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Late results and current indications of latissimus dorsi breast reconstructions
EritirhJowd ofPlastic Surm-v 119911.44. l-4 0 1991 The T&tees of B&h Aswciatio~bf Plastic Surgeons
Late results and current indications of latissimus dorsi breast reconstructions A. De Mey, M. Lejour, A. Declety and A. M. Meythiaz Department of Plastic Surgery, Brussels Free University, Brugmann Hospital, Brussels, Belgium SUMMARY. One hundred and fifty latissiius dorsi flaps were used in 145 patients out of a series of 483 breast reconstructions performed from 1977 to 1988. There were few hnmediate complications and a durable, good cosmetic result was obtained in two-thirds of the 103 cases reviewed after at least one year. The main reasons for dissatisfaction with long-term resuits were capsular contracture (grades III and IV) and upper displacement of the implant. The rate of these late complications was 30%, the same as found in the simpler subpectoral reconstruction. However, prostheses with a thick outer envelope induced only 10% of severe capsular contracture. Reconstructions with autologous tissue are currently replacing latissimus dorsi gap reconstructions unless local or general conditions contraindicate such major surgery or when the patient lacks motivation.
After the first report of chest wall reconstruction with a latissimus dorsi (LD) musculocutaneous flap by Tansini (1906) the method was forgotten for seven decades, then rediscovered by Olivari in 1976 and soon applied to breast reconstruction by Miihlbauer and Olbrich (1977) and Schneider et al. (1977). For several years the LD flap was recognised as the best method to reconstruct a breast after radical mastectomy in difficult cases (Bostwick and Scheflan, 1980) and as a salvage procedure for mastectomy cripples (Pendergast et al., 1980). More recently, new techniques have been developed which tend to replace the LD flap. Skin expansion makes immediate reconstruction easier (Becker, 1984) and allows reconstruction of larger breasts (Versacci, 1987). The rectus abdominis (TRAM) flap permits reconstruction using only autologous tissue (Hartrampf et al., 1982; Petit et al., 1983; Hartrampf and Bennett, 1989) sometimes even as a free flap (Holmstriim, 1979; Grotting et al.,
flap was also used to match a small and ptotic opposite breast or in obese patients to recreate a larger breast than would have been possible with an implant alone. In 19 cases the LD flap was a secondary procedure after unsatisfactory reconstructions : -in 11 cases after simple implantation, 6 for a recurrent grade IV capsular contracture and 5 for skin atrophy after cortisone resorption through the implant, -in 6 cases after partial failure of an upper rectus flap, -in 2 cases, combined with a TRAM flap to fill the axillary region. In 6 cases, no implant was needed to obtain a satisfactory volume as the LD flap was used as an additional procedure to another flap or after tumourectomy. For the others, the implants were double-lumen or gel-filled prostheses.
1989).
The purpose of this paper is to review our experience and to draw conclusions concerning the advantages, disadvantages and current indications of the LD flap.
Patients
Among 483 breast reconstructions performed between January 1977 and December 1988, 150 LD flaps were used in 145 patients. Most of the patients were reconstructed one year after mastectomy. One hundred and eleven patients (76%) had had a modified radical mastectomy (Patey or Madden), 27 (18%) a radical mastectomy (Halsted), 4 a tumourectomy and 3 a subcutaneous mastectomy (2 bilateral). Ninety-four patients had been irradiated. Latissimus dorsi flaps were first chosen when local conditions were unsatisfactory : lack of subcutaneous tissue, partial or total absence of pectoralis muscle, moderate or severe radiodermatitis. Later on, the LD
Method Among the various techniques described for taking and placing the LD flap, we present the method which in our experience has given the best results. The skin flap is harvested horizontally in the upper portion of the muscle, this technique giving a better scar on the back than vertical flaps and avoiding circumferential tightness of the thorax. This skin will be placed in an anterior chest incision, which may be the mastectomy scar, but experience has shown that the best results are obtained when the skin is placed on the lateral and lower portions of the breast. To obtain this, the mastectomy scar is disregarded. If a correction of the opposite breast is planned, it is performed during the same operation. The nipple-areola complex is reconstructed after 2 to 3 months, usually as a minor procedure under local anaesthesia.
British Journal of Plastic Surgery
2
Results
As in other indications of latissimus flap, the safety of the method has been very good (Duchateau et al., 1987). Immediate results At the end of a latissimus reconstruction the result is usually excellent, better than with any other method : simple implantations never give such an immediately spectacular result, and TRAM flaps are performed without surgery on the opposite breast at the first stage. Complications (Table 1) Immediate complications were infrequent (38/150 = 23%) and mainly minor (34/38). Dorsal seroma (13 cases) required aspiration but no reoperation. Infection was solved with antibiotics, without removal of the implant, in four cases out of five. Total necrosis of the flap occurred in one early case in which the muscle had been devascularised during the mastectomy. The result was successfully salvaged with an upper rectus flap. Table 1
Complications
(150 cases) Immediate
Seroma Haematoma Infection Necrosis total tip of flap Implant displaced Implant extrusion
Late
13 10
5 -
1 5 4
3 38
Total
3
Displacement of the prosthesis to the back soon after surgery (four cases) was no longer observed after the muscular pocket was limited laterally by suture of the deep surface of the LD to the serratus anterior muscle. Late perforation of the irradiated chest skin near the distal part of the skin island, probably due to distal atrophy of the LD muscle, occurred in three patients and required the removal of the implant in two patients. Lute results (Table 2) One hundred and three patients were followed up for at least one year. Their results were evaluated Table 2
Late results (103 cases)
IJI
Capsular contracture
64 (62%)
High
(1) Evolution of the flap After one year, in 55% of the cases the colour and texture of the skin ellipse from the back matched those of the anterior skin. Colour was good in 57 patients, paler in 16 cases and darker in 30 cases. This contradicts a commonly held opinion (Bohmert et al., 1989). It is likely that the evaluation of the result is often made too early, before adjustment of the skin colour to a region which is less frequently exposed to the sun than the back. Sensitivity never recovered, even less than with other flaps, as flaps transplanted to the breast region are surrounded by insensitive skin due to undermining and dissection during mastectomy. The scar in the back widened in 41 patients but was acceptable in the 62 others. Most of the horizontal scars were hidden by the brassiere and the sole difference between both sides was due to the lack of skin folds on the donor side in elderly or obese patients. It has to be noted that the four flaps which were harvested laterally had a good colour match but caused a widened scar in three cases and even a hypertrophic scar in one case. (2) Capsular contracture and symmetry As the latissimus muscle keeps its contractility even after transposition, upward displacement of the breast may be a problem, especially during sporting activities. Distal atrophy of the muscle flap is frequently observed during secondary procedures but cannot be measured. A grade I or II capsular contracture was observed in 76 patients (73x), a grade III in 25 patients and a grade IV in 2 patients. The position of the reconstructed breast was satisfactory in 64 cases (62x), too high in 38 cases (36%) and too low in one case only. Capsulotomy was performed in 26 cases, usually at the time of areola reconstruction 3 months after the operation, and in only two cases more than one year after the operation. Seventeen of these patients could be evaluated after more than a year. The results were satisfactory in 15 patients and the situation unchanged in two. However, in the last 38 patients operated on between 1986 and 1988, Silastic II Dow Coming prostheses with a thick envelope were used. Nineteen patients in this group were reviewed and 18 presented with a grade I or II capsular contracture after one year. The improved quality of modern prostheses is certainly an argument in favour of carrying on with simpler techniques of reconstruction requiring only an implant. Symmetry, the most important factor for the patients, was therefore satisfactory in 79 of the 103 reviewed (76%).
IV
25 (24%) Normal
Position of breast
III
concerning evolution of the flap, capsular contracture and symmetry of position and volume with the opposite breast.
Discussion LOW
After the publications of Olivari (1976) and Mtihlbauer and Olbrich (1977), the latissimus dorsi rapidly became the workhorse in breast reconstruction. Its safety and reliability allowed Bostwick et al. (1979) and Maxwell
Late Results and Current Indications of Latissimus Dorsi Breast Reconstructions
(198 1) to refine the technique, impressively improving the aesthetic results by positioning a pie wedge-shaped flap in the lower external quadrant. Whatever the position of the scar, it was possible to obtain a sling effect and to reconstruct a large and sometimes slightly ptotic breast with a good projection. Later, Millard (198 1) proposed adjusting the shape of the skin flap to particular requirements, creating pie wedge to diamond-shaped flaps, but adding more scars. As pointed out by Vasconez (1982), the most important purposes of the LD flap are to recreate a submammary fold, to cover the implant with muscle and to avoid taking more skin in the back than can be closed primarily. These objectives are usually fulfilled with regular pie wedge-shaped flaps. The rate of complications reported here is low, as in other series (Maxwell, 1981). The safety of the flap is so good that it can even be used if the pedicle has been severed (Maxwell er al., 1979; Fisher et al., 1983) although this should not be recommended. The rate of 30% of severe capsular contracture (grades III and IV) already observed in the review of our first 56 cases (Lejour et al., 1985) has been confirmed. It is the same as in simple implantations (Asplund and KBrlof, 1984; Lejour ef al., 1988), but it should be stressed that the cases reconstructed by LD flaps are usually less favourable than those using simple implantation. The scar on the back is a minor disadvantage, nearly never objected to by the patients. This problem is partially solved by taking a horizontal ellipse of skin and hiding it under the brassiere strap, parallel to the skin tension lines. Berrino et al. (1986) tried to solve the problem by using a muscular flap, harvested by a small lateral incision, in combination with a tissue expander in the breast area. This is, however, a longer and more complicated procedure. Attempts to solve the problem of the prosthesis were made by Marshall et al. (1984) and Hokin and Silfverskiold (1987) who used an extended LD flap to obtain more soft tissue, and by Papp et al. (1988) who kept subcutaneous fat on the muscle to increase its volume and obviate the prosthesis. This is possible only with a longer scar in the back, and again an increase in the magnitude of the procedure and of the rate of dorsal complications. This technique of latissimus dorsi breast reconstruction has, however, to be compared to more recent techniques. In breast reconstruction, expanders lead to the usual
3
complications of implants and add some others (Cohen and Turner, 1987). In recent years, more interest has been given to the rectus (TRAM) flap: it allows breast reconstruction with autologous tissue and replaces the scar in the back by an abdominal scar (Hartrampf, 1987). In many cases, the abdominoplasty effect of this flap improves the body contour, an advantage highly appreciated by the patients. The risk of hernia, considered by many authors as an objection to this type of operation, has not been a problem in our series of nearly 100 TRAM flaps. However, even in skilled hands the TRAM flap remains a more sophisticated operation, with lower safety and a longer recovery period. TRAM flaps should consequently be confined to highly motivated and carefully selected patients. Other authors have proposed free buttock flaps (Shaw, 1983), free rectus flaps (Holmstriim, 1979; Harashina, 1980; Friedman et al., 1985; Amez et al., 1988; Grotting et al., 1989) and even free thigh flaps (Elliott et al., 1990). The difficulty of microsurgical techniques in breast reconstruction concerns the recipient vessels, especially in irradiated patients, more than the donor vessels. Up to now, these techniques remain uncommon and reserved for selected cases. Our current indications for LD flap breast reconstruction are now rare (Fig. l), but the technique is preferred in patients with local conditions contraindicating reconstruction with a prosthesis alone and
(4 whose general condition contraindicates a TRAM flap (hypertension, diabetes, cancer with poor prognosis, smoking habits, obesity or old age); (b) whose local conditions contraindicate a TRAM flap (scarred abdomen, flat and thin abdomen, or simply a beautiful abdomen which should be preserved intact); (4 who are not motivated for a major procedure like the TRAM flap. This is a more debatable indication as it depends also on the experience and expertise ‘of the surgeon performing the operation and the way he proposes it to the patient. An LD flap is a fairly simple operation with which most surgeons feel comfortable, while a TRAM flap remains a major procedure with more possible severe complications, requiring greater experience, excellent anaesthesia and postoperative conditions. prostheses
latissimus dorsi
1986-1988
1977-1985 Fig. 1
Figure l-Comparative
indications
of different techniques.
British Journal of Plastic Surgery
4
Conclusions The LD musculocutaneous flap has for years been the best method of breast reconstruction in patients who were not suitable for simple implantation of a prosthesis. The procedure is safe and simple and the refinements developed over the years allow good symmetry with the contralateral breast in two-thirds of the cases. The major drawback of the method is that it requires an implant which induces the same rate of severe capsular contracture as observed in simple reconstruction. For this reason, the TRAM flap has progressively replaced the LD flap in most of our cases. However, the LD flap certainly remains the best procedure for breast reconstruction when a simple implant is contraindicated and when local or general conditions preclude a TRAM flap.
References Amez, Z. M., Smith, R. W., Eder, E., Solid, M. and Kersnic, M. (1988). Breast reconstruction by the free lower transverse rectus abdominis musculocutaneous flap. British Journal of Plostic Surgery, 41,500. Aspkmd, 0. aud Kiirlof, B. (1984). Late results following mastectomy for cancer and breast reconstruction. Scundin&un Journal of Plastic and Reconstructiue Surgery, 18,221. Becker, H. (1984). Breast reconstruction using an inflatable breast implant with detachable reservoir. Plastic and Reconstructive Surgery, 73,678. Berrino, P., Galli, A. and Santi, P. L. (1986). New options in breast reconstructive surgery: alternatives to the latissimus dorsi myocutaneous flap. Aesthetic Plastic Surgery, 10,237. Bohmert,H., Daigeler,R.,Bikhela, H. andBubb,C. (1989). Aesthetic and technical considerations of breast reconstruction with the latissimus dorsi flap. In Bohmert, H. H., Leis, H. P. and Jackson, I. T. (Eds) Breast Cancer: ConservativeandReconst~ctive Surgery. Stuttgart, New York: Georg Thieme Verlag. Bostwick, J., Nakai, F., WaIIace, J. G. and Vascoaez, L. 0. (1979). Sixty latissimus dorsi flaps. Plastic ana’ Reconstructive Surgery, 63, 31. Bostwick,J. and S&elan, M. (1980). The latissimus dorsi musculocutaneous flap: a one stage breast reconstruction. Chirurgia Plastica, 7, 71. Cohen, I. K. and Turner, D. (1987). Immediate breast reconstruction with tissue expander. Clinics in Plastic Surgery, 14,491. Duchateau, J., Guelinekx, P. J., Deraemaecker, R., De Mey, A., Declety, A., Jabri, M. and Lejour, M. (1987). Analyse de 163 lambeaux de grand dorsal. Acto Chirurgica Be&co, 87,275. Elliott, L. F., Beegle, P. H and Hnrtrampf, C. R. (1990). The lateral transverse thigh free flap: an alternative for autogenous tissue breast reconstruction. Plastic and Reconstructive Surgery, 85, 169. Fisher, J., B&wick, J. and Powell, R. W. (1983). Latissimus dorsi blood supply after thoracodorsal vessel division: the serratus collateral. Plastic and Reconstructive Surgery, 72,502. Friedman, R. J., Argenta, L. C. and Anderson, R. (1985). Deep inferior epigastric free flap for breast reconstruction after radical mastectomy. Plastic and Reconstructive Surgery, 76,455. Grotting, J. C., Urist, M. N., Maddox, W. A. and Vasconez, L. 0. (1989). Conventional TRAM flap versus free microsuraical TRAM flap for immediate breast reconstruction. Plastic-and Reconstructive Surgery, %J, 828. Haraskina, T. (1980). Breast reconstruction with microsurgical free composite type tissue transfer. British Journal of Plastic Surgery, 33,30. Hartrampf, C. R. (1987). Breast reconstruction with a transverse abdominal island flap. A retrospective evaluation of 335 patients. Perspectives in Plastic Surgery, 1, 1. Hartrampf, C. R. and Bennett, G. K. (1989). Breast reconstruction using the transverse abdominal island flap. In Bohmert, H. H., Leis, H. P. and Jackson, I. T. (Eds) Breast Cancer: Conservative
and Reconstructive Surgery. Stuttgart, New York: Georg Thieme Verlag. Hartrampf, C. R., Seheflau, M. and Black, P. W. (1982). Breast reconstruction with a transverse abdominal island flap. Plastic and Reconstructive Surgery, 69,216. Hokln. J. A. B. And Silfverskiold. H. L. (1987). Breast reconstruction without an implant: results aid complications using an extended latissimus dorsi flap. Plastic and Reconstructive Surgery, 79,58. Hohnstriw, H. (1979). The free abdominoplasty flap and its use in breast reconstruction. Scandinavian Journal of Plastic and Reconstructive Surgery, 13,423. Lejour, M., AIematmo, P., De Mey, A., Gerard, T. and F.&r, H. (1985). Analyse de 56 reconstructions mammaires par lambeau de grand dorsal. Annales de Chirurgie Plostique et Esthetique, 30, 7. Lejour, M., Jab& M. and Deraemaecker, R. (1988). Analysis and long term results of 326 breast reconstructions. Clinics in Plastic Surgery, 15,689. Marshall, D., An&e, E. J. and Stapletw, M. J. (1984). Soft tissue reconstruction of the breast using an extended composite latissimus dorsi myocutaneous flap. British Journal of Plastic Surgery, 37,361. Maxwell, 6. P. (198 1). Latissimus breast reconstruction :an aesthetic assessment. Clinics in Plastic Surgery, 8, 373. Maxwell, G. P., MeGibbon, G. M. and Huopes, J. E. (1979). Vascular considerations in the use of a latissimus dorsi myocutaneous flap after amastectomywithaxillarydissection. PlasticandReconstTuctive Surgery, 64,771. Millard, D. R. (1981). Variations in the design of the latissimus dorsi flap in breast reconstruction. Annals of Plastic Surgery, 7, 269. Mlihlbauer, W. and Olbrich, R. (1977). The tatissimus dorsi myocutaneous flap for breast reconstruction. Chirurgica Plastica, 4,27. Olivari, N. (1976). The latissimus flap. British Journal of Plastic Surgery, 29,126. Papp, C., Zanon, T. and McGraw, J. (1988). Breast volume replacement using the deepithelialized latissimus dorsi myocutaneous flap. European Journalof Plastic Surgery, 11, 120. Pendergast, W., B&wick, J. and Jurkiewicz, J. M. (1980). The subcutaneous mastectomy cripple: surgical rehabilitation with the latissimus dorsi flap. Plastic and Reconstructive Surgery, 66, 554. Petit, J. Y., Margulls, A. and RIga&, L. (1983). Reconstruction mammaire sans prothbse par un lambeau musculocutanb abdominal ptdicule sur le grand droit. Annales de Chirurgie Plastique et EsthPtique, 28,283. Schneider, W. J., HBI, H. L. and Brown, R. G. (1977). Latissimus dorsi myocutaneous flap for breast reconstruction. British Journal of Plastic Surgery, 30,277. Shaw, W. W. (1983). Breast reconstruction by superior gluteal microvascular free flaps without silicone implants. Plastic and Reconstructive Surgery, 72,490. Tansini, I. (1906). Sopra il mio nuovo processo di amputazione della mamella. Gazetta Medica Italiana, 57, 141. Vasconez, L. 0. (1982). Discussion of breast aesthetics when reconstructing with the latissimus dorsi musculocutaneous flap. Plastic and Reconstructive Surgery, 70, 172. Versa&, A. (1987). A method of reconstructing a pendulous breast utilizing the tissue expander. Plastic and Reconstructive Surgery, 80.387.
The Authors A. De Mey, MD, M. Lejour, MD, A. Declety, MD, A. M. Meythlaz,
Chef de clinique adjoint Professor and Head of Department Resident MD, Resident
Department of Plastic Surgery, Brussels Free University, Brugmann Hospital, Place A. Van Gehuchten 4, 1020 Brussels, Belgium. Requests
for reprints
to Dr De Mey.
Paper received 26 May 1989. Accepted 8 May 1990 after revision.
Late results and current indications of latissimus dorsi breast reconstructions A. De Mey, M. Lejour, A. Declety and A. M. Meythiaz Department of Plastic Surgery, Brussels Free University, Brugmann Hospital, Brussels, Belgium SUMMARY. One hundred and fifty latissiius dorsi flaps were used in 145 patients out of a series of 483 breast reconstructions performed from 1977 to 1988. There were few hnmediate complications and a durable, good cosmetic result was obtained in two-thirds of the 103 cases reviewed after at least one year. The main reasons for dissatisfaction with long-term resuits were capsular contracture (grades III and IV) and upper displacement of the implant. The rate of these late complications was 30%, the same as found in the simpler subpectoral reconstruction. However, prostheses with a thick outer envelope induced only 10% of severe capsular contracture. Reconstructions with autologous tissue are currently replacing latissimus dorsi gap reconstructions unless local or general conditions contraindicate such major surgery or when the patient lacks motivation.
After the first report of chest wall reconstruction with a latissimus dorsi (LD) musculocutaneous flap by Tansini (1906) the method was forgotten for seven decades, then rediscovered by Olivari in 1976 and soon applied to breast reconstruction by Miihlbauer and Olbrich (1977) and Schneider et al. (1977). For several years the LD flap was recognised as the best method to reconstruct a breast after radical mastectomy in difficult cases (Bostwick and Scheflan, 1980) and as a salvage procedure for mastectomy cripples (Pendergast et al., 1980). More recently, new techniques have been developed which tend to replace the LD flap. Skin expansion makes immediate reconstruction easier (Becker, 1984) and allows reconstruction of larger breasts (Versacci, 1987). The rectus abdominis (TRAM) flap permits reconstruction using only autologous tissue (Hartrampf et al., 1982; Petit et al., 1983; Hartrampf and Bennett, 1989) sometimes even as a free flap (Holmstriim, 1979; Grotting et al.,
flap was also used to match a small and ptotic opposite breast or in obese patients to recreate a larger breast than would have been possible with an implant alone. In 19 cases the LD flap was a secondary procedure after unsatisfactory reconstructions : -in 11 cases after simple implantation, 6 for a recurrent grade IV capsular contracture and 5 for skin atrophy after cortisone resorption through the implant, -in 6 cases after partial failure of an upper rectus flap, -in 2 cases, combined with a TRAM flap to fill the axillary region. In 6 cases, no implant was needed to obtain a satisfactory volume as the LD flap was used as an additional procedure to another flap or after tumourectomy. For the others, the implants were double-lumen or gel-filled prostheses.
1989).
The purpose of this paper is to review our experience and to draw conclusions concerning the advantages, disadvantages and current indications of the LD flap.
Patients
Among 483 breast reconstructions performed between January 1977 and December 1988, 150 LD flaps were used in 145 patients. Most of the patients were reconstructed one year after mastectomy. One hundred and eleven patients (76%) had had a modified radical mastectomy (Patey or Madden), 27 (18%) a radical mastectomy (Halsted), 4 a tumourectomy and 3 a subcutaneous mastectomy (2 bilateral). Ninety-four patients had been irradiated. Latissimus dorsi flaps were first chosen when local conditions were unsatisfactory : lack of subcutaneous tissue, partial or total absence of pectoralis muscle, moderate or severe radiodermatitis. Later on, the LD
Method Among the various techniques described for taking and placing the LD flap, we present the method which in our experience has given the best results. The skin flap is harvested horizontally in the upper portion of the muscle, this technique giving a better scar on the back than vertical flaps and avoiding circumferential tightness of the thorax. This skin will be placed in an anterior chest incision, which may be the mastectomy scar, but experience has shown that the best results are obtained when the skin is placed on the lateral and lower portions of the breast. To obtain this, the mastectomy scar is disregarded. If a correction of the opposite breast is planned, it is performed during the same operation. The nipple-areola complex is reconstructed after 2 to 3 months, usually as a minor procedure under local anaesthesia.
British Journal of Plastic Surgery
2
Results
As in other indications of latissimus flap, the safety of the method has been very good (Duchateau et al., 1987). Immediate results At the end of a latissimus reconstruction the result is usually excellent, better than with any other method : simple implantations never give such an immediately spectacular result, and TRAM flaps are performed without surgery on the opposite breast at the first stage. Complications (Table 1) Immediate complications were infrequent (38/150 = 23%) and mainly minor (34/38). Dorsal seroma (13 cases) required aspiration but no reoperation. Infection was solved with antibiotics, without removal of the implant, in four cases out of five. Total necrosis of the flap occurred in one early case in which the muscle had been devascularised during the mastectomy. The result was successfully salvaged with an upper rectus flap. Table 1
Complications
(150 cases) Immediate
Seroma Haematoma Infection Necrosis total tip of flap Implant displaced Implant extrusion
Late
13 10
5 -
1 5 4
3 38
Total
3
Displacement of the prosthesis to the back soon after surgery (four cases) was no longer observed after the muscular pocket was limited laterally by suture of the deep surface of the LD to the serratus anterior muscle. Late perforation of the irradiated chest skin near the distal part of the skin island, probably due to distal atrophy of the LD muscle, occurred in three patients and required the removal of the implant in two patients. Lute results (Table 2) One hundred and three patients were followed up for at least one year. Their results were evaluated Table 2
Late results (103 cases)
IJI
Capsular contracture
64 (62%)
High
(1) Evolution of the flap After one year, in 55% of the cases the colour and texture of the skin ellipse from the back matched those of the anterior skin. Colour was good in 57 patients, paler in 16 cases and darker in 30 cases. This contradicts a commonly held opinion (Bohmert et al., 1989). It is likely that the evaluation of the result is often made too early, before adjustment of the skin colour to a region which is less frequently exposed to the sun than the back. Sensitivity never recovered, even less than with other flaps, as flaps transplanted to the breast region are surrounded by insensitive skin due to undermining and dissection during mastectomy. The scar in the back widened in 41 patients but was acceptable in the 62 others. Most of the horizontal scars were hidden by the brassiere and the sole difference between both sides was due to the lack of skin folds on the donor side in elderly or obese patients. It has to be noted that the four flaps which were harvested laterally had a good colour match but caused a widened scar in three cases and even a hypertrophic scar in one case. (2) Capsular contracture and symmetry As the latissimus muscle keeps its contractility even after transposition, upward displacement of the breast may be a problem, especially during sporting activities. Distal atrophy of the muscle flap is frequently observed during secondary procedures but cannot be measured. A grade I or II capsular contracture was observed in 76 patients (73x), a grade III in 25 patients and a grade IV in 2 patients. The position of the reconstructed breast was satisfactory in 64 cases (62x), too high in 38 cases (36%) and too low in one case only. Capsulotomy was performed in 26 cases, usually at the time of areola reconstruction 3 months after the operation, and in only two cases more than one year after the operation. Seventeen of these patients could be evaluated after more than a year. The results were satisfactory in 15 patients and the situation unchanged in two. However, in the last 38 patients operated on between 1986 and 1988, Silastic II Dow Coming prostheses with a thick envelope were used. Nineteen patients in this group were reviewed and 18 presented with a grade I or II capsular contracture after one year. The improved quality of modern prostheses is certainly an argument in favour of carrying on with simpler techniques of reconstruction requiring only an implant. Symmetry, the most important factor for the patients, was therefore satisfactory in 79 of the 103 reviewed (76%).
IV
25 (24%) Normal
Position of breast
III
concerning evolution of the flap, capsular contracture and symmetry of position and volume with the opposite breast.
Discussion LOW
After the publications of Olivari (1976) and Mtihlbauer and Olbrich (1977), the latissimus dorsi rapidly became the workhorse in breast reconstruction. Its safety and reliability allowed Bostwick et al. (1979) and Maxwell
Late Results and Current Indications of Latissimus Dorsi Breast Reconstructions
(198 1) to refine the technique, impressively improving the aesthetic results by positioning a pie wedge-shaped flap in the lower external quadrant. Whatever the position of the scar, it was possible to obtain a sling effect and to reconstruct a large and sometimes slightly ptotic breast with a good projection. Later, Millard (198 1) proposed adjusting the shape of the skin flap to particular requirements, creating pie wedge to diamond-shaped flaps, but adding more scars. As pointed out by Vasconez (1982), the most important purposes of the LD flap are to recreate a submammary fold, to cover the implant with muscle and to avoid taking more skin in the back than can be closed primarily. These objectives are usually fulfilled with regular pie wedge-shaped flaps. The rate of complications reported here is low, as in other series (Maxwell, 1981). The safety of the flap is so good that it can even be used if the pedicle has been severed (Maxwell er al., 1979; Fisher et al., 1983) although this should not be recommended. The rate of 30% of severe capsular contracture (grades III and IV) already observed in the review of our first 56 cases (Lejour et al., 1985) has been confirmed. It is the same as in simple implantations (Asplund and KBrlof, 1984; Lejour ef al., 1988), but it should be stressed that the cases reconstructed by LD flaps are usually less favourable than those using simple implantation. The scar on the back is a minor disadvantage, nearly never objected to by the patients. This problem is partially solved by taking a horizontal ellipse of skin and hiding it under the brassiere strap, parallel to the skin tension lines. Berrino et al. (1986) tried to solve the problem by using a muscular flap, harvested by a small lateral incision, in combination with a tissue expander in the breast area. This is, however, a longer and more complicated procedure. Attempts to solve the problem of the prosthesis were made by Marshall et al. (1984) and Hokin and Silfverskiold (1987) who used an extended LD flap to obtain more soft tissue, and by Papp et al. (1988) who kept subcutaneous fat on the muscle to increase its volume and obviate the prosthesis. This is possible only with a longer scar in the back, and again an increase in the magnitude of the procedure and of the rate of dorsal complications. This technique of latissimus dorsi breast reconstruction has, however, to be compared to more recent techniques. In breast reconstruction, expanders lead to the usual
3
complications of implants and add some others (Cohen and Turner, 1987). In recent years, more interest has been given to the rectus (TRAM) flap: it allows breast reconstruction with autologous tissue and replaces the scar in the back by an abdominal scar (Hartrampf, 1987). In many cases, the abdominoplasty effect of this flap improves the body contour, an advantage highly appreciated by the patients. The risk of hernia, considered by many authors as an objection to this type of operation, has not been a problem in our series of nearly 100 TRAM flaps. However, even in skilled hands the TRAM flap remains a more sophisticated operation, with lower safety and a longer recovery period. TRAM flaps should consequently be confined to highly motivated and carefully selected patients. Other authors have proposed free buttock flaps (Shaw, 1983), free rectus flaps (Holmstriim, 1979; Harashina, 1980; Friedman et al., 1985; Amez et al., 1988; Grotting et al., 1989) and even free thigh flaps (Elliott et al., 1990). The difficulty of microsurgical techniques in breast reconstruction concerns the recipient vessels, especially in irradiated patients, more than the donor vessels. Up to now, these techniques remain uncommon and reserved for selected cases. Our current indications for LD flap breast reconstruction are now rare (Fig. l), but the technique is preferred in patients with local conditions contraindicating reconstruction with a prosthesis alone and
(4 whose general condition contraindicates a TRAM flap (hypertension, diabetes, cancer with poor prognosis, smoking habits, obesity or old age); (b) whose local conditions contraindicate a TRAM flap (scarred abdomen, flat and thin abdomen, or simply a beautiful abdomen which should be preserved intact); (4 who are not motivated for a major procedure like the TRAM flap. This is a more debatable indication as it depends also on the experience and expertise ‘of the surgeon performing the operation and the way he proposes it to the patient. An LD flap is a fairly simple operation with which most surgeons feel comfortable, while a TRAM flap remains a major procedure with more possible severe complications, requiring greater experience, excellent anaesthesia and postoperative conditions. prostheses
latissimus dorsi
1986-1988
1977-1985 Fig. 1
Figure l-Comparative
indications
of different techniques.
British Journal of Plastic Surgery
4
Conclusions The LD musculocutaneous flap has for years been the best method of breast reconstruction in patients who were not suitable for simple implantation of a prosthesis. The procedure is safe and simple and the refinements developed over the years allow good symmetry with the contralateral breast in two-thirds of the cases. The major drawback of the method is that it requires an implant which induces the same rate of severe capsular contracture as observed in simple reconstruction. For this reason, the TRAM flap has progressively replaced the LD flap in most of our cases. However, the LD flap certainly remains the best procedure for breast reconstruction when a simple implant is contraindicated and when local or general conditions preclude a TRAM flap.
References Amez, Z. M., Smith, R. W., Eder, E., Solid, M. and Kersnic, M. (1988). Breast reconstruction by the free lower transverse rectus abdominis musculocutaneous flap. British Journal of Plostic Surgery, 41,500. Aspkmd, 0. aud Kiirlof, B. (1984). Late results following mastectomy for cancer and breast reconstruction. Scundin&un Journal of Plastic and Reconstructiue Surgery, 18,221. Becker, H. (1984). Breast reconstruction using an inflatable breast implant with detachable reservoir. Plastic and Reconstructive Surgery, 73,678. Berrino, P., Galli, A. and Santi, P. L. (1986). New options in breast reconstructive surgery: alternatives to the latissimus dorsi myocutaneous flap. Aesthetic Plastic Surgery, 10,237. Bohmert,H., Daigeler,R.,Bikhela, H. andBubb,C. (1989). Aesthetic and technical considerations of breast reconstruction with the latissimus dorsi flap. In Bohmert, H. H., Leis, H. P. and Jackson, I. T. (Eds) Breast Cancer: ConservativeandReconst~ctive Surgery. Stuttgart, New York: Georg Thieme Verlag. Bostwick, J., Nakai, F., WaIIace, J. G. and Vascoaez, L. 0. (1979). Sixty latissimus dorsi flaps. Plastic ana’ Reconstructive Surgery, 63, 31. Bostwick,J. and S&elan, M. (1980). The latissimus dorsi musculocutaneous flap: a one stage breast reconstruction. Chirurgia Plastica, 7, 71. Cohen, I. K. and Turner, D. (1987). Immediate breast reconstruction with tissue expander. Clinics in Plastic Surgery, 14,491. Duchateau, J., Guelinekx, P. J., Deraemaecker, R., De Mey, A., Declety, A., Jabri, M. and Lejour, M. (1987). Analyse de 163 lambeaux de grand dorsal. Acto Chirurgica Be&co, 87,275. Elliott, L. F., Beegle, P. H and Hnrtrampf, C. R. (1990). The lateral transverse thigh free flap: an alternative for autogenous tissue breast reconstruction. Plastic and Reconstructive Surgery, 85, 169. Fisher, J., B&wick, J. and Powell, R. W. (1983). Latissimus dorsi blood supply after thoracodorsal vessel division: the serratus collateral. Plastic and Reconstructive Surgery, 72,502. Friedman, R. J., Argenta, L. C. and Anderson, R. (1985). Deep inferior epigastric free flap for breast reconstruction after radical mastectomy. Plastic and Reconstructive Surgery, 76,455. Grotting, J. C., Urist, M. N., Maddox, W. A. and Vasconez, L. 0. (1989). Conventional TRAM flap versus free microsuraical TRAM flap for immediate breast reconstruction. Plastic-and Reconstructive Surgery, %J, 828. Haraskina, T. (1980). Breast reconstruction with microsurgical free composite type tissue transfer. British Journal of Plastic Surgery, 33,30. Hartrampf, C. R. (1987). Breast reconstruction with a transverse abdominal island flap. A retrospective evaluation of 335 patients. Perspectives in Plastic Surgery, 1, 1. Hartrampf, C. R. and Bennett, G. K. (1989). Breast reconstruction using the transverse abdominal island flap. In Bohmert, H. H., Leis, H. P. and Jackson, I. T. (Eds) Breast Cancer: Conservative
and Reconstructive Surgery. Stuttgart, New York: Georg Thieme Verlag. Hartrampf, C. R., Seheflau, M. and Black, P. W. (1982). Breast reconstruction with a transverse abdominal island flap. Plastic and Reconstructive Surgery, 69,216. Hokln. J. A. B. And Silfverskiold. H. L. (1987). Breast reconstruction without an implant: results aid complications using an extended latissimus dorsi flap. Plastic and Reconstructive Surgery, 79,58. Hohnstriw, H. (1979). The free abdominoplasty flap and its use in breast reconstruction. Scandinavian Journal of Plastic and Reconstructive Surgery, 13,423. Lejour, M., AIematmo, P., De Mey, A., Gerard, T. and F.&r, H. (1985). Analyse de 56 reconstructions mammaires par lambeau de grand dorsal. Annales de Chirurgie Plostique et Esthetique, 30, 7. Lejour, M., Jab& M. and Deraemaecker, R. (1988). Analysis and long term results of 326 breast reconstructions. Clinics in Plastic Surgery, 15,689. Marshall, D., An&e, E. J. and Stapletw, M. J. (1984). Soft tissue reconstruction of the breast using an extended composite latissimus dorsi myocutaneous flap. British Journal of Plastic Surgery, 37,361. Maxwell, 6. P. (198 1). Latissimus breast reconstruction :an aesthetic assessment. Clinics in Plastic Surgery, 8, 373. Maxwell, G. P., MeGibbon, G. M. and Huopes, J. E. (1979). Vascular considerations in the use of a latissimus dorsi myocutaneous flap after amastectomywithaxillarydissection. PlasticandReconstTuctive Surgery, 64,771. Millard, D. R. (1981). Variations in the design of the latissimus dorsi flap in breast reconstruction. Annals of Plastic Surgery, 7, 269. Mlihlbauer, W. and Olbrich, R. (1977). The tatissimus dorsi myocutaneous flap for breast reconstruction. Chirurgica Plastica, 4,27. Olivari, N. (1976). The latissimus flap. British Journal of Plastic Surgery, 29,126. Papp, C., Zanon, T. and McGraw, J. (1988). Breast volume replacement using the deepithelialized latissimus dorsi myocutaneous flap. European Journalof Plastic Surgery, 11, 120. Pendergast, W., B&wick, J. and Jurkiewicz, J. M. (1980). The subcutaneous mastectomy cripple: surgical rehabilitation with the latissimus dorsi flap. Plastic and Reconstructive Surgery, 66, 554. Petit, J. Y., Margulls, A. and RIga&, L. (1983). Reconstruction mammaire sans prothbse par un lambeau musculocutanb abdominal ptdicule sur le grand droit. Annales de Chirurgie Plastique et EsthPtique, 28,283. Schneider, W. J., HBI, H. L. and Brown, R. G. (1977). Latissimus dorsi myocutaneous flap for breast reconstruction. British Journal of Plastic Surgery, 30,277. Shaw, W. W. (1983). Breast reconstruction by superior gluteal microvascular free flaps without silicone implants. Plastic and Reconstructive Surgery, 72,490. Tansini, I. (1906). Sopra il mio nuovo processo di amputazione della mamella. Gazetta Medica Italiana, 57, 141. Vasconez, L. 0. (1982). Discussion of breast aesthetics when reconstructing with the latissimus dorsi musculocutaneous flap. Plastic and Reconstructive Surgery, 70, 172. Versa&, A. (1987). A method of reconstructing a pendulous breast utilizing the tissue expander. Plastic and Reconstructive Surgery, 80.387.
The Authors A. De Mey, MD, M. Lejour, MD, A. Declety, MD, A. M. Meythlaz,
Chef de clinique adjoint Professor and Head of Department Resident MD, Resident
Department of Plastic Surgery, Brussels Free University, Brugmann Hospital, Place A. Van Gehuchten 4, 1020 Brussels, Belgium. Requests
for reprints
to Dr De Mey.
Paper received 26 May 1989. Accepted 8 May 1990 after revision.