ABSTRACT: Plastic surgery represents a small but critical component of the comprehensive care of cancer patients. Its primary role in the treatment of cancer patients is to extend the ability of other surgeons and specialists to more radically treat cancer, offering patients the best opportunity for cure. Although the most convincing data for improved psychosocial well-being through plastic surgery is in the setting of breast cancer reconstruction after mastectomy, it is reasonable to assume that all patients who undergo major reconstruction to minimize deformity due to cancer therapy feel some improvement in quality of life. This article will provide an overview of the role of plastic surgery in cancer treatment. [ONCOLOGY 16:1685-1708, 2002]
Cancer treatment is the epitome of multidisciplinary patient care. The vast scope and interwoven facets of cancer treatment are brought together in our nation’s comprehensive cancer centers. The very existence of these centers is testimony to the broad interdisciplinary approach to cancer care today. Plastic surgery represents a small but critical component of the comprehensive care of cancer patients. This article will provide an overview of the role of plastic surgery in cancer treatment.
Role of Plastic Surgery
Plastic surgery is not confined by anatomic boundaries. Oncologic plastic surgery can involve treatment of disease and deformity from head to toe. Its primary role is to extend the ability of other surgeons and specialists to more radically treat cancer, thus offering patients the best opportunity for cure. Many of the advances in this field are in surgical treatment of head and neck cancer, sarcoma, and tumors of the breast and chest wall, but surgical oncology is not the only discipline to be affected by plastic surgery. Radiation therapy options increase when well-vascularized tissue covers an area of planned treatment. An example of this is the use of flaps to allow the insertion of radiation rods for postoperative brachytherapy.
Plastic surgeons advance the care provided by medical oncologists in two ways: (1) Plastic surgery provides well-vascularized tissue coverage that allows the medical oncologist to begin treatment earlier and with less risk of chemotherapy interruption to treat infections and delayed wound healing. (2) Plastic surgeons and medical oncologists consult on the use of intravenous (IV) infiltrates of chemotherapy and other cytotoxic medications into subcutaneous tissues. Prompt injection of diluting and dispersing agents can limit skin loss, and proper treatment of open wounds (with moist dressings and extremity elevation) can hasten healing.[1-6] A plastic surgery consultation for this activity is part of the protocol of most cancer care teams, allowing for the evaluation of possible flap or skin graft closure when necessary.
Although the most convincing data for improved psychosocial well-being following plastic surgery is in the setting of breast cancer reconstruction after mastectomy, it is reasonable to assume that all patients who undergo major reconstruction to minimize deformity due to cancer therapy achieve some improvement in quality of life. The following sections will address the major areas of cancer reconstruction in greater detail.
Breast reconstruction is a mix of reconstructive and aesthetic ideals, involving much more than closing a chest wound or filling in a defect. The appearance of the breast after reconstruction is an important component of a successful procedure. In October 1998, the Federal Breast Reconstruction Law was passed, mandating that no insurance company can consider breast reconstruction cosmetic or elective. The law requires coverage for reconstruction of the affected breast as well as for symmetry procedures performed on the opposite breast. Reconstruction has limitations, particularly with larger, more pendulous breasts and smaller breasts without rounded contours. In these situations, the symmetry of the reconstruction can be significantly improved by reducing or lifting the larger breast or by inserting a subpectoral implant to give a rounded shape to a smaller breast.
There are three main forms of breast reconstruction: the expander/implant technique, the latissimus flap with or without a permanent implant, and the transverse rectus abdominis myocutaneous (TRAM) flap. In consultation, we offer our patients a choice among these options, weighing the pros and cons of each. We use a chart, as adapted in Table 1, to help patients reach a decision that best suits their needs.
When a woman is diagnosed with breast cancer, she experiences a significant degree of psychological trauma.[7-9] Often, the ability to take part in restoration of the breast allows the patient to focus on recovery rather than diagnosis. In addition, patients who present for delayed reconstruction often have to relive the unpleasant experience of cancer diagnosis and treatment, as opposed to patients who undergo immediate reconstruction.[10,11]
The use of a tissue expander followed by insertion of a saline or silicone prosthesis (Figures 1A-C) is the most common method of breast reconstruction performed in the United States. For patients who are uncertain about which type of breast reconstruction to choose, the tissue expander followed by implant is the most advisable. This method has the lowest morbidity and maintains the viability of the other more intensive reconstructive techniques, should the patient change her mind in the future.
The expander is a thicker or more durable implant with a built-in self-sealing access port, much like the venous access port-a-cath. This allows a standard needle to be inserted through the denervated mastectomy flap so that saline may be gradually added. The expander is only partially filled when inserted to avoid placing undue stress on the mastectomy flaps that have been vascularly compromised by removal of the underlying breast tissue. Inserting a partially filled expander allows the skin to recover, and expansion is typically initiated in the office 2 to 3 weeks thereafter.
Another reason that tissue expanders are used instead of a fully filled implant at initial reconstruction is the somewhat compromised blood supply to the skin. Nevertheless, the expander/implant reconstruction has several advantages: The surgery is performed using the mastectomy incision and residual mastectomy flap skin, thus avoiding the creation of a new scar. The overall magnitude of surgery is less, and the patient recovers faster. By comparison, these patients usually spend the same amount of time in the hospital as patients who undergo mastectomy only.
The use of an expander is limited by the quality and availability of the overlying chest skin (ie, mastectomy flap). This reliance on the overlying tissue is also the reason that radiation has a relatively profound effect on this type of reconstruction. This technique does not typically produce ptosis of the reconstructed breast. Therefore, symmetry procedures on the opposite breast are more commonly needed with expander/implant reconstruction than with latissimus or TRAM flap reconstruction.
Without question, the complication rate for implant reconstruction is higher among patients who undergo radiation therapy, and the plastic surgery literature regarding the advisability of this type of reconstruction in an irradiated patient contains a good deal of controversy. We believe the procedure is acceptable as long as the patient is informed of the increased risk—ie, the risk that a firm, sometimes painful implant will need to be removed or changed to either a latissimus flap with implant or a TRAM flap reconstruction.
The expander/implant reconstruction is also limited in the way it looks and feels without clothing. Because it is composed of a silicone shell filled with saline or silicone gel, it does not have the same feel and contour as a native breast. This difference is minimized in bilateral reconstruction: the symmetrical appearance of two implants gives the illusion of a more natural result. Correction of a ptotic contralateral breast is necessary to achieve symmetry with implant reconstruction. If this is not acceptable to the patient, then a latissimus or TRAM flap reconstruction would be a better choice.
Latissimus With Implant
The latissimus flap represents the next level of reconstruction beyond an implant alone (Figures 2A-D). It can be used with or without an implant, depending on volume needs. Noticeable muscular weakness is rarely associated with harvesting of the latissimus muscle. The latissimus is a powerful adductor of the arm, pulling the arm down toward the body. The strength of this muscle could be missed by athletes, so patients should be asked if they are seriously involved in activities that require a strong downward pull of the arm.
When compared with the expander/implant technique, the latissimus procedure provides superior aesthetic results and protection from radiation changes. An elliptical paddle of skin is elevated along the underlying muscle. The incision may be made either horizontally, to hide under the bra line, or obliquely, to allow open-back clothing to be worn. The choice of the incision angle and location, as with any type of reconstruction, should be discussed with the patient so that the surgery may be tailored as much as possible to the patient’s needs.
The muscle and skin unit is transposed from the back to the front, bringing skin and soft tissue into the mastectomy defect and partially or completely restoring the breast. The skin, nipple, and areola that are removed during a mastectomy typically can be fully replaced with skin from the back, maintaining the natural skin envelope and leading to a more natural look and feel. Although the volume of the breast is rarely matched with soft-tissue volume from the back alone, the tissue that is brought forward decreases the size of the implant required to match the opposite breast. This is the crux of the advantage of the latissimus flap over an expander/implant procedure alone.
Symmetry procedures may still need to be performed on the opposite breast to achieve maximal symmetry. Latissimus reconstruction is most often chosen by patients who desire a more natural result; ie, those who want to look good without a bra, but do not want to or cannot utilize abdominal tissue, as in the TRAM flap.