The musculoskeletal consequences of breast reconstruction using the latissimus dorsi muscle for women following mastectomy for breast cancer: A critical review

Simultaneous sequential anterolateral thigh free flaps with interposition comitant vein graft for one-stage lower extremity reconstruction: A case report

Developments in the microsurgery have made perforator fasciocutaneous free flaps more popular in lower extremity reconstructions. They have acceptable donor site morbidities when compared to traditional methods. However; there are some possible limitations with these flaps such as anatomical variations and insufficiency to cover large and/or complex defects with a single flap. Anterolateral thigh flap (ALT), which has proven its advantages in the reconstruction of many regions of the body, is one of the versatile perforator fasciocutaneous flap options. We present our experience of using sequential double ALTs for complex lower extremity reconstruction. A 44-year-old patient, who had a history of multiple traumas as a result of a traffic accident, had interconnected anterior tibial (6 × 4 cm) and bimalleolar defects (4 × 4 cm, 4 × 5 cm) in his left lower extremity. Double ALT flaps (16 × 9 cm, 17 × 10 cm) were used to reconstruct three individual defects. The posterior tibial artery was the only uninjured artery perfusing the lower extremity, so the already occluded anterior tibial artery was chosen as the recipient to avoid disturbing the posterior tibial vessels. The dominant comitant vein of one of the flaps was leaving the pedicle too early and following an aberrant path with increased diameter. As it was understood that the other comitant vein had poor drainage, it was taken as an interposition vein graft to lengthen the dominant aberrant vein. The two flaps were customized as one by flow-through anastomoses on the operating table. The anterior tibial artery was washed and debrided distal to proximal until arterial spurting was seen. At the distance of 8 cm superior, the artery was found as feasible and anastomoses were performed. The proximal flap was inset vertically and the distal flap was inset on the horizontal axis to reach the bilateral malleolar defect. No complications were observed in both flaps. The patient was followed-up for 8 months. Despite the successful reconstruction, the patient is still unable to walk unaided due to multiple traumas and the rehabilitation process continues. We believe that the use of sequential double ALT may be a useful alternative to reconstruct large lower extremity defects with minimal donor site morbidity when a suitable single recipient vessel is available.

Hybrid Microsurgical Breast Reconstruction:: HyFIL® & HyPAD™ Techniques

There are numerous indications for hybrid breast reconstruction, with the most common being patients who have inadequate donor site volume to achieve the desired breast volume. This article reviews all aspects of hybrid breast reconstruction, including preoperative and assessment, operative technique and considerations, and postoperative management.

Pushing the Boundaries of Pedicled Chest Wall Perforator Flaps in Oncoplastic Breast Surgery

Among 145 chest wall perforator flaps (CWPFs) performed at City Hospital, Birmingham (September 2017-February 2022), 11 were for novel indications, four were for whole breast reconstructions, two were for implant salvage procedures, three were CWPFs with skin paddle to replace excised skin/nipple-areola complex, and two were for upper inner quadrant tumours. Tumour characteristics and post-operative complications were noted. Patient-reported outcomes measures (PROMs) were measured using a questionnaire adapted from the National Mastectomy and Breast Reconstruction Audit (NMBRA) study. Among 11 patients, nine (81.81%) did not develop any complications. Ten patients responded to PROMs (median follow-up of eight months). The PROMs assessment showed that all patients (100%) were satisfied with the post-operative breast appearance. Of the patients, 90% (9/10) felt the results of their surgery to be good, very good, or excellent. Of the patients, 70% (7/10) said that they have no/little persistent pain. None of the patients had difficulty carrying out normal activities. Thus, the applications of CWPFs could be extended for whole breast reconstruction, implant salvage procedures, where skin paddle is needed, and for upper inner quadrant tumours.

"I'm Hooked on e-cycling, I Can Finally Be Active Again": Perceptions of e-cycling as a Physical Activity Intervention during Breast Cancer Treatment

Electrically-assisted bicycles (e-bikes) are a means through which to increase individual physical activity (PA) and overcome some commonly reported barriers to engaging in conventional cycling. Fatigue is a common side effect to breast cancer treatment, and the rate of PA engagement drops significantly following a breast cancer diagnosis. The aim of this qualitative study was to examine perceptions of e-cycling as a means of increasing PA in this population. Twenty-four participants (mean age = 57.88 (standard deviation 10.8), 100% female) who have had a breast cancer diagnosis, completed two semi-structured interviews via Zoom. One interview was conducted prior to an e-bike taster session and a second, after the session. Taster sessions were conducted by certified cycling instructors in the community. Interviews were conducted between December 2021 and May 2022. Data were transcribed verbatim and analyzed thematically using NVivo 12 software. An inductive and deductive approach to analysis was adopted. Five themes were generated: (1) Perceived role of e-bikes during treatment, (2) The relationship between e-bikes and fatigue, (3) Cancer-specific considerations, (4) Is e-cycling 'enough'?, and (5) Optimizing the intervention. Negative perceptions of e-bikes noted before the taster session were altered following riding an e-bike. The multiple levels of assistance made cycling manageable and less impacted by fatigue, thereby enabling individuals to re-establish previous cycling habits. E-cycling may be a suitable option to increase PA behavior amongst individuals being treated for breast cancer, with the potential to overcome many of the barriers of conventional cycling. Enabling this population to trial an e-bike elicits positive physical and psychological responses that may help to promote future engagement.

[Morbidity and quality of life following breast reconstruction by autologous latissimus dorsi, muscle sparing and perforator flaps]

INTRODUCTION

Morbidity following autologous latissimus dorsi flap (ALD), muscle sparing latissimus dorsi flap (MSLD) and thoracodorsal artery perforator flap (TAP) is controversial. The purpose of this study was to measure morbity using Quick Dash at 1 month and 1 year following breast reconstruction with one of these three flaps. The second objective was the evaluation of quality of life using Breast-Q.

PATIENTS AND METHOD

Thirty four consecutive patients who had undergone breast reconstruction were included in this monocentric and prospective study: 10 patients in the ALD group, 12 patients in the MSLD group and 12 patients in the TAP group.

RESULTS

At 1 month and 1 year following surgery, the variation of Quick Dash was 13,63 and 2,38 in the ALD group, 3,41 and -1,13 in the MSLD group and 5,69 and 0 in the TAP group. Satisfaction whith breasts, psychosocial, sexual and chest well-being were higher in the ALD group. Satisfaction with back was higher in the MSLD and TAP groups. Back and shoulder well-being was comparable regardless of the flap. Seroma occurrence was very rare in case of TAP, rare and not abundant in case of MSLD and frequent in case of ALD.

CONCLUSION

This study appears to confirm that immediate morbidity is less important with MSLD or TAP than ALD. Hoewever at one year following surgery, morbity seems to be comparable with the 3 flaps. Patients satisfaction seems to be higher with ALD except for the aspect of the back.

Effect of Serial Home-Based Exercise Immediately after Latissimus Dorsi Reconstruction in Patients with Breast Cancer

Purpose: This study investigated the effects of a serial home-based exercise program in the affected upper extremity immediately after latissimus dorsi (LD) flap reconstruction with mastectomy in order to improve the functional impairment and quality of life in breast cancer survivors. Methods: Patients with breast cancer scheduled for a mastectomy immediately followed by autologous LD flap reconstruction surgery were enrolled. Forty-five patients were included as an intervention group who received a serial home-based exercise program with stretching and strengthening for upper extremities preoperatively (T0), and 2 weeks (T1), 6 weeks (T2), and 3 months (T3) postoperatively. Thirty-five patients were included as the control group. We evaluated the range of movement in the shoulder at T0, T1, T2, T3, 6 months (T4), and 12 months (T5) postoperatively. We also evaluated the disability of the upper extremity using disabilities of the arm, shoulder, and hand (DASH) questionnaire and quality of life using the 36-Item Short-Form Health Survey (SF-36) at T0, T3, T4, and T5. Results: There were significant differences in interaction effects between time and shoulder flexion and internal and external rotation. Post hoc, the intervention group showed more improvement of movement in internal rotation at T2 and T5 and external rotation at T2, T3, and T4. Furthermore, there were significant differences in interaction effects between DASH scores and time in the two groups. Post hoc, there were significantly lower DASH scores at T3, T4, and T5 in the intervention group. There were significant differences in interaction effects of physical role functioning, vitality, and mental health scores of SF-36 and time in the two groups. Post hoc, physical role functioning scores at T3 and T4 and vitality and mental health scores at T3 were elevated in the intervention group. Conclusion: A serial home-based exercise after LD flap reconstruction is effective for the rehabilitation of the affected upper extremity and enhances the quality of life.

Breast Reconstruction: Necessity for Further Standardization of the Current Surgical Techniques Attempting to Facilitate Scientific Evaluation and Select Tailored Individualized Procedures Optimizing Patient Satisfaction

Background

Various breast cancer reconstruction methods and novel surgical techniques include autologous or allogenic procedures, which can increase patient's quality of life and provide options when dealing with patients seen as challenging clinical scenarios.

Summary

Our aim was to review the current literature and present published evidence on innovative standards in whole breast reconstruction. Advances in flap monitoring or newly published data regarding neurotization in breast reconstruction, arm lymphedema management, breast implant-associated anaplastic large cell lymphoma reconstruction treatment, and robotic surgery with regard to radiotherapy define innovative standards in the breast reconstruction setting. The role of meshes/acellular dermal matrix and fat grafting as well as optimal sequencing of postmastectomy radiotherapy in autologous and alloplastic breast reconstruction appear highly debatable also in expert panel meetings rendering further clinical research including RCTs imperative.

Key Messages

There is an abundance of novel available techniques, which mandate further standardization, facilitating scientific evaluation in an attempt to help surgeons select tailored procedures for each patient with the goal to promote informed decision-making in breast reconstruction.

The Hybrid Latissimus Dorsi Flap in Immediate Breast Reconstruction: A Comparative Study With the Abdominal-Based Flap

PURPOSE

The implant-enhanced latissimus dorsi (LD) flap, or a hybrid LD flap, is widely used in certain indications, even though abdominal-based flaps are now considered the gold standard of autologous breast reconstruction. However, few articles distinguish the hybrid LD flap from traditional LD flaps, and not many articles have compared the surgical outcomes, with the abdominal-based flap procedure, especially in the area of immediate breast reconstruction. In addition, it is often overlooked that the reported esthetic comparisons are based on different populations and contralateral balancing procedures (CBPs). Thus, this study aimed to review the reconstruction outcomes and to compare the variable-matched esthetic outcomes between 2 groups.

METHODS

A retrospective review of patients who underwent immediate breast reconstruction with either a hybrid LD flap or an abdominal-based free flap and had completed at least 2 years of follow-up visits was carried out. The patient demographics, oncologic data, breast parameters, and postoperative outcomes were compared across the entire patient group. The body mass index (BMI)- and CBP-matched cohort was randomly selected and assessed using the Aesthetic Outcome parameter of the Aesthetic Item Scale.

RESULT

Thirty-eight hybrid LD flap and 51 abdominal-based free flap procedures were included. The hybrid LD group showed a shorter operation time (330 ± 260 minutes vs 550 ± 480 minutes, respectively; P < 0.01), and fewer patients in the hybrid LD group underwent additional revision surgeries (7 [18.4%] vs 20 [39.2%], respectively; P < 0.01). Other complication rates were not significantly different between groups. A BMI- and CBP-matched esthetic analysis revealed that the hybrid LD group showed superior results in symmetry (Mann-Whitney U test, P = 0.047).

CONCLUSIONS

The LD flap in combination with an implant remains a viable option in immediate breast reconstruction and had a similar complication profile while having a shorter operative time compared with the abdominal-based autologous breast reconstruction procedure. If properly used in certain populations, hybrid LD flaps may offer superior results regarding symmetry over the abdominal-based flap procedure.

Thoracodorsal artery flaps for breast reconstruction-the variants and its approach

Thoracodorsal artery (TDA) flaps, ranging from the vascular-pedicled thoracodorsal artery perforator (TDAP) flap, the propeller TDAP flap, and the muscle-sparing latissimus dorsi (MSLD) flap to the conventional latissimus dorsi (LD) flap and the extended LD flap, can all be used for breast reconstruction. The aim of this paper and review is to share our experiences and recommendations for procedure selection when applying TDA-based flaps for breast reconstruction. We describe the different surgical techniques and our thoughts and experience regarding indications and selection between these procedures for individual patients who opt for breast reconstruction. We have performed 574 TDA flaps in 491 patients: 60 extended LD flaps, 122 conventional LD flaps, two MSLD flaps, 233 propeller TDAP flaps, 122 TDAP flaps, and 35 free contralateral TDAP flaps for stacked TDAP breast reconstruction. All the TDA flaps are important flaps for reconstruction of the breast. The LD flap is still an option, although we prefer flaps without muscle when possible. The vascular-pedicled TDAP flap is an option for experienced surgeons, and the propeller TDAP flap can be used in most reconstructive cases of the breast, although a secondary procedure is often necessary for correction of the pedicle bulk. The extended LD flap is an option for women with a substantial body mass index, although it is associated with the highest morbidity of all the TDA flaps. The MSLD flap can be used if the perforators are small or if dissection of the perforators is assessed to be hazardous.

Effects of latissimus dorsi (LD) flap harvest on shoulder function in delayed breast reconstruction. A long-term analysis considering the acromiohumeral interval (AHI), the WOSI, and BREAST-Q questionnaires

BACKGROUND

The latissimus dorsi (LD) flap is reliable and versatile with many indications and low donor site morbidity. The aim of this study is to evaluate the long-term effects of LD flap on the shoulder function in patients undergoing delayed breast reconstruction.

METHODS

This case-control study enrolled women who underwent implant-based (IB) breast reconstruction, radical lymphadenectomy, and radiotherapy between 2006 and 2016. The study group included 72 women, with a history of severe capsular contracture, who received a secondary LD flap reconstruction. The control group consisted of a matched cohort of 80 patients with IB breast reconstruction. Shoulder function was assessed using the acromiohumeral interval (AHI) measurement in standard X-rays. The validated Western Ontario Shoulder Instability (WOSI) and BREAST-Q questionnaires were used to assess outcomes one year postoperatively and data were analyzed using Fisher's exact test and the Mann-Whitney test.

RESULTS

Out of 72 patients from the study group, 40 had valuable pre- and postoperative X-rays to measure the AHI. An AHI reduction was recorded only in 7/40 patients. From the WOSI analysis, no significant differences in shoulder function and back pain between the two groups were registered. BREAST-Q scores in the LD group were higher in most domains, including satisfaction with breasts and psychosocial well-being. However, the Mann-Whitney test showed no significant difference between the two groups (p > 0.05).

CONCLUSION

LD flap, with detachment of its insertions from the humerus, does not seem to have a negative impact on back and shoulder function and is correlated with high patient satisfaction in breast reconstruction following radiotherapy.

Physical side-effects following breast reconstructive surgery impact physical activity and function

PURPOSE

To investigate the incidence and severity of physical side-effects experienced by women following breast reconstructive surgery and the effect of these side-effects on physical activity and function.

METHODS

Two hundred and thirty-one Australian women (55 years SD 6.5) who had previously had breast reconstruction surgery retrospectively self-reported the incidence and severity of eight physical side-effects and the perceived effect of these side effects on six physical functions, at three time points after their surgery. The frequency of the combined incidence/severity scores and their impact at the three time points were tabulated and compared using Chi-squared tests. A general linear regression was used to identify characteristics associated with moderate-very high (≥ 5/10) combined incidence/severity scores.

RESULTS

At 6 months following surgery, approximately 50% of respondents reported moderate to very high incidence/severity scores for physical side-effects across multiple body regions, which were perceived to limit their physical function and activity levels. The highest incidence/severity scores were associated with the following: (i) pre-existing physical problems before surgery, (ii) post-operative complications (seroma, infection, necrosis), and (iii) autologous rather than implant-based reconstructions.

CONCLUSION

A large percentage of women reported moderate to severe physical side-effects across multiple body regions following breast reconstructive surgery. These side-effects were perceived to negatively impact both physical function and activity. Early intervention, education and treatment are recommended to alleviate these issues and minimise their negative impact.

Regarding the Necessity of Functional Assessment Including Motor Control Assessment of Post-Mastectomy Patients Qualified for Latissimus Dorsi Breast Reconstruction Procedure-Pilot Study

The purpose of the paper is a functional assessment of post-mastectomy patients who underwent latissimus dorsi breast reconstruction (LDBR), and of healthy women, through an analysis of selected muscle function parameters, including motor control assessment. Twenty participants were included in the study (ten LDBR-procedure individuals and ten healthy controls). The research consisted of a DASH (The Disabilities of the Arm, Shoulder and Hand) questionnaire assessment, shoulder area static assessment, shoulder mobility assessment, latissimus dorsi flexibility assessment and shoulder motor control assessment. LDBR-procedure individuals-when compared to healthy controls-exhibited a decrease in physical aspects of quality of life, shoulder area postural alterations, limitations in shoulder mobility and decrease in shoulder motor control. LDBR procedure may have an influence on limiting shoulder active mobility, as well as on decrease of shoulder motor and postural control. Standard functional assessment diversified on motor control assessment of post-mastectomy patients qualified for the LDBR procedure seems to be necessary.

A Systematic Review and Meta-analysis of Functional Shoulder Impairment After Latissimus Dorsi Breast Reconstruction

PURPOSE

The latissimus dorsi flap (LDF) is a very reliable flap and may be used for a multitude of reconstructive purposes. It is widely used for breast reconstruction when performed. It has few complications, except for a possible impact on shoulder function. The aims of this study were to evaluate the validity of the literature by investigating the level of evidence and to perform a meta-analysis.

METHODS

A systematic literature search was conducted using the databases PubMed, Scopus, and Web of Science. Predictor variables were shoulder function after breast reconstruction with the LDF. Articles were chosen according to 4 different outcomes: shoulder range of motion (ROM), shoulder strength, DASH score, and subjective evaluation.

RESULTS

Twenty-six articles were found, including 1045 patients: 8 level II, 16 level III, 1 level IV, and 1 level V articles. The meta-analysis showed that both ROMs for flexion and abduction are significantly impaired at less than or at 3 months of follow-up.

CONCLUSIONS

There are several influencing factors, such as age, smoking, obesity, radiotherapy, and physiotherapy. Moreover, the impact on shoulder function seemed influenced by the type of thoracodorsal vessel-based flap. From the level of evidence analysis, there is a tendency that the LDF transfer does affect shoulder function. This limitation seems to be minimal, and few patients experience a major impact on shoulder function. However, the existing literature on total shoulder impairment after breast reconstruction with LDF is insufficient to draw any final conclusion. There is a need for future studies and current articles that suggest that the initial measurement should be performed preoperatively (preferably at the time of diagnosis or initial biopsy) and follow-ups with measurements at 6, 12, and 24 months (long-term effect) after surgery. We recommend measurements of both operated and nonoperated sides. Each measurement should be accompanied by a history with special emphasis on shoulder function. The methods of measuring outcomes of recommendation are DASH score, ROM with use of a goniometer preferably by a physiotherapist or a health care professional trained by a physiotherapist, and strength measured by, for example, a handheld dynamometer.

Incidence of shoulder functional morbidity following ipsilateral mastectomy and latissimus dorsi flap reconstruction

INTRODUCTION

The aim of this study was to investigate the incidence of shoulder morbidity in our cohort of patients with latissimus dorsi flap reconstruction after mastectomy.

METHODS

This is a retrospective study of prospectively collected data of 72 patients using validate Oxford shoulder score for function and quickDASH score for disability. Scores were collected preoperatively and at time of final review or study. We also reviewed patient records for patients who had a formal diagnosis of shoulder pathology. Results were analysed with student t-test.

RESULTS

Analysis of scores showed a statistically significant worsening of both oxford shoulder score (p < 0.005) and quickDASH score (p < 0.005), when pre and post-operative scores were compared. Seven patients had a formal diagnosis of shoulder pathology, and all of them recovered well. There was no significant difference in oxford shoulder score or quickDASH scores between patients with or without shoulder pathology. About 40% patients had some functional loss or disability at 4 years after the surgery.

CONCLUSION

Our study shows a high incidence of significant shoulder functional morbidity following latissimus dorsi flap reconstruction but number of patients requiring specific treatment is low.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Oncoplastic Volume Replacement for Breast Cancer: Latissimus Dorsi Flap versus Thoracodorsal Artery Perforator Flap

Volume replacement oncoplastic breast techniques have become one of the standard lines in the treatment of early breast cancer. They have better cosmetic outcome and patient satisfaction. Latissimus dorsi (LD) flap is one of the most commonly used flaps for these techniques. Although it shows satisfactory surgical outcomes, postoperative shoulder dysfunction is an obvious drawback. The aim of this study was to compare LD flap with thoracodorsal artery perforator (TDAP) flap after breast-conserving surgery regarding surgical outcomes, patient satisfaction, and impact on shoulder function.

Quality of life and shoulder function after latissimus dorsi breast reconstruction☆

BACKGROUND

Breast reconstruction using a latissimus dorsi flap impacts one of the principal muscles of the shoulder. There is therefore concern that this procedure could impair shoulder function. The primary objective of this study was to study the effect of breast reconstruction using the latissimus dorsi flap on patient reported shoulder function and quality of life, compared to women who underwent total mastectomy without reconstruction.

METHODS

A case-controlled cross-sectional study was conducted using the validated Breast-Q questionnaire and a functional back and shoulder questionnaire. Questionnaires were mailed to women who had undergone latissimus dorsi flap breast reconstruction (n = 100) and women who had undergone total mastectomy without reconstruction (n = 121). The responses from the 2 groups were compared, and results were analysed with t-test and Pearson's Correlation.

RESULTS

Responses were received from 119 patients (60 latissimus dorsi patients and 59 mastectomy alone patients). Latissimus dorsi flap patients had significantly higher Breast-Q scores for all quality of life domains when compared to mastectomy alone patients. There was, however, no significant difference in functional back and shoulder scores between the two groups. Latissimus dorsi flap patients also scored highly for satisfaction with outcome and satisfaction for the 'back'.

CONCLUSION

Patients report high levels of satisfaction following Latissimus dorsi flap breast reconstruction. This type of reconstruction did not adversely impact back and shoulder function.

Current pharmacological and surgical treatment of underactive bladder

Generally accepted guidelines are not yet available on the management of underactive bladder (UAB). Although the natural history of UAB is still not fully understood, observation may be an acceptable management option in patients with tolerable lower urinary tract symptoms and little risk of upper urinary tract damage. If needed, scheduled and double voiding may be recommended as an effective and safe add-on therapy. Parasympathomimetics have been widely used for the management of UAB, but the evidence does not support clinical benefit. The efficacy of alpha-blockers has also not yet been clearly demonstrated. However, selective alpha-blockers may help to enhance voiding efficiency and to decrease possible upper tract damage. Sacral neuromodulation is a surgical option for nonobstructive UAB approved by the Food and Drug Administration. However, the response rate of test stimulation is not high and the efficacy of permanent implants does not always coincide with that of test stimulation. Although surgery to reduce outlet resistance may be a viable option in UAB with presumed obstruction, surgery seems to have little role in those without obstruction. Latissimus dorsi detrusor myoplasty has shown promising results in restoring voluntary voiding in selected patients. The procedure requires a multidisciplinary team approach of urologists and plastic reconstructive experts. In summary, current treatments of UAB remain unsatisfactory. The multifactorial nature of UAB pathogenesis complicates the appropriate management for each patient. Future research to establish a more clinically relevant definition of UAB will be required to open new era of UAB management.

Anatomical versus functional motor points of selected upper body muscles

INTRODUCTION

In this study we aimed to identify nerve entry points (NEPs) of superficial skeletal muscles obtained by dissection of 20 human cadavers and compared them with motor points (MP) obtained previously by electrical stimulation.

METHODS

The biceps brachii (BB), trapezius (TZ), latissimus dorsi (LD), pectoralis major (Pmaj), and pectoralis minor (Pmin) muscles were dissected from human cadavers. NEP data (mean ± standard deviation) from each muscle were calculated. F-tests with Bonferroni corrections were used to compare NEPs and MPs.

RESULTS

The number of NEPs was 2 in BB, 1 in Pmin, 4 in TZ, and 3 in LD, whereas the total number in Pmaj varied from 3 to 5. NEPs and MPs were statistically equal only in Pmin and in the descending part of TZ.

DISCUSSION

The findings show crucial differences between NEPs and MPs, possibly impacting the effectiveness of several medical treatment strategies. Muscle Nerve 57: 460-465, 2018.