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

Updated Trends and Outcomes in Autologous Breast Reconstruction in the United States, 2016-2019

INTRODUCTION

Autologous breast reconstruction (ABR) has increased in recent decades, although concerns for access remain. As such, our goal is to trend national demographics and operative characteristics of ABR in the United States.

METHODS

Using the National Inpatient Sample, 2016-2019, the International Classification of Disease , Tenth Edition codes identified adult female encounters undergoing ABR. Demographics and procedure-related characteristics were recorded. Discharge weights generated national estimates. Statistical analysis included univariate testing and multivariate regression modeling.

RESULTS

A total of 52,910 weighted encounters met the criteria (mean age, 51.5 ± 10.0 years). Autologous breast reconstruction utilization increased (Δ = +5%), 2016-2019, primarily driven by a rise in deep inferior epigastric perforator (DIEP) reconstructions (Δ = +28%; incidence rate ratio [IRR], 1.070; P < 0.001), which were predominant throughout the study period (69%). More recent surgery year, bilateral reconstruction, higher income levels, commercial insurance, and care in the South US region increased the odds of DIEP-based ABR ( P ≤ 0.036). Transverse rectus abdominis myocutaneous flaps, bilateral reconstructions, higher comorbidity levels, and experiencing complications increased the length of stay ( P ≤ 0.038). Most ABRs (75%) were privately insured. The rates of immediate reconstructions increased over the study period (from 26% to 46%; IRR, 1.223; P < 0.001), as did the rates of bilateral reconstructions (from 54% to 57%; IRR, 1.026; P = 0.030). The rates of ABRs performed at teaching hospitals remained high (90% to 93%; P = 0.242).

CONCLUSIONS

As of 2019, ABR has become more prevalent, with the DIEP flap constituting the most common modality. With the increasing ABR popularity, efforts should be made to ensure geographic and financial accessibility.

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

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.