Latissimus Dorsi Myocutaneous Flap in Immediate Reconstruction after Salvage Mastectomy Post-Lumpectomy and Radiation Therapy

Abstract

Background: Breast reconstruction after salvage mastectomy (SM) for recurrent cancer represents a challenge in preradiated patients due to the increased complication rate. Latissimus dorsi myocutaneous flap (LDMF) represents a good reconstructive option due to its versatility, safety, and adaptability. Methods: Fifty-nine patients treated in the Breast Surgery Unit at the University Hospital of Parma (Italy) between January 2010 and December 2017 for ipsilateral breast recurrent cancer, previously treated by partial mastectomy plus whole-breast radiation therapy, were analyzed. They underwent SM and immediate reconstruction with implant-assisted pedicled LDMF. We registered local treatment, oncologic characteristics, complications, capsular contracture rate, DASH test, and BREAST-Q scores. Results: Mean implant volume was 403 g (range 135–650 g). Contralateral operations were 16/59 (27.1%). We obtained complete postoperative pain control in most cases with paracetamol. Medium hospital stay was 2.8 days. We registered 3.4% major complications and 6.8% minor ones. Mean follow-up was 26.65 months (range 3–91.9 months). DASH questionnaire evidenced no disability for 71.19% of patients and minimum disability for 28.81% of them. BREAST-Q Aesthetic Questionnaire obtained 92.72%. No patient developed Baker III or IV capsular contracture. Conclusions: LDMF with implant is a reliable and safe procedure for 1-step breast reconstruction after SM for recurrent cancer in radiated breast. It entails a low rate of major complications, achieving stable and pleasant results without significant upper limb functional impairment, also for elderly women and larger breasts. Thus, a definite role is yet predictable for this flap in the setting of SM in all cases not suitable for free-flap reconstruction.

Systematic Review of Patient-Reported Outcomes and Complications of Pedicled Latissimus Flap Breast Reconstruction

“…19,21 Patients who underwent LD flap reconstruction had similar BREAST-Q scores when compared to other autologous reconstruction techniques. 6,22 This is consistent with a large survey study that reported similar BREAST-Q scores between the LD flap and other types of reconstruction. 18 The meta-analysis conducted in this review compared BREAST-Q scores in patients who underwent LD flap reconstruction with and without implants (Figure 2).…”

“…A total of five studies met eligibility criteria and were included for data extraction and analysis (Figure 1). 6,16,19,21,22 Four studies consisted of level III evidence and one consisted of level IV evidence per the Levels of Evidence rating scale as described by the American Society of Plastic Surgeons (Table 2). 6,16,19,21,22 One study was a case-control design, and the remaining were retrospective cohort studies.…”

“…The pedicled latissimus dorsi (LD) flap has reemerged as a reliable option with minimal complications in autologous breast reconstruction. 1,2,6 The indications, techniques, and complications of the LD flap have been well-described in the available literature; however, there is a paucity of patient-reported outcome measures that illustrate the patient's perspective following LD flap reconstruction. 3,7 BREAST-Q was first introduced in 2009 and is the only validated outcome measure that quantifies health-related quality of life and patient satisfaction following breast reconstructive surgery.…”

Surgical Outcomes of Implant Versus Autologous Breast Reconstruction in Patients with Previous Breast-Conserving Surgery and Radiotherapy

“…The addition of an LD flap to IBR has also been proposed for patients with prior BCS and radiotherapy. 21,29–31 Disa et al reported a 30% complication rate in 57 patients who underwent LD/IBR following BCS, with 70% of patients achieving a very good/excellent aesthetic result. 21 Similarly, Cattelani et al reported a 10% complication rate, good postoperative upper limb function, and high patient-reported satisfaction using LD/IBR after prior BCS and radiotherapy 29 ; however, neither report compared the outcomes of patients with LD/IBR to IBR.…”

“…The addition of an LD flap to IBR has also been proposed for patients with prior BCS and radiotherapy. 21,[29][30][31] 29 ; however, neither report compared the outcomes of patients with LD/IBR to IBR. In our study, we found a similar overall and major complication rate between LD/IBR and IBR.…”