The nature of local recurrence following radical mastectomy

E tectomy for the treatment of breast cancer, repeated discussions have arisen as to how much skin and subcutaneous tissue should be removed in the performance of an adequate radical mastectomy. Halsted quite regularly removed large amounts of skin and covered the resulting defect with Thiersch grafts. "Nothing is gained," he stated, "by saving skin which, either because it is too close to the cancer or by reason of impairment of its circulation, is questionable."2 Thus there are really two reasons for advocating removal of large amounts of skin, the one dependent on -the other. The first and most important one is that if only a small amount of skin be sacrificed, it is likely that the skin incision will be placed perilously close to the tumor, and as dissection is carried deeply in the subcutaneous tissues, microscopic cancer extensions will be transected, thus paving the way for postoperative local recurrences. To avoid the latter complication, the cutting of very thin skin flaps has been advocated by some, notably by Haagensen,' who recommended that the dissection be carried superficial to the superficial layer of the superficial fascia. However, in these instances grafts must usually be used too, because if tension of almost any degree be used to approximate these very thin flaps, with their tenuous blood supply, necrosis of varying amounts of the edges is sure to result. Thus, in the one instance a large amount of skin is removed to stay wide of any likely extension of cancer and in the other to avoid the necessity of cutting large thin flaps of doubtful viability. Consideration of the foregoing stems from the efforts on the part of surgeons to prevent development of local recurrence of cancer in the operative field. All surgeons who have had any appreciable experience with breast cancer From the Department of Surgery, Presbyterian Hos-