Functional recovery after bilateral extended autologous latissimus dorsi breast reconstruction: A prospective observational study

Breast reconstruction after mastectomy

Patients requesting breast reconstruction after mastectomy is an increasing group at plastic- and breast surgery departments in Denmark. This review summarises the present surgical techniques for reconstruction with/without postoperative chemotherapy and/or radiation therapy. These surgical techniques are continuously updated. The most determining factor when selecting a reconstructive technique, is postoperative radiation therapy. Each patient is unique, and an individual assessment is made when planning surgery. The concept of a "babysitter implant" is currently being investigated in Denmark and might be an option for selected patients.

Alteration in skeletal posture between breast reconstruction with latissimus dorsi flap and mastectomy: a prospective comparison study

Background

The latissimus dorsi (LD) flap is used in cases of immediate breast reconstruction after total or partial mastectomy. However, studies on the effect of unilateral LD flap reconstruction on skeletal posture and comparison with results from mastectomy-only have been sparse. Thus in this prospective, observational study, we compared skeletal posture and functional recovery in patients who underwent a mastectomy-only versus those who underwent breast reconstruction with a LD flap after mastectomy.

Methods

From January 2018 to February 2020, a total of 54 patients were enrolled. The control group included 23 patients who underwent mastectomy-only and the experimental group included 31 patients who underwent breast reconstruction using a LD flap immediately after mastectomy. We assessed the Cobb's angle in spine X-rays, parameters derived from photometry, computed tomography (CT), and 3D scanning preoperatively (T0), 6 months post-surgery (T1), and 1-year post-surgery (T2). We also evaluated functional outcomes, such as pain intensity, disability of the upper extremities, and quality of life.

Results

In the control and experimental groups, the average age was 58.7/46.2 years, body mass index (BMI) was 24.9/22.5, and excised mass weight was 386.8/259.1 g, respectively. In the control group, differences in the Cobb's angle were significant between T0 and T2 (P=0.003). There were significant differences in the Cobb's angle and time interaction effects between the two groups (P=0.015). The degree of change in the Cobb's angle between T0 and T1 was positively correlated with change in the vertical distance from the 3D scanner midline to the nipple (P=0.009).

Conclusions

The experimental group showed improved recovery in skeletal posture compared to the control group. Further, discovering the parameters that can predict the change of skeletal posture through a 3D scanner will have clinical significance. Accordingly, performing breast reconstruction by unilaterally applying the LD muscle is a safe, reliable, and useful method of autologous tissue transfer for breast cancer patients.

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.

Effects of latissimus dorsi (LD) flap harvest on shoulder function in delayed breast reconstruction. A long-term analysis considering the acromiohumeral interval (AHI), the WOSI, and BREAST-Q questionnaires

BACKGROUND

The latissimus dorsi (LD) flap is reliable and versatile with many indications and low donor site morbidity. The aim of this study is to evaluate the long-term effects of LD flap on the shoulder function in patients undergoing delayed breast reconstruction.

METHODS

This case-control study enrolled women who underwent implant-based (IB) breast reconstruction, radical lymphadenectomy, and radiotherapy between 2006 and 2016. The study group included 72 women, with a history of severe capsular contracture, who received a secondary LD flap reconstruction. The control group consisted of a matched cohort of 80 patients with IB breast reconstruction. Shoulder function was assessed using the acromiohumeral interval (AHI) measurement in standard X-rays. The validated Western Ontario Shoulder Instability (WOSI) and BREAST-Q questionnaires were used to assess outcomes one year postoperatively and data were analyzed using Fisher's exact test and the Mann-Whitney test.

RESULTS

Out of 72 patients from the study group, 40 had valuable pre- and postoperative X-rays to measure the AHI. An AHI reduction was recorded only in 7/40 patients. From the WOSI analysis, no significant differences in shoulder function and back pain between the two groups were registered. BREAST-Q scores in the LD group were higher in most domains, including satisfaction with breasts and psychosocial well-being. However, the Mann-Whitney test showed no significant difference between the two groups (p > 0.05).

CONCLUSION

LD flap, with detachment of its insertions from the humerus, does not seem to have a negative impact on back and shoulder function and is correlated with high patient satisfaction in breast reconstruction following radiotherapy.