Phillip G. Arnold

Efficacy of Bilateral Prophylactic Mastectomy in Women with a Family History of Breast Cancer

BACKGROUND Options for women at high risk for breast cancer include surveillance, chemoprevention, and prophylactic mastectomy. The data on the outcomes for surveillance and prophylactic mastectomy are incomplete. METHODS We conducted a retrospective study of all women with a family history of breast cancer who underwent bilateral prophylactic mastectomy at the Mayo Clinic between 1960 and 1993. The women were divided into two groups - high risk and moderate risk - on the basis of family history. A control study of the sisters of the high-risk probands and the Gail model were used to predict the number of breast cancers expected in these two groups in the absence of prophylactic mastectomy. RESULTS We identified 639 women with a family history of breast cancer who had undergone bilateral prophylactic mastectomy: 214 at high risk and 425 at moderate risk. The median length of follow-up was 14 years. The median age at prophylactic mastectomy was 42 years. According to the Gall model, 37.4 breast cancers were expected in the moderate-risk group; 4 breast cancers occurred (reduction in risk, 89.5 percent; P<0.001). We compared the numbers of breast cancers among the 214 high-risk probands with the numbers among their 403 sisters who had not undergone prophylactic mastectomy. Of these sisters, 38.7 percent (156) had been given a diagnosis of breast cancer (115 cases were diagnosed before the respective probands prophylactic mastectomy, 38 were diagnosed afterward, and the time of the diagnosis was unknown in 3 cases). By contrast, breast cancer was diagnosed in 1.4 percent (3 of 214) of the probands. Thus, prophylactic mastectomy was associated with a reduction in the incidence of breast cancer of at least 90 percent. CONCLUSIONS In women with a high risk of breast cancer on the basis of family history, prophylactic mastectomy can significantly reduce the incidence of breast cancer.

Chest-wall reconstruction: an account of 500 consecutive patients.

&NA; Our experience with 500 consecutive chest‐wall reconstructions over the past 18 years is reviewed. Of the 500 patients, 286 were male and 214 were female. Their ages ranged from 1 day to 85 years (average 55 years). Among the patients, 275 had chest‐wall tumors, 142 had infected median sternotomies, 119 had radiation necrosis, and 121 had combinations of the three. Skeletal resection of the chest wall was done in 443 patients. An average of 3.9 ribs were resected in 241 patients. Total or partial sternectomies were performed in 231 patients. Four‐hundred and seven patients underwent 611 muscle flaps: 355 pectoralis major, 141 latissimus dorsi, and 115 others, including serratus anterior, rectus abdominis, and external oblique. The omentum was transposed in 51 patients. Chest‐wall skeletal defects were closed with polyletralluoroethylene soft‐tissiue patch in 116 patienits, polypropylene mesh in 55, and autogenous rib in 13. The 500 patients underwvent an average of 2.3 operations. Hospitalization averaged 21 days. There were 15 perioperative deaths. Twenty‐three patients required tracheostomy. The average duration of follow‐up was 57 months. There were 229 late deaths; the cause of death was cancer in 147 patients, cardiac in 49, pulmonary in 7, and other in 26. Four‐hundred and three of the 485 patients (83.1 percent) who were alive 30 days after the operation had excellent results and had a healed, asymptomatic chest wall at the time of death or last follow‐up. We conclude that chest‐wall reconstruction is safe, durable, and associated with long‐term survival. (Plast. Reconstr. Surg. 98: 804, 1996.)

Early and long-term results of prosthetic chest wall reconstruction.

OBJECTIVE The purpose of this report is to evaluate our results in patients who underwent prosthetic bony reconstruction after chest wall resection. METHODS We retrospectively reviewed all patients who underwent chest wall resection and reconstruction with prosthetic material at the Mayo Clinic. RESULTS From January 1, 1977, to December 31, 1992, 197 patients (109 male patients and 88 female patients) underwent chest wall resection and reconstruction with prosthetic material. Median age was 59 years (range, 11-86 years). The indication for resection was recurrent chest wall malignancy in 65 patients (33.0%), primary chest wall malignancy in 62 patients (31.5%), contiguous lung or breast carcinoma in 58 patients (29.4%), and other reasons in 12 patients (6.1%). Three patients (1.5%) each had an open draining wound. This review covers 2 time periods. Sixty-four patients (32.5%) underwent reconstruction with polypropylene mesh during the period from 1977 to 1986. One hundred thirty-three patients (67.5%) underwent reconstruction with polytetrafluoroethylene from 1984 to 1992. Soft tissue coverage was achieved with transposed muscle in 116 patients (58.9%), local tissue in 81 patients (41.1%), and omentum in 3 patients (1.5%). There were 8 deaths (operative mortality rate, 4.1%). Ninety-one patients (46.2%) experienced complications. Seromas occurred in 14 patients (7.1%). Wound infections occurred in 9 patients (4.6%; 5 patients with polypropylene mesh and 4 patients with polytetrafluoroethylene). The prosthesis was removed in all 5 patients with polypropylene mesh and in none of the patients with polytetrafluoroethylene. Follow-up was complete in 179 operative survivors (94.7%) and ranged from 1 to 204 months (median, 26 months). A well-healed asymptomatic wound was present in 127 patients (70.9%). CONCLUSIONS Chest wall resection and reconstruction with prosthetic material will yield satisfactory results in most patients. Little difference exists between polypropylene mesh and polytetrafluoroethylene.

Chest wall reconstruction. Experience with 100 consecutive patients.

Experience with 100 consecutive chest wall reconstructions during the past 7 years was reviewed. There were 52 female and 48 male patients with ages ranging from 13 to 78 years (average 53). Of the 100 patients, 42 had tumors of the chest wall, 19 had radiation necrosis, 24 had infected median sternotomies , and 15 had combinations of the three. Seventy-six patients underwent skeletal resection of the chest wall. An average of 5.7 ribs were resected in 63 patients. Total or partial sternectomies were performed in 29. Ninety-two patients underwent 142 muscle flaps: 77 pectoralis major, 29 latissimus dorsi, and 36 other muscles, including serratus anterior, rectus abdominis, and external oblique muscles. The omentum was transposed in ten patients. Chest wall skeletal defects were closed with Prolene mesh in 29 patients and with autogenous ribs in 11. Eighty-nine patients underwent primary closure of the skin. The 100 patients underwent an average of 2.1 operations. Hospitalization averaged 17.5 days. There was one perioperative death (29 days). Two patients required tracheostomy. Follow-up averaged 21.6 months. There were 24 late deaths. All 99 patients who were alive 30 days after operation had excellent results at the time of death or last follow-up.

Use of pectoralis major muscle flaps to repair defects of anterior chest wall.

We closed defects of the anterior chest wall in 6 patients, using either unilateral or bilateral pectoralis major muscle flap transpositions. In 4 of these patients the defect was stabilized with autogenous rib grafts, and none of these had a flail chest. All of the transposed muscle flaps remained viable and innervated. The deformities and the functional disturbances resulting from the transpositions were minimal.

Long-term results of pectoralis major muscle transposition for infected sternotomy wounds.

During an 11.5-year period, 100 consecutive patients (79 male, 21 female) underwent repair of an infected sternotomy wound. Sixty-five patients had failed attempts at wound closure by other physicians. Median age was 61.5 years (range, 5 to 85 years). Reconstruction included muscle in 79 patients, omentum in 4, and both in 15. A total of 175 muscles were transposed, including 169 pectoralis major, 3 rectus abdominis, 2 external oblique, and 1 latissimus dorsi. Median number of operations was four (range, 1 to 11). Mechanical ventilation was required in 30 patients. Two perioperative deaths occurred, one related to sepsis. Median follow-up was 4.2 years (range, 1.3 to 13.5 years). Twenty-six patients had recurrent infection. Median time from our closure to recurrence was 5.5 months (range, 0.3 to 27.6 months). Cause of recurrence was inadequate removal of cartilage in 16 patients, bone in 6, and retained foreign body in 4. Eighteen patients had the wound reopened with further resection; 10 had another muscle or omentum transposition. There were 30 late deaths, only one related to recurrent infection. At the time of death or last follow-up, 92 patients had a healed chest wall. Transposition of the pectoralis major muscle remains an excellent method of management for infected sternotomy wounds. Failure is directly related to persistent infection of cartilage, bone, or retained foreign bodies.

Thoracic Wall Defects: Surgical Management of 205 Consecutive Patients

In this article, we review our experience during the past 9 years with 205 consecutive thoracic wall reconstructions. The 100 female and 105 male patients ranged in age from 12 to 85 years (mean, 53.4 years). One hundred fourteen patients had thoracic wall tumors, 56 had radiation necrosis, 56 had infected median sternotomy wounds, and 8 had costochondritis. Twenty-nine of these patients had combinations of the aforementioned conditions. One hundred seventy-eight patients underwent skeletal resection. A mean of 5.4 ribs were resected in 142 patients. Total or partial sternectomies were performed in 60. Skeletal defects were closed with prosthetic material in 66 patients and with autogenous ribs in 12. One hundred sixty-eight patients underwent 244 muscle flap procedures: 149 pectoralis major, 56 latissimus dorsi, 14 rectus abdominis, 13 serratus anterior, 8 external oblique, 2 trapezius, and 2 advancement of diaphragm. The omentum was transposed in 20 patients. The mean number of operations per patient was 1.9 (range, 1 to 8). The mean duration of hospitalization was 16.5 days. One perioperative death occurred (at 29 days). Four patients required tracheostomy. During a mean follow-up of 32.4 months, there were 49 late deaths, predominantly due to malignant disease. All 204 patients who were alive 30 days after operation had excellent surgical results at last follow-up examination or at the time of death due to causes unrelated to the reconstructive procedure.

Intrathoracic muscle flaps. An account of their use in the management of 100 consecutive patients.

One hundred consecutive patients underwent intrathoracic muscle transposition between May 1977 and February 1988. Seventy-three procedures were performed to manage the complications of infection, which included treatment of bronchopleural fistula, postpneumonectomy empyema, perforations of the heart or great vessels, and fistulae of the esophagus and trachea. Prophylactic reinforcement of the repaired viscus was done in the remaining 27 patients because of either increased airway tension or previous intrathoracic radiation. There were 71 male and 29 female patients. Ages ranged from 16 to 82 years (median, 58 years). One hundred thirty muscle transpositions were performed and included 60 serratus anterior flaps, 33 latissimus dorsi, 28 pectoralis major, 3 intercostal, 2 rectus abdominus, and 4 others. The number of operations per patient ranged from 1 to 13 (median, 2). Seventy-six complications occurred in 35 patients. There were 16 operative deaths. Follow-up ranged from 3.4 to 150.7 months (median, 41 months). Infection was controlled or avoided in 73 patients. Forty-three of the operative survivors died. Cause of death was cancer in 27 patients, cardiac in 4, pulmonary in 3, infection in 3, suicide in 1, and unknown in 5. We conclude that although associated with a significant morbidity and mortality, intrathoracic muscle transposition when there is an actual or potential leak of an intrathoracic viscus can be life saving. Long-term survival, however, is determined by the pre-existing thoracic disorder.

Muscle Flaps in Irradiated Wounds: An Account of 100 Consecutive Cases

Radiation-related wounds challenge surgeons in all disciplines of surgery. Wound-healing complications are commonplace, and solutions for reconstruction are limited. Muscle and musculocutaneous flaps have improved this situation. We ask the question, Does previous radiation of the muscle to be transposed affect the outcome? One hundred consecutive previously irradiated wounds closed with muscle or musculocutaneous flaps composed the group under consideration. These 100 patients had 151 muscles transposed. The overall complication rate for muscle transposition to close a radiated wound was 25 percent. Of the 100 patients who received radiation, 43 patients had the muscle transposed for wound closure from the primary field of radiation. Fifty-seven patients were closed with nonirradiated muscle. When the transposed muscle had been radiated, the complication rate was 32 percent; in 14 percent, the entire muscle died, requiring total removal and a second tissue transposition from a nonirradiated source to achieve closure. The subgroup using nonirradiated muscle had a complication rate of 19.3 percent; no patient in this group had complete flap death requiring a second tissue transposition. Two postoperative deaths, one in each group, unrelated to the operative procedure were recorded. We feel that nonirradiated muscle is the best choice for closure of a radiated wound, if possible. (Plast. Reconstr. Surg. 93: 324, 1994.)

Making the Most of the Gastrocnemius Muscles

The two heads of the gastrocnemius muscle are easily mobilized and very dependable. It is our first choice for local muscle transpositions in and about the knee. Thirty-four consecutive gastrocnemius muscle flaps performed on one service are evaluated. Seven maneuvers and some technical points are presented and illustrated to enable the surgeon to get the most possible use of these two reliable structures.