Immediate breast reconstruction with latissimus dorsi flap and implant: audit of outcomes and patient satisfaction survey

Is Immediate Breast Reconstruction With a Latissimus Dorsi Myocutaneous Flap Safe for Starting Adjuvant Chemotherapy in Patients With Breast Cancer?

INTRODUCTION

Immediate breast reconstruction following mastectomy reduces perceptions of mutilation and femininity issues in oncological patients, but surgical complications should not delay chemotherapy. This study evaluated postsurgical complications in patients who underwent radical breast surgery followed by immediate reconstruction with latissimus dorsi myocutaneous flaps and silicone implants, along with resulting impacts in delaying chemotherapy.

MATERIALS AND METHODS

This retrospective study utilized a prospectively maintained database. Clinical, surgical, and oncological data from 196 women were collected according to the operated side. Patients were grouped according to the time elapsed between surgery and the first cycle of adjuvant chemotherapy: ≤ 60 days (group 1), 61 to 90 days (group 2), or > 90 days (group 3).

RESULTS

A total of 198 immediate reconstructions were performed on 196 patients between August 1, 2010 and March 31, 2020; after surgery, 47.4% had minor complications and 7.1% had major complications. Ninety-six patients (48.5%) received adjuvant chemotherapy. The mean time elapsed between surgery and the first chemotherapy cycle was 65.4 days (median: 59), with 52.7% of the patients assigned to group 1, 37.4% to group 2, and 9.9% to group 3. The occurrence of major postoperative complications significantly affected the start of chemotherapy (64.0 vs. 94.5 days; P = .044). Additionally, patients with 2 or more comorbidities were more likely to experience major complications (OR: 3.35; 95% CI: 1.03-10.95; P = .045) than those with 1 or 0.

CONCLUSION

Major postoperative complications significantly delayed initiation of adjuvant chemotherapy in oncological patients who underwent radical breast surgery followed by immediate reconstruction with a latissimus dorsi myocutaneous flap and silicone implants.

Does a Latissimus Dorsi Flap Improve Surgical Outcomes of Implant-based Breast Reconstruction following Infected Device Explantation?

Background:

The goal of this study was to assess whether adding a latissimus dorsi (LD) flap to a secondary implant-based reconstruction (IBR) improves outcomes following explantation of the primary device due to infection.

Methods:

We conducted a retrospective study of patients who underwent a second IBR with or without the addition of an LD flap during 2006–2019, following explantation due to infection. Surgical outcomes were collected and compared between reconstruction types.

Results:

A total of 6093 IBRs were identified during the study period. Of these, 109 underwent a second attempt at breast reconstruction with IBR alone (n = 86, 79%) or IBR/LD (n = 23, 21%) following explantation of an infected device. Rates of secondary device explantation due to a complication were similar between the two groups (26% in the IBR/LD group and 21% in the IBR group; P = 0.60). Among the patients who underwent prior radiotherapy, the IBR/LD group had lower rates of any complication (38% versus 56%; P = 0.43), infection (25% versus 44%; P = 0.39), and reconstruction failure (25% versus 44%; P = 0.39); however, differences were not statistically significant.

Conclusion:

Following a failed primary breast reconstruction due to infection, it may be appropriate to offer a secondary reconstruction. For patients with a history of radiotherapy, combining an LD flap with IBR may provide benefits over IBR alone. Although not statistically different, this outcome may have clinical significance, considering the magnitude of the effect, and may result in decreased complication rates and a higher chance of reconstructive success.

The Use of Local Perforator Flaps in Delayed or Secondary Breast Reconstruction

Supplemental Digital Content is available in the text.

Local perforator flaps are used as immediate volume replacement techniques in breast conserving surgery. Here, we describe a case series of local perforator flaps used in the delayed setting to correct defects following previous breast surgery, including previous breast conservation surgery or mastectomy with reconstruction. All cases were performed in a tertiary referral breast unit between 2014 and 2020. Cases were identified using a prospectively maintained database. Indications, type of perforator flap used, immediate post-operative complications, and longer term outcomes were recorded. Fifteen cases were identified: 8 following previous breast conserving surgery and radiotherapy, 6 following mastectomy and reconstruction, and 1 for developmental breast asymmetry following childhood radiotherapy. Indications included volume deficit, contour defect, asymmetry, and capsular contracture. One patient a major complication requiring return to theater due to implant-related infection. There were no flap losses. Longer term, 2 patients underwent lipomodeling to further augment breast volume as part of a planned, staged revision. One patient subsequently elected to have bilateral breast implant exchange to increase volume. Our series shows the versatility of local perforator flaps in the correction of complex breast defects that can occur following previous breast surgery. Delayed local perforator flaps are associated with low morbidity, and further revision surgery is not commonly required.

Comparisons of complications between extended latissimus dorsi flap and latissimus dorsi flap in total breast reconstruction: A prospective cohort study

Background

The latissimus dorsi (LD) flap is one of the most popular techniques in breast reconstruction. Although numerous studies have not shown functional impairment of the shoulder after surgery, other studies have reported significant functional impairment, especially after extended LD flap reconstruction. The present study compared functional deficit and shoulder movement between extended LD and LD flap reconstruction.

Materials and methods

Between December 2015 and May 2018, this study enrolled 31 patients undergoing LD flap reconstruction. Data on patient demographics, operative details, morbidities, and degree of shoulder movement were collected. Outcomes were compared between the extended LD and LD flap groups.

Results

Twenty-one women and 10 women underwent LD flap and extended LD flap reconstruction, respectively. The median patient age was 43 years. No demographic data differed between groups. Seroma, especially around the back incision, was the most common complication (90.5% in the LD flap and 90% in the extended LD group). Five patients in the LD flap group and one patient in the extended LD flap group showed decreased shoulder range of motion (ROM) at 6 months post-operation. Only one patient in the LD flap group showed impairment based on American Shoulder and Elbow Surgeons Shoulder Score (ASES). The results did not differ significantly between groups; however, the LD flap group showed faster functional recovery.

Conclusion

LD flap reconstruction can be performed with a very low impact on shoulder function. We observed a slightly decreased ROM for both LD flap techniques, with no impact on functional outcome.

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After 6 months, 5 out of 16 patients in LD group and 1 out of 6 patients ELD group had decreasing of shoulder movement.

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Patients in ELD group needed more time to recover their movement compare with LD group (4 vs 1.5 months, respectively).

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According to our subjective outcome, only 1 patient in LD group had decreasing in her shoulder movement after 6 months.

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The median time to fully recovered of ASES score was only 1 month in both groups.

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All results were not statistically significant.

Latissimus Dorsi Myocutaneous Flap in Immediate Reconstruction after Salvage Mastectomy Post-Lumpectomy and Radiation Therapy

Breast reconstruction after salvage mastectomy (SM) for recurrent cancer represents a challenge in preradiated patients due to the increased complication rate. Latissimus dorsi myocutaneous flap (LDMF) represents a good reconstructive option due to its versatility, safety, and adaptability.

Latissimus Dorsi Musculocutaneous Flap for Complex Breast Reconstruction: Indications, Outcomes and a Proposed Algorithm

The latissimus dorsi (LD) flap is an ideal flap for salvage following failed primary breast reconstruction in the setting of radiation therapy. This study will review outcomes following secondary reconstruction with the LD flap with or without a tissue expander (TE) or implant (I).

Body mass index and nipple preservation are major contributors to satisfaction and aesthetic outcome rates after implant-based immediate breast reconstruction

Introduction

Immediate breast reconstructions (IBR) have become an integral part of modern breast cancer management. However, in a small breast unit the spectrum of methods used for IBR could be limited, which could result in poorer results in some cases. The aim of the study is to evaluate the patient satisfaction and aesthetic outcome results in a breast unit where only implant-based IBR were performed.

Material and methods

During 2009–2016, 64 cases of implant-based IBR were performed in the university hospital. 55 patients completed the questionnaire and 38 underwent evaluation by a plastic surgeon. 33 skin-sparing and 22 nipple-sparing mastectomies were included. The study included 30 two-stage expander/implant and 25 direct-toimplant IBR cases.

Results

Overall satisfaction was reported by 89% of respondents. 93% were satisfied with appearance in clothes and 82% with appearance in a bra. There was a significant difference with satisfaction in nude appearance between groups with a removed (3%) and a spared nipple (46%). The plastic surgeon evaluated overall outcome as satisfactory in 61% and poor in 39%. Spearman coefficient showed a moderate negative correlation between body mass index (BMI) and aesthetic outcome (p = 0.02), as well as BMI and volume differences between breasts (p = 0.03). Patients evaluated their breast symmetry as satisfactory in 55%, and the plastic surgeon concluded the same in 55% of 38 cases.

Conclusions

Most of the patients were satisfied with the aesthetic outcome of IBR. Nipple preservation considerably improved satisfaction rates. However, implant-based IBR revealed suboptimal cosmetic results in the subset of cases with increased BMI and other IBR methods should be considered in those cases.

Adjacent skin rotation flap for large defect in primary breast tumor

BACKGROUNDS

Surgical resection of large primary breast tumor often results in large chest wall defects. The purpose of this study is to evaluate the feasibility of using adjacent skin rotation (ASR) flap in patients with giant primary breast tumor.

METHODS

A total of 26 giant primary breast tumor patients treated with ASR flap were included in this study. The postoperative conditions, including operating time, blood loss, length of hospital stay, and clinical complications were observed. Meanwhile, the information on 17 breast tumor patients treated with transverse rectus abdominis myocutaneous (TRAM) flap were collected and assigned to a control group.

RESULTS

The mean defect size after mastectomy was 16.7 × 13.4 cm, while the median follow-up period was 13 months after surgery. A total of 15.4% patients had developed with local complications, and one of them had more than one complication. When comparing the postoperative outcomes, statistically significant differences were found between the two groups with respect to operating time, blood loss, and length of hospital stay (P < 0.001).

CONCLUSIONS

ASR flap is a reliable technique for immediate reconstruction of massive chest wall defects in patients with giant primary breast tumor.

Retrospective observational study of breast reconstruction with extended latissimus dorsi flap following skin-sparing mastectomy

The study was aimed to evaluate oncological safety and patient satisfaction in relatively late stage breast cancer patients who was treated with skin-sparing mastectomy (SSM) followed by breast reconstruction with an extended latissimus dorsi (LD) flap. Oncological safety, postoperative complications, and cosmetic results were retrospectively analyzed in patients who underwent extended LD flap breast reconstruction following SSM between October 2011 and August 2014. A total of 62 patients who underwent 63 breast reconstructions were enrolled in the study. Local recurrence rate was 1.6% over a median follow-up of 63 months. On final aesthetic assessment, 37 reconstructions were rated excellent, 19 good, 5 fair, and 2 poor. Reconstruction-related complications occurred in 22 patients (34.9%); these patients' satisfaction scores were significantly lower than those of patients without complications (P < .05). Five patients developed shoulder movement limitation, and 2 had minor twitching and pain in the reconstructed breast. However, these patients did not find their problems disabling and were able to live normally. SSM followed by breast reconstruction with extended LD flap can improve patients' postoperative quality of life and is as oncologically safe as total mastectomy even in patients with tumors of relatively late stage.

Latissimus Dorsi Flap Breast Reconstruction-A Nationwide Inpatient Sample Review

INTRODUCTION

The latissimus dorsi (LD) myocutaneous flap has been a long term standard for breast reconstruction. The variable indications for the LD flap have not been statistically examined because of the relative infrequency of its use by any single surgeon or institution.

METHODS

The Nationwide Inpatient Sample data set was queried for all patient encounters involving a LD myocutaneous flap procedure. The study population was further restricted to female patients with a history of breast cancer or previous mastectomy. Demographics, Charlson Comorbidity Index scores, previous radiation history, and additional simultaneous procedures were extracted. Analysis was performed using nonparametric correlation coefficients and linear regression models.

RESULTS

In total, 2304 LD breast reconstruction hospitalizations were identified between 2008 and 2010. Average patient age was 52.1 years, average hospital length of stay (LOS) was 2.8 days, bilateral latissimus reconstruction was performed in 252 (10.9%) patients, and 1414 patients (61.4%) were delayed reconstruction. Previous irradiation was present in 389 (16.9%) patients and was correlated with delayed reconstruction (P < 0.001).Younger age was associated with bilateral latissimus reconstructions (P < 0.05), contralateral free flap reconstruction (P < 0.0001), and combination with implants or tissue expanders (both P < 0.0001).After adjustment for age and Charlson Comorbidity Index, increased LOS was observed in patients undergoing contralateral free flap reconstruction (+1.29 days, P < 0.05) and immediate reconstruction (mastectomy, +0.39 days unilateral, P < 0.05; +0.64 days, bilateral, P < 0.001). The use of tissue expanders and implants were found to decrease hospital LOS (bilateral implant, -0.65 days, P < 0.001; bilateral expander, -0.72 days, P < 0.001), likely from confounding comorbidities. Charlson Comorbidity Index was strongly related to LOS (+0.08 days per point, P < 0.005), whereas age was not statistically significant when considered with comorbidity.

CONCLUSIONS

The LD is most commonly used for delayed or salvage breast reconstruction, with particular utility in irradiated patients. Younger patients tend to undergo more involved LD variants with bilateral reconstructions and expanders or implants. After adjusting for comorbidity, age and the use of bilateral latissimus flaps with implants or expanders have no adverse impact on LOS.

Latissimus dorsi myocutaneous reconstruction: a study of long-term outcomes in a district general hospital

INTRODUCTION The aim of this study was to evaluate the long-term outcome and durability of both autologous and implant-assisted latissimus dorsi reconstruction in a district general hospital over a 10-year follow-up period. METHODS A prospective cohort study was carried out using a detailed database of all latissimus dorsi flap reconstructions performed by a single consultant surgeon between 2003 and 2013 at the Royal United Hospital, Bath. The long-term outcome following reconstruction was assessed by analysing all episodes of 'reconstruction-specific' operations required from 6 months after the initial surgery. RESULTS The study included 110 patients with latissimus dorsi flap reconstructions, 21 autologous and 95 implant-assisted. Radiotherapy was given to 27 patients with reconstructed flaps. Mean follow-up was 69 months. Further reconstruction-specific surgery was needed in 27 (23%) cases, with 5 of these being post-radiotherapy flaps. Implant-related surgery was the most common reason for further surgery. Complications of the implant itself made up 52% of these cases, chronic sepsis being the most common. The rate of symptomatic capsular contracture requiring further surgery was 4.2%. Of these, one of four patients had undergone radiotherapy. DISCUSSION In our institution, latissimus dorsi reconstruction is durable and safe over the long term, with limited need for further substantial intervention to maintain a good outcome from the initial reconstruction. Autologous flaps were less likely to require further surgery over the long term compared with implant-based reconstructions. The low rate of symptomatic capsular contracture may be due to the protective mechanism provided by the extended harvest flap used.

Acceptability and pilot efficacy trial of a web-based breast reconstruction decision support aid for women considering mastectomy

OBJECTIVE

The study aim was to test the acceptability and preliminary efficacy of a novel interactive web-based breast reconstruction decision support aid (BRAID) for newly diagnosed breast cancer patients considering mastectomy.

METHODS

Fifty-five women considering mastectomy were randomly assigned to receive the BRAID versus the Cancer Support Community's Frankly Speaking About Cancer: Breast Reconstruction pamphlet. Participants completed measures of breast reconstruction (BR) knowledge, preparation to make a decision, decisional conflict, anxiety, and BR intentions before randomization and 2 weeks later.

RESULTS

In terms of acceptability, enrollment into the study was satisfactory, but the rate of return for follow-up surveys was lower among BRAID participants than pamphlet participants. Both interventions were evaluated favorably in terms of their value in facilitating the BR decision, and the majority of participants completing the follow-up reported viewing the materials. In terms of preliminary efficacy, both interventions resulted in significant increases in BR knowledge and completeness and satisfaction with preparation to make a BR decision, and both interventions resulted in a significant reduction in decision conflict. However, there were no differences between interventions.

CONCLUSION

A widely available free pamphlet and a web-based customized decision aid were highly utilized. The pamphlet was as effective in educating women about BR and prepared women equally as well to make the BR decision as compared with a more costly, customized web-based decision support aid. Copyright © 2015 John Wiley & Sons, Ltd.

The efficacy of simultaneous breast reconstruction and contralateral balancing procedures in reducing the need for second stage operations

Background

Patients having unilateral breast reconstruction often require a second stage procedure on the contralateral breast to improve symmetry. In order to provide immediate symmetry and minimize the frequency and extent of secondary procedures, we began performing simultaneous contralateral balancing operations at the time of initial reconstruction. This study examines the indications, safety, and efficacy of this approach.

Methods

One-hundred and two consecutive breast reconstructions with simultaneous contralateral balancing procedures were identified. Data included patient age, body mass index (BMI), type of reconstruction and balancing procedure, specimen weight, transfusion requirement, complications and additional surgery under anesthesia. Unpaired t-tests were used to compare BMI, specimen weight and need for non-autologous transfusion.

Results

Average patient age was 48 years. The majority had autologous tissue-only reconstructions (94%) and the rest prosthesis-based reconstructions (6%). Balancing procedures included reduction mammoplasty (50%), mastopexy (49%), and augmentation mammoplasty (1%). Average BMI was 27 and average reduction specimen was 340 grams. Non-autologous blood transfusion rate was 9%. There was no relationship between BMI or reduction specimen weight and need for transfusion. We performed secondary surgery in 24% of the autologous group and 100% of the prosthesis group. Revision rate for symmetry was 13% in the autologous group and 17% in the prosthesis group.

Conclusions

Performing balancing at the time of breast reconstruction is safe and most effective in autologous reconstructions, where 87% did not require a second operation for symmetry.

Propeller thoracodorsal artery perforator flap for breast reconstruction

BACKGROUND

The thoracodorsal artery perforator (TDAP) flap has been described for breast reconstruction. This flap requires intramuscular dissection of the pedicle. A modification of the conventional TDAP surgical technique for breast reconstruction is described, utilizing instead a propeller TDAP flap. The authors present their clinical experience with the propeller TDAP flap in breast reconstruction alone or in combination with expanders or permanent implants.

METHODS

From January 2009 to February 2013, sixteen patients had breast reconstruction utilizing a propeller TDAP flap. Retrospective analysis of patient characteristics, clinical indications, procedure and outcomes were performed. The follow-up period ranged from 4 to 48 months.

RESULTS

Sixteen patients had breast reconstruction using a TDAP flap with or without simultaneous insertion of an expander or implant. All flaps survived, while two cases required minimal resection due to distal flap necrosis, healing by second intention. There were not donor-site seromas, while minimal wound dehiscence was detected in two cases.

CONCLUSIONS

The propeller TDAP flap appears to be safe and effective for breast reconstruction, resulting in minimal donor site morbidity. The use of this propeller flap emerges as a true alternative to the traditional TDAP flap.

Comparing five alternative methods of breast reconstruction surgery: a cost-effectiveness analysis

BACKGROUND

The purpose of this study was to assess the cost-effectiveness of five standardized procedures for breast reconstruction to delineate the best reconstructive approach in postmastectomy patients in the settings of nonirradiated and irradiated chest walls.

METHODS

A decision tree was used to model five breast reconstruction procedures from the provider perspective to evaluate cost-effectiveness. Procedures included autologous flaps with pedicled tissue, autologous flaps with free tissue, latissimus dorsi flaps with breast implants, expanders with implant exchange, and immediate implant placement. All methods were compared with a "do-nothing" alternative. Data for model parameters were collected through a systematic review, and patient health utilities were calculated from an ad hoc survey of reconstructive surgeons. Results were measured in cost (2011 U.S. dollars) per quality-adjusted life-year. Univariate sensitivity analyses and Bayesian multivariate probabilistic sensitivity analysis were conducted.

RESULTS

Pedicled autologous tissue and free autologous tissue reconstruction were cost-effective compared with the do-nothing alternative. Pedicled autologous tissue was the slightly more cost-effective of the two. The other procedures were not found to be cost-effective. The results were robust to a number of sensitivity analyses, although the margin between pedicled and free autologous tissue reconstruction is small and affected by some parameter values.

CONCLUSIONS

Autologous pedicled tissue was slightly more cost-effective than free tissue reconstruction in irradiated and nonirradiated patients. Implant-based techniques were not cost-effective. This is in agreement with the growing trend at academic institutions to encourage autologous tissue reconstruction because of its natural recreation of the breast contour, suppleness, and resiliency in the setting of irradiated recipient beds.

Outcome of single-stage breast reconstruction using the Natrelle 150 expander implant

The Natrelle 150 offers the advantage of single-stage reconstruction. However, there is lack of published data on its long term outcomes, which does not allow for definitive conclusions as to whether it truly meets its design objective of a lasting single stage breast reconstruction. This is a retrospective review of all Natrelle 150 reconstructions by a single surgeon over 5 years. A total of 143 procedures were performed in 125 patients with a mean follow-up of 33 months (range, 3-65 months). Most (120, 84%) received the implant after oncological mastectomies, 22 (15%) after risk-reducing mastectomies, and 1 (0.8%) for hypoplasia. Fifty-one (35.7%) implants were explanted an average of 12.9 months after implantation. A Kaplan-Meier survival analysis demonstrates an explantation rate of 25% by 11 months. Explantation was more likely after subpectoral placement compared to reconstructions in combination with latissimus dorsi flaps (P<0.05). Risk-reducing reconstructions were also more likely to undergo explantation (P<0.05) compared to reconstructions for oncological reasons. Our data suggest that this prosthesis is only successful as a 1-stage procedure in certain patients, and has led to more careful patient selection and counseling.

Breast reconstruction with the denervated latissimus dorsi musculocutaneous flap

OBJECTIVE

To analyze clinical implications of the thoracodorsal nerve division in the latissimus dorsi musculocutaneous flap breast reconstruction.

PATIENTS AND METHODS

Prospective cohort study was conducted on 29 patients. Breast reconstruction with latissimus dorsi musculocutaneous flap was performed unilaterally in 20 patients or bilaterally in 9 women (38 breasts). Thoracodorsal nerve was divided during reconstruction of 20 breasts (group 1) and was preserved for 18 breasts (group 2). Height, width, projection, area of the covering skin and volume of the reconstructed and healthy breasts were measured on the 3D images of the anterior chest wall, taken 6 weeks and 6 months postoperatively with the Di3D 3D camera. Data regarding tissue consistency, painfulness and animation of the reconstructed breast, symmetry of both breasts and overall satisfaction after the surgery were collected at 6 months.

RESULTS

The reconstructed and healthy breasts decreased in volume in group 1 (-45.85 cm(3) ± 48.41 cm(3), p = 0.0004; -29.13 cm(3) ± 14.98 cm(3), p = 0.0009) and in group 2 (-31.5 cm(3) ± 25.35 cm(3), p = 0.0001; -15.4 cm(3) ± 21.96 cm(3), p = 0.0537). There were no differences in decrease in volume between groups 1 and 2 (p > 0.05). Respondents in group 1 in comparison to group 2 showed similar satisfaction of the tissue consistency of the reconstructed breast (p > 0.05) and the level of symmetry between both breasts (p > 0.05), gave lower scores for painfulness (p < 0.0001), animation (p < 0.0001) and higher scores for the overall satisfaction about the reconstructed breast (p = 0.0001).

CONCLUSION

We suggest that division of the thoracodorsal nerve during latissimus dorsi musculocutaneous flap breast reconstruction is a useful undertaking to minimize unnatural animation of the reconstructed breast.

Fasciocutaneous flaps of the subscapular artery axis to reconstruct large extremity defects

INTRODUCTION

The scapular, parascapular and thoracodorsal artery perforator (TDAP) flaps represent fasciocutaneous flaps derived from the subscapular artery axis. These flaps can be harvested individually or combined as conjoint flaps, tailored to reconstruct a wide variety of defects in the extremities. ANALYSIS AND METHODS: All patients undergoing free-flap reconstruction at North Bristol trust with a fasciocutaneous flap of the subscapular axis from April 2006 until April 2010 were included. This cohort of 45 patients was retrospectively analysed. The Enneking score for return of limb function was used as an outcome measure after reconstruction. Donor-site morbidity analysis was carried out prospectively using Oxford Medical Research Council (MRC) score, Vancouver Scar Scale and disability of arm, shoulder and hand questionnaire (DASH) scores.

RESULTS

A total of 45 patients had extremity reconstruction using flaps of the subscapular artery axis following severe limb trauma, often comprising open tibial fractures. A total of 42 patients had lower limb injuries and three had upper limb injuries. All flaps survived. The mean Injury Severity Score (ISS) was 9.3, the mean Enneking score was 27 at 12 months mean follow-up. In the nine conjoint flaps, the mean area of tissue resurfaced was 257 cm2.

CONCLUSIONS

In this case series of fasciocutaneous flaps of the subscapular artery axis, we establish that these flaps are robust and versatile. They replace 'like-with-like' and have good patient satisfaction. The donor site can be closed primarily, is discrete and has minimal donor morbidity. The conjoint flaps can be used for reconstruction of very large defects without the need to sacrifice functionally important muscle.

Immediate locally advanced breast cancer and chest wall reconstruction: surgical planning and reconstruction strategies with extended V-Y latissimus dorsi myocutaneous flap

BACKGROUND

Surgical resection in locally advanced breast cancer produces large defects that may not be suitable for primary closure. Immediate reconstruction is controversial and presents a complicated scenario for breast surgeons and plastic surgeons.

METHODS

In this study, a different design was planned for the latissimus dorsi musculocutaneous flap with primary closure in V-Y for the correction of major lesions in the anterior chest wall. Twenty-five patients underwent immediate locally advanced breast cancer reconstruction with a V-Y latissimus dorsi musculocutaneous flap. This flap was raised from adjacent tissue located on the lateral and posterior thoracic region and presented a triangular shape whose base was the lateral aspect of the mastectomy wound. The technique was indicated in patients with large thoracic wounds.

RESULTS

Mean follow-up time was 16 months. Closure was obtained in the donor and recipient sites without the use of skin grafts or other more major procedures. Complications occurred in nine patients (36 percent), including dorsal wound dehiscence in five patients and seroma in three. All cases except one were treated by a conservative approach with a good result. No total flap loss was reported. All patients achieved a satisfactory thoracic reconstruction and adequate wound care.

CONCLUSIONS

The V-Y latissimus dorsi musculocutaneous flap is a reliable technique for immediate locally advanced breast cancer reconstruction. The technique is advantageous because the V-Y design allows primary closure of the chest wound and donor defect. Success depends on patient selection, coordinated planning with the breast cancer surgeon, and careful intraoperative management.

Immediate latissimus dorsi pedicle flap reconstruction following the removal of an eight kilogram giant phyllodes tumour of the breast: a case report

INTRODUCTION

Phyllodes tumors account for less than 1% of breast tumors in women, and giant phyllodes tumors are those that are larger than 10 cm in diameter. Removal of such large tumors places a huge burden on the surgeon to reconstruct a breast that is aesthetically acceptable by the patient. We report what may be the largest giant phyllodes tumor and, most likely, the first latissimus dorsi flap used to cover such a large defect caused by the resection.

CASE PRESENTATION

We report the case of a 36-year-old Malaysian woman who presented with a three-year history of gradually increasing swelling of the left breast, with skin changes. Examination revealed a huge, globular, lobulated mass measuring 400 mm by 350 mm. The patient had a mastectomy with an immediate latissimus dorsi pedicled myocutaneous flap reconstruction. The breast weighed 8.27 kg, and ex vivo, the tumor measured 280 mm by 250 mm by 180 mm. Histopathologic analysis confirmed the diagnosis as a giant phyllodes tumor. At 12-month follow-up, the patient reports no complications and is satisfied with the aesthetic outcome.

CONCLUSION

Giant phyllodes tumors are very rare tumors that can reach up to 40 cm in diameter. Reconstruction of such a defect is a great challenge, and we report what we believe is the first latissimus dorsi flap to cover successfully a defect of approximately 400 mm by 350 mm.