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Avoiding back wound dehiscence in extended latissimus dorsi flap reconstruction
Abstract
The latissimus dorsi breast reconstruction flap has a number of advantages, but despite the advances in surgical techniques, it has remained vulnerable to skin dehiscence or necrosis at the donor site. We describe a novel surgical technique to prevent this.
Patients treated with extended latissimus dorsi flap reconstruction between January 2005 and January 2010 were studied prospectively.
Eighteen patients were reviewed (12 immediate and 6 delayed). Two patients were smokers. The mean age was 54.4 (range: 42–64) years and the mean body mass index was 31.6 (range: 22.3–38). The mean weight of the mastectomy specimen was 551 g (range: 280–980 g). Six patients developed back seroma which required aspiration, and one patient developed a haematoma of the reconstructed breast. All wounds healed primarily.
The new technique is safe, simple and effective in avoiding wound dehiscence at the donor site after extended latissimus dorsi flap reconstruction.
... 21,770 breast reconstructions (Abdalla et al., 2006;Anker et al., 2020;Arnez et al., 1999;Ascherman et al., 2016;Baker et al., 2018;Bordoni et al., 2017;Casella et al., 2014;Casella et al., 2018;Chatterjee et al., 2013;Chatterjee et al., 2015;Clough et al., 1996;Cordeiro et al., 2014;Dancey et al., 2010;Davidge et al., 2015;Devulapalli et al., 2018;Dikmans et al., 2017;Edsander-Nord et al., 1998;Francisco et al., 2010;Gahm et al., 2010;Gatherwright et al., 2018;Gerber et al., 1999;Grover et al., 2013;Gubitosi et al., 2014;Halim & Alwi, 2014;Hansson et al., 2021;Harper et al., 2012;Hayes et al., 1997;Holm et al., 2006;Holm et al., 2008;Hupkens et al., 2016;Jones et al., 2009;Kim et al., 2007;Kim et al., 2009;Krishnan et al., 2013;Krishnan et al., 2014;Lee & Chang, 1999;Longo et al., 2016;Lynch et al., 2013;Mahdi et al., 1998;Malagon-Lopez et al., 2019;Mannu et al., 2013;McCarthy et al., 2005;McCarthy et al., 2012;McGuire et al., 2017;McKane & Korn, 2012;Mohebali et al., 2010;Nava et al., 2011;Nava et al., 2017;Negenborn et al., 2019;Nelson et al., 2019;Newman & Samson, 2009;Offodile et al., 2015;Ohno et al., 2013;Paget et al., 2013;Pestana et al., 2009;Rella et al., 2015;Rossetto et al., 2009;Rossetto et al., 2014;Salgarello et al., 2015;Salzberg, 2006;Schusterman et al., 1992;Shafighi et al., 2013;Spear et al., 2007;Suh et al., 2020;Suominen et al., 1996;Szychta et al., 2013;Taghizadeh et al., 2015;Tepper et al., 2008;Thoma et al., 2003;Thoma et al., 2004;Thomson et al., 2008;Toesca et al., 2017;Tuinder et al., 2018;Vandeweyer, 2003;Venturi et al., 2013;Wijayanayagam et al., 2008;Youssef et al., 2016;Zeidler et al., 2014;Zoccali et al., 2019). We adhered to the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) reporting guidelines (Husereau et al., 2013). ...
... Thick straight arrows indicated transitions to first-cycle health states; thin straight dashed red arrows indicated transitions to second-cycle health states. DIED/SIEA, deep inferior epigastric perforator/superficial inferior epigastric artery free flap; DTI, direct-to-implant; LD, latissimus dorsi flap alone; LDI, latissimus dorsi flap-to-implant; TEI, tissue expander-to-implant; TRAM, transverse rectus abdominis myocutaneous flap Halim & Alwi, 2014;Hansson et al., 2021;Harper et al., 2012;Hayes et al., 1997;Holm et al., 2006;Holm et al., 2008;Hupkens et al., 2016;Jones et al., 2009;Kim et al., 2007;Kim et al., 2009;Lee & Chang, 1999;Longo et al., 2016;Lynch et al., 2013;Mahdi et al., 1998;Malagon-Lopez et al., 2019;Mannu et al., 2013;McCarthy et al., 2005;McCarthy et al., 2012;McGuire et al., 2017;McKane & Korn, 2012;Mohebali et al., 2010;Nava et al., 2011;Nava et al., 2017;Negenborn et al., 2019;Nelson et al., 2019;Newman & Samson, 2009;Ohno et al., 2013;Paget et al., 2013;Pestana et al., 2009;Rella et al., 2015;Rossetto et al., 2009;Rossetto et al., 2014;Salgarello et al., 2015;Salzberg, 2006;Schusterman et al., 1992;Shafighi et al., 2013;Spear et al., 2007;Suh et al., 2020;Suominen et al., 1996;Szychta et al., 2013;Taghizadeh et al., 2015;Tepper et al., 2008;Thomson et al., 2008;Toesca et al., 2017;Tuinder et al., 2018;Vandeweyer, 2003;Venturi et al., 2013;Wijayanayagam et al., 2008;Youssef et al., 2016;Zeidler et al., 2014;Zoccali et al., 2019). Clinical examinations, laboratory testing, ultrasound imaging, and magnetic resonance imaging (MRI) were used to determine complications requiring surgical interventions during the first 12-month cycle. ...
... Clinical examinations, laboratory testing, ultrasound imaging, and magnetic resonance imaging (MRI) were used to determine complications requiring surgical interventions during the first 12-month cycle. Complications requiring surgical interventions occurred 35.5% for DTI (Baker et al., 2018;Casella et al., 2014;Clough et al., 1996;Dikmans et al., 2017;Gahm et al., 2010;Gubitosi et al., 2014;Mahdi et al., 1998;Negenborn et al., 2019;Rella et al., 2015;Wijayanayagam et al., 2008;Youssef et al., 2016), 24.7% for pedicled TRAM (Edsander-Nord et al., 1998;Jones et al., 2009;Kim et al., 2009;McCarthy et al., 2005;Rossetto et al., 2009;Rossetto et al., 2014;Suominen et al., 1996;Vandeweyer, 2003;Wijayanayagam et al., 2008), 20.6% for free TRAM (Arnez et al., 1999;Edsander-Nord et al., 1998;Halim & Alwi, 2014;Nelson et al., 2019;Pestana et al., 2009;Schusterman et al., 1992;Suominen et al., 1996), 20.3% for LD, (Dancey et al., 2010;Harper et al., 2012;Lee & Chang, 1999;Mannu et al., 2013;Szychta et al., 2013) 16.4% for DIEP/SIEA, (Anker et al., 2020;Arnez et al., 1999;Francisco et al., 2010;Halim & Alwi, 2014;Holm et al., 2006;Holm et al., 2008;Malagon-Lopez et al., 2019;Mohebali et al., 2010;Nelson et al., 2019;Newman & Samson, 2009;Pestana et al., 2009;Shafighi et al., 2013;Taghizadeh et al., 2015;Wijayanayagam et al., 2008) 15.4% for LDI (Abdalla et al., 2006;Davidge et al., 2015;Gerber et al., 1999;Longo et al., 2016;Wijayanayagam et al., 2008) and thigh-based flaps (Hupkens et al., 2016;McKane & Korn, 2012;Pestana et al., 2009;Tuinder et al., 2018;Wijayanayagam et al., 2008), 8.9% for TEI (Ascherman et al., 2016;Bordoni et al., 2017;Casella et al., 2018;Devulapalli et al., 2018;Dikmans et al., 2017;Hansson et al., 2021;Hayes et al., 1997;Lynch et al., 2013;McCarthy et al., 2012;Nava et al., 2017;Negenborn et al., 2019;Venturi et al., 2013;Zeidler et al., 2014), and 8.8% for gluteal-based flaps (Pestana et al., 2009;Zoccali et al., 2019). Over subsequent 12-month cycles, patient preferences, clinical examinations, ultrasound imaging, and MRI were used to determine revisions requiring surgical interventions. ...
Background:
Women undergoing immediate breast reconstruction without radiation therapy have reconstruction methods available with uncertain long-term costs associated with complications requiring surgery and revisions. We evaluated cost-effectiveness of nine methods of immediate breast reconstruction for women with localized breast cancer.
Methods:
Markov modeling was performed over 10-years for unilateral/bilateral breast reconstructions from healthcare/societal perspectives. PubMed, Embase, Cochrane, Scopus, and CINAHL were searched to derive data from 13,744 patients in 79 prospective studies. Complications requiring surgery (mastectomy necrosis, total/partial flap necrosis, seroma, hematoma, infection, wound dehiscence, abdominal hernia, implant removal/explantation) and revisions (fat necrosis, capsular contracture, asymmetry, scars/redundant tissue, implant rupture/removal, fat grafting) were evaluated over yearly cycles. Reconstructions included: direct-to-implant (DTI), tissue expander-to-implant (TEI), latissimus dorsi flap-to-implant (LDI), latissimus dorsi (LD), pedicled transverse rectus abdominis myocutaneous (TRAM), free TRAM, deep inferior epigastric perforator/superficial inferior epigastric artery (DIEP/SIEA), thigh-based, or gluteal based flaps. Outcomes were incremental cost-effectiveness ratios (ICER) and net monetary benefits (NMB). Willingness-to-pay thresholds were $50,000 and $100,000.
Results:
From a healthcare perspective for unilateral reconstruction, compared to LD, the ICER for DTI was -$42,109.35/quality-adjusted life-years (QALY), LDI was -$25,300.83/QALY, TEI was -$22,036.02/QALY, DIEP/SIEA was $8307.65/QALY, free TRAM was $8677.26/QALY, pedicled TRAM was $13,021.44/QALY, gluteal-based was $17,698.99/QALY, and thigh-based was $23,447.82/QALY. NMB of DIEP/SIEA was $404,523.47, free TRAM was $403,821.40, gluteal-based was $392,478.64, thigh-based was $387,691.70, pedicled TRAM was $376,901.83, LD was $370,646.93, DTI was $339,668.77, LDI was $334,350.30, and TEI was $329,265.84.
Conclusions:
All nine methods of immediate breast reconstruction were considered cost-effective from healthcare/societal perspectives. LD provided the lowest costs, while DIEP/SIEA provided the greatest effectiveness and NMB.
... It involves placing interrupted absorbable sutures between the mastectomy flap and pectoral muscle prior to wound closure. It has been described in several studies assessing the technique at donor sites of autologous breast reconstruction.[6][7][8][9]However, it has not yet been prospectively investigated in a large patient population in the context of addressing seroma formation following mastectomy. ...
Introduction. Seroma formation is one of the most frequently encountered complications following mastectomy. It may cause significant morbidity, including delayed wound healing, infection and frequent clinic attendance for seroma aspiration. Objective. To evaluate the effect of surgical quilting after mastectomy in the prevention of postoperative seroma and to investigate which factors influence seroma formation. Methods. This was a single-centre prospective cohort study over a 1-year period. All patients who had a mastectomy operation during this period were included in this study. Group 1 patients (quilting) had mastectomy flaps sutured to pectoral muscle using interrupted absorbable sutures. Seroma requiring aspiration, number of aspirations and volume aspirated were recorded postoperatively. Results. During the study period, 168 patients were recruited, with 54 patients in group 1 (quilting) and 114 patients in group 2 (nonquilting). The proportion of patients who developed seroma requiring aspiration was 69% (n=79) in the non-quilting group and 29% (n=15) in the quilting group (p<0.001). Additionally, the total volume of seroma drained was 427 mL (standard error (SE)=69) in the nonquilting group and 63 mL (SE=21) in the quilting group (p=0.0008). The total number of seroma aspirations was 152 in the non-quilting group compared with 23 in the quilting group (p=0.0001). Seroma was more common in smokers (p=0.003) and was not decreased by the presence of drains. Conclusion. Quilting of the mastectomy flaps significantly reduces seroma formation. Both total volume of seroma aspirated and number of aspirations are significantly reduced using this technique. We would therefore recommend quilting of mastectomy flaps to reduce the incidence of postoperative seromas and morbidity.
Background
Pedicled breast reconstruction is a mainstay treatment for plastic surgeons. Although indications vary for each breast reconstruction technique, there exist some overlapping characteristics that may determine a successful outcome. We aimed to determine the impact flap selection has on postoperative outcomes and resource utilization.
Materials and methods
Nationwide Inpatient Sample database (2010–2011) was reviewed for cases of latissimus dorsi (LD; International Classification of Diseases, Ninth Revision, Clinical Modification, 85.71) and pedicled transverse rectus abdominis myocutaneous (pTRAM; 85.72) breast reconstruction. Males were excluded. Demographic, socioeconomic, clinical factors, postoperative complications, length of stay (LOS), and total charges (TC) were assessed. Chi-squared and multivariate analyses were performed to identify independent risk factors of resource utilization and postoperative complications.
Results
A total of 29,074 cases were identified; 17,670 (61%) LD and 11,405 (39%) pTRAM. 74% percent were Caucasian, 94% insured, and 66% were treated in teaching hospitals. There were 24 mortalities (15 LD, 9 pTRAM). LD patients were more likely to be obese (odds ratio [OR] = 1.3), suffer from flap loss (OR = 1.4), wound infection (OR = 1.6), wound dehiscence (OR = 2.2), and hematoma (OR = 1.3), P < 0.05. Patients undergoing pTRAM were more likely to undergo surgical revision (OR = 6.9), suffer from systemic infection (OR = 1.8), pneumonia (OR = 5.0), or pulmonary embolism (OR = 29.2), P < 0.05. Risk-adjusted multivariate analysis demonstrated LD was an independent risk factor for postoperative complication (OR = 1.4) and increased TC (OR = 1.3), P < 0.001. Conversely, undergoing pTRAM was an independent risk factor for increased LOS (OR = 6.3), P < 0.001.
Conclusions
Analysis of a national database found LD breast reconstruction to have higher TC and increased risk for surgical site complications. Patients undergoing pTRAM had increased risk for pulmonary complications and LOS. Procedure selection may be refined as additional characteristics are discovered using outcomes-based research.
Background
Sentinel lymph node biopsy (SLNB) before mastectomy and immediate breast reconstruction (IBR) may help to avoid the negative cosmetic effects of radiotherapy on reconstructed breasts in lymph node-positive patients. Concerns have been raised regarding possible delays whilst awaiting the SLNB result prior to definitive surgery, which needs to be performed within 31 days of cancer diagnosis. The aim was to investigate whether initial SLNB delays mastectomy and IBR.Methods
All patients who had IBR between January 2005 and 2007 were reviewed retrospectively. Before October 2005 axillary staging was performed simultaneously with mastectomy and IBR (Group I). After October 2005, SLNB was performed as an initial procedure and patients with positive SLNB were only offered a temporary tissue expander to be replaced by autogenous reconstruction after completing the cancer treatment (Group II). Date of diagnosis and waiting times were recorded and the two groups were compared. Different reasons for delays in treatment were studied.ResultsOne hundred and thirty-nine IBR (123 patients) were included in the statistical analysis (67 IBR in Group I and 72 IBR in Group II). Seventy-one patients (57.7%) had no delay (mean waiting time of 23 days). Fifty-two patients (42.3%) had delay longer than 31 days (mean waiting time of 66 days). Group I patients had a mean waiting time (standard deviation) of 38.8 (38) days and Group II patients 42.7 (24) days (p = 0.51).Conclusions
In this group of patients, SLNB before mastectomy and IBR does not significantly delay definitive breast cancer surgery.
Widespread adoption of the extended latissimus dorsi myocutaneous flap in breast reconstruction has been limited by donor-site complications. The dissection plane may be either above or below the superficial layer of the thoracolumbar fascia, which may be transferred with the flap or retained on the back skin flaps. The aim of this study was to investigate whether varying the plane of dissection improves donor-site morbidity and complications.
A comparative analysis of consecutive women treated with extended latissimus dorsi myocutaneous breast reconstruction by a single surgeon (D.F.) between 2006 and 2012 was performed.
Eighty patients were reviewed. Between 2006 and 2011, 47 patients were treated with traditional suprafascial harvest (group A); the subsequent 33 patients between 2011 and 2012 had subfascial harvest (group B), retaining the superficial fascia on the back skin flaps. When compared with group A, group B patients showed significant reduction in both mean number of seroma drainage events (p = 0.027) and mean total aspirated seroma volume, which was reduced by half (p = 0.006). Group B patients also reported significant reduction in donor-site pain (p = 0.041) and donor-site scar adherence to the chest wall (p = 0.026). No increases in flap or donor-site dehiscence, partial flap loss, or other minor or major complications were observed.
The technique of subfascial harvest during autologous latissimus dorsi flap breast reconstruction significantly improves back donor-site morbidity without compromising flap survival.
Therapeutic, III.
Adjuvant post-mastectomy radiotherapy (RT), which is often unpredicted, is known to increase complications following immediate breast reconstruction (IBR).
To investigate the role of sentinel lymph node biopsy (SLN) in predicting RT and improving the choice of IBR.
All patients who had mastectomy and IBR between January 2004 and January 2007 were reviewed retrospectively. Axillary staging (clearance or SLN) was performed at the same time until October 2005 (Group 1), when the Unit's protocol was updated to perform SLN initially prior to mastectomy and IBR (Group 2). Patients in Group 2 with positive SLN were offered either a delayed reconstruction or a temporary subpectoral immediate tissue expander, while all options were offered if SLN was negative and in Group 1 patients.
One hundred and thirty-nine patients were reviewed. 20 patients received unexpected RT in Group 1 (14 tissue expander, 4 Latissimus Dorsi flap with an implant and 2 DIEP flaps) compared to 11 patients in Group 2 who had a temporary tissue expander due to expected RT (P=0.03). Unexpected RT caused delayed complications in 14 patients (70%) compared to no delayed complications in patients who received expected RT in Group 2.
SLN biopsy before IBR helps to predict RT and avoids its complications on breast reconstruction. Patients with positive SLN biopsy are best offered a temporary subpectoral tissue expander for IBR.
Form-stable silicone gel breast implants represent the fifth generation of silicone gel augmentation devices. Additional crosslinking between the silicone molecules allows these implants to retain their shape, especially in the vertical position.
The authors evaluate the efficacy of Silimed form-stable silicone gel breast implants.
A total of 355 patients (708 implants) were enrolled prospectively over a 60-month period. Data were collected on patient demographics, implant factors, complications, and revisions. Chi-square analysis and Fisher's exact test were implemented to compare groups with respect to differences in complication and revision rates.
The overall tissue-related complication rate was 8.2% per patient, or 4.1% per breast. The overall implant-related cosmetic complication rate was 2.5% per patient, or 1.3% per implant. The overall implant-related complication rate, which was represented by the capsular contracture (CC) rate, was 1.4% per patient and 0.7% per implant. There were no complications in any of the reconstruction patients. There were no deep vein thromboses, pulmonary emboli, myocardial infarctions, or deaths among the patients in this study. In addition, there were no instances of flap necrosis, hematoma, or loss of implant integrity. The overall complication rate was 9.6% per patient, or 4.8% per implant. The overall tissue-related revision rate was 5.4% per patient, with the most common tissue-related reason for revision being unacceptable scarring. The overall implant-related cosmetic revision rate was 7.6% per patient, with the most common reason for revision in this category being size change. The overall implant-related revision rate was 1.1% per patient and was solely due to CC.
This study demonstrates that form-stable silicone gel breast implants are safe and have a complication profile similar to other models of silicone breast implants, with a lower CC rate and a decreased incidence of wrinkling compared to fourth-generation silicone gel implants (as well as other published studies of fifth-generation implants).
Autologous breast reconstruction using the extended latissimus dorsi flap has been infrequently reported. In the current study, the authors are reporting their own clinical experience with this method. A review of the literature is also discussed.
Over a three year period, 14 patients underwent breast reconstruction using the extended latissimus dorsi (LD) flap. Patients with small to medium sized breasts were selected. The age of the patients ranged from 29 to 42 years with a follow-up period ranging from six to 18 months. The indications, flap-related complications and donor site morbidity and aesthetic results were evaluated.
The main indication to use the flap was dorsal donor site preference by patients. The remaining patients were either not suitable for a flap from the abdomen or wished to get pregnant and were offered the dorsal donor site. Neither total nor partial flap loss was recorded but donor site morbidity was mainly due to seroma, which was treated conservatively in all patients, except for one who required surgery. Another two patients suffered from wound breakdown and distal necrosis of the back flaps. Mild contour deformity was also noted on the back of all patients but caused no major concern. Indeed, the overall patient satisfaction was very high.
The extended LD flap proved to be a good option for autologous breast reconstruction in selected patients. Patients should be warned of the potential for seroma and mild contour back deformity.
The introduction of skin-sparing mastectomy has revolutionized both breast cancer surgery and breast reconstruction. Latissimus dorsi myocutaneous flap is a versatile flap that is gaining renewed popularity with the development of flap modifications and the continued recognition of its reliability and safety. We report our results with a new modification of the extended latissimus dorsi flap after skin-sparing mastectomy for breast cancer.
From January 2002 to January 2006, 140 patients of breast carcinoma had unilateral skin-sparing mastectomy and immediate breast reconstruction. A total of 132 cases of invasive duct carcinoma and eight cases of invasive lobular carcinoma are included. Age ranged from 27 to 53 (median, 40.5) years. Tumor stage was stage I in 22 cases, stage II in 100 cases, and stage III in 18 cases. We performed a new modification to the standard extended latissimus dorsi flap, which allowed us to obtain enough autologous tissue to reconstruct the relatively large breast of the Egyptian women without implant. The postoperative aesthetic results and donor side morbidity, including contour deformity and scaring, were examined.
We applied both an objective and subjective aesthetic result monitoring. Aesthetic grading results of breast reconstruction were excellent in 85, good in 42, fair in ten and poor in three cases. Both flap and donor site complications were minor. Patients were followed for a median of 32.4 (range, 12-48) months. During this period of follow-up, no episode of local or distant failure was observed.
Skin-sparing mastectomy with immediate breast reconstruction using our new modification of extended latissimus dorsi flap allows single-stage, totally autologous reconstruction with satisfactory aesthetic results and low morbidity.
This article presents our technique of autologous breast reconstruction using the latissimus dorsi flap and studies the advantages, disadvantages, and results that can be expected. A consecutive sample of 100 patients was studied. The average length of follow-up was 20 months (range 8 to 44 months), and all of the subjects were reviewed in consultation without loss to follow-up. The supplementary volume of the latissimus dorsi was obtained from five fatty zones: fat on the cutaneous paddle, fat taken from the surface of the muscle, the scapular fat pad, the anterior fatty zone, and the supra-iliac fat pad. This technique must be measured against the transverse rectus abdominis muscle (TRAM) flap, free or pedicled, when the patient needs an autologous breast reconstruction. It can be used when the TRAM flap is contraindicated (this corresponds to 45 percent of patients of our sample) or when the dorsal donor site is preferred (55 percent of cases of our sample). The major complications are rare (1 percent partial necrosis and 1 percent total necrosis of the flap). The minor complications are represented mainly by the dorsal seroma, This is the main drawback of the technique, as it occurs in 79 percent of cases and regularly in obese patients. In view of this frequency, patients should be warned of its likely occurrence. The dorsal donor-site morbidity is relatively low; 4 percent of dorsal sequelae were classed as moderate, and 96 percent were considered low. The scapular sequelae have been classed as low in 97 percent of cases, and temporary scapular sequelae aggravation has been noted in 3 percent. Results of breast reconstruction using this technique are most encouraging. The level of patient satisfaction is high; 87 percent of them were deeply satisfied, 10 percent were satisfied, and only 3 percent were poorly satisfied. This group of poorly satisfied subjects (3 percent) consists of patients who suffered a serious postoperative complication. The aesthetic results have been judged excellent by surgeons in 85 percent of the cases, good in 12 percent of the cases, and poor in 3 percent of the cases; no result has been judged bad. This technique of breast reconstruction by autologous latissimus dorsi brings a major advance in breast reconstruction. The best indications of this technique are when one can bury the cutaneous paddle: cases of skin-sparing mastectomy, cases where the latissimus dorsi flap can be combined with an abdominal advancement flap, and cases of conversion of implant reconstruction to an autologous reconstruction.
Adjuvant post-mastectomy radiotherapy (RT), which is often unpredicted, is known to increase complications following immediate breast reconstruction (IBR).
To investigate the role of sentinel lymph node biopsy (SLN) in predicting RT and improving the choice of IBR.
All patients who had mastectomy and IBR between January 2004 and January 2007 were reviewed retrospectively. Axillary staging (clearance or SLN) was performed at the same time until October 2005 (Group 1), when the Unit's protocol was updated to perform SLN initially prior to mastectomy and IBR (Group 2). Patients in Group 2 with positive SLN were offered either a delayed reconstruction or a temporary subpectoral immediate tissue expander, while all options were offered if SLN was negative and in Group 1 patients.
One hundred and thirty-nine patients were reviewed. 20 patients received unexpected RT in Group 1 (14 tissue expander, 4 Latissimus Dorsi flap with an implant and 2 DIEP flaps) compared to 11 patients in Group 2 who had a temporary tissue expander due to expected RT (P=0.03). Unexpected RT caused delayed complications in 14 patients (70%) compared to no delayed complications in patients who received expected RT in Group 2.
SLN biopsy before IBR helps to predict RT and avoids its complications on breast reconstruction. Patients with positive SLN biopsy are best offered a temporary subpectoral tissue expander for IBR.
To systematically analyze the effectiveness of quilting of latissimus dorsi (LD) flap donor site in the prevention of seroma and related morbidities.
All published studies comparing the effectiveness of quilting versus no-quilting of LD flap donor site in the prevention of seroma and related morbidities in patients undergoing breast reconstruction were analysed systemically.
Five comparative studies on quilting versus no-quilting encompassing 440 patients were suitable for statistical analysis. There was no heterogeneity among trials. Therefore, in the fixed-effects model, quilting was effective in terms of reducing the incidence of donor-site seroma formation, reducing the average volume of the seroma, and reducing the total volume of drained seroma. In addition, quilting did not increase the risk of postoperative complications. Combined quilting and fibrin glue was also effective in reducing the average volume of the seroma and total drained volume of the seroma. Combination of quilting and glue did not influence the incidence of seroma formation at LD flap donor site and overall operative complications.
Quilting of the LD flap donor site is helpful in reducing the incidence of seroma formation, reducing seroma volume, and reducing total drained seroma volume. Combined quilting and fibrin glue further enhances its effectiveness. Quilting with or without fibrin glue may be considered an option in patients undergoing LD flap breast reconstruction to control seroma-related morbidity. However, a major multicenter randomized controlled trial is required to achieve stronger and reliable evidence before recommending it as a routine procedure.
The recent withdrawal of PIP (Poly Implant Prosthese, France) implants for breast augmentation enforced by the Medicines and Healthcare products Regulatory Agency (MHRA) on 31st March 2010 has ignited speculation into possible side effects relating to an unauthorized gel fill content. Local and migratory silicone granulomata and regional lymphadenopathy are well reported in the literature. Gel bleed from high cohesive gel implants with similar effect is also well known. However dissemination to sites distant from the breast manifest as cutaneous abnormalities in a patient implanted with a PIP product raises concern. We report such a case.
Seroma is the most frequent minor complication after harvesting latissimus dorsi flap for breast reconstruction. It induces patient's discomfort and multiple consultations for punctions. The dead space resulting from the harvest has to be closed by the "quilting suture" in order to prevent the seroma. Our aim is to evaluate the efficiency and the tolerance of the quilting suture by comparing two groups of 100 patients who had a breast reconstruction by the same technic of extended latissimus dorsi flap, performed by the same surgeon, from 2004 to 2007. Half of patients had the classic way of dorsal closure, and the other half of patients had the dorsal quilting suture.
In order to compare the two groups we have collected data concerning age, body mass index (BMI), tobacco use, postoperative complications, number and volume of punctions, draining time and postoperative pain. The efficiency of the quilting suture lies on a rigorous repartition of at least six sutures on the upper skin flap, 12 on the lower skin flap and under the skin suture line. The suture model is based on the one used for the Chippendale-designed sofa. We suture the skin flap while pushing down the shoulder, in order to split the skin tension and avoid traction on the final skin suture line. The procedure takes 15 minutes.
The "Chippendale" technic allows to reduce draining time from 12 days to 6 days. The incidence of chronic seroma is reduced by 50%. The dorsal wound healing seems also better thanks to tension reduction resulting from the quilting suture.
The "Chippendale" technic is a quick, cheap and easy learned procedure, efficient for preventing chronic seroma after the latissimus dorsi flap. The postoperative recovery is eased and the patients comforted.
In a review of 325 postmastectomy breast reconstructions, the aesthetic quality of the result and the risk of unsuccessful outcome were compared for three techniques: tissue expansion (105 breasts), latissimus dorsi myocutaneous flap (47 breasts), and TRAM flap (173 breasts). The aesthetic successes achievable with the three methods were similar, and some excellent results were achieved with each of them. The failure rate after tissue expansion (21 percent) was significantly higher than those observed with the TRAM (3 percent) and latissimus (9 percent) flaps. Tissue expansion also was not as aesthetically successful as other techniques in obese patients. For immediate breast reconstruction, the TRAM flap was the most aesthetically successful technique. Although tissue expansion has advantages and may be the best choice for some patients, methods that used autogenous tissue provided more consistent success.
To evaluate the early and long-term results of the latissimus dorsi musculocutaneous flap for breast reconstruction, a series of 92 women who underwent surgery at my department from 1979 to 1989 was critically reviewed. Special attention was directed to the late foreign body reactions leading to deformation, asymmetry, and induration of the reconstructed breast. Guidelines regarding prevention of capsular contraction are discussed and some essential surgical refinements outlined.
Surgeons and anatomists have largely ingored the superficial fascia of the body. In fact, many anatomists have doubted the existence of this fascia as a distinct entity. The superficial fascia does exist and is functionally important. Understanding the anatomy and pathologic changes with age of the superficial fascial system (SFS) of the trunk and extremities may help explain body-contour deformities and provide the anatomic basis for surgical correction. The anatomy of the superficial fascial system was studied in 12 fresh and embalmed cadavers, cross-sectional cadaver segments, and 20 body-contour patients. The superficial fascial system is a connective-tissue network that extends from the subdermal plane to the underlying muscle fascia. It consists primarily of one to several thin, horizontal membranous sheets separated by varying amounts of fat with interconnecting vertical or oblique fibrous septae. Superficial fascial system anatomy varies with sex, adiposity, and body region. The topographic landmarks of the human body are largely the result of superficial fascial system anatomy (zones of adherence) and its relationships with fat and muscle fascia. The primary function of the superficial fascial system is to encase, support, and shape the fat of the trunk and extremities and to hold the skin onto the underlying tissues. With age and sun damage, the entire skin-superficial fat-superficial fascial system unit relaxes and stretches, resulting in ptotic soft tissues, pseudo-fat deposit deformity, and cellulite. There are two types of cellulite in women. Primary cellulite, or cellulite of adiposity, is due to hypertrophied superficial fat cells and is not amenable to surgical treatment. Secondary cellulite, or cellulite of laxity, results from laxity of the skin and soft tissues as a result of age, sun damage, or massive weight loss, or after liposuction. Secondary cellulite is surgically correctable by lifting techniques. Superficial fascial system suspension is an important adjunct to body-contour surgery of the trunk and extremities. Similar to the SMAS role in rhytidoplasty, repair of the superficial fascial system diffuses the tension on the skin flap, more effectively lifts areas of soft-tissue ptosis, and provides longer-lasting support. In addition, the superficial fascial system suspension allows more normal contours in both static and dynamic activities. The superficial fascial system repair has been used to enhance the following body-contour procedures: abdominoplasty, thigh-buttock lift, back-flank lift, medial thigh lift, inframammary fold reconstruction, and augmentation mammaplasty.
The distribution of the fat tissue in the subcutaneous layer is described. Since it has specific characteristics in each region of the human body, careful evaluation of the distribution before selecting patients for surgery is necessary. The subcutaneous tissue after an operation frequently demonstrates a thick and hard fibrosis which is evidence that liposuction should be performed in the lamellar layers. This type of fibrotic tissue in the subcutaneous areola layer often brings on irregularities and ungraceful waves on the skin surface.
It has been the experience of many surgeons that results following breast reconstruction change with time. To evaluate long-term results, the 350 breast reconstructions performed in the authors' department from January 1977 to April 1986 were reviewed. The results of the 326 cases in which there were sufficient data are presented here, and some late results are shown.
Dissections on 8 fresh and 10 embalmed cadavers were used to determine the anatomy of the subcutaneous adipose tissue in the trunk and extremities. These dissections, along with CT scans, confirmed Gray's original description of the subcutaneous tissue consisting of a superficial and deep adipose layer. The superficial adipose layer is contained within organized, compact fascial septa. The deep adipose layer demonstrated regional variations with respect to its fascial framework, but was contained within a relatively loose, less organized, and more widely spaced fascial septa. We observed that the adipose layers are partitioned by a discrete subcutaneous fascia which fuses with the underlying muscle fascia at particular anatomic locations. The deep layer is thus contained by the subcutaneous fascia above and the muscle fascia below to form what we termed the deep adipose compartments. The deep adipose compartments contributed significantly to overall adipose thickness, are bilateral, and are found in the abdomen and paralumbar and gluteal-thigh regions.
The results of 55 breast reconstructions using an extended latissimus dorsi myocutaneous flap without an implant are reported. A method for preoperatively estimating the flap volume, operative details, and a technique for insetting the flap are reviewed. Good, fair, and poor results were achieved in 69, 24, and 7 percent of patients, respectively. Examples are illustrated. The poor results were all due to major complications and are analyzed in detail. Significant complications affecting the end result occurred in 14.5 percent of patients, and nonsignificant and minor complications occurred in 33 percent. Flap volume is shown to be fairly accurately predictable. Seventy percent of flaps had a volume in excess of 400 cc. The reconstructed volume, cosmetic results, and complication rates are compared with those of other reported series. Good results can be achieved with this method, quite comparable to other methods, and with similar complication rates, but without the problems associated with the use of a prosthetic implant.
A rectus abdominis musculocutaneous island flap for breast reconstruction following mastectomy is presented. The vascular anatomy of the abdominal wall has been clinically studied in patients undergoing abdominal lipectomy. Cadaver dissections are shown, demonstrating the anatomy, arc of rotation, and design alternatives of the rectus abdominis flap. The surgical technique is demonstrated and representative patients are shown.
A method of breast mound reconstruction without an implant is described whereby a large latissimus dorsi flap alone is employed. A method of calculation of the minimal breast flap volume is also described. Examples of three representative cases are shown.
The history of autogenous breast reconstruction is outlined followed by a review of the problems associated with prosthetic reconstructive techniques. The advantages of and indications for autogenous tissue reconstruction are highlighted and illustrated with clinical examples.
The latissimus dorsi added fat flap is an alternative method of natural tissue breast reconstruction. A significant volume of additional subcutaneous back fat is left attached to a traditional latissimus dorsi flap, avoiding the need for an additional implant. The surgical technique and results in 15 patients are discussed.
Autologous breast reconstruction started with the use of a myocutaneous latissimus dorsi flap. The need for an additional silicone implant to obtain sufficient breast volume intensified the search for new flaps, resulting in the microvascular TRAM flap, which is currently considered the "gold standard" in autologous breast reconstruction. For patients who are not suited for this procedure or reject this treatment option, a modified extended latissimus dorsi flap was designed and used in 47 patients. Additional volume is obtained by including the scapular fat fascia, based on perforators from the cranial edge of the latissimus dorsi muscle. Flap survival was 100 percent in the series, and sufficient volume could be achieved in 42 patients. Main complications were seromas at the donor site (n = 9). The results demonstrate that in selected patients the extended latissimus dorsi flap provides an excellent alternative to a TRAM flap in reconstruction of small and moderate-sized breasts.
To review the experience of a single unit in post-mastectomy reconstruction using the latissimus dorsi flap.
A retrospective review of 111 cases treated between 1984 and 1993. The notes were evaluated for type of procedure, associated treatment and complications.
A significant morbidity of this procedure was demonstrated with 41 (37%) patients requiring a second operation during the period of the study. The majority of these second operations were related to the prosthesis used to achieve symmetry. Second operations were more common in those who had saline-filled prostheses. Other complications seen included wound infection, small areas of flap necrosis, hypertrophic scars and problems with the donor scar. No differences in complication rates were demonstrated for delayed vs immediate procedures or for patients receiving or not receiving radiotherapy. No life-threatening complication were seen during the study.
The latissimus dorsi reconstruction is reliable but the overall programme is beset with considerable morbidity. This factor needs to be taken into consideration when discussing reconstructive options with the post-mastectomy patient.
In the past decade, changing attitudes toward breast reconstruction among both patients and providers have led a growing number of women to seek breast reconstruction after mastectomy. Although investigators have documented the psychological, social, emotional, and functional benefits of breast reconstruction, little research has evaluated the effects of procedure choice on these outcomes. The current study prospectively evaluated and compared psychosocial outcomes for three common options for mastectomy reconstruction: tissue expander/implant, pedicle TRAM, and free TRAM techniques. In a prospective cohort design, patients undergoing postmastectomy reconstruction for the first time with expander/implant, pedicle TRAM, or free TRAM procedures were recruited from 12 centers and 23 plastic surgeons in the United States and Canada. Before reconstruction and at 1 year after reconstruction, patients were evaluated by a battery of questionnaires consisting of both generic and condition-specific surveys. Outcomes assessed included emotional well-being, vitality, general mental health, social functioning, functional well-being, social well-being, and body image. Baseline (preoperative) scores and the change in scores (the difference between postoperative and preoperative scores) were compared across procedure types using t tests and analysis of covariance. Preoperative and 1-year postoperative surveys were obtained from 273 patients. Procedure type was reported in 250 patients, of whom 56 received implant reconstructions, 128 pedicle TRAM flaps, and 66 free TRAM flaps. A total of 161 immediate and 89 delayed reconstructions were performed. Among women receiving immediate reconstruction, significant improvements were observed in all psychosocial variables except body image. However, no significant effects of procedure type on these changes over time existed. Similarly, delayed reconstruction patients had significant increases in emotional well-being, vitality, general mental health, functional well-being, and body image. Although the choice of reconstructive technique did not significantly impact most of these outcomes, significant differences existed among procedure types for three psychosocial subscales. Patients undergoing delayed expander/implant reconstructions reported greater improvements in vitality and social well-being relative to women receiving delayed TRAM procedures. By contrast, delayed TRAM patients noted significantly greater gains in body image compared with women choosing delayed expander-implant reconstruction. The authors conclude that both immediate and delayed breast reconstructions provide substantial psychosocial benefits for mastectomy patients. Although the choice of reconstructive procedure does not seem to significantly affect improvements in psychosocial status with immediate reconstruction, our data suggest that procedure type does have a significant effect on gains in vitality and body image for women undergoing delayed reconstruction.
Breast reconstruction using autologous tissue is increasingly gaining in interest. A review of results obtained from a series of consecutive patients undergoing breast reconstruction with the latissimus dorsi flap (LDF) was carried out to evaluate the effects of the authors' refinements to the procedure. Data collected during the perioperative course and a minimum follow-up of 12 months in 121 patients (mean age, 47 years; 50% with previous radiotherapy) who underwent treatment from 1994 to 1998 were analyzed retrospectively. In addition, a structured interview was conducted to evaluate patient satisfaction. Eighteen different surgeons in one teaching hospital were involved in the operative procedures. No patient was referred to the intensive care unit. An additional implant was used in 25% of patients. With the exception of the occurrence of seroma, the complication rate was low (seroma, 60%; bleeding, 4%; hematoma, 5%; minor wound dehiscence, 3%; wound infection, 2%). No flap was lost. Donor site morbidity was extremely low; 90% of patients had no complaints. The result of surgery was rated as excellent or good by 59% of patients, 89% would undergo this type of breast reconstruction again, and 91% would recommend it to other women. Refinements that improved the technique substantially included incision lines exclusively in the bra line, improved flap volume resulting from the harvest of an extended fat pad, and quilting sutures to reduce the formation of seroma. In the current study, endoscopic muscle harvest did not represent an improvement in procedure. The technique of breast reconstruction with the LDF has been improved substantially during the past few years, and provides the plastic surgeon with an excellent, safe, and consistently successful method for breast reconstruction.
The indications for autologous reconstruction are increasing. The standard procedure is the transverse rectus abdominis muscle flap; however, this flap has contraindications and drawbacks. The latissimus dorsi muscle flap is simple and reliable. Hokin et al. demonstrated in 1983 that this flap can be extended and used for breast reconstruction without an implant. Since then, it has been widely studied in this setting and is known to provide good aesthetic results. Dorsal sequelae, conversely, were not appraised. The aim of this study was to assess objective and subjective dorsal sequelae after the harvest of an extended flap. Forty-three consecutive patients who had had breast reconstruction with an autologous latissimus dorsi flap were assessed by a surgeon and a physiotherapist for muscular strength and shoulder mobility. Patient opinion was studied through a questionnaire. Mean delay between the operation and the evaluation was 19 months. Early complications, mainly dorsal seromas, were frequent after the harvest of an extended flap (72 percent). There was no late morbidity and, especially, no flap loss or partial necrosis. As for functional results, 37 percent of the patients had complete adjustment and 70 to 87 percent demonstrated no change in shoulder strength. Sixty percent of the patients experienced no limitation in everyday life, and 90 percent said they would undergo this procedure again. The authors show that dorsal sequelae after an extended latissimus dorsi flap are minimal and that this technique compares favorably with the transverse rectus abdominis muscle flap.
The extended latissimus dorsi myocutaneous flap can provide autogenous tissue replacement of breast volume without an implant. Nevertheless, experience with the extended latissimus dorsi flap for breast reconstruction is relatively limited. In this study, the authors evaluated their experience with the extended latissimus dorsi flap for breast reconstruction to better understand its indications, limitations, complications, and clinical outcomes. All patients who underwent breast reconstruction with extended latissimus dorsi flaps at the authors' institution between January of 1990 and December of 2000 were reviewed. During the study period, 75 extended latissimus dorsi flap breast reconstructions were performed in 67 patients. Bilateral breast reconstructions were performed in eight patients, and 59 patients underwent unilateral breast reconstruction. There were 45 immediate and 30 delayed reconstructions. Mean patient age was 51.5 years. Mean body mass index was 31.8 kg/m2. Flap complications developed in 21 of 75 flaps (28.0 percent), and donor-site complications developed in 29 of 75 donor sites (38.7 percent). Mastectomy skin flap necrosis (17.3 percent) and donor-site seroma (25.3 percent) were found to be the most common complications. There were no flap losses. Patients aged 65 years or older had higher odds of developing flap complications compared with those 45 years or younger (p = 0.03). Patients with size D reconstructed breasts had significantly higher odds of flap complications compared with those with size A or B reconstructed breasts (p = 0.05). Obesity (body mass index greater than or equal to 30 kg/m2) was associated with a 2.15-fold increase in the odds of developing donor-site complications compared with patients with a body mass index less than 30 kg/m2 (p = 0.01). No other studied factors had a significant relationship with flap or donor-site complications. In most patients, the extended latissimus dorsi flap alone, without an implant, can provide good to excellent autologous reconstruction of small to medium sized breasts. In selected patients, larger breasts may be reconstructed with the extended latissimus dorsi flap alone. This flap's main disadvantage is donor-site morbidity with prolonged drainage and risk of seroma. Patients who are obese are at higher risk of developing these donor-site complications. In conclusion, the extended latissimus dorsi flap is a reliable method for total autologous breast reconstruction in most patients and should be considered more often as a primary choice for breast reconstruction.
The optimal method for breast reconstruction should be safe, reliable, and accessible for every patient, and it should display little or no donor-site morbidity. After comparing mammary implants it has been found that autogenous breast reconstruction can create a ptotic, soft, symmetrical breast mound. The transverse rectus abdominis musculocutaneous flap (TRAM) remains the most popular method for autogenous reconstruction. Modern trends in breast reconstruction using the TRAM flap have promoted adequate blood supply to the flap while minimizing donor-site defects in the anterior abdominal wall. The pedicled TRAM flap remains one of the most frequently used flaps, but the indirect blood supply in this flap has required many modifications and refinements. Such modifications have included the bipedicled TRAM flap, the free TRAM flap, and the supercharged TRAM flap. To avoid donor-site morbidities, the muscle-sparing free TRAM, deep inferior epigastric perforator flap (DIEP), and superficial inferior epigastric artery (SIEA) flap were introduced. The DIEP perforator flap requires meticulous technique but offers proven reliability and a low rate of complications. As surgeons become more comfortable with harvesting DIEP flaps, the frequency of usage seems likely to increase. The latissimus dorsi musculocutaneous flap, gluteus maximus musculocutaneous flap, and others may be selected when these modifications of free TRAM flap are unavailable or unusable.
Latissimus dorsi (LD) flap breast reconstruction is associated with a high incidence of donor site seromas, despite the use of surgical drains. The aim of this study was to evaluate the use of donor site quilting sutures, as well as drains, on the incidence, volume and frequency of seroma aspiration.
The trial randomized 108 women undergoing LD breast reconstruction to quilting procedures (54) or control group (52) for intention-to-treat analysis; two were excluded. Outcome measures were the incidence and volume of postoperative seroma. Secondary outcome measures included postoperative back pain, analgesic consumption, shoulder movement and duration of hospital stay.
Quilting significantly reduced the overall incidence of seroma from 46 of 48 (96 per cent) to 43 of 52 (83 per cent) (P = 0.036), including the 38 women who had extended LD flap (with or without implants). There were further significant reductions in seroma volume (P = 0.004), frequency of aspiration (P = 0.001) and overall seroma volumes, including surgical drainage and symptomatic seromas (P = 0.013). Subset analyses for LD-implant (60 women) and extended LD (with or without implant) showed similar significance. Quilting did not affect back pain or compromise shoulder mobility.
Quilting significantly reduced overall seroma volumes after LD breast reconstruction including extended LD, and is recommended in combination with surgical drains.