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Soft tissue reconstruction of the breast using an extended composite latissimus dorsi myocutaneous flap
British Journal of Plastic Surgery (1984) 37, 361-368 Cc‘ 1984 The Trustees of British Association oi Plastic Surgeons
Soft tissue reconstruction of the breast using an extended composite latissimus dorsi myocutaneous flap D. R. MARSHALL, Victorian
Plastic
E. J. ANSTEE and M. J. STAPLETON
Surgery
Unit,
Melbourne,
Australia
Summary-A method of breast reconstruction using the whole of the latissimus dorsi muscle is described in which the usual skin flap is extended to include a large de-epithelialised flap of dermis and subcutaneous tissue from the loin to provide the necessary augmentation with living tissue rather than with a prosthesis. The method can be used as a reliable one-stage reconstruction, without a prosthesis, either secondarily or as a synchronous combined procedure at the time of the mastectomy. of the breast is most commonly carried out using a latissimus dorsi myocutaneous flap to provide muscle and skin cover, while the breast volume is usually replaced with a prosthesis. The early results of this type of reconstruction are good but there is a significant complication rate relating to the prosthesis and, in the long term, capsule formation is common and outright rejection happens not infrequently (Marshall and Mutimer, 1983). A soft tissue reconstruction is preferable to one using a prosthesis but is of necessity more complex and may require multiple stages. Experience of all methods of breast reconstruction has revealed that whereas the viability of the latissimus dorsi myocutaneous flap is unmatched by any other (Bostwick, 1978), prostheses cause many problems in the long term and soft tissue reconstructions have precarious vascularity which detract from their common use. The skin and fat of the lower abdomen is an obvious donor site for a soft tissue reconstruction but, as yet, no entirely satisfactory method of accomplishing this has been described. The rectus abdominis flap is not without donor site problems (Dinner et al., 1982). The direct flap transfer (Marshall et al., 1981) is too cumbersome, and the external oblique myocutaneous flap (Marshall et al., 1982), while holding great early promise, has been found to have a too unpredictable blood supply to be recommended for routine use, particularly in the overweight patient. A possible solution would be to use the highly vascular latissimus dorsi flap to provide the normal muscle and skin required in a post mastectomy reconstruction but, in some way, to carry enough soft tissue with it to do away with the need for a prosthesis.
Reconstruction
Various methods have been described of siting the skin incision and of taking the underlying muscle when performing a latissimus dorsi flap (Wolf and Biggs, 1982). They all, of necessity, cut across the latissimus dorsi muscle and, whether a small or large portion of the muscle remains, it is completely denervated and subsequent to the operation gradually atrophies. There is thus no reason why one should not transfer the whole of the latissimus dorsi muscle and carry with it into the breast a much larger volume of skin and subcutaneous tissue than was previously possible. The muscle extends from the angle of the scapula to the iliac crest and there is considerably more subcutaneous tissue sited over the lower part of the muscle than there is over the upper portion. Method
The whole of the muscle and a large volume of adherent subcutaneous tissue from the loin, equal to that of the prosthesis usually employed in breast reconstruction, can be safely raised on the subscapular vascular pedicle and be used to achieve a one-stage breast reconstruction without the need for a prosthesis. The operation is most suitable in a woman with a breast of average size and, as illustrated in the first case (Figs. 1 and 2), is carried out with the patient on her side. A large sickle of skin and fat is outlined on the back, lower down than usual. The sickle is planned to be let into the submammary groove, and is outlined to lie basically in the skin fold below the scapula, as more tissue can be taken in this plane and the wound can be closed without tension (Fig. 3). The large dart of skin, marked out beneath the sickle, extends down over the lower portion of the 361
362
BRITISH JOURNAL OF PLASTIC SURGERY
Fig. 1
Fig. 2
Figures 1 and 2-This patient had a Patey mastectomy for carcinoma of the breast two years prior to reconstruction. She has a normal left breast of average size. The planned incision is shown as the flap placed in the submammary groove, in general, produces a better breast contour.
latissimus dorsi muscle as far as the iliac crest to provide a “T’‘-shaped flap of skin and subcutaneous tissue. The epithelium is removed from the vertical portion of the “T” of skin and fat (Fig. 4) and then the flap is elevated in the usual way. The muscle is dissected off the underlying serratus anterior and from the overlying skin and fat up to the axilla but it is not necessary to dissect beyond the branches of the subscapular vessels to the serratus anterior muscle. The lower portion of the muscle is dissected off the thoracic and lumbar spines and from the posterior portion of the iliac crest and out laterally
to its free border. The muscle is dissected upwards off the rib cage where it interdigitates with the external oblique muscle and the large flap of subcutaneous tissue is left attached to the muscle throughout (Fig. 5). There is no problem with the viability and at the completion of the dissection the flap is seen bleeding freely. It is fortunate that the subcutaneous tissue situated in the loin corresponds in most women to the size of the breast. In a relatively thin woman there is a small but adequate amount of soft tissue in the loin for breast reconstruction, whereas in a woman with a larger breast, there is a large amount of subcutaneous
SOFT TISSUE RECONSTRUCTION
OF THE BREAST
Fig. 3
/
Fig. 4 Figures 3 and 4-The sickle-shaped skin flap and its dermis/subcutaneous the area which is de-epithelialised are shown.
tissue in this region which can be used. Direct closure of the defect is achieved by rnobilising the skin across the midline by dissecting it off the spines of the lumbar vertebrae (Fig. 6). The flap is transferred around anteriorly and is let into the incision in the submammary groove. The skin and subcutaneous tissue is lifted off the chest wall to accomm’l)date the new breast. Any remnant of pectoral muscle is left attached to the skin flap as problems of viability are more likely to be encountered here than with the composite latissimus dorsi flap. The sickle-shaped flap of skin is inserted into the defect created in the submammary groove and the
extension all overlying the latissimus dorsi muscle and
de-epithelialised skin and subcutaneous tissue and the lower portion of muscle is turned beneath the skin flap and sutured to the muscle higher up to provide adequate bulk in the upper portion of the reconstructed breast. Only a few sutures are necessary and the breast tissue is allowed to fall into the somewhat dependent shape of the normal breast. The wounds are closed with drainage. The operation takes approximately 1 to 1% hours. Blood loss is usually less than 500 ccs and blood transfusion is only occasionally necessary. The end result three months later is a soft breast similar to the other side. The new breast has normal mobility on the chest wall (Figs. 7,8 and 9).
364
BRITISH JOURNAL OF PLASTIC SURGERY
I
Fig. 5
Figure 5-The
whole of the latissimus dorsi muscle is elevated and extends to the limits of the de-epithelialised flap.
Fig. 6
Figure 6-Wound drain tube.
closure is achieved directly as shown by wide mobilisation of the skin and subcutaneous tissue. Note the large
SOFT TISSUE
RECONSTRUCTION
365
OF THE BREAST
Fig. 7 Fig. 10
Fig.
a Fig. 11
Fig. 9 Figures 7, 8 and 9-Three months post-operatively the flap has settled into position, is quite mobile and soft and is the same volume as the opposite breast. Note the mobility of the breast when the arms are extended. In this case, no nipple reconstruction has been carried out.
Fig. 12 Figures 10, 11 and 12-Photographs of a 40-year-old woman in whom mastectomy has been carried out some 2 years prior to the reconstruction. Note the normal breast of moderate size. Again the flap is to be inserted into an incision to be made in the submammary groove.
366
BRITISH JOURNAL OF PLASTIC SURGERY
Fig. 16 Fig1ure l&The limits of the latissimus dorsi muscle are shoIwn and the large sickle of skin and fat to replace the skin defec :t is shown running in the crease line, well below the angle of the scapula. The large dart of skin to be de-epithehalised runs inferiorly to this, down to and over the iliac crest. Figures 14, 15 and 16-The result 3 months later is seen and the breast is of similar volume to the normal side. A nipple reconstruction has been carried out using a composite graft and symmetrical breasts of normal consistency are the result. No prosthesis has been used.
Fig. i4
The second case illustrates a complete one-stage reconstruction of a more ptotic breast of average size (Figs 10, 11 and 12). The extent of the donor flap is shown (Fig. 13). At the completion of the operation a nipple reconstruction may be carried out by taking a composite graft from the central prominence with a circumareolar whole skin graft from the normal side. This also allows a minimum uplift. The end result of the reconstruction is a breast of satisfactory contour and volume, either the same as, or greater than the normal side (Fig. 14, 15 and 16). No prosthesis is required, the operation is carried out in one stage, the donor scar while obvious, is acceptable (Fig. 17), and the complication rate is sufficiently small to allow its routine use for reconstruction of the breast after mastectomy. In appropriate cases the reconstruction can also be carried out as a synchronous combined procedure in combination with a mastectomy (Fig. 18). Under these circumstances, two teams work together: the skin flap and subcutaneous attachment on the back is planned to replace accurately the loss and is transferred forward on the muscle where it is inserted into the skin defect
SOFT TISSUE RECONSTRUCTION
367
OF THE BREAST
Fig. 17
Figure 17-The donor scar can be seen and, although extensive, is in a position where it is not normally seen by the patient and is well accepted.
to produce a breast of normal shape and size (Figs. 19 and 20). Discussion The soft tissue reconstruction eliminates the problem of late complications caused by the prosthesis
and the reconstructed breast looks and feels remarkably normal. The only shortcoming of the operation as a solution for the patient with prosthetic problems is that it cannot be performed once a standard latissimus dorsi flap and prosthesis has already been carried out. The decision to use this method of reconstruction thus needs to be made in the first instance and should always be considered, as the main problem of breast reconstruction, namely, those related to the prosthesis, are effectively circumvented. The end result is a breast of normal contour and mobility, which alters in size with changes in the patient’s weight: truly a “living breast”. The main advantage of the method is that the excellent blood supply of the latissimus dorsi myocutaneous flap allows the transfer of a large volume of subcutaneous tissue required for the reconstruction without any problems of viability. The procedure is well tolerated by the patient and the post-operative recovery has been much faster than for a rectus abdominis or external oblique myocutaneous flap reconstruction. The method has been used in twelve cases without any vascular problems. The only complication has been the development of a seroma beneath the skin flaps of the back in three patients which responded promptly to aspiration. The donor scar, while obvious, is in an area where it is out of sight and has been well accepted.
Fig. 18 Figure 18-Photograph of a 27-year-old woman with a small breast in whom a biopsy has proven a carcinoma on the right side. The intended excision of the skin and nipple for a Patey-type mastectomy is shown.
368
BRITISH JOURNAL OF PLASTIC SURGERY
Figures 19 and 20-A simultaneous extended composite latissimus dorsi flap reconstruction was performed and the result is seen some 3 months later showing symmetrical breasts of soft and normal contour. No prosthesis has been used.
References Bostwick, J., Vasconez, L. 0. and Jurkiewicz, M. J. (1978). Breast reconstruction after radical mastectomy. Plastic and Reconstructive Surgery, 61, 682.
Dinner, M. I., Labandter, H. P. and Dowden, R. V. (1982). The role of the rectus abdominis myocutaneous flap in breast reconstruction. Plastic and Reconstructive Surgery, 69, 209. Marshall, D. R., Anstee, E. J. and Stapleton, M. J. (1981). Post-mastectomy breast reconstruction using a direct flap from an abdominal lipectomy. British Journal of Plastic Surgery, 34,280.
Marshall, D. R. and Mutimer, K. A. (1983). Paper delivered at the 56th General Scientific Meeting of the Royal Australasian College of Surgeons, Hong Kong.
Wolf, L. E. and Biggs, T. M. (1982). Aesthetic refinements in the use of the latissimus dorsi flap in breast reconstruction. Plastic and Reconstructive Surgery, 69, 788.
The Authors Donald R. Marshall, FRACS, FACS, Senior Plastic Surgeon, Prince Henry’s Hospital, Melbourne, Australia. E. John Anstee, FRACS, Senior Plastic Surgeon, Alfred Hospital, Melbourne, Australia. Murray J. Stapleton, FRACS, Senior Plastic Surgeon, Queen Victoria Medical Centre, Melbourne, Australia. Requests for reprints to: Donald R. Marshall, FRACS, FACS, P.O. Box 198, Kew 3101, Melbourne, Australia.
Soft tissue reconstruction of the breast using an extended composite latissimus dorsi myocutaneous flap D. R. MARSHALL, Victorian
Plastic
E. J. ANSTEE and M. J. STAPLETON
Surgery
Unit,
Melbourne,
Australia
Summary-A method of breast reconstruction using the whole of the latissimus dorsi muscle is described in which the usual skin flap is extended to include a large de-epithelialised flap of dermis and subcutaneous tissue from the loin to provide the necessary augmentation with living tissue rather than with a prosthesis. The method can be used as a reliable one-stage reconstruction, without a prosthesis, either secondarily or as a synchronous combined procedure at the time of the mastectomy. of the breast is most commonly carried out using a latissimus dorsi myocutaneous flap to provide muscle and skin cover, while the breast volume is usually replaced with a prosthesis. The early results of this type of reconstruction are good but there is a significant complication rate relating to the prosthesis and, in the long term, capsule formation is common and outright rejection happens not infrequently (Marshall and Mutimer, 1983). A soft tissue reconstruction is preferable to one using a prosthesis but is of necessity more complex and may require multiple stages. Experience of all methods of breast reconstruction has revealed that whereas the viability of the latissimus dorsi myocutaneous flap is unmatched by any other (Bostwick, 1978), prostheses cause many problems in the long term and soft tissue reconstructions have precarious vascularity which detract from their common use. The skin and fat of the lower abdomen is an obvious donor site for a soft tissue reconstruction but, as yet, no entirely satisfactory method of accomplishing this has been described. The rectus abdominis flap is not without donor site problems (Dinner et al., 1982). The direct flap transfer (Marshall et al., 1981) is too cumbersome, and the external oblique myocutaneous flap (Marshall et al., 1982), while holding great early promise, has been found to have a too unpredictable blood supply to be recommended for routine use, particularly in the overweight patient. A possible solution would be to use the highly vascular latissimus dorsi flap to provide the normal muscle and skin required in a post mastectomy reconstruction but, in some way, to carry enough soft tissue with it to do away with the need for a prosthesis.
Reconstruction
Various methods have been described of siting the skin incision and of taking the underlying muscle when performing a latissimus dorsi flap (Wolf and Biggs, 1982). They all, of necessity, cut across the latissimus dorsi muscle and, whether a small or large portion of the muscle remains, it is completely denervated and subsequent to the operation gradually atrophies. There is thus no reason why one should not transfer the whole of the latissimus dorsi muscle and carry with it into the breast a much larger volume of skin and subcutaneous tissue than was previously possible. The muscle extends from the angle of the scapula to the iliac crest and there is considerably more subcutaneous tissue sited over the lower part of the muscle than there is over the upper portion. Method
The whole of the muscle and a large volume of adherent subcutaneous tissue from the loin, equal to that of the prosthesis usually employed in breast reconstruction, can be safely raised on the subscapular vascular pedicle and be used to achieve a one-stage breast reconstruction without the need for a prosthesis. The operation is most suitable in a woman with a breast of average size and, as illustrated in the first case (Figs. 1 and 2), is carried out with the patient on her side. A large sickle of skin and fat is outlined on the back, lower down than usual. The sickle is planned to be let into the submammary groove, and is outlined to lie basically in the skin fold below the scapula, as more tissue can be taken in this plane and the wound can be closed without tension (Fig. 3). The large dart of skin, marked out beneath the sickle, extends down over the lower portion of the 361
362
BRITISH JOURNAL OF PLASTIC SURGERY
Fig. 1
Fig. 2
Figures 1 and 2-This patient had a Patey mastectomy for carcinoma of the breast two years prior to reconstruction. She has a normal left breast of average size. The planned incision is shown as the flap placed in the submammary groove, in general, produces a better breast contour.
latissimus dorsi muscle as far as the iliac crest to provide a “T’‘-shaped flap of skin and subcutaneous tissue. The epithelium is removed from the vertical portion of the “T” of skin and fat (Fig. 4) and then the flap is elevated in the usual way. The muscle is dissected off the underlying serratus anterior and from the overlying skin and fat up to the axilla but it is not necessary to dissect beyond the branches of the subscapular vessels to the serratus anterior muscle. The lower portion of the muscle is dissected off the thoracic and lumbar spines and from the posterior portion of the iliac crest and out laterally
to its free border. The muscle is dissected upwards off the rib cage where it interdigitates with the external oblique muscle and the large flap of subcutaneous tissue is left attached to the muscle throughout (Fig. 5). There is no problem with the viability and at the completion of the dissection the flap is seen bleeding freely. It is fortunate that the subcutaneous tissue situated in the loin corresponds in most women to the size of the breast. In a relatively thin woman there is a small but adequate amount of soft tissue in the loin for breast reconstruction, whereas in a woman with a larger breast, there is a large amount of subcutaneous
SOFT TISSUE RECONSTRUCTION
OF THE BREAST
Fig. 3
/
Fig. 4 Figures 3 and 4-The sickle-shaped skin flap and its dermis/subcutaneous the area which is de-epithelialised are shown.
tissue in this region which can be used. Direct closure of the defect is achieved by rnobilising the skin across the midline by dissecting it off the spines of the lumbar vertebrae (Fig. 6). The flap is transferred around anteriorly and is let into the incision in the submammary groove. The skin and subcutaneous tissue is lifted off the chest wall to accomm’l)date the new breast. Any remnant of pectoral muscle is left attached to the skin flap as problems of viability are more likely to be encountered here than with the composite latissimus dorsi flap. The sickle-shaped flap of skin is inserted into the defect created in the submammary groove and the
extension all overlying the latissimus dorsi muscle and
de-epithelialised skin and subcutaneous tissue and the lower portion of muscle is turned beneath the skin flap and sutured to the muscle higher up to provide adequate bulk in the upper portion of the reconstructed breast. Only a few sutures are necessary and the breast tissue is allowed to fall into the somewhat dependent shape of the normal breast. The wounds are closed with drainage. The operation takes approximately 1 to 1% hours. Blood loss is usually less than 500 ccs and blood transfusion is only occasionally necessary. The end result three months later is a soft breast similar to the other side. The new breast has normal mobility on the chest wall (Figs. 7,8 and 9).
364
BRITISH JOURNAL OF PLASTIC SURGERY
I
Fig. 5
Figure 5-The
whole of the latissimus dorsi muscle is elevated and extends to the limits of the de-epithelialised flap.
Fig. 6
Figure 6-Wound drain tube.
closure is achieved directly as shown by wide mobilisation of the skin and subcutaneous tissue. Note the large
SOFT TISSUE
RECONSTRUCTION
365
OF THE BREAST
Fig. 7 Fig. 10
Fig.
a Fig. 11
Fig. 9 Figures 7, 8 and 9-Three months post-operatively the flap has settled into position, is quite mobile and soft and is the same volume as the opposite breast. Note the mobility of the breast when the arms are extended. In this case, no nipple reconstruction has been carried out.
Fig. 12 Figures 10, 11 and 12-Photographs of a 40-year-old woman in whom mastectomy has been carried out some 2 years prior to the reconstruction. Note the normal breast of moderate size. Again the flap is to be inserted into an incision to be made in the submammary groove.
366
BRITISH JOURNAL OF PLASTIC SURGERY
Fig. 16 Fig1ure l&The limits of the latissimus dorsi muscle are shoIwn and the large sickle of skin and fat to replace the skin defec :t is shown running in the crease line, well below the angle of the scapula. The large dart of skin to be de-epithehalised runs inferiorly to this, down to and over the iliac crest. Figures 14, 15 and 16-The result 3 months later is seen and the breast is of similar volume to the normal side. A nipple reconstruction has been carried out using a composite graft and symmetrical breasts of normal consistency are the result. No prosthesis has been used.
Fig. i4
The second case illustrates a complete one-stage reconstruction of a more ptotic breast of average size (Figs 10, 11 and 12). The extent of the donor flap is shown (Fig. 13). At the completion of the operation a nipple reconstruction may be carried out by taking a composite graft from the central prominence with a circumareolar whole skin graft from the normal side. This also allows a minimum uplift. The end result of the reconstruction is a breast of satisfactory contour and volume, either the same as, or greater than the normal side (Fig. 14, 15 and 16). No prosthesis is required, the operation is carried out in one stage, the donor scar while obvious, is acceptable (Fig. 17), and the complication rate is sufficiently small to allow its routine use for reconstruction of the breast after mastectomy. In appropriate cases the reconstruction can also be carried out as a synchronous combined procedure in combination with a mastectomy (Fig. 18). Under these circumstances, two teams work together: the skin flap and subcutaneous attachment on the back is planned to replace accurately the loss and is transferred forward on the muscle where it is inserted into the skin defect
SOFT TISSUE RECONSTRUCTION
367
OF THE BREAST
Fig. 17
Figure 17-The donor scar can be seen and, although extensive, is in a position where it is not normally seen by the patient and is well accepted.
to produce a breast of normal shape and size (Figs. 19 and 20). Discussion The soft tissue reconstruction eliminates the problem of late complications caused by the prosthesis
and the reconstructed breast looks and feels remarkably normal. The only shortcoming of the operation as a solution for the patient with prosthetic problems is that it cannot be performed once a standard latissimus dorsi flap and prosthesis has already been carried out. The decision to use this method of reconstruction thus needs to be made in the first instance and should always be considered, as the main problem of breast reconstruction, namely, those related to the prosthesis, are effectively circumvented. The end result is a breast of normal contour and mobility, which alters in size with changes in the patient’s weight: truly a “living breast”. The main advantage of the method is that the excellent blood supply of the latissimus dorsi myocutaneous flap allows the transfer of a large volume of subcutaneous tissue required for the reconstruction without any problems of viability. The procedure is well tolerated by the patient and the post-operative recovery has been much faster than for a rectus abdominis or external oblique myocutaneous flap reconstruction. The method has been used in twelve cases without any vascular problems. The only complication has been the development of a seroma beneath the skin flaps of the back in three patients which responded promptly to aspiration. The donor scar, while obvious, is in an area where it is out of sight and has been well accepted.
Fig. 18 Figure 18-Photograph of a 27-year-old woman with a small breast in whom a biopsy has proven a carcinoma on the right side. The intended excision of the skin and nipple for a Patey-type mastectomy is shown.
368
BRITISH JOURNAL OF PLASTIC SURGERY
Figures 19 and 20-A simultaneous extended composite latissimus dorsi flap reconstruction was performed and the result is seen some 3 months later showing symmetrical breasts of soft and normal contour. No prosthesis has been used.
References Bostwick, J., Vasconez, L. 0. and Jurkiewicz, M. J. (1978). Breast reconstruction after radical mastectomy. Plastic and Reconstructive Surgery, 61, 682.
Dinner, M. I., Labandter, H. P. and Dowden, R. V. (1982). The role of the rectus abdominis myocutaneous flap in breast reconstruction. Plastic and Reconstructive Surgery, 69, 209. Marshall, D. R., Anstee, E. J. and Stapleton, M. J. (1981). Post-mastectomy breast reconstruction using a direct flap from an abdominal lipectomy. British Journal of Plastic Surgery, 34,280.
Marshall, D. R. and Mutimer, K. A. (1983). Paper delivered at the 56th General Scientific Meeting of the Royal Australasian College of Surgeons, Hong Kong.
Wolf, L. E. and Biggs, T. M. (1982). Aesthetic refinements in the use of the latissimus dorsi flap in breast reconstruction. Plastic and Reconstructive Surgery, 69, 788.
The Authors Donald R. Marshall, FRACS, FACS, Senior Plastic Surgeon, Prince Henry’s Hospital, Melbourne, Australia. E. John Anstee, FRACS, Senior Plastic Surgeon, Alfred Hospital, Melbourne, Australia. Murray J. Stapleton, FRACS, Senior Plastic Surgeon, Queen Victoria Medical Centre, Melbourne, Australia. Requests for reprints to: Donald R. Marshall, FRACS, FACS, P.O. Box 198, Kew 3101, Melbourne, Australia.