Dataset Information

Modified Incision for Muscle-sparing Latissimus Dorsi to Increase Flap Perfusion in the Morbidly Obese.

ABSTRACT: The muscle-sparing latissimus dorsi flap relies on perforators from the descending branch of the thoracodorsal artery. Previous descriptions placed a transverse skin island independent of perforator location, as any design was thought to capture enough perforators to ensure flap survival. We have found this approach prone to complications when attempting breast reconstruction in obese patients who require large flap volumes. Although the most proximal perforators have the most reliable blood flow, inclusion of these perforators reduces the arc of rotation, as the flap would be close to the pivot point at the most cranial point of muscle division, leaving significant volume in the axilla. Here we describe a modified skin incision that includes all of the proximal perforators but also allows us free design of the skin island to harvest those areas of the back with maximal subcutaneous tissue and with enough distance from the pivot point to optimize arc of rotation.

SUBMITTER: Schwartz JD

PROVIDER: S-EPMC8751769 | biostudies-literature | 2021 Nov

REPOSITORIES: biostudies-literature

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Modified Incision for Muscle-sparing Latissimus Dorsi to Increase Flap Perfusion in the Morbidly Obese.

Schwartz Jean-Claude D JD

Plastic and reconstructive surgery. Global open 20211111 11

The muscle-sparing latissimus dorsi flap relies on perforators from the descending branch of the thoracodorsal artery. Previous descriptions placed a transverse skin island independent of perforator location, as any design was thought to capture enough perforators to ensure flap survival. We have found this approach prone to complications when attempting breast reconstruction in obese patients who require large flap volumes. Although the most proximal perforators have the most reliable blood flo ...[more]

PMID: 35028259

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Project description:BackgroundBreast reconstruction using the latissimus dorsi (LD) flap is one of the most popular and common breast reconstruction techniques among Asian patients. There are increasing numbers of cases wherein breasts need to be reconstructed to moderate to large sizes among the Asian population. Most reconstructive surgeons use abdominal-based flaps-such as the deep inferior epigastric perforator and transverse rectus abdominis myocutaneous flap, or LD flap with an implant-to supplement the volume. Here, we compare the usefulness of the boomerang LD (bLD) flap-a technique developed by modifying the design of the conventional extended LD flap-with that of the LD flap with implant (LDi).MethodsThis was a prospective cohort study including patients with breast cancer aged between 25 and 60 years who underwent unilateral total or skin/nipple-sparing mastectomy, or postmastectomy. The exclusion criteria were advanced breast cancer (stages 3 and 4); a history of cognitive impairment affecting ability to complete the self-reported questionnaire; a history of neurologic or musculoskeletal disorder; and a history of alcohol or drug abuse. Statistical analysis was performed, and correlations between the two technique types were analyzed [including age, body mass index, preoperative breast volume, operation time, flap elevation time, admission duration, adjuvant treatment (radiotherapy, chemotherapy), drain indwelling duration, and drain total sum volume].ResultsIn total, 85 patients who underwent immediate breast construction through the LDi group (n=63) or bLD group (n=25) techniques after total mastectomy between January 2015 and June 2022 were analyzed (mean age: LDi group, 46±7.7 years; bLD group, 45.6±7.8 years). We observed that the flap weight, operative time, mean admission duration, and drain indwelling duration were statistically significantly different in the bLD group (P<0.05). Body mass index, preoperative breast volume, specimen weight, flap elevation time, and drain total time were comparable between groups.ConclusionsBreast reconstruction using the bLD flap was found to be a suitable alternative technique for patients who desire an autologous tissue transfer (rather than an implant) but are contraindicated for abdominal-based flaps and do not mind long postoperative scars.

Project description:The latissimus dorsi flap (LDF) has gained popularity given its versatile nature and broad applicability in breast reconstruction. Its resurgence has been attributed to its ability to be enhanced using implant or high-volume fat grafting, rendering it a primary option for selected patients. The aim of this review is to tackle current indications and subjects of controversy regarding use of complete-autologous and implant-enhanced LDF in breast reconstruction. Also, a case-series showcasing the authors’ experience with this versatile reconstructive option is presented. A search across Web of Science and PubMed MEDLINE from inception through January 3, 2023, was conducted. Articles reporting postoperative outcomes of autologous breast reconstruction with LDF were included. Regarding the case series, electronic medical records of patients who underwent total mastectomy and autologous breast reconstruction with LDF from January 2011 to December 2021 were retrospectively reviewed. Data on demographic and oncologic characteristics, and surgical characteristics and outcomes were extracted. Our review suggests that LDF is suitable for patients who lack alternative donor site, have a history of abdominoplasty or no access to microsurgery, smokers or obese. Latissimus dorsi (LD) harvesting has almost complete shoulder function recovery in the long-term. Thoracodorsal nerve division does not cause volume loss or animation deformity. Multisite multilayer fat grafting, beveling the edges of the skin paddle and fat, folding the LD muscle and plicating the paddle allow adequate projection and contour achievement. Our case-series included 234 reconstructions. Almost half of the patients had immediate fat transfer during reconstruction (51.3%). The rate of recipient site hematoma was 3.0%, seroma was 7.7%, wound disruption 32.1%, wound disruption events requiring unplanned procedures was 13.7%, and surgical site infection (SSI) was 12.4%. The LDF is reliable and safe for immediate or delayed breast reconstruction or salvage after reconstruction failure. Its versatility, reliable anatomy, easy dissection, and relative low complication rate have revived this modality as valuable opportunity for breast reconstruction in this era.

Dataset Information

Modified Incision for Muscle-sparing Latissimus Dorsi to Increase Flap Perfusion in the Morbidly Obese.

Publications

Modified Incision for Muscle-sparing Latissimus Dorsi to Increase Flap Perfusion in the Morbidly Obese.

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