The scarless latissimus dorsi flap provides effective lower pole prosthetic coverage in breast reconstruction

Abstract

Background: The evolution of surgical breast cancer treatment has led to the oncologically safe preservation of greater amounts of native skin, yet we are still often using flaps with large skin paddles, thereby resulting in significant donor-site scars. This explains the increasing appeal of acellular dermal matrix reconstructions. Acellular dermal matrices can, however, have significant problems, particularly if there is any vascular compromise of the mastectomy skin flaps. We have developed a method of raising the latissimus dorsi flap through the anterior mastectomy incisions without requiring special instruments or repositioning. This can provide autologous vascularized cover of the prosthesis.

Methods: A clear surgical description of the scarless latissimus dorsi flap harvest is provided, and our results of a retrospective cohort review of 20 consecutive patients with 27 traditional latissimus dorsi breast reconstructions were compared with those of 20 consecutive patients with 30 scarless latissimus dorsi breast reconstructions.

Results: Operative time, length of stay, and complication rates were reduced in the scarless group. Patients Breast-Q scores were equivalent in each group. The aesthetic assessment was good/excellent in 77% of both groups; however, subscale assessment was better in the scarless group. This was statistically significant (P = 0.0).

Conclusions: Breast reconstruction using the scarless latissimus dorsi flap is time effective, requires no patient repositioning, and uses standard breast instrumentation. It is safe and versatile while reducing the risk of exposed prosthesis if native skin necrosis occurs. It is a vascularized alternative to acellular dermal matrices.

Fig. 1.

Patient positioning.

Fig. 2.

Anterior border of latissimus dorsi.

Fig. 3.

Dissection procedure.

Fig. 4.

Critical landmark.

Fig. 5.

The flap is released inferiorly and medially.

Fig. 6.

The scarless latissimus dorsi harvested on the thoracodorsal vessels.

Fig. 7.

The latissimus dorsi flap is sutured to inferior edge of pectoralis major and inframammary fold.

Fig. 8.

Direct-to-implant/tissue expander 75% fill. External bolster sutures and 2 closed suction drains.

Fig. 9.

Patient with scarless latissimus dorsi with overlying skin necrosis safely managed nonoperatively with excellent result.

Fig. 10.

Breast-Q questionnaire results.

Fig. 11.

Overall aesthetic assessment.

Fig. 12.

Aesthetic assessment subscale analysis (P = 0).

Fig. 13.

Preoperative (A) and postoperative (B) views of the patient with native skin necrosis.

Fig. 14.

Preoperative and postoperative views. A, Skin- and nipple-sparing mastectomy and scarless latissimus dorsi flap reconstruction. B, Skin-sparing mastectomy and bilateral scarless latissimus dorsi flap reconstruction.