Accidental injury of the latissimus dorsi flap pedicle during axillae dissection: Types and reconstruction algorithm

Abstract

The intra-operative latissimus dorsi (LD) pedicle damage during axillary lymph-node dissection by the general surgeon is a rare complication leading to flap failure and poor outcomes. The authors present their experience on this topic and develop a classification of the thoracodorsal (TD) pedicle injuries and reconstruction algorithm. Pedicle damage of LD occurred in five cases, three of which were experienced during immediate breast reconstruction and two observed in patients who underwent prior surgery. In two cases the thoracodorsal vein (TDV) was damaged in its proximal segment, thus end-to-end anastomosis was performed between distal stump of TDV and circumflex scapular vein (CSV). In one case the TDV required simple microsurgical repair while in other two cases the severe damage of vein and artery required more complex surgical strategies in attempt to salvage the flap. Four cases completely survived with one case of rippling phenomenon. One case had partial flap necrosis that required subtotal muscle resection. Based on these cases, the authors have developed a reconstruction algorithm in attempt to repair LD pedicle damage while preserving breast reconstruction. Taking into account its anatomical conformation, TD pedicle injuries are classified in four different types and available options are suggested for all of them according to the anatomical site and to the mechanism and timing of injury.

The effect of deep muscle relaxation on the force required during Latissimus Dorsi dissection for breast reconstructive surgery: results of a prospective, double-blinded observational pilot study

“…Not formally investigated by this trial, but empirically noted by surgeons during the investigation was the absence of strong and irritating muscle twitches when diathermy was used after the patient had been paralysed. Above described changes support the claim for a facilitating effect of muscle relaxants during LD flap surgery [ 2 – 4 ].…”

“…Nonetheless, after identification of the neurovascular bundle, NMBA have been suggested to facilitate the dissection of the latissimus dorsi (LD) muscle for breast reconstructive surgery [ 2 ]. Potential benefits of muscle relaxation may be the “softer” muscle requiring less manual force when raising the flap, hence facilitating dissection, as well as the absence of strong, irritating muscle twitches during electrocoagulation [ 3 , 4 ].…”

Latissimus Dorsi Flap for Total Autologous Immediate Breast Reconstruction without Implants

“…[1][2][3][4][5] Despite the consensus regarding this procedure, its use has traditionally been limited by the desired size of the reconstructed breast. [1][2][3][4][5] Despite the consensus regarding this procedure, its use has traditionally been limited by the desired size of the reconstructed breast.…”

Autologous Latissimus Dorsi Breast Reconstruction Flap Salvage: Microvascular Anastomosis with Serratus Branch

“…Previous groups have documented flap salvage using primary anastomosis techniques, 2 conversion to a free flap, 2 , 3 vein graft techniques, 2 , 4 or by harvesting a new flap altogether. 5 Although flap salvage by anastomosis to the serratus branch of the thoracodorsal artery has been previously recognized, 2 we are not aware of any groups attempting this flap salvage technique. Our choice to proceed with this method was an unpremeditated decision made in the operating room that required a thorough knowledge of local vascular anatomy.…”