Tertiary Breast Reconstruction Using a Free Contralateral Latissimus Dorsi Musculocutaneous Flap

The latissimus dorsi musculocutaneous flap is a reliable and dependable option and has been used for autologous breast reconstruction since the 1970s.[1] [2] With the evolution of muscle sparing methods of breast reconstruction, the pedicled thoracodorsal artery perforator (TDAP) flap has become increasingly popular. In cases where a TDAP flap has failed, reconstruction with the ipsilateral latissimus dorsi musculocutaneous flap is no longer an option because the thoracodorsal artery and vein as well as the cutaneous component have been sacrificed. Secondary donor sites such as the abdomen, thighs, and buttock are considered and often used; however, in some patients these donor sites are either not suitable or declined. Another option in these situations is to consider the contralateral latissimus dorsi musculocutaneous flap as a free tissue transfer. We describe the use of a free contralateral latissimus dorsi musculocutaneous flap for delayed breast reconstruction following radiation therapy and previous ipsilateral TDAP failure.

A 39-year-old woman presented following mastectomy, radiation, and multiple attempts at breast reconstruction all resulting in failure ([Fig. 1]). Relevant history included previous bilateral breast augmentation with saline implants placed in a submuscular position 4 years before a diagnosis of stage IIIa invasive ductal breast cancer. The patient had a left mastectomy with immediate reconstruction using a tissue expander and acellular dermal matrix. Six months after completing adjuvant chemotherapy and radiation, she underwent exchange of the tissue expander for a high profile 550 mL round silicone gel breast implant, which was complicated by incisional dehiscence prompting a return to the operating room and exchange of the device for a 450 mL silicone gel implant. The incision again dehisced and the decision was made to perform a pedicled TDAP flap with implant removal. This reconstruction was unsuccessful and resulted in a flap failure. These operations were all performed at another hospital.

Fig. 1 Photograph of the patient on initial examination following failed attempts at left breast reconstruction including failed thoracodorsal artery perforator attempt following mastectomy and adjuvant radiation therapy. The patients right breast was previously augmented using a subpectorally placed saline implant.

On initial examination the patient was 5 ft 1 in tall and weighed 118 lb (body mass index 22.3). She had an acquired absence of her left breast with significant contour abnormality and thin skin with radiation damage. She was also noted to have a previously augmented right breast. Her abdomen demonstrated minimal skin and fat, as did the superior gluteal region. Autologous tissue reconstruction options were explained to the patient including a pedicled transverse rectus abdominis myocutaneous (TRAM) flap, free unilateral abdominal flap (deep inferior epigastric perforators vs. muscle sparing-TRAM), superior gluteal artery perforator flap, or a contralateral latissimus dorsi musculocutaneous free flap. She ultimately decided on a free tissue transfer using the contralateral latissimus dorsi musculocutaneous flap.

At the time of surgery, the patient was marked in the standing position with her skin paddle oriented along the relaxed skin tension lines. . The internal mammary artery and vein were exposed and prepared as the recipient vessels with the patient supine. Thereafter, a closed suction drain was inserted, and the skin was temporarily closed to reposition the patient in the left lateral decubitus position with her right side up ([Fig. 2]). The proposed latissimus dorsi myocutaneous flap was marked again and fluorescent angiography was performed. An extended latissimus dorsi musculocutaneous free flap was harvested in the standard fashion and the donor site was closed in layers following placement of two closed suction drains. The duration from the time of flap harvest to the end of redraping was 28 minutes. After repositioning the patient supine, the operating microscope was utilized and the thoracodorsal artery and vein were prepared. The arterial and venous anastomosis was performed using 8–0 nylon sutures placed in an interrupted fashion. The duration of the microvascular anastomosis was 51 minutes. The flap was inset, the latissimus dorsi muscle edges were sutured to the pectoralis major, the closed suctions drain was properly positioned, and the skin edges were closed. No prosthetic device was inserted during this operation to minimize the risk of anastomotic compromise.

Fig. 2 Intraoperative photograph of the patient in the right decubitus position with preoperative markings for latissimus dorsi harvest. The skin paddle was placed obliquely in relaxed skin tension lines.

Her postoperative course was without incident and the flap remained viable ([Fig. 3]). After 7 months, a 275 mL tissue expander (Mentor Corporation, Santa Barbara, CA) was placed underneath the latissimus dorsi muscle and a single closed suction drain was placed, and she was serially expanded to a volume of 275 mL. After 4 months, she returned to the operating room for the exchange to a 425 mL round base–shaped silicone gel device. There were no postoperative complications and the patient remains very satisfied with a symmetric and nicely contoured left breast reconstruction ([Fig. 4]).

Fig. 3 Postoperative photograph of the patient following contralateral free latissimus dorsi musculocutaneous flap reconstruction of her left mastectomy defect before placement of the tissue expander.

Fig. 4 Photographs of the patient's final reconstructive outcome after placement of 425 mL form stable silicone implants underneath the latissimus dorsi musculcutaneous flap demonstrating a natural appearance of her desired size along with good symmetry to her contralateral previously augmented breast. (A.) Frontal view. (B) Lateral View.

The pedicled latissimus dorsi musculocutaneous is a reliable and frequently used flap for breast reconstruction. The flap is based on the thoracodorsal artery and vein and is capable of maintaining perfusion through the serratus branch of the thoracodorsal artery.[1] [2] As a free tissue transfer, the latissimus dorsi muscle is usually used as a thin flap for resurfacing regions such as the scalp or lower extremity. Its use as a free flap for breast reconstruction is rare but has been reported. Martano et al described the successful conversion of an avulsed pedicled latissimus dorsi flap to a free flap for breast reconstruction. Serletti et al used a free latissimus dorsi for revisionary breast reconstruction in a patient with a previous abdominal flap for breast reconstruction wherein the bulk of the reconstruction still relied on the original abdominal flap.[3] [4] [5]

The TDAP flap was introduced in 1995 for both pedicled and free tissue transfer and has been occasionally applied to breast reconstruction.[6] [7] [8] Its main indication has been to reconstruct the partial breast deformity because of its limited volume. The principle advantage is that the latissimus dorsi muscle is spared and there is a relatively long vascular pedicle that facilitates mobility and insetting of the flap. In addition, seroma formation, a frequent complication following latissimus dorsi muscle elevation, is rare following TDAP harvest.[6] [9] The main disadvantages are that it requires a meticulous dissection, surgeon experience, and possibly perforator mapping to define the optimal skin territory. In the event of flap failure, the ipsilateral latissimus musculocutaneous flap is no longer an option. Outcome data regarding pedicled TDAP flaps is limited with a reported flap failure rate of 6.8% in the largest study of 87 flap reconstructions.[7] [8] [10]

This case represents the first report in the literature of a free contralateral latissimus dorsi musculocutaneous flap used for delayed tertiary breast reconstruction. The patient presented a unique reconstructive challenge given her history of previous implant failure, chest wall radiation, thin body habitus, aversion to abdominal donor sites, and failure of an ipsilateral pedicled TDAP flap. The contralateral free latissimus dorsi myocutaneous free flap is a viable alternative and can result in excellent surgical outcomes.

• References

• 1 Chun JK, Sterry TP. Latissimus dorsi musculocutaneous flap based on the serratus branch with microvascular venous augmentation. J Reconstr Microsurg 2001; 17 (2) 95-98
• 2 Hartmann CE, Branford OA, Malhotra A, Chana JS. Survival of a pedicled latissimus dorsi flap in breast reconstruction without a thoracodorsal pedicle. J Plast Reconstr Aesthet Surg 2013; 66 (7) 996-998
• 3 Kim JT, Koo BS, Kim SK. The thin latissimus dorsi perforator-based free flap for resurfacing. Plast Reconstr Surg 2001; 107 (2) 374-382
• 4 Martano A, Malata CM. Accidental latissimus dorsi flap pedicle avulsion during immediate breast reconstruction: salvage by conversion to free flap. J Plast Reconstr Aesthet Surg 2012; 65 (8) 1107-1110
• 5 Serletti JM, Higgins J, Carras AJ. Free latissimus dorsi myocutaneous flap for secondary breast reconstruction after partial loss of a TRAM flap. Plast Reconstr Surg 1997; 100 (3) 690-694
• 6 Angrigiani C, Grilli D, Siebert J. Latissimus dorsi musculocutaneous flap without muscle. Plast Reconstr Surg 1995; 96 (7) 1608-1614
• 7 Guerra AB, Metzinger SE, Lund KM, Cooper MM, Allen RJ, Dupin CL. The thoracodorsal artery perforator flap: clinical experience and anatomic study with emphasis on harvest techniques. Plast Reconstr Surg 2004; 114 (1) 32-41 , discussion 42–43
• 8 Schwabegger AH, Bodner G, Ninković M, Piza-Katzer H. Thoracodorsal artery perforator (TAP) flap: report of our experience and review of the literature. Br J Plast Surg 2002; 55 (5) 390-395
• 9 Ayhan S, Tuncer S, Demir Y, Kandal S. Thoracodorsal artery perforator flap: a versatile alternative for various soft tissue defects. J Reconstr Microsurg 2008; 24 (4) 285-293
• 10 Hamdi M, Van Landuyt K, Monstrey S, Blondeel P. Pedicled perforator flaps in breast reconstruction: a new concept. Br J Plast Surg 2004; 57 (6) 531-539