Skin-Sparing Mastectomy with Immediate Breast Reconstruction by a New Modification of Extended Latissimus Dorsi Myocutaneous Flap
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- Denewer, A., Setit, A., Hussein, O. et al. World J Surg (2008) 32: 2586. doi:10.1007/s00268-007-9401-z
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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.
Breast carcinoma is the commonest malignant tumor in adult Egyptian females. It accounts for nearly 37% of cancer cases in this population .
We have come a long way from the days of radical mastectomies to modified radical mastectomies to conservative breast surgery. Skin-sparing mastectomy has improved the postoperative outcome of breast reconstruction with autogenous tissue .
The latissimus dorsi (LD) myocutaneous flap for breast reconstruction was introduced in 1977 . Neven Olivari was the first to describe it for chest wall reconstruction after cancer. It may have been the first method for breast reconstruction using purely autogenous tissue . The major limitation for its widespread use in breast reconstruction was the insufficiency of bulk to recreate an adequate breast mound. In fact, it is a common practice to combine the latissimus dorsi flap with an implant to achieve adequate breast volume.
The extended LD flap by comparison allows a completely autologous method of breast reconstruction. Extra volume is created by including all the LD muscle and its overlying fat. The firstly extended latissimus dorsi flap was described by Hokin in 1983 and included lumbar fat extension . McCrew and Papp modified this technique by using a fleur-de-lis skin paddle design to carry additional fat on the surface of LD muscle . The design of an extended LD flap has evolved to include the parascapular and scapula “fat fascia” in addition to the lumbar fat for additional volume.
We report our modification to include fat overlying the serratus anterior muscle to gain enough volume for a totally autologous breast reconstruction for the large breasts of the Egyptian ladies. We also evaluate our center experience with modified extended LD flap for breast reconstruction after skin-sparing mastectomy and report our limitations, complications, and clinical outcome.
Materials and methods
A total of 140 patients with invasive breast carcinoma were included in the study from January 2002 to January 2006. American Joint Committee on Cancer (AJCC) TNM staging was as follows: stage I, 22 patients; stage II, 100 patients; and stage III, 18 patients. Extensive skin involvement, areolar tethering, and inflammatory carcinoma were excluded.
The options presented to these women were conservative breast surgery (when indicated) and modified radical mastectomy. Egyptian women preferred autogenous breast reconstruction compared with conservative breast surgery because they worried about tumor recurrence in the remaining breast tissue; in addition they did not prefer the modality, including radiotherapy.
Teardrop incision encompassing the nipple and rising toward the axilla was performed. The magnitude of the skin incised varied with the degree of skin involvement and the scar of previous biopsy if any. Standard mastectomies with level II and I axillary dissection was performed.
Patients’ body mass index was not assessed. Patients’ breast size removed was variable from cup sizes B, C, to D.
Our new modification
The thoracodorsal vessels were carefully followed from their origin from the subscabular pedicle until the point of bifurcation to a dorsal branch supplying the LD muscle and the thoracic branch supplying the fat and underlying digitations of the serratus anterior on the lateral chest wall.
A transverse skin puddle with its long axis centered over the seventh rib extending from the posterior axillary line to the parascapular line is marked. Dimensions of skin paddle were 5–7 cm to 7–9 cm according to the diameter of the removed nipple areola complex.
The LD muscle with overlying fat is elevated and transected near the iliac crest inferiorly and tendon of insertion is separated from the humerus superiorly. The muscle flap together with the attached vascularized fat are tunneled to the skin envelop. The vascularized fat is fixed to the pectoralis major muscle, forming the first layer of the reconstructed breast, and then the flap is folded on itself to form the second layer of the desired reconstructed mound, fixed with a few absorbable sutures (Fig. 2). Drains are administrated as usual, and skin is closed by using interrupted intradermal 4\0 undyed polyglactin stitches.
Subscale analysis of breast reconstruction 
Volume of breast mound
Marked discrepancy relative to contralateral side*
Mild discrepancy relative to contralateral side
Contour (shape) of breast mound
Marked contour deformity or shape asymmetry.
Mild contour deformity or shape asymmetry
Natural or symmetrical contour
Placement of breast mound
Symmetrical and aesthetic placement
Poorly defined/not identified
Defined but with asymmetry
Defined and symmetrical
From January 2002 to January 2006, a total of 140 patients with pathologically proven breast carcinoma were enrolled in this study. Patients’ age ranged from 27 to 53 (median, 40.5) years. Pathologic types were: 132 of invasive duct carcinoma, and 8 cases of invasive lobular carcinoma.
The procedure did not delay the initiation of chemotherapy beyond the conventional 3-week period. Seventeen cases were eligible for postoperative chest wall irradiation, which was scheduled as usual. Radiotherapy was applied on internal mammary area and did not influence the aesthetic results.
Patients were followed for a median of 32.4 (range, 12–48) months. During this period, no episode of local recurrence or distant metastasis was observed. Average operating time was 3–4 hours (1–1.5 hours for skin-sparing mastectomy and 2–2.5 hours for reconstruction). Average hospital stay was 8–12 days.
Incidence of flap and donor site complications in patients with extended latissimus dorsi flap breast reconstruction after skin-sparing mastectomy
Partial flap loss
Skin envelop necrosis
Donor site complications
Donor site seroma
Donor site hematoma
Donor site infection
Donor wound necrosis
Donor site morbidity
Aesthetic grading results of breast reconstruction
Toth and Lappert introduced skin-sparing mastectomy in 1991 . Pathological studies demonstrated the safety of preserving native breast skin that was shown to be free of tumor or duct epithelium. Slavin et al. failed to demonstrate duct epithelium in 114 native skin biopsies from 32 consecutive patients who underwent skin-sparing mastectomy . Local recurrence (LR) and distant spread was shown to be comparable to the traditional modified radical mastectomy (MRM) [10, 11].
Most patients who underwent skin-sparing mastectomy and immediate reconstruction underwent TRAM reconstruction, and approximately 3% only underwent latissimus dorsi (LD) reconstruction . The TRAM flap, both free and pedicled, was preferred for several reasons. One of the reasons is a simpler patient positioning; both mastectomy and flap harvest can be performed at the same time with TRAM flap but not with LD. However, the main reason was that the standard LD flap alone does not provide sufficient volume for breast reconstruction and addition of an implant became a must . The extended LD flap by comparison allows a totally autologous method of breast reconstruction. The main advantage of extended LD flap is that it avoids the addition of implants with its potential complications. Other potential advantages include shorter operative time and hospital stay, compared with TRAM flap, and microvascular procedures are not required.
1. Egyptian women prefer that the scare of donor site is hidden in the back; they did not accept any scare in the belly.
2. Obesity is one key indication for autogenous reconstruction with LD myocautaneous flap. Although obese patients have more than enough TRAM tissue, they are at risk of abdominal wall complications and partial TRAM flap loss. Additionally, the obese have an adequate thickness of fat on the back.
3. DIEP is technically more demanding and takes more time in the operating room compared with our modification of extended LD myocautaneous flap.
The precise indication when our method should be used is for patients who have large breast cup sizes C or D, who are seeking totally autogenous breast reconstruction without any additional implants and not preferring belly scar.
The overall flap complication rate was 23.9%, which compares well with free TRAM complication rate of 23.7% . Seroma was the commonest flap complication (7.8%), which was treated conservatively in most patients.
An important observation was that the reconstructed breast size was not a risk factor in flap complications. Chang et al.  reported that large reconstructed breast size was a significant risk factor for flap complications. Nine cases in their series had a D cup size breast reconstruction. Among them, four (44.4%) developed flap complications. They expected a larger percentage of fat necrosis in larger flaps. In our series, 16 patients had D cup size breast reconstruction with a lower rate of flap complications (25%).
The extended LD flap is ideal for reconstruction of small- and medium-sized breasts. However, the extended flap also can be used for larger breasts in selected patients. Most women with larger breasts have a heavier build and will have a substantially larger flap . The only limitation to the widespread use of extended LD flap in reconstruction of larger breasts of D cup size was the anticipated higher frequency of fat necrosis. Larger breast means larger flap. Because most of the bulk on extended LD flap is from the fat overlying the LD muscle, with some from beyond the borders of the muscle, a higher incidence of fat necrosis is expected in large flaps. Our modification of the technique of extended LD flap avoids this by harvesting the fat overlying the serratus anterior muscle with its own blood supply directly driven from the thoracic branch of the thoracodorsal artery. Addition of this richly vascularized fat with part of the serratus anterior muscle adds a significant bulk with decreasing incidence of fat necrosis, enabling us to reconstruct larger breast sizes without a contralateral reduction operation and without an implant with a less flap complication rate (Figs. 2 and 4).
Another important issue is that our modification did not increase donor site complications. With extended LD flap, and with more extension, donor site complications can be a significant problem. In our series 14.1% developed a donor site complication. Seroma formation was the most common donor site complication, developing in 7.8% of cases. This phenomenon is well known and was reported by others in as many as 79% of patients . We followed the quilting technique in closure of the donor defect followed by a thoracic compression bandages. Menke et al.  reported donor site seroma in 60% of his patients. The incidence of seroma decreased to 19% when quilting sutures were used to close the defect at the donor site. Our modification allowed harvesting a thicker flap without any increase in donor site complications.
Several different skin paddle designs for the extended LD flap have been described [6, 17]. We prefer a simple ellipse-shaped transverse skin paddle marked out along the bra line, which allows concealing the scar. One potential limitation of the extended LD flap used to be the smaller size of skin paddle compared with the TRAM flap; however, this became unnecessary when skin-sparing mastectomy was adopted.
Long-term donor site morbidity is an important factor in autologous breast reconstruction. Most of our patients reported that they had no restriction to their professional and private life. Donor site morbidity was very low in our series compared with complications with TRAM and other flaps [18, 19].
Gabka and colleges  reported 17 cases of skin-sparing mastectomy and immediate reconstruction (TRAM 9 cases and LD flap 8 cases). Lowery and associates  found the 4-point ordinal scale to have unacceptable interrater reliability in evaluating the results of breast reconstruction. Using a modification of the subscale described by Garbay and colleagues , the aesthetic results in our study was excellent in 85 cases, good in 42 cases, fair in 10 cases, and poor in 3 cases only. In their series of 18 patients who underwent latissimus dorsi flap reconstruction after skin-sparing mastectomy, Carlson et al.  reported a satisfactory result (excellent and good) in 69.3% of patients. De la Torre et al.  used latissimus dorsi flap with implant after skin-sparing mastectomy in 18 cases and achieved satisfactory results in 17 of them. Delay et al.  used autologous LD flap in 100 patients. Excellent satisfaction was achieved in 87% of cases.
It is important to mention that these results by others were reported on reconstruction of small- and medium-sized breasts. Our results compare well to them, although we are reconstructing larger breasts.
The additional volume obtained by using our new modification of latissimus dorsi fat added flap allows single-stage, skin-sparing mastectomy with immediate autologous breast reconstruction without implant and without contralateral operations in medium- and large-sized breasts of C and D cup brassier sizes. The flap and donor site complication rates are low and become negligible when the problem of seroma can be avoided. Patient satisfaction with this procedure is high.