Tertiary Breast Reconstruction Using a Free Contralateral Latissimus Dorsi Musculocutaneous Flap

Abstract

The latissimus dorsi musculocutaneous flap is a reliable and dependable option and has been used for autologous breast reconstruction since the 1970s. 1,2 With the evolution of muscle sparing methods of breast reconstruction, the pedicled thoracodorsal artery perforator (TDAP) flap has become increasingly popular. In cases where a TDAP flap has failed, reconstruction with the ipsilateral latissimus dorsi musculocutaneous flap is no longer an option because the thoracodorsal artery and vein as well as the cutaneous component have been sacrificed. Secondary donor sites such as the abdomen, thighs, and buttock are considered and often used; however, in some patients these donor sites are either not suitable or declined. Another option in these situations is to consider the contralateral latissimus dorsi musculocutaneous flap as a free tissue transfer. We describe the use of a free contralateral latissimus dorsi musculocutaneous flap for delayed breast reconstruction following radiation therapy and previous ipsilateral TDAP failure.A 39-year-old woman presented following mastectomy, radiation, and multiple attempts at breast reconstruction all resulting in failure (►Fig. 1). Relevant history included previous bilateral breast augmentation with saline implants placed in a submuscular position 4 years before a diagnosis of stage IIIa invasive ductal breast cancer. The patient had a left mastectomy with immediate reconstruction using a tissue expander and acellular dermal matrix. Six months after completing adjuvant chemotherapy and radiation, she underwent exchange of the tissue expander for a high profile 550 mL round silicone gel breast implant, which was complicated by incisional dehiscence prompting a return to the operating room and exchange of the device for a 450 mL silicone gel implant. The incision again dehisced and the decision was made to perform a pedicled TDAP flap with implant removal. This reconstruction was unsuccessful and resulted in a flap failure. These operations were all performed at another hospital.On initial examination the patient was 5 ft 1 in tall and weighed 118 lb (body mass index 22.3). She had an acquired absence of her left breast with significant contour abnormality and thin skin with radiation damage. She was also noted to have a previously augmented right breast. Her abdomen demonstrated minimal skin and fat, as did the superior gluteal region. Autologous tissue reconstruction options were explained to the patient including a pedicled transverse rectus abdominis myocutaneous (TRAM) flap, free unilateral abdominal flap (deep inferior epigastric perforators vs. muscle sparing-TRAM), superior gluteal artery perforator flap, or a contralateral latissimus dorsi musculocutaneous free flap. She ultimately decided on a free tissue transfer using the contralateral latissimus dorsi musculocutaneous flap.At the time of surgery, the patient was marked in the standing position with her skin paddle oriented along the relaxed skin tension lines. . The internal mammary artery and vein were exposed ...

Immediate implant replacement with DIEP flap: a single-stage salvage option in failed implant-based breast reconstruction

“…Hamdi et al coined the term “tertiary breast reconstruction” for those “redo” reconstructions of cases with unsatisfactory results or failure of previous immediate or delayed procedures [ 17 ]; several authors have used that term afterwards [ 20 – 23 ].…”