Reconstruction of Oncologic Axillary Defects

Case 1

A 52-year-old male was diagnosed with malignant melanoma of the axilla involving the axillary lymph nodes (Figure 1A). His disease progressed on immunotherapy, and he therefore underwent wide local excision of melanoma and axillary lymphadenectomy. This left a 13 x 8-cm defect (Figure 1B). Reconstruction was performed with a superiorly based transposition flap (Figures 1C and 1D).

Case 2

A 65-year-old female was diagnosed with right breast cancer for which she underwent lumpectomy and axillary lymph node dissection followed by radiation and chemotherapy. She developed an axillary recurrence (Figure 2A) for which she underwent axillary lymph node dissection and excision of overlying involved skin. This left a 15 x 8-cm cutaneous defect (Figure 2B). Reconstruction was performed with a thoracodorsal artery perforator flap (Figures 2C and 2D). 

Case 3

A 64-year-old female developed a fungating tumor in the left axilla. Biopsy and workup revealed a Merkel cell carcinoma with axillary lymph node involvement. The tumor did not respond to radiation and immunotherapy. Surgical resection, which included axillary lymph nodes, overlying skin, and parts of the pectoralis major and minor muscle, was performed (Figure 3A). This left a deep wound that was 15 x 8.5 cm in size. Reconstruction was performed with an anterolateral thigh free flap (Figure 3B). Microvascular anastomosis was performed to the thoracoacromial vessels.

The principal goals of axillary reconstruction are restoration of shoulder mobility by minimizing secondary contracture and coverage of neurovascular structures. The most common reasons for reconstruction are burn contractures, tumors, and hidradenitis suppurativa.^1-4 Axillary burn contractures are seen most commonly in developing countries due to paucity of burn care and rehabilitation. Tumors of the axilla are most commonly breast cancers and cutaneous tumors with axillary lymph node involvement. Some oncologic defects may be extensive, requiring chest wall reconstruction. Hidradenitis suppurativa is a chronic recurring skin condition commonly involving the axilla. Management options consist of antibiotics, corticosteroids, immunosuppressants and biologic therapy (ie, adalimumab or infliximab), and surgical excision.⁵ Surgical options range from incision and drainage to localized or extensive resection.⁶

Axillary reconstruction can be performed with local flaps, regional pedicled flaps, and free flaps. Local flaps are used for smaller defects. Flap designs include transposition flaps, VY flaps, and rhomboid flaps.^7,8 Defects that are large or require coverage of neurovascular structures may require regional pedicled flaps like the parascapular flap, latissimus dorsi myocutaneous flap, or pectoralis major muscle/myocutaneous flap.⁹ Regional perforator flaps decrease donor site morbidity by sparing muscle and allow for longer vascular pedicles. The thoracodorsal artery perforator flap is in an ideal location for axillary resurfacing.¹⁰ Free flaps are needed when defects are very large or when regional flap options are not available; tumor resection may include regional flap pedicles, and previous radiation may render regional tissue quality unsuitable for reconstruction. Common recipient vessels for free tissue transfer are the thoracodorsal and thoracoacromial vessels.^7,11

The most important consideration in the immediate postoperative period is to prevent compression of the flap or its vascular pedicle. As per our protocol, patients are kept in a 45-degree abduction splint. This is to prevent compression of the flap pedicle while not putting too much stress on the suture lines. After 2 weeks, abduction is gradually increased. Full movements without restrictions are allowed at 4 weeks. Patients need to be followed closely, as early aggressive shoulder motion may cause flap dehiscence, and prolonged immobilization can cause permanent shoulder stiffness. 

Axillary reconstruction with flaps carries a risk of infection, bleeding, wound dehiscence, and flap necrosis.¹² Hematoma may compress flap pedicle and axillary vessels. Lymphatic fluid leak from transected lymphatic vessels may cause prolonged drain output. Chyle leak is a rare complication that occurs due to transection of aberrantly terminating thoracic duct.¹³ Removal of axillary lymph nodes can lead to long-term upper extremity lymphedema. A recent meta-analysis found the risk of lymphedema after axillary lymph node dissection for breast cancer to be 24%.¹⁴ Prophylactic lymphovenous bypass at the time of lymph node removal is a newer technique that has been shown to decrease the incidence of lymphedema.¹⁵