Discussion
Of the nine patients analyzed, only one had partial necrosis of skin due to poor wound healing after previous MRM with an advanced flap. All patients were treated with NPWT applied to the complex breast wound comprising LD muscle flaps and STSG skin graft. Two of the patients developed seroma LD flap over donor site, for which they received aspiration and achieved resolution at three weeks of follow-up. Despite the presence of diabetes and morbid obesity, which were believed to be risk factors for flap failure, the patient’s recovery was satisfactory(8).
For reconstruction of large wounds in advanced breast cancer, the musculocutaneous flap provided a reliable skin island. In 1982, Hartrampf et. al. first used cranially pedicled rectus abdominis muscle flap with a horizontally oriented adipocutaneous skin island. In this technique, blood is supplied to the skin island via perforating vessels piercing the rectus abdominis muscle, arising from the deep epigastric system.(9) Patients with advanced breast cancer are appropriate candidates for TRAM flap reconstruction.(10) However, several complications must be considered, such as abdominal weakness, which may cause abdominal bulges or hernias.(11) Contraindications for TRAM flap reconstruction are those who received previous abdominal surgery that may have interrupted blood supply to the flap, in addition to those unwilling to quit smoking, obese patients, and those with an uncontrollable underlying condition, such as diabetes mellitus or ongoing steroid treatment. By contrast, LD flap reconstruction presents advantages in reliability, size, and location.(12) The dominant blood supply for the LD muscle mainly comes from thoracodorsal vessels and from perforating branches of the posterior intercostal vessels. The feasible rotation of the LD flap allows coverage of the ipsilateral side of the chest wall and the adjacent area. Because of the insufficiency of skin coverage for large defects in our patients, STSG was harvested from either the scalp or thigh for reconstruction.
Complications of LD flap reconstruction are few and may include visible scarring at the back, seroma at the donor site, shoulder functional disability, and numbness and weakness postoperatively.(13) In our study, two patients presented with donor-site seroma. Aspiration was performed in these patients, and the seroma gradually subsided in the following days. Partial skin island nonhealing was observed in one patient, which was resolved satisfactory through topical wound care.
As for wound healing after breast cancer surgery, prolonged wound processing may postpone further chemotherapy or radiation therapy for the patient. The acceleration of wound healing has several modalities, and the NPWT system can achieve faster wound healing, especially in difficult recipient wound beds.(14, 15)Vacuum-assisted closure is a well-established form of NPWT, which was introduced in 1996.(16, 17) The NPWT system generates negative pressure when applied to the wound through foam dressing to serve as a sealant. It promotes granulation tissue formation by increasing the blood flow, eliminates infectious debris and exudates, and facilitates the skin graft by immobilizing the graft.(14, 18) Previously, NPWT was used to promote wound healing by immobilizing the graft, removing edematous fluid, increasing the blood flow, stimulating granulation tissue and neovascularization, and reducing bacterial contamination.(19, 20) Nakamura et. al. conducted a retrospective study and suggested that NPWT may be superior to the tie-over method for the stabilization of skin grafts, especially in large or muscle-exposing defects in the trunk or extremities.(7) NPWT yielded higher graft survival rates and shorter operative times.(7, 21) We used NPWT as a graft stabilization modality to limit shear stress over the graft. The wound was opened on postoperative day four to evaluate the flap condition. All patients in our study exhibited favorable skin acceptance of the flap.
This study has several limitations. First, the reviewed literature regarding the use of NPWT in large breast wounds in combination with muscle and skin graft reconstruction is limited. Second, the sample size was small. Finally, because local recurrence is a major concern in breast cancer surgery, long-term follow-up is warranted in our patients.