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A new method of bipedicled transverse rectus abdominis myocutaneous flap splitting to reconstruct the contralateral breast 1 year after the first breast reconstruction is presented. This technique can be useful in cases of large salvage mastectomy for asynchronous breast cancers allowing a bilateral thoracic closure.
this procedure has become very popular and largely used both for breast reconstruction and thoracic wall repair. The flap can be harvested as a monopedicled island unit, a bipedicled one and as a microvascular transfer. Once it has been used to reconstruct a breast mound, it is usually not possible to use the same flap to reconstruct the contralateral breast.
In this case a new method of flap splitting is described to reconstruct the contralateral breast one year after the first breast reconstruction.
1. Case report
A 43-year-old woman was admitted to our department in July 1996 with a right breast cancer. She underwent quadrantectomy and axillary dissection. Histopathological findings revealed invasive ductal carcinoma grade III, pT2 (2.2 cm), N1b (1/27) with absence of estrogens and progesterone receptors. She received postoperative radiotherapy and adjuvant chemotherapy consisting of six cycles of CMF (Cyclophosphamide, Methotrexate and Fluoruracil).
In January 1998, the patient developed a local recurrence in the right breast and she received chemotherapy with V-FUP (Vinorelbin, Cisplatinum and Fluoruracil) for four cycles, until the end of April 1998. One month later, she developed again a large local recurrence with a total skin infiltration. She underwent right total mastectomy with large skin removal and thoracic wall repair using a bipedicled TRAM flap (Fig. 1) . Histopathological findings showed foci of invasive ductal carcinoma (0.2 cm) with diffuse neoplastic emboli in the dermis and the nipple (ypT4d).
Fig. 1Preoperative drawing of a right mastectomy and immediate reconstruction with a bipedicled TRAM flap.
In September 1999, the patient developed a left breast cancer staging pT2 (4.5 cm) N1b and therefore she received neo-adjuvant chemotherapy with TEF (Taxotere, Epirubicin and Fluoruracil) for three cycles. Four months later she underwent left modified radical mastectomy with wide skin removal, due to the large size of the tumour. At the moment, the problem was to cover the left thoracic wall defect achieving an acceptable cosmetic result without additional scars (Fig. 2) . The whole bipedicled TRAM flap previously performed (May 1998) was elevated from the chest wall. The pedicles were identified using an intraoperative Doppler probe and carefully preserved. The rectus muscles, atrophied and close to each other were carefully separated avoiding any damage of the vascular pedicles. Finally, the flap was split into two similar halves: the left half was used to cover the left thoracic defect and the right unit to repair the right thoracic area (Fig. 3) . Postoperative period was uneventful and early postoperative results are shown (Fig. 4) .
Fig. 2Right breast reconstruction with a bipedicled TRAM flap. On the left side a modified radical mastectomy is planned.
Histopathological findings yielded invasive ductal carcinoma staging pT3 (9 cm) pN1b (16/30) showing no hormonal receptors. Postoperative high dose chemotherapy plus chest wall radiotherapy were performed. The patient is currently disease-free at 18 month follow-up, requiring a bilateral implant placement to improve the size and shape of the breast.
2. Discussion
Although the surgical treatment of breast cancer has become more conservative in the last decades, in case of large tumours, skin infiltration or multiple skin recurrences the radical mastectomy with large skin removal still represents the first indication. Several surgical solutions are available for breast reconstruction and thoracic wall repair: local skin flaps,
and micro-vascular transfers. In this clinical case, the problem was to cover a large thoracic wall defect after bilateral asynchronous mastectomy requiring wide skin removal. Local transposition of abdominal skin was not possible after a TRAM flap; a latissimus dorsi musculocutaneous flap would not have been large enough to cover the defect without skin grafts. Free flaps or omental flap could have been performed increasing the risk of complications, especially related to the general condition of the patient treated with high chemotherapy. For this reasons we decided to split the bipedicled TRAM flap, as first described by Delaney et al.
In this case the bipedicled TRAM flap demonstrated to be a versatile solution allowing a contralateral breast reconstruction 1 year after the first one.
Although oncologists frequently contraindicate extended surgery in case of locally advanced cancer, the patient is currently disease-free at 18 month follow-up.
References
Hartrampf C.
Scheflan M.
Black P.
Breast reconstruction with a transverse abdominal island flap.
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