Breast reconstruction with a latissimus dorsi myocutaneous flap and implants: evaluation of strategies adopted to improve the results and evaluation of satisfaction by Breast-Q

The paper describes a 14-year experience with breast reconstruction using a latissimus dorsi myocutaneous flap (LDMF) and breast implants. The objective was to delineate the experience with LDMF and breast implants, skin island schedules and dissection details, flap transposition and placement of the implant under a double layer, strategies to minimize damage in the donor area, and strategies of breast symmetry and reconstruction of the nipple-areola complex, in association with evaluation using the Breast-Q questionnaire.

Methods:

A review of medical records was performed between April 2003 and June 2017.

Results:

In the period, 76 patients with a mean age of 50.09 years underwent reconstruction with a LDMF, which was bilateral in 11, for the right breast in 34, for the left breast in 31, immediate in 41, late in 22, and for rescue in 13.

Conclusion:

We conclude and verified with the Breast-Q questionnaire that with a precise indication, the proposed reconstruction technique with a double subpectoral plane and coverage with a LDMF is safer with a lower complication rate.

Keywords:
Breast neoplasms; Surveys and questionnaires; Myocutaneous flap; Treatment outcome; Breast implants.

Authorship

LEONARDO DAVID PIRES BARCELOS

Hospital Daher Lago Sul, Serviço de Cirurgia Plástica, Brasília, DF, BrazilHospital Daher Lago Sul, Serviço de Cirurgia Plástica, Brasília, DF, BrazilHospital Daher Lago Sul, Serviço de Cirurgia Plástica, Brasília, DF, Brazil

JEFFERSON DI LAMARTINE GALDINO AMARAL ^**Corresponding author: Jefferson Di Lamartine Galdino Amaral, SCN QD.02, Torre A, Salas 1121 e 1123 - 11º Andar - “Shopping Liberty Mall” - Brasília, DF, Brazil Zip Code 70712-903, E-mail: jefferson@dilamartine.com.br

Clínica Di Lamartine, Cirurgia Plástica, Brasília, DF, BrazilClínica Di Lamartine, Cirurgia Plástica, Brasília, DF, BrazilClínica Di Lamartine, Cirurgia Plástica, Brasília, DF, Brazil

JOSE CARLOS DAHER

LEONARDO MARTINS COSTA DAHER

JULDASIO GALDINO DE OLIVEIRA JUNIOR

Clínica Di Lamartine, Cirurgia Plástica, Brasília, DF, BrazilClínica Di Lamartine, Cirurgia Plástica, Brasília, DF, BrazilClínica Di Lamartine, Cirurgia Plástica, Brasília, DF, Brazil

GABRIEL CAMPELO DOS SANTOS

AMANDA COSTA CAMPOS

RONAN CAPUTI SILVA DIAS

*Corresponding author: Jefferson Di Lamartine Galdino Amaral, SCN QD.02, Torre A, Salas 1121 e 1123 - 11º Andar - “Shopping Liberty Mall” - Brasília, DF, Brazil Zip Code 70712-903, E-mail: jefferson@dilamartine.com.br

Conflicts of interest: none.

SCIMAGO INSTITUTIONS RANKINGS

Clínica Di Lamartine, Cirurgia Plástica, Brasília, DF, BrazilClínica Di Lamartine, Cirurgia Plástica, Brasília, DF, BrazilClínica Di Lamartine, Cirurgia Plástica, Brasília, DF, Brazil

Figures | Tables

Figures (19)
Tables (2)

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Figure 1
Chemotherapy and/or radiotherapy.

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Figure 2
Neoadjuvant chemotherapy.

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Figure 3
The impact of radiotherapy on breast reconstruction to highlight the relationship between radiotherapy and capsular contracture when performed before the rescue LDMF (cases) and after the LDMF.

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Figure 4
Type of reconstruction of the peroniomaleolar complex (NAP).

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Figure 5
Radiotherapy is directly related to capsular contracture and the need for reintervention of the reconstructed breasts.

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Figure 6
Radiotherapy as a potential causative agent of reconstruction failure or need for reintervention.

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Figure 7
Satisfaction when looking in the mirror.

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Figure 8
Sexually confident.

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Figure 9
Difficulty in raising or moving the arms.

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Figure 10
Appearance of the reconstructed nipple and areola.

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Figure 11
Late reconstruction with a LDMF and textured round implant of 325 cc and symmetrization with a textured round implant of the same volume (both retropectoral). The refinements were made with fat graft on the reconstructed breast and dorsum. The fat donor site included the contralateral dorsum and abdomen. NAC reconstruction with a graft of the opposite areola.

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Figure 12
In the first row, the strategy for implant placement in the retromuscular plane on both sides is shown. In the second row, reconstruction of the NAC with a LDMF in a case of immediate breast reconstruction with a LDMF to the left and an expander to the right (modified layout of the DOF to obtain a circular NAC) is shown. The third row shows the use of fat graft and skin adjustments on the dorsum to harmonize the donor area in an elderly patient with flaccidity in the dorsum, in which torsoplasty was used to improve the dorsum.

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Figure 13
Patient with an immediate LDMF in which radiotherapy caused severe capsular contracture, and at the moment of symmetrization, capsulotomy/ capsulectomy, replacement and repositioning of the implant associated with liposuction were performed to alleviate the deleterious effects of radiotherapy. In the third surgical moment, besides the NAC constructed with a C-V Flap, a new liposuction was necessary in the right reconstructed breast.

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Figure 14
A case of late reconstruction of the left breast with a LDMF with an oblique skin island to favor a greater amount of tissue and better rotation of the flap. Given that the patient found the reconstructed breast large, at the moment of symmetrization, we proceeded with a reduction of the breast, with a marking mimicking an inverted T, together with reconstruction of the NAC with the DOF and refinements on the back with liposuction/fat graft.

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Figure 15
Implant under a double muscle layer.

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Figure 16
In this case of a salvage LDMF, the patient had a reconstruction with expander with severe contracture at the first consultation and then successfully underwent the LDMF technique. In the first reconstruction, an intense volume reduction of the left breast was made, with removal of 8070 g of tissue and the use of the Torek technique with a free graft from the left NAC) with the inclusion of an implant in the retropectoral plane. LDMF transposition was performed in the second moment, and reconstruction of the NAC with the DOF, skin adjustments in the right reconstructed breast, and liposuction/ fat graft in the back were performed in the third moment. Note here the benefits for the donor area with adequate fat management and, sometimes, skin adjustments when necessary.

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Figure 17
Case of immediate reconstruction with bilateral LDMF and implant in a patient with reduction mammoplasty and previous dermolipectomy. In the first moment, transposition of the flaps with a circular skin island was performed. In the second moment, reconstruction of the NAC with the DOF and adjustments of skin on previous scars from Pitanguy mammoplasty were performed. Note that DOF provides a relief of the NAC in relation to adjacent tissues and that after dermopigmentation, there is a natural appearance.

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Figure 18
A case of reconstruction with a salvage LDMF in which after using a temporary expander, the capsular contracture was severe due to RT. The tomography image shows the scarce coverage on the expander and contracture. Removal of the expander and capsulotomy/capsulectomy associated with fat grafting/liposuction are adequate strategies to improve the results. After removal of the expander, dissection was performed between the flap and the pectoralis to test the LDMF over the implant/pectoral assembly. The same is true for the dorsum. The NAC was reconstructed with the DOF already pigmented at 6 months after the second reconstruction.

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Figure 19
A case of bilateral reconstruction with a LDMF (myocutaneous to the right and only muscle to the left). On the fifth postoperative day, infection occurred with signs of sepsis with foci in the new breast, so the implants were removed. After >20 months, the patient returned and requested new implants under the pectoralis major/LDMF assembly; at which point, the right NAC was reconstructed with the DOF and refinements in the left NAC and dorsum were performed.

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LDPB Análise e/ou interpretação dos dados; análise estatística; aprovação final do manuscrito; coleta de dados; conceitualização; concepção e desenho do estudo; gerenciamento de recursos; gerenciamento do projeto; investigação; metodologia; realização das operações e/ou experimentos; redação - preparação do original; redação - revisão e edição; visualização. JDLGA Análise e/ou interpretação dos dados; análise estatística; aprovação final do manuscrito; aquisição de financiamento; coleta de dados; conceitualização; concepção e desenho do estudo; gerenciamento de recursos; gerenciamento do projeto; investigação; metodologia; redação - revisão e edição; supervisão; visualização. JCD Gerenciamento de recursos; gerenciamento do projeto; metodologia; redação - revisão e edição; supervisão. LMCD Coleta de dados; conceitualização; investigação; redação - preparação do original; redação - revisão e edição. JGOJ Análise e/ou interpretação dos dados; análise estatística; coleta de dados; investigação; metodologia; realização das operações e/ ou experimentos; redação - preparação do original; redação - revisão e edição. GCS Análise e/ou interpretação dos dados; análise estatística; aprovação final do manuscrito; coleta de dados; investigação; realização das operações e/ou experimentos; redação - preparação do original; redação - revisão e edição. ACC Análise e/ou interpretação dos dados; coleta de dados; realização das operações e/ou experimentos; redação - preparação do original; redação - revisão e edição RCSD Análise e/ou interpretação dos dados; análise estatística; coleta de dados; redação - preparação do original; redação - revisão e edição; visualização.

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LDPB Analysis and/or interpretation of data; statistical analysis; final approval of the manuscript; data collection; conceptualization; conception and design of the study; project management; research; methodology; completion of operations and/or experiments; writing, including preparation, review, and editing of the original manuscript. JDLGA Analysis and/or interpretation of data; statistical analysis; final approval of the manuscript; funding; data collection; conceptualization; conception and design of the study; project management; research; methodology; writing, including review and editing; and research supervision. JCD Resource management; project management; methodology; writing, including revision and editing; and research supervision. LMCD Data collection, conceptualization, and research; writing, including preparation, revision, and editing of the original manuscript. JGOJ Analysis and/or interpretation of data; statistical analysis; data collection; research; methodology; completion of operations and/or experiments; writing, including preparation, revision, and editing of the original manuscript. GCS Analysis and/or interpretation of data; statistical analysis; final approval of the manuscript; data collection; research; completion of operations and/or experiments; writing, including preparation, revision, and editing of the original manuscript. ACC Analysis and/or interpretation of data; data collection; completion of operations and/or experiments; writing, including preparation, revision, and editing of the original manuscript. RCSD Analysis and/or interpretation of data; statistical analysis; data collection; writing, including preparation, revision, and editing of the original manuscript.

Figure 1 Chemotherapy and/or radiotherapy.

Figure 2 Neoadjuvant chemotherapy.

Figure 3 The impact of radiotherapy on breast reconstruction to highlight the relationship between radiotherapy and capsular contracture when performed before the rescue LDMF (cases) and after the LDMF.

Figure 4 Type of reconstruction of the peroniomaleolar complex (NAP).

Figure 5 Radiotherapy is directly related to capsular contracture and the need for reintervention of the reconstructed breasts.

Figure 6 Radiotherapy as a potential causative agent of reconstruction failure or need for reintervention.

Figure 7 Satisfaction when looking in the mirror.

Figure 8 Sexually confident.

Figure 9 Difficulty in raising or moving the arms.

Figure 10 Appearance of the reconstructed nipple and areola.

Figure 11 Late reconstruction with a LDMF and textured round implant of 325 cc and symmetrization with a textured round implant of the same volume (both retropectoral). The refinements were made with fat graft on the reconstructed breast and dorsum. The fat donor site included the contralateral dorsum and abdomen. NAC reconstruction with a graft of the opposite areola.

Figure 12 In the first row, the strategy for implant placement in the retromuscular plane on both sides is shown. In the second row, reconstruction of the NAC with a LDMF in a case of immediate breast reconstruction with a LDMF to the left and an expander to the right (modified layout of the DOF to obtain a circular NAC) is shown. The third row shows the use of fat graft and skin adjustments on the dorsum to harmonize the donor area in an elderly patient with flaccidity in the dorsum, in which torsoplasty was used to improve the dorsum.

Figure 13 Patient with an immediate LDMF in which radiotherapy caused severe capsular contracture, and at the moment of symmetrization, capsulotomy/ capsulectomy, replacement and repositioning of the implant associated with liposuction were performed to alleviate the deleterious effects of radiotherapy. In the third surgical moment, besides the NAC constructed with a C-V Flap, a new liposuction was necessary in the right reconstructed breast.

Figure 14 A case of late reconstruction of the left breast with a LDMF with an oblique skin island to favor a greater amount of tissue and better rotation of the flap. Given that the patient found the reconstructed breast large, at the moment of symmetrization, we proceeded with a reduction of the breast, with a marking mimicking an inverted T, together with reconstruction of the NAC with the DOF and refinements on the back with liposuction/fat graft.

Figure 15 Implant under a double muscle layer.

Figure 16 In this case of a salvage LDMF, the patient had a reconstruction with expander with severe contracture at the first consultation and then successfully underwent the LDMF technique. In the first reconstruction, an intense volume reduction of the left breast was made, with removal of 8070 g of tissue and the use of the Torek technique with a free graft from the left NAC) with the inclusion of an implant in the retropectoral plane. LDMF transposition was performed in the second moment, and reconstruction of the NAC with the DOF, skin adjustments in the right reconstructed breast, and liposuction/ fat graft in the back were performed in the third moment. Note here the benefits for the donor area with adequate fat management and, sometimes, skin adjustments when necessary.

Figure 17 Case of immediate reconstruction with bilateral LDMF and implant in a patient with reduction mammoplasty and previous dermolipectomy. In the first moment, transposition of the flaps with a circular skin island was performed. In the second moment, reconstruction of the NAC with the DOF and adjustments of skin on previous scars from Pitanguy mammoplasty were performed. Note that DOF provides a relief of the NAC in relation to adjacent tissues and that after dermopigmentation, there is a natural appearance.

Figure 18 A case of reconstruction with a salvage LDMF in which after using a temporary expander, the capsular contracture was severe due to RT. The tomography image shows the scarce coverage on the expander and contracture. Removal of the expander and capsulotomy/capsulectomy associated with fat grafting/liposuction are adequate strategies to improve the results. After removal of the expander, dissection was performed between the flap and the pectoralis to test the LDMF over the implant/pectoral assembly. The same is true for the dorsum. The NAC was reconstructed with the DOF already pigmented at 6 months after the second reconstruction.

Figure 19 A case of bilateral reconstruction with a LDMF (myocutaneous to the right and only muscle to the left). On the fifth postoperative day, infection occurred with signs of sepsis with foci in the new breast, so the implants were removed. After >20 months, the patient returned and requested new implants under the pectoralis major/LDMF assembly; at which point, the right NAC was reconstructed with the DOF and refinements in the left NAC and dorsum were performed.

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Breast reconstruction with a latissimus dorsi myocutaneous flap and implants: evaluation of strategies adopted to improve the results and evaluation of satisfaction by Breast-Q

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[1] *Corresponding author: Jefferson Di Lamartine Galdino Amaral, SCN QD.02, Torre A, Salas 1121 e 1123 - 11º Andar - “Shopping Liberty Mall” - Brasília, DF, Brazil Zip Code 70712-903, E-mail: jefferson@dilamartine.com.br