Skip to main content

Advertisement

SpringerLink
Log in

Extended Latissimus Dorsi Kite Flap (ELD-K Flap): Revisiting an Old Place for a Total Autologous Breast Reconstruction in Patients with Medium to Large Breasts

  • Original Article
  • Breast Surgery
  • Published:
Aesthetic Plastic Surgery Aims and scope Submit manuscript

Abstract

Background

The latissimus dorsi (LD) flap represents one of the most reliable methods for autologous breast reconstruction. However, in many patients, the exclusive use of this technique may not guarantee the restoration of an adequate volume and projection. We report our experience with the extended latissimus dorsi kite flap (ELD-K flap), an alternative surgical approach to maximize the volume of the fleur-de-lis pattern LD flap, for total autologous breast reconstruction.

Methods

Between 2016 and 2018, 23 patients were subjected to mastectomy and immediate autologous reconstruction with "extended latissimus dorsi kite flap" (ELD-K flap), technique that employs an extended version of the LD musculocutaneous flap, based on the skeletonized thoracodorsal pedicle and a trilobate skin incision with an inferiorly based vertical branch. The BREAST-Q questionnaire was administered preoperatively, and one year after surgery to evaluate the quality of life results of the patients. BREAST-Q latissimus dorsi module was also provided.

Results

Average body mass index was 29.7 kg/m2 (range 25–40 kg/m2). Mild complications occurred in only six cases, and eight patients underwent treatment to improve the donor site scar outcome. Patients indicated high scores in quality of life measures with an increase in all BREAST domains from the preoperative to the postoperative period. A statistically significant increase (p < 0.05) was noted in: “overall satisfaction with breasts” (p < 0.05), “psychosocial well-being” (p < 0.05), “physical impact of the surgery” (p < 0.05). Within the LD module, participants reported a mean score of, respectively, 73.8 and 67.9 for “satisfaction with back” and “satisfaction with shoulder and back function” domains.

Conclusions

The extended incision allows the recruitment of additional tissue to provide enough volume to complete the reconstruction without implants. The isolation of the vascular pedicle allows for extreme freedom and mobilization of the flap, ensuring adequate filling of the breast. ELD-K flap may expand the indications for a total autologous LD immediate breast reconstruction, representing an additional and reliable alternative in selected cohorts of patients.

Level of Evidence IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig.  6
Fig.  7

Similar content being viewed by others

References

  1. Ribuffo D, Cigna E, Gerald GL, Houseman N, Seneviratne S, Lombardi E, Parisi P, Scuderi N (2015) Iginio Tansini revisited. Eur Rev Med Pharmacol Sci 19(13):2477–2481

    CAS  PubMed  Google Scholar 

  2. Olivari N (1976) The latissimus flap. Br J Plast Surg. https://doi.org/10.1016/0007-1226(76)90036-9,April1976

    Article  PubMed  Google Scholar 

  3. Muhlbauer W, Olbrisch R (1977) The latissimus dorsi myocutaneous flap for breast reconstruction. Chir Plast 4:27

    Google Scholar 

  4. Bostwick J 3rd, Vasconez LO, Jurkiewicz MJ (1978) Breast reconstruction after a radical mastectomy. Plast Reconstr Surg 61(5):682–693

    PubMed  Google Scholar 

  5. Olivari N (1979) Use of thirty latissimus dorsi flaps. Plast Reconstr Surg 64(5):654–661

    CAS  PubMed  Google Scholar 

  6. Giacalone PL, Bricout N, Dantas MJ, Daurés JP, Laffargue F (2002) Achieving symmetry in unilateral breast reconstruction: 17 years experience with 683 patients. Aesthet Plast Surg. https://doi.org/10.1007/s00266-002-2034-6,Jul-Aug,2002

    Article  Google Scholar 

  7. Marcasciano M, Kaciulyte J, Marcasciano F, Lo Torto F, Ribuffo D, Casella D (2019) “No Drain, No Gain”: simultaneous seroma drainage and tissue expansion in pre-pectoral tissue expander-based breast reconstruction. Aesthet Plast Surg 43(4):1118–1119

    Google Scholar 

  8. Schneider WJ, Hill HL Jr, Brown RG (1977) Latissimus dorsi myocutaneous flap for breast reconstruction. Br J Plast Surg 30(4):277–281

    CAS  PubMed  Google Scholar 

  9. McCraw JB, Papp C, Edwards A, McMellin A (1994) The autogenous latissimus breast reconstruction. Clin Plast Surg 21(2):279–288

    CAS  PubMed  Google Scholar 

  10. Maxwell GP, McGibbon BM, Hoopes JE (1979) Vascular considerations in the use of a latissimus dorsi myocutaneous flap after a mastectomy with an axillary dissection. Plast Reconstr Surg 64(6):771–780

    CAS  PubMed  Google Scholar 

  11. Hodgson EL, Malata CM (2002) Implant-based breast reconstruction following mastectomy. Breast Dis 16:47–63

    PubMed  Google Scholar 

  12. McCraw JB, Papp CT (1991) Latissimus dorsi myocutaneous flap: fleur-de-lis reconstruction. Hartrampf’s breast reconstruction with living tissue. Hampton Press, Norfolk, Virginia, pp 211–241

    Google Scholar 

  13. Papp C, McCraw JB (1998) Autogenous latissimus breast reconstruction. Clin Plast Surg 25(2):261–266

    CAS  PubMed  Google Scholar 

  14. Hokin JA (1983) Mastectomy reconstruction without a prosthetic implant. Plast Reconstr Surg 72(6):810–818

    CAS  PubMed  Google Scholar 

  15. Santanelli di FP, Laporta R, Sorotos M, Pagnoni M, Falesiedi F, Longo B (2014) Latissimus dorsi flap for total autologous immediate breast reconstruction without implants. Plast Reconstr Surg 134(6):871e–e879

    Google Scholar 

  16. Economides JM, Song DH (2018) Latissimus dorsi and immediate fat transfer (LIFT) for complete autologous breast reconstruction. Plast Reconstr Surg Glob Open 6(1):e1656

    PubMed  PubMed Central  Google Scholar 

  17. Demiri EC, Dionyssiou DD, Tsimponis A, Goula CO, Pavlidis LC, Spyropoulou GA (2018) Outcomes of fat-augmented latissimus dorsi (FALD) flap versus implant-based latissimus dorsi flap for delayed post-radiation breast reconstruction. Aesthet Plast Surg 42(3):692–701

    Google Scholar 

  18. Foucher G, Braun JB (1979) A new island flap transfer from the dorsum of the index to the thumb. Plast Reconstr Surg 63(3):344–349

    CAS  PubMed  Google Scholar 

  19. Pusic AL, Klassen AF, Scott AM, Klok JA, Cordeiro PG, Cano SJ (2009) Development of a new patient-reported outcome measure for breast surgery: the BREAST-Q. Plast Reconstr Surg 124(2):345–353

    CAS  PubMed  Google Scholar 

  20. Zhong T, Hu J, Bagher S, Vo A, O'Neil AC, Butler K, Novak CB, Hofer SO, Metcalfe KA (2016) A comparison of psychological response, body image, sexuality, and quality of life between immediate and delayed autologous tissue breast reconstruction: a prospective long-term outcome study. Plast Reconstr Surg 138(4):772–780

    CAS  PubMed  Google Scholar 

  21. Bailey SH, Sant-Cyr M, Oni G, Wong C, Maia M, Nguyen V, Pessa JE, Colohan S, Rohrich RJ, Mojallal A (2011) The low transverse extended latissimus dorsi flap based on fat compartments of the back for breast reconstruction: anatomical study and clinical results. Plast Reconstr Surg 128(5):382e–394e

    PubMed  Google Scholar 

  22. Marshall DR, Anstee EJ, Stapleton MJ (1984) Soft tissue reconstruction of the breast using an extended composite latissimus dorsi myocutaneous flap. Br J Plast Surg 37(3):361–368

    CAS  PubMed  Google Scholar 

  23. Fausto A, Bernini M, La Forgia D, Fanizzi A, Marcasciano M, Volterrani L, Casella D, Mazzei MA (2019) Six-year prospective evaluation of second-look US with volume navigation for MRI-detected additional breast lesions. Eur Radiol 29(4):1799–1808

    PubMed  Google Scholar 

  24. Fausto A, Bernini M, Giacomo LD, Schivartche V, Marcasciano M, Casella D, Volterrani L, Mazzei MA (2018) Diagnostic value and safety of dynamic MRI of contralateral breast and axilla in subjects with tissue expander. J Plast Reconstr Aesthet Surg 71(9):1282–1285

    PubMed  Google Scholar 

  25. Barellini L, Marcasciano M, Lo Torto F, Fausto A, Ribuffo D, Casella D (2019) Intraoperative ultrasound and oncoplastic combined approach: an additional tool for the oncoplastic surgeon to obtain tumor-free margins in breast conservative surgery—A 2-year single-center prospective study. Clin Breast Cancer. https://doi.org/10.1016/j.clbc.2019.10.004,December6,2019

    Article  PubMed  Google Scholar 

  26. Marcasciano M, Frattaroli J, Mori FLR, Lo Torto F, Fioramonti P, Cavalieri E, Kaciulyte J, Greco M, Casella D, Ribuffo D (2019) The new trend of pre-pectoral breast reconstruction: an objective evaluation of the quality of online information for patients undergoing breast reconstruction. Aesthet Plast Surg 43(3):593–599

    CAS  Google Scholar 

  27. Casella D, Di Taranto G, Marcasciano M, Lo Torto F, Barellini L, Sordi S, Gaggelli I, Roncella M, Calabrese C, Ribuffo D (2019) Subcutaneous expanders and synthetic mesh for breast reconstruction: long-term and patient-reported BREAST-Q outcomes of a single-center prospective study. J Plast Reconstr Aesthet Surg 72(5):805–812

    CAS  PubMed  Google Scholar 

  28. Lo Torto F, Marcasciano M, Kaciulyte J, Redi U, Barellini L, De Luca A, Perra A, Frattaroli JM, Cavalieri E, Di Taranto G, Greco M, Casella D (2020) Prepectoral breast reconstruction with TiLoop® bra pocket: a single center prospective study. Eur Rev Med Pharmacol Sci 24(3):991–999

    CAS  PubMed  Google Scholar 

  29. Calabrese C, Casella D, Di Taranto G, Marcasciano M, Kothari A, Sordi S, Barellini L, Lo Torto F, Tarallo M, Perra A, Fausto A, Ribuffo D (2018) Oncoplastic conservative surgery for breast cancer: long-term outcomes of our first ten years experience. Eur Rev Med Pharmacol Sci 22(21):7333–7342

    CAS  PubMed  Google Scholar 

  30. Casella D, Di Taranto G, Marcasciano M, Sordi S, Kothari A, Kovacs T, Lo Torto F, Cigna E, Ribuffo D, Calabrese C (2018) Nipple-sparing bilateral prophylactic mastectomy and immediate reconstruction with TiLoop® bra mesh in BRCA1/2 mutation carriers: a prospective study of long-term and patient reported outcomes using the BREAST-Q. Breast 39:8–13

    CAS  PubMed  Google Scholar 

  31. Casella D, Di Taranto G, Marcasciano M, Sordi S, Kothari A, Kovacs T, Lo Torto F, Cigna E, Calabrese C, Ribuffo D (2019) Evaluation of prepectoral implant placement and complete coverage with TiLoop bra mesh for breast reconstruction: a prospective study on long-term and patient-reported BREAST-Q Outcomes. Plast Reconstr Surg 143(1):1e–9e

    CAS  PubMed  Google Scholar 

  32. Dessy LA, Corrias F, Marchetti F, Marcasciano M, Armenti AF, Mazzocchi M, Carlesimo B (2012) Implant infection after augmentation mammaplasty: a review of the literature and report of a multidrug-resistant Candida albicans infection. Aesthet Plast Surg 36(1):153–159

    Google Scholar 

  33. Santanelli di Pompeo F, Sorotos M (2018) EURAPS Editorial: BIA-ALCL, a brief overview. J Plast Reconstr Aesthet Surg 71(6):785–787

    PubMed  Google Scholar 

  34. Kim B, Roth C, Chung KC, Young VL, Van Busum K, Schnyer C, Mattke S (2011) Anaplastic large cell lymphoma and breast implants: a systematic review. Plast Reconstr Surg 127(6):2141–2150

    CAS  PubMed  Google Scholar 

  35. Ribuffo D, Lo Torto F, Giannitelli SM, Urbini M, Tortora L, Mozetic P, Trombetta M, Basoli F, Licoccia S, Tombolini V, Cassese R, Scuderi N, Rainer A (2015) The effect of post-mastectomy radiation therapy on breast implants: unveiling biomaterial alterations with potential implications on capsular contracture. Mater Sci Eng C 57:338–343

    CAS  Google Scholar 

  36. Barry M, Kell MR (2011) Radiotherapy and breast reconstruction: a meta-analysis. Breast Cancer Res Treat 127(1):15–22

    CAS  PubMed  Google Scholar 

  37. Vaia N, Lo Torto F, Marcasciano M, Casella D, Cacace C, MasiC De, Ricci F, Ribuffo D (2018) From the “Fat Capsule” to the “Fat Belt”: limiting protective lipofilling on irradiated expanders for breast reconstruction to selective key areas. Aesthet Plast Surg 42(4):986–994

    Google Scholar 

  38. Lo Torto F, Cigna E, Kaciulyte J, Casella D, Marcasciano M, Ribuffo D (2017) National breast reconstruction utilization in the setting of postmastectomy radiotherapy: two-stage implant-based breast reconstruction. J Reconstr Microsurg 33(5):e3

    PubMed  Google Scholar 

  39. Angrigiani C, Rancati A, Escudero E, Artero G (2015) Extended thoracodorsal artery perforator flap for breast reconstruction. Gland Surg 4(6):519–527

    PubMed  PubMed Central  Google Scholar 

  40. Bonomi S, Settembrini F, Salval A, Gregorelli C, Musumarra G, Rapisarda V (2012) Current indications for and comparative analysis of three different types of latissimus dorsi flaps. Aesthet Surg J 32(3):294–302

    PubMed  Google Scholar 

  41. Aitken ME, Mustoe TA (2002) Why change a good thing? Revisiting the fleur-de-lis reconstruction of the breast. Plast Reconstr Surg 109(2):525–533

    PubMed  Google Scholar 

  42. Ciudad P, Singhal D, Sapountzis S, Chilgar RM, Nicoli F, Chen HC (2013) The extended fleur-de-lis latissimus dorsi flap: a novel flap and approach for coverage of lower back defects. J Plast Reconstr Aesthet Surg 66(12):1811–1813

    PubMed  Google Scholar 

  43. Ciudad P, Manrique OJ, Bustos SS, Pafitanis G, Forte AJ, Huayllani MT, Boczar D, Vargas M, Escalante S, Parra Pont L, Bustamante A, Chen HC (2020) The modified extended fleur-de-lis latissimus dorsi flap for various complex multi-directional large soft and bone tissue reconstruction. Cureus 12(2):e6974

    PubMed  PubMed Central  Google Scholar 

  44. Correia Anacleto J, Mavioso C, Gouveia PF, Magalhaes A, Bastos Martins J, Moura A, Pinto D, Cardoso MJ (2016) The kite latissimus dorsi flap for breast reconstruction: an attempt to reduce lateral chest wall deformity and axillary bulking. Aesthet Plast Surg 40(4):514–516

    CAS  Google Scholar 

  45. Calabrese C, Kothari A, Badylak S, Di Taranto G, Marcasciano M, Sordi S, Barellini L, Lo Torto F, Tarallo M, Gaggelli I, D'Ermo G, Fausto A, Casella D, Ribuffo D (2018) Oncological safety of stromal vascular fraction enriched fat grafting in two-stage breast reconstruction after nipple sparing mastectomy: long-term results of a prospective study. Eur Rev Med Pharmacol Sci 22(15):4768–4777

    CAS  PubMed  Google Scholar 

  46. Ter Louw RP, Nahabedian MY (2017) Prepectoral breast reconstruction. Plast Reconstr Surg 140(5S):51S–59S

    PubMed  Google Scholar 

  47. Casella D, Di Taranto G, Lo Torto F, Marcasciano M, Kaciulyte J, Greco M, Onesti MG, Ribuffo D (2020) Body mass index can predict outcomes in direct-to-implant prepectoral breast reconstruction. Plast Reconstr Surg 145(4):867e–868e

    CAS  PubMed  Google Scholar 

  48. Browne JP, Jeevan R, Pusic AL, Klassen AF, Gulliver-Clarke C, Pereira J, Caddy CM, Cano SJ (2018) Measuring the patient perspective on latissimus dorsi donor site outcomes following breast reconstruction. J Plast Reconstr Aesthet Surg 71(3):336–343

    PubMed  Google Scholar 

  49. Koh E, Watson DI, Dean NR (2018) Quality of life and shoulder function after latissimus dorsi breast reconstruction. J Plast Reconstr Aesthet Surg 71(9):1317–1323

    PubMed  Google Scholar 

  50. Rios JL, Pollock T, Adams WP (2003) Progressive tension sutures to prevent seroma formation after latissimus dorsi harvest. Plast Reconstr Surg 112(7):1779–1783

    PubMed  Google Scholar 

  51. Hammond DC (2009) Latissimus dorsi flap breast reconstruction. Plast Reconstr Surg 124(4):1055–1063

    CAS  PubMed  Google Scholar 

  52. Clough KB, Louis-Sylvestre C, Fitoussi A, Couturaud B, Nos C (2002) Donor site sequelae after autologous breast reconstruction with an extended latissimus dorsi flap. Plast Reconstr Surg 109(6):1904–1911

    PubMed  Google Scholar 

  53. Delay E, Gounot N, Bouillot A, Zlatoff P, Rivoire M (1998) Autologous latissimus breast reconstruction: a 3-year clinical experience with 100 patients. Plast Reconstr Surg 102(5):1461–1478

    CAS  PubMed  Google Scholar 

  54. Sisti A, Grimaldi L, Tassinari J, Cuomo R, Fortezza L, Bocchiotti MA, Roviello F, D'Aniello C, Nisi G (2016) Nipple-areola complex reconstruction techniques: a literature review. Eur J Surg Oncol 42(4):441–465

    CAS  PubMed  Google Scholar 

  55. Renzoni A, Pirrera A, Lepri A, Cammarata P, Molinaro R, Dalla Vedova A (2017) Medical tattooing, the new frontiers: a case of nail bed treatment. Annali dell'Istituto Superiore di Sanità 53(4):334–336

    PubMed  Google Scholar 

  56. Halvorson EG, Cormican M, West ME, Myers V (2014) Three-dimensional nipple-areola tattooing: a new technique with superior results. Plast Reconstr Surg 133(5):1073–1075

    CAS  PubMed  Google Scholar 

Download references

Acknowledgement

We here acknowledge Miss Ottavia Cecchi, for her explanatory drawing of the flap.

Funding

The authors did not receive any sources of funding for research and/or publication.

Author information

Authors and Affiliations

  1. UOC Chirurgia Oncologica Della Mammella, Azienda Ospedaliera Universitaria Senese, Siena, Italy

    Donato Casella & Dario Cassetti

  2. Department of Surgery, “P. Valdoni”, Unit of Plastic and Reconstructive Surgery, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy

    Jacopo Nanni, Federico Lo Torto, Ugo Redi, Juste Kaciulyte, Diego Ribuffo & Marco Marcasciano

  3. Unità Di Oncologia Chirurgica Ricostruttiva Della Mammella, “Spedali Riuniti” Di Livorno, “Breast Unit” Integrata Di Livorno Cecina, Piombino Elba, Azienda USL Toscana Nord Ovest, Livorno, Italy

    Leonardo Barellini & Marco Marcasciano

Authors
  1. Donato Casella
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jacopo Nanni
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Federico Lo Torto
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Leonardo Barellini
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Ugo Redi
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Juste Kaciulyte
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Dario Cassetti
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Diego Ribuffo
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Marco Marcasciano
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Marco Marcasciano.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

Approval was obtained from the ethics committee. The procedures used in this study adhere to the tenets of the Declaration of Helsinki.

Consent to Participate

Informed consent was obtained from all individual participants included in the study.

Consent to Publish

Patients signed informed consent regarding publishing their data and photographs.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Intraoperative video shows the preparation of the ELD-K flap while simulating the inset. The intraoperative building procedures of the breast mound are highlighted and simplified for a clearer demonstration. The ELD-K flap is mobilized on pure island vessels, and the bulk of the fat is placed in the central-inferior part, defining the inframammary fold and enhancing the volume of the reconstructed breast. The flap is molded in a conical fashion folding on itself the vertical V-shaped segment, providing additional tissue that is useful to gain projection (MOV 75814 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Casella, D., Nanni, J., Lo Torto, F. et al. Extended Latissimus Dorsi Kite Flap (ELD-K Flap): Revisiting an Old Place for a Total Autologous Breast Reconstruction in Patients with Medium to Large Breasts. Aesth Plast Surg 45, 390–401 (2021). https://doi.org/10.1007/s00266-020-01990-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00266-020-01990-x

Keywords

Search

Navigation