8
Breast reconstruction is an essential part of the inter- disciplinary treatment for breast cancer. Early attempts to restore the post-mastectomy defect were accomplished with the ipsilateral latissimus dorsi flap, 1 which has the advantages of reliable vascularity, prox- imity to the defect and simplicity in dissection. However, the classic latissimus dorsi flap suffers from its lack of sufficient volume, so that the addition of a prosthetic implant becomes mandatory. With the growing concern about the long-term safety and stability of implants, 2,3 reconstruction with auto- genous tissue alone is much preferred. As a result, the transverse rectus abdominis musculocutaneous (TRAM) flap, with its abundant tissue bulk, has become the gold standard for breast reconstruction since the 1980s. With all its merits however, the TRAM flap also has limitations. Complications such as abdominal weakness or flap necrosis remain a constant threat, especially among obese individuals. 4 Furthermore, for patients with multiple previous abdominal incisions, patients suffering from chronic back pain, or young women expecting pregnancy in the future, this opera- tion is problematic. For such cases, the latissimus dorsi flap is a valuable alternative, which would be even more satisfactory if the tissue bulk of the flap could be increased to reduce the need for an alloplastic implant. Early success was achieved by Hokin in 1983, 5 who subsequently reported a series of 55 reconstructions without implant in 1987. 6 Marshall et al, 7 in 1984, published a T-shaped flap design, and in 1988, Papp et al 8 suggested harvesting the maximally available skin paddle and using the de-epithelialised dermal–fat pad to augment the tissue bulk. Barnett and Gianoutsos 9 then introduced their method of the latissimus dorsi added-fat flap, and Germann and Steinau 10 showed their successful experience in 47 cases using the extended latissimus dorsi flap. These reports showed that it was possible to use the latissimus dorsi flap alone as a means for breast recon- struction. However, it remains unclear what kind of patient tends to have a favourable result, what weight of tissue is obtainable and do the body build and the size and shape of the breast have any influence upon the cosmetic results? In order to answer these ques- tions, we measured and analysed several relevant para- meters and tried to find out their significance as regards the final aesthetic quality. Material and methods From July 1996 to November 1997, 12 consecutive patients underwent breast reconstruction using the extended latissimus dorsi flap at The National Cheng Kung University Hospital. Their ages ranged from 25 to 71 years, with an average of 44.6 years. Follow-up evaluations, conducted for all patients, ranged from 6 to 21 months, with a mean of 11.8 months. Surgical technique The flap design is marked preoperatively with the patient upright. The largest available skin paddle is determined by the pinch test and outlined with a marking pen. The proposed extension of the fat–fascia 365 Extended latissimus dorsi musculocutaneous flap for breast reconstruction: experience in Oriental patients J.-W.Lee and T.-W. Chang* Division of Plastic Surgery, and *Division of General Surgery, Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan, R.O.C. SUMMARY. Unilateral breast reconstruction with an extended latissimus dorsi musculocutaneous flap was car- ried out for 12 women in the National Cheng Kung University Hospital.Eleven patients acquired a good or fair result cosmetically. We analysed the net weight of the flap as well as various anthropometric data to see what effect they have on the final aesthetic outcome. The weight of the flap ranged from 180 to 610 g, and the resected specimen weighed from 160 to 635 g. The flap weight was equivalent to 61%–113% of the specimen weight. A sat- isfactory result could be achieved when the bulk of the flap attained 70% of the mass resected. We also observed that the aesthetic quality is better when the breast is less ptotic. All of the muscle transfers survived completely without any flap loss. The only complications included one minor wound edge slough and another modest seroma formation at the donor site.This reconstructive method is a viable option for young women with small or medium-sized breasts who anticipate pregnancy in the future. It is especially advisable in Oriental society, since the breast size of the patients is generally smaller and the donor scar is hidden, given the hypertrophic tendency of the lower abdominal scar in Asian people undergoing TRAM flap reconstruction. Keywords: breast, reconstruction, latissimus dorsi musculocutaneous flap, extended. British Journal of Plastic Surgery (1999), 52, 365–372 © 1999 The British Association of Plastic Surgeons

Extended latissimus dorsi musculocutaneous flap for breast reconstruction: experience in Oriental patients

  • Upload
    j-w-lee

  • View
    221

  • Download
    6

Embed Size (px)

Citation preview

Page 1: Extended latissimus dorsi musculocutaneous flap for breast reconstruction: experience in Oriental patients

Extended latissimus dorsi musculocutaneous flap for breast reconstruction:experience in Oriental patients

J.-W. Lee and T.-W. Chang*

Division of Plastic Surgery, and *Division of General Surgery, Department of Surgery, National Cheng KungUniversity Hospital, Tainan, Taiwan, R.O.C.

SUMMARY. Unilateral breast reconstruction with an extended latissimus dorsi musculocutaneous flap was car-ried out for 12 women in the National Cheng Kung University Hospital. Eleven patients acquired a good or fairresult cosmetically. We analysed the net weight of the flap as well as various anthropometric data to see whateffect they have on the final aesthetic outcome. The weight of the flap ranged from 180 to 610 g, and the resectedspecimen weighed from 160 to 635 g. The flap weight was equivalent to 61%–113% of the specimen weight. A sat-isfactory result could be achieved when the bulk of the flap attained 70% of the mass resected. We also observedthat the aesthetic quality is better when the breast is less ptotic. All of the muscle transfers survived completelywithout any flap loss. The only complications included one minor wound edge slough and another modest seromaformation at the donor site. This reconstructive method is a viable option for young women with small ormedium-sized breasts who anticipate pregnancy in the future. It is especially advisable in Oriental society, sincethe breast size of the patients is generally smaller and the donor scar is hidden, given the hypertrophic tendencyof the lower abdominal scar in Asian people undergoing TRAM flap reconstruction.

Keywords: breast, reconstruction, latissimus dorsi musculocutaneous flap, extended.

British Journal of Plastic Surgery (1999), 52, 365–372© 1999 The British Association of Plastic Surgeons

Breast reconstruction is an essential part of the inter-disciplinary treatment for breast cancer. Earlyattempts to restore the post-mastectomy defect wereaccomplished with the ipsilateral latissimus dorsi flap,1

which has the advantages of reliable vascularity, prox-imity to the defect and simplicity in dissection.

However, the classic latissimus dorsi flap suffersfrom its lack of sufficient volume, so that the additionof a prosthetic implant becomes mandatory. Withthe growing concern about the long-term safety andstability of implants,2,3 reconstruction with auto-genous tissue alone is much preferred. As a result, thetransverse rectus abdominis musculocutaneous(TRAM) flap, with its abundant tissue bulk, hasbecome the gold standard for breast reconstructionsince the 1980s.

With all its merits however, the TRAM flap alsohas limitations. Complications such as abdominalweakness or flap necrosis remain a constant threat,especially among obese individuals.4 Furthermore, forpatients with multiple previous abdominal incisions,patients suffering from chronic back pain, or youngwomen expecting pregnancy in the future, this opera-tion is problematic. For such cases, the latissimus dorsiflap is a valuable alternative, which would be evenmore satisfactory if the tissue bulk of the flap could beincreased to reduce the need for an alloplastic implant.Early success was achieved by Hokin in 1983,5 whosubsequently reported a series of 55 reconstructionswithout implant in 1987.6 Marshall et al,7 in 1984,published a T-shaped flap design, and in 1988, Papp etal8 suggested harvesting the maximally available skinpaddle and using the de-epithelialised dermal–fat pad

365

to augment the tissue bulk. Barnett and Gianoutsos9

then introduced their method of the latissimus dorsiadded-fat flap, and Germann and Steinau10 showedtheir successful experience in 47 cases using theextended latissimus dorsi flap.

These reports showed that it was possible to use thelatissimus dorsi flap alone as a means for breast recon-struction. However, it remains unclear what kind ofpatient tends to have a favourable result, what weightof tissue is obtainable and do the body build and thesize and shape of the breast have any influence uponthe cosmetic results? In order to answer these ques-tions, we measured and analysed several relevant para-meters and tried to find out their significance asregards the final aesthetic quality.

Material and methods

From July 1996 to November 1997, 12 consecutivepatients underwent breast reconstruction using theextended latissimus dorsi flap at The National ChengKung University Hospital. Their ages ranged from 25to 71 years, with an average of 44.6 years. Follow-upevaluations, conducted for all patients, ranged from 6to 21 months, with a mean of 11.8 months.

Surgical technique

The flap design is marked preoperatively with thepatient upright. The largest available skin paddle isdetermined by the pinch test and outlined with amarking pen. The proposed extension of the fat–fascia

Page 2: Extended latissimus dorsi musculocutaneous flap for breast reconstruction: experience in Oriental patients

366 British Journal of Plastic Surgery

Figure 1—Intraoperative markings of the extended latissimus dorsimusculocutaneous flap. The heavy broken line defines the range ofextra fat–fascia flap recruited, which corresponds to the territory ofa standard scapular flap.

Figure 2—A sterilised spring-coil weighing scale is used to measurethe weight of a pedicled flap intraoperatively.

complex, which corresponds to the territory of the‘scapular flap’, is demarcated with a heavy broken line(Fig. 1).

The flap is raised with the patient in the lateral posi-tion and the shoulder abducted 90°. The perimeter ofthe skin island is incised down to the subdermal layeronly. The plane of dissection then continues along theimmediately subcutaneous plane until the maximalamount of the surrounding adipofascial tissue isincorporated within the flap. The origin and the inser-tion of the latissimus dorsi muscle are then transectedpreserving the neurovascular pedicle. This manoeuvreallows the flap to go as far medially as possible in theanterior chest wall, and a bulge in the axillary fossa isavoided. The thoracodorsal nerve is preserved to helpmaintain the muscle bulk, and it also serves as a ‘guyrope’ to protect the vascular pedicle from inadvertentstretching.

The whole flap is delivered to the defect region andanchored onto the chest wall musculature. Theextended fat–fascia flap is folded underneath the skinpaddle for extra bulk. The lateral contour of thebreast mound is defined with the addition of sometransfixing sutures. The back is closed in layers, and6–8 bolster sutures are placed to compress and immo-bilise the back skin flap. A large bore hemovac drain isused and kept for 1–2 weeks to prevent seroma forma-tion. A bulky fluffed gauze dressing is applied to the

back region for a better cushion as well as forenhanced compression.

Data collection

Measurements were made of body weight, bodyheight, bust circumference, chest circumference, waistand hip girth before and periodically after theprocedure.

During the operation, the total weight of theresected tissue was determined with an ordinaryweighing scale. The weight of the flap tissue was mea-sured with a sterilised spring-coil scale (Fig. 2). Theflap is hooked up to the scale with a pair of towelclamps and the weight of the flap was calculated bysubtracting the weight of the towel clamp from thegross reading.

Categorisation of the body build was based on aweight/height index (WHI) derived by dividing weightin kilogrammes by height in metres. Patients were des-ignated as thin (WHI less than 35), average (WHIbetween 35 and 39), moderately obese (WHI between39 and 49) or markedly obese (WHI greater than 49).

The aesthetic result of the reconstruction was eval-uated from colour slides by independent observerswho were not members of the surgical team and whowere unaware of the surgical details. The evaluationresults were rated as good, fair or poor. A good result

Page 3: Extended latissimus dorsi musculocutaneous flap for breast reconstruction: experience in Oriental patients

Extended latissimus dorsi flap 367

Table 1 Patient profile and anthropometric data

Case no. Age Marital Skin paddle size Preop. B/C Postop. B/Cstatus (cm) (inches) (inches)

1 51 Married 13 × 7 29.5/26.5 30/26.52 28 Unmarried 15 × 8.5 33/29.5 33.5/303 37 Unmarried 13 × 8 30/27 30.5/274 40 Married 15 × 7.5 32/28.5 32.5/28.55 71 Married 15 × 8.5 35.5/29 34.5/28.56 36 Unmarried 15 × 7.5 35.5/27.5 33.5/28.57 25 Married 16 × 9 34.5/30.5 34/318 66 Unmarried 15 × 6 31.5/28 31/279 46 Married 15 × 10.5 33/30 33.5/30.510 45 Married 15 × 10 35/31 35.5/32.511 35 Married 16 × 9 32/28 32/2912 56 Married 16 × 10 37.5/34 36/32.5

Preop. B/C: preoperative bust circumference versus chest circumference; Postop. B/C: postoperative bust circumference versus chestcircumference.

was a symmetrical appearance with similar size andshape of both breasts; a fair result showed a moderatedisparity in size or shape which could be easily camou-flaged by clothing or was even negligible; a poor resultreflected an objectionable appearance or ugly scarringwhich might require further corrective surgery.

Data analysis

The correlations of various anthropometric data orbody build with the final aesthetic rankings wereanalysed to see whether and how they influenced thereconstructive result. The weight of the resected tissueand that of the transposed flap were evaluated withregard to their impact upon the cosmetic quality. Thepre- and postoperative bust circumference change wasevaluated with the paired t-test and the weight mea-surements for the favourable group versus those of theunfavourable group were assessed using the t-test forindependent groups. P < 0.05 indicated statistical sig-nificance.

Results

Comparison of the preoperative and postoperativebust circumference showed no significant difference(Table 1) and the bust size and contour remained rela-tively constant throughout the follow-up period.

The aesthetic results were evaluated as ‘good’ fornine patients (Figs 3, 4), ‘fair’ for another two patients(Fig. 5) and ‘poor’ for one case. The weight/heightratios of the 12 patients are listed in Table 2. Ninepatients were thin, two others were average and onlyone was moderately obese. It is noteworthy that sevenout of the nine ‘thin’ patients had a good reconstruc-tive result.

The weight of the resected tissue ranged from 160to 635 g, with a mean of 405 g (SD = 144 g). That ofthe latissimus dorsi flap measured approximately180–610 g, with an average of 348 g (SD = 128 g).Patients with a ‘good’ result had a mean specimenweight of 389 g (SD = 162 g) and an average flapweight of 366 g (SD = 146 g). Those with a ‘fair’ or

‘poor’ result had a mean specimen weight of 450 g (SD= 96 g) and an average flap weight of 302 g (SD = 55 g).There were no significant intergroup differences.

The weight ratio (w/w) of the flap to the specimenshowed a more distinct intergroup variation. Two ofthe less favourable cases had a ratio below 70%, whichoccurred in the early stage of our series. In thefavourable group, the ratio ranges from 71% to 113%.There was a statistically significant difference betweenthe weight ratio in the favourable group comparedwith the less satisfactory one.

There was only one case with a poor result. Thatwas a 46-year-old patient with rather ptotic breasts,for whom a symmetric reconstruction is extremely dif-ficult to achieve, unless a balancing procedure is car-ried out on the opposite breast (Fig. 6).

All of the transposed flaps survived. The only com-plications were the occurrence of one donor woundedge slough and the development of a seroma of theback region in another patient, which respondedquickly to aspiration. Hospital stay ranged from 10 to25 days, with a mean of 13.3 days.

The contour change on the back region wasinsignificant in eight cases (Fig. 7) and noticeable infour others (Fig. 3C,D). Three patients mentionedreduced soft tissue padding on the back, yet the condi-tion was not serious enough to cause discomfort dur-ing sleep. There were no complaints about disturbanceof upper limb function or limitation of shoulder jointmovement on the operated side.

Discussion

Autogenous tissue transfer is widely accepted as thefirst choice for post-mastectomy breast reconstructionand among the various procedures available, theTRAM flap is by far the most frequently performedoperation because of its exuberant tissue volume.

However, there remain a considerable number ofpatients who are not suitable for the TRAM flapprocedure. Such were the cases in our series. Of the12 cases, four are unmarried ladies, one was newlymarried and wished to have children, three cases had

Page 4: Extended latissimus dorsi musculocutaneous flap for breast reconstruction: experience in Oriental patients

368 British Journal of Plastic Surgery

Figure 3—Case 2. (A) Immediate reconstruction with left side extended latissimus dorsi flap, 6 months postoperatively. The resectedspecimen weighed 250 g and the transferred flap weighed 270 g. (B) Postoperative left lateral view, with adequate prominence of thereconstructed breast mound. (C) Postoperative follow-up at 21 months, posterior view. (D) Postoperative follow-up at 21 months, posteriorview from right oblique. The contour defect for the upper back is considered as ‘noticeable’.

A B

C D

Page 5: Extended latissimus dorsi musculocutaneous flap for breast reconstruction: experience in Oriental patients

Extended latissimus dorsi flap 369

Figure 4—Case 5. (A) Preoperative view of the 71-year-old patient with needle biopsy-proved adenocarcinoma of the right breast.(B) Immediate reconstruction with right side extended latissimus dorsi flap, 7 months postoperatively. The whole specimen weighed 425 gand the transferred flap weighed 390 g, which is equivalent to 91% of the former.

Figure 5—Case 7. (A) Preoperative view of a 25-year-old newly married lady with an advanced breast cancer on the right side. Retraction ofthe nipple is noticed on this photograph. (B) Postoperative view revealed suboptimal reconstructive result, since the harvesting technique isof a traditional manner rather than in an ‘extended’ style. The flap/specimen weight ratio is around 63% only.

BA

BA

Page 6: Extended latissimus dorsi musculocutaneous flap for breast reconstruction: experience in Oriental patients

370 British Journal of Plastic Surgery

Table 2 Body build and weight measurement

Case no. WHI Body build Specimen weight Flap weight *Weight ratio Result(g) (g)

1 30 Thin 290 270 93% Good2 33.9 Thin 250 270 108% Good3 29.6 Thin 160 180 113% Good4 31.5 Thin – – Good5 33.8 Thin 425 390 91% Good6 30.6 Thin 560 345 62% Fair7 36.5 Average 380 240 63% Fair8 29.5 Thin 450 320 71% Good9 31.6 Thin 410 320 78% Poor10 35 Average 635 550 87% Good11 33.8 Thin 330 335 102% Good12 41.9 Mod. obese 570 610 107% Good

*Weight ratio = weight of the flap/weight of the resected tissue.

Figure 6—Case 9. (A) Preoperative view of a 46-year-old patient with a right side breast cancer. (B) Postoperative picture demonstratedfrank asymmetry due to the severely ptotic form of the unaffected breast. The result is rated as ‘poor’.

A B

relatively small-sized breasts, one patient had had mul-tiple previous operations in the abdomen, one casehad long-standing back pain and two others just dis-liked the idea of an abdominal scar. A latissimus dorsiflap was considered to be a reasonable option for eachof these cases.

Using a modified design, we were able to optimisethe aesthetic result of this procedure. The techniqueused was the extended latissimus dorsi flap, similar tothat proposed by Germann and Steinau,10 based uponthe anatomic study of Kim et al.11 Kim demonstratedthat there are a number of perforators emerging from

the cephalic edge of the latissimus dorsi muscle, whichare invariably present and could nourish an extensivearea of back tissue.

We observed that the net weight of the flap itself isa less significant indicator of the final outcome thanthe weight ratio between the flap and the resectedmass. The cosmetic results appear to be acceptable ifthis weight ratio attains a level of 70% or higher. Onemay question that this value seems to be too low, yetwe recognised that the affected breast usually is largerthan the opposite breast. Also, the resected specimencomprises the breast tissue as well as the axillary

Page 7: Extended latissimus dorsi musculocutaneous flap for breast reconstruction: experience in Oriental patients

Extended latissimus dorsi flap 371

Figure 7—Case 11. 35-year-old lady with left side breast cancer undergoing extended latissimus dorsi flap reconstruction. Postoperativefollow-up at 7 months. (A) Front view. (B) Left lateral view. (C) Posterior view from left oblique. (D) Posterior view. Note the transverse scaris well hidden in the back strap of a brassiere. The contour defect for the upper back was considered to be insignificant.

A B

C D

Page 8: Extended latissimus dorsi musculocutaneous flap for breast reconstruction: experience in Oriental patients

372 British Journal of Plastic Surgery

contents, and only the former needs to be restored,therefore it would be understandable that a grosslysymmetric breast reconstruction could be achievedwhen the volume of the transferred tissue is equivalentto only a modest portion of the whole mass removed.

In the present series, the weight of the resectedmass measured 160–635 g, and most were between 300and 400 g. If the above assumption is true, a flap witha weight of 300 g or so would be sufficient for use, andthat is relatively easy to attain. Up to 64% of our caseshad a flap weight beyond this value. The breast size inOriental females is generally smaller, which makes thelatissimus dorsi flap even more applicable.

It is noteworthy that for patients undergoing breastreconstruction with implant alone, the volume of theprosthesis averaged between 200 cc and 400 cc –Mendelson, 295 cc;12 Noone et al, 333 cc;13 andRadovan, 300–400 cc.14 The data coincide preciselywith our observations about the volume demanded. Itlends support to our belief that a reasonable resultcould usually be achieved with this extended latissimusdorsi flap alone.

The maximal weight of the flap that we used was610 g (Case 12). This particular patient had only amoderately obese body build. We believe that an evengreater amount of soft tissue bulk could possibly beharvested in an obese-type individual. Hokin andSilfverskiold6 reported one flap of 820 cc and anothertwo flaps of about 775 cc in volume, measured by awater replacement test. It has been repeatedly stressedthat the technique is suitable for individuals with smallor medium-sized breasts only and Papp et al empha-sised that the technique was not recommended for thinpatients. There remain no firm guidelines to follow.8

In this series, eight out of the nine low-weightpatients (WHI < 35) had either fair or good results.This implies that a thin body build in itself seems notto be a contraindication to this procedure. A possibleexplanation is that the soft tissue volume on the backis proportionate to the breast size for an ordinarypatient. In other words, a thin patient tends to have arelatively small breast. Problems do occur when a verythin patient happens to possess very prominent breastmounds, which is relatively unusual, although highlydesirable as the ideal image for a fashion model. Wehad only one such case in this group of patients (Case6), for whom a free gluteal musculocutaneous flapmight have been more appropriate. The form of thebreast is another critical factor. Severe ptosis willdefeat most reconstructive attempts, unless correctivesurgery for the ptotic breast is done at the same time,or as a secondary procedure.

There is a relatively high incidence of seroma for-mation in the donor region on the back, and it is evenhigher with such an extended dissection.7,10 However,we encountered this problem only once. We think thatthe application of multiple bolster sutures with a com-pressive dressing helps to avoid this problem.

In summary, our preliminary experience reconfirmsthe belief that the extended latissimus dorsi musculocu-taneous flap is a reliable technique for post-mastectomy

breast reconstruction. Quantitative assessment of thetissue amount of the flap verifies its applicability inmany clinical cases. This procedure is a valuable alter-native to the TRAM flap. It is perhaps especially use-ful in Oriental people as the breast volume isgenerally smaller; also, the localisation of the donorscar in an unseen area is another advantage in lightof the tendency to hypertrophic scar formation inthe lower abdomen in Asian people receiving TRAMflaps.

References1. Maxwell GP. Iginio Tansini and the origin of the latissimus

dorsi musculocutaneous flap. Plast Reconstr Surg 1980; 65:686–92.

2. Evans GRD, Schusterman MA, Kroll SS, et al. Reconstructionand the radiated breast: is there a role for implants? PlastReconstr Surg 1995; 96: 1111–15.

3. McCraw JB, Maxwell GP. Early and late capsular ‘deformation’as a cause of unsatisfactory results in the latissimus dorsibreast reconstruction. Clin Plast Surg 1988; 15: 717–26.

4. Kroll SS, Netscher DT. Complications of TRAM flap breastreconstruction in obese patients. Plast Reconstr Surg 1989;84: 886–92.

5. Hokin JAB. Mastectomy reconstruction without a prostheticimplant. Plast Reconstr Surg 1983; 72: 810–18.

6. Hokin JAB, Silfverskiold KF. Breast reconstruction without animplant: results and complications using an extended latis-simus dorsi flap. Plast Reconstr Surg 1987; 79: 58–66.

7. Marshall DR, Anstee EJ, Stapleton MJ. Soft tissue reconstruc-tion of the breast using an extended composite latissimusdorsi myocutaneous flap. Br J Plast Surg 1984; 37: 361–8.

8. Papp C, Zanon E, McCraw J. Breast volume replacement usingthe de-epithialized latissimus dorsi myocutaneous flap. Eur JPlast Surg 1988; 11: 120–5.

9. Barnett GR, Gianoutsos MP. The latissimus dorsi added fatflap for natural tissue breast reconstruction: report of 15cases. Plast Reconstr Surg 1996; 97: 63–70.

10. Germann G, Steinau H-U. Breast reconstruction with theextended latissimus dorsi flap. Plast Reconstr Surg 1996; 97:519–26.

11. Kim PS, Gottlieb JR, Harris GD, Nagle DJ, Lewis VL. Thedorsal thoracic fascia: anatomic significance with clinicalapplications in reconstructive microsurgery. Plast ReconstrSurg 1987; 79: 72–80.

12. Mendelson BC. Submuscular mammary prostheses in recon-structive breast surgery. Aust NZ J Surg 1982; 52: 297–302.

13. Noone RB, Murphy JB, Spear SL, Little JW. A 6-year experi-ence with immediate reconstruction after mastectomy forcancer. Plast Reconstr Surg 1985; 76: 258–69.

14. Radovan C. Breast reconstruction after mastectomy usingthe temporary expander. Plast Reconstr Surg 1982; 69:195–208.

The Authors

Jing-Wei Lee MD, Instructor and Attending Plastic Surgeon,Division of Plastic Surgery,

Tsai-Wang Chang MD, Instructor and Attending General Surgeon,Division of General Surgery,

National Cheng Kung University Hospital, 138 Seng Li Road,Tainan 70428, Taiwan, R.O.C.

Correspondence to Dr Jing-Wei Lee.

Paper received 26 June 1998.Accepted 2 November 1998, after revision.