Breast reconstruction after mastectomy without additional scarring: application of endoscopic latissimus dorsi muscle harvest

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.

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

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Novel technique for laparoscopic harvesting of latissimus dorsi flap with prosthesis implantation for breast reconstruction: A preliminary study with 2 case reports

BACKGROUD

An important drawback of the traditional technique for harvesting latissimus dorsi (LD) myocutaneous flap is a long, posterior donor-site incision. Current techniques involve endoscopic or robotic harvesting via a combined approach of open and closed surgery, which necessitates an open axillary incision and the use of special retractors. In this paper, we introduce a fully enclosed laparoscopic technique for harvesting LD flap (LDF) using only 3 small trocar ports. This technique eliminates the need for axillary and donor-site incisions and specialized retractors and considerably reduces the incision size.

METHODS

We performed laparoscopic harvesting of LDF with prosthesis implantation for immediate breast reconstruction (IBR) after nipple-sparing mastectomy in 2 patients with malignant breast neoplasm who wished to avoid a long scar on the back.

RESULTS

IBR using this technique was uneventful in both cases, without any donor-site complications or flap failure. Both patients were satisfied with the esthetic results of the procedure, especially the absence of a visible scar on the back.

CONCLUSION

Enclosed laparoscopic harvesting of LDF is simpler and less invasive than the traditional methods. These preliminary results warrant further evaluation in a larger population to validate the benefits of this technique.

Latissimus dorsi flap for total autologous immediate breast reconstruction without implants

BACKGROUND

The latissimus dorsi flap provides suitable recipient tissue for fat transfer, with a good blood supply and a reasonable volume of host tissue to inject into. The authors present their experience with use of the pedicled latissimus dorsi flap for fat grafting in total autologous immediate breast reconstruction without implants.

METHODS

From 2010 to 2013, 23 patients underwent breast reconstruction with primary fat augmented latissimus dorsi flaps (21 unilateral procedures and two bilateral procedures). Mean patient age was 52.3 years (range, 39 to 68 years); mean body mass index was 24.77 kg/m2 (range, 21.5 to 28.7 kg/m2). Fat was harvested using the Coleman technique with 10-ml syringes and injected into the adipose layer and muscle fascia of the latissimus dorsi flap skin paddle with 1-ml syringes.

RESULTS

The mean size of the harvested skin paddle was 19.7 × 11.04 cm (range, 18 × 10 cm to 21 × 12 cm). Mean operative time was 2.62 hours (range, 2.10 to 3.20 hours) and 4.12 hours (range, 4.10 to 4.15 hours) for unilateral and bilateral reconstructions, respectively. Mean harvested fat volume was 126 ml (range, 90 to 180 ml), and mean injected fat volume was 101 ml (range, 60 to 150 ml). All flaps healed uneventfully, no seroma occurred at the flap donor-site, and no fat grafting-related complications were observed.

CONCLUSION

To the best of the authors' knowledge, this is the first report in which fat transfer was used to achieve immediate latissimus dorsi flap volume augmentation as an alternative for total autologous reconstruction, avoiding implant-related complications.

Single incision for quadrantectomy and laparoscopic axillary lymph node dissection in the treatment of early breast cancer: initial experience of 5 cases

PURPOSE

Quadrantectomy with multiple-incision laparoscopic axillary clearance for the treatment of early breast cancer is already well established. With the aim of reducing the axillary scar, we shared our 5 cases to demonstrate the safety and feasibility of quadrantectomy with laparoscopic axillary clearance through a single incision.

PATIENTS AND METHODS

From May 2010 to January 2013, single-incision quadrantectomy and laparoscopic axillary clearance were performed on 5 patients with early breast cancer by using conventional laparoscopic instruments. Surgical techniques and short-term outcomes were summarized and analyzed retrospectively.

RESULTS

All the operations were successful with operative duration of 85-120 minutes, intraoperative blood loss of 20-50 mL, and hospital stay of 4-6 days. No intraoperative or postoperative complications were recorded. The incision wound healed uneventfully, with no scar in the axillary fossa.

CONCLUSIONS

The combination of single-incision quadrantectomy and laparoscopic axillary clearance in the treatment of early breast cancer appears to be a technically safe and feasible alternative to the standard laparoscopic procedure and can be performed using conventional laparoscopic instruments.

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

BACKGROUND

Results obtained with breast-conserving therapy are not always satisfactory. Reconstruction with a pure latissimus dorsi muscle flap is a useful option. The techniques described for endoscopic dissection of the flap create several scars on the back. As a result, they do not improve on the open approach, which causes a horizontal scar at the level of the bra strap. The authors' technique avoids all scars on the back using a single incision in the highest folds of the axilla, which also is used for the sentinel node biopsy or lymphadectomy and quadrantectomy.

METHODS

The study was performed with 23 patients. The tumor was extracted via a clockwise downward periareolar incision and via another incision in a fold of the axilla. Through this axillary incision, the sentinel lymph node biopsy or lymphadectomy was performed, and the external part of the latissimus dorsi muscle was harvested endoscopically for the reconstruction.

RESULTS

Both the medical team and the patients reported high satisfaction with the aesthetic and functional results due to the preservation of the breast shape and the absence of any scarring on the back.

CONCLUSION

Endoscopy-assisted techniques make either three small scars on the back or one long scar, with the muscle sectioned distally, or a vertical incision in the midaxillary line, which may form a hypertrophic or keloid scar. The authors' approach avoids the creation of these scars on the back because the endoscopy and the distal sectioning of the muscle flap are performed through the single axillary incision.

Minimally invasive harvesting of adipofascial scapular flaps

INTRODUCTION

Scapular flaps are a reliable system for reconstruction. Disadvantages of reconstruction with these flaps include unsightly scars at the donor site due to wound healing under excessive tension and the use of skin grafts. Minimally invasive harvesting techniques may reduce potential donor-site morbidity. There has been no report on endoscopically assisted harvesting of the scapular adipofascial flap.

METHODS

Two patients with large defects are reviewed. Endoscopically assisted minimally invasive techniques for harvest of scapular adipofascial flaps were used in reconstruction of these soft-tissue defects.

RESULTS

Both defects were successfully reconstructed in the primary setting without any donor-site wound complications.

CONCLUSIONS

This is the first time that a scapular flap has been harvested successfully with a minimally invasive technique for reconstruction. This technique allows the use of a scapular flap as a pedicled flap or as a free flap. Minimally invasive harvest of the adipofascial scapular flap has the advantages of short incision and better cosmesis of the donor site, for scarring is minimized and the incision can be closed primarily without skin grafting therefore reducing donor-site morbidity compared with the traditional open technique.

A review of the surgical management of breast cancer: plastic reconstructive techniques and timing implications

The oncologic management of breast cancer has evolved over the past several decades from radical mastectomy to modern-day preservation of chest and breast structures. The increased rate of mastectomies over recent years made breast reconstruction an integral part of the breast cancer management. Plastic surgery now offers patients a wide variety of reconstruction options from primary closure of the skin flaps to performance of microvascular and autologous tissue transplantation. Well-coordinated partnerships between surgical oncologists, plastic surgeons, and patients address concerns of tumor control, cosmesis, and patients' wishes. The gamut of breast reconstruction options is reviewed, particularly noting state-of-the-art techniques, as well as the advantages and disadvantages of various timing modalities.

Delayed breast reconstruction with latissimus dorsi flap

BACKGROUND

The ideal method of breast reconstruction should be safe, reliable, and have minimal or no donor-site morbidity. We present our experience with the latissimus dorsi musculocutaneous flap for delayed breast reconstruction with immediate permanent implant insertion.

METHODS

The latissimus dorsi musculocutaneous flap was performed on patients who presented for delayed breast reconstruction. From 1999 to 2007, charts of patients were reviewed for age, type of mastectomy, history of chest wall irradiation, nipple-areola complex reconstruction, and complications at both the donor site and the reconstructed breast site.

RESULTS

The latissimus dorsi was used as a musculocutaneous flap in 33 patients who had breast cancer surgery. The mean age was 51.14 (range = 30-63) years. Nine patients (27%) asked for nipple-areola reconstruction. Three patients had major complications (9%), including infection, partial flap ischemia, and liponecrotic pseudocysts. Eight patients required revision. Seroma was the most common problem observed at the donor site.

CONCLUSION

The latissimus dorsi flap provides adequate soft tissue with a reliable blood supply for the enhancement of missing tissue after mastectomy. It is a safe method for breast reconstruction and an excellent alternative flap for patients at high risk for abdominal flap complications.

Endoscopic latissimus dorsi flap harvesting

BACKGROUND

Immediate breast reconstruction using the latissimus dorsi musculocutaneous flap is a standard technique that allows for cosmetically acceptable results yet leaves a great scar on the donor site. To reduce the scars, we have been using a different surgical technique consisting of endoscopic harvesting of the latissimus dorsi pure muscular flap with a virtual cavity created by CO2 gas distention.

METHODS

Between May 1, 2001, and June 30, 2005, there were 52 patients who underwent latissimus dorsi endoscopic harvesting for an immediate breast reconstruction after a skin-sparing mastectomy.

RESULTS

The mean surgical endoscopic time was 64 minutes. There was one conversion to an open technique. We reported no deaths, but complications included 2 hematomas, 6 inflammatory syndromes, and 1 pulmonary embolism.

CONCLUSIONS

The endoscopic harvesting of the latissimus dorsi flap when performed with this mixed technique is feasible, reproducible, and permits a significant reduction of incision size and postoperative pain, with good aesthetic results.

Latissimus Dorsi Muscle Flap and Tissue Expansion for Breast Reconstruction

BACKGROUND

After mastectomy for breast cancer, especially when combined with radiation, inadequate wall thickness and insufficient elasticity of the skin are problems frequently encountered in breast reconstruction. We describe a reconstruction method using a latissimus dorsi muscle flap, followed by expansion, that creates no additional scar.

METHODS

This retrospective study included 30 patients who underwent this 4-surgery reconstruction: the muscle flap was raised and drawn through the mastectomy scar; the expander was inserted; expander replacement with the definitive prosthesis and concomitant symmetrization of the contralateral breast; finally, reconstruction of the nipple-areola complex.

RESULTS

Only 1 failure, prosthesis extrusion, was observed. A surgeon scored the outcomes as above average for 26 women, who were satisfied.

DISCUSSION

We noted an overall lower complication rate and a lower reconstruction-failure rate compared with reported results. This approach obtained better tissue quality; the flap provided better covering thickness and expansion, yielding a larger muscle-skin pocket.

CONCLUSIONS

This reconstruction procedure seems reliable and extends the indications of skin expansion, with satisfactory results.

Endoscopic muscular latissimus dorsi flap harvesting for immediate breast reconstruction after skin sparing mastectomy

AIM

Immediate breast reconstruction after mastectomy using the latissimus dorsi musculo-cutaneous flap is well recognized. It allows for satisfactory aesthetic results. To minimize scanning in skin sparing mastectomy patients, we used a surgical technique consisting of an endoscopic harvesting of the latissimus dorsi pure muscular flap with a virtual cavity created by CO(2) gas distention.

METHOD

Between 9 April 2001 and 30 September 2001, 8 patients underwent latissimus dorsi endoscopic harvesting for an immediate breast reconstruction after skin sparing mastectomy.

RESULT

The mean operating endoscopic time was 112 minutes. No open surgical conversion was necessary. The mean lymphatic drainage was 2720 ml with removal of the drainage on post operative day 15.

CONCLUSION

The endoscopic harvesting of the latissimus dorsi muscular flap, using a mixed technique of dissection guided by the lighted cleaver forceps and a closed technique by CO(2) insufflation using an endoscope is feasible, reproducible and has acceptable morbidity. This technique brings encouraging aesthetic results after skin sparing mastectomy.

[Endoscopic harvesting of the latissimus dorsi flap in breast reconstructive surgery. Feasibility study and review of the literature]

STUDY AIM

Breast reconstructive surgery with latissimus dorsi flap is routinely performed with a long dorsal scar ransom. To reduce the scar the authors propose an endoscopic technique to harvest the pure latissimus dorsal flap. We evaluate our first experience.

PATIENTS AND METHODS

Between April 2001 and december 2001, 13 patients were operate using an endoscopic pure muscular latissimus dorsal flap for breast reconstruction surgery.

RESULTS

Mean operative time is 116 min. No open conversion was necessary. One patient was transfused. The average lymphatic drainage was of 2520 ml with removal of the drainage on postoperative day 15.

CONCLUSION

The endoscopic harvesting of the latissimus dorsi pure muscular flap, brings less scar than the open surgery.

Endoscopic harvest of the medial gastrocnemius muscle flap: a cadaveric study

The aim of our study was to prove that endoscopic-assisted harvest of the medial gastrocnemius muscle is as effective as the conventional technique. We performed endoscopic dissection on 10 fresh human cadavers, and found that the medial gastrocnemius muscle was easily harvested through a minor donor-site incision, because of its topography and constant dominant proximal vascular pedicle. The operative technique is described.

Endoscopic harvest of four muscle flaps: safe and effective techniques

The recent explosion of endoscopic techniques in plastic surgery has led to the successful harvest of a number of useful muscle flaps. The gracilis, rectus femoris, external oblique, and gastrocnemius muscles can all be harvested safely and reproducibly using endoscopic techniques. The aim of this study was to identify a safe and effective technique for endoscopic muscle flap harvest. Harvesting the gracilis muscle as a free flap and the gastrocnemius as a pedicle flap lends themselves best to the use of endoscopic techniques.

Transareolar endoscopy-assisted partial mastectomy: a preliminary report of six cases

Six patients with breast cancer in the upper inner quadrant underwent endoscopy-assisted partial mastectomy. The tumor was removed with a 2-cm-wide surgical margin through a periareolar semicircular incision using a special retractor and endoscope system for plastic surgery. Another small incision was made in the axilla for total lymph node dissection or sentinel lymph node biopsy. The average of total operation time in five patients who underwent partial mastectomy was 241 minutes (range, 190-315 minutes), and the average time for the procedure of partial mastectomy in six cases was 84 minutes (range, 69-113 minutes). The cosmetic outcome was excellent. Transareolar endoscopic partial mastectomy can be considered as an alternative surgery option and can offer great cosmetic advantage for patients with small cancers in the inner quadrants of the breast.

Single axillary incision for quadrantectomy, axillary clearance and immediate reconstruction with latissimus dorsi

This paper describes a method of immediate breast reconstruction following conservative breast surgery. The technique is innovative in that axillary clearance, quadrantectomy and the harvest of the latissimus dorsi muscle are carried out through a small transverse axillary incision with no incision in the breast.

Techniques for improving the cosmetic outcome of breast conservation surgery

This paper presents techniques to enhance the aesthetic results of conservative breast surgery. A number of methods are described to improve results of conservative surgery by limiting deformity, reducing scars and by immediate replacement of tissue. By application of the appropriate technique breast tumours may be excised from any quadrant in a large or small breast with a good cosmetic outcome. Attention to detail with pre-operative planning of the estimated tissue loss, placement of incisions, fish-tailing of quadrantectomy scars, utilization of reduction mammoplasty incisions and immediate replacement of defects after wide excision are useful in obtaining good aesthetic results.

Minimal damage during endoscopic latissimus dorsi muscle mobilization with the harmonic scalpel

BACKGROUND

To reduce wound-related complications, a video-assisted surgical technique has been adopted for the mobilization of the latissimus dorsi muscle. We postulated that thermal damage to the muscle might be minimized by using a Harmonic Scalpel instead of electrocautery during this procedure.

METHODS

Canine latissimus dorsi muscles were mobilized through a small incision, assisted by a videoscope. In 6 dogs, dissection with electrocautery was used to mobilize the latissimus dorsi muscle. In 6 other dogs, the Harmonic Scalpel was used. We compared operation times, wound infection rates, histologic changes in the muscles, and ease of handling between these groups.

RESULTS

The operation time was significantly shorter in the Harmonic Scalpel group than in the electrocautery group (61.5 versus 106.5 minutes, p = 0.00014). The Harmonic Scalpel caused less histologic damage to the mobilized muscles and produced less vision-obscuring smoke.

CONCLUSIONS

The Harmonic Scalpel shortens the operation, minimizes muscle damage, and facilitates the performance of video-assisted latissimus dorsi muscle mobilization.