Journal of Surgical Oncology 47:239-242 (1991)

A Myocutaneous Flap for Closure of Upper Arm Amputations for Uncontrolled

Axillary Tumors

JAMES NORMAN, MD, CHARLES COX, MD, C. WAYNE CRUSE, MD, KAREN WELLS, MD, AND

DOUGLAS REINTGEN, MD

From the Department of Surgery, Division of General and Plastic Surgery, H. Lee Moffitt Cancer Center, the University of South Florida, Tampa, Florida

Tumor spread or recurrence in the axilla is usually treated with nodal dissections. At times disease recurrence is uncontrolled, causing signifi- cant morbidity including pain, bleeding, lymphedema, and neurologic symptoms. Previously, forequarter amputation has been the treatment for this problem, resulting in a significant cosmetic and functional deficit. This report describes a novel myocutaneous flap that can be used to cover soft tissue defects after major disarticulations of the upper extremity. The deltoid myocutaneous flap has been used to successfully treat three patients with uncontrolled tumors in the axilla and preserve the shoulder structures to lessen the functional deficit.

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KEY WORDS: axillary neoplasms, surgical treatment, major amputation

INTRODUCTION The quality of life of the cancer patient has been

receiving increasing emphasis over the past several decades, and the trend has been away from disabling procedures. By contrast, some cutaneous and soft tissue tumors as well as breast cancer show a propensity to metastasize to the regional lymphatic basins that, if neglected, can arise in a difficult local management problem. Recurrences in the axilla for these tumors can usually be handled by surgical excision with clear margins. Rarely, the disease becomes uncontrolled in the axilla, resulting in a number of symptoms secondary to the tumor burden. Often the tumor mass causes debili- tating lymphedema of the arm, particularly when the axilla had been previously treated with dissection and/or radiation therapy. The tumor may involve branches of the brachial plexus causing a chronic pain syndrome of the involved extremity or even paralysis. Bleeding with ulceration and secondary infection are also commonly seen in these patients, often requiring repeated hospital- izations and blood transfusions. When there is tumor involvement of the axillary artery or vein, exsanguinating hemorrhage is a potential.

This paper details our experience with a myocutaneous flap based on the deltoid muscle and its blood supply

from the thoracoacromial trunk. This flap was developed to spare the shoulder and permit primary closure of the large soft tissue defect left when the arm and axillary contents have been removed. This technique is preferable to the more disabling and disfiguring interscapulotho- racic or forequarter amputation in selected cases in which the metastatic tumor can be resected completely for an effective palliation and avoidance of further local recur- rences in the stump. In addition, the wound is closed primarily with healthy tissues that have not been within the axillary radiation field, giving a high degree of successful closure without the use of more complicated flaps or skin grafts.

MATERIAL AND METHODS During the past 12 months, three patients have pre-

sented to the H. Lee Moffitt Cancer Center at the University of South Florida, with uncontrolled tumors in the axilla. All patients had recurrent tumors arise in their axillas after a previous nodal dissection. The tumor type

Accepted for publication April 2, 1991. Address reprint requests to Dr. Douglas Reintgen, H. Lee Moffitt Cancer Center at the University of South Florida, P.O. Box 280179, Tampa, FL 33682-0179.

0 1991 Wiley-Liss, Inc.

240 Norman et al.

A

F-- ‘L.

B

Fig. 1. Line of incision for the deltoid myocutaneous flap. A. Anterior view. B. Posterior view.

for these three patients was recurrent sweat gland tumor, recurrent metastatic melanoma, and recurrent metastatic breast carcinoma 3.5 years after a modified radical mastectomy. All three cases recurred in the axilla; they were treated with external beam radiation therapy without a visible effect. The patients with recurrent melanoma and sweat gland tumors had ulcerated necrotic masses that required repeated transfusions secondary to chronic bleeding. The last particular patient with metastatic melanoma had been hospitalized 6 times over a 4-month period and had received a total of 10 units of blood. All the patients had debilitating lymphedema and chronic pain in the involved arm, and all suffered from a moderate to severe neurologic deficit.

Operative Technique The patient is placed in a semilateral decubitus position

on a bean bag; the entire shoulder and arm are prepared sterilely. The incision is outlined to remove the axillary contents with the overlying skin, since this skin is almost always involved with the tumor or has been radiated. Anteriorly, the incision extends just medial to the lateral edge of the pectoralis major muscle from the coracoid process down to the insertion of this muscle onto the chest wall and the 6th rib. From this point, the incision is carried directly posterior to the anterior border of the latissimus dorse muscle, where it is directed cephalad following the border of the latissimus to the most inferior aspect of the arm. At this point, the incision makes an acute angle down the posterior aspect of the arm to a point several centimeters distal to the insertion of the deltoid onto the humerus. The incision is then curved around the arm horizontally and brought back up the anterior aspect of the arm to join the starting point at the coracoid process (Fig. IA,B).

With the arm abducted, the dissection is begun at the most caudal aspect of the axilla staying superficial to the serratus anterior muscle as the axillary contents are being raised cephalad. This muscle can be sacrificed if needed; however, a better cosmetic result can be achieved by preservation of this muscle and its long thoracic nerve.

As the dissection proceeds cephalad, the insertion of the pectoralis major muscle on the humerus is divided. The pectoralis minor muscle may or may not be involved with tumor near its insertion onto the coracoid process so that transection of this muscle may be necessary. This maneuver also gives excellent exposure to the axillary artery and vein high in the axilla.

The deltoid myocutaneous flap is developed by starting at the distal aspect of the arm incision and working proximally, lifting the deltoid off the humerus. Care should be taken along the anterior and posterior border of the muscle, since the anterior and posterior circumflex humeral arteries will be encountered as they course horizontally from the third portion of the axillary artery into the substance of the deltoid. These arteries are best identified at their origin from the axillary artery and followed distally. It may be necessary to sacrifice one or both of these arteries because of tumor involvement. This is of little consequence, however, as long as the major branches of the thoracoacromial trunk are preserved.

The axillary artery and vein are taken as high as necessary, preserving as many branches as possible. The thoracodorsal neurovascular bundle may have to be sacrificed, with the latissimus surviving by its extensive collateral blood supply, but sparing its first and largest branch, the circumflex scapular artery, is preferable. The thoracoacromial trunk arises high enough in the axilla that it is usually spared by the metastatic disease, and its deltoid and acromial branches should be superior to the

Myocutaneous Flap for Arm Amputations 241

Fig. 2. Axillary artery with large thoracoacromial trunk, giving rise to the deltoid artery supplying the deltoid muscle. The axillary artery has been ligated just distal to the thoracoacromial trunk. D, deltoid muscle; S, serratus anterior; A, axillary artery; T, thoracoacromial trunk; da, deltoid artery.

axillary contents and are therefore easily preserved (Fig. 2). The venous tributaries to the axillary vein and the axillary vein itself usually need to be sacrificed high in the axilla secondary to tumor involvement. This should not compromise the integrity of the flap.

The brachial plexus is sacrificed as proximal as necessary. It is preferable to follow the long thoracic and thoracodorsal nerves to their origins and transect the plexus distal to this point. This may be impractical at times secondary to tumor involvement of these nerves or the plexus itself.

The actual disarticulation of the humerus is accom- plished by severing the capsular ligaments between the humeral head and the scapula; the specimen is removed (Fig. 3). The wound is closed in a typical manner after excising the glenohumeral and subdeltoid bursas (Fig. 4).

DISCUSSION Avoidance of an amputation is always a high priority

in maintaining the quality of life in cancer patients. This is somewhat impractical or impossible when tumors involve the axilla, especially when lymphedema, paral- ysis, ulceration, bleeding, and chronic pain result from the recurrent tumor itself or from complications of the therapy. Several upper extremity amputations are well known, with the two most common being the arm disarticulation and the interscapulothoracic or forequarter amputation [ 13. The forequarter amputation is mainly indicated for a life-threatening tumor of the upper arm or shoulder girdle [2-4]. This operation is quite disfiguring, and as a rule is not performed for metastatic disease within the axilla.

Disarticulation of the shoulder offers the advantage of

Fig. 3. noma within the axilla and lymphedema of the arm.

Gross specimen showing large ulcerated metastatic mela-

leaving the shoulder girdle in place and maintains the normal contour of the thorax. This procedure is much less disfiguring and even allows the patient to wear the same clothes. Heretofore, wound closure was a major concern in the presence of axillary skin involvement. Several flaps have been described to aid in the closure of these wounds [5 ,6] , but many times a skin graft is also needed.

The extensive collateral blood supply around the shoulder is well known [7,8]. The major contributions are the dorsal scapular artery, a branch of the subclavian and the thoracoacromial trunk arising from the second portion of the axillary artery. This trunk gives rise to the clavicular, acromial, deltoid, and pectoral branches. The deltoid also receives blood on its anterior and posterior aspects from the anterior and posterior circumflex hum- era1 arteries, respectively, both branches coming from the third portion of the axillary artery. The thoracodorsal artery, also a branch of the third portion of the axillary artery, gives rise to the circumflex scapular artery in route to supplying the latissimus dorsi muscle. Finally, the thyrocervical trunk from the subclavian artery contributes to the rich collaterization via the suprascapular artery.

It is the rich blood supply around the shoulder that permits the use of a long myocutaneous flap taken from the lateral arm. The skin and subcutaneous tissue as far as 6 cm distal to the transection of the deltoid muscle can

242 Norman et al.

be used with this flap, making primary closure of large a x i l l q defects relatively easy.

CONCLUSION The myocutaneous scapular flap is a versatile flap that

shows quick healing and an acceptable cosmetic result. It allows for the radical resection of the axilla in selected patients with large tumor burdens in whom amputation of the extremity is the only palliative alternative, so that the more extreme forequarter amputation can be avoided.

REFERENCES 1. Baumgartner RF: The surgery of the arm and forearm amputation.

Orthop Clin North Am 12:805-817, 1981. 2. Bladder S, Gunterberg B, Markhede G: Amputation for tumor of

the upper arm. Acta Orthop Scand 54:226-229, 1983. 3. Karakousis CP: The technique of major amputations for malignant

tumors. J Surg Oncol 23:43-55, 1983. 4. Mansour KA, Powel W: Modified technique for radical transme-

diastinal forequarter amputation and chest wall reconstruction. J Thor Cardiovasc Surg 76:358-363, 1978.

5 . Ariel IM: Interscapulo-mamothoracic amputation for advanced breast cancer. Semin Surg Oncol 3:26&265, 1987.

6. Meland NB, Ivy EJ, Woods JE: Coverage of chest wall and pelvic defects with the external oblique musclofasciocutaneous flap. Ann Plast Surg 21:297-302, 1988.

7. Anderson JE: “Grant’s Atlas of Anatomy.” Baltimore: Williams & Wilkins, 1988.

8. Netter FH: “Atlas of Human Anatomy.” Summit, New Jersey: Ciba-Geigy Corporation, 1989.

Fig. 4. girdle is preserved.

Deltoid myocutaneous flap after closure. The entire shoulder