Indications and Controversies for Complete and Implant-Enhanced Latissimus Dorsi Breast Reconstructions

This article describes the use of implant-enhanced and total-autologous latissimus dorsi myocutaneous flaps in breast reconstruction. It addresses the indications for use of this reconstruction alternative, which have recently been expanded thanks to the advent of high-volume fat grafting. Given its straightforward dissection, reliable vascular pedicle, variety of approaches, and potential for excellent aesthetic results, use of latissimus dorsi flaps may be considered among first-line options in selected patients.

Key points

  • The latissimus dorsi flap is a viable alternative in autologous breast reconstruction, whether an implant or fat-enhanced modality is used.

  • Implant-enhanced latissimus dorsi flaps are useful in situations in which microvascular techniques are unavailable, other donors sites are unfavorable, or local tissues provide insufficient implant coverage.

  • High-volume fat grafting has given this traditional reconstructive alternative new life, and it may now be considered a primary option in selected patients.

Introduction

The latissimus dorsi (LD) has been used by reconstructive surgeons for more than 120 years, with Tansini first describing use of an LD myocutaneous flap in 1896. Its use in postmastectomy reconstruction was first reported by D’Este in 1912, but it was not until the late 1970s that the use of LD flaps was widely reintroduced as a method of autologous breast reconstruction. Factors associated with its popularity include its straightforward dissection, varying orientations and shapes possible, and a consistent, reliable vascular pedicle.

Drawbacks of this technique include potentially insufficient volume necessitating prosthetic inclusion and donor site issues including dehiscence and seroma. Additionally, the initial enthusiasm regarding LD use in breast reconstruction has been tempered over ensuing years by the advent of abdominally based pedicled and free tissue transfer options.

Recently, the LD flap has had a resurgence in popularity. High-volume fat grafting to enhance flap volume, quilting sutures at the donor site, and changing reimbursement patterns for free tissue transfer have all been implicated in this resurgence. The purpose of this article is to describe the contemporary indications and areas of controversy surrounding the use of total-autologous and implant-enhanced LD flaps in breast reconstruction.

Introduction

The latissimus dorsi (LD) has been used by reconstructive surgeons for more than 120 years, with Tansini first describing use of an LD myocutaneous flap in 1896. Its use in postmastectomy reconstruction was first reported by D’Este in 1912, but it was not until the late 1970s that the use of LD flaps was widely reintroduced as a method of autologous breast reconstruction. Factors associated with its popularity include its straightforward dissection, varying orientations and shapes possible, and a consistent, reliable vascular pedicle.

Drawbacks of this technique include potentially insufficient volume necessitating prosthetic inclusion and donor site issues including dehiscence and seroma. Additionally, the initial enthusiasm regarding LD use in breast reconstruction has been tempered over ensuing years by the advent of abdominally based pedicled and free tissue transfer options.

Recently, the LD flap has had a resurgence in popularity. High-volume fat grafting to enhance flap volume, quilting sutures at the donor site, and changing reimbursement patterns for free tissue transfer have all been implicated in this resurgence. The purpose of this article is to describe the contemporary indications and areas of controversy surrounding the use of total-autologous and implant-enhanced LD flaps in breast reconstruction.

Indications for latissimus dorsi breast reconstruction

Given the reliability and versatility of the LD flap, almost any patient is a potential candidate for an LD flap. Its traditional use is in patients for whom prosthetic reconstruction is not desirable, including both tissue expander or single-stage implant-based reconstruction. Specific situations that make the flap appealing include patients with unsuitable donor sites elsewhere. These situations include patients in whom an abdominally based flap would not be appropriate, such as in very thin or extremely obese individuals or those who have undergone previous abdominal body contouring procedures. The flap is also a useful option when microvascular tissue transfer is not preferred or available. High-volume fat grafting has also enabled use of the flap in situations that were previously not possible, such as a medium- or large-breasted patient who requests complete autologous reconstruction but whose back has insufficient volume without use of an implant.

Controversies for latissimus dorsi breast reconstruction

  • There is still debate as to whether harvest of the LD results in a significant functional deficit for shoulder and upper extremity function.

  • There has been question regarding the adequacy of volume for transfer and the role of nerve preservation to maintain volume.

  • Some have questioned the caliber of aesthetic results using the LD, in terms of the donor site and final breast reconstruction, as well as patient satisfaction.

Evidence base for latissimus dorsi breast reconstruction

Indications

Patients who prefer not to have prosthetic devices, have a history of ipsilateral breast radiation, or have a high likelihood of requiring radiation are candidates for autologous reconstruction. There are several reasons why an LD flap may be preferred over other reconstructive options. Previous abdominal surgeries may prohibit the use of the usual abdominal donor site for autologous reconstruction. Abdominal body contouring procedures, for example, typically divide perforators, which would otherwise be used to support a pedicled or free TRAM or DIEP. Although there is evidence to support revascularization, the caliber of the vessels is not typically adequate to support an abdominally based reconstruction.

Another scenario in which LD flaps may be preferred is when microsurgical techniques are not available. Recent studies have found that few patients have access to a practicing microsurgeon, with surveys finding that only one-fourth of practicing US plastic surgeons perform any microsurgical breast reconstruction. Furthermore, even practicing microsurgeons can be deterred by procedure length and poor reimbursement associated with free tissue transfer in some markets. Pedicled TRAMs have become a popular alternative when free tissue transfer is not available; however, such flaps can have significant abdominal morbidity, especially in bilateral cases. The LD myocutaneous flaps offer an excellent option for the patient seeking autologous reconstruction without microsurgery and furthermore allows for the avoidance of the donor site issues associated with the pedicled TRAM flap.

Even among individuals with access to a microsurgeon, there are several reasons why free tissue transfer may not be advisable. Relative contraindications include patients with multiple comorbidities, diabetes, cigarette smoking, and a history of multiple abdominal surgeries. Others have noted obesity to be associated with an elevated incidence of overall donor site and flap complications in abdominal tissue transfer. The pedicled LD flap has a reliable pedicle, and is associated with less flap fat necrosis in the flap in the obese population. Similarly, although donor site wound healing issues have been noted in smokers undergoing abdominal free tissue transfer, the same has not been observed in this cohort of patients receiving LD flaps.

Controversies

Concern over residual weakness after harvest of the LD has been one concern among critics. However, this concern has not been substantiated in the literature. Yang and colleagues prospectively followed up with 31 patients after immediate, pedicled LD reconstruction using standardized surveys at 3-month and 1-year intervals. One year after LD flap surgery, shoulder strength and range of motion returned to preoperative baseline. Similarly, Russell and colleagues reported that most patients with free and pedicled LD flaps had transient mild-to-moderate shoulder weakness initially, but this recovered after several months. Thus, although sacrifice of the LD muscle may initially cause some functional impairment, with time it is very well tolerated and only noticeable in particularly athletic patients, even then with only mild loss of function noted.

The topic of thoracodorsal nerve transection has been a source of controversy, both in terms of volumetric maintenance and animation deformities. When the nerve is left intact, distortion in the shape of the breast can result. Szychta and colleagues prospectively followed up with 29 patients, dividing them into 2 cohorts based on denervation of the LD. The group for which the thoracodorsal was cut showed similar satisfaction of the tissue consistency and symmetry but reported less pain, less animation deformities, and higher satisfaction scores. That said, this finding has not been consistently demonstrated in the literature.

Regarding volumetric loss from denervation, reports indicate that atrophy occurs to a variable degree regardless of nerve division. MRI studies show no difference in ultimate thickness of flap from denervation, possibly attributed to normal fatty replacement of the muscle. Although others maintain that the nerve should not be divided unless it is easily identified as to avoid vascular pedicle injury, there does not seem to be any quantifiable volumetric consequence from either approach.

Traditionally, the LD muscle was thought to be insufficient to reconstruct larger-breasted women. There have been several techniques used to counter this deficiency. Prior variants of the total autologous flap included a fleur-de-lis skin paddle. Although this technique does increase flap volume, it is also associated with a concomitantly higher rate of donor site healing issues. More recent techniques have focused on including a larger amount of subcutaneous fat to provide the necessary volume. This technique is accomplished technically by beveling out on both sides of the skin paddle, including supra-Scarpa and sub-Scarpa fat. The final result of this modification is increased flap volume transferred to the mastectomy defect and a smoother, gentler contour. The remaining subcutaneous fatty layer has a robust vascular supply and provides reliably excellent soft tissue coverage.

A powerful technique to augment volume of the LD flap is fat grafting, either during the first or subsequent stages of reconstruction. Multilayer, multisite fat grafting has been described, with sites of injection including the LD muscle, LD skin paddle, mastectomy skin flaps, and the pectoralis major and serratus muscles. In a study by Zhu and colleagues, an average fat grafting volume of 176 mL was injected per side in patients with an average body mass index of 29.3. They describe 100% flap survival and complete wound healing, and no seromas or fat grafting–related complications were observed. Approximately one-fourth of patients required additional fat grafting. Santanelli di Pompeo and colleagues report similar results in a series of 23 patients, with a mean injected volume of 101 mL. Again, no fat grafting–related complications were observed.

Finally, some have questioned the aesthetic caliber of the results achievable with an LD flap. Recent advances described above have led to concomitant benefits in the aesthetics of this reconstructive modality. By artistically shaping the skin/subcutaneous fat paddle, contours can be achieved that far exceed those created when an implant is simply placed under the thin mastectomy flaps. Previously, such maneuvers were limited in cases of relatively small flaps. Further, the thick dermis of the skin paddle can be aggressively pleated, folded, and contorted to create an aesthetic shape with little regard to harming the flap’s vascularity.

Studies have examined the aesthetic perceptions of both patients and surgeons after LD breast reconstruction. Lindegren and colleagues studied 24 consecutive patients who received neoadjuvant radiation therapy and then received postmastectomy reconstruction with either DIEP or LD flaps in combination with prostheses. Plastic surgeons found the DIEP superior regarding size and shape, whereas patients were more satisfied with the size, shape, and overall appearance of the LD when patients’ and surgeons’ opinions were compared. No statistically significant differences were seen between the groups regarding patients’ willingness to recommend this technique or to choose the same technique again.

Regarding the donor scar, the LD flap was favored compared with DIEP flap reconstruction by both patients ( P = .036) and surgeons ( P = .001). Overall, patients were more satisfied with LD flap reconstruction compared with surgeons. Although some studies suggested an increased number of secondary revision surgeries in LD flaps, this may not be representative of the most recent iterations of this flap.

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Nov 21, 2017 | Posted by in Dental Materials | Comments Off on Indications and Controversies for Complete and Implant-Enhanced Latissimus Dorsi Breast Reconstructions
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