Immediate Latissimus Dorsi and Prosthetic Reconstruction in the Setting of Postmastectomy Radiation

Abstract

Background In immediate breast reconstruction, the plastic surgeon must strive to create an aesthetically pleasing result while minimizing complications. The latissimus dorsi (LD) myocutaneous flap has long been used a workhorse flap in breast reconstruction. Often times, it is used a salvage flap after other methods of breast reconstruction have failed. In this study, we review the use of this flap in conjunction with prosthetic devices, regardless of the need for adjuvant radiation, to determine the safety and efficacy of this approach as a primary method of reconstruction. Methods A single surgeon practice with a standardized reconstructive algorithm was reviewed. This compromises a 2-stage approach involving the use of LD myocutaneous flaps and tissue expanders for immediate reconstruction after mastectomy, followed by exchange for implants at a secondary surgery. A retrospective chart review was performed on 201 patients (376 breast reconstructions) who met inclusion criteria. Patient demographics and outcomes were compared based on radiation status. The primary outcome, reconstructive success, was defined as no need for further autologous reconstruction beyond the 2-stage approach utilized. Results Statistical analysis was performed on both patient demographics, complications, and reconstructive outcomes. Demographics were equivalent between the 2 groups. When analyzing complications and outcomes, there was no difference between nonradiated patients and radiated patients except when looking at reconstructive loss, which was 3.6% in the nonradiated group and 16.6% in the radiated group (P = 0.03). However, one third of the patients in the radiated group who had reconstructive losses were due to reasons not related to radiation therapy. Taking this into account, overall reconstructive success showed no statistical significance between the 2 groups. Conclusions The findings from this study show that immediate reconstruction with LD myocutaneous flaps in conjunction with prosthetic devices is a reliable and safe option, even in the setting of adjuvant radiation therapy, as the autologous tissue mitigates many sequelae of radiation therapy. Not only does this type of reconstruction provide an aesthetically pleasing result in 2 stages, but also has a favorable complication profile and success rate.

Do Socioeconomic Status and Race Impact the Safety and Efficacy of Breast Reconstruction?

“…Breast reconstruction can be performed at the time of mastectomy or delayed for months to years 18,19 . Immediate reconstruction is generally preferred over delayed reconstruction for better aesthetic results and higher reported patient quality of life scores 18,20–23 . Several studies in the field have documented that access to breast reconstruction is influenced by patient factors, such as ethnicity, insurance, and age 8,9,22 .…”

“…18,19 Immediate reconstruction is generally preferred over delayed reconstruction for better aesthetic results and higher reported patient quality of life scores. 18,[20][21][22][23] Several studies in the field have documented that access to breast reconstruction is influenced by patient factors, such as ethnicity, insurance, and age. 8,9,22 Recent studies have begun to investigate the disparities in outcomes in patients undergoing breast reconstruction in immediate autologous reconstruction, but few studies have looked at outcomes in the setting of radiotherapy in an institution designated as a safety-net-hospital (SNH).…”

Myocutaneous flap reconstruction after radiation therapy for breast cancer

“…The well-vascularized tissue of the LD flap decreases direct contact of the implant with the proximate radiated tissue 10. LD-based reconstruction can have a protective effect on implants in patients who have had radiation, resulting in the lowest rates of reoperation compared with patients who only had radiation and implants without the use of an LD flap 6,11…”

“…10 LD-based reconstruction can have a protective effect on implants in patients who have had radiation, resulting in the lowest rates of reoperation compared with patients who only had radiation and implants without the use of an LD flap. 6,11 Cosmetic appearance Aesthetically, the LD flap procedure permits the use of additional skin and tissue to compensate for the effects of radiation, allowing for improved breast symmetry. 3 The subsequent placement of a tissue expander provides additional expansion of the breast envelope.…”

Immediate Skin Replacement Allows for Nipple-sparing, Direct-to-implant Reconstruction in Patients with Advanced Breast Cancers

“…8 Previous reports have detailed use of these flaps to immediately replace just the NAC or large areas of skin after a nonskin sparing mastectomy to facilitate either single-stage or two-stage reconstructions. 9 To the best of our knowledge, this is the first report to demonstrate the utility of a flap to facilitate an NSM and DTIR in more advanced cancers requiring significant skin resection.…”