Chimeric pedicled latissimus dorsi flap with lateral thoracic lymph nodes for breast reconstruction and lymphedema treatment in a hypercoagulable patient.

Abstract

Sir: Lymphedema of the upper extremity after breast cancer treatment has recently become an area of great interest. The reported incidence of lymphedema is approximately 21.4 percent and it generally develops within the first 2 years of treatment for breast cancer.1 Certainly, the risk of lymphedema is much higher with axillary lymph node dissection as opposed to sentinel lymph node biopsy (19.9 percent versus 5.6 percent).1 Additional risk factors for the development of lymphedema include obesity and radiation treatment.2 As the incidence of breast cancer increases with more patients being diagnosed at a younger age, the risk of developing lymphedema is anticipated to increase beyond the current rate of one in five survivors of breast cancer.1 Consequently, there is a tremendous need to develop and perfect therapeutic options to treat those afflicted with this condition. Currently, lymphovenous bypass and vascularized lymph node transfers are the only surgical treatments available.3,4 However, these procedures require microvascular anastomoses. Here, we present a 34-year-old woman with right upper extremity lymphedema resulting from bilateral breast cancer that was initially treated with bilateral lumpectomies, axillary lymph node dissection, and adjuvant radiation therapy. She then underwent bilateral prophylactic mastectomies with immediate tissue expander reconstruction at an outside institution that was complicated by infection and extrusion of the expanders. In addition, she also had a history of multiple pulmonary embolisms and deep venous thromboses. Eventually, she presented to our institution complaining of significant pain and was found to have a 9 percent increase in the size of her right arm compared with the left. Because of her history of venous thromboembolic disease, the microvascular techniques were deemed to be at extremely high risk for increased morbidity and even mortality. The patient underwent bilateral pedicled latissimus dorsi flap reconstruction with transfer of the lateral thoracic lymph nodes on the right side (Fig. 1). The patient’s postoperative course was uncomplicated and she reported complete resolution of her symptoms after 10 weeks. Currently, the patient has experienced a significant reduction in the size of her right arm by 44.4 percent to only being 5 percent larger than her left arm (Fig. 2).Fig. 1: Pedicled latissimus dorsi flap with lateral thoracic lymph nodes.Fig. 2: (Left) Preoperative view. (Right) Postoperative view after reconstruction.Delayed reconstruction with free tissue transfer from the abdomen in conjunction with vascularized lymph node transfer based on the superficial circumflex vessels or superficial inferior epigastric vessels would have been the primary option for addressing both the mastectomy defects and lymphedema in the absence of venous thromboembolic disease history.4 The lateral thoracic lymph nodes have been described as a potential donor site that can be harvested to treat both upper and lower extremity lymphedema.5 Because the lateral thoracic vessels communicate with the thoracodorsal vascular pedicle, elevation of a chimeric latissimus dorsi myocutaneous flap with a second pedicle to the lymph nodes is possible. As breast cancer treatment continues to evolve with increasing numbers of survivors, plastic and reconstructive surgeons are expected to encounter more patients with upper extremity lymphedema. In this particular subset of patients who are not candidates for microvascular procedures, a chimeric latissimus flap with vascularized lymph nodes provides an excellent option not only for breast reconstruction but also for lymphedema management. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. Dev Vibhakar, D.O. Division of Plastic and Reconstructive Surgery Sanjay Reddy, M.D. Department of Surgical Oncology Wilma Morgan-Hazelwood, O.T.R./L., C.L.T./L.A.N.A. Department of Rehabilitation Therapy Eric I. Chang, M.D. Division of Plastic and Reconstructive Surgery Fox Chase Cancer Center Philadelphia, Pa.