Postmastectomy Breast Reconstruction With the Totally Autologous Latissimus Dorsi Flap in the Thin, Small-Breasted Woman: Give It More Thought!

Abstract

Introduction: Thin women have fewer autologous tissue breast reconstructive options than their higher body mass index counterparts-due to a lack of adequate donor sites. They are therefore usually offered expander/implant techniques. The total autologous latissimus dorsi flap is generally used in "well-padded" individuals, as they have enough fat on their back on which a completely autologous reconstruction could be based. When implant-based reconstruction is contraindicated (for instance due to planned adjuvant radiotherapy) or unacceptable to the patient, the total autologous latissimus dorsi flap can provide adequate tissue volume by utilizing the additional back fat deposits even in the thin, small-breasted patient. This option is often overlooked by many surgeons. Our case series assesses indications and patient and surgeon satisfaction with the cosmetic outcome of this technique. Methods: The oncological and clinical details of 6 patients with breast cancer who underwent total autologous latissimus dorsi myocutaneous flap immediate breast reconstruction by a single surgeon over an 8-year period were reviewed. An objective assessment of satisfaction with the cosmetic result was made by whether any additional surgical interventions (ipsilateral fat grafting/implant augmentation or contralateral liposuction/ reduction) were needed or not. A subjective assessment of breast symmetry by the surgeon using photographic records was also undertaken. The aesthetic outcomes were also objectively quantified using the BCCT.core software, initially developed for assessing the results of breast conservation surgery. Results: All 6 patients had small breasts and a low or normal body mass index. The mastectomies were performed for invasive carcinoma (n = 3) and extensive high-grade ductal carcinoma in situ (n = 3). Four had axillary surgery (2 sentinel lymph node biopsies and 2 axillary clearances), and 3 received adjuvant radiotherapy. All were happy with their reconstructive outcomes, and none suffered major postoperative complications or disease recurrence. None requested or needed any subsequent ipsilateral adjustment or contralateral symmetrizing procedures. Subjectively, the reconstructions provided acceptable or excellent cosmetic results. The cosmetic results were categorized as excellent or good on the BCCT.core scoring system. Conclusion: This underutilized method of totally autologous breast reconstruction in thinner patients with lower body mass indexes yielded good, well-accepted cosmetic results without recourse to adjustment procedures, contralateral balancing surgery, or complex microvascular surgery. We recommend that the total autologous latissimus dorsi flap should be given more consideration when planning immediate breast reconstruction in this challenging group of thin, small-breasted patients.

Keywords: autologous reconstruction; breast cancer; breast reconstruction; latissimus dorsi; mastectomy.

Figure 1

Patient 1, a 52-year-old woman with extensive ductal carcinoma in situ who under-went a left mastectomy and TALD reconstruction 1 year later. Note the excellent postoperative symmetry. Photographs prior to nipple reconstruction (a, c, e) and after TALD reconstruction (b, d, f). TALD indicates totally autologous latissimus dorsi.

Figure 2

Patient 2, a 40-year old female with A cup size breasts and body mass index of 20, shown preoperatively (a, c, e) and 1 year following immediate left breast reconstruction with a totally autologous latissimus dorsi flap (b, d, f) and nipple-areolar reconstruction with acceptable cosmetic results.

Figure 3

Patient 3, a 54-year-old woman with a body mass index of 26 and 36A/B cup-sized breasts, undertook a left breast latissimus dorsi reconstruction as demonstrated in the preoperative (a, c, e) and postoperative (b, d, f) photographs. She previously had a right skin-sparing mastectomy and reconstruction with a pediceled TRAM flap.

Figure 4

Patient 4, a 45-year-old woman with 36B cup size breasts and body mass index 27, shown preoperatively (a, c, e,) and 1-year after reconstruction (b, d, f). The nipple reconstruction has produced good cosmetic results, and there is reasonable donor site scarring. The breast mounds on the left-lateral view (e, f) highlight that there is more than adequate volume to match the opposite breast.

Figure 5

Patient 6, this 35-year-old woman with 34C cup size breasts and a left multifocal high-grade carcinoma of no specific type underwent bilateral nipple-sparing mastectomies (left therapeutic, right risk-reducing) and immediate reconstruction with bilateral latissimus dorsi flaps. The preoperative (a, c, e) and postoperative (b, d, f) appearances demonstrate that excellent cosmetic results were obtained.