Delayed division of the thoracodorsal nerve: a useful adjunct in breast reconstruction

Breast reconstruction utilizing the latissimus dorsi musculocutaneous flap with an underlying breast implant is a well-established technique. Postoperative shoulder limitation is usually limited if at all noticeable. The muscle itself may, however, remain active in the new anterior position. Many patients find the muscle twitches with extension of the humerus, despite the anterior translocation of the muscle. This leads to a disturbing contraction, superolaterally, of the entire reconstruction. In addition, the resting tone can lead to a sense of tightness, despite a lack of clinically obvious capsular contracture. Division of the thoracodorsal nerve during initial flap elevation can prevent this problem. When raising the routine flap however, the pedicle itself is often not visualized and there is anxiety related to dividing the nerve and accidentally injuring the vascular pedicle. In addition, many of the transferred muscles atrophy, thereby avoiding this potential problem. When the muscle remains active, delayed division of the thoracodorsal nerve via a 2.5-cm axillary incision will stop the active twitching, decrease the resting tone of the muscle, and in most patients offer significant relief from symptoms of tightness. During the past 2 1/2 years, 100 latissimus dorsi flap breast reconstructions in 80 patients were performed. Forty-one nerves in 28 patients have been divided, with successful denervation in 37 of the 41 reconstructions, for a success rate of 90%. Delayed division of the thoracodorsal nerve can offer relief to patients complaining of tightness and muscle activity post-latissimus flap breast reconstruction.