As described
previously, ALND may be safely avoided in the
80% of women with negative sentinel node
biopsies. What about the 20% of patients with
a positive sentinel node biopsy? As many as
one half of patients with a positive SLN will have
additional disease detected in the nonsentinel
lymph nodes (NSLNs). Documenting the num-
ber of involved nodes provides further staging
information that may impact adjuvant chemo-
therapy and radiation decisions because multi-
ple involved lymph nodes are associated with
increased recurrence rates and decreased sur-
vival. In many patients, however, simply know-
ing the patient is node positive or node
negative may be enough information to deter-
mine the remainder of their therapy. In these
patients, is there a therapeutic benefit to gaining
regional control, or can these patients be
observed, with ALND performed, only if they
recur?
As almost all patients with node-positive SLN
will receive adjuvant systemic therapy, regional
recurrence in this situation may be extremely
low. But even if recurrence did occur, and the
patient undergoes a delayed ALND, would this
impact
their
survival?
As
mentioned,
the
NSABP B-04 trial specifically addressed this issue,
and after a 25-year follow-up, did not dem-
onstrate
any
difference
in
overall
survival
among patients undergoing axillary dissec-
tion, axillary radiation, or delayed axillary clear-
ance
for
recurrence.
This
is
the
strongest
evidence against the need for ALND. However,
the study was not large enough to detect a small
but meaningful difference in survival, and
many surgeons, in the habit of routinely
performing MRMs, still removed a substantial
number
of
axillary
lymph
nodes
when
performing a simple mastectomy, clouding the
results. There are also other studies suggesting
there is a survival benefit to the early removal
of micrometastatic disease in the lymph nodes.
One of the largest of these studies was con-
ducted at the Institut Curie from 1982 to
1987. The Curie study randomized 658 patients
to either lumpectomy and axillary dissection or
lumpectomy
with
postoperative
radiation.
Enrollment was limited to patients who were
clinically node negative with tumors less than
3 cm in size. Five-year follow-up demonstrated
a 4% survival benefit (p ¼ 0.014) for patients
undergoing axillary dissection compared with
those with axillary radiation only. A meta-
analysis of six randomized controlled trials exa-
mining axillary node dissection in early breast
cancer demonstrated a 5.4% overall survival
benefit for patients who were clinically node
negative undergoing axillary dissection.
However, these studies have limitations. The
meta-analysis included several sizable Euro-
pean studies (including the Institut Curie
study) conducted from the 1950s to the 1980s.
Since that time, there have been significant
advances in screening, surgical management,
and adjuvant therapy. It is unclear whether
these results translate to today. More impor-
tantly, in some of these studies, patients who
were found to be node positive were treated
with adjuvant chemotherapy, an option not
available to women who did not undergo
ALND. Thus, there is a significant treatment
bias between the two groups.
Although
these
data
suggest
a
possible
benefit to controlling regional disease, one can
not assume that the results obtained with the
omission of ALND among patients who were
clinically node negative from years ago would
be the same as among patients who are SLN
positive today. Neither the risk of distant dis-
ease, nor the amount of residual disease in the
axillary nodes, is directly comparable. The only
way to determine whether ALND may be safely
omitted for patients with a positive SLN would
be a randomized trial, which was initiated by
the American College of Surgeons Oncology
Group (ACoSOG), but unfortunately closed pre-
maturely as a result of poor accrual. Therefore,
the therapeutic benefit of completion ALND
remains unknown.
Rather than declaring whether ALND is or is
not necessary, if one could accurately predict
which patients are so unlikely to harbor addi-
tional disease in the remaining nodes, a selec-
tive approach to complete ALND could be
applied. Although some clinicopathologic fea-
tures such as the size and grade of the primary
200
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

tumor, the size of the lymph node metastases,
or the ratio of positive SLN to the number of
SLN removed may help stratify risk, no factor
appears sufficient to select patients who may
avoid dissection. Even the lowest risk groups
have a 10% to 20% chance of harboring addi-
tional disease. Although the use of statistical
models
or
nomograms
may
better
select
patients with a low likelihood of harboring
disease in the NSLN, it must be cautioned that
these studies underestimate the risk of addi-
tional disease, as the NSLN are not subjected
to the histologic scrutiny to which the sentinel
node is subjected.
Complete ALND is not the only option avail-
able to patients with a positive SLN. Axillary
radiation may be a reasonable alternative, as
evidenced by data from before the emergence
of SLN biopsy. In a series of 418 women treated
with axillary radiation therapy after either no
or limited ALND, only 1.4% developed a
regional failure after 8 years of follow-up. Of
the subset of patients who had a limited
ALND with positive nodes, the regional failure
rate was 7% (3 of 42 cases). A randomized trial
in Italy of ALND versus axillary radiation ther-
apy accrued 435 patients, and after a mean
follow-up of 66 months, recorded only one
axillary recurrence in the radiation arm and
two axillary recurrences in the surgery arm.
Although these data suggest that axillary radia-
tion may be effective in obtaining regional
control, it is again difficult to transpose these
numbers to the population who is SLN posi-
tive. A randomized trial of axillary radiation
versus ALND for patients who are SLN positive
is presently accruing patients and will not only
answer these questions, but also help deter-
mine whether axillary radiation truly decreases
the morbidity of treatment compared with
surgery.
Complications Associated with
Sentinel Lymph Node Biopsy
Sentinel node biopsy has greatly reduced the
morbidity of breast cancer surgery, sparing
80% of women from the morbidity of an axil-
lary node dissection. However, sentinel node
biopsy is not without morbidity. While the
complications of sentinel node biopsy are rela-
tively minor compared with a full node dissec-
tion, there can be serious complications that
must be discussed with the patient. In addi-
tion to the surgical complications of the proce-
dure, there are also technical complications,
specifically a failure to find the sentinel lymph
node at all or a false negative finding.
Inability to Find the Sentinel Node
Being unable to find the sentinel node is a
relatively rare occurrence. A meta-analysis of
SLN biopsy, reveals overall identification rate
of 96% and overall false negative rate of
8.4%; this analysis included data from 69 stud-
ies involving 10,454 patients. Many of these
occurred when surgeons had just started using
sentinel node biopsy (early on the learning
curve) and when surgeons were using a single
mapping agent in comparison to using both
blue dye and isotope. With more experience
and more surgeons using the dual-tracer tech-
nique, the identification rate is likely higher
and the false-negative rate lower. Older age,
obesity,
previous
excisional
biopsy,
tumor
location, and tumor size have been implicated
as other factors leading to either a failure to
find
the
SLN
or
a
false-negative
finding,
although these have been variable across stud-
ies, and many decrease as significant factors
with increased experience. For example, if the
mapping procedure is being performed after a
prior excisional biopsy, there is a risk of inad-
vertent injection into the biopsy cavity and
the mapping agent will not reach the nodal
basin. As experience with lymphatic mapping
grew, these technical failures declined and
investigators
have
specifically
documented
the ability to reliably identify the SLN in the
setting of prior excisional biopsy. The method
of injection of the tracers may also impact
the ability to find the SLN biopsy, as previ-
ously discussed.
Given the importance of the axillary nodal
status on guiding adjuvant therapy decisions
and the potential benefit of removing nodal
disease early, if a SLN is not identified, a level
I and II axillary lymph node dissection should
be performed. Patients should be warned and
consented for this possibility.
Allergic Reaction to Blue Dye
A rare, but serious, risk of sentinel node biopsy
is the potential allergic reaction to isosulfan
blue or patent blue dye. Allergic reactions to
methylene blue have not been described. This
complication requires rapid recognition and
intervention. Within a few minutes to an hour
following blue dye injection, 1% to 2% of
patients may experience sudden hemodynamic
instability and other sequelae of intraoperative
201
13—REGIONAL MANAGEMENT OF BREAST CANCER

anaphylaxis. It is therefore prudent to alert the
anesthesiologist when beginning the injection
of the blue dye. Although it can be a shocking
moment to have a young healthy woman sud-
denly drop her heart rate and blood pressure,
these episodes are usually readily responsive to
supportive care, which includes discontinuation
of
the
gaseous
anesthetics,
100%
oxygen,
aggressive fluid resuscitation, and pressor sup-
port. In most cases the anesthesia and surgical
procedure can be resumed and completed
uneventfully after the patient has been stabi-
lized. If there is any question, it is not unreason-
able to abandon the procedure, let the patient
recover, and schedule it at a later date using
radiocolloid only. Either way, patients should
be monitored closely for 24 hours because
continued uptake of the blue dye from skin
and soft tissue can result in protracted or
delayed secondary (biphasic) reactions.
Surgeons and anesthesiologists should also
be aware that blue dyes can also cause a spuri-
ous decline in pulse oximetry measurements,
related to intravascular uptake and interfer-
ence with spectroscopy; arterial blood gases
in these circumstances will reveal normal oxy-
genation. Although the impact of the blue dye
should be recognized as the most likely cause,
a sudden drop in pulse oximetry measure-
ments should still prompt verification that
the pulse oximetry is working, the endotra-
cheal tube is in place, and the patient is
ventilating well. A less severe form of allergic
reaction to the blue dye that can occur is
“blue urticaria” or “blue hives.”
Allergic reactions to isosulfan blue dye or
patent blue dye do not seem to correlate with
past allergy history. A history of sulfa allergy
does not preclude the use of isosulfan blue
dye, but a known allergy to triphenylmethane
is a contraindication to blue dye use. It is
believed that prior sensitization from exposure
to industrial dyes in cosmetics, textiles, deter-
gents, and such may be the cause, but preoper-
ative skin testing is unreliable in identifying
high-risk patients. Some anesthesiologists pre-
fer to premedicate patients before the injec-
tion of blue dye with steroids, antihistamines,
or histamine receptor blockade, although the
true benefit of this approach is unknown.
Methylene blue dye does not appear to carry
the same risk of allergic reaction, and there are
several reports that methylene blue dye is just
as reliable as isosulfan or patent blue dye.
However, methylene blue dye does carry a risk
of skin necrosis after dermal injection. If meth-
ylene blue dye is to be used, it should not be
injected intradermally or subareolarly unless
that area will be widely resected (as with a
mastectomy), and it should be diluted with
normal saline before injection (2 ml of methy-
lene blue with 3 ml of saline).
Surgical Complications of Sentinel
Lymph Node Biopsy
As with any incision, the SLN biopsy can be
associated
with
bleeding
(hematoma)
and
wound infection, although both of these are
rare complications. Seroma formation after
SLN biopsy can occur and is readily treatable
by needle aspiration. Other complications of
SLN biopsy are similar to those seen in ALND,
including axillary web formation, neurosen-
sory disturbances, and lymphedema. Although
it is rare, and certainly less common than with
ALND, it is a mistake to believe that SLN biopsy
completely avoids the risk of lymphedema.
Lymphedema rates have been described in as
many of 5% to 7% of SLN biopsy procedures.
Complications of Axillary
Lymph Node Dissection
Nerve Injuries
Nerve injuries can occur during ALND that can
result in a variety of neuropathies (Box 13–6).
The most severe is a brachial plexopathy,
which can occur from direct injury to the bra-
chial
plexus
during
dissection,
or
from
extreme manipulations of the arm during posi-
tioning or during the procedure. This can
result in both numbness and tingling of the
fingers and dysesthesias of the arm. It can also
BOX 13–6 MAJOR COMPLICATIONS
OF AXILLARY LYMPH NODE
DISSECTION
Seroma
Infection
Paresthesia
Chronic pain
Shoulder immobility
Axillary vein thrombosis
Thoracodorsal nerve injury
Long thoracic nerve injury (winged
scapula)
Brachial plexopathy
Arm lymphedema
Breast lymphedema
202
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

cause weakness of the upper extremity, and in
the most severe of cases, paralysis. All of these
are temporary. Physical therapy is helpful in
this situation.
The most common neuropathy comes from
ligation of the intercostobrachial nerve, which
is often done routinely during an ALND
(although it can be preserved). This causes
numbness in the inner side of the upper arm.
Sometimes this is simply an absence of sensa-
tion. Other patients may describe pain similar
to that of a sunburn or a dull ache. The painful
sensations will resolve, although it does take
some time. In severe cases, Neurontin may be
of benefit. When the intercostobrachial nerve
is cut, the size of the anesthetic area may get
smaller with time, although there may always
be some areas without sensation.
Motor nerve injuries are less common with
ALND. Injury to the long thoracic nerve
results in paralysis of the serratus anterior
and the “winged scapula.” This presents as a
posterior shoulder bony protrusion. Patients
will often complain of discomfort sitting up
against a hard surface. Asking the patient to
extend her arms in front of her will exaggerate
the deformity. Often, the nerve is intact but
overstimulation or stretching causes a tempo-
rary paralysis. In this case, return of normal
muscle function (and alleviation of the winged
scapula) will occur in a few weeks. If the nerve
was transected, this will be a permanent
deformity.
The thoracodorsal nerve innervates the latis-
simus dorsi muscle. Atrophy of this muscle
after injury to the nerve will make the tip of
the scapula more prominent. It will also limit
the patients from abducting and internally
rotating the humerus. Patients may notice an
inability to reach posteriorly as high on the
back as before. Injury to the medial pectoral
nerve will deprive the lateral half of the pector-
alis major muscle of innervation. This may not
be noticed by a patient who had breast conser-
vation or reconstruction, but it may detract
from the cosmetic results of a mastectomy.
Cording or Limited Range
of Motion
Cording (axillary web syndrome) can occur after
ALND and is defined as visible cordlike bands in
the chest wall and axilla that may run down the
upper arm. They can sometimes reach as far as
the thumb. These restrict the motion of the
upper arm and can occasionally be tender. The
reported occurrence of cording is between 5%
and 10% after ALND, although neither the true
incidence nor the pathophysiology is well
understood. Cording will eventually resolve in
about 2 months, particularly with physical ther-
apy, which includes passive stretch and soft tis-
sue mobilization. Other patients may have
stiffness and limited range of motion of the
shoulder, without cording or axillary webs.
These patients also often respond rapidly to a
program of exercises and physical therapy.
Lymphedema
The most significant complication of an ALND
is lymphedema of the upper extremity. Approx-
imately 10% to 30% of patients who have an
ALND
will
experience
lymphedema.
This
increases dramatically if the axilla is irradiated
after an ALND. The risk of lymphedema also
increases with obesity and the extent of the dis-
section (Box 13–7). The standard ALND is lim-
ited to levels I and II. A level III dissection is
generally considered unnecessary (unless there
is grossly apparent disease present in the axil-
lary apex) because skip metastases to level III
only occur in 2% to 3% of cases.
The greatest risk of lymphedema occurs
within the first 3 years after surgery; however,
there is a lifelong risk and even a minor trauma
can trigger lymphedema many years after
ALND. Often a precipitating event cannot be
identified. Axillary irradiation alone can cause
lymphedema, as can the regional recurrence of
disease. Any patient who develops lymph-
edema years after ALND should be evaluated
for signs of recurrent disease.
Lymphedema occurs when increased pro-
tein leakage into the interstitial fluid increases
the osmotic pressure and draws more water
into the tissue spaces. Normally, there is a bal-
ance between the hydrostatic pressure and col-
loid osmotic pressure as one goes from the
BOX 13–7 RISK FACTORS FOR
LYMPHEDEMA AMONG PATIENTS
UNDERGOING AXILLARY SURGERY
Extent of surgery
Radiation
Regional recurrence
Infection
Inflammatory diseases (rheumatoid
arthritis, chronic dermatitis)
Venous obstruction
Obesity
Air travel
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13—REGIONAL MANAGEMENT OF BREAST CANCER

arteriole to the capillary and then to the
venule. However, obstruction to the outflow
of lymph (as occurs with ALND) will increase
the leakage of plasma protein into the tissue.
Other factors that accelerate protein leakage
include venous obstruction, injury, infection,
or arteriolar dilation (as with heat or exercise).
Early in its development, lymphedema is
reversible (see Box 13–7). However, untreated
it can progress to fibrosis and nonpitting
edema. Fibroblasts organize the excess pro-
teins within the tissues, and this process can-
not be reversed. Long-standing lymphedema
can result in limited mobility of the arm, bra-
chial plexus stretch injury from the increased
weight, and Stewart-Treves syndrome. This is
one of the most serious long-term sequelae of
chronic lymphedema and describes the devel-
opment of angiosarcoma in the affected arm.
Although frequently referred to as “lymphan-
giosarcoma,” the cancer arises in the endothe-
lial cells of blood vessels, so this term is
technically incorrect. Angiosarcoma of the
involved extremity often presents as bluish-
reddish macular lesions nodules on the skin
of the arm and can be difficult to treat, some-
times requiring amputation of the extremity.
Unfortunately, most patients who develop
angiosarcoma will die of distant disease, with
a median survival of only 2 years.
Given the difficult in treating lymphedema
and the long-term risks, great emphasis is placed
on prevention and early intervention if lymph-
edema
occurs.
Prevention
of
lymphedema
begins with educating the patient on what to
avoid (Box 13–8). Any patient who has had an
ALND will need to minimize the chance of
injury to that extremity for life. The patient
needs to inform all doctors and nurses that they
have had an ALND so that blood pressures, intra-
venous lines, or blood draws can be done on the
opposite arm. The patient should wear protec-
tive clothing (long sleeves or gloves) to avoid
cuts or scratches when gardening or doing
household projects. If a minor injury does occur,
it should be treated promptly with antiseptics.
A compression garment should be worn prophy-
lactically when on an airplane. Extremes in tem-
perature
should
also
be
avoided,
as
with
sunburns, hot tubs or saunas, or reaching into
hot water or ovens and dryers.
Management of Lymphedema
The onset and presentation of lymphedema
may be quite variable. Some patients may have
a
transient
lymphedema
within
the
first
2 monthsof treatment (surgery orradiation) that
resolves on its own. Other patients may go
months to years without any signs or symptoms
of lymphedema, and then notice its onset after
air travel, excessive use of the arm, minor
trauma, or sitting in a hot tub. Other triggers
include venipuncture or cellulitis. In some cases
this may be reversible, or at least manageable,
whereas in others, the disease will progress to
a morbid and irreversible situation (Box 13–9).
Patients with lymphedema may have symp-
toms of lymphedema before the onset of a
notable swelling. These may include a sensa-
tion of fullness or heaviness of the arm. When
swelling does occur, it may occur anywhere in
the upper extremity. It may start in the hand
BOX 13–8 RECOMMENDATIONS
AFTER AXILLARY LYMPH NODE
DISSECTION TO MINIMIZE
LYMPHEDEMA

Use the opposite arm for
intravenous catheters, blood draws,
injections, or blood pressure
measurements. Always inform all
doctors and nurses that you have had
a lymph node dissection on that side.

Avoid cuts, scratches, or burns to your
hand and arm by wearing long sleeves
and/or gloves when doing cooking,
gardening, household projects, etc. If
you do cut yourself, wash immediately
with soap and water and apply an
antiseptic. Notify your physician of any
redness or swelling.

Do not wear tight or constricting jewelry
or clothing. Bra straps should be wide,
padded, and not cut into the skin.

Avoid heavy lifting with that arm. Try
not to carry a purse or suitcase on that side
when possible. Avoid repetitive heavy
lifting in particular, and wear a
compression sleeve if lifting is necessary.

Avoid sunburn of the arm by wearing
long sleeves and sunscreen.

Do not pick at cuticles or hangnails.

Use insect repellents.

Avoid high temperatures (saunas or hot
tubs, reaching into hot ovens or clothes
driers).

Shave under the arm with an electric
razor rather than a blade.

Wear a compression sleeve on the arm
when traveling on an airplane.

Maintain an ideal body weight.
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SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

or forearm and then progress up the arm, or it
may begin in the upper arm or trunk. Left
untreated, lymphedema can cause multiple
adverse effects.
Lymphedema is typically not painful, but it is
associated with uncomfortable feelings such as
the arm being “achy,” “heavy,” or “tight.” The
most common consequence of lymphedema is
limited range of motion of the upper extremity.
Depending on the location and severity of the
swelling, this can involve any of the joints of
the arm. Lymphedema can be particularly hard
on the shoulder joint as a result of the increased
weight of the arm and the traction it places on
the joint. This can lead to tendonitis or bursitis.
Patients with lymphedema have an increased
risk of developing cellulitis or erysipelas (a super-
ficial cellulitis with lymphatic vessel involve-
ment). This can begin as a few red blotchy areas
that spread and coalesce and trigger fever, chills,
and myalgias. Management of cellulitis requires
rest, elevation, and antibiotics. The most com-
mon organism associated with cellulitis in
patients with lymphedema is Streptococcus pyo-
genes (Group A b-hemolytic strep). Less common
are Staphylococcus aureus, Escherichia coli, and
Pseudomonas. If the case is mild, oral antibiotics
are appropriate; however, a severe infection or
signs of systemic disease should prompt admis-
sion and intravenous antibiotics. Patients who
are prone to recurrent episodes of cellulitis may
require prophylactic antibacterial therapy. The
most worrisome consequence of chronic lymph-
edema is the development of an angiosarcoma of
the involved extremity (Stewart-Treves syn-
drome). Any new blue or reddish blue nodules
on the arm that grow rapidly and bleed easily
should be biopsied.
Risk Reduction
Because lymphedema is difficult to manage and
the consequences can be dramatic, significant
energy is placed on risk reduction. Several pre-
cautions should be explained to patients who
have undergone ALND to reduce the risk of
both infection and any increased lymphatic
load in the extremity (Table 13–4). These are
lifelong
recommendations
because
lymph-
edema can occur decades after the surgery. It is
also
important
that
these
precautions
be
described to the patient before undergoing an
ALND so that patients may make truly informed
decisions regarding the risks and benefits of
ALND. It is not adequate to simply explain that
lymphedema may occur as a risk of the proce-
dure because all patients undergoing the surgery
will need to make these lifestyle changes to
reduce their risk.
Because even transient infections or mild cel-
lulitis can incite lymphedema, patients are cau-
tioned against behaviors that may result in
nicks or cuts. These include cutting cuticles, or
gardening or other hobbies without gloves or
long sleeves. Mild burns can occur with cooking
or ironing, so care should be taken. Sunscreen
should be used to avoid sunburns and insect
repellent used to avoid bug bites. Increased tem-
peratures for extended periods of time, such as
occurs with hot tubs or saunas, can lead to an
increased lymphatic load and should also be
avoided. Air travel has been associated with
the onset of lymphedema, presumably from
the lower cabin pressure, dehydration, and sta-
sis. Most reported cases have been on longer
trips, and the swelling occurs while they are
TABLE 13–4  International Society of
Lymphology Staging of Lymphedema
Stage
Description
Severity
based on
limb
volume
0
Lymphostasis: A
subclinical condition in
which swelling is not
evident despite impaired
lymph transport.
None
I
An early accumulation of
fluid relatively high in
protein content. Edema
decreases with elevation.
Pitting may occur.
Minimal
(<20%
increase)
II
Edema that does not
significantly reduce with
elevation. In late stage II
the tissues are
increasingly fibrotic.
Moderate
(20% to
40%
increase)
III
Lymphostatic
elephantiasis: Pitting is
absent, and there are
trophic changes
(acanthosis, fat deposits,
verrucous hyperplasia).
Severe
(>40%
increase)
BOX 13–9 SYMPTOMS ASSOCIATED
WITH EARLY LYMPHEDEMA

Pain, dull aching

Tightness

Stiffness or limited range of motion

Heavy feeling

Decreased strength
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13—REGIONAL MANAGEMENT OF BREAST CANCER

on the plane. It is therefore recommended that
any patient who has had an ALND should wear
a 20 to 30 mm Hg upper extremity support gar-
ment from departure to destination when fly-
ing.
In
addition,
patients
should
remain
adequately hydrated and move around during
the flight.
Several studies have shown that an increased
body mass index (BMI) among patients under-
going ALND is associated with an increased risk
of lymphedema. Clearly, patients should be
counseled on the importance of maintaining a
healthy weight after surgery. Patients who are
already overweight should be encouraged to lose
weight, although this is a challenge in the
patient with breast cancer. Many women actu-
ally gain weight during their adjuvant chemo-
therapy for breast cancer. However, increased
exercise, weight loss, and decreased fat intake
have been associated with a decrease in breast
cancer recurrence and improved survival, so this
should be strongly encouraged. In women who
are overweight and who do develop lymph-
edema, weight loss should be a critical part of
their treatment. Essential to weight loss is exer-
cise, however, there is some concern that vigor-
ous, repetitive exercises of the at-risk extremity
may cause lymph overload and result in lymph-
edema. The literature is mixed on this subject.
Treatment
Women who develop upper extremity swelling
should
be
thoroughly
evaluated
for
both
regional recurrence and deep vein thrombosis
because this may be the cause of a sudden
onset of lymphedema. Diagnostic studies such
as venous Doppler ultrasonography, computed
tomography (CT) scan, or magnetic resonance
imaging (MRI) may be helpful. Lymphoscinti-
grams are rarely necessary.
The
degree
of
lymphedema
should
be
measured and documented, although there are
multiple methods for doing so. Subjective
reports by the patient or semiobjective reports
by the physician are unreliable. The simplest
method is to perform circumferential measure-
ments. There is some normal variation between
the two arms, and the degree of lymphedema
may be underestimated in a woman who is
obese or overestimated in a woman who is thin.
However, this is inexpensive and easily per-
formed on each physical examination. The
upper and lower arms should be measured,
and the measurement should be performed
10 cm above and below the crease of the elbow
to assure the same area is measured each time.
Arm volume can also be measured by the
water displacement method. Although this is
more accurate than circumferential measure-
ments (with a volume difference of 200 ml or
more between the two arms considered lymph-
edema), it is not easily performed in an office
setting, especially on every visit.
Once lymphedema has been identified, early
treatment is recommended. This should be
done by physicians with expertise in the area.
As lymphedema can not typically be reversed,
and the anatomic changes can not be corrected,
the goal of treatment is to control swelling of
the arm. The most common approach uses a
combination of massage, exercise, external
pressure, and physical therapy. The physical
therapy departments associated with most
major cancer centers typically have a dedicated
lymphedema program, and prompt referral is
recommended.
The mainstay of treatment is the graded
compression garment. These elastic lymph-
edema sleeves can deliver pressures of 20 to
60 mm Hg, and the pressure decreases as one
moves proximally, encouraging edema mobili-
zation. Depending on the symptoms and
degree of lymphedema, these can be worn 24
hours a day or only when awake or when the
arm is in use. The garments do lose their elas-
ticity over time and will need to be replaced
every 4 to 6 months.
A specific form of upper extremity massage,
known
as
manual
lymphedema
drainage
(MLD), may be of benefit, although the results
of randomized controlled trials are mixed. The
technique uses light pressure to move fluid
from distal to proximal. It should be per-
formed by a trained practitioner. Massage
should be avoided if there is concern of active
infection or active neoplasm. These should be
ruled out first, along with the possibility of
an acute deep venous thrombosis.
More severe cases of lymphedema may require
external pneumatic compression or complex
physical therapy. Intermittent or sequential
pneumatic
compression
can
be
achieved
through the use of a plastic sleeve that is inflated
sequentially by pumps in a distal to proximal
direction. These must be used in combination
with the other techniques if they are to be
effective. As with massage, they should be
avoided in the face of active injection, cancer,
or thrombosis.
Complex physical therapy is a complicated
combination of preventative care, compression
wrapping, and manual lymphedema treatment.
It should be initiated in any woman not
206
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

responding to standard elastic compression
therapy and needs to be coordinated by a dedi-
cated multimodality lymphedema program.
Other therapies, such as diuretics, antibiotics,
anticoagulants, laser therapy, and surgery have
not been proven to be effective and are not
recommended unless being used to treat a
specific cause or complication of lymphedema.
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node in breast cancer: A Multicenter Validation
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16. Mamounas EP, Brown A, Smith R, et al. Accuracy of
sentinel node biopsy after neoadjuvant chemother-
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14
Principles of Breast
Reconstruction
TYPES OF BREAST
RECONSTRUCTION
Expander/Implants
Reconstruction with Autolo-
gous Tissues
The Skin-Sparing Mastectomy
Nipple and Areolar
Reconstruction
TIMING OF BREAST
RECONSTRUCTION
Breast Irradiation and
Reconstruction
Sentinel Node Biopsy and
Reconstruction
ONCOPLASTIC APPROACHES TO
LUMPECTOMY
Principles of Breast Reconstruction: Key Points
Describe the reconstruction options patients have after
mastectomy.
Know the implications of postmastectomy radiation therapy on breast
reconstruction and the pros and cons of delayed versus immediate breast
reconstruction.
Be familiar with the techniques used for free and pedicled transverse rectus
abdominis myocutaneous flaps and the deep inferior epigastric perforator
flap.
Understand other forms of free flaps for breast reconstruction.
Describe the technique used for a skin-sparing mastectomy.
Understand oncoplastic approaches to performing a lumpectomy.
The goals of the surgical therapy of breast can-
cer include not only local control of the tumor
and accurate surgical staging of disease, but
also the restoration of an acceptable cosmetic
outcome. Although breast-conserving surgery
has significantly improved the aesthetic result
after breast cancer therapy, numerous women
still undergo mastectomy. Many of these women
will opt for breast reconstruction. It is becoming
increasingly apparent that breast reconstruction
can improve the psychosocial well-being and
quality of life of the patient. Despite early
209

concerns, breast reconstruction does not delay
adjuvant therapy, increase the risk of local recur-
rence, or impact the ability to detect recurrence.
Breast reconstruction has also been aided by
advances on the health policy front. In 1998,
Congress passed the Women’s Health and Can-
cer Rights Act (WHCRA), guaranteeing insur-
ance reimbursement for breast reconstruction
or external prostheses, contralateral procedures
for symmetry, and treatment for any sequelae
of mastectomy.
There are several options for reconstruction,
and the most appropriate choice and timing of
reconstruction must be balanced with the
need for adjuvant systemic therapy and post-
mastectomy radiation. It is imperative that
the desire for the best possible cosmetic out-
come not supersede the patient’s oncologic
treatment or carry unnecessary risk. The opti-
mal management in this situation requires a
collaborative effort between breast and recon-
structive surgeons, radiologists, pathologists,
and radiation and medical oncologists.
Types of Breast
Reconstruction
Breast reconstruction can be divided into two
categories according to the material used to re-
create the breast: autologous tissue or pros-
thetics (Table 14–1). Autologous methods use
tissue flaps. There are many types of flaps avail-
able (Box 14–1). These can be pedicled flaps, in
which the tissue is rotated on the vascular sup-
ply, or free flaps, which involve a microsurgical
vascular anastomosis. The most commonly
used is the transverse rectus abdominal myo-
cutaneous (TRAM) flap. This tends to give the
best cosmetic result with the fewest complica-
tions. Prosthetic methods of reconstruction
involve the use of implants—either saline or
silicone. Often the patient has the implantation
of a temporary tissue expander, followed by
placement of a permanent implant.
Expander/Implants
Breast reconstruction can be obtained with
either a silicone gel or saline-filled implant.
Using implants for reconstruction is techni-
cally easier, requiring less experience on the
part of the plastic surgeon. The initial recovery
is also easier for the patient, making implant-
based reconstruction an excellent choice for
older patients and those with comorbidities,
who may not be able to tolerate the longer
time under general anesthesia.
Implants can be placed immediately after a
mastectomy, without the use of expanders,
although this is not common. This simple
technique requires skin flaps that can suffi-
ciently cover the implant, and this is not typi-
cal. There is also an increased risk of skin
necrosis secondary to the tension. It is prefera-
ble to place implants beneath the pectoralis
major muscle, in the submusculofascial space,
rather
than
directly
underneath
the
skin
because there is increased soft tissue coverage
over the foreign material. However, it is the
rare woman who after a mastectomy has
enough laxity to the pectoralis muscle to allow
for an implant large enough to equal the size
of their breast. It is typically not possible to
insert an implant greater than 300 ml and pro-
vide adequate coverage. So unless the woman
is an A or B cup or wants to undergo a reduc-
tion mammoplasty at the time of her recon-
struction, the use of a tissue expander is
necessary. In general, implant placement with-
out tissue expansion is discouraged.
Instead, most patients will undergo tissue
expansion followed by permanent implant
TABLE 14–1
Relative Advantages
of Autologous versus Prosthetic
Reconstruction
Autologous
Reconstruction
Prosthetic
Reconstruction
No foreign material
Less complex surgery
Improved cosmesis
Less expensive
Natural aging of breast
Quicker postoperative
recovery
Less subsequent
revisions necessary
Color match
Intact sensation
Less scarring and no
donor site defect
BOX 14–1 AUTOLOGOUS TISSUE
FLAPS USED FOR BREAST
RECONSTRUCTION


Transverse rectus abdominis
myocutaneous (TRAM) flap


Latissimus dorsi myocutaneous flap


Inferior and superior gluteal flaps


Lateral transverse thigh flap


Taylor-Rubens periiliac flap
210
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

placement. For the tissue expander, a balloon-
like expander is placed beneath the pectoralis
major
muscle
following
the
mastectomy.
Intraoperatively, the goal is to provide com-
plete coverage of the expander so that the
implant is protected should the skin break
down. If there is any question that the skin is
at an increased risk of necrosis secondary to a
compromised vascular supply, expander place-
ment should be delayed. This underscores the
importance of the surgeon in not devasculariz-
ing the skin while creating the skin flaps. In
addition, it may be necessary for the plastic
surgeon to raise the lateral portion of the serra-
tus anterior and possibly the superior aspect of
the rectus abdominis muscle to provide com-
plete soft tissue coverage, and injury to these
structures during removal of the breast may
also compromise the ability of the plastic sur-
geon to perform an immediate expander place-
ment (Fig 14–1).
Over the next 2 months, saline is intermit-
tently injected into the expander to enlarge it
and stretch the overlying skin and muscle
(Fig 14–2) This is typically done once a week.
The volume injected depends on patient com-
fort and the tightness of the skin. Once this
has been accomplished (usually the expander
is overexpanded by about 25% to improve
the skin drape over the implant) and main-
tained long enough to become permanent
(4 to 6 months), the patient returns to the
operating room for removal of the expander
and placement of a permanent implant, either
silicone gel or saline (Fig 14–3). Although
silicone-gel implants have a more natural
feel to them, there is a higher risk of capsular
contracture. There is always some degree of con-
tracture around the implant; however, when
this is severe, the breast can become hard and
painful. There are also heightened concerns
among patients regarding silicone leaks. For
these reasons, many surgeons and patients
prefer saline implants.
Complications include hematoma, seroma, or
the need to remove the expander or implant for
exposure, infection, malposition, or leak. Long-
term complications can include capsular con-
tracture, implant deflation, and visible wrinkling
of the implant (especially in thin women).
There
are
several
disadvantages
to
the
expander/implant. Although it requires the
least amount of initial surgery and less overall
operative time, it does require weekly visits
and a second surgery several months down the
Figure 14–1. Transection of the pectoralis major for
placement of the tissue expander. The plastic sur-
geon will create a pocket for the tissue expander
under the pectoralis major muscle and may need to
use the serratus anterior or rectus abdominis to pro-
vide complete soft tissue coverage. Injury to these
structures
during
mastectomy
may
compromise
that, precluding expander placement. (From Roses D.
Breast cancer. Philadelphia: Elsevier, 2005).
Figure 14–2. The expander is overexpanded by
about 25% to improve the skin drape over the implant
and maintained long enough to become permanent
before the patient returns to the operating room for
removal of the expander and placement of a perma-
nent implant. (From Roses D. Breast cancer. Philadel-
phia: Elsevier, 2005).
211
14—PRINCIPLES OF BREAST RECONSTRUCTION

road. Even the best contoured breast implants
are rarely able to completely match the curves
of the natural breast, and while the other breast
changes over time, the implant side will remain
unchanged, leading to an increasingly notice-
able difference. The implant also will not move
like the opposite breast, remaining upright
when the woman lies down. Although the sym-
metry is often corrected by wearing a bra, many
times surgery on the opposite breast will be nec-
essary. This may involve a lift to decrease the
ptosis or improve fullness in the upper aspect
of the breast or a reduction so that a smaller
implant can be used.
Reconstruction with Autologous
Tissues
Although implant breast reconstruction remains
the most common method for reconstructing
the breast, there are problems previously des-
cribed (capsular contracture, migration of the
implant) and the difficulty in achieving a ptotic
breast mound that matches the opposite breast.
Reconstruction with autologous tissue solves
some of these problems by reconstructing the
breast with the patient’s own tissues. The breast
is softer and more natural than a breast recon-
structed with an implant, and rather than
deteriorating with time (as implant-based recon-
structions usually do), they tend to improve.
A successful breast reconstruction with autolo-
gous tissue often looks, moves, and feels much
like a real breast.
Although
the
initial
surgical
procedure
required to reconstruct a breast with autolo-
gous tissue is much longer and more compli-
cated than that required for implant-based
reconstruction, subsequent surgical procedures
are simpler, shorter, and less frequent. Thus,
there are several advantages to autologous
tissue breast reconstruction when that option is
available. Several methods for reconstructing the
breast using autologous tissue are available.
Transverse Rectus Abdominis
Myocutaneous Flaps
The first successful method of breast reconstruc-
tion was the pedicled TRAM flap. The TRAM flap
is based on the dual blood supply to the rectus
abdominis muscle, allowing for either a pedicled
TRAM based on the superior epigastric system
or a free flap based on the inferior epigastric
(Fig 14–4). The pedicled TRAM involves remov-
ing a wide ellipse of skin and fat from the lower
abdomen left attached to one of the two rectus
abdominis muscles. The flap is then tunneled
between the abdominal dissection and the mas-
tectomy defect, maintaining its blood supply
from the superior epigastric artery and vein.
The abdominal defect is closed primarily, and
the flap is shaped to form the breast mound.
Patient selection
is extremely important
when determining whether a TRAM flap is
appropriate. The ideal candidate is a generally
healthy patient without significant medical
comorbidities. Patients with medical problems
that increase the risk of the additional operative
time required for autogenous reconstruction
Figure 14–3. The expander is removed, and a per-
manent implant is placed beneath the pectoralis
major muscle. (From Bland K, Copeland E. The breast,
3e. Philadelphia: Elsevier, 2004.)
Intercostal
perforators
Intercostal a.
Lumbar a.
*Superficial
epigastric a.
*Superficial
circumflex
iliac a.
*External
pudendal a.
Epigastric
perforators
Superior
epigastric a.
*Inferior axial
vessels
Figure 14–4. Blood supply to the rectus abdominis
muscle and overlying skin. (From Bland K, Copeland E.
The breast, 3e. Philadelphia: Elsevier, 2004.)
212
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

are a relative contraindication to a TRAM flap.
The patient’s body habitus and expectations
regarding the size of the reconstructed breast
are important considerations. They should nei-
ther be too thin or more than moderately obese.
Patients without an adequate amount of lower
abdominal soft tissue to reconstruct one or both
breasts would be poor candidates. The biggest
risk of the pedicled TRAM flap is loss of the flap
secondary to an insufficient blood supply.
Patients with comorbidities that compromise
the blood supply (diabetes, heart disease, signif-
icant obesity, and smoking) are poor candidates
for a pedicled TRAM. In these patients, either an
implant reconstruction should be considered or
the patients should undergo a free-flap TRAM
because this technique provides for better skin
island perfusion.
The donor site can be a source of problems for
patients. Patients can have postoperative abdo-
minal weakness, bulging, or hernia, although
these risks are low. Patients who are active phy-
sically may be better served by a free-flap mus-
cle-sparing technique so as to limit the donor
site impact.
Pedicled Transverse Rectus Abdominis
Myocutaneous Flap Procedure
In the preoperative area, the patient should be
marked while in the upright position. Particu-
larly important is the inframammary line. For
the breast surgeon, this defines the lower limit
of the dissection, however sometimes during a
mastectomy, this may become detached. If this
occurs, the plastic surgeon must reestablish this
important aesthetic landmark or risk asymme-
try of the breasts. The incision on the breast is
marked out as either a standard mastectomy
incision, or better yet, a skin-sparing incision.
The general boundaries of the breast are also
generally marked. The transverse skin island
of the TRAM flap is marked out over the lower
abdomen, encompassing as much redundant
tissue as is available. A midline mark is made
from above the umbilicus, through the TRAM
skin island, and onto the pubis. This helps to
close the defect symmetrically.
After the patient is placed under general
anesthesia, he or she is positioned with each
arm extended and secured. The patient should
be positioned and secured on the table so he or
she may be sat straight up. A lower extremity
warming blanket is placed after insertion of
a Foley catheter. The entire chest and abdo-
men is prepped and draped into a single oper-
ative field. It is possible, and desirable, that a
two-team approach is used, so that the breast
surgeon performs the mastectomy at the same
time that the plastic surgeon is working on the
TRAM flap.
The skin island is dissected to the first row
of both medial and lateral perforators, preserv-
ing a lateral and medial band of muscle and
fascia. The anterior rectus fascia is divided
up to and over the costal margin, and then
dissected off of the rectus abdominis muscle
medially and laterally. This preserves the en-
tire rectus fascia from the costal margin to
the superior edge of the fascial defect for the
skin island. Although the pedicled TRAM flap
will be based on the superior epigastrics, it is
a wise idea to dissect out the inferior epigas-
trics with the flap and ligate them distally. Pre-
serving them allows for providing additional
blood flow (supercharging) should the skin
island appear compromised at the completion
of the case. Once this is done, the inferior
portion of the rectus abdominis muscle is
divided with electrocautery, and the muscle
is dissected off of the peritoneum and poste-
rior rectus sheath. The muscle is freed to the
costal margin and then transpositioned into
the mastectomy defect (Fig 14–5). At this
point, the skin island should be observed for
a few minutes to look for evidence of venous
congestion or poor arterial perfusion. If pres-
ent, it is possible to anastomose the inferior
epigastrics to the thoracodorsal system to pro-
vide additional blood flow.
The fascial incision in the upper anterior rec-
tus fascia can be primarily repaired and an inlay
mesh used to repair the defect from the flap
harvest. The abdominal skin is reapproximated
with replacement of the umbilicus. The patient
is then repositioned upright, and the TRAM
flap modeled so that it matches the contralat-
eral breast. The final step is to deepithelialize
the buried portion of the TRAM skin island
and approximate the skin incisions.
If there is concern preoperatively about the
blood supply to the pedicled TRAM flap, it is
reasonable to take the patient to the operating
room 1 to 2 weeks before the TRAM reconstruc-
tion to divide the blood vessels that enter the
flap from below. Dividing the inferior epigas-
tric vessels will encourage the superior epi-
gastrics to be come larger. This is effective in
reducing the risk of vascular insufficiency to
the flap. Although it requires an additional
minor procedure, it may be combined with a
sentinel lymph node (SLN) biopsy in patients
with clinically node-negative cancer. In this
manner, it is known at the time of the
213
14—PRINCIPLES OF BREAST RECONSTRUCTION

definitive operation whether an axillary lymph
node dissection (ALND) is necessary, which
helps avoid a return to the operating room for
a lymph node dissection in a patient who has
already undergone reconstruction.
Free Transverse Rectus Abdominis
Myocutaneous Flaps
The free TRAM flap gets its blood supply from
below, from the deep inferior epigastric vessels
(Fig 14–6). This requires the division and
microsurgical reanastomosis of these vessels.
The main disadvantage of this approach is
the total dependence of the flap on the anasto-
mosed blood vessels. Should they become
obstructed, the entire flap will die. In experi-
enced hands, however, this occurs less than
2% of the time. If done correctly, however,
there are several advantages to the free TRAM
flap. The blood supply is stronger and less
likely to cause partial flap loss or fat necrosis.
Less of the rectus abdominis muscle needs to
be sacrificed so that there is less postoperative
pain and abdominal wall weakness. The aes-
thetic results tend to be better because the
strong blood supply allows for more aggressive
shaping of the flap.
The
patient
is
marked,
positioned,
and
prepped as previously described. The plastic
surgeon must decide where the inferior epigas-
trics will be anastomosed to. For patients
undergoing a simple mastectomy (with or
without SLN biopsy), or when this is done as
a delayed flap in a patient who already had
an ALND, the internal mammary vessels are
usually selected. If the patient is having an
immediate reconstruction and an ALND is to
be performed, the thoracodorsal vessels are
often chosen.
In the case of a free TRAM flap, the inferior
epigastrics are divided near their attachment
to the external iliacs. Both the superior and
inferior muscle is then divided and the entire
flap is moved to the chest site, where the
I
II
III
IV
I
II
III
IV
Figure 14–5. The transverse rectus abdominis myocutaneous flap rotation. A, Contralateral technique.
B, Ipsilateral technique. (From Bland K, Copeland E. The breast, 3e. Philadelphia: Elsevier, 2004.)
Figure 14–6. The blood supply to the free trans-
verse rectus abdominis myocutaneous flap is based
on the deep inferior epigastric vessels. (From Roses
D. Breast cancer. Philadelphia: Elsevier, 2005).
214
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

vascular anastomosis is performed. This can
be done with either surgical loupes or the
operating microscope. Once complete, the ves-
sel clamps are removed and the flap assessed
for anastomotic patency. The flap tissue is tem-
porarily attached to the chest wall so that it
does not move and disrupt the anastomosis
while the abdominal defect is closed. Once
that is completed, the patient is placed in the
upright position and the flap modified appro-
priately. After removing the skin that would
be buried under the natural skin and reapprox-
imating the skin, it is wise to identify and
mark a site on the exposed portion of the
flap where a surface arterial Doppler signal is
present. This is then used for postoperative
monitoring.
After a TRAM flap, patients are transferred
directly to their hospital bed and kept in a
semi-Fowler position to limit the tension on
the abdominal donor site. Close observation
is used in patients who had a free TRAM flap,
with frequent checking of the arterial Doppler
signal (every 30 minutes for the first 24 hours,
every hour on day 2, every two hours on day
3 and then every 4 hours until discharge).
The Foley catheter remains in place for 24 to
48 hours. Patients typically are discharged
on postoperative day 3 to 5. Drains can be
removed before discharge depending on their
output. At home, patients should avoid lifting
anything greater than 10 lbs or do anything
more athletic than walking. These restrictions
are maintained for 6 weeks.
Deep Inferior Epigastric Perforator and
Superficial Inferior Epigastric Artery
(Perforator) Flaps
A new method of autologous breast recon-
struction is the deep inferior epigastric perfora-
tor (DIEP) flap. The skin and fat island are the
same as the TRAM flap, but the perforating
blood vessels are dissected through the rectus
abdominis muscle so that the muscle can be
left behind (Fig 14–7). By not sacrificing the
muscle, the patient has less postoperative pain
and a stronger abdominal wall. The main dis-
advantages of this flap are the technical com-
plexity and an increased risk of partial flap
loss and fat necrosis as a result of a somewhat
reduced blood supply. It is prudent to reserve
the DIEP flap for patients who will not require
the entire flap to reconstruct the breast. Con-
traindications to the DIEP flap are a history
of abdominoplasty or abdominal liposuction,
active smoking, or previous large transverse
or oblique abdominal incisions.
It is often preferable to use the contralateral
abdomen because it is easier to inset the flap.
The setup is similar as with a standard TRAM
flap, but in addition to the standard preopera-
tive markings, a Doppler probe is used to iden-
tify the main perforators of the medial and
lateral branches of the deep inferior epigastric
artery and the superficial inferior epigastric
artery (SIEA). The internal mammary artery
(IMA) and internal mammary vein (IMV) are
the preferred recipient vessels, although the
thoracodorsal vessels may be used as well.
The superior and inferior skin incisions are
made and the superficial inferior epigastric
vessels are identified. If the vessels are large
enough, then an SIEA flap can be performed.
The SIEA flap is preferable because there is less
donor-site morbidity because no incision must
be made in the abdominal fascia and no dis-
section performed through the rectus abdomi-
nis muscle. Unfortunately the SIEA is not
always present, and often when it is present,
it is not large enough. However, if it does have
sufficient caliber, it is followed down to its ori-
gin from the common femoral artery and
saphenous vein. The flap can be raised without
opening the rectus abdominis fascia and trans-
ferred to the mastectomy defect.
More commonly, the SIEA is not adequate,
and a DIEP flap will be necessary, but the ves-
sels should still be dissected free for several
centimeters to be used as a backup. The skin
island is carefully elevated from lateral to
Skin flap
Arcuate line
Rectus
muscle
Rectus
sheath
Perforator arteries
Deep inferior epigastric artery
Rectus
muscle
Perforating artery
Scarpa’s fascia
Subdermal plexus
Figure 14–7. Mobilization of the deep inferior epi-
gastric perforator flap. (From Roses D. Breast cancer.
Philadelphia: Elsevier, 2005).
215
14—PRINCIPLES OF BREAST RECONSTRUCTION

medial until the lateral row of perforators is
encountered. These are dissected and included
with the flap. The medial row is approached
in a similar fashion. As many perforators in
the same row that can be preserved should
be, as often more than one perforator may
be necessary to perfuse the flap if there is
not one dominant perforator. Once the per-
forators are chosen, the anterior rectus sheath
is opened around these vessels and they are
dissected down through the muscle to the
deep inferior epigastric artery and vein. The
muscle is spread apart in the direction of the
fibers to expose the vessels. This dissection
requires high-power loupe magnification and
careful
microsurgical
technique
and
con-
tinues until the pedicle is of sufficient length
(typically 8 to 10 cm). The artery and veins
are ligated, and then the flap is transferred
to the anterior chest wall. With great care
not to twist or kink the vessels (this is aided
by marking the anterior surface of the ves-
sels), temporary stay sutures are placed in
the flap and the operating microscope is used
to anastomose the vessels. An anastomotic
coupling device may be used to connect the
veins. If an SIEA flap is being performed, it
may be preferable to anastomose the vessels
to smaller perforating branches of the inter-
nal mammary vessels to better match the size
between the flap and recipient vessels.
Once the surgeon is sure that the flap is well
perfused and not congested, the abdomen is
flexed so that the wound can be closed. Mesh
is not used, the abdominal fascia is closed pri-
marily and then the skin. The flap is inset and
sutured in place similar to the standard TRAM
flap.
Extended Latissimus Dorsi Flaps
Another alternative for patients who are not
good
candidates
for
a
TRAM
flap
is
the
extended latissimus dorsi flap (Figs. 14–8,
14–9). In this flap, the standard latissimus
dorsi flap is modified so that additional skin
and fat are removed from the back and trans-
ferred to the chest. The donor site on the back
is more scarred than after a standard latissimus
dorsi flap, but in many cases, the breast can
be reconstructed without an implant. The
breasts are therefore softer than after a stan-
dard latissimus dorsi reconstruction, and the
risk of capsular contracture is avoided.
The main advantage of this flap over a TRAM
flap is that it is a simpler technique and can be
used in less healthy patients who might not be
good enough surgical candidates to have a
TRAM flap. It is therefore particularly indicated
in
obese
patients
and
in
older
patients.
Although poor surgical candidates should not
have any reconstruction, some patients who
are not healthy enough to undergo a TRAM
flap are acceptable candidates for an extended
latissimus dorsi flap. This flap is also a reason-
able choice for healthy patients who cannot
have a TRAM flap because they have had a pre-
vious TRAM flap or abdominoplasty. Patients
in this category may also be good candidates
for a gluteal free flap. The choice between these
donor sites is usually made after considering
the relative laxity of tissues in the back versus
the buttock in each individual and patient
preference.
Gluteal Artery Perforator Flaps
The gluteal artery perforator (GAP) flaps are
good choices for autologous reconstruction in
women who have more skin and fat available
Surperior
border of
latissimus
dorsi muscle
Tip of
scapula
Position
of skin
island
Anterior
border of
latissimus
dorsi muscle
Figure 14–8. Skin and fat are removed from the
back along with the latissimus dorsi muscle. (From
Bland K, Copeland E. The breast, 3e. Philadelphia:
Elsevier, 2004.)
216
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

in the buttock area than in the abdomen.
Donor site morbidity is minimal and no mus-
cle must be sacrificed. The GAP flaps may be
based on either the superior gluteal artery per-
forator (S-GAP) or inferior gluteal artery perfo-
rator (I-GAP).
Superior Gluteal Artery Perforator Flap
The S-GAP flap is taken from the buttock and
is based on the superior gluteal artery, which
arises from the internal iliac artery and exits
the pelvis superior to the piriformis muscle
(Figs. 14–10, 14–11). It enters the gluteus
maximus muscle approximately one third of
the distance along the line between the poste-
rior superior iliac spine and the greater tro-
chanter. The S-GAP flap requires no muscle
to be sacrificed because the flap is only skin,
fat, and blood vessels. It is more difficult than
a TRAM flap because the gluteal tissue is
harder to shape into a breast, but is an excel-
lent choice for patients who cannot undergo
a TRAM but are otherwise good surgical
candidates.
Figure 14–10. The superior gluteal artery perfora-
tor flap is based on the superior gluteal artery. (From
Roses D. Breast cancer. Philadelphia: Elsevier, 2005).
Figure 14–11. In the superior gluteal artery perfo-
rate flap, the superior gluteal artery is anastomosed
to the internal thoracic artery. (From Roses D. Breast
cancer. Philadelphia: Elsevier, 2005).
Suture
to the
pectoralis
major
muscle
Suture
to the
lateral
edge of
the
sternum
Suture
to the
serratus
anterior
muscle
Latissimus dorsi
myocutaneous flap
Figure 14–9. The extended latissimus dorsi flap is
passed anteriorly through the axilla. (From Bland K,
Copeland E. The breast, 3e. Philadelphia: Elsevier,
2004.)
217
14—PRINCIPLES OF BREAST RECONSTRUCTION

Preoperatively the patient is marked first in
the lateral position, using the Doppler probe
to identify the perforating vessels from the
superior gluteal artery. The skin paddle is then
marked in an oblique pattern from inferome-
dial to superolateral so that these perforators
are included. The S-GAP flap has a short pedi-
cle, and so anastomosis to the internal mam-
mary vessels is preferred.
The patient is placed in the lateral decubitus
position. The internal mammary vessels are
prepared as previously described. The flap is
divided down to the gluteus maximus, with
significant beveling to ensure adequate tissue
for reconstruction. The flap is elevated from
the muscle in the subfascial plane and the per-
forators approached from lateral to medial. If
present, a single large perforator is preferable,
but sometimes multiple perforators in the
same plan can be taken together. The muscle
is spread in the direction of the fibers to allow
dissection of the perforating vessels until the
artery and vein are of sufficient length and
diameter to be anastomosed. The patient is
repositioned supine and the microvascular
anastomosis is performed.
Inferior Gluteal Artery Perforator Flap
The I-GAP flap is taken from the lower buttock
and is based on the inferior gluteal vessels
(Fig 14–12). It requires sacrifice of a small
amount of the gluteus maximus vessels. Like
the S-GAP flap, it is more difficult than a TRAM
but indicated in patients who cannot have a
TRAM flap yet are otherwise good surgical can-
didates. The inferior gluteal artery is a branch of
the internal iliac artery and leaves the pelvis
through the greater sciatic foramen. The artery
is accompanied by the greater sciatic nerve,
internal pudendal vessels, and posterior femo-
ral cutaneous nerve. Because the inferior gluteal
vessel is more oblique through the gluteus max-
imus muscle than the superior gluteal artery,
the length of the I-GAP pedicle is typically lon-
ger than the S-GAP and can be anastomosed to
the thoracodorsals if the internal mammary
vessels are not an ideal choice.
Figure 14–12. The inferior gluteal free flap uses tissue from the lower buttock and is based on the inferior
gluteal artery.
218
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

When marking the patient, the patient
stands so that the gluteal fold may be marked.
The inferior limit for this flap is marked 1 cm
inferior and parallel to the gluteal fold. The
patient is then placed in the lateral position
and the Doppler probe is used to find the per-
forating vessels from the inferior gluteal artery.
An ellipse is drawn for the skin paddle to
include these perforators.
The Skin-Sparing Mastectomy
One of the cosmetic drawbacks to autologous
flaps has been the difference in color between
the skin of the flap and the skin of the chest
wall. This has been greatly improved with
the introduction of the skin-sparing mastec-
tomy. Although there was initial concern
regarding the oncologic appropriateness of
this operation with early reports of increased
local
recurrence,
subsequent
studies
have
shown no increased local recurrence rates
when proper technique is used. This tech-
nique allows for the preservation of as much
uninvolved breast skin as possible, which pro-
vides improved symmetry (skin color and
shape), form (cleavage), contour, and mini-
mal scar. Any patient who does not require a
significant amount of skin to be resected with
the tumor is a candidate for a skin-sparing
mastectomy. Skin-sparing technique can be
used for both simple mastectomy and modi-
fied radical mastectomy (MRM).
There are several principles of the skin-
sparing mastectomy that must be adhered to
(Box 14–2). The breast and arm are prepped
and draped as with a total or MRM. The key
to the skin-sparing mastectomy is the choice
of incision. If the cancer was diagnosed by
needle biopsy, then only an incision is needed
around the nipple and areola (another advan-
tage to using needle biopsies for diagnosis).
Depending on the size of the areola and the
size of the breast, the entire mastectomy may
be feasible through this incision. Otherwise, a
keyhole approach can be used (Fig 14–13).
If a previous biopsy or lumpectomy has been
performed, the skin surrounding the incision
can be excised with approximately a 1-cm
margin surrounding it. If the incision is near
the nipple areolar complex, these can be
incorporated into one incision (Fig 14–14). This
may or may not require a keyhole for added
exposure. If the previous incision is further
away from the areola, any number of incisions
can be used to incorporate both while preserv-
ing as much skin as possible (Figs. 14–15,
14–16,
14–17).
These
incisions
should
be
designed by both the breast surgeon and the
plastic surgeon in the preoperative area, to
be sure that an appropriate oncologic operation
can be performed with optimal reconstruction.
BOX 14–2 SURGICAL PRINCIPLES
OF THE SKIN-SPARING
MASTECTOMY


Excision of the nipple-areolar
complex


Excision of the biopsy/lumpectomy
incision


Total glandular mastectomy, adhering to
the same surgical principles of a total
mastectomy


Sentinel node biopsy or axillary node
dissection through breast incision (with
possible lengthening) or separate
incision in the axilla
A
B
C
Figure 14–13. Skin-sparing mastectomy incisions
can be periareolar (A), periareolar with a keyhole
extension (B) or elliptic (C). (From Roses D. Breast
cancer. Philadelphia: Elsevier, 2005).
219
14—PRINCIPLES OF BREAST RECONSTRUCTION

A sentinel node biopsy can often be per-
formed through a skin-sparing incision, but if
there is any concern, a separate incision in
the axilla can be performed. In patients who
require a lymph node dissection, a separate,
standard axillary dissection incision should
be used.
After making the skin incision(s), flap eleva-
tion proceeds (Fig 14–18). The skin flaps are ele-
vated widely to reach the same boundaries as
with a standard mastectomy, and with the
same technique to assure all breast tissue is
removed. Compromising this for the sake of a
skin-sparing mastectomy is oncologically inap-
propriate and likely the reason for increased
local recurrence rates in some series. Care is
taken not to compromise the vascular supply
to the flaps. The main difference in technique
with a skin-sparing mastectomy is that the sur-
geon needs to work circumferentially rather
than raising the superior flap and then the infe-
rior flap. Otherwise, the surgeon risks working
deep in a hole, with limited visibility. It
becomes more difficult to see the appropriate
planes and if bleeding is encountered, it may
be difficult to control. Therefore, a part of the
superior flap is raised, and once visibility
diminishes, the retraction is relocated and the
surgeon works on another part. This may
require returning to the same location several
times
before
the
anatomic
landmarks
are
reached.
The breast is then taken off of the pectoralis
major muscle using the same technique as
with a simple mastectomy, removing the
pectoralis major fascia with the specimen.
This may be slightly more challenging at first,
given the limited space, but gets easier as the
operation proceeds, particularly if the par-
tially raised breast can be brought out the
incision.
In patients who require an SLN biopsy, this
can usually be done through the same incision
with adequate retraction of the pectoralis
major, allowing access to the axillary contents.
If not, the keyhole incision can be extended or
a separate incision can be made in the axilla.
For patients who require an MRM, it is possible
to remove the breast and axillary contents
en bloc using two incisions. If, however, this
proves technically challenging, it is not unrea-
sonable to remove the entire breast and then
perform the level I and II dissection through
the axillary incision.
Nipple and Areolar Reconstruction
Nipple and areolar reconstruction is usually
performed only after the breast shaping has
been completed and the reconstructed breast
form has stabilized (at least 6 to 8 weeks after
reconstruction). The most important part of
nipple reconstruction is its location. Even the
best nipple will not look right if it is in the
wrong place. It is also important to have com-
parable appearance and color to the contralat-
eral nipple-areolar complex because even small
discrepancies are obvious.
Although there are many techniques for
nipple reconstruction, most modern techni-
ques use local flaps of skin and fat to create
a projecting nub (Fig 14–19). Full-thickness
skin grafts can be performed to reconstruct
the areola (with donor skin coming from
the opposite areola, abdominal wall after a
TRAM or medial thigh), although medical
tattooing alone will usually result in an excel-
lent cosmetic outcome. Nipple reconstruc-
tion can be performed in the office or clinic
under local anesthesia. In this way it can be
kept simple, inexpensive, convenient, and rela-
tively painless. Although the results of nipple
Axillary incision
Reexcision
with 1-cm margin
Incision
Figure 14–14. If the biopsy scar is close to the are-
ola, they can be incorporated into one incision.
(From Bland K, Copeland E. The breast, 3e. Philadel-
phia: Elsevier, 2004.)
220
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

reconstruction are not perfect, the presence of
a reconstructed nipple does contribute signifi-
cantly to the illusion of having recreated a
normal breast. Patients are therefore encour-
aged to undergo nipple reconstruction and
complete the process of breast reconstruction
whenever possible.
Treatment of the Contralateral Breast
An important aspect of reconstruction is sym-
metry. Given the limitations of expander/
implants and autogenous flaps, it may not be
feasible to reconstruct the absent breast to
the same size as the remaining breast. Or in
a small-breasted woman, the reconstructed
breast may be larger than the contralateral
size. Therefore, women may require breast
reduction, breast augmentation, or a breast lift
(mastopexy) to create symmetry. This can be
done at the same time as the reconstruction
or at a later date. However, it is important to
point out that breast reconstruction does not
always produce a breast that is symmetrical
to the contralateral side.
TimingofBreastReconstruction
Historically, all reconstruction was delayed so
that the reconstructed breast would not interfere
with the detection of recurrent disease. Recon-
struction was only performed in patients with
early-stage disease and often delayed for 2 years
because most recurrences occur within 2 years
of mastectomy. These practices have been aban-
doned, and today patients may choose to have
their reconstruction performed simultaneously
with mastectomy (“immediate”), or they may
wish to undergo mastectomy and then return
for reconstruction after completion of their adju-
vant therapies (“delayed”). Even in the more
recent past, delayed reconstruction was pre-
ferred secondary to concerns that complications
of reconstruction could delay adjuvant therapy,
putting patients at increased risk of recurrence.
Subsequent studies have failed to demonstrate
any increased risk with immediate reconstruc-
tion, so this method is an appropriate choice.
However, there are several relative advantages
and disadvantages to immediate versus delayed
reconstruction (Table 14–2).
No axillary incision
A
Axillary incision
necessary
Reexcision
with1-cm margin
B
Figure 14–15. A, B, When the biopsy scar is further away from the areola, alternate incisions can be used to
excise them together while still preserving a maximum amount of natural skin. (From Bland K, Copeland E.
The breast, 3e. Philadelphia: Elsevier, 2004.)
221
14—PRINCIPLES OF BREAST RECONSTRUCTION

Axillary incision
Tumor
Incision
with 1-cm margin
A
No axillary incision
Tumor
Incision
with 1-cm margin
B
Axillary incision
Tumor
Reexcision
with 1-cm margin
C
No axillary incision
Tumor
Reexcision
with 1-cm margin
D
Figure 14–16. A-D, Additional options for excising both the nipple-areolar complex and biopsy scar for skin-
sparing mastectomy. (From Bland K, Copeland E. The breast, 3e. Philadelphia: Elsevier, 2004.)
222
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

Immediate reconstruction has the obvious
benefit of avoiding the psychological impact
of waking from surgery without a breast. It
also reduces the number of times the patient
needs to undergo general anesthesia. By using
as much of the native skin of the breast as
possible, this improves the cosmetic outcome.
Immediate reconstruction can be an excellent
option for patients with ductal carcinoma in
situ (DCIS) or with early-stage disease. Autoge-
nous tissue reconstructions performed at the
time of the mastectomy tend to have better
aesthetic
results
than
delayed
procedures
because this allows for a skin-sparing mastec-
tomy to be performed. Recovery is faster and
overall cost is reduced.
Delayed reconstruction has its advantages as
well. For the patient who is unsure about
reconstruction, it allows time to make the
decision. Many patients are not as disap-
pointed with the absent breast as they thought
they might be and ultimately decide to forego
reconstruction. The recovery period from the
simple mastectomy is quicker. Patients do not
typically have much choice about when they
need cancer surgery, but they can delay the
reconstruction until they have more time for
recovery. In addition, it is usually easier and
faster to schedule a simple mastectomy than
for the breast surgeon and the plastic surgeon
to
find
time
for
a
combined
procedure.
Patients can also proceed quicker to adjuvant
therapy, if necessary, after a simple mastec-
tomy. It is important to point out, however,
that most studies have shown no significant
delay in adjuvant therapy with immediate
reconstruction. With delayed reconstruction,
the nodal status is known, so there is no
chance of having to return to the operating
room for an ALND after reconstruction or
the need to irradiate the reconstructed breast.
Via axillary incision
Breast
Unclosed
excision site
for previous
incision scar
Pectoralis
muscle in base
Excised skin
(1-cm margin)
of previous
biopsy scar
Figure
14–17. The
biopsy
scar may also be excised sepa-
rately from the nipple-areolar
complex. It is important that
the island of skin between the
two incisions be well perfused.
(From Bland K, Copeland E.
The breast, 3e. Philadelphia:
Elsevier, 2004.)
Axillary incision
Breast
Figure 14–18. Skin flap elevation during the skin-
sparing mastectomy moves in a centripetal fashion to
provide optimum exposure. (From Bland K, Copeland
E. The breast, 3e. Philadelphia: Elsevier, 2004.)
223
14—PRINCIPLES OF BREAST RECONSTRUCTION

The avoidance of postmastectomy radiation to
the reconstructed breast is one of the strongest
arguments for delayed reconstruction.
Breast Irradiation and
Reconstruction
The most challenging aspect of incorporating
reconstruction in with breast cancer therapy
is the interaction of radiation therapy and
reconstruction. Over the past several years,
the indications and use of postmastectomy
radiation have risen (see Chapter 15). Indica-
tions for postmastectomy radiation include
the size of the primary tumor (>5 cm), close
margins after mastectomy, or four or more pos-
itive lymph nodes. The benefit of postmastec-
tomy radiation for patients with one to three
positive lymph nodes is still debated, but its
use
is
increasing.
It
becomes
obvious,
therefore, that a percentage of patients who
are scheduled to undergo mastectomy may fall
into one of these categories once the final
pathology is known. If a patient opts to have
immediate reconstruction, the situation may
arise that radiation needs to be delivered to
the reconstructed breast.
Delivery of radiation to the reconstructed
breast may present some challenges to the
radiation
oncologist.
Some
reconstruction
techniques distort the chest wall anatomy, so
radiotherapy portals may need to be modified.
A steeply sloping contour of the new breast
may make it difficult to match fields. The for-
eign material may affect the radiation dose dis-
tribution within the breast. All of these factors
must be taken into account during the radia-
tion planning. With the use of computed
tomography (CT) based planning and immobi-
lizing devices, radiation can still be safely and
effectively
delivered
to
the
reconstructed
breast and chest wall, with no compromise of
local recurrence rates or increased damage to
the lung or heart. So in the hands of an expe-
rienced radiation oncologist, the reconstruc-
tion should not markedly affect the radiation
dose distribution. However, the radiation may
affect the reconstruction.
Effects of Irradiating a Tissue
Expander/Implants
Postoperative radiation when an implant has
been placed is generally contraindicated. How-
ever, there are situations where only after an
expander has been placed does the possibility
of postmastectomy radiation arise (such as a
positive margin or positive lymph nodes). If
it is known that radiation will be used, recon-
struction can be delayed, although this is not
without increased complications. If, however,
the expander has already been placed (or the
patient is strongly against delayed reconstruc-
tion but not a candidate for a flap), the options
TABLE 14–2
Relative Advantages
of Immediate versus Delayed
Reconstruction
Immediate
Reconstruction
Delayed
Reconstruction
Avoidance of second
operation
Less complexity, shorter
operations
Lower cost
No delay to adjuvant
therapies
Possible better
cosmetic outcome
Less need for integration
of radiation and
reconstruction
Better scarring,
increased skin
availability (skin
sparing)
Allows additional time to
consider reconstruction
and what time
No period of time
without breast
Increased satisfaction of
reconstruction
compared with absent
breast, as compared to
previous breast (some
women expect an exact
duplicate)
Figure 14–19. Local flap nipple reconstruction. A, Markings. B, Flap elevation, C, Flap rotation, D, Final
appearance. (From Roses D. Breast cancer. Philadelphia: Elsevier, 2005).
224
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

include
performing
the
radiation
before
expansion, after tissue expansion but before
placement of the permanent implant, or after
placement of the implant. Radiation before
expansion means expansion of the recently
irradiated field. Radiating after the expansion
process is complete means having to replace
the expander with the implant in the face of
acute radiation changes. The radiation should
be delayed until the acute changes have set-
tled
but
ideally
before
chronic
radiation
changes set in, or the radiation can be delayed
until after the placement of the final implant.
However, this means a delay in radiation,
which may decrease its effectiveness. This will
in part depend on whether the patient will be
receiving systemic therapy. If chemotherapy
is to be used, a good option is to expand dur-
ing
the
chemotherapy
and
then
do
the
exchange 3 to 4 weeks after chemotherapy
finishes. The radiation is initiated, 3 to 4
weeks later.
Radiating an expander or permanent implant
will increase the rate of capsular contracture.
However, despite the fact that the radiation
of an expander or an implant is often described
as contraindicated, that is not the case. Despite
an increased rate of contracture, successful
reconstruction is still accomplished in most
patients. Although aesthetic outcomes as gra-
ded by the surgeon or independent observers
are less than when radiation is employed, these
rates can still be acceptable. More importantly,
the difference in patient opinions between
implants after mastectomy alone and implants
followed by radiation does not appear to be
as significant as physician or third-party opi-
nions, at least in the short term. Satisfaction
rates do tend to separate more by 5 years,
thought to be the result of progressive asym-
metry between the natural and reconstructed
breast, which tends to be more pronounced
if the implant has been irradiated. It is also
important to keep in mind that delayed expan-
sion and implants after radiation also have a
higher rate of complication rates.
Effects of Irradiating the Autologous
Flap
If postmastectomy radiation is indicated, and
the patient does not want a delayed reconstruc-
tion, the ideal reconstruction is an autologous
flap. However, postoperative radiation after
a flap reconstruction may be associated with
increased wound complications and an altered
cosmetic outcome. A well-vascularized TRAM
flap should tolerate the 5000 to 6000 Gy
typically delivered to the chest wall after a
mastectomy. However, an individual patient’s
response to radiation may be quite variable,
and the resulting edema and fibrosis can
significantly alter the shape and softness of
the reconstructed breast. The resultant volume,
contour,
and
symmetry
loss
is
unpredic-
table and may require additional surgeries
to
correct
the
radiation-induced
changes,
which may not always be as successful as
hoped.
For
this
reason,
many
plastic
surgeons
would recommend that if it is known that
the patient will need postmastectomy radia-
tion, or it is suspected that this might be the
case, consideration should be made to delay-
ing the reconstruction until 3 to 6 months
after the completion of radiation therapy.
It is still debated by plastic surgeons whether
delayed autologous reconstruction after radia-
tion is truly superior to immediate autolo-
gous radiation followed by radiation. Many
plastic surgeons report excellent outcomes
with autologous flaps after post-mastectomy
radiation.
Effects of Placing a Prosthesis
after Irradiation
It is generally accepted that if postmastectomy
radiation is necessary and expander/implant is
the reconstruction of choice, then it is best to
do the radiation first, followed by delayed
placement of the expander. However, recon-
struction of the irradiated chest wall after mas-
tectomy still has complications. The effects of
radiation limit the success of tissue expansion.
The
expansion
process
is
associated
with
increased pain, less leeway in overexpansion,
rib cage contour deformities, a greater infec-
tion rate, and expander extrusion. Compared
to expander/implants in the nonirradiated
breast, the resultant breast may be harder,
asymmetric and lack projection. Some series
have reported complication rates (including
unfavorable aesthetic results) as high as 60%
and an increased use of capsular contracture
releases, additional tissue coverage and other
additional procedures.
If, after the patient has recovered from radia-
tion, the flaps show little evidence of radiation
damage, or the amount of skin expansion
needed is not excessive, expansion after radia-
tion can be done safely with an increased but
not unreasonable complication rate. If, how-
ever, the skin shows clear evidence of radiation
225
14—PRINCIPLES OF BREAST RECONSTRUCTION

induced changes, or a significant volume is
needed for symmetry, it may be preferable to
combine a latissimus dorsi flap with the tissue
expander or breast implant. This allows the
use of nonirradiated, well-vascularized tissue
for reconstruction. The latissimus dorsi readily
covers the device and expands nicely. In addi-
tion, the skin island that comes with the flap
can replace heavily irradiated skin.
Effects of Performing an Autologous
Flap after Irradiation
The ideal choice for reconstruction when post-
mastectomy radiation is needed is a delayed
autologous reconstruction using any of the
aforementioned methods. It is worth noting
that pedicled TRAM flaps have a higher rate
of fat and skin necrosis when their pedicle
has been exposed to radiation preoperatively.
Free TRAM flaps have a lower complication
rate than pedicled TRAM flaps in irradiated
beds. There is a slightly higher rate of healing
complications secondary to the irradiated tis-
sue’s ability to heal. To overcome this, it is pru-
dent to use a larger amount of skin from the
flap and excise a correspondingly wider area
of the irradiated, fibrotic chest wall skin.
Sentinel Node Biopsy
and Reconstruction
Two recent changes in the management of
breast cancer have altered the clinical scenario;
the introduction of SLN biopsy (see Chapter
13) and the suggestion that post-mastectomy
radiation may be beneficial in patients who
are node positive, including patients with
one to three positive nodes (see Chapter 15).
This has introduced the not uncommon sce-
nario of a patient who is clinically node nega-
tive, requires (or desires) a mastectomy and is
interested in immediate reconstruction. Those
patients who turn out to be node positive, will
not only need to return to the operating room
for an ALND (which can be performed after
immediate reconstruction) but will be candi-
dates
for
postmastectomy
radiation.
This
might mean radiating an expander or implant
or radiating an autologous flap, both of which
appear to have higher complication rates than
performing the reconstruction after the radia-
tion is complete.
The optimal management will depend on
the stage of the primary cancer (and thus
the likelihood of finding regional metas-
tases), the chosen method of reconstruction,
the need for systemic therapy (thus delaying
the radiation), the opinion of the plastic sur-
geon on radiating the reconstructed breast,
and the opinion of the radiation oncologist
on the relative benefits of chest wall radiation
depending on the number of involved nodes.
In some cases it may be reasonable to proceed
with mastectomy, SLN biopsy and reconstruc-
tion and wait until the final pathology report
to decide on the relative pros and cons of
radiating the reconstructed breast. However,
in some cases it may be preferable to take
the patient to the operating room for a SLN
biopsy
alone.
Frozen
section
should
be
planned on, with ALND performed if the
SLN positive. Often this procedure can be
combined with a ligation of the inferior epi-
gastric vessels if a pedicled TRAM flap is
planned. If the nodes are negative, the patient
returns to the operating room for a mastec-
tomy and reconstruction with minimal risk
of needing postmastectomy with external
beam radiation therapy. If the nodes are posi-
tive, a discussion can be held with the patient
and reconstruction potentially delayed.
Oncoplastic Approaches
to Lumpectomy
The ultimate goal of breast conservation ther-
apy is to both remove the cancer with an
adequate surgical margin and maintain the
breast’s shape and appearance. This can be
difficult depending on the tumor size and
location. When a tumor is too large to accom-
plish this goal, the surgeon typically has
two options. The first is to perform a mastec-
tomy with reconstruction, and the second is
to give neoadjuvant chemotherapy in hopes
of downstaging the primary tumor to allow a
more cosmetic lumpectomy. For situations
in which neither option is desirable, a third
possibility is using oncoplastic techniques
for the lumpectomy. The term oncoplastic sur-
gery refers to a host of volume displacement
operations in which the defect created by a
large lumpectomy is filled in using a breast-
flap
mastopexy
closure;
advancing
breast
tissue along the chest wall to help fill in the
defect,
using
a
full-thickness
segment
of
breast fibroglandular tissue.
With a typical lumpectomy, the resulting
defect is spherical or oblong in shape and left
to fill in with seroma fluid and then reabsorb
at radiation. If this defect is large, leaving
226
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

redundant skin over the defect, infolding can
occur so that the skin adheres to the chest wall
and the nipple deviates toward the lumpec-
tomy site. Oncoplastic approaches to lumpec-
tomy use full thickness lumpectomies, with
an overlying skin island removed with the
lumpectomy
and
the
fibroglandular
tissue
resected down to the chest wall. The goal is
that there is no direct contact between the
skin and the chest wall to prevent this indent-
ing. After the lumpectomy, the breast gland is
lifted off of the pectoralis muscle with preser-
vation of the fascia over the muscle. This is
advanced over the chest wall and the defect
is then closed. If advancement of the tissue
seems as though it will displace the nipple-are-
olar complex, this can be avoided by widely
undermining the nipple-areolar complex at
the level of the pectoralis fascia, which allows
the tissues to shift to an anatomically natural
position.
When doing so, the vascular perforators
between the pectoralis and breast must be kept
in mind. However, the extensive collateral cir-
culation of the breast allows much flexibility
for oncoplastic techniques. Once the fibro-
glandular tissue is mobilized, the breast defect
is closed at full thickness. The deep margin of
the advanced breast tissue is sutured at the
deepest and most superficial edges, and the
skin is reapproximated. This decreases the size
of the seroma cavity and prevents the skin
from adhering to the chest wall, resulting in
a better cosmetic outcome.
The removal of a skin island will often cause
a distortion of the breast. In some cases,
excision of a large amount of skin will cause
upward displacement of the nipple-areolar
complex, which can be quite awkward look-
ing. In this situation, it is better to use a linear
incision in the skin and not remove any skin
island. When a skin island is to be resected
with the specimen, the ideal defect has supe-
rior and inferior margins that are equal in
length. A useful design is a rounded parallelo-
gram (Fig 14–20). The two skin incisions are
tapered at the corners so that the two incision
lines can approach each other easily at the cor-
ners, diminishing the V angle at the corner
and minimizing any dog ear. Full thickness
excision is performed with advancement of
the fibroglandular tissue.
A useful approach for cancers underneath
the nipple-areolar complex is the batwing
mastopexy (Fig 14–21). Two closely similar
half-circle incisions are made with angled
wings to each side of the areola. Full thickness
excision is performed with advancement of
the fibroglandular tissue. This will minimize
the defect and maintain the natural shape
of the breast, however, it will cause lifting of
the nipple, resulting in asymmetry. A contra-
lateral lift will be necessary to alleviate the
asymmetry.
For large tumors in the lateral or upper
portions of the breast, the donut mastopexy
lumpectomy can be used. A donut of skin is
excised around the nipple-areolar complex
A
B
C
D
Standard
lumpectomy
Parallelogram
mastopexy
lumpectomy
Figure 14–20. The rounded parallelogram is useful when skin needs to be excised.
227
14—PRINCIPLES OF BREAST RECONSTRUCTION

(Fig 14–22). This tissue ring is removed to
allow adequate access to the breast tissue.
A generous lumpectomy is performed down
to the chest wall and the remaining fibro-
glandular tissue is advanced and sutured at
both the deep and superficial margins. The
skin is reapproximated with a purse-string clo-
sure. Cancer in the lower part of the breast is
difficult because retraction of the lumpectomy
cavity will cause downturning of the nipple.
For large lesions in the lower hemisphere of
the breast, the approach used for breast reduc-
tion can also be used to perform a lumpec-
tomy (Fig 14–23). The donut mastopexy and
reduction mastopexy are more challenging
oncoplastic techniques and surgeons without
specific training should be cautious.
There are several issues that need to be kept
in mind when the decision is made to perform
an oncoplastic resection. Positive margins are
often more difficult to deal with after an onco-
plastic lumpectomy than with a standard
lumpectomy. Knowing the exact extent of
the cancer before and during the operation is
helpful, so preoperative magnetic resonance
imaging (MRI) and intraoperative ultrasound
may facilitate achieving negative margins on
the first excision. Taking additional margins
at the time of the lumpectomy will help mini-
mize the likelihood of positive margins, espe-
cially considering that the close or positive
margin is often the result of ink running down
cracks in the fibroglandular tissue (especially
after wire localized specimens are imaged). As
with standard lumpectomy, specimens should
be inked with the six-color system so that the
surgeon knows which margin is positive. Some
surgeons ink their own specimens for opti-
mum confidence. Using multiple colors allows
the surgeon to reenter the biopsy cavity and
excise the one or two margins of concern.
When a donut mastopexy or reduction masto-
pexy is used, reexcision may not be possible,
and a mastectomy is indicated for positive
margins. One advantage of the donut masto-
pexy is that the periareolar incision still allows
for a skin-sparing mastectomy.
Another concern with oncoplastic lumpec-
tomy is the planning of the adjuvant radiation
therapy. The incisions used may confuse the
Figure 14–21. Incision for the batwing mastopexy.
Figure 14–22. Incision for the donut mastopexy.
228
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

radiation oncologist as to the location of the
lumpectomy cavity. The placement of multiple
clips around the cavity will help, however, these
have to be placed carefully to truly represent the
extent of the cancer because the advancement
of fibroglandular tissue will distort the true
cavity. Oncoplastic techniques may also not be
compatible
with
partial
breast
irradiation
(PBI), in which knowledge of the cavity is essen-
tial to success. However, oncoplastic surgery is
typically reserved for big tumors and PBI is
typically not recommended for larger tumors.
Finally, oncoplastic techniques will often
maintain the natural shape of the breast and
avoid large indentations, but will often decrease
the volume of the breast. Many of these patients
will require contralateral breast reduction. This
can be done at the same time asthe lumpectomy,
which helps avoid a second surgery or can be
done at a later date. Delaying the breast reduc-
tion until it is known that mastectomy will not
be necessary and the radiation is completed is
beneficial so that the contralateral breast can be
perfectly matched to the final result.
Suggested Readings
1. Alderman AK, Wilkins E, Kim M, et al. Complica-
tions in post-mastectomy breast reconstruction:
two year results of the Michigan breast recon-
struction outcome study. Plast Reconstr Surg 2002;
109:2265–2274.
2. Alderman AK, Kuhn LE, Lowery JC, et al. Does
patient
satisfaction
with
breast
reconstruction
change over time? Two-year results of the Michigan
Breast Reconstruction Outcomes Study. J Am Coll
Surg 2007;204(1):7–12.
3. Alderman AK, Wilkins EG, Kim HM, et al. Compli-
cations in postmastectomy breast reconstruction:
two-year results of the Michigan Breast Reconstruc-
tion Outcome Study. Plast Reconstr Surg 2002;
109(7):2265–2274.
4. Anderson BO, Masetti R, Silverstein MJ. Oncoplas-
tic approaches to partial mastectomy: an overview
of volume-displacement techniques. Lancet Oncol
2005;6:145–157.
5. Asgeirsson KS, Rasheed T, McCulley SJ, et al. Oncolo-
gical and cosmetic outcomes of oncoplastic breast
conserving surgery. Eur J Surg Oncol 2005;31(8):
817–823.
6. Chawla A, Kachnic L, Taghian A, et al. Radiotherapy
and breast reconstruction: complications and cosm-
esis with TRAM versus tissue expander/implant.
Int J Radiat Oncol Biol Phys 2002;54(2):520–526.
7. Cunnick GH, Mokbel K. Skin-sparing mastectomy.
Am J Surg 2004;188(1):78–84.
8. Garvey PB, Buchel EW, Pockaj BA, et al. DIEP and
pedicled TRAM flaps: a comparison of outcomes.
Plast Reconstr Surg 2006;117(6):1711–1719.
9. Harcourt D, Rumsey N, Amber NR, et al. The psy-
chological effect of mastectomy with or without
breast reconstruction: A prospective multicenter
study. Plast Reconstr Surg 2003;111:1060–1068.
10. Helvie MA, Bailey JE, Roubidoux MA, et al. Mam-
mographic screening of TRAM flap breast recon-
structions for detection of nonpalpable recurrent
cancer. Radiology 2002;224(1):211–216.
11. Javaid M, Song F, Leinster S, et al. Radiation effects
on
the
cosmetic outcomes of
immediate and
delayed autologous breast reconstruction: An argu-
ment about timing. J Plast Reconstr Aesthet Surg
2006;59:16–26.
12. Jones G. The pedicled TRAM flap in breast recon-
struction. Clin Plast Surg 2007;34(1):83–104.
13. Jugenburg M, Disa JJ, Pusic AL, et al. Impact of
radiotherapy on breast reconstruction. Clin Plast
Surg 2006;x(x):29–37.
14. Masetti R, Di Leone A, Franceschini G, et al. Onco-
plastic techniques in the conservative surgical treat-
ment of breast cancer: an overview. Breast J 2006;
12(5 Suppl 2):S174–S180.
15. Nahabedian MY, Momen B, Galdino G, et al. Breast
reconstruction with the free TRAM or DIEP flap:
patient selection, choice of flap, and outcome. Plast
Reconstr Surg 2002;110(2):466–475.
16. Nahabedian MY. Nipple reconstructon. Clin Plast
Surg 2007;34(1):131–137.
17. Rainsbury RM. Skin-sparing mastectomy. Br J Surg
2006;93(3):276–281.
18. Rainsbury RM. Surgery insight: Oncoplastic breast-
conserving reconstruction—indications, benefits,
choices and outcomes. Nat Clin Pract Oncol 2007;
4(11):657–664.
Figure 14–23. Incision for the reduction
mastopexy.
229
14—PRINCIPLES OF BREAST RECONSTRUCTION

19. Senkus-Konefka E, Welnicka-Jaskeiwicz M, Jaskeiwicz
J, et al. Radiotherapy for breast cancer in patients
undergoing breast reconstruction or augmentation.
Cancer Treat Rev 2004;30:671–682.
20. U.S. Department of Labor. Your rights after a mas-
tectomy ... Women’s Health & Cancer Rights Act
of 1998. Available at
tions/whcra.
21. Wilkins E. University of Michigan Breast Recon-
struction
Handbook.
Available
at

umich.edu/surgery/plastic/clinical/breast/index.
shtml.
230
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

15
Principles of Radiation
Therapy for Primary
Breast Cancer
INTRODUCTION
HOW DOES RADIATION KILL
CANCER?
BENEFIT OF RADIATION
THERAPY IN BREAST CANCER
Breast Conservation Therapy
Postmastectomy Radiation
DELIVERY OF RADIATION TO
THE BREAST AND CHEST WALL
COMPLICATIONS OF BREAST
AND CHEST WALL RADIATION
PARTIAL BREAST IRRADIATION
Interstitial Brachytherapy
Balloon-Catheter Brachytherapy
External Beam Radiation
Intraoperative Radiation
Therapy
Principles of Radiation Therapy for Primary
Breast Cancer: Key Points
Describe how radiation kills cells and the concept of sublethal
damage repair.
Be familiar with the prospective randomized data comparing lumpectomy
alone to lumpectomy and radiation therapy.
Understand how reducing local recurrence risk may improve overall survival.
Describe the indications for postmastectomy radiation.
Understand how radiation is delivered to the breast and chest wall.
Appreciate the complications of radiation therapy and their management.
Know the methods and potential for partial breast irradiation and the
unanswered questions and possible risks.
231

Introduction
Shortly after the discovery of x-rays by Wilhelm
Roentgen in 1895 and of radium by Marie Curie
in 1898, it was realized that ionizing radiation
could be used against breast cancer. In 1905,
the first radiologic textbooks proposed the use
of radiation therapy for unresectable primary
tumors, including breast cancer. In 1937, Sir
Geoffrey Keynes, a surgeon in England, pro-
posed the notion of radium needle insertion into
operable breast cancer as an alternative to mas-
tectomy. He reported 5-year local recurrence
rates and survivals similar to what was being
obtained
with
radical
mastectomy.
Similar
results were obtained from the Curie Foundation
in Paris and other European investigators.
These results, combined with improved meth-
ods of delivering radiation, eventually led to
the recognition and implementation of using
radiation to eradicate cancer cell aggregates
remaining after surgical excision. This of course
depended on the size of the aggregates and the
dose of radiation used. Although radiation doses
of 45 to 50 grays (Gy) are capable of eliminating
subclinical deposits of cancer 90% to 95% of the
time, larger tumor masses require substantially
larger doses. Masses greater than a few centi-
meters require doses greater than the radiation
tolerance of the surrounding normal tissue.
Therefore, the optimum use of radiation is when
it must contend only with microscopic disease.
Radiation is used in all stages of breast cancer,
from the adjuvant therapy of ductal carcinoma
in situ (DCIS) to the palliative treatment of
metastases. This chapter will primarily review
the most common use of radiation therapy in
the management of breast cancer, that is, as an
adjuvant to surgical therapy.
How Does Radiation Kill
Cancer?
Understanding the way radiation therapy is
incorporated into the treatment of breast cancer
requires a basic understanding of how ionizing
radiation kills cancer cells. Ionizing radiation is
defined as energy with sufficient strength to
cause the ejection of an orbital electron from
an atom when the radiation is absorbed. When
this occurs in biologic tissue, the ejected elec-
trons can indirectly or directly lead to irrepara-
ble double-stranded DNA breaks. When the
cell next enters mitosis, it cannot divide and cell
death occurs (reproductive cell death).
Ionizing radiation can take either an electro-
magnetic form, as high-energy photons, or
particulate forms, such as electrons, protons,
neutrons, alpha particles, or other particles.
Most radiation is delivered through either elec-
trons or photons. Electrons interact directly
with tissue causing ionization, in contrast to
photons, which affect tissues by the electrons
that they eject. Electron beams deliver a
high-skin dose and exhibit a rapid fall-off after
only a few centimeters, so they are typically
only used to treat superficial targets such as
skin cancers or lymph nodes within a few cen-
timeters of the surface of the body. Irradiation
with photons can penetrate deeper into tis-
sues. Photons can cause the ejection of elec-
trons by a variety of methods (Fig. 15–1), but
the most important is the Compton Effect, in
which a photon collides with an electron,
transferring some of its energy to the electron
and scattering both the photon and the elec-
tron in various directions. The photon can
then undergo additional interactions (with a
subsequently lower energy), while the electron
begins to ionize with the energy it gained from
the photon.
The electrons either interact directly with
the target molecules within the cell, or they
interact indirectly with water to produce free
radicals
(such
as
hydroxyl
radicals)
that
Compton effect
e–
Pair production
e–
e+
N
N
Figure 15–1. Photons can release electrons (which
react directly with tissue) by a number of methods. In
the Compton Effect, a photon collides with an electron,
transferring energy to the electron and scattering both.
The photon can go on to have additional interactions,
albeit with a lower energy. In pair production, the pho-
ton interacts with the nucleus that absorbs the energy
and releases a pair of electrons, one positively charged
(positron) and one negatively charged.
232
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

subsequently interact with target molecules.
During their brief life span, electrons and free
radicals interact with molecules in a random
fashion. If they interact with molecules that
are not crucial to cell survival, the effect of
the radiation will be harmless. If they react
with biologically important molecules, the
effect will be detrimental. Molecular oxygen
prolongs the life of reactive radicals, increasing
the likelihood that it will have a detrimental
effect. This is why tumor hypoxia tends to
increase resistance to radiation. Antioxidants
reduce the life span of free radicals by combin-
ing with them, thereby also increasing cellular
resistance to radiation.
Although ionizing radiation may damage
many molecules with the cell, the most critical
injury with respect to cell death appears to
be DNA damage in the form of single- or
double-strand breaks (Fig. 15–2). Cells have
relatively efficient repair mechanisms for sin-
gle-strand breaks in DNA because there is an
intact template on which to replicate a repair
patch. However, repair errors may occur result-
ing in mutations, and ultimately may lead to
the increased incidence of secondary malig-
nancies that occur in between 1 in 500 and 1
in 1000 patients who have had radiation.
Double-strand breaks in DNA are much
more difficult for cells to repair because the
integrity of the molecule is compromised with
the creation of two free ends that separate
from one another in space, leaving no tem-
plate on which to repair the break. Cellular
mechanisms for double-strand break repair do
exist, however, their efficiency is variable and
repair may not be sufficient before cells trigger
pathways leading to programmed cell death
(apoptosis) or enter into mitosis with damaged
DNA, leading to mitotic catastrophe and cell
death. Therefore,the ability of ionizing radiation
to kill cells is dependent not only on the genera-
tion of enough DNA double-strand breaks to
overwhelm repairpathways, but alsoon the time
the cell has to repair those breaks before the next
mitotic cell division.
This explains the phenomenon known as
sublethal damage repair in which increased cell
survival is observed if a dose of radiation is
divided into two fractions separated by a time
O
H
H
e−
e−
Photon
OH
radical
Photon
Direct
damage
Indirect
damage
DNA
A
Normal DNA
Single-strand break
Double-strand break
T
T
T
T
T
C
C
C
C
T
T
T
T
T
C
C
C
C
T
T
T
T
T
C
C
C
A
A
A
A
A
G
G
G
G
A
A
A
A
G
G
G
A
A
A
A
A
G
G
G
Figure 15–2. Whether directly or indirectly, the electrons lead to DNA damage. This occurs when the “back-
bone” of the molecule is broken. Single-strand breaks can be easily restored by DNA repair mechanisms within
the cell, whereas double-strand breaks are more damaging because they are more difficult to repair by cellular
mechanisms. (From Sabel M, Sondak V, Sussman J. Essentials of Surgical Oncology. Philadelphia: Elsevier,
2006.)
233
15—PRINCIPLES OF RADIATION THERAPY FOR PRIMARY BREAST CANCER

interval. As the time interval between the frac-
tions increases, the surviving fraction of the
cells also increases because the cells are able
to repair double-strand DNA breaks. Further-
more, if the time interval is sufficiently long,
the cells will once again begin to proliferate
in a process known as repopulation.
Of course, in clinical radiation therapy, the
goal is to kill the cancer cells but spare the nor-
mal cells. Delivering a single large dose of radi-
ation will have a high rate of killing tumor
cells, but the concordant killing of the normal
tissue cells may limit the clinical use because
of normal tissue toxicity. Fractionation of radi-
ation (delivering a fraction of the dose daily)
spares normal tissues because of their greater
ability to repair sublethal damage between
dose fractions and repopulate with cells if the
overall time is sufficiently long. Although
tumors may also repair sublethal damage and
repopulate, there is increased damage to the
tumor because dividing a dose into a number
of fractions allows reoxygenation of hypoxic
regions within the tumor and reassortment of
tumor cells into radiosensitive phases of the
cell cycle between dose fractions.
Benefit of Radiation Therapy
in Breast Cancer
Radiation has been used for the treatment of
locally advanced or inoperable breast cancer
for almost a century, beginning shortly after
the discovery of radiation’s effects on human
tissue. After British surgeon Keynes reported
how treating operable breast tumors with
radium needle insertion alone had both local
recurrence rates and survival rates similar to
that of radical mastectomy, several European
trials of radiation with and without surgery for
operable breast cancers began and laid the foun-
dation for breast-conserving therapy (BCT).
Today radiation therapy has multiple uses in
the management of breast cancer, such as the
treatment of chest wall recurrences or palliation
of bone metastases, but the primary use of radi-
ation is in the management of early therapy as
either a component of BCT, or chest wall irradi-
ation following mastectomy. The optimal local
management of breast cancer requires coordi-
nation between the surgeon, the plastic sur-
geon, and the radiation oncologist.
Radiation therapy clearly reduces local recur-
rence rates. However, does the addition of radi-
ation to surgery improve survival? Several of
the randomized trials that established the effi-
cacy of breast conservation included arms in
which women underwent lumpectomy alone,
without radiation (Table 15–1). These studies
demonstrated no significant survival difference
between those two groups despite a significant
increase in local recurrence. Unfortunately, this
led to the incorrect conclusion that “preventing
local recurrence has no impact on survival.” For
this reason, some physicians became willing to
offer local therapies that carried a high local
recurrence rate under the impression that if
patients do recur and undergo salvage mastec-
tomy,
their
survival
remained
unchanged.
There was little evidence that preventing the
local recurrence would have prevented the dis-
tant disease. However, the original randomized
trials that demonstrated no difference in sur-
vival between lumpectomy alone and lumpec-
tomy with radiation did not have the power to
detect a small survival advantage from the addi-
tion of radiation therapy. In addition, the mor-
bidity and mortality associated with radiation
therapy negated some survival advantage, par-
ticularly with older methods for delivering radi-
ation. More recent data clearly demonstrates
TABLE 15–1
Randomized Trials of Lumpectomy Versus Lumpectomy and External
Beam Radiation Therapy
Local Recurrence
Study
N
Follow-Up
(Years)
Maximum Tumor
Size (cm)
Surgery
(%)
Surgery þ External
Beam Therapy (%)
Milan III
567
4.3
2.5
8.8
0.3
NSABP B-06
1262
12
4
35
10
Ontario
837
7.6
3
35
11
Scottish
585
5.7
4
24.5
5
Upsalla-Orebro
381
10
2
24
8.5
NSABP B-21
1009
6
1
12
5.6
234
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

that improved local control does impact sur-
vival and establishes that radiation is a critical
component of BCT.
Breast Conservation Therapy
The emergence of BCT as an alternative to mas-
tectomy is discussed in detail in Chapter 12
(Box 15–1). The benefits of adding radiation to
lumpectomy are clear when one examines the
trials comparing lumpectomy to lumpectomy
and radiation therapy (see Table 15–1). However,
these trials also showed no significant difference
in overall survival between these groups. The
conclusion was that radiation reduced in-breast
recurrence but had minimal impact on the
overall survival of the patient.
Subsequent to this, several series noted that
patients who underwent lumpectomy and radia-
tion therapy and experienced a local recurrence
had a lower survival than their counterparts
who did not have a local recurrence. However,
it was not able in these retrospective series to
determine whether the local recurrence led to
the distant metastases. It is also possible (and
likely) that patients with more aggressive tumors
were more likely to experience both local and
distant recurrences, and that preventing the
local recurrence would not have improved sur-
vival (Fig. 15–3). The strongest evidence for this
latter argument was the absence of a survival dif-
ference between lumpectomy and lumpectomy
with radiation in the randomized trials, despite
large differences in recurrence.
Although many patients who experience
local recurrence may have harbored distant
micrometastases at the time of their initial sur-
gery, is there a fraction of patients whose local
recurrence led to their distant disease? The cor-
ollary to this is that preventing local recurrence
would improve survival. Unfortunately, the
individual randomized trials were all under-
powered to detect a small difference in survival.
In addition, the cardiac toxicity of radiation
therapy, and the negative impact it has on sur-
vival, may have masked any survival benefit of
local control. This is particularly true of the
older techniques for delivering radiation.
The improved local control rate achieved
with radiation therapy is impressive. The most
recent update of the Early Breast Cancer Trialists
Collaborative Group (ECGTCG) meta-analysis
Aggressive tumor biology leads to
both local recurrence and distant
recurrence. Preventing local
recurrence has no impact on
survival.
A
B
Distant disease did not exist at the
time of surgery, but the local
recurrence metastasized.
Preventing local recurrence does
impact survival.
Figure 15–3. Impact of local recurrence on distant recurrence. A, An aggressive tumor biology leads to both
the local recurrence and the distant metastases. Thus, preventing local recurrence has no impact on survival
because the micrometastases exist before therapy. B, There was no distant disease at the time of definitive sur-
gery, but inadequate local therapy led to a local recurrence, which subsequently developed the ability to
metastasize. In this scenario, preventing local recurrence would impact survival. Although it was for a long
time accepted that scenario A was most relevant to breast cancer, recent evidence has shown that scenario B
is more significant than previously believed.
BOX 15–1 CONTRAINDICATIONS
TO BREAST-CONSERVING THERAPY
Multicentric disease
Previous radiation
Diffuse malignant-appearing
microcalcifications on mammography
First or second trimester of pregnancy
Collagen vascular disease
Unable to achieve negative margins
235
15—PRINCIPLES OF RADIATION THERAPY FOR PRIMARY BREAST CANCER

demonstrated a 5-year local recurrence rate of
7% for breast conservation with radiation ther-
apy and 26% when radiation therapy was
excluded. The most recent update of the
ECGTCG meta-analysis demonstrates that the
15-year breast cancer mortality risks were also
significantly lower in the patients who received
radiation therapy (30.5 versus 35.9, p ¼ 0.002).
A pooled analysis of mortality data from 13
randomized trials also showed a worse survival
in women who did not receive radiation ther-
apy, with an 8.6% excess mortality. This data
clearly demonstrates that improved local con-
trol does impact survival, and women with an
exceedingly high risk of in-breast recurrence
with BCT compared to mastectomy may be
better served by the latter. It also establishes
that radiation is a critical component of breast
conservation therapy.
Lumpectomy without Radiation
The benefits of adding radiation are clear, but
this is certainly not without cost. Radiation
to the breast has both acute and late complica-
tions, and although radiation will reduce local
recurrence, many patients treated with lump-
ectomy alone will not recur. Therefore, there
has been significant interest in whether there
exist subsets of patients for whom the in-
breast recurrence risk is low enough that the
toxicity of radiation therapy may not be justi-
fied. Overall, attempts to identify such a subset
of patients who have a low enough risk of
local recurrence to justify surgery alone have
not been overly successful. Several of the ran-
domized trials sought to identify subsets that
may not require radiation therapy. In the
Uppsala-Orebro trial, in women over 55 with
tumors less than 2 cm (excluding comedo or
lobular histologies), the local recurrence rate
was 6% with radiation, but only 11% without
radiation. The authors suggest that radiation
may not be of benefit in this subset because
20 women need to be treated to prevent just
one breast recurrence. In contrast to this, the
Ontario group could identify no such group.
Even among women over 50 with tumors less
than 1 cm, the local recurrence rate was 18%
without radiation therapy.
Other trials specifically attempted to stratify
or select patients to answer whether radiation
was needed in all patients. The Scottish trial
was designed to specifically look at the impact
of radiation therapy in the setting of appropri-
ate systemic therapy. Patients with estrogen
receptor (ER)-positive tumors who received
tamoxifen had a drop in local recurrence from
14% to 3% with the addition of radiation.
Patients who received adjuvant therapy had a
decrease from 38.5% to 9%. The conclusion
was that adjuvant systemic therapy was not a
substitute for breast irradiation. Another study
of the need for radiation in the face of adjuvant
therapy was NSABP B-21. This tria1 included
1009 women undergoing lumpectomy for inva-
sive breast cancer equal to 1 cm in size and
found that women treated by lumpectomy
with tamoxifen had a 16.5% local recurrence
rate compared to 2.8% for lumpectomy, radia-
tion, and tamoxifen (and 9.3% for lumpectomy
and radiation therapy without tamoxifen). This
demonstrates that even with the use of sys-
temic therapy, radiation therapy significantly
decreases local recurrence in patients with
small tumors. Finally, a prospective trial of
women with the most favorable features (tumor
size 2 cm, histologically negative axillary nodes,
absence of angiolymphatic invasion, or exten-
sive intraductal component [EIC] and margins
>1 cm) who underwent surgery alone, the trial
needed to be stopped early because of the high
local recurrence rate (20%).
One subset of patients for whom the avoid-
ance of radiation seems possible is older women
with hormone receptor positive tumors. Several
retrospective series of conservative surgery
alone in older women have shown varying rates
of local recurrence, but similar distant recur-
rence and survival rates. Two randomized trials
have shown comparable results. In a Canadian
trial randomizing women over the age of 50
undergoing lumpectomy with adjuvant tamox-
ifen to radiation or none, radiation therapy sig-
nificantly decreased the risk of local recurrence
(17.6% versus 3.5% at 8 years), but did not
appear to impact rates of distant metastases,
overall survival, and the number of deaths as a
result of breast cancer. However, given what
we now appreciate about local control and over-
all survival, this local recurrence rate seems
uncomfortably high. A Cancer and Leukemia
Group B (CALGB) trial of women over the age
of 70 also showed a difference in the risk of local
recurrence in women treated with tamoxifen
with or without radiation therapy (4% versus
1%), but no impact on overall survival (86%
versus 87% at 5 years). Rates of mastectomy
for local failure were also similar. Although the
Canadian trial included tumors up to 5 cm,
the CALGB trial was limited to tumors less than
2 cm. Thus, in selected women over the age of
236
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

70 with small ER-positive breast cancer, treat-
ment with lumpectomy and tamoxifen alone
may be a reasonable option.
Postmastectomy Radiation
It is often presented to patients that one of the
advantages of mastectomy over BCT is that radi-
ation therapy will not be necessary. However,
chest wall recurrence after mastectomy alone
is not an infrequent event. The risk of local-
regional failure after mastectomy increases with
both increasing tumor size and increasing num-
bers of involved axillary nodes. Trials of post-
mastectomy radiation, accruing patients in the
60s and 70s, demonstrated that postmastec-
tomy radiation could decrease chest wall recur-
rences. Similar to the experience with BCT,
however, these trials did not demonstrate any
significant effect on overall survival. In fact,
there was even the suggestion of a decreased
survival. But as before, these trials were under-
powered to detect a small survival benefit, and
they mostly involved radiation techniques
that had increased morbidity and mortality
compared to today’s approaches.
Meta-analysis of these trials, with long-term
follow-up and cause-specific mortality recorded,
present a different picture. These demonstrate
that mortality from late cardiac effects were
responsible for canceling out any survival ad-
vantage to radiation therapy, something not
present to the same degree today using modern
radiotherapy techniques. The most recent meta-
analysis by the ECGTCG, including 46 rando-
mized trials involving over 23,000 patients,
found that postmastectomy radiation therapy
was associated with a significant reduction in
both local recurrence (5.8% versus 22.8% at
5 years) and in breast cancer mortality for
women who are node positive (54.7% versus
60.1%, p ¼ 0.0002).
Several trials using more modern radiother-
apy
and
adjuvant
systemic
therapy
have
further demonstrated the impact of postmas-
tectomy radiation. The first Danish Breast Can-
cer Cooperative Group trial included 1708
premenopausal women with either positive
nodes or T3 or T4 tumors to undergo mastec-
tomy, axillary sampling, and postoperative che-
motherapy and then be randomized to receive
chest wall and regional nodal irradiation or
not. With a median follow-up of about 10 years,
postmastectomy radiotherapy was associated
with a significant improvement in locoregional
failure (32% versus 9%), disease-free survival
(48% versus 34%), and overall survival (54%
versus 45%). However, this trial required only
axillary sampling, not a complete dissection,
and the majority of recurrences were in the
axilla, a relatively rare occurrence in patients
who had a level I and II dissection. It is unclear
what the results of this trial would have been
had the patients had a complete axillary lymph
node dissection (ALND), as is done routinely in
the United States.
In the British Columbia trial, 318 premen-
opausal women with node-positive breast
cancer undergoing modified radical mastec-
tomy (MRM) were randomly assigned to cyclo-
phosphamide, methotrexate, and fluorouracil
(CMF) plus chest wall radiotherapy versus
CMF alone. Improvements in local-regional
recurrence and disease-free survival (DFS) were
again seen, with a trend toward improved sur-
vival. With 20-year follow-up, the overall sur-
vival
benefit
was
statistically
significant
(overall survival 47% versus 37%, hazard ratio
[HR] 0.73 95% confidence interval [CI] 0.55
to 0.98). A third trial, also from the Danish
Breast Cancer Cooperative Group, randomized
1375 postmenopausal women with stage II or
III breast cancer to adjuvant tamoxifen (30
mg/day for 1 year) alone or with postoperative
chest wall irradiation. Once again, significant
improvements were seen with postmastec-
tomy radiation therapy in regard to local-
regional recurrence (8% versus 35%), 10-year
DFS (36% versus 24%), and overall survival
(45% versus 36%, p ¼ 0.03).
Based on these studies, postmastectomy radia-
tion is recommended for several subsets of
patients. Patients with four or more positive
lymph nodes clearly benefit from postmastec-
tomy radiation therapy. The data is less clear for
patients with one to three positive nodes.
Although the impact of treatment on survival
might be similar, the risk of recurrence and death
is less, and given the questions regarding the sur-
gery used in the Danish trials, it is difficult to
translate these findings to the U.S. practice of
axillary clearance. For now, there is insufficient
evidence to recommend routine chest wall radia-
tion therapy for women with one to three axil-
lary nodes, but these women should have the
relative pros and cons of postmastectomy radia-
tion presented to them. Other patients who
should undergo postmastectomy radiation ther-
apy include women with T3 and T4 tumors,
those with positive margins after mastectomy,
patients with advanced nodal disease (N2 or
N3), or with gross extranodal extension.
237
15—PRINCIPLES OF RADIATION THERAPY FOR PRIMARY BREAST CANCER

It is important to keep in mind that if post-
mastectomy radiation is to be used, this may
impact the timing and method of reconstruc-
tion. The cosmetic outcome of immediate
breast reconstruction will be affected by radia-
tion (Chapter 14). This is particularly true if
tissue expanders and implants are used, but
radiation can also negatively affect autologous
reconstructions. Another less-recognized prob-
lem is that the reconstruction can negatively
impact the delivery of radiation. One option
is to simply delay reconstruction until all treat-
ment is completed. However, if immediate
reconstruction is desired, there are options to
minimize the likelihood of radiating a recon-
structed breast. The simplest option is to per-
form the sentinel lymph node (SLN) biopsy
as a separate procedure before mastectomy.
This can be combined with ligation of the
inferior epigastric vessels when indicated for
reconstruction purposes. If the SLN is nega-
tive, the next step is mastectomy and recon-
struction. If the patient is node positive,
reconstruction can be delayed, especially if tis-
sue expanders were planned.
Delivery of Radiation to the
Breast and Chest Wall
When adjuvant chemotherapy is necessary,
radiation will follow the chemotherapy. If neg-
ative margins were not achieved and the initi-
ation of chemotherapy is being delayed by the
need for reexcision, it is reasonable to proceed
with the chemotherapy and return to surgery
between chemotherapy and radiation therapy.
Either way, negative margins must be obtained
before beginning radiation. Concomitant che-
moradiotherapy may minimize the time nec-
essary to complete therapy, but it also limits
the doses of chemotherapeutic agents second-
ary to increased myelosuppression, increases
side effects, and negatively impacts cosmesis.
Its use in this setting is strongly discouraged.
When chemotherapy is not used, radiation
should follow surgery once adequate time for
healing has been allowed (typically 4 weeks).
Sometimes this may be delayed because of the
formation of a seroma. Repeated aspirations of
the seroma during therapy will cause fluctua-
tions in the breast contour and the skin marks.
Thus, the need to aspirate the seroma must be
balanced against when radiation will com-
mence or conclude and the patient’s symptoms.
Radiation may also be delayed by the patient’s
inability to abduct and maintain the arm in
the treatment position, as may be seen after an
ALND or MRM. A small delay is reasonable;
however, a delay in the initiation of radiation
therapy beyond 12 to 16 weeks has been asso-
ciated with increased rates of relapse.
The hallmark of the modern era of radio-
therapy is the delivery of radiation in the
megavoltage range. This minimized many of
the undesirable effects resulting from lower-
energy radiation (such as orthovoltage, 150 to
500 kV, or supervoltage, 500 to 1000 kV). The
most common machines providing megavol-
tage radiation therapy are linear accelerators
(Fig. 15–4). These have several advantages over
the older approaches that have greatly limited
toxicity and ultimately allowed the survival
advantages of local control to surpass the mor-
bidity of radiation (Box 15–2).
Delivering radiation begins with simula-
tion. Most simulation today is accomplished
Figure 15–4. Linear accelerator.
BOX 15–2 ADVANTAGES OF THE
LINEAR ACCELERATOR


A higher-energy x-ray beam that
treats deeper lesions with greater skin
sparing


In addition to the x-ray beam, it can
deliver a high-energy electron beam for
more superficial lesions


Sharper beam edges for more accurate
shaping to match the desired target and
minimize radiation to surrounding
structures


Greater dose rate, allowing treatment to
be accomplished faster


No exposure to personnel


No need to change the radioactive
material because of isotope delay
238
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

using computed tomography (CT) scanning
(Figure 15–5). With modern CT technology,
virtual simulation allows for better visualiza-
tion of the breast, chest wall, and most impor-
tantly the relation to the lung and heart, thus
minimizing
damage
to
normal
tissues.
Minimizing toxicity to the underlying heart
and lung must be carefully considered in the
treatment plan. The patient is scanned with
the breast in an immobilization device so that
the patient position is reproducible from day
to day. Typically this is in the supine position,
but the prone position can be used for the
patient with a pendulous breast, provided ade-
quate coverage of the tumor is achieved.
The scanned information is then brought up
on the treatment planning console and the
treatment plan is created. The target volume
for whole breast radiation therapy extends
medially to the middle of the sternum, and lat-
erally to the midaxillary line. The inferior edge
of the field is approximately 1 cm below the
inframammary fold in the intact breast or
the contralateral inframammary fold when
treating the chest wall. Superiorly, the field typ-
ically ends at the base of the head of the clavicle.
For the initial whole-breast irradiation, 6-MV
photon therapy generated by a linear accelera-
tor is generally used. This provides an optimal
balance between skin sparing and treatment of
the entire breast. Electron beams can be used
for postmastectomy irradiation but are unable
to penetrate deeper into the breast for whole-
breast irradiation.
Once the treatment plan has been formu-
lated, small tattoos are placed to mark the field
for daily radiation and treatment is initiated.
The radiation will be administered through a
medial and lateral tangent field arrangement
that parallels the arc of the chest wall. Although
they may vary, typical whole breast irradiation
doses are 45 to 50 Gy, using daily fractions of
1.8 or 2.0 Gy. Treatments are delivered daily, 5
days per week, Monday through Friday. This
takes 5 to 6½ weeks to complete. Several ques-
tions need to be addressed when planning
whole-breast irradiation as a component of
breast conservation therapy.

Fractionation
schedules—In
countries
where availability to radiation is limited,
there is interest in shortening the time it
takes to complete therapy. A Canadian
trial demonstrated no difference in 5-year
local-recurrence free survival, DFS, overall
survival, and cosmetic outcome between
node-negative patients receiving 50 Gy in
25 fractions (taking 35 days) and those
receiving 42.5 Gy in 16 fractions (taking
22 days). Although more information is
needed, for selected patients this may be
an alternative to the 5 1/2 weeks presently
needed.

Boost—A boost of radiation, often using
electrons, can be delivered to the primary
tumor site, increasing the total dose deliv-
ered to 60 to 66 Gy. Three randomized trials
have been performed, two showing that
adding a boost can reduce the rate of local
failure. The larger trial, performed by the
European Organization for Research and
Treatment of Cancer (EORTC), stratified
patients by resection margins (negative or
positive). Local recurrence was signifi-
cantly lower (4.3% versus 7.3%) in women
with
negative
resection
margins
who
received a boost, without a drop-off in cos-
metic outcome. The placement of surgical
clips around the cavity at the time of sur-
gery greatly assists the radiation oncologist
in planning the boost and should be a stan-
dard component of a lumpectomy.

Regional lymph nodes—Another decision is
whether to include the regional lymph
nodes in the field. There is no indication to
treat the axilla when surgical staging has
demonstrated the axillary nodes to be path-
ologically negative. In addition, it is not
recommended when a complete ALND has
been performed because the combination
of surgery and radiation results in a high rate
of lymphedema. Radiation to the axilla can
be considered when the axilla has not been
Figure 15–5. Computed tomography simulation
allows for better visualization of the breast, chest
wall, heart, and lungs. Medial and lateral tangent
fields are arranged to minimize damage to normal
tissues.
239
15—PRINCIPLES OF RADIATION THERAPY FOR PRIMARY BREAST CANCER