Two-Stage Latissimus Dorsi Flap with Implant for Unilateral Breast Reconstruction: Getting the Size Right

Abstract

Background: The aim of unilateral breast reconstruction after mastectomy is to craft a natural-looking breast with symmetry. The latissimus dorsi (LD) flap with implant is an established technique for this purpose. However, it is challenging to obtain adequate volume and satisfactory aesthetic results using a one-stage operation when considering factors such as muscle atrophy, wound dehiscence and excessive scarring. The two-stage reconstruction addresses these difficulties by using a tissue expander to gradually enlarge the skin pocket which eventually holds an appropriately sized implant.

Methods: We analyzed nine patients who underwent unilateral two-stage LD reconstruction. In the first stage, an expander was placed along with the LD flap to reconstruct the mastectomy defect, followed by gradual tissue expansion to achieve overexpansion of the skin pocket. The final implant volume was determined by measuring the residual expander volume after aspirating the excess saline. Finally, the expander was replaced with the chosen implant.

Results: The average volume of tissue expansion was 460 mL. The resultant expansion allowed an implant ranging in volume from 255 to 420 mL to be placed alongside the LD muscle. Seven patients scored less than six on the relative breast retraction assessment formula for breast symmetry, indicating excellent breast symmetry. The remaining two patients scored between six and eight, indicating good symmetry.

Conclusions: This approach allows the size of the eventual implant to be estimated after the skin pocket has healed completely and the LD muscle has undergone natural atrophy. Optimal reconstruction results were achieved using this approach.

Keywords: Breast; Radiotherapy; Reconstructive surgical procedures; Surgical flaps; Tissue expansion.

Fig. 1. Two-stage LD reconstruction with an expander

Inferior placement of the port through the inframammary fold. A skin paddle is used to cover the nipple-areolar complex defect. Anchoring sutures are placed along the borders of the latissimus dorsi (LD) muscle.

Fig. 2. Two-stage LD reconstruction for patient C

(A) Preoperative photograph. (B) Over-expansion with a tissue expander volume of 540 mL. (C) The tissue expander deflated to 250 mL to achieve symmetrization. (D) Postoperative photograph at nine months after placement of a 255-mL Mentor implant and nipple reconstruction. LD, latissimus dorsi.

Fig. 3. Breast prostheses volumes

Volume of the tissue expander and implant size during two-stage reconstruction for the nine patients (A–I).

Fig. 4. Two-stage LD reconstruction in patient A

(A) Preoperative photograph. (B) The latissimus dorsi (LD) flap skin paddle marking. (C) Subpectoral placement of a 550-mL Mentor expander pre-filled with 20 mL of saline and the LD flap. (D) Tension-free closure of the reconstructed breast. (E) Tissue expansion and size symmetrization stages. (F) One-year postoperative photograph after placement of a 255-mL implant and nipple reconstruction.

Fig. 5. Two-stage LD reconstruction for patient B

(A) Preoperative photograph. (B) Subpectoral placement of a 550-mL Mentor expander pre-filled with 100 mL of saline and the latissimus dorsi (LD) flap. (C) Thirteen-month postoperative photograph after placement of a 375-mL implant and nipple reconstruction.