Muscle-sparing Latissimus Dorsi Flap Research Articles

Enhancing Viability of the Muscle-Sparing Latissimus Dorsi Flap

Aim:The aim of this study is to enhance the viability of the muscle-sparing latissimus dorsi flap. In this study, the muscle-sparing latissimus dorsi myocutaneous flap was designed with the skin paddle of the flap over the distal perforators of the thoracodorsal artery and perforators of the 10th or 11th posterior intercostal arteries. The flap was elevated together with the deep fascia at the base. Methods: Sixteen flaps were used for the repair of defects in different regions in 14 patients, five female and nine male, with a mean age of 45 years. Flap sizes vary from 9x21 to 14x27 cm. The defects were located in anterior thoracic wall in patient four, arm in patient three, axillary fossa in patient three, deltopectoral region in patient two and posterior thoracic wall in patient two. The mean follow-up period was 13 months. Result: All flaps survived without total or partial loss. Seroma or contour deformity in the donor area did not develop. A visible scar developed in the donor area in a patient. Flap thinning was performed on two flaps. In all patients, shoulder joint function returned to normal in the last months postoperatively. Conclusions: If the muscle-sparing latissimus dorsi flap is prepared to include the skin paddle 10th or 11th posterior intercostal arteries and together with the deep fasciae (dorsal thoracic fascia and scarpa’s fascia), it can be safely elevated large sizes.

Combining Wise-pattern Volume Displacement and Autologous Volume Replacement to Facilitate Oncoplastic Breast Conservation

Background: Oncoplastic breast conservation has been classically divided into volume displacement (VD) or volume replacement (VR) techniques. There have been few descriptions of merging these two approaches. This report describes our experience combining Wise-pattern VD and autologous VR to repair extensive partial mastectomy defects in patients with ptosis. Methods: A retrospective chart review was performed for patients who underwent combined Wise-pattern VD surgery and autologous VR by the author from June 2017 to June 2023, with at least 6 months follow-up. Patient demographics, oncological and intraoperative details, and complications were recorded. Results: Forty patients underwent Wise-pattern VD surgery combined with a medial intercostal artery perforator flap (five patients), lateral thoracic artery perforator/lateral intercostal artery perforator flap (18 patients), anterior intercostal artery perforator flap (five patients), or muscle-sparing latissimus dorsi flap (12 patients). The average tumor size was 4.0 cm (range, 1.5–9.1 cm), and specimen weight was 152 g (range, 33–415 g). Six patients (15%) required re-operation for positive margins. There was delayed healing of three (7.5%) donor sites. There were no flap failures. Two (5%) patients had clinically apparent fat necrosis without requirement for surgical revision. Conclusions: This report demonstrates the feasibility of combining Wise-pattern VD and autologous VR. We propose that oncoplastic breast-conserving surgery be no longer divided into two mutually exclusive approaches and that surgeons make liberal use of combining these approaches to address challenging cases of breast-conserving surgery.

Muscle-sparing latissimus dorsi flap for inferior limbÓ?s defects reconstruction in children

Muscle-sparing latissimus dorsi flap for inferior limbÓ?s defects reconstruction in children

Morbidity and quality of life following breast reconstruction by autologous latissimus dorsi flap, muscle sparing latissimus dorsi flap and thoracodorsal artery perforator flap

Background: Morbidity following autologous latissimus dorsi flap (ALD), muscle sparing latissimus dorsi flap (MSLD) and thoracodorsal artery perforator flap (TAP) is controversial. The purpose of this study was to measure morbity using Quick Dash at 1 month and 1 year following breast reconstruction with one of these three flaps. The second objective was the evaluation of quality of life using Breast-Q.

Morbidité et qualité de vie après reconstruction mammaire par lambeau de grand dorsal autologue, à épargne musculaire et perforant

Morbidity following autologous latissimus dorsi flap (ALD), muscle sparing latissimus dorsi flap (MSLD) and thoracodorsal artery perforator flap (TAP) is controversial. The purpose of this study was to measure morbity using Quick Dash at 1month and 1year following breast reconstruction with one of these three flaps. The second objective was the evaluation of quality of life using Breast-Q. Thirty four consecutive patients who had undergone breast reconstruction were included in this monocentric and prospective study: 10patients in the ALD group, 12patients in the MSLD group and 12patients in the TAP group. At 1month and 1year following surgery, the variation of Quick Dash was 13,63and 2,38in the ALD group, 3,41and -1,13in the MSLD group and 5,69and 0in the TAP group. Satisfaction whith breasts, psychosocial, sexual and chest well-being were higher in the ALD group. Satisfaction with back was higher in the MSLD and TAP groups. Back and shoulder well-being was comparable regardless of the flap. Seroma occurrence was very rare in case of TAP, rare and not abundant in case of MSLD and frequent in case of ALD. This study appears to confirm that immediate morbidity is less important with MSLD or TAP than ALD. Hoewever at one year following surgery, morbity seems to be comparable with the 3flaps. Patients satisfaction seems to be higher with ALD except for the aspect of the back.

Salvage of infected implant-based breast reconstructions in morbidly obese patients with explantation and replacement with an autologous muscle-sparing latissimus dorsi flap

Morbidly obese patients who undergo reconstruction with implants after mastectomy are at higher risk of reconstructive failure. Prosthetic infection historically required explantation with plans for delayed implant-based reconstruction or conversion to autologous tissue. Loss of the skin envelope in the delayed setting often leads to poor aesthetic outcomes. Recently, several different approaches for salvage of infected implant-based reconstructions with immediate prosthetic replacement have been described. While these strategies have proven useful in many patients, we find a prohibitive risk of failure of this approach in the morbidly obese, especially in those undergoing chemotherapy or who have been radiated. Instead, we have offered these patients salvage of their reconstructions with explantation and immediate autologous conversion to a muscle-sparing latissimus dorsi flap. Here, we report on 11 morbidly obese patients where this strategy was utilized.

Optimizing Aesthetics in Reconstructive Breast Surgery Using Muscle-Sparing Latissimus Dorsi Flap in Radiated and Nonradiated Patients.

The latissimus dorsi musculocutaneous flap (LDMF) has been a workhorse for breast reconstruction. Its high rate of donor-site morbidity has led to the advent of the muscle-sparing latissimus dorsi flap (MSLDF). However, there are very limited reports using the MSLDF in irradiated patients. Prior studies of MSLDF have either precluded previously radiated patients from receiving MSLDF or have included them as part of their larger MSLSDF cohort without specifically analyzing their outcome as a separate group or comparing them to the traditional LDMF group. We describe the technique and outcome of MSLDF in both radiated and nonradiated patients and compare the outcome to our LDMF patients. A retrospective chart review of patients undergoing breast reconstruction between 2003 and 2020 using either a pedicled MSLDF or LDMF with a transverse skin paddle was conducted. All patients underwent a 2-stage reconstruction with the flap and tissue expander placement done during the first stage, and replacement with implant and, if needed, fat grafting to enhance soft tissue during the second stage. Complications, subjective functional morbidity, and aesthetic outcomes were reviewed. A total of 35 MSLDFs and 40 LDMFs were performed: 24 MSLDFs (69%) and 25 LDMFs (63%) were inset into a previously irradiated field. There were 2 cases of infection requiring explantation in both MSLDF (8.3%) and LDMF (8.0%) radiated cohorts. There were no cases of donor-site seroma in the MSLDF cohorts versus 12 (30%) in the LDMF cohorts. Minor distal tip superficial epidermolysis was seen in 5 MSLDFs (14.3%), 3 of which were in the radiated cohort, and in 1 LDMF (2.5%) radiated cohort with no cases of flap loss. Functional and aesthetic outcomes were satisfactory. Four patients who had a unilateral MSLDF had a completion upper back lift. This is the largest series to date demonstrating the use of the MSLDF in both nonradiated and radiated patients and comparing it to a standard LDMF for breast reconstruction by the same surgeon. The pedicled MSLDF is a versatile option for breast reconstruction in radiated patients, and radiation should not be considered a contraindication for its use.

Immediate Skin Replacement Allows for Nipple-sparing, Direct-to-implant Reconstruction in Patients with Advanced Breast Cancers.

Summary:Mastectomy has evolved from approaches that involved extensive skin resection to nipple-sparing mastectomy (NSM). However, patients with advanced breast cancers who require extensive skin resection usually also have their nipple areola complexes (NACs) removed, even if they are distant from the cancer. Implant reconstruction in these patients is challenging as they require tissue expansion and, typically, radiotherapy with additional surgeries to complete their reconstruction. The aesthetic results of this approach are inferior to NSM and direct-to-implant reconstruction. In patients who require significant skin resection but whose NACs are free of tumor, we have found that immediate skin replacement using a muscle-sparing latissimus dorsi flap allows for NSM and direct-to-implant reconstruction, obviating the need for tissue expansion, delayed implant placement, and NAC reconstruction. Here, we report on 12 patients in whom this approach is utilized.

Combined Endoscopy-Assisted Muscle-Sparing Latissimus Dorsi Flap Harvesting with Lipofilling Enhancement as a New Volume Replacement Technique in Breast Reconstruction.

Introduction This study evaluated the feasibility and patient satisfaction of combined endoscopy-assisted muscle-sparing latissimus dorsi flap harvesting, with lipofilling enhancement for skin-preserving mastectomy. Methods This is a prospective study that included 21 female patients with small breasts (cup size A-B), subjected to skin-preserving mastectomy as a management of breast cancer. Combined endoscopy-assisted muscle-sparing latissimus dorsi flap harvesting with lipofilling enhancement was performed for immediate breast reconstruction. Patients were followed up for early and late postoperative complications including recurrence for at least 24 months. Postoperative patient satisfaction was assessed using the Kyungpook National University Hospital breast reconstruction satisfaction questionnaire. Results The study included 21 female patients with a mean age of 42.10 ± 8.46 years. Patients were followed up for 26.67 ± 3.38 months. The procedure was successful in all patients with a mean duration of 172.05 ± 28.22 minutes. Local recurrence was encountered in one patient (4.67%). Eighteen patients declared their satisfaction 6 months after the operation, while two patients were satisfied only after the second session of lipofilling. The overall postoperative patient satisfaction was 95.24%. The majority of the patients (93.3%) who underwent NSM surgery were satisfied, while only two-thirds (66.6%) of the patients who underwent SSM surgery were satisfied. Conclusions Combined endoscopy-assisted muscle-sparing latissimus dorsi flap harvesting with lipofilling enhancement seems to be a feasible and encouraging technique for the volume adjustment of small breasts, especially in nipple-sparing mastectomy. It leaves a minor back scar and has an acceptable rate of postoperative complications. The procedure showed high postoperative patient satisfaction.

Muscle sparing latissimus dorsi flap for reconstruction of a large chemo-necrosis of the chest wall: A case report

Extravasation of chemotherapeutic agents is a common complication in cancer centers. In severe cases involving large tissue necrosis, surgery may be needed to resect necrotic tissues and to cover the exposed areas. A 71 years old women was referred to our unit two month after extravasation of epirubicin from an implanted port-a-cath with a large chemonecrosis of the anterior chest wall. She presented an evolutive tissue necrosis extending from the upper anterior thoracic region to the right breast. Surgical debridements and negative wound pressure therapy were necessary in order to obtain clean areas. The final chest wall defect was covered using a Muscle Sparing Latissimus Dorsi pedicled flap. This surgical management have permitted a satisfying wound healing and functional recovery without any complication. Chemotherapeutics' extravasations can be a severe complication of oncologic treatment and have to be discussed between oncologists and plastic surgeons to find the most effective and suitable solution with consideration of the specificities of cancer therapy. In chest wall skin defect, the use of muscle sparing latissimus dorsi pedicled flap is a robust solution with low morbidity of the donor site.

Muscle-Sparing Latissimus Dorsi Flap in Breast Reconstruction: Experience from a Tertiary Care Center in a Developing Country

Muscle-Sparing Latissimus Dorsi Flap in Breast Reconstruction: Experience from a Tertiary Care Center in a Developing Country

Evaluation of seromas in postmastectomy breast reconstruction: A retrospective observational study

BackgroundTo evaluate seroma complications, two techniques were carried out in breast reconstruction: conventional latissimus dorsi flap (CLD) and muscle-sparing latissimus dorsi flap (MSLD) after cancer-related mastectomy. MethodsA total of 108 postmastectomy procedures were performed with autologous tissue reconstruction with latissimus dorsi flaps (LDs) between January 2016 and May 2020. The patients were divided into two groups. The first group was reconstruction with the CLD, and the second group was reconstruction with the MSLD. Forty (40) patients in the first group and 68 patients in the second group were analyzed. Seroma formation was evaluated as the primary outcome. ResultsThe total number of seromas found in the donor area was 27, of which 45% (n = 18) were found with the CLD and 13.24% (n = 9) with the MSLD, with a difference of 31.76% in favor of the MSLD, with an 95% CI of 14–49 (p < 0.001). ConclusionsWe found a significantly lower incidence of seroma as a complication in patients who underwent MSLD breast reconstruction compared with those who underwent CLD breast reconstruction.

Outcome comparison between thoracodorsal artery perforator flap and muscle-sparing latissimus dorsi flap in axillary reconstruction after hidradenitis suppurativa excision.

Thoracodorsal artery perforator (TDAP) flap and muscle-sparing latissimus dorsi (MSLD) flap have been frequently used for axillary coverage after hidradenitis suppurativa (HS) excision. However, none showed superiority to others. This study compared both flaps to define the ideal option, highlighting flap outcomes and functional and aesthetic results. A retrospective study was conducted to compare both flaps that were used for axillary reconstruction in nine patients with bilateral HS Hurley stage III between 2017 and 2020. Eight TDAP and 10 MSLD flaps underwent functional evaluation using shoulder abduction angle (SA); the Disabilities of the Arm, Shoulder, and Hand (DASH) score; visual analog scale (VAS) for pain; and the Dermatology Life Quality Index (DLQI) questionnaires. Aesthetic assessment included the Scar Cosmesis Assessment and Rating (SCAR) scale and arm-chest interval. The mean operating time was 194.4 ± 51.58 and 128.5 ± 31.45 min for TDAP and MSLD (p =.009), respectively. Flap complications were significantly higher in the TDAP group (p =.034). There was no significant difference between both groups regarding SA; DASH, DLQI, VAS, and SCAR scale (p > .05). The mean arm-chest interval was significantly longer in the MSLD than in the TDAP group by 6.9 mm (p =.001). TDAP and MSLD are comparable versatile flaps to eradicate axillary HS with higher TDAP flap complications. Although the TDAP flap is less bulky than the MSLD flap, the MSLD flap shortens the harvesting time without a significant difference in functional outcomes and scar results.

Modified Incision for Muscle-sparing Latissimus Dorsi to Increase Flap Perfusion in the Morbidly Obese.

Summary:The muscle-sparing latissimus dorsi flap relies on perforators from the descending branch of the thoracodorsal artery. Previous descriptions placed a transverse skin island independent of perforator location, as any design was thought to capture enough perforators to ensure flap survival. We have found this approach prone to complications when attempting breast reconstruction in obese patients who require large flap volumes. Although the most proximal perforators have the most reliable blood flow, inclusion of these perforators reduces the arc of rotation, as the flap would be close to the pivot point at the most cranial point of muscle division, leaving significant volume in the axilla. Here we describe a modified skin incision that includes all of the proximal perforators but also allows us free design of the skin island to harvest those areas of the back with maximal subcutaneous tissue and with enough distance from the pivot point to optimize arc of rotation.

Lower Pole Breast Reconstruction Using Muscle-sparing Latissimus Dorsi Flap in Postburn Breast Deformity.

Background:Full-thickness burns of the anterior chest wall during childhood are a devastating problem that results in significant distortion of the developing breast. This deformed burnt breast represents a serious aesthetic problem, and can lead to functional impairment as well as severe emotional trauma for patients.Methods:Patients with postburn scarring affecting the lower pole of the breast were included. Only patients with small to medium-sized breasts were targeted. The lower breast pole was reconstructed using muscle-sparing latissimus dorsi flap. All patients had been subjectively assessed, including overall patient satisfaction regarding breast aesthetics, donor site morbidity, and functional deficits of latissimus dorsi muscle, 3 months postoperatively.Results:Six patients (seven breasts) were included in this study. Muscle-sparing latissimus dorsi flap was used to reconstruct lower breast pole in all patients. A horizontally-oriented skin paddle was used in five patients, whereas a vertically oriented skin paddle was used in one patient. Average patient satisfaction was 9.1 (SD 0.6) for the reconstructed lower breast pole. For the donor site, average overall satisfaction was 9.1 (SD 0.8). Latissimus dorsi muscle function was objectively confirmed in 90% of cases after 3 months postoperatively. Patients had an average score of 3.9 (SD 0.4) for the activity score as well.Conclusions:The muscle-sparing latissimus dorsi flap is a good reconstructive tool for lower breast pole in postburn breast reconstruction. It has a reliable versatile skin paddle that can resurface the whole lower breast pole, while avoiding many of the latissimus flap morbidities.

Less is more – retrospective comparison of shoulder strength and range of motion between conventional and muscle-sparing harvesting technique of a latissimus dorsi flap

The muscle-sparing latissimus dorsi flap poses an alternative to the conventional latissimus dorsi flap when a defect requires a smaller flap volume with a long vascular pedicle. The aim of the study was to analyze the functional outcome following muscle-sparing versus conventional harvest of a latissimus dorsi flap. Patients who received a muscle-sparing latissimus dorsi muscle flap transplantation (group 1) and patients with a complete latissimus dorsi muscle flap harvest (group 2) for defect reconstruction at the University Hospital of Erlangen between 2007 and 2016 were examined. The evaluation included a physical examination with the measurement of strength and range of motion of the shoulder of both the donor side as well as the nonoperated side. Furthermore, the DASH score was evaluated. Additionally, patients in group 1 received a neurophysiological examination. The DASH score did not show statistically significant differences between both groups. Both strength (p = 0.031) and range of motion (p<0.05) of the shoulder of the donor side were statistically significantly lower than the nonoperated side in group 2, while no difference was found in group 1. The neurophysiological examination in group 1 showed a reduced nerve conduction velocity of the donor side as compared to the nonoperated side in most patients (60% and n = 3). Harvesting the muscle-sparing latissimus dorsi flap leads to less functional impairments of the shoulder than harvesting the complete latissimus dorsi flap.

Thoracodorsal artery flaps for breast reconstruction-the variants and its approach.

Thoracodorsal artery (TDA) flaps, ranging from the vascular-pedicled thoracodorsal artery perforator (TDAP) flap, the propeller TDAP flap, and the muscle-sparing latissimus dorsi (MSLD) flap to the conventional latissimus dorsi (LD) flap and the extended LD flap, can all be used for breast reconstruction. The aim of this paper and review is to share our experiences and recommendations for procedure selection when applying TDA-based flaps for breast reconstruction. We describe the different surgical techniques and our thoughts and experience regarding indications and selection between these procedures for individual patients who opt for breast reconstruction. We have performed 574 TDA flaps in 491 patients: 60 extended LD flaps, 122 conventional LD flaps, two MSLD flaps, 233 propeller TDAP flaps, 122 TDAP flaps, and 35 free contralateral TDAP flaps for stacked TDAP breast reconstruction. All the TDA flaps are important flaps for reconstruction of the breast. The LD flap is still an option, although we prefer flaps without muscle when possible. The vascular-pedicled TDAP flap is an option for experienced surgeons, and the propeller TDAP flap can be used in most reconstructive cases of the breast, although a secondary procedure is often necessary for correction of the pedicle bulk. The extended LD flap is an option for women with a substantial body mass index, although it is associated with the highest morbidity of all the TDA flaps. The MSLD flap can be used if the perforators are small or if dissection of the perforators is assessed to be hazardous.

Muscle-sparing Latissimus Dorsi: A Safe Option for Postmastectomy Reconstruction in Extremely Obese Patients.

Background:Postmastectomy reconstruction in obese patients has a significant risk of complications and poor outcomes after implant-based and autologous methods. Here we present 22 consecutive patients with Class III obesity [body mass index (BMI) > 40 kg/m2] who underwent reconstruction with a muscle-sparing latissimus dorsi (MSLD) flap.Methods:A chart review of a single surgeon experience with 22 consecutive patients with Class III obesity who underwent postmastectomy reconstruction with an MSLD flap was performed. Demographics, operative details, outcomes, and complications were evaluated.Results:Twenty-two patients underwent 29 mastectomy and MSLD reconstructions. There were no flap failures. The average BMI was 47.2 kg/m2, including 12 patients with BMI > 50 kg/m2. Seven breasts demonstrated partial nipple and or mastectomy flap necrosis. There was 1 (3.4%) donor site dehiscence that healed with outpatient wound care and 1 (3.4%) seroma that required multiple aspirations in the office. The average operative times were 178 and 420 minutes for unilateral and bilateral mastectomy and immediate reconstructions, respectively. The average hospital length of stay was 0.56 and 1.3 days for unilateral and bilateral surgeries, respectively.Conclusions:These results demonstrate the utility of the MSLD flap in reconstructing the very obese. Operative times and lengths of stay compare favorably with conventional latissimus dorsi flap and abdominal-based microvascular free tissue transfer reconstructions. While our complication rates were higher than historically seen for patients with normal BMIs, there were no instances of flap failure, making this a viable reconstructive option for these very high-risk patients.

Encapsulated chronic recurrent seroma following modified radical mastectomy: surgical resection and reconstruction by muscle-sparing latissimus dorsi flap—a case report and review of literature

: Seroma formation is known to be one of the most common complications following modified radical mastectomy. The best management for seroma is prevention by manoeuvres such as attentive surgical techniques, suction drains, quilting and fibrin sealant. Recurrent seroma could be managed by repeated aspiration, compression, seroma-desis and/or sclerotherapy. Surgical intervention is reserved for refractory cases. We hereby present the case of a 43-year-old woman with chronic recurrent chest wall and axillary seroma following modified radical mastectomy that persisted for over 6 years. It was associated with neuropathic pain and stiffness around the axillary and shoulder regions. This was eventually managed by surgical excision of the encapsulated seroma, which was found to receive feeding lymphatic vessels and to entangle a nerve in the scar tissue. The defect was reconstructed with a muscle-sparing latissimus dorsi flap (MS-LD). The patient had uneventful recovery. She had no recurrence of seroma and significant improvement in the quality of life on follow-up, 10 months down the line. We present the progression of the condition, its treatment modalities, the interesting operative findings and post-operative outcome. We also performed a review of literature for the management of similar cases. Patients with chronic encapsulated seroma can pose a challenging treatment dilemma. Surgical resection of such seromas should be considered when managing cases which are refractory to conservative efforts. Importing vascularised tissue to the resection site of the seroma cavity is recommended when the overlying skin is under tension, of poor quality, affected by radiotherapy changes and at risk of delayed wound healing.

Pre-expanded Muscle-sparing Latissimus Dorsi Flaps for Reconstruction of Severe Scar Contractures on the Anterior Chest

ABSTRACT Objective To investigate the utility of pre-expanded muscle-sparing latissimus dorsi flaps in the reconstruction of deformities secondary to severe scar contractures on the anterior chest. Methods The function of the latissimus dorsi was preserved with blood supply from the main or lateral branch of the thoracodorsal artery. The entire treatment period was divided into two stages, during which segmental latissimus dorsi flaps were pre-expanded in stage I and anterior chest scar deformities were reconstructed in stage II. During stage I, the musculocutaneous perforators arising from the lateral branch of the thoracodorsal artery were determined by ultrasound preoperatively; the flap design included the anterior segment of the latissimus dorsi supplied by the musculocutaneous perforators from the lateral branch; and a tissue expander was placed following flap dissection and then infused with saline intermittently for 4–6 months. In stage II, the chest scars were excised, and breast tissues were repositioned; the continuity of the medial branch of the thoracodorsal nerve to the muscle was preserved when reconstruction was performed using the segmental latissimus dorsi flaps supplied by the main or lateral branch of the thoracodorsal artery. Results From October 2010 to October 2019, 21 patients (on 24 sides) underwent reconstructive procedures for extensive scar contractures on the anterior chest. All flaps survived, and their donor sites were sutured directly. During a follow-up of 3 months to 8 years, the flaps became soft and exhibited color similar to that of the adjacent tissues. The limited neck and shoulder movements improved, and postoperatively, all female patients were satisfied with the shape of their breasts. Additionally, neither apparent weakening on the adduction, internal rotation, or extension strength of the shoulder joint on the affected side nor marked depression deformity in the back was observed. Conclusion Pre-expanded muscle-sparing latissimus dorsi flaps with blood supply from the main or lateral branch of the thoracodorsal artery proved to be a desirable option for the reconstruction of extensive scar contractures on the anterior chest.