The most common palliative surgical procedure for breast cancer is simple mastectomy and axillary clearance. Often a standard mastectomy technique with carefully planned skin excision can remove a symptomatic, ulcerating cancer with primary closure of the skin and subcutaneous tissues [8]. Likewise a simple wedge of underlying chest wall muscle may also obtain resection of a locally advanced tumour. Palliative simple mastectomy can be combined with appropriate axillary dissection as dictated by the extent of local lymph node involvement. Appropriate local chest wall radiotherapy is an important adjunct therapy for these procedures [9].

Where possible a simple primary closure of the skin with healthy, viable flaps is the best palliative option. In many cases skin closure will not be possible and more complex techniques for soft issue coverage will be needed.

Historically, split-skin grafting has been widely employed when repairing skin defects post mastectomy. Skin grafting has problems with extent of graft take, coverage of large defects and healing when deployed over cartilage, bone or previously irradiated tissues. Cosmesis is usually poor. Vascularised omental grafts from the peritoneal cavity have been used extensively in the past to provide an improved soft tissue underlay for split-skin grafts on the chest wall [10]. They remain an option but are little used now in modern surgical practice. Negative-pressure wound therapy (VAC dressings) is now used to improve graft take in hostile wound beds and to simplify dressing care for patients. VAC dressings are the currently preferred dressing for split-skin grafting post mastectomy [11].

The modern practice of reconstructive breast surgery has made the use of local soft tissue flaps very routine. These are now the best option for skin and soft tissue closure after radical palliative mastectomy associated with extensive soft tissue excision.

Latissimus dorsi (LD) myocutaneous flaps are the simplest option for new skin and soft tissue. They can be mobilised and rotated into a postmastectomy defect with relatively little surgical morbidity. An LD flap provides robust skin and muscle coverage, which allows postsurgical radiotherapy to be performed [12]. There is an issue with the potential for upper-limb dysfunction, and the skin paddle available for transfer can be limited for large defects.

In patients where large soft tissue defects are anticipated, or where the option of an LD flap has already been used, the next option to consider is a trans rectus abdominis (TRAM) myocutaneous flap. TRAM flaps can be rotated into position on the chest using a pedicle based on the superior epigastric vessels or can be a free flap employing a microvascular anastomoses [13]. In general the pedicled flaps are simpler to construct and have a lower failure rate than free TRAM flaps. Both types of TRAM flap are associated with considerable surgical morbidity, particularly at the abdominal wall harvest site.

As pedicled TRAM flaps depend on the integrity of the superior epigastric pedicle, they may be compromised during breast cancer therapy, such as local surgery and radiotherapy. In this situation double pedicle or super-charged TRAM flaps may be a useful option [14].

Free tissue transfer TRAM flaps represent the most complex of the local soft tissue coverage options. As such they have the largest rate of failure or flap loss [15]. This is particularly an issue in palliative surgery where the option of reverting to simple suture closure is not possible or when patients with a limited life expectancy can be subjected to major morbidity, impacting on their quality of life. In general, the need for robust soft tissue coverage, capable of withstanding post-operative radiotherapy, means that full muscle TRAM flaps are more appropriate in this setting. For this reason, muscle-sparing, perforator-type flaps (e.g. DIEP) are increasingly being used in breast reconstruction to reduce abdominal wall morbidity but are usually avoided in the setting of radical palliative breast surgery [16].

The key to success in free TRAM flap construction is selecting the site for microvascular anastomosis. Commonly internal mammary or subscapular pedicles are selected as anastomotic sites, but both can have been compromised by prior surgery or radiotherapy. Again, dual vascular anastomoses are an option to improve graft survival.

Although well described, attempts at chest wall resection and reconstruction are very rarely employed. If the patient’s projected survival and extent of local disease warrant such an approach, the muscles, ribs, cartilages, sternum and pleura can all be resected en bloc and soft tissue coverage obtained. Such surgery is inappropriate if more than minimal disease exists at other sites and must have the reasonable expectation of obtaining clear local surgical margins. Incomplete resection is a failure of surgical selection. Likewise, any more than microscopic pleural involvement indicates that a patient is a poor candidate for such aggressive local surgery. The simplest soft tissue coverage is a prosthetic mesh placed into the chest wall defect. PFTE, which is nonpermeable, is favoured for this task. A robust soft tissue flap, either LD or TRAM, is then used to provide outer coverage. Large chest wall resections can compromise the mechanics of ventilation, and there has been some experience with rigid prosthetic supports to deal with this problem [17].

Local axillary involvement can be extremely symptomatic for patients. Prior surgery and local radiotherapy create considerable surgical challenges in this region.

In many cases axillary dissection to level III can be a very important palliative surgical procedure. Sometimes, a palliative procedure can be facilitated by a number of simple additional surgical manoeuvres, such as enlarged or novel skin incisions or the division/resection of pectoralis muscles. In the era of sentinel lymph node biopsy as standard therapy for early breast therapy, palliative completion axillary dissection is an important surgical tool [18].

In palliative axillary surgery it is important to ensure that all options for systemic therapy to debulk extensive local disease have been explored and applied. Careful consideration needs to be given to use of local radiotherapy to control axillary disease. Prior irradiation considerably increases the technical challenge and threatens the success of palliative axillary surgery. Where possible all surgical options should have been completed or explored prior to employing local radiotherapy. In palliative axillary surgery, issues such as post-operative lymphoedema, sensory changes and upper-limb motor dysfunction must be anticipated and managed. They should not limit the extent of surgical excision, as the goal remains clear surgical margins [19].

The contraindications to resection of axillary disease are involvement of the axillary artery and brachial plexus. The axillary vein can usually be resected with relatively little morbidity, particularly if there is prior tumour-related venous thrombosis. The axillary artery, if resected, can be reconstructed with either a reverse vein graft or prosthetic (usually PTFE) graft. Axillary artery involvement is usually associated with brachial plexus involvement that is virtually impossible to resect with any hope of surgical clearance. Sacrifice of the axillary artery or brachial plexus without hope of complete tumour resection is not palliative and is not justifiable. Resection of the brachial plexus for neuropathic pain can be devastatingly disappointing. Forequarter amputation as an approach to uncontrolled local disease is not palliative in breast cancer. Attempts at axillary neurovascular bundle resection, with or without reconstruction, will lead to very high levels of morbidity and often mortality if complications arise. These procedures must be planned and undertaken with full specialist support. Patient selection is paramount [20].