Current Indications for and Comparative Analysis of Three Different Types of Latissimus Dorsi Flaps

Abstract

Background: Free tissue transfer with lower abdominal flaps for autologous breast reconstruction is not suitable for all patients. The latissimus dorsi (LD) musculocutaneous flap is an alternative, effective method for both immediate and delayed breast reconstruction.

Objectives: The authors assess their experience with LD flaps for breast reconstruction, including indications for patient selection, donor site choice, aesthetic outcomes, complications, and patient satisfaction.

Methods: Charts for all patients who underwent breast reconstruction with one of three types of LD myocutaneous flaps during a three-year period at a single institution were retrospectively reviewed. Patients (n = 82) were divided into three groups: (1) 35 patients received a standard LD myocutaneous flap with implant, (2) 18 patients underwent a muscle sparing LD flap procedure with implant, and (3) 29 patients had an autologous LD flap. A questionnaire was administered to assess flap and donor site complications, aesthetic outcomes, patient satisfaction, and shoulder function.

Results: Flap complications occurred in 13 patients (15%). Donor site complications occurred in 24 patients (28%), mostly consisting of back seroma with the autologous LD flap. There was no significant difference in shoulder range of motion or muscle strength between the operated and unoperated sides. Patient satisfaction was high in all three study groups.

Conclusions: The LD is a safe, versatile, and reproducible technique for breast reconstruction. The procedure benefits from ease of flap harvesting and setting and may provide satisfactory results in diverse patients, including those for whom an abdominal flap is neither indicated nor feasible.

Level of Evidence: 4

Technique selection in breast reconstruction can be difficult because women are offered an increasingly large range of options, from implant to autologous reconstruction. Although implant-based breast reconstruction remains the most common method after mastectomy, autologous tissue may yield a superior aesthetic result.^1-3 In some patients, free tissue transfer may be the best and most durable option. Autologous reconstruction is an alternative for those patients who decline implant-based reconstruction, require a salvage procedure for preoperative radiotherapy or implant failure, or may need to undergo radiation therapy.^4-6

The pedicled transverse rectus abdominis musculocutaneous (TRAM) flap may provide a soft, ptotic, and natural breast mound.⁷ However, in an attempt to reduce the donor site morbidity of the TRAM flap, the deep inferior epigastric perforator (DIEP) flap was developed to provide the benefits of natural tissue reconstruction without sacrificing the abdominal musculature.⁸ Despite the favorable outcomes of free abdomen-based flap reconstructions, the procedure is not appropriate for, or desired by, all women. Patients who smoke, are extremely over- or underweight, or have a history of prior abdominal surgery may be poor candidates for lower abdominal free flaps. In addition, many women are deterred by the extensive operative time and risks with lower abdominal flap reconstruction.

The latissimus dorsi myocutaneous (LD) flap has long been an option for breast reconstruction, from the initial description in 1906^9,10 to its subsequent acceptance as a standard method in the 1970s.^11-15 The LD flap is an effective method for immediate and delayed breast reconstruction, especially without implants or expanders, and may include only autologous tissue.^16-20 It remains popular because of the simplicity of flap tissue harvest, the very reliable and consistent vascularity of the flap, its ability to provide additional prosthetic coverage, and the fact that intensive postoperative monitoring is not required. Several variations of this flap have been described: the LD myocutaneous flap with an expander or implant,^9-15 the autologous or extended LD flap,^16-20 and the muscle-sparing LD flap.^21,22 Multiple designs and orientations of the skin paddle have also been reported.^23,24

The aim of this study is to evaluate the indications, patient selection, aesthetic outcomes, and patient satisfaction of LD flap reconstruction and to analyze the goals of minimizing potential complications at the donor site, maximizing quality of the aesthetic results in a wide range of patients, and evaluating reliability and efficacy for breast reconstruction.

Methods

All patients who underwent immediate, delayed, or revision breast reconstruction with LD flaps after mastectomy between December 2007 and January 2011 in the Department of Plastic Reconstructive Surgery and Burn Unit Center at the Ospedale Niguarda in Milan, Italy, were included in this study, for a total of 82 patients. Surgery was performed in all patients by the first author (SB). Demographic, preoperative, and postoperative data were collected retrospectively by review of medical records. Patients receiving LD flap for other purposes, such as Poland syndrome correction or partial mastectomy reconstruction, were excluded. All patients were informed about the study and written informed consent was obtained before study enrollment.

The reasons for selection of the LD flap for breast reconstruction are outlined in Table 1. LD flaps were primarily indicated for patients who wished or needed to have autologous breast reconstruction but were poor candidates for TRAM or DIEP flaps or who did not wish to have free abdominal flap breast reconstruction. Again, patients were considered poor candidates for TRAM or DIEP flap procedures if they were too obese or too thin, had undergone previous abdominal surgery, or were considered at high risk for free tissue transfer because of a medical comorbidity or advanced age. Comorbid conditions included diabetes, hypertension, peripheral vascular disease, connective tissue disease, coronary artery or pulmonary disease, and previous deep venous thrombosis (Table 1).

Patients were categorized according to the three types of LD flaps utilized for total breast reconstruction: Group 1, standard latissimus dorsi musculocutaneous (S-LD) flap with implant (35 patients); Group 2, descending branch muscle-sparing latissimus dorsi myocutaneous (MS-LD) flap with implant (18 patients); and Group 3, autologous latissimus dorsi (ALD) flap (29 patients). Patients in Groups 1 and 2 underwent immediate placement of an anatomic, cohesive silicone gel implant (Memory gel Contour Profile 300 series, Mentor Inc., Santa Barbara, CA; or Natrelle Style 410, Allergan, Inc., Irvine, CA) underneath the musculocutaneous flap, without any previous tissue expander. The thoracodorsal nerve was usually dissected and sectioned in the patients in Groups 1 and 2 but spared in Group 3 to maintain muscular trophism and volume.

Data on complications, aesthetic outcomes, and patient satisfaction in these three groups were collected and reviewed. Flap complications were evaluated, including total or partial flap loss, marginal necrosis, hematoma, infection, seroma, mastectomy skin flap necrosis, implant malposition, capsular contracture, and rippling (Groups 1 and 2) and fat necrosis (> 2 cm) (Group 3). Donor site complications included delayed wound healing, wound necrosis and dehiscence, back seroma, hematoma, infection, asymmetry of the back, and impaired shoulder function. A questionnaire was administered to patients four to seven months after reconstruction to assess functional outcome and satisfaction. The questionnaire evaluated changes in the patients’ ability to perform daily living activities, hobbies, and sports; changes in job status; shoulder or scar discomfort; and aesthetic satisfaction. Satisfaction with appearance and position of the scar, symmetry of the back and silhouette, and the overall outcome of the surgery were also assessed. In the questionnaire, patients were asked to rank their satisfaction with breast reconstruction (very disappointed, disappointed, satisfied, moderately satisfied, very satisfied, or highly satisfied). Patients were then asked whether they would undergo the same reconstructive procedure again and whether they would recommend it to other women.

The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire was also distributed at the same time as the satisfaction questionnaire.²⁵ The DASH questionnaire scores the patient’s ability to perform tasks that are a part of activities of daily living, work, sports, and music (0 to 20, no difficulty; 21 to 40, mild difficulty; 41 to 60, moderate difficulty; 61 to 80, severe difficulty; > 80, inability to perform tasks). A postoperative physical examination was performed comparing the operated and unoperated sides. Evaluation consisted of active range of motion assessment of the shoulder and muscle strength tests. A physiotherapist performed testing on patients six months after reconstruction to evaluate their active range of motion at the shoulder joint of the operated and unoperated sides.

The two-sided Fisher exact test was applied to evaluate the significance of findings, and significance was defined by P < .05 (Database: Stata/SE version 11.2; StataCorp, Texas, USA). We calculated the incidence of each complication in the three subgroups, including incidence of flap complications in the total number of flaps performed (n = 85) and the incidence of donor site complications in the patients who had undergone the operation (n = 82).

Results

There were 85 LD flaps performed on 82 patients in this series (three patients underwent bilateral flap procedures). The average patient age was 49 years (range, 32 to 70 years). The average follow-up time was 21 months (range, three to 39 months). LD reconstructions represented 28% of overall breast reconstructions in the authors’ practice during the study period. Reconstruction was immediate in 26 patients (32%), including 11 patients who required salvage mastectomy for cancer recurrence after breast lumpectomy surgery and radiotherapy. Reconstruction was delayed after previous mastectomy in 41 patients (50%). In 14 patients (17%), LD flap reconstruction was performed to revise a previous expander/implant reconstruction because of implant extrusion, capsular contracture (CC), and/or unsatisfactory aesthetics. Reconstruction with an LD flap was performed in one patient (1%) for failed DIEP flap replacement. Most patients underwent a procedure with either an S-LD flap with implant or an ALD flap (Table 2). Most patients had contralateral procedures—including reduction mammaplasty, mastopexy with or without implant, or augmentation mammaplasty—to improve breast shape, symmetry, and aesthetic outcome.

Flap complications occurred in 13 reconstructions (15%; Table 2). There were no flap failures or returns to surgery for flap-related problems in any of the patients. Flap-related complications included mastectomy skin flap necrosis, minor skin paddle tip necrosis, implant malposition, liponecrosis, and rippling (the latter was in one slim patient 13 months postoperatively; Table 2). In one of the two patients who experienced liponecrosis, there had been severe intraoperative venous congestion because of occlusion of the thoracodorsal vein during previous axillary dissection, even though the flow was restored by vein graft. There were no significant differences in flap complications between the three groups (Table 2). Donor site complications were noted in 24 reconstructions (28%), most commonly seroma after ALD reconstruction (Table 2).

All 82 patients returned the questionnaires (response rate, 100%). The mean DASH scores showed that patients had no difficulty with activities of daily living (mean score, 7.8), work status (mean, 11.3), or sports and music (mean, 19.0). There was no change in the patients’ ability to perform hobby or sport-related activities in 72 patients (88%), and 76 patients (93%) perceived no permanent functional impairment of the shoulder postoperatively. Patients did not perceive any differences in muscle strength or range of motion between the operated and unoperated sides. Based on physiotherapist assessment, there was a difference of ≤ 10° between the ranges of flexion, extension, and external rotation between the operated and unoperated shoulders in 11 patients (13%). Seventy-three patients (89%) rated the appearance of the scar as good or very good. Patient satisfaction was very high for all three types of reconstruction in breast shape, size, appearance, position of back scar, and symmetry of the back. Of all the patients, 74 (90%) reported that they would have elected to undergo the procedure again based on their experience and aesthetic outcome.

Discussion

The aim of this systematic review of LD flap breast reconstruction was to evaluate this procedure as an option for patients seeking breast reconstruction. The present findings showed that LD flap reconstruction provided satisfactory results for most patients with few complications.

The LD flap has several important advantages. The flap is very well vascularized, versatile, safe, reliable, and has a success rate of more than 99%. The procedure is suitable for high-risk patients, including those who smoke, are obese, have diabetes, or are older. The LD flap may be employed for immediate or delayed reconstruction, unilateral and bilateral cases, cases in which an implant is not indicated or desired because of radiotherapy,⁶ cases in which the chest wall tissues are unsuitable for tissue expansion, or cases in which additional soft tissue requirements are present (Figure 1). This technique is also suitable for chest wall reconstruction²⁶ or resurfacing in cases of advanced or recurrent breast cancer. It also can be applied for partial breast reconstruction, backup flap after abdominal flap loss, or correction of breast hypoplasia in Poland syndrome. Other indications include breast reconstruction in patients who are not suitable for TRAM/DIEP flaps (Figure 2) or who need conversion of failed implant reconstruction. The LD flap technique is contraindicated in very few patients, such as patients with previous thoracotomy and division of the muscle or damage to the thoracodorsal vessels.

Even if the amount of skin that can be provided by the LD flap is less than that of an abdominal flap, the dorsal skin palette can usually compensate for a large cutaneous defect, and the skin can be completely de-epithelialized and buried to avoid a patch effect or partially preserved for reconstruction of the nipple-areola complex after a skin-sparing mastectomy.²⁷ A recent report of a sophisticated procedure may expand the candidacy for DIEP flap breast reconstruction in thin patients, making use of the entire abdominal donor volume; in this procedure, two DIEP free flaps are stacked and combined in a layered fashion with microsurgical sequential linkage of the two pedicles and resultant flow-through from recipient internal mammary vessels.²⁸ Nevertheless, the LD flap can still provide an aesthetically satisfactory result in thin patients for whom the amount of abdominal tissue is inadequate and precludes abdominal tissue transfer.

The low incidence of seroma after S-LD and MS-LD reconstruction in this study was likely attributable to the use of glue, quilting sutures, and minimal dead space from the limited undermining of the skin flap. Seroma was more frequent in the ALD flap group compared with the other two groups (Table 2), despite quilting stitches and fibrin glue, most likely because of wide and extensive undermining of tissue with the ALD flap procedure. Furthermore, the ALD flap may include a major volume of fat, which may give bulk to the breast without the addition of a prosthesis and may yield a reconstructed breast with a soft, natural consistency and which gains deep sensitivity after several months (Figure 3). Spontaneous return of sensitivity after LD flap reconstruction, with integration of the reconstructed breast into the patient’s body image, has been reported in several studies.^29-31 The ALD flap also represents a viable option over free abdominal tissue transfer in morbidly obese patients, for whom free abdomen-based flap reconstruction of the breast has a higher risk of total flap loss and delayed abdominal wound healing.³²

The LD flap is also a highly effective tool in dealing with the many difficult situations observed with the irradiated breast. These include correction of CC after irradiation of a tissue expander, immediate reconstruction after mastectomy following failed breast conservation therapy, delayed reconstruction after mastectomy and radiotherapy, revision of an unsatisfactory implant reconstruction in a radiated breast, and reconstruction of a partial breast defect after breast conservation therapy (Figures 4, 5).

Prior radiation therapy to the chest may have a detrimental effect on the recipient vessels and may affect microvascular success. In recent studies, prereconstruction radiation therapy increased the frequency of vascular complications in free flap breast reconstruction.^33,34 To minimize microvascular complications and optimize outcomes in free flap breast reconstruction in patients undergoing postmastectomy radiation, a delay interval of more than 12 months should be observed. However, this delay is not required with LD flap reconstruction of the breast. Some of the prior irradiated patients received breast reconstruction a few months after the completion of radiotherapy. Although LD flap reconstruction is a major operation, it is less complex than free tissue transfer and does not require microsurgical skills; intensive, sophisticated, and costly postoperative flap monitoring (as with free flaps);^35-38 or any preoperative CT scan to evaluate the vascular anatomy.^39-43 Perioperative cost is less with LD flap reconstruction than free tissue transfer because physical examination before surgery is usually sufficient to test the function of the LD muscle and, if necessary, color Doppler studies may be sufficient to establish the continuity of the thoracodorsal vessels. The LD flap alone or combined with an implant also represents a safe and reliable alternative in patients with a failed microsurgical breast reconstruction, because it is a relatively simple procedure with low morbidity, especially in patients with coagulation disorders that may contribute to free flap failure.⁴⁴

Sacrifice of the LD muscle is very well tolerated in most patients, functionally-speaking, and any deficit usually affects very few specific activities such as rowing or mountain climbing. Patients have few complaints after LD muscle transfer and functional sequelae are minimized by compensation with the teres major muscle.^45-49 Therefore, as noted in the present study, the LD flap minimally impairs shoulder function, with little detectable change in range of motion, muscular strength, and function of the donor shoulder. Axillary dissection for removal of lymph nodes can be responsible for more limitation in shoulder function than the LD flap reconstruction. With the help of a physiotherapist, we demonstrated that most patients showed no objective limitation in muscular function and all patients reported that they experienced no limitation in daily life.

Donor site seroma may occur after 6% to 56% of S-LD flaps and 70% to 80% of ALD flaps.^19,50-53 Numerous treatments and preventive measures have been described to decrease this problem, including quilting sutures, fibrin sealant, endoscopic harvest, long-term distant exit drainage, pressure dressings, and avoidance of electrocautery for dissection.^54-60 Quilting sutures combined with fibrin sealant were used in all three types of LD flap procedures in the present study, with few postoperative seromas compared with the experience reported by others (Table 2).^19,53 Other authors have shown new risk factors for donor site seroma formation after LD flap reconstruction, including antidepressant drugs (selective serotonin reuptake inhibitors) and low postoperative calcium levels, in addition to well-established risk factors such as age, obesity, and surgical technique.⁶¹

In the present study, patient satisfaction was very high, confirming that the LD flap may provide an excellent breast reconstruction in diverse patients. The only disadvantage observed was the high incidence of back seroma in the ALD flap group, which may limit the choice of this type of reconstruction. However, various preventive maneuvers and treatments can be added to decrease and control this complication; these instances of seroma can be treated on an outpatient basis and have a lower detrimental effect on the patient compared with free flap loss or an abdominal bulge or hernia. This disadvantage is mitigated by the many advantages and benefits that make the LD flap a valuable option for breast reconstruction, especially in patients not suited for free abdominal flaps.

Conclusions

This study has confirmed the clinical versatility, reliability, and selection guidelines for use of the LD flap in breast reconstruction. This flap is simple to harvest and is an excellent alternative to other procedures, since it provides satisfactory, consistent, and reliable results. The success of the procedure depends on patient selection, careful intraoperative management, and adequate postoperative care.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article.

References