Modified muscle sparing latissimus dorsi with implant for total breast reconstruction - extending the boundaries

Refinements in breast reconstruction have led to a better understanding of aesthetics and a reduction of donor morbidity. The muscle sparing latissimus dorsi (MS-LD) is a step towards this. It has previously been described for reconstruction in partial mastectomy defects. We describe a modification of the MS-LD that permits total breast reconstruction.

Between June 2006 and October 2008, 22 MS-LD flaps were used in 18 patients. A tiny lateral muscle segment containing the descending branch of the thoracodorsal artery along with its thoracodorsal artery perforators (TDAPs) was used as a pedicle to carry a large skin and fascial flap in all cases. The fascial component permitted complete coverage of the implant in a pre-pectoral pocket. Innervation and vascularity to the remaining muscle was preserved. Postoperatively, DASH questionnaires were sent out to the patients to objectively assess shoulder morbidity.

Skin dimensions ranged from 16x8 centimetres (cm) to 25x10cm. Follow up ranged from 3 to 30 months. Four minor and three major complications occurred. There was no total flap loss and no seromas. We achieved high patient satisfaction regarding the aesthetic outcome and with preservation of functional latissimus dorsi (LD) muscle.

The muscle sparing technique is useful in a selected group of highly active post-mastectomy patients. It is quicker and more reliable(1) than a pure perforator flap approach and can be used to reconstruct the entire breast, preserving the remaining functional muscle for possible backup option in cases of salvage.