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Toward a Classification of the Chest and Breast prior to Immediate Reconstruction

Goldwyn, Robert M. M.D.

Plastic and Reconstructive Surgery: October 2004 - Volume 114 - Issue - p 56-57
EDITORIALS
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Originally published in Plastic and Reconstructive Surgery in November 1991 (Plast. Reconstr. Surg. 88: 876, 1991).

Hampering our evaluation of the results of the various methods of breast reconstruction has in general been not only the reluctance of surgeons to report objectively their results in consecutive patients,1,2 but also the absence of sufficient information concerning the prereconstructive defect and status of the patient undergoing reconstruction. A significant step in the right direction to supply the needed data, but largely for delayed reconstruction, was made by Hartrampf and Bried3 in their classifying patients according to “risk factors” for the transverse abdominal flap operation. Their risk factors include obesity, small-vessel disease (smoking, diabetes, autoimmune disease, e.g., scleroderma), psychosocial problems (personality disorder, substance abuse), abdominal scars, patient’s attitude, surgeon’s inexperience, and systemic disease (chronic lung or severe cardiovascular disease).

When reconstruction is delayed, an audience or readership usually has the benefit, at least in some patients, of preoperative photographs to guide them in knowing with what the surgeon had to contend before achieving the final result. With patients undergoing immediate reconstruction, however, such helpful information is almost always lacking. This situation makes evaluating a specific series of patients difficult and makes comparing that group with others impossible. The reconstructive chore is decidedly greater if one is faced with a large defect in a previously irradiated patient with recurrence who happens also to be a heavy smoker and has a very large opposite breast than if one has to rebuild a breast in a nonsmoking patient whose defect is small, whose opposite breast is modest, and whose mastectomy was done for an untreated small primary breast cancer or, perhaps, as a prophylactic measure utilizing a minimastectomy that has left almost all the breast skin and maybe the areola as well. Getting an excellent result with an expander, for example, or an extended latissimus dorsi flap under the latter conditions would be a likely expectation, whereas in the former instance it would be a magnificent achievement.

If we were to evolve a proper classification of the prereconstructive conditions, it would have to include information about the size of the defect, previous irradiation (if any), quality of surrounding skin (e.g., flaps thick or thin with good or poor vascularity), presence or absence of recurring cancer, size of opposite breast, smoking history, status of pectoral muscle, and status of inframammary fold.

Some of these factors are obviously more important in affecting the final result than others, e.g., size of defect, recurrence of cancer, and history of irradiation. Furthermore, these factors, singly or in combination, will influence choice of reconstruction: a flap rather than an expander or implant. When reconstruction is delayed, the concern is not so much with the size of the defect as with the other factors just mentioned.

It has long been apparent to me and, I assume, to almost everyone that in the patient who has a small defect with well-vascularized, nonirradiated surrounding tissue, it is easier to get a good result with almost any kind of reconstruction. A series composed of these patients will be much different from a series with recurrent disease after heavy irradiation whose defects are considerably larger and who have lost their infrmammary fold.

Since an operation involves not just the patient but also the surgeon, one could reasonably ask for information about the surgeon, as Hartrampf and Bried have supplied. The size of the patient’s defect is probably less important to the result than the breadth of the surgeon’s experience with any specific method. Since this type of self-revelation is probably too much to expect from most surgeons, particularly those with minimal experience, I would settle for knowing more about the patients at the time of their reconstruction, most especially if the reconstruction had been immediate. P. R. Marshall once remarked that, “What this country needs is a good five-cent cigar” (probably more to the point was F. P. Adams’ quip that, “What this country needs is a good five-cent nickel”). I would be happy with a classification at the going Blue Shield rate. The Baker classification of breast firmness after augmentation4 has improved communication between author and audience and has reduced chaos in a field that admittedly is still disordered.

The following represents a start that I am confident others wiser than I can improve:

Grade A Major Criteria:

  • Defect less than 3 cm
  • Surrounding tissue well vascularnized
  • Pectoralis muscles intact (except for fascia removed)
  • No previous irradiation
  • Opposite breast small or moderate in size
  • Inframammary fold preserved
  • Lesser Criteria:
  • Nonsmoker
  • No systemic or small-vessel disease

Grade B Major Criteria:

  • Defect 3.0 to 9 cm
  • Surrounding tissue well vascularnized
  • Pectoralis muscles intact (except for fascia removed)
  • No previous irradiation
  • Opposite breast large
  • Lesser Criteria:
  • Smoker
  • No systemic or small-vessel disease

Grade C Major Criteria:

  • Defect greater than 9 cm
  • Surrounding tissue of questionable viability
  • Previous irradiation
  • Opposite breast large
  • No inframammary fold
  • Lesser Criteria:
  • Smoker
  • Obesity

Grade D Major Criteria:

  • Defect greater than 9 cm
  • Surrounding tissue poorly vascularnized
  • Pectoralis major muscle partially or totally resected
  • Previous irradiation
  • Opposite breast large
  • No inframammary fold
  • Local recurrence
  • Lesser Criteria:
  • Smoker
  • Systemic or small-vessel disease

One might argue justifiably that what I have listed as lesser criteria in grade D are truly major criteria.

Intraoperative photographs of the defect should be taken prior to immediate reconstruction for every patient, and these photographs should be done under standard conditions (e.g., the patient should be flat). To measure the defect in a uniform way, the flaps should be approximated as much as possible without obvious tension.

As mentioned earlier, the classification that I have proposed is patently imperfect, but it is an attempt to get readers to think about the problem and hopefully offer something better than what I have concocted. Our ultimate objective is to have a standardized way of presenting our data in order to facilitate progress.

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REFERENCES

1.Goldwyn, R. M. Reality in plastic surgery: A plea for complete disclosure of results (Editorial). Plast. Reconstr. Surg. 80: 713, 1987.
2.Goldwyn, R. M. Consecutive patients (Editorial). Plast. Reconstr. Surg. 86: 962, 1990.
3.Hartrampf, C. R., Jr., and Bried, J. T. General Considerations in TRAM Flap Surgery. In C. R. Hartrampf (Ed.), Hartrampf’s Breast Reconstruction with Living Tissue. Norfolk, Va.: Hampton Press, 1991. Pp. 33–43.
4.Baker, J. L., Jr. Augmentation Mammoplasty. In J. Q. Owsley and R. A. Peterson (Eds.), Symposium on Aesthetic Surgery of the Breast. St. Louis: Mosby, 1978. P. 256.
©2004American Society of Plastic Surgeons