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Abstract
The Wise-pattern skin-sparing mastectomy (SSM) is well known for its efficacy in large ptotic breasts, and its safety in facilitating immediate breast reconstruction. An unfortunate sequalae for all SSM techniques is mastectomy skin flap necrosis (MSFN) with a reported range of occurrence of 5%–30%. For the Wise pattern, the common area of wound dehiscence or necrosis is the T-junction. Different techniques have been described in the management of MSFN—ranging from primary closure to local and distant flaps. Full thickness MSFN results in wound breakdown and can expose a prosthesis, subsequently closure must be obtained with potential for the prosthesis to be explanted. To date, there has been no reports in the literature of the usage of a rhomboid flap in an SSM with immediate prepectoral implant. We discuss our experience in the usage of this local cosmetic flap to avoid prosthesis loss and have reviewed the literature regarding MSFN, the application of the rhomboid (Limberg) flap in breast surgery and its applicability in MSFN to preserve underlying prosthesis.
- breast surgery
- plastic and reconstructive surgery
- surgical oncology
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Background
The rhomboid (Limberg) flap, first developed in 1928, is a highly versatile well-described flap.1 2 In breast surgery, the rhomboid flap has been described in breast conserving surgery techniques and in mastectomies for locally advanced disease.3 4 Mastectomy skin flap necrosis (MSFN) is reported in the literature, and the management of T-junction MSFN is varied.5 We discuss the usage of a small Limberg flap in salvaging a postmastectomy T-junction necrosis, while retaining the underlying prepectoral prosthesis with mesh.
Case presentation
A young woman was diagnosed with a left breast 6 mm Grade 1 invasive ductal carcinoma (IDC) that was hormone receptor (HR) positive. This was on a background of a previous right breast 9 mm Grade 1 IDC HR+, 5 years prior. Her management then was breast conservation therapy (BCT); however, she was unable to tolerate adjuvant hormonal therapy. Though BCT was offered for the left breast cancer, the final decision was for bilateral Wise-pattern skin sparing mastectomies with immediate breast reconstruction due to her large ptotic breasts. Intraoperatively, the prostheses were prepared with an antibiotic wash. The mastectomy pockets were irrigated with betadine prior to prepectoral implant placement with bilateral TiLoop meshes. Drains were placed and the patient was on intravenous antibiotics. The postoperative period was unremarkable apart from an area of poor wound healing associated with the left breast vertical limb, however with no evidence of infection.
The patient lived rurally, and given the active COVID climate, follow-up was carried out remotely. Wound care was organised with the local hospital nursing staff with regular imaging and correspondence with our metropolitan surgical team. Unknown to the treating team, the patient had recommenced smoking, which she had ceased leading up to her surgery. The left vertical limb failed to completely heal with ongoing iodine-based dressings and antibiotic therapy. Six weeks postoperatively scab formation developed at three areas: two on the vertical limb and one at the T-junction (figure 1). Gentle examination removed the scab with fluid spontaneously expressed and mesh visible. Given the MSFN and subsequent risk of prosthesis loss, the patient was taken to theatre for evaluation and repair.
Initial wound breakdown at T-junction and vertical limb of left breast incision after primary operation.
Treatment
Intraoperatively, a 20-mm wound dehiscence at the T-junction was identified with mesh on view. This was debrided and the visible capsule excised. There was no evidence of infection involving the implant. A betadine and antibiotic wash irrigated the implant. Attempts at primary closure failed due to tension, and a rhomboid flap from the anterior abdominal wall was fashioned. The flap was measured, subcutaneously dissected and rotated to close the T-junction defect without tension (figure 2). It was secured with deep Monocryl and superficial Vicryl Rapide sutures with superficial negative pressure wound therapy applied (PICO).
Rhomboid flap creation.
Outcome and follow-up
Postoperatively, the patient had a Bair Hugger applied to increase flap perfusion and was allowed only a limited range of motion to her left upper arm to minimise sheer stress to the flap for 5 days. On day 5, her drain and PICO dressing were removed. The wound was healing well, a new PICO applied, and the patient was discharged. Strict smoking cessation was discussed and adhered to. On day 12, her PICO was removed, displaying a well healing flap. At 2 months her wound was completely healed (figure 3).
Rhomboid flap appearance 2 months postsurgery.
Discussion
MSFN is a significant complication, especially when implant-based reconstruction is performed. Sue et al reviewed MSFN and its management, in patients undergoing delayed implant-based reconstruction.6 Of 293 patients reviewed who underwent implant-based reconstruction after mastectomy, 38 (8.1%) developed necrosis. Median necrosis size was quoted at 8 cm2. Operative debridement was performed for median necrosis size of 15 cm2. Sixteen patients (42.1%) underwent operative debridement of which nine were primarily closed. Five required prosthetic explants with two requiring latissimus dorsi flaps for additional soft tissue coverage. Unfortunately, the indications for explant were not discussed. However, we can determine that 7 of 38 patients (18.4%) had such severe necrosis that primary closure was not appropriate. A latissimus dorsi flap is quite an extensive undertaking, and a simple local flap can provide soft tissue coverage with far less morbidity.
The rhomboid (Limberg) flap, first developed in 1928, is a highly versatile and well-described flap.1 2 In breast surgery, the rhomboid flap has been described in breast conserving surgery techniques and in mastectomies for locally advanced breast cancer (LABC).3 4 Kubo et al, reviewed 68 patients with LABC, comparing the capabilities of the rhomboid flap to direct closure, post mastectomy.3 The rhomboid flap was able to close a statistically significantly larger defect area, compared with direct closure (112.7 cm2 vs 45.4 cm2, respectively, p=0.0002). They did identify a statistically significant increase in operative duration for local flap compared with direct closure, with an average increase of 25 min (142.5 min vs 117.7 min, respectively, p=0.016). However, this was not in the context of underlying prosthesis.
The only discussion of rhomboid flap usage for MSFN postimmediate reconstruction has been by Yazar et al.7 Eight patients of 58 discussed, developed T-junction necrosis after skin-reducing inverted-T mastectomies. Of these eight patients, two were identified with implant exposure postwound debridement. These two patients underwent rhomboid flap closure with no loss of prosthesis and no reported postoperative complications. These cases were all performed by plastic surgeons, and the prosthesis was placed in the submuscular plane.
It is important to reiterate a key issue in the management of MSFN as discussed by Robertson et al.5 There is ‘no clearly defined course of action… with management often decided on a case-by-case basis, in line with the surgeon’s preference’. Though primary closure is preferential in MSFN, tension-free closure is pivotal for wound healing. The usage of a local well-perfused flap can obviate the need for prosthesis explant in selected situations. There is an obvious porosity in the data in the description of the Limberg flap usage in MSFN. By discussing this simple local well-perfused flap, we can provide another option in treating full-thickness necrosis with an underlying prosthesis, beyond either primary repair or prosthesis explant.
Patient’s perspective
My breast cancer experience
Being diagnosed in 2016 due to a self-examination check finding a small pea size lump on my right breast, I was sent to Perth to for a lumpectomy followed by 6 weeks of radiation treatment for it. As I was only a young and single mum at the time, it was very overwhelming. If it had not been the nurses and doctors with their utmost care and support with also clear and understanding information that I had received about my situation, the procedure and what to expect come recovery, I don’t know that I could have mentally survived the ordeal.
With several more biopsies in the 5 years that had passed, I had attended my last appointment on the 8th of November 2021 which led to the all-clear and was discharged from the hospital finally until I had received a phone call from my doctor on the Friday, stating that sever other radiologist had examined my results which had led to some distortion and was probably nothing to worry about. Another biopsy later and it had appeared that the cancer had returned. My doctor had advised me of another lumpectomy with radiation to follow. As I did not want that Trauma of it all I had asked what my options were. As discussed, I adopted to have a mastectomy with the option of reconstruction.
It was all so overwhelming and traumatic that I had left all decisions up to my doctor to decide and to do what they had thought the best options were. Best decision I could have made. Once again with all the support from all nurses and doctors involved, had just made this journey so much more manageable throughout.
Everything had gone well, and everyone was happy with the outcome to my knowledge and was able to go home a week after. As I am always so used to doing all household chore myself, I had over done it and as I was smoking still at the time, my wound was not healing as it should have been. After many attempts to help with the healing, I was required to make the journey back to Perth in preparation for another procedure due to the implant netting being visible. Another week in hospital and it all had seemed to be ok apart from a little incision on my left breast that was not healing in a hurry.
I was then able to return home with a PICO to help with the healing process. This device was required for the next month but had eventual helped with the healing. After getting all clear and now having to wear silicon strips for 12 weeks to help with the scar tissue and another appointment with the breast cancer physio, everything seems to be on track again. I am currently taking Tamoxifen as a precaution as instructed by oncologist.
Learning points
The Wise pattern skin-sparing mastectomy is effective in large ptotic breasts.
A key area for postmastectomy skin flap necrosis in the Wise pattern is the T-junction.
The Limberg flap is a well-perfused local flap that can aesthetically repair T-junction necrosis repair and avoid implant loss.
Ethics statements
Patient consent for publication
Footnotes
Contributors All authors were involved in the development of this paper. KP was the managing consultant whom treated the patient and was instrumental in the paper development. DVH developed the original concept of the paper and wrote the provisional paper. AO significantly modified the paper, facilitated the graphical designer and has been the lead in submission.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.