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.