Endoscopic reconstruction of partial mastectomy defects using latissimus dorsi muscle flap without causing scars on the back

Endoscopic-Assisted Latissimus Dorsi Muscle Flap for Chest Wall Reconstruction in Poland Syndrome: Clinical Application and Literature Review

BACKGROUND

Poland syndrome is a rare congenital chest wall developmental defect. Traditional reconstruction applies open to harvest of the latissimus dorsi muscle flap, but issues like large incisions and high complication rates exist. Endoscopic-assisted harvest of the latissimus dorsi muscle flap has minimally invasive advantages worth exploring for application in Poland syndrome patients.

METHODS

We retrospectively analyzed the surgical situations of five Poland syndrome patients at our center, and systematically searched the literature, including 31 cases of endoscopic-assisted latissimus dorsi muscle flap reconstruction. Data on surgical complications, postoperative shoulder function scores, aesthetic scores, and patient satisfaction were collected and comprehensively analyzed in combination with literature reports.

RESULTS

Endoscopic surgery had smaller incisions, fewer complications, shorter recovery time, and high patient scar satisfaction. Postoperative aesthetic results were good, but the obtained flap tissue volume was limited. Upper limb function at the donor site was preserved, but there was some degree of strength decline.

CONCLUSIONS

Endoscopic-assisted latissimus dorsi flap surgery (ELDM) allows for clear visualization of the surgical field, reduces complications, minimizes scarring, shortens recovery time, and provides better cosmetic results, making it suitable for young Poland syndrome patients seeking improved aesthetic outcomes.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .

Endoscopy-assisted latissimus dorsi muscle flap harvesting technique for immediate breast reconstruction

BACKGROUND

The purpose of this study is to investigate the usefulness of endoscopy-assisted latissimus dorsi muscle flap (LDMF) harvesting in immediate breast reconstruction following partial mastectomy.

MATERIALS AND METHODS

From November 2016 to December 2019, sixteen female breast cancer patients who underwent immediate breast reconstruction following partial mastectomy underwent LDMF harvesting with endoscopic assistance. This surgical technique was carried out with only one subaxillary skin incision without leaving a scar on the back. Patients' demographic characteristics, histopathologic factors, operative data, postoperative complications, and oncologic safety were collected through electronic chart review.

RESULTS

In sixteen patients, LDMFs were harvested successfully using an endoscopy-assisted technique without conversion to an open technique. The mean age of the patients was 48.0±8.0 years, and the mean body mass index was 24.4±3.9kg/m2. The most common histologic subtype was invasive ductal carcinoma, with a mean tumor size of 3.2±2.3cm. In terms of LDMF harvesting time, it took 168.4±44.0minutes. The most common postoperative complication, donor site seroma (75%), was managed non-surgically during the outpatient visit. In terms of cosmetic aspects, we've seen a high level of patient satisfaction, especially with scarring.

CONCLUSIONS

Endoscopy-assisted LDMF harvesting technique is safe and useful for breast reconstruction after partial mastectomy. Compared to the conventional open technique, this method does not leave a long scar on the donor site. As a result, it leads to better cosmetic outcomes and improves patient satisfaction.

Latissimus dorsi muscle flap transfer through endoscopic approach combined with the implant after tissue expansion for breast reconstruction of mastectomy patients

BACKGROUND

Implant-based breast reconstruction is easy to be performed but has flaws that an unnatural appearance might be presented when no sufficient coverage existing. While autologous tissue reconstruction also has disadvantages like donor site scar and skin patch effect. There is a demand for a new method to obtain natural and aesthetic appearance while surmounting drawbacks of conventional breast reconstruction surgery.

METHODS

A retrospective review of thirty-one patients undergoing tissue expander (TE)/implant two-stage breast reconstruction with latissimus dorsi muscle flap (LDMF) transfer through endoscopic approach in Peking University Third Hospital from April 2016 to August 2020 was performed. The LDMF harvest time, drain time, and complications were reviewed. The 3D volume was obtained to assess the volume symmetry of bilateral breasts. The BREAST-Q reconstruction module was used to evaluate the satisfaction.

RESULTS

The mean endoscopic LDMF harvest time was 90.4 min. In the mean follow-up of 11.2 months, there were no severe capsular contracture happened. The reconstructed side achieved good volume symmetry to the contralateral side (P = 0.256). Based on the evaluation of the BREAST-Q scores, the outcome of Satisfaction with Breasts was excellent or good in 87.1% of the cases.

CONCLUSIONS

The novel type of two-stage breast reconstruction protocol, which includes tissue expansion followed by implant insertion with endoscopy-assisted LDMF transfer, could effectively reduce visible scars, avoid the patch effect, while require short time for LDMF harvest and present low incidence of complications. It is a promising method for breast reconstruction because it achieves good outcomes in the mastectomy patients.

Pneumoendoscopic single port approach to breast cancer. How we do it?

Endoscopic procedures have not become the gold standard in breast surgery. In order to improve today's outcomes we have developed a pilot study in the Breast Pathology Unit of Hospital Germans Trias i Pujol. A surgical procedure was performed creating a pneumoendoscopic cavity by using a Single Incision Laparoscopic Surgery (Single port) approach with a follow up of four years. Four patients underwent pneumoendoscopic single-port breast surgery receiving skin-sparing quadrantectomy and axillary surgery requiring lymphadenectomy in all of them. All patients had immediate reconstruction with a Latisimus Dorsi flap. No perioperative complications appeared. Mean operative time was 290 min (range 240-315 min) and mean hospital stay was 3,2 days. Surgical margins of all cases were pathologically negative and all patients were disease free after four years of monitoring. All patients were satisfied with the cosmetic outcome in the immediate postoperative and during the follow up. Although all innovative techniques generate hesitation on their beginnings and are liable to improve, we believe that pneumoendoscopic single-port breast surgery can be suitable for breast cancer, offering better cosmetic outcomes with oncological safety.

Comparing the use of differentiated adipose-derived stem cells and mature adipocytes to model adipose tissue in vitro

In vitro models of human adipose tissue may serve as beneficial alternatives to animal models to study basic biological processes, identify new drug targets, and as soft tissue implants. With this approach, we aimed to evaluate adipose-derived stem cells (ASC) and mature adipocytes (MA) comparatively for the application in the in vitro setup of adipose tissue constructs to imitate native adipose tissue physiology. We used human primary MAs and human ASCs, differentiated for 14 days, and encapsulated them in collagen type I hydrogels to build up a three-dimensional (3D) adipose tissue model. The maintenance of the models was analyzed after seven days based on a viability staining. Further, the expression of the adipocyte specific protein perilipin A and the release of leptin and glycerol were evaluated. Gene transcription profiles of models based on dASCs and MAs were analyzed with regard to native adipose tissue. Compared to MAs, dASCs showed an immature differentiation state. Further, gene transcription of MAs suggests a behavior closer to native tissue in terms of angiogenesis, which supports MAs as preferred cell type. In contrast to native adipose tissue, genes of de novo lipogenesis and tissue remodeling were upregulated in the in vitro attempts.

The Latissimus Dorsi Myocutaneous Flap Is a Safe and Effective Method of Partial Breast Reconstruction in the Setting of Breast-Conserving Therapy

BACKGROUND

Reconstruction of partial breast defects in low-volume, nonptotic breasts can be challenging. The authors hypothesized that use of the latissimus dorsi flap in partial breast reconstruction is safe and associated with low complication and high patient satisfaction rates.

METHODS

All patients who underwent breast-conserving therapy and latissimus dorsi flap reconstruction from January 1, 2006, to December 31, 2016, were identified in a prospectively maintained database. Patient demographics, tumor characteristics, and complications were recorded. Patient-reported outcomes were assessed with the BREAST-Q breast-conserving therapy module. A group of plastic surgeons and laypersons used a five-point Likert scale to evaluate aesthetic outcomes in representative patients.

RESULTS

Forty-seven patients met the inclusion criteria. Median follow-up was 5.4 years. Most patients (93.6 percent) underwent immediate reconstruction. The mean resection volume was 219.5 cc (range, 70 to 877 cc). The overall complication rate was 8.5 percent. Grade 2 or 3 ptosis (OR, 1.21; 95 percent CI, 1.0 to 1.46; p = 0.03), smoking (OR, 13.1; 95 percent CI, 1.2 to 143.2; p = 0.03), and multicentric tumor (OR, 1.23; 95 percent CI, 1.04 to 1.64; p = 0.02) were associated with a higher complication rate. Ductal carcinoma in situ was associated with reoperation for positive margins (OR, 14.4; 95 percent CI, 2.1 to 100; p = 0.009). Of particular interest, patient-reported outcomes were favorable, with the highest rated domains being Satisfaction with Breasts (61; interquartile range, 37 to 77), Psychosocial Well-being (87; interquartile range, 63 to 100), and Physical Well-being (87; interquartile range, 81 to 100). The median aesthetic score was 4 (of 5).

CONCLUSIONS

This is the first study to date using the BREAST-Q to assess patient-reported outcomes associated with the latissimus dorsi flap for partial breast reconstruction. The flap is safe and effective for reconstruction in the setting of breast-conserving therapy, providing aesthetically pleasing results with high patient satisfaction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Breast Reconstruction in Poland Syndrome Patients with Latissimus Dorsi Myo Flap and Implant: An Efficient Endoscopic Approach Using Single Transverse Axillary Incision

BACKGROUND

Breast hypoplasia or amastia with pectoralis major muscle defect in female Poland syndrome patients always necessitates surgical intervention. This study aims to introduce an efficient endoscopic technique to perform breast reconstruction in Poland syndrome patients with a latissimus dorsi myo flap and an implant using a single transverse axillary incision (ELDM + IMPLANT) and to evaluate its safety and effectiveness.

METHODS

A prospective study was designed to recruit Poland syndrome candidates for ELDM + IMPLANT breast reconstruction. Only one transaxillary incision was made to harvest the LDM flap and create the anterior chest wall pocket. The LDM flap was transposed to the front to reconstruct the breast with a silicone implant. Patient demographics, LDM area, implant size, contralateral symmetry surgery, operative time and post-operative complications were collected. The BREAST-Q reconstruction module was used to evaluate patient quality of life. The disabilities of the arm, shoulder and hand (DASH) outcome questionnaire was used to evaluate patient upper extremity disabilities.

RESULTS

Sixteen eligible patients were recruited and received ELDM + IMPLANT-BR. Mean endoscopic time for LDM flap harvesting was 61.6 min. All of the 16 patients recovered uneventfully without any significant complications. The post-operative scores of satisfaction with breast and psychosocial well-being were significantly higher than the pre-operative ones. The score of DASH was 7.1 pre-operatively and 8.3 post-operatively with no significant difference either. The score of satisfaction with outcome was 80.0.

CONCLUSIONS

Our proposed ELDM + IMPLANT technique provides a safe and efficient way to reconstruct breasts in Poland syndrome patients with a high satisfaction rate, optimized aesthetic outcome and minimized donor site morbidity.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Selection of oncoplastic surgical technique in Asian breast cancer patients

BACKGROUND

Oncoplastic surgery is being increasingly performed in Korean women; however, unlike Westerners, Korean women usually have small to moderate-sized breasts. To achieve better outcomes in reconstructed breasts, several factors should be considered to determine the optimal surgical method.

METHODS

A total of 108 patients who underwent oncoplastic surgery from January 2013 to December 2016 were retrospectively investigated. We used various methods, including glandular tissue reshaping, latissimus dorsi (LD) flap transposition, and reduction oncoplasty, to restore the breast volume and symmetry.

RESULTS

The mean weight of the tumor specimens was 40.46 g, and the ratio of the tumor specimen weight to breast volume was 0.12 g/mL in the patients who underwent glandular tissue reshaping (n=59). The corresponding values were 101.47 g and 0.14 g/mL, respectively, in the patients who underwent reduction oncoplasty (n=17), and 82.54 g and 0.20 g/mL, respectively, in those treated with an LD flap (n=32). Glandular tissue reshaping was mostly performed in the upper outer quadrant, and LD flap transposition was mostly performed in the lower inner quadrant. No major complications were noted. Most patients were satisfied with the aesthetic results.

CONCLUSIONS

We report satisfactory outcomes of oncoplastic surgical procedures in Korean patients. The results regarding specimen weight and the tumor-to-breast ratio of Asian patients will be a helpful reference point for determining the most appropriate oncoplastic surgical technique.

Endoscopic Delayed Breast Reconstruction With Expanders and Implants via the Axillary Incision Made for Sentinel Lymph Node Biopsy or Lymphadenectomy

BACKGROUND

Classic techniques of delayed prosthetic breast reconstruction use the mastectomy scar as an access route. As a result, the filling of the expander must be postponed until the wounds have healed. This creates an asymmetry between the breasts with the volume changes caused by the filling of the expander, which may occur over several weeks and cause considerable discomfort.

METHODS

Delayed breast reconstruction was performed via the axillary incision made for sentinel lymph node biopsy or lymphadenectomy with endoscopic assistance and detachment of the pectoralis major muscle. The filling of the expander and symmetrization with the contralateral breast was performed in the first stage.The expander was replaced with the definitive prosthesis 3 months later, after endoscopic capsulotomy. Fat grafting was performed to create a lipobed around the implant and to improve tissue quality.

RESULTS

Sixty-two patients underwent surgery. Mean follow-up was 19 months. There were no major complications in the reconstructed breast. One case of hematoma in a contralateral breast reduction and an oil cystic mass secondary to fat grafting were recorded. In all cases, the filling of the expander with the definitive volume was possible during the first stage.

CONCLUSIONS

Endoscopic delayed breast reconstruction with insertion of implants through the axillary incision for sentinel node biopsy or lymphadenectomy is safe and feasible. It achieves complete intraoperative expansion, symmetry between the volumes of the breasts during the first stage, and avoids problems with the scar and the risk of extrusion, as the scar is placed remotely in the axilla.

Present status of endoscopic mastectomy for breast cancer

Endoscopy is now being used for breast cancer surgery. Though it is used for mastectomy, lymph node dissection, and breast reconstruction, its prime use is for mastectomy. Because an incision can be placed inconspicuously in the axillary site, a relatively large incision can be created. A retractor with an endoscope, CO₂, and an abrasion device with the endoscope are used for operation space security. It is extremely rare that an endoscope is used for lymph node dissection. For breast reconstruction, it may be used for latissimus muscle flap making, but an endoscope is rarely used for other reconstructions. Endoscopic mastectomy is limited to certain institutions and practiced hands, and it has not been significantly developed in breast cancer surgery. On the other hand, endoscopic surgery may be used widely in breast reconstruction. With respect to the spread of robotic surgery, many factors remain uncertain.

Endoscopy Assisted Oncoplastic Breast Surgery (EAOBS)

Endoscopic oncoplastic breast surgery represents a minimal invasive approach with the aim of both removing cancer safely and also restoring the breast image. It has less noticeable scar, excellent cosmetic outcomes, high patient satisfaction rate and recently reported relatively long term safety. Operative techniques for both endoscopic breast conserving surgery and endoscopic nipple/areola/skin sparing mastectomy have been described in detail. Two different working planes in which one of them is subcutaneous and the other one is sub-mammary planes are being used during the surgery. Surgical techniqe needs some instruments such as endoscopic retractor, light guided specific mammary retractor, wound protector and bipolar scissor. Endoscopic breast retractors provide magnified visualization and extensive posterior dissection facility. Tunneling method and hydrodissection simplify the technique in the subcutaneous field. Oncoplastic reconstruction techniques are also applied after the tumor resection by endoscopic method. Complication rates of endoscopic breast surgery are similar to open breast surgery rates. Quite succesful local recurrence, distant metastasis and overall survival rates have been declared. However it looks reasonable to wait for the results with longer follow-up before having a judgement about oncologic efficiency and safety of the endoscopic breast cancer surgery.

Endoscopy-assisted breast-conserving surgery for breast cancer patients

Breast-conserving surgery (BCS) combined with postoperative radiotherapy is a standard therapy for early-stage breast cancer patients. In addition, recent developments in oncoplastic surgery have improved cosmetic outcomes and patient satisfaction. Therefore, a breast surgeon's current role in BCS is not only to perform a curative resection of cancerous lesions with adequate surgical margins, but also to preserve the shape and appearance of the treated breast. Endoscopy-assisted breast-conserving surgery (EBCS), which has the advantage of a less noticeable scar, was developed more than ten years ago. Recently, some clinical studies have reported the feasibility, oncological outcomes, aesthetic outcomes, and patient satisfaction of EBCS. Herein, we will review the EBCS clinical studies that have been conducted so far and discuss current issues regarding this operative method.