Improving the latissimus dorsi myocutaneous flap with tissue expansion

Although the latissimus dorsi myocutaneous flap is a safe and reliable technique for breast reconstruction, its versatility is limited when large cutaneous units are needed to resurface a heavily irradiated or scarred breast and chest wall. The thick back skin, in particular, may be unsuitable for reconstruction opposite either a hyperplastic or moderate sized but ptotic breast. Also, the likely need for a prosthesis can result in encapsulation and firmness. Expanding the latissimus flap has been suggested as a means of improving its aesthetic and reconstructive results. Indications for choosing an expanded flap in 10 patients included: (1) a need for autogenous tissue reconstruction of irradiated breast and chest wall tissues; (2) cutaneous coverage requirements that exceeded the availability of donor site skin; (3) the presence of a hyperplastic or ptotic contralateral breast that the patient preferred to match rather than alter; and (4) unavailability of an alternative flap such as a TRAM and unsuitability of an implant or expander without a flap. Results of this study in 10 patients requiring breast and chest wall reconstruction demonstrate that flap dimensions increased by approximately a factor of 1.5 after expansion. The latissimus flap was pre-expanded on the back before transfer in two patients when skin and soft tissues were inadequate, or was expanded post-transfer in eight patients for both immediate and delayed breast reconstruction. Eight patients underwent a total of two operations, including two who had nipple areolar reconstruction. Earlier in the series, two other patients had nipple areolar reconstruction performed as a third procedure. Mean follow-up was 15.1 months. Complications consisted of partial dehiscence of the donor site wound in one patient after transfer of an expanded flap measuring 16 x 28 cm; three patients developed symptomatic seromas requiring drainage. All patients had soft, nonpalpable implants and no distortion of the flap's shape. The application of tissue expansion techniques yields latissimus flaps that are notable for their capacious dimensions, thinned tissues, and improved pliability. Advantages include an avoidance of reduction or mastopexy procedures in patients with large, ptotic breasts and uncomplicated wound healing in those with a history of prior irradiation. Not all latissimus flaps need to be expanded, but some can be significantly improved when specific indications are present. Most importantly, expanded latissimus flaps appear to resist the early formation of periprosthetic encapsulation.