Plastic Surgery: A Component in the Comprehensive Care of Cancer Patients

Plastic surgical reconstructionextends the capabilities of surgical and radiation therapy for cancer patients. Resection defects that arelarge, involve functional structures, aesthetically sensitive areas, and/or areat increased risk for wound healing complications are successfully reconstructedwith a wide variety of techniques. Cancer and the complications of cancertreatment can involve virtually any area of the body, and to address everypotential circumstance, the breadth of oncologic reconstruction must beextensive. A multidisciplinary team approach is the optimal method of cancertreatment, and plastic surgical reconstruction has become a critical componentof that treatment, with the ability to restore form and function to the involvedareas.

It is with great pleasure that I have the opportunity to reflect on thearticle by Drs. Hasen, Few, and Fine, who nicely summarize some of the commonlyperformed oncologic reconstructive procedures. The authors are to be commendedfor their succinct and simplified overview of the complex decision-making andexecution involved in oncologic reconstruction.

Choosing a Procedure

Decisions about breast reconstruction should be individualized, based oninput from both the surgeon and patient. It is crucial that there be open andaccurate communication with the medical oncologist, breast surgeon, andradiation therapist, who will influence the potential reconstructive options andultimate procedure selected.

As stated in the article, tissue expander/implant reconstruction can be usedfor patients who are uncertain of the type of reconstruction they desire. Thisoption is the least invasive, reversible, maintains the shape of the breast skinenvelope, does not involve surgery outside the breast area, and usually can beconverted to an alternative type of reconstruction in the future, if desired.Although this strategy "burns no bridges," I would strongly emphasizethe benefit of choosing and performing the reconstructive option best suited forthe patient as the primary procedure, to reduce the potential need foradditional operative procedures.

Every attempt should be made to educate the patient about each availableoption, providing a detailed comparison of the risks, complications, expectedoutcomes, and recovery considerations. Additional sources of information thathave been helpful include written literature, diagrams, photographs, videos, anddiscussions with patients who have undergone each procedure (ie, those who havehad positive and negative experiences).

I am much more reluctant than the authors to use tissue expander/implantreconstruction in patients who have had or will receive chest-wall irradiation,particularly if an autologous tissue reconstructive option is available. Thefunctional and aesthetic outcome is often compromised and, as mentioned, thecomplication rates are considerably higher.

The Radiation Dilemma

Reconstruction of patients who are at risk for receiving postmastectomyradiation therapy is a heavily debated dilemma among reconstructive surgeons.Certainly, radiation administered to any type of breast reconstruction often hasa negative impact on outcome. Unfortunately, it is not always possible topredict who will be recommended for postmastectomy irradiation. Permanentpathologic assessment of the mastectomy specimen and axillary lymph node(s)commonly determines whether these patients will receive radiation therapy. Thetwo compelling dilemmas for these patients involve (1) the use of immediatetissue expander/implant reconstruction, and (2) immediate vs delayedreconstruction.

The need for postmastectomy radiation is frequently the major factor indeciding between prosthetic (tissue expander/implant or latissimus/implant) orautologous tissue (transverse rectus abdominis myocutaneous [TRAM] or latissimusflap) reconstruction. However, this often cannot be determined pre- orintraoperatively. Reconstructive surgeons are frequently reluctant to performprimary reconstruction (including autologous tissue reconstruction) in patientswho are more likely to receive postoperative radiation therapy.

The alternative choice is delayed reconstruction. However, this approach doesnot preserve the shape of the breast skin envelope and may compromise the finalaesthetic outcome. In addition, delayed reconstruction subjects the patient toadditional surgical procedure(s) and does not provide the psychological benefitof having a reconstructed breast mound immediately following mastectomy.

In general, I prefer to delay breast reconstruction in patients who are at"higher risk" of receiving postmastectomy radiation therapy. Moreover,I recommend that these patients undergo a preoperative work-up that will providethe most accurate assessment of that risk. In addition to a detailed physicalexamination and diagnostic mammogram, this may involve further imaging of thebreast and regional nodal basins with ultrasound and fine-needle aspirationbiopsy of suspicious nodes. With the information from these studies, the patientand surgeon, together, can make a more informed decision regarding the methodand timing of reconstruction.

Latissimus Dorsi Flap

I agree that the latissimus dorsi with implant is superior in some respectsto tissue expander/implant reconstruction because the implant is less palpable,the breast feels softer, the overall aesthetic outcome is better, and theimplant complication rate is lower. However, I strongly prefer "autologousonly" reconstruction in the face of pre- or postoperative radiationtherapy.

I consider the major advantage of latissimus dorsi/implant over tissueexpander/implant reconstruction to be the ability to create a breast mound atthe time of mastectomy (usually without the need for serial tissue expansionand/or implant exchange). In addition, the latissimus dorsi muscle and overlyingskin paddle provide a thicker layer of tissue over the implant, thus improvingthe "feel" of the breast and reducing the risk of capsularcontraction, implant palpability, and wound healing complications that couldlead to implant exposure and/or infection.

TRAM Flap

I agree with the authors that the free or pedicled TRAM flap reconstructionprovides the most natural feel and appearance of the breast but is a moreinvasive procedure. The greater vascularity of the free, compared to thepedicled, TRAM flap allows for a greater volume of flap tissue to be reliablyused and may reduce the risk of partial-flap and fat necrosis. This isparticularly beneficial for patients who have compromised vascularity to theTRAM tissue (eg, tobacco smokers). Moreover, the free TRAM includes less rectusabdominis muscle, potentially reducing donor site morbidity.

Head and Neck Reconstruction

The choice of flap for head and neck reconstruction should be based on thecharacteristics of the resection defect, including the thickness or bulk oftissue required, the need for a bone component, and the amount of skin requiredfor oral lining. As pointed out by the authors, the free radial forearm flap isan excellent choice for many head and neck defects, particularly for intraoraldefects, because it provides thin, pliable skin-containing tissue. I would addthat when thin tissue is required, the anterolateral thigh and lateral arm flapare good alternatives to the radial forearm.

A free vertical rectus abdominis myocutaneous (VRAM) flap is a good choicewhen there is a need for both bulk and intraoral lining, such as with totalglossectomy defects. I would also emphasize that select intraoral defects, suchas hemiglossectomy defects that do not significantly involve the floor of themouth and/or base of the tongue, can be reconstructed with primary closure, skingrafting, and/or secondary-intention healing, with a good functional outcome.

Mandibular Reconstruction

The free fibula flap is clearly the "work horse" for mandibularreconstruction. Because the fibula is a long, bicortical vascularized bone, itcan be cut into multiple individually vascularized segments that are then platedtogether to accurately restore the natural shape of the missing mandible. A thinskin paddle can be included with this flap for intraoral lining. The use of asoft-tissue-only reconstruction (such as a free VRAM), however, is anacceptable alternative for posterior mandibular defects without the need for anosseous flap, particularly when the coudyle is resected.

Conclusions

Plastic surgery reconstruction has had a significant impact on the care ofcancer patients, as this article clearly outlines. In addition to the areascovered by the authors, considerable success has been achieved in numerous otherareas including reconstruction of the vagina/perineum, lumbosacral area,chest/abdominal wall, scalp, ear, craniofacial region, upper and lowerextremities, and defects involving radiation injury.