Robotic-assisted latissimus dorsi harvest in delayed-immediate breast reconstruction

Abstract

For two-stage, implant-based, delayed-immediate reconstruction of the radiated breast, robotic-assisted latissimus dorsi harvest (RALDH) is a good option for patients who wish to avoid a traditional latissimus dorsi donor-site incision. The purpose of this study was to compare outcomes of RALDH and the traditional open technique (TOT) for patients undergoing delayed-immediate breast reconstruction following radiation therapy. A retrospective analysis of a prospective database of all consecutive patients undergoing latissimus dorsi harvest for radiated breast reconstruction between 2009 and 2013 was performed. Indications, surgical technique, complications, and outcomes were assessed. One hundred forty-six pedicled latissimus dorsi muscle flaps were performed for breast reconstruction and 17 were performed robotically during the study period (average follow-up 14.6 ± 7.3 mo). Latissimus dorsi breast reconstruction following radiation was performed in 64 patients using TOT and 12 using RALDH. Surgical complication rates were 37.5% in TOT versus 16.7% in RALDH (p = 0.31) including seroma (8.9% versus 8.3%), infection (14.1 versus 8.3%), delayed wound healing (7.8% versus 0), and capsular contracture (4.7% vs. 0). Robotic-assisted harvest of the latissimus dorsi muscle is associated with a low complication rate and reliable results for delayed reconstruction of the irradiated breast while eliminating the need for a donor-site incision.

Keywords: breast reconstruction; delayed immediate; latissimus dorsi; radiated breast; robotic assisted.

Fig. 1

Delayed-immediate breast reconstruction protocol.

Fig. 2

Delayed-Immediate reconstruction of an irradiated breast using a robotic-assisted latissimus dorsi harvest (RALDH). A 42-year-old woman was diagnosed with invasive ductal carcinoma of the right breast with positive lymph node metastasis. She was treated with bilateral mastectomies, right axillary dissection, and immediate reconstruction using tissue expanders (133MX 400 cc; Allergan Corp., Irvine, CA) followed by external beam radiation therapy (60 Gy) to the right chest wall. (A) Immediately and (B) 6 months following radiation therapy. Note radiation-induced constriction and elevation of the right inframammary fold, which must be corrected.

Fig. 3

Intraoperative views during robotic-assisted latissimus dorsi harvest. (A) Predissection of latissimus dorsi with exposure of thoracodorsal artery and vein. Note all dissection is accomplished through anterior mastectomy incision with no additional skin incisions required. (B) 12- and two 8-French ports placed at the lateral border of the latissimus dorsi muscle.

Fig. 4

Intraoperative views during robotic-assisted latissimus dorsi harvest. (A) Transposition of latissimus dorsi muscle underneath a subcutaneous skin bridge. (B) Latissimus dorsi muscle achieves total muscle coverage over a permanent silicone shaped implant (410 FF 425 cc, Allergan Corp., Irvine, CA). Note previous port sites are utilized for drain placement.

Fig. 5

Postoperative results. (A) Patient is 10 months postoperative and has now received nipple construction with areolar tattooing. (B) Patient was noted to have a minor contour defect of her donor site. (C) Her postoperative course was without complication.

Fig. 6

(A) Before and (B) after donor site for robotic-assisted latissimus dorsi harvest, demonstrating virtually no change in contour and no incision on the back. The muscle was taken from the patient's left side.