|Year : 2015 | Volume
| Issue : 3 | Page : 291-295
Breast reconstruction in low resource settings: Autologous latissimus dorsi flap provides a viable option
N Kaur, A Gupta, S Saini
Department of Surgery, University College of Medical Sciences and GTB Hospital, University of Delhi, Delhi, India
|Date of Web Publication||18-Feb-2016|
Department of Surgery, University College of Medical Sciences and GTB Hospital, University of Delhi, Delhi
Source of Support: None, Conflict of Interest: None
Background: Breast reconstruction (BR) plays a significant role in the woman's physical, emotional and psychological recovery from breast cancer. However, the current most accepted methods of reconstruction are expensive, may require microsurgical skills and can be offered to a very small number of patients seeking treatment in tertiary care centers. For the large majority of women seeking treatment in public hospitals, solution lies in finding a method of reconstruction, which is autologous, produces a reasonable match to the contralateral breast in size, shape and symmetry and produces minimal donor site morbidity. It should also be a technique, which is cost effective and can withstand the effects of radiotherapy (RT). The autologous latissimus dorsi (LD) flap is one such versatile technique, which can serve as an ideal reconstructive option for the majority of patients. Materials And Methods: During a period of 6 years, 19 patients underwent immediate BR using this flap in the Department of General Surgery. Patients who were young (mean age 37.4 years), had small to medium sized breasts, with operable breast cancer (Stage II and IIIa) were selected for the procedure. Results: Satisfactory cosmetic results as rated by patients as well as surgeons were achieved in the majority. Donor site morbidities were seroma formation (78%) and donor site wound breakdown (21%). Post-operative RT was well-tolerated by the reconstructed breast. Conclusion: Autologous LD flap reconstruction is a safe and economical option for BR in low resource settings and is suitable for women with small and medium sized breasts.
Keywords: Autologous latissimus dorsi flap, immediate breast reconstruction, seroma
|How to cite this article:|
Kaur N, Gupta A, Saini S. Breast reconstruction in low resource settings: Autologous latissimus dorsi flap provides a viable option. Indian J Cancer 2015;52:291-5
|How to cite this URL:|
Kaur N, Gupta A, Saini S. Breast reconstruction in low resource settings: Autologous latissimus dorsi flap provides a viable option. Indian J Cancer [serial online] 2015 [cited 2019 Jun 24];52:291-5. Available from: http://www.indianjcancer.com/text.asp?2015/52/3/291/176701
| » Introduction|| |
Breast reconstruction (BR) is increasingly becoming an integral part of interdisciplinary treatment of breast cancer. Loss of body image is one of the critical issues negatively impacting quality-of-life of breast cancer survivors. Restoration of body image is an important step toward their rehabilitation., Nowadays, various options of BR are available. It can be an implant based reconstruction or the ones using autologous tissue such as transverse myocutaneous rectus abdominis transverse rectus abdominis myocutaneous (TRAM) flap, latissimus dorsi (LD) flap or more complex techniques such as deep inferior epigastric perforator (DIEP) flap or Superior inferior epigastric artery flap. Currently, implants or expanders are the most frequently used techniques for reconstruction. However, option of BR is available to only a very small percentage of patients, due to constraints of cost as well as technical skills.
LD has been the very first flap to be developed, to cover post-mastectomy defects way back in 1897 by Iginio Tansini. Traditionally the latissimus dorsi myocutaneous flap (LDMF) has been used to cover a breast implant if the patient was not suitable for an implant reconstruction alone or an abdominal flap. It is based on the triangular shaped latissimus muscle and includes a patch of overlying skin and its fat tissue. Ever since the early 1980s, surgeons tried to modify the LD flap harvest in order to increase the volume of the flap and avoid the use of a breast implant. McCraw and Pepp were the first to harvest additional soft-tissue in the form of a thin layer of fat on the surface of the LD muscle, the scapular muscle and the so-called supra iliac fat pad.
The most recent and most reliable modification of extended or autologous LD flap was described by delay and colleagues in 1998. They were able to double the flap volume by harvesting a large skin island, the entire muscle and subcutaneous fat tissue from six areas of additional fat harvest at the level of or below Scarpa's fascia. The additional areas of fat harvest were: (i) Fat under skin island; (ii) fat overlying surface of muscle; (iii) parascapular adipofascial extension; (iv) fat anterior to muscle; (v) supra iliac love handles and (vi) fat underneath muscle.
Several series of this type of autologous LD flap have since been published and this very versatile technique has established itself as a reliable and cost-effective method of BR with acceptable donor site function and cosmesis., However, there is hardly any data reported on the use of autologous LD flap from India. The current report describes the author's experience with this technique and also discusses as to why this can be a workhorse for patients seeking BR at low cost and with reasonable esthetic expectations.
| » Materials and Methods|| |
From July 2006 to January 2012, 19 patients underwent immediate BR using the LD autologous flap in the Department of General Surgery. Patient work-up included detailed history, physical examination and investigations to stage the disease for appropriate oncological surgery. Patients considered suitable candidates for immediate BR (Stage II and IIIa) were further assessed for option of reconstruction by autologous LD flap by the state of the donor area tissue and the size of the contralateral breast. Clinical assessment of the subcutaneous fat on the back as well as iliac region was performed by pre-operative skin pinch test and adipose tissue thickness of 2 cm or more was considered suitable for harvesting the LD flap.
Young patients, with small or medium sized breasts who were very keen to have BR were taken up for the surgery. All patients gave their informed consent and were fully explained the expected cosmetic outcome of BR and potential complications. Details of the operative procedures were noted including the duration of surgery, number of blood transfusions and any intraoperative complications. Immediate or delayed post-operative complications and secondary procedures such as seroma aspirations, wound re-suturing, etc., were also recorded.
The esthetic outcome of BR was assessed independently by patients as well as an independent team of two surgeons. The assessment by surgeons was determined by evaluating the reconstructed breast for its size, shape, degree of ptosis, symmetry with opposite breast, definition of inframammary fold and the anterior axillary line as well as the scars of suture lines. They categorized their results as: Good, fair and poor. Patient's esthetic evaluation was based on their personal satisfaction with the reconstructed breast. Their feedback was categorized as very satisfied, satisfied or not satisfied.
In the morning of surgery, pre-operative markings were done for the modified radical mastectomy (MRM) incisions as well as the LD flap, with patient in a standing position [Figure 1]. For the donor site, various skin incisions and designs of skin islands have been described. We used a transversely oriented skin paddle for our patients, which were marked out by the pinch technique. The largest possible area of skin which would allow a comfortable direct wound closure was marked in the middle part of the muscle.
|Figure 1: Pre-operative markings of the autologous latissimus dorsi flap|
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First, patients underwent MRM [Figure 2] and special attention was paid to maintain the integrity of the thoracodorsal pedicle during the axillary dissection. Care was also taken not to disturb the inframammary fold as well the fascial attachment along the lateral chest wall. Then patients were turned to lateral decubitus position with 90° abducted shoulder. The incisions on donor site were made down to the subdermal layer [Figure 3]. The plane of dissection was kept along the subcutaneous plane just above Scarpa's fascia, maintaining a thickness of skin flap of at least 1 cm. As much fat as possible was harvested from the scapular and the iliac region, so as to lift largest possible flap in terms of volume.
The muscle was divided from its attachments into the iliac crest and the thoracolumbar fascia. Its anterior border was separated carefully from the underlying serratus anterior muscle. The pedicle of the flap was freed as high in the axilla as possible [Figure 4]. To gain additional mobility as well as to keep the bulk of the flap, which would finally position in axilla low, the insertion of the muscle into the intertubercular groove on the humerus was subtotally divided. The thoracodorsal nerve was preserved to minimize future atrophy of the muscle. After complete mobilization of the flap, it was delivered through a subcutaneous tunnel high in the axilla to the pectoral region. The flap was supported anteriorly with opsite dressing while wound on the back was closed in two layers over suction drains. After dressing on the back, patient was turned supine again and the work was done to inset the flap [Figure 5].
The myoadipofascial flap was folded under the skin paddle in a way to provide best possible projection with fullness mainly formed inferiorly to match the contour of the opposite breast. The muscle was anchored to the underlying muscle. The lateral contour of the breast mound was defined with the addition of some sutures to the lateral chest wall. In two patients, immediate reconstruction of nipple was done by making a skate flap from paddle of harvested skin. However, it did not seem to improve the esthetic results.
| » Results|| |
The age of the patients ranged from 33 to 45 years (mean age 37.4 years) with a follow-up period ranging from 6-60 months. All patients underwent immediate breast reconstruction (IBR) after MRM. The indications for surgery were Stage II disease in eight patients and Stage IIIa disease in 11 patients. Neoadjuvant chemotherapy was administered to all 11 patients with Stage IIIa disease. Eight patients received an average of four cycles of Cyclophosphamide, Adriamycin, 5-Fluorouracil regime and three patients received adriamaycin and taxane based combination. All these patients receiving neoadjuvant chemotherapy showed good response (two clinical complete responses and nine showed partial response) and hence were considered good candidates for reconstruction.
Option of reconstruction by autologous LD flap was chosen because none could afford to buy implants; patients were young and very keen to preserve body image; had a good amount of subcutaneous fat on the back; and had medium sized breasts which could be matched in the size. TRAM flap reconstruction was not considered because of its donor site morbidity as these women were expected to continue to do a lot of physical work to address their family's needs.
In all these patients, epidural catheters were placed for post-operative analgesia and none had any intraoperative or immediate post-operative complication. The average operating time was 5.6 h and average blood loss was 650 cc [Table 1].
Six patients received post-operative radiotherapy (RT), which was well-tolerated by the reconstructed breast. None of these patients had any locoregional recurrence in the follow-up. However, one patient died of metastatic disease after 3 years.
Details of complications are provided in [Table 2]. There was one instance of partial flap loss caused by a technical fault, due to accidental separation of subcutaneous fat from muscle. It was caused by a very good layer of subcutaneous fat causing an error in judgment while lifting the medial border of the muscle. Patient was taken up for second surgery after 1 week with reshaping of the residual viable tissue. However, the cosmetic outcome was poor.
Donor site morbidity
The most common donor site problem was seroma formation, which occurred in 15 patients. It was treated conservatively by repeated aspiration and on an average required aspirations three times. In four patients, partial breakdown of suture line occurred. It was managed by dressings in two and two patients who had some necrosis of the flap required secondary suturing.
Persistent post-mastectomy pain after 3 months was reported by three patients and in one of them it was severe enough to impair the patient's daily activities. She responded to medication by tablet pregabalin (75 mg twice daily) for 2 months.
Patient's ratings were overall better than surgeon's rating. [Figure 6]. Esthetic evaluation by the surgeons was rated as good in eight, fair in 10 and poor in one. Suboptimal results generally were caused by mild to moderate asymmetry in the size of the breasts. In few patients RT induced firmness and skin edema, which affected esthetic result. Fourteen patients were very satisfied with their cosmetic result while five were satisfied. Even the patient with partial loss who had the worst result did not grade her own result unsatisfactory, making us wonder about the expectation of patients from their breast cancer treatment.
|Figure 6: Cosmetic outcomes of autologous latissimus dorsi flap breast reconstruction|
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| » Discussion|| |
The main aim in BR is to create a breast, which offers softness, symmetry, sensibility, esthetically acceptable scars as well as color and texture similar to the healthy side. The optimal method should also be safe, reliable and accompanied by little donor site morbidity. By achieving an acceptable appearance, reconstruction of the breast should improve the patient's quality-of-life and offer no subsequent health risk.
Among the currently available options, implant based reconstruction are most commonly performed. However, they are expensive and have their esthetic limitations. Implant based reconstruction are usually round and a natural ptosis is difficult to reproduce. Therefore, in approximately 60% cases, it is necessary to perform a contralateral mammoplasty to improve the symmetry.
Another major drawback of implant based reconstruction is capsular contracture, which occurs in at least 15% of patients after a follow-up of 2 years. In severe cases of capsular contracture, it may even be necessary to perform a surgical capsulotomy.
Among autologous flaps, TRAM and DIEP flaps are the methods of first choice after mastectomy. Pedicled or free TRAM flaps allow a more reliable transfer of large tissue and thus reconstruction of larger breasts than LDMF flaps. The major disadvantage of pedicled TRAM flap is a much higher incidence of donor site morbidity in the form of development of defects such as epigastric fullness, upper bulge, lower bulge and hernia., It is also not proper for patients who may consider bearing children because of decreased compliance of the abdominal wall. Free TRAM, DIEP, etc., require high microsurgical skills and experience and a much longer operating time.
Autologous LD flap has proven to be one of the most reliable and versatile methods of BR. The esthetic results from totally autologous LD reconstructions are superior to reconstruction with implants due to their more natural appearance, consistency and durability. Autologous tissue can also withstand RT better. Although RT may cause some reduction in the volume of the upper pole, the overall cosmetic outcome remains acceptable enough to advocate the autologous LD for IBR. Functional impairment after LD flap harvest is also minimal and compares favorably with the morbidity caused by pedicled or free TRAM flaps. The functional deficit after transfer of a LD flap affects only very specific activities like rowing, cross country skiing or mountain climbing, but appear to have little effect on most other activities. There is a clinically significant reduction in function for up to 3 months, but the recovery plateaus after 6 months and the long-term function is normal in most patients.
One of the limitation of autologous LD flap is the volume of the harvested tissue and it is usually not possible to match the size of a large breast. Some workers have reported on the harvest of superficial fibers of serratus anterior muscle along with overlying fat to increase the volume of the flap. Lipomodeling by coleman fat transfer can also be another method to augment the flap volume. However, an ideal patient for autologous LD reconstruction should have a small or medium size of the breast.
Donor site morbidity is another potential problem of this flap. Seroma collection and skin necrosis of the dorsal skin flaps has been variably reported by several authors.,, Seroma formation is common after harvest of the autologous LD flap and almost 80% our cases had seroma collection. Several strategies have been suggested to reduce the incidence of post-operative seroma such as quilting sutures and injection of topical fibrin glue., In our series, four patients (21%) had breakdown of suture line and two (10.5%) had partial necrosis of skin flaps. Delay et al. reported 3% incidence in 100 patients, while Chang et al. reported 16% necrosis rate in 75 patients. To avoid this complication, it is important that primary wound closure of the donor site should be relatively tension free and the width of the skin paddle should not exceed 6 cm.
| » Conclusion|| |
In this age of limited financial resources but rising expectations, it is very important to select a technique, which is cost-effective, relatively easy to learn and gives acceptable esthetic results. The autologous LD flap is one such highly versatile technique, which can serve as an ideal reconstructive technique for patients with small and medium sized breasts.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2]