Radiation Wounds & Injury around the Breast for Cancer

Radiation treatment (RT) is a double edge sword in the treatment of cancers.  Just as with chemotherapy, it attacks the cancers cells, but also damages normal cells.   This is quite evident when the "marks" of radiation are left behind on the skin in the form of a tattoo, and more seriously, as a radiation wound that may ulcerate or turn into cancer.  RT is a common treatment for breast cancer, especially for "breast conservation" techniques and to treat the local area for possible recurrence even after mastectomy.

Despite advanceces in RT, long-term complications of radiation injury are still quite common, in the range of 20%,  Depending upon the cycle and total dose, the body's response to radiation is similar to a "burn."  There is soft tissue fibrosis and decreased blood flow which can lead to ulceration, tissue necrosis, infection, chronic wounds, and sometimes, cancer.  This may not be apparent for many years, but it is often a slow, progressive injury with difficult treatment options.   .

RT makes wound healing extrmely difficult because of the tissue"fibrosis" and decreased blood flow. Once a wound forms in a radiated area, it is often a sign of more serious injury deep below the skin, including muscles, bones, cartilage, blood vessels and nerves.   Typical "wound care" with dressings are usually not enough to heal this damaged area.   Hyperbaric oxygen (HBO) may help in these circumstances, but ultimately, the radiated wound needs additional blood flow and cleaning out of the damaged and/or necrotic/infected tissue.  Additional oxygen with HBO can only do so much when blood flow has already been reduced by the RT.     

In select wounds, especially around the breast, the best form of treatment to heal radiation damaged breast tissue is with new, non radiated tissue that is brought to the area with additional blood flow, in the form of a "flap."   This reqiures careful assesment and planning and is the gold standard by which a complex wound can be healed.    Fortunatley, around the breast, there are many options to bring new tissue from the abdomen or back to treat the damaged area.    The breast can be completely reconstructed at the same time as the wound with designer flaps such as the DIEP or SIEA perforator flap in a single procedure.

Most importantly, the health practitioner must recognize when the current treatment of an irradiated breast wound is not working.   Far too often, I have seen patients who have had over 100 treatments with HBO, or years of a chronic, nonhealing wound, or with recurrent implant/tissue expander infections/capsular contracture.    3 months is the maximum time that a wound should be treated in the same manner with minimal progress;  it is at this time that a higher, expert level of assesment must be performed to determine further treatment options.  

What is the difference between "Immediate" and "Delayed" Breast Reconstruction?

This is "surgical" terminology to describe the timing of breast reconstruction in either the "immediate" situation after mastectomy, or in a "delayed" fashion, after many months or years after the mastectomy.  So the key difference is months, not hours.
There are advantages and disadvantages to each "timing" method.  First, the advantage of "immediate" reconstruction is that breast reconstruction and mastectomy are performed in 1 operation.  One does not have to wait for the "healing" after the mastectomy (typically 3-6 months), and wait for another operation to reconstruct the breast.  In terms of aesthetics, if a "skin sparing" mastectomy can be performed, the breast shape can be excellent and the overall result of the breast reconstruction can be superb.   The "skin sparing" techninque allows the surgeon to use the remaining skin as a cover over the flap (DIEP, SIEA, TRAM) or implant/tissue expander that will help shape the breast into a more natural mound.

The disadvantage of the "immediate" technique lies with the potential oncologic issues that can occur if the cancer issues are not fully eradicated, and the breast has been reconstructed with the possibility that cancer cells may come back to recur in the reconstructed breast.  The other concern is radiation therapy.  In the immediate reconstruction, radiation can adversely affect the outcome of the breast reconstruction (shape, healing, capsular contracture, etc).

The "delayed" technique is still the safest.  It provides the optimum time for healing after mastectomy, addresses issues of "recurrence," and allows the operation to be split in 2 stages allowing the patient to recover from the initial mastectomy and then address the reconstruction later.  The cosmetic result can still be excellent, with the "immediate" reconstruction having a slight advantage in overall shape.

The choice of "immediate" versus "delayed"  is not an easy one.  The overall team that is available is critical in choosing either method.  This includes the general surgeons, plastic surgeons, oncologists, and nurses.  

A Perfect Microsurgical Anastomosis (Blood Vessel Repair)

Above: Microsurgical anastomosis between the Internal Mammary Artery and Vein to the Deep Inferior Epigastric Artery Perforator (DIEP) Vessels using an Operating Microscope.  Dr. Alexis Carrell from the University of Chicago (1902) proved that we can successfully reconnect blood vessels using a technique called "triangulation"--he received the Nobel Prize for his efforts.  Microscopes were used in vascular surgery in the 1960s (Jacobsen) and this allowed for blood vessels to be repaired that were less than 2millimeters.  This began the revolution in Reconstructive MicroSurgery, the same techniques that allow us to Reconstruct the Breast by Tissue Transplantation (from the abdomen --TRAM, DIEP--, thighs, etc) and also allows Plastic Surgeons to transplant a hand or face.

Above:  Close up of the Microsurgical Anastomosis (Reconnection between blood vessels)
Note the fine black sutures and precise interspacing to allow for free flow of blood between the 2 connectected blood vessels.  These sutures are finer than human hair.  The top, purple vessel is the Vein; the smaller, lighter pink vessel is the Artery.  Reconnecting these blood vessels takes significant skill and patience. 

The temperment of a Plastic Surgeon who performs Microsurgery is different from the average surgeon. Focused intensity, absolute precision (there is little margin of error for a microsurgical blood vessel connection to avoid a blood clot), creativity and the steadiest of hands are basic hallmarks.  There is a reason why Reconstructive MicroPlastic Surgeons are a rare breed.

What is an SIEA Flap?

The SIEA Flap is a pure abdominal skin and fat flap.  SIEA stands for Superficial Inferior Epigastric Artery.  This blood vessel system comes from the same branches of the DIEP flap, however, it is more superficial.    It allows the surgeons to use the skin and fat from the abdomen (tummy tuck) tissue and blood vessel without having to enter the abdominal wall fascia.  It is the most IDEAL flap for breast reconstruction in terms of donor site morbidity (the process of taking from one area to fix a different area).    However, not every patient has this particular blood vessel system, somewhere around 40% of the time these blood vessels exist.  When the blood vessels do exist, another 20% may not be usable because of their size.   The great advantage of this flap is that the abdominal wall is not "touched" and therefore the rectus muscles (six pack muscles on the abdomen), are not touched.  The disadvantage is that the blood vessels can be quite small the blood flow through the tissue can be variable.  The success of this flap depends upon your body's anatomy and surgeon experience and technical expertise.

We can perform a color duplex ultrasound at the initial evaluation to determine if you are candidate for this flap procedure.

Note the Blood Vessels (SIEA System) over the blue background.  These are more superficial than the DIEP system.

What is a TAP flap?

Pic #1: Flap Design on Chest
Pic #2: TAP flap elevated
Pic #3: Donor Site of Chest (note incision, no loss of muscle)
Pic #4: Donor Site on Back

The TAP flap is a new perforator flap that originates from the same blood vessels as the Latissimus muscle. TAP stands for Thoracodorsal Artery Perforator flap. Because of its location, it has a very nice donor site, underneath the arm pit area and back. It can be used in breast reconstruction as a local flap or free flap, giving a lot of versatility.

This flap is not as large as the abdominal tissue flaps from the DIEP, SIEA, or TRAM, but has good indications for smaller to midsize breast issues. Typically, a lumpectomy or partial mastectomy defect can leave a significant breast deformity. This flap can be "rotated" into the wound defect or deformity or microvascularly transplanted into the wound.

New treatment options for postmastectomy lymphedema

Lymphedema after a mastectomy is an extremely difficult problem. The mainstay of treatment has been lymphatic massage and physical therapy. Lymphedema usually progresses over time and the tissues become more and more recalcitrant to physical therapy and massage. Because of the inadequate lymphatic flow, tissue that is lymphedematous is more at risk for infections. This sets up the extremity into a downward spiral as the remaining lymphatic vessels are further destroyed by subsequent nfections. This then causes further lymphatic obstruction and edema and causes a worsening of the inflammation and scarring process, which leads to further fibrosis of the extremity.

The only true way to treat this condition is to restore the lymphatic flow where the obstruction is sitting. Previously, this has been done by lymphovenous bypass procedures. They have been only moderately successful. This requires extremely delicate microvascular anastomoses to reconnect lymphatics to the veins so that the lymphatics have a channel to leave the swollen extremity.

A more novel approach and more anatomically correct operation would be to replace the lymphatic channels with lymph tissue, and lymph nodes to help re-create new lymphatic channels. This can be accomplished by lymph node transplantation with a vascularized skin flap. This is a cutting-edge operation and the worldwide literature is quite sparse. The preliminary findings after this operation have been extremely promising. There has been a dramatic decrease in the number of infections as well as a significant increase and the diameter of the extremity after this surgery. These results are far better than the previous lymphovenous bypass surgeries and represents a new paradigm in treating extremely difficult lymphedema. This operation will likely serve as a more permanent solution to an extremely difficult and debilitating problem.

Use of the Internal Mammary Artery Perforator, No Rib Resection

The internal mammary artery has become the vessel of choice for microsurgical breast reconstruction. It has become popular because the position the of the vessel allows the flap to be positioned on the chest at a more medial position, versus the more lateral position of the lateral thoracic vessels. If you study the breast mound position, you will find that medial placement of the mound is more important than lateral placement.

The main issue with the use out of this vessel are twofold. #1. It requires removal of rib cartilage and deeper dissection into the thoracic cavity to gain access to this vessel. This sometimes leaves an indentation on the chest wall where the rib was removed. #2. The left internal mammary artery is a common source vessel for coronary artery bypass surgery to revascularize the heart. This means that in some rare cases, if this vessel has been used for breast reconstruction, it is no longer available for heart bypass surgery.

It is our philosophy that we should try to avoid use of this vessel when possible. We have been able to find, in a majority of our cases, the perforating artery and vein to the internal mammary vessel. This has shortened our operating time as well as avoiding the issues discussed above with removable are written and use of the main source vessel for coronary artery bypass surgery. We have been able to identify this vessel with ultrasound techniques as well with finesse, microsurgical dissection.