Latissimus Flap Breast Reconstruction Treatment & Management

Preoperative considerations

See the list below:

• Mastectomy defect

• Neurovascular pedicle integrity

• Previous radiation

• Contralateral breast size and shape

• Posterior scar location

Planning the flap harvest and inset requires an adequate assessment of the patient's profile, particularly with respect to the anterior chest wall defect to be reconstructed. ^{[25, 26]} Repairing a segmental defect has significantly different ramifications than planning reconstruction after modified or radical mastectomy. A partial transfer of the latissimus dorsi muscle flap may suffice to fill a segmental defect. However, the same transfer is far from adequate for filling the subclavicular and anterior axillary loss noticed by patients who have undergone more involved procedures.

In secondary reconstruction, the existing mastectomy scar may pose challenges to planning flap inset. Compared to an oblique mastectomy scar, a vertical or horizontal scar may be difficult to conceal or may compromise projection. Proper flap placement requires attention to breast symmetry with preservation of ptosis and contour of the inferior breast pole. If the flap position is too high, which may be imposed by inset into a vertical or horizontal incision, the bulk of the muscle is out of position to accomplish this goal. Sacrifice of the inferior breast skin flap or inset into an additional incision at the projected inframammary fold and placement of the skin flap into an inferior lateral position can guarantee inferior projection.

When considering the latissimus dorsi for autogenous reconstruction, communication with the surgeon who performed the mastectomy is critical. Ligation of the neurovascular pedicle is not an uncommon complication of axillary dissection. In the preoperative assessment for delayed reconstruction, innervation can be tested indirectly by evaluation of isometric contraction of the muscle. To test muscle function, have the patient put both hands on her waist and push downward. Contraction of viable muscle is assessed by palpation of the lateral edge of the latissimus dorsi from the posterior axilla to the iliac crest and by contralateral comparison. Electrical stimulation or electromyography can be used for further evaluation of muscle function in ambiguous cases. If muscular contraction is not elicited by any of the above techniques, assume that muscle has been denervated, which results in an atrophic flap.

Posterior markings include identification of the muscle projection and, if used, isolation of the skin island. Orientation of the skin segment depends on the extent of the anterior chest defect and patient preference. Loss of the pectoralis major muscle after radical mastectomy results in significant tissue loss that leaves an undesired subclavicular space, with projection of the superior ribs through the skin. In this or similar situations, arranging the skin island in a horizontal pattern is beneficial. Orientations with oblique skin islands running perpendicular to the muscle fibers and fleur-de-lis patterns have also been described. The critical takehome message is that each breast reconstruction requires a careful consideration of skin island needs regarding scar issues.

See preoperative markings in the image below.

Transposition of this skin island to an inferolateral location in the reconstructed breast causes most of the muscle to shift superiorly. This arrangement allows the muscle to reach the superior defect while still maintaining bulk in the inferior pole. After modified radical mastectomy in which the superior defect is less of an issue, an oblique skin island may be adequate. This orientation positions the medial portion of the skin island farther away from the pivot point so as to allow greater reach on the anterior chest.

The ultimate location of the back scar also is taken into account. Traditionally, the horizontal scar was favored because it can be camouflaged conveniently with the brassiere strap. The preoperative markings can be made with the patient wearing the brassiere to ensure proper placement. The oblique pattern results in a lower, less conspicuous scar. Oblique skin islands also can be planned to create scars along the relaxed skin tension lines of the back, which reduces the chance of hypertrophic scarring that is more common with horizontal scars.

The skin island should measure approximately 8 cm wide by 20 cm long. Wider islands tend to be difficult to close primarily. The shape is an ellipse with a slightly wider portion at the inferomedial pole. This distribution provides the widest piece to the inferior breast for creation of the lower curvature. The superolateral end of the ellipse should begin at the posterior axillary line below the tip of the scapula. This ensures a skin island location that is anterior to the muscle flap.

Intraoperative details are discussed in the sections below.

Operative preparation

Preparation for the operation includes the standard medical clearance and assessment of anesthetic risks.

Once in the operating room, position the patient with pneumatic compression stockings after Foley catheterization. The preferred position is lateral decubitus because it allows exposure of both the anterior and posterior operating fields. This is useful for planning and enables room for the assistant to prepare the recipient site.

In cases of immediate reconstruction, the general surgery team can perform the mastectomy at the time of flap harvest. ^[27] If this is not possible, then simply prepare and drape the patient in the lateral decubitus position after the mastectomy is complete.

Once the patient is in position, take care to ensure that the dependent points of the patient are padded to prevent pressure necrosis. The ipsilateral arm should be flexed to 90°, partially abducted, and stabilized using a Mayo stand. This configuration concurrently gives maximal exposure of the axilla and adjacent thorax. Then prepare and drape the patient to isolate an operative field that does not obscure the necessary bony landmarks for dissection.

Intraoperative details

The procedure then begins by incising the skin island and dissecting through the subcutaneous tissue to the muscle. Bevel this tissue away to maximize the number of vascular perforators from the muscle to the skin island.

Once into the subcutaneous tissue, continue this plane of dissection inferiorly to elevate the skin from the remainder of the muscle.

Using electrocautery, skin elevation proceeds until visualization of the muscle's inferior and medial origins at the spinous processes and posterior iliac spine.

In the lateral direction, identify the full vertical edge of the muscle and free it from the skin in this plane of dissection. Continue this action superiorly from the skin island at the tip of the scapula to the axilla to identify the superior origins of the muscle.

Flap elevation

The next step is to release and elevate the muscle flap completely from its origin. This is accomplished by identifying the plane of dissection beneath the muscle that is superficial to the deep posterior muscles of the thorax. Starting laterally, the approximate location of the origin of fibers from the lower ribs is at a position that is one-third the distance of the muscle's insertion. In this area, the serratus anterior and external oblique lie deep to the muscle.

An avascular plane can be created with careful dissection medially. This plane continues to the inferior points of origin overlying the serratus posterior inferior muscle. Once this point has been reached, transect the inferior origin of the muscle medial to lateral through the thoracodorsal fascia. With the muscle detached, elevate it and reflect it from the thorax from inferior to superior.

At this point in the procedure, the medial and lateral rows of the segmental arteries that feed the muscle come into view. Clip and coagulate these perforators that arise from the lumbar and intercostal arteries to ensure hemostasis and to prevent postoperative hematoma.

Once the muscle is reflected completely, detach the superior border of the muscle from the tip of the scapula. In this area, the teres major, serratus anterior, and rhomboids meet with the connective tissue of the superior origin of the latissimus dorsi. Completely detach all points of origin and tether the muscle to the axilla by its insertion and neurovascular pedicle.

With the muscle reflected, using scissor dissection, isolate the pedicle and separate the thoracodorsal nerve. Further assess the integrity of the vascular anatomy and excise the nerve.

Flap transfer

The anterior chest incision now is made to prepare flap inset. Position this incision using either the old mastectomy scar or creating a fresh curvilinear incision at the inframammary fold. With the anterior skin flap elevated in the subcutaneous plane, create an axillary tunnel to connect the anterior and posterior wounds. Creating this tunnel high in the axilla with the exact amount of space needed for the flap to pass through is essential. This prevents the implant from slipping to the back and replenishes the anterior axillary defect that remains after mastectomy.

Bring the flap into position on the anterior chest by gently pushing it through the tunnel. Inset the transferred skin flap into its proposed position to ensure adequate reach without compromising the vascular pedicle.

If additional length or mobility is needed, the flap can be extended either by dividing the muscle from its point of insertion or by ligating the thoracodorsal vascular branches to the serratus anterior. Before dividing these branches to the serratus, ensuring that perfusion is occurring through the primary thoracodorsal vessel and not through retrograde flow from these branches is imperative. Intraoperatively, a Doppler flow meter can aid in assessment of flow through the thoracodorsal trunk.

Once a satisfactory length and position is achieved, close the back incision in 3 layers using absorbable sutures over drains.

Creation of the breast mound

Attention now is directed at implant placement and molding of the breast mound. The flap can be placed into the anterior breast pocket and the entire wound covered with a sterile occlusive dressing while the patient is repositioned and draped in the supine position.

Elicit further dissection from the lateral border of the pectoralis major to create a subpectoral pocket, which eventually is the location for the implant. This dissection should be limited to secure a permanent space for the implant, which prevents excessive movement of the implant.

Position a temporary implant sizer into this newly created space to function as a template for the future permanent prosthesis. The sizer can be inflated and deflated with saline so that the proper implant size can be chosen based on comparison with the contralateral breast. Then replace the sizer with the implant of choice and bring the latissimus flap into position.

If the pectoralis major muscle is insufficient to cover the implant completely or is too thin to ensure stability of the implant, the implant can be placed in a subcutaneous position covered with the latissimus flap.

In primary reconstruction, the location of the inframammary fold easily is appreciated due to the immediacy of reconstruction, especially if the general surgery team is cognizant of its preservation. Regardless, proper alignment can be accomplished by suturing the structure into position using permanent suture. In situations in which the inframammary fold is recreated using the previously formed curvilinear incision, the skin island can be positioned in an inferolateral orientation. This allows the bulk of the muscle flap to provide ptosis and the inferior curvature of the breast.

When an acceptable position is attained, suture the flap to the chest wall with absorbable sutures, ensuring security of the lateral border and implant fixation. Position a suction drain at the dependent portion of the wound and tunnel to exit though the axilla. Then close the skin island in two layers.

Extended latissimus dorsi flap

Variations to this procedure are available to adapt this flap to larger reconstructive tasks. In patients in whom the volume defect is substantial, a variant of the standard flap can be used to supply an increased amount of tissue. Such reconstructive scenarios include irradiated anterior chest wall and breast with significant skin loss, large mastectomy scars, and desire for completely autogenous reconstruction. This situation may arise when planning reconstruction in robust women with small breasts, in whom an implant is not necessary to match the fullness of the contralateral breast.

In these circumstances, a fleur-de-lis skin island can be used, or simply greater amounts of adipose tissue and fascia can be included with the dissection of the standard skin island. The fleur-de-lis pattern consists of an inverted T-shaped island with 7-cm wings that increase the amount of soft tissue available for reconstruction. This pattern can be used to provide volumes up to 400 mL.

Another variation to the extended flap harvest is to excise the standard flap skin paddle with the inclusion of the parascapular and iliac subcutaneous tissue and fascia. This dissection begins superiorly to the teres major muscle and is carried inferiorly to the iliac crest. Chang et al recently reviewed an institutional experience of the extended latissimus dorsi flap. ^[28] Their review revealed successful outcomes for varying volumes of reconstruction, negating the need for an additional prosthesis. However, the authors advise caution with the use of the extended flap in obese patients who are at higher risk for postoperative donor-site complications.

Small reconstructions

Conversely, correction of segmental defects does not use the entire muscle flap and may not require the use of a skin island. The posterior dissection is accomplished by harvesting the necessary muscle through a horizontal incision inferior to the scapula. Since the inframammary fold, nipple, and general breast shape are intact, these should be conserved. The anterior preparation is limited to a lateral breast incision or opening the previous breast wound. The flap then is brought into position either superficial to the pectoralis major beneath remaining breast tissue or deep to the elevated skin surrounding the defect. The former option may yield superior aesthetic results since it better prevents deformity of the superior slope of the breast.

Additionally, flap harvest can be accomplished using laparoscopic assistance. By incorporating the preexisting mastectomy scar, a feasible muscle flap can be attained without the addition of a posterior wound.

See the list below:

• Once the operation is complete, dress the breast with antibiotic ointment along the incisions.

• Wrap the superior chest wall with a loosely applied dressing, placing fluffed gauze at the inferolateral breast curvature and foam tape at the upper breast pole. This dressing is used to prevent implant migration during the immediate healing period and may be changed 48 hours postoperatively.

• The dressing then is changed each day for 2 weeks, after which the patient is encouraged to proceed with the use of a wireless brassiere.

• The suction drains usually are kept in place until they drain less than 30 mL in a 24-hour period.

• Physical therapy, for upper extremity strengthening and range-of-motion exercises, is begun within the first postoperative week.

Complications can include the following:

• Implant contracture ^[29]

• Implant rupture

• Hematoma

• Seroma

• Flap necrosis

• Hypertrophic scarring of donor site

• Infection

A prospective cohort study by Bennett et al on 2-year complication rates in postmastectomy breast reconstruction techniques found that all flap reconstruction methods except latissimus dorsi flap surgery had a greater likelihood of reoperative complications than did expander-implant reconstruction. However, the chance of complications in general for all flap procedures in the study, which also included reconstruction via pedicled TRAM flaps, free TRAM flaps, deep inferior epigastric perforator (DIEP) flaps, or superficial inferior epigastric artery (SIEA) flaps, was greater than it was for the expander-implant technique, with the odds ratio for complications in latissimus dorsi flap reconstruction being 1.87. The investigators also found, however, that failure rates for the expander-implant and direct-to-implant techniques were greater than for the flap procedures. ^[30]

A study by Lee et al found the incidence of postmastectomy lymphedema to be lower in immediate breast reconstruction using latissimus dorsi flaps than in such reconstruction employing abdominal flaps or tissue expanders/implants. In the three study groups, the 5-year cumulative incidences of lymphedema were, respectively, 3.7%, 10.6%, and 10.9%. The investigators reported a significantly higher axillary lymph node dissection rate in the latissimus flap patients. ^[31]

Most complications related to latissimus flap reconstruction stem from issues related to the implant or to donor site closure. Implants alone carry the risk of displacement contracture and rupture. These risks mandate a thorough discussion with and acceptance by the patient preoperatively of the possibility of further operations to correct implant position. In addition, the patient should be warned that the implant will have to be replaced at some point in the future, since its viability is finite.

A retrospective cohort study by Leuzzi et al indicated that in patients who undergo breast reconstruction with a latissimus dorsi flap, use of an implant with the procedure may lead to a higher surgical complication rate (18.8%) than if the surgery is performed in association with lipofilling (14.2%). No significant differences between implant and lipofilling were seen with regard to the number of revision procedures and hospitalization time, while patient satisfaction, as measured using the BREAST-Q, was higher with lipofilling. ^{[32, 33]}

A study by Palve et al comparing different latissimus dorsi flap techniques in breast reconstruction found that the complication rate did not significantly differ between patients who underwent plain flap reconstruction and those who were also treated with immediate lipofilling or in whom the surgery was implant enhanced. Among the major complications associated with the techniques, plain flaps tended to more often be associated with donor site problems, as opposed to deep breast infections and partial flap necrosis in, respectively, the implant-enhanced and lipofilling patients. ^[34]

A study by Kang et al of 16 patients indicated that volume change in latissimus dorsi myocutaneous flaps following breast reconstruction is primarily due to muscle atrophy, as opposed to fat shrinkage. The report determined that the average muscle volume in the flaps decreased by about 24% in the period between 6 months and 2 years postoperatively. Muscle atrophy then slowed, being another 2.9% at 3 years, 0.5% at 4 years, and 1.5% at 5 years. Meanwhile, the investigators found that the flaps’ fat volume remained relatively stable over time. They therefore indicated that in breast reconstruction, greater patient satisfaction could be achieved by maximizing the fat portion of the latissimus dorsi flap. ^[35]

Inadequate hemostasis and postoperative drainage of chest wounds predisposes to hematoma and seroma formation. Conservative management of the drains postoperatively is best to prevent this complication. Although flap necrosis is a possible complication, actual problems with flap inset and wound healing are rare. These issues are more significant in the patient who has undergone irradiation. ^[36] Lastly, as with any wound under extremes of tension, the posterior donor site may tend to form hypertrophied scars. This can be avoided by creating an oblique incision or skin island to better distribute the opposing forces on the wound.

Generally, latissimus dorsi breast reconstruction is a safe procedure with a small risk of complication. Kroll compared his experience with the latissimus dorsi to implant and TRAM reconstruction. ^[37] He found that complications and reconstructive failure were considerably less using the latissimus dorsi versus expander with implant reconstruction and equal to those experienced with TRAM procedures. The safety of the procedure was demonstrated in Roy's review of 111 cases in which no life-threatening sequelae were identified. ^[38]

A study by Teisch et al comparing the outcomes of breast reconstruction with the latissimus dorsi myocutaneous flap versus the pedicled TRAM flap found a greater risk for surgical site complications with the latissimus dorsi procedure, but an increased risk for pulmonary complications and a greater length of stay with the pedicled TRAM flap operation. The study involved more than 29,000 cases contained in the National (Nationwide) Inpatient Sample database. ^[39]

Outcomes are expected to be as follows:

• High level of patient satisfaction ^[40]

• Acceptable symmetry achieved without manipulation of the contralateral breast

• Aesthetically excellent results with soft contour and sensitivity

• Reconstruction that does not interfere with detection of recurrent disease

Based on the experience of many centers, breast reconstruction using the latissimus dorsi has favorable outcome with significant patient satisfaction. In a review of 170 patients who underwent latissimus dorsi reconstruction, Moore revealed that more than 90% of patients were satisfied with the results and would recommend the procedure to other patients. ^[41] In the same review, physician evaluators concurred that 80% of patients had satisfactory size and shape compared to the opposite breast and 5% were found to have firm breasts. ^[41] Also, of those patients who experienced disease recurrence, this method of reconstruction did not delay or mask its detection.

Delay et al found similar results with respect to patient satisfaction and aesthetic approval in his experience with 100 patients who underwent the procedure. ^[4] Additionally, in subsequent studies, patients reported objective and subjective fine sensitivity in their reconstructed breasts, which greatly improved satisfaction. ^[42]

A study by Atisha et al found that women who underwent latissimus dorsi flap breast reconstruction were as satisfied with the results as those who underwent breast-conservation surgery with radiation (BCS). The study surveyed more than 7600 women who had undergone BCS or any of a variety of breast reconstruction procedures, with the greatest outcome satisfaction reported by women who underwent abdominal flap or buttock or thigh flap reconstruction. ^[43]

Assessing outcome with the BREAST-Q reconstruction module, a study by Löfstrand et al indicated that satisfaction with donor-site aesthetics is greater in patients who undergo breast reconstruction with a latissimus dorsi flap than in those in whom a deep inferior epigastric perforator (DIEP) flap is used. However, patients in the study’s latissimus dorsi flap group more commonly experienced impairment resulting from muscular weakness of the donor site than did the DIEP flap patients. ^[44]

Latissimus dorsi miniflap

Mastectomy is often recommended for patients who are candidates for breast conservation therapy based on tumor stage, when the ratio of tumor to breast volume is too large to allow acceptable cosmetic results. The latissimus dorsi miniflap (LDMF) has been considered a technique for extending breast conservation, allowing wide local excision of large tumors with preservation of the breast envelope and nipple-areola complex. ^[45]

The procedure, as described above for small reconstructions, involves harvesting the latissimus dorsi muscle with or without the overlying subcutaneous tissue. This can proceed through a lateral incision used for tumor excision or axillary dissection. ^[46] Alternatively, the miniflap is harvested through a short posterior horizontal incision.

Nano and Gendy have recently published their experiences with the latissimus miniflap. ^{[47, 48]} In their series, women with large tumor-to-breast size ratios underwent partial mastectomy with miniflap reconstruction. Quality-of-life assessment revealed high patient satisfaction regarding psychological morbidity, cosmesis, and preservation of nipple sensation. Compared to patients who had skin-sparing mastectomy and standard latissimus dorsi flap reconstruction, the patients who underwent LDMF endured fewer postoperative complications.

LDMF reconstruction is a useful adjuvant in a select group of patients with a large tumor-to-breast volume ratio, allowing breast conservation in early stage disease. However, further oncologic evaluation is warranted to determine outcomes with this modality of treatment with respect to local control and prognosis in this group of patients.

Serratus branch transfer

Because of the relative approximation of the thoracodorsal vasculature to the nerve, the vessels may be injured in patients in whom the thoracodorsal nerve was damaged. Significant compromise of the pedicle can reduce the bulk of the proposed flap, warranting the consideration of alternative reconstruction options. Techniques have been described that achieve transfer based on retrograde blood flow through the vascular branches of the serratus anterior. Several reports of serratus branch transfer have been documented; however, this technique has been most successful for small-volume transfers or when the vascular supply has been delayed or enhanced via microsurgical augmentation. Although success has been achieved under these conditions, because of the operative modifications to preserve the collateral circulation and the delicacy of the atrophied muscle, acceptable aesthetic results may be difficult to achieve.

Sensate latissimus dorsi myocutaneous flap

Owing to the extent of dissection during mastectomy and latissimus dorsi harvest, the lateral branches of the cutaneous nerve to both the breast and latissimus dorsi skin island are sacrificed. These losses of cutaneous innervation pose a significant disadvantage with regard to achieving sensation of the reconstructed breast mound. Without sensory neurorrhaphy, spontaneous recovery of sensation in breast reconstruction with myocutaneous flaps has been reported; however, recovery was slow and incomplete.

Yano and colleagues recently presented a technique in which the lateral cutaneous branch of the of the seventh thoracic nerve is anastomosed to the lateral cutaneous branch of the fourth intercostal nerve. ^[49] In their experience, gradual recovery of perception of touch, pain, and temperature that equaled the normal side occurred within a year. This technique depends upon the preservation of the third through fifth cutaneous branches of the intercostal nerves, which may not be feasible during mastectomy secondary to tumor location or associated technical issues.