Lateral Breast and Axillary Reconstruction With Pedicled Parascapular Flap

METHODS

A 57-year-old woman presented with a 2-year history of subcutaneous nodules in her right anterior axilla. On examination, there was no ectopic breast tissue, dominant mass, nipple retraction, or discharge. The right axilla had multiple small, firm subcutaneous nodules that occupied most of the hair-bearing skin. Mammography demonstrated suspicious micro-calcifications in the right axilla and faint calcifications in the superior right breast, and magnetic resonance imaging of the breast did not reveal any abnormality. Stereotactic breast biopsy was negative for tumor; however, biopsy of the skin and subcutaneous nodules demonstrated high-grade ductal carcinoma in situ (DCIS) with central necrosis.

Prior to resection by the oncologic team, the planned parascapular flap was marked (Fig 1). She underwent a wide excision of the axillary skin en bloc with partial mastectomy including the tail of Spence and sentinel lymph node biopsy. After the resection (Fig 2), the ipsilateral pedicled parascapular flap was used for reconstruction (Fig 3) and the donor site was closed primarily.

Figure 1. Preoperative parascapular flap design.

Figure 2. Defect of axilla and lateral breast.

Figure 3. Elevated parascapular flap.

RESULTS

Her immediate postoperative course was uneventful. Final pathology showed DCIS in the right axillary skin with a 2-mm focus of invasive ductal carcinoma in the partial mastectomy specimen, widely negative margins, and negative sentinel nodes. Hormone status was ER+ and PR− with Her2Neu overexpression. The patient received adjuvant treatment with tamoxifen, followed by anastrozole, and whole breast and axillary radiotherapy, which resulted in increased flap edema. However, there were no wound complications and she maintained active range of motion of her shoulder. Seven years postoperatively, she remained disease free, contracture free, with normal shoulder range of motion, and good cosmesis (Fig 4).

Figure 4. Seven-year postoperative follow-up.

DISCUSSION

The need for adjuvant radiotherapy complicates decision making when performing immediate flap reconstruction. Postreconstruction radiotherapy is associated with increased potential for complications including inferior aesthetic outcome, asymmetry, contracture, and hyperpigmentation.^13,14 Despite such controversy, the efficacy of free and pedicled flaps for immediate reconstruction in the setting of likely adjuvant radiation therapy has previously been demonstrated.¹⁵ In our case, immediate flap coverage was needed to cover the axillary contents, and this outweighed flap risks posed by radiation. Wound contractures over joints can be problematic, and the axilla is especially prone to contractures secondary to contour and postoperative postitioning.¹⁶ Fibrosis and contracture of this anatomic site carry the morbidity of decreased shoulder range of motion and loss of function.

At 7 years postoperatively, the patient still maintained full functional range of motion and no contractures were present (Fig 4). The flap remained bulky with moderate contour abnormality, but the patient was satisfied with the result and elected to forego any debulking or revision. It is noteworthy to mention that the flap thickness might have contributed to its durability in the setting of postoperative radiotherapy.

This case demonstrates the benefits and versatility of this flap. The relatively thin, hairless skin paddle and primary donor site closure make it cosmetically favorable. It also provides stable soft tissue coverage without the need for muscle sacrifice, allows a quick functional recovery, and withstands adjuvant radiotherapy without significant contracture.