An Algorithmic Approach to Breast Reconstruction Using Latissimus Dorsi Myocutaneous Flaps:

Defect-Oriented Versus Back Scar-Oriented Flap Design in Breast Reconstruction with Latissimus Dorsi Musculocutaneous Flap: A Patient-Reported Satisfaction Outcome Comparison Using BREAST-Q

BACKGROUND

The design of the latissimus dorsi musculocutaneous flap in breast reconstruction has several options. To date, there have been no reports on the surgical outcomes with flap designed based on the defect shape of the mastectomy site and flap shape of the donor site. To compare patient satisfaction according to the flap design, we designed and conducted independent three sub-studies targeting fifty-three breast reconstruction patients using BREAST-Q© scale.

METHODS

In study 1, there was no difference in patient satisfaction between the group with the flap designed according to the shape of mastectomy defect (defect-oriented group) that with the flap designed according to patient's wish regardless of defect shape (back scar-oriented group). In study 2, comparing the results based on the shape of the flap, vertically designed flap showed a statistically significant difference in the psychosocial well-being. In study 3, comparing the results based on the shape of the defect, no significant difference was noted.

RESULTS

Even though designing a donor flap based on the shape and orientation of the mastectomy defect has no statistical significance in patient satisfaction or quality of life compared with that based on the patient preference in placement of the donor site scar, the group with the vertical donor design showed better psychosocial well-being than the group with other shapes of the donor flap. By considering the advantages and disadvantages of each flap design, enhanced patient satisfaction and durability and natural aesthetic goal can be achieved. This is the first study to compare the differences in results according to the flap design method during breast reconstruction. Patient satisfaction according to the design of the flap was investigated in the form of a questionnaire survey, and the results were displayed. In addition to breast shape, donor scars and complications were also investigated.

LEVEL OF EVIDENCE IV

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Latissimus dorsi flap for breast reconstruction: a large single-institution evaluation of surgical outcome and complications

PURPOSE

The use of autologous tissues is considered gold standard for patients undergoing breast reconstruction and is the preferred method in the post-radiation setting. Although the latissimus dorsi flap (LDF) has been replaced by abdominal flaps as technique of choice, it remains a valuable option in several specific clinical situations and its use has been regaining popularity in recent years. In this work, we present an 18-year retrospective analysis of a single-institution single-surgeon experience with LDF-based reconstruction with focus on early complications and reconstructive failures.

METHODS

Hospital records of all patients undergoing breast surgery for any reason in the Certified Breast Cancer Center, Regio Klinikum Pinneberg, Germany between April, 1st 2005 and October, 31st 2022 were reviewed. 142 consecutive LDF-based reconstructive procedures were identified. Detailed information was gathered on patient characteristics, treatment-related factors, and complications.

RESULTS

One hundred forty patients (139 female, 1 male) received 142 LDF-based surgeries. The flap was used mainly for immediate breast reconstruction with or without implant (83% of patients), followed by defect coverage after removal of a large tumor (7%), implant-to-flap conversion with or without placement of a new implant (6%), and delayed post-mastectomy reconstruction (4%). The use of LDF decreased between 2005 and 2020 (2005: 17, 2006: 13, 2007: 14, 2008: 16, 2009: 5, 2010: 9, 2011: 8, 2012: 3, 2013: 10, 2014: 8, 2015: 8, 2016: 7, 2017: 7, 2018: 4, 2019: 4, 2020: 2, 2021: 6, 2022: 4). Surgery was performed for invasive breast cancer in 78%, ductal carcinoma in situ in 20% and other reasons such as genetic mutation in 1% of patients. Ipsilateral radiation therapy was received by 12% of patients prior to LDF surgery and by 37% after the surgery. 25% of patients were smokers. The median duration of surgery, including all procedures conducted simultaneously such as e.g., mastectomy, axillary surgery, or implant placement, was 117 min (range 56-205). Patients stayed in the hospital for a median of 7 days (range 2-23 days). The most common complication was seroma (26%), followed by wound dehiscence (8%), surgical site infection (7%), partial skin and/or nipple necrosis of any size (7%) and hematoma requiring surgical evacuation (2%). 19% of all patients required seroma aspiration or drainage, mostly at the donor site and performed under ultrasound guidance in the ambulatory setting. Flap loss due to necrosis occurred in 2% of patients.

CONCLUSIONS

Latissimus dorsi flap is a well-established surgical technique commonly used for immediate breast reconstruction as well as defect coverage in locally advanced breast cancer. To the best of our knowledge, this is one of the largest single-surgeon analyses of early complications in patients receiving LDF. As expected, seroma was the most common complication observed in nearly one third of patients and requiring a therapeutic intervention in every fifth patient. Serious adverse events occurred rarely, and flap loss rate was very low.

Spontaneous Tissue Expander Migration in an Irradiated Field: A Case Report

A 59-year-old woman with a history of bilateral breast cancer, bilateral mastectomy, and bilateral latissimus dorsi flap reconstruction with tissue expanders, before expansion, developed spontaneous unilateral tissue expander migration on the side that had been irradiated. During the operation to return the migrated tissue expander to the chest, the expander was found at the back with a seroma. The chest pocket had collapsed, and a subcutaneous tunnel inferior to the flap inset was encountered, indicating the path of migration. To our knowledge, this is the first case reported of spontaneous tissue expander dislodgement to the donor site. This case is unique in that the patient had bilateral procedures but developed tissue expander migration only on the irradiated side. This highlights the need during pocket creation to account for the fibrosis caused by radiation that can create a constricted pocket promoting migration.

[Application of modified designed bilobed latissimus dorsi myocutaneous flap in chest wall reconstruction of locally advanced breast cancer patients]

Objective

To explore the effectiveness of the modified designed bilobed latissimus dorsi myocutaneous flap in chest wall reconstruction of locally advanced breast cancer (LABC) patients.

Methods

Between January 2016 and June 2019, 64 unilateral LABC patients were admitted. All patients were female with an average age of 41.3 years (range, 34-50 years). The disease duration ranged from 6 to 32 months (mean, 12.3 months). The diameter of primary tumor ranged from 4.8 to 14.2 cm (mean, 8.59 cm). The size of chest wall defect ranged from 16 cm×15 cm to 20 cm×20 cm after modified radical mastectomy/radical mastectomy. All defects were reconstructed with the modified designed bilobed latissimus dorsi myocutaneous flaps, including 34 cases with antegrade method and 30 cases with retrograde method. The size of skin paddle ranged from 13 cm×5 cm to 17 cm×6 cm. All the donor sites were closed directly.

Results

In antegrade group, 2 flaps (5.8%, 2/34) showed partial necrosis; in retrograde group, 6 flaps (20%, 6/30) showed partial necrosis, 5 donor sites (16.7%, 5/30) showed partial necrosis; and all of them healed after dressing treatment. The other flaps survived successfully and incisions in donor sites healed by first intention. There was no significant difference in the incidence of partial necrosis between antegrade and retrograde groups ( χ ²=2.904, P=0.091). The difference in delayed healing rate of donor site between the two groups was significant ( P=0.013). The patients were followed up 15-30 months, with an average of 23.1 months. The appearance and texture of the flaps were satisfactory, and only linear scar left in the donor site. No local recurrence was found in all patients. Four patients died of distant metastasis, including 2 cases of liver metastasis, 1 case of brain metastasis, and 1 case of lung metastasis. The average survival time was 22.6 months (range, 20-28 months).

Conclusion

The modified designed bilobed latissimus dorsi myocutaneous flap can repair chest wall defect after LABC surgery. Antegrade design of the flap can ensure the blood supply of the flap and reduce the tension of the donor site, decrease the incidence of complications.

Lipofilled Mini Dorsi Flap: An Efficient Less Invasive Concept for Immediate Breast Reconstruction

INTRODUCTION

The traditional extended latissimus dorsi flap technique, in addition to lipofilling, has been one of the main procedures used for breast reconstruction after mastectomy. However, to obtain excellent results, this technique requires a large muscle harvest and further lipofilling sessions. The lipofilled mini dorsi flap technique, performed in a single operation, appealed to us as a way to improve the traditional technique.We present our experience with the lipofilled mini dorsi flap technique in a new scenario.

MATERIALS AND METHODS

We performed breast reconstruction with a lipofilled mini dorsi flap in female patients with breast cancer who underwent mastectomy and immediate breast reconstruction with a lipofilled mini dorsi flap. The operative technique is detailed in this article. The results were evaluated by the patients and the surgical team.

RESULTS

We performed 72 lipofilled mini dorsi flap procedures during breast reconstruction surgery from May 2017 to January 2019. Fifty-nine (81.9%) cases were immediate reconstructions. Complications, such as infection or necrosis of the flap, were not observed in this study. We noticed seroma and 1 case of infected lymphocele, which was drained.Body mass index (BMI) was directly related to postoperative dorsal seroma. The authors reported that greater BMI was associated with a higher seroma volume.Most patients evaluated their reconstruction as satisfactory. The surgical team evaluated most of the results as very satisfactory or satisfactory. There were no cases of unsatisfactory results reported either by the patients or the surgical team.

CONCLUSIONS

The lipofilled mini dorsi flap technique is an efficient, elegant, and less invasive solution that is more easily and quickly performed and achieves excellent long-term results in the immediate breast reconstruction scenario. For the first time to our knowledge, lipofilling was used to reduce the extent of latissimus dorsi dissection. The postoperative follow-up was better tolerated by patients. This technique may be offered to patients regardless of oncological treatment. In our experience, the lipofilled mini dorsi flap method has become the primary technique for immediate breast reconstruction.

Latissimus Dorsi Myocutaneous Flap in Immediate Reconstruction after Salvage Mastectomy Post-Lumpectomy and Radiation Therapy

Breast reconstruction after salvage mastectomy (SM) for recurrent cancer represents a challenge in preradiated patients due to the increased complication rate. Latissimus dorsi myocutaneous flap (LDMF) represents a good reconstructive option due to its versatility, safety, and adaptability.

Vertical Inset of the Latissimus Dorsi Flap Improves Reconstruction Aesthetics by Reducing Scar Burden in the "Social Breast"

PURPOSE

The skin paddle of the latissimus dorsi flap is typically inset horizontally (HILD) in breast reconstruction. We describe our experience with the vertical inset of the latissimus dorsi (VILD) and its aesthetic benefit.

METHODS

We performed a case-control study comparing the most recent cases of both VILD and HILD. Scar, as seen on anterior-posterior photographs, was digitally measured and compared from 3 clinically relevant areas: (1) all visible scarring ("mirror view"), (2) scarring above the nipple ("self-view"), and (3) scarring above or medial to the nipple ("social view"). Demographics and outcomes were statistically compared.

EXPERIENCE/RESULTS

Fifty of the most recent patients receiving HILD or VILD were selected for each group. Average patient age was 55.6 and 51.6 years (P = 0.32), and average follow-up was 531.6 and 606.7 days (P = 0.20), respectively. The VILD scar-length ratios were decreased by 17% in the mirror view (P ≤ 0.01), 37% in the self-view (P ≤ 0.01), and 37% in the social view (P ≤ 0.01). There were no statistically significant differences between groups regarding smoking (P = 0.75), diabetes (P = 0.70), body mass index (P = 0.74), seroma (P = 0.46), infection (P = 1.0), or flap necrosis (P = 0.70).

CONCLUSIONS

The VILD is safe and reliable. Measurements from anterior-posterior photographs illustrate statistically significant decreases in overall scar burden (mirror view) and statistically significant reductions in the highly visible self-view and social view. Our study is the first to quantify a reduction in scar burden by using VILD technique.

[Shift the skin paddle in an additional incision improves the result: Study of a series of 82 breast reconstructions by latissimus dorsi flap and prosthesis implantation at 10 years]

The position of the skin paddle on the breast area is a fundamental element for the breast reconstructions by latissimus dorsi flap and prosthesis implantation. Should, as Millard advocated, to recreate the initial defect and include it in the mastectomy scar or is it better in an additional incision as have others authors. This study compares the long-term morphological results of these two attitudes, with or without additional incision.

PATIENTS AND METHODS

Eighty-two breast reconstructions by latissimus dorsi flap and prosthesis implantation, with a mean follow-up of 9.5 years were scored from 1 to 5 by a panel of expert and non-expert. The patients scored also their own reconstruction. Various parameters of the reconstructed breast were thus evaluated. We compared the results, according to the positioning of the skin paddle: with additional incision (50 cases); without additional incision (32 cases). The characteristics of the mastectomy scar on the breast area, high or low, horizontal or oblique, defined 6 groups where the results of the 2 surgical options were compared.

RESULTS

Only the reconstructions with additional incision get significantly higher results than those without additional incision (P<0.05). This involves the two panels, in the case of high mastectomy scars. In the others cases the additional incision is not essential.

CONCLUSIONS

If the realization of an additional incision can be perceived like misfit on an area already "mutilated", we plead for this solution in selected cases. This provides a benefit stable in time, in terms of overall results, shape and even rendering scar.

Propeller thoracodorsal artery perforator flap for breast reconstruction

BACKGROUND

The thoracodorsal artery perforator (TDAP) flap has been described for breast reconstruction. This flap requires intramuscular dissection of the pedicle. A modification of the conventional TDAP surgical technique for breast reconstruction is described, utilizing instead a propeller TDAP flap. The authors present their clinical experience with the propeller TDAP flap in breast reconstruction alone or in combination with expanders or permanent implants.

METHODS

From January 2009 to February 2013, sixteen patients had breast reconstruction utilizing a propeller TDAP flap. Retrospective analysis of patient characteristics, clinical indications, procedure and outcomes were performed. The follow-up period ranged from 4 to 48 months.

RESULTS

Sixteen patients had breast reconstruction using a TDAP flap with or without simultaneous insertion of an expander or implant. All flaps survived, while two cases required minimal resection due to distal flap necrosis, healing by second intention. There were not donor-site seromas, while minimal wound dehiscence was detected in two cases.

CONCLUSIONS

The propeller TDAP flap appears to be safe and effective for breast reconstruction, resulting in minimal donor site morbidity. The use of this propeller flap emerges as a true alternative to the traditional TDAP flap.

Evidence-based medicine: breast reconstruction

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Differentiate among the various techniques available to reconstructive breast surgeons. 2. Perform a comprehensive assessment of the breast reconstruction candidate. 3. Gain knowledge about the indications and contraindications for different breast reconstructive procedures. 4. Understand the complications inherent in different reconstructive breast procedures. 5. Summarize the long-term objective and subjective implications of surgery.

SUMMARY

This article was prepared to accompany practice-based assessment with ongoing surgical education for the Maintenance of Certification for the American Board of Plastic Surgery. It is structured to outline the care of the patient with the postmastectomy breast deformity.

Current trends in breast reconstruction: survey of American Society of Plastic Surgeons 2010

BACKGROUND

We conducted a retrospective survey of American Society of Plastic Surgeons to ascertain the current trends in breast reconstruction (BR).

METHODS

Surveys were sent to 2250 active American Society of Plastic Surgeons members by e-mail with a cover letter including the link using Survey Monkey for the year 2010. In all, 489 surveys (a response rate of 21.7%) were returned. Three hundred fifty-eight surveys from respondents performing BR in their practices were included in the study. The survey included questions on surgeon demographics, practice characteristics, BR after mastectomy, number of BR per year, type and timing of BR, use of acellular dermal matrix, reconstructive choices in the setting of previous irradiation and in patients requiring postmastectomy radiation therapy, timing of contralateral breast surgery, fat grafting, techniques used for nipple-areola reconstruction, the complications, and physician satisfaction and physician reported patient satisfaction. Returned responses were tabulated and assessed.

RESULTS

After prophylactic mastectomy, 16% of BRs were performed. In all, 81.2% of plastic surgeons predominantly performed immediate BR. In patients requiring postmastectomy radiation therapy, 81% did not perform immediate BR. Regardless of practice setting and laterality of reconstruction, 82.7% of respondents predominantly performed implant-based BR. Half of the plastic surgeons performing prosthetic BR used acellular dermal matrix. Only 14% of plastic surgeons predominantly performed autologous BR. Surgeons in solo, plastic surgery group practices, and multispecialty group practices preferred implant-based BR for both unilateral and bilateral cases more frequently than those in academic practices (P < 0.05). Overall, plastic surgeons in academic settings preferred autologous BR more frequently than those in other practice locations (P < 0.05). Of total respondents, 64.8% did not perform microsurgical BR at all; 28% reported performing deep inferior epigastric perforator flap BR. Pedicled transverse rectus abdominis myocutaneous flap was the most often used option for unilateral autologous reconstruction, whereas deep inferior epigastric perforator flap was the most commonly used technique for bilateral BR. The overall complication rate reported by respondents was 11%.

CONCLUSION

The survey provides an insight to the current trends in BR practice with respect to surgeon and practice setting characteristics. Although not necessarily the correct best practices, the survey does demonstrate a likely portrayal of what is being practiced in the United States in the area of BR.

Delayed breast reconstruction using the inverted latissimus dorsi musculocutaneous flap: A novel approach to create ptosis and projection

The latissimus dorsi musculocutaneous flap is commonly used for delayed breast reconstruction. The authors present several technical refinements to better address the requirements for an aesthetically pleasing breast in delayed breast reconstruction including flap recipient site preparation, flap inset and breast shaping. The authors describe their modified technique using the inverted latissimus dorsi musculocutaneous flap and their experience in 27 consecutive patients following this type of delayed breast reconstruction. This novel approach provides improved breast ptosis and projection in delayed breast reconstruction.