The use of contralateral free extended latissimus dorsi myocutaneous flap for a tertiary failed breast reconstruction: Is it still an option?

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Summary

Background

Unsuccessful breast reconstruction management represents a complex challenge for the plastic surgeon. Although these events rarely occur, many patients are not suitable candidates for conventional flaps, because of either previous donor-site surgery or lack of sufficient tissue.

Methods

In this study, a contralateral free latissimus dorsi musculocutaneous flap (CL–LDMF) was planned for correction of major lesions in the anterior chest wall. Twelve patients underwent secondary/tertiary breast reconstruction with CL–LDMF with a customized shape (horizontal, oblique, or “fleur-de-lis”) depending on the amount of tissue necessary. The technique was indicated in patients with large thoracic defects who lacked a donor site and had undergone previous unsuccessful pedicled LDMF.

Results

The mean follow-up time was 42.5 months (range: 18–72 months). Five local complications occurred in four of the 12 patients. Dorsal dehiscence was observed in one, local wound infection in one, small partial CL–LDMF necrosis in one, and dorsal seroma in one patient. All cases of complications were limited and treated with a conservative approach except for one implant extrusion 4 months after reconstruction. No total flap loss was reported. All patients achieved a satisfactory thoracic and breast reconstruction.

Conclusion

The results of this study demonstrate that free CL–LDMF is a reliable technique and should be considered in selected cases of tertiary reconstructions. The majority of complications were immediate, minor, and comparable to other reconstructive techniques. We believe that in selected patients, especially those who do not have available donor-site areas, free CL–LDMF is advantageous and should be part of the armamentarium of all plastic surgeons who deal with tertiary breast reconstructions.

Introduction

Currently, management of severe complications of breast reconstruction is a complex challenge for the plastic surgeon.1, 2 Although these events are infrequent and there have been few reports concerning their surgical management, this group of patients is not negligible.1, 2, 3, 4 In addition, many patients presenting for secondary or tertiary reconstruction are not suitable candidates for conventional flaps because of either previous donor-site surgery or lack of sufficient tissue.3, 4

Delayed management of a previous unsuccessful reconstruction is debatable.1, 2, 3, 4, 5, 6, 7 In addition, salvage breast surgery with free flaps can carry slightly higher risks than primary and secondary flap reconstructions. The breast region usually requires tissue replacement as a result of the deleterious effects of radiotherapy and previous scar tissue. Among the technical alternatives, the latissimus dorsi myocutaneous flap (LDMF) has been an option, but indication of this procedure for previously unsuccessful LDMF reconstruction is limited, because contralateral free flap transfer is required and the quality of recipient vessels can be unpredictable.8, 9, 10

Although immediate breast reconstruction is a well-described procedure and there are previous series evaluating the results of LDMF,11, 12, 13, 14, 15, 16, 17, 18, 19, 20 there are few reports of the outcomes following contralateral free LDMF breast reconstruction (CL–LDMF).8, 9, 10, 11, 12, 13, 14 Moreover, less information is available concerning surgical planning for “reoperating” on failed breast reconstruction.1, 2, 3 Thus, this article describes the free CL–LDMF surgical approach and reports our experience with secondary or tertiary reconstruction, while focusing attention on preoperative and intraoperative planning, advantages, and the outcome of this technique.

Section snippets

Patients and methods

All patients undergoing immediate reconstruction between January 1999 and December 2013 were reviewed. All patients undergoing secondary and tertiary breast reconstruction after failure of pedicled LDMF breast reconstruction and submitted to free CL–LDMF reconstruction during this period were selected. Oncological information on tumor size and location, axillary lymph node surgery, adjuvant radiotherapy, and chemotherapy and postoperative course were obtained. Patient characteristics included

Results

Of 1510 patients who underwent immediate breast reconstruction, 12 patients required a secondary or tertiary free CL–LDMF reconstruction. None of the patients presented an adequate abdominal donor area. Initial tumors were invasive breast carcinomas in eight patients, and eight patients underwent total axillary lymph node dissection. Eight patients received adjuvant chemotherapy and radiation therapy following the first oncological surgery. The dimension of the chest wall defect ranged from 24

Discussion

The LDMF has been an option for partial11, 12, 13, 14 and total breast reconstruction.15, 16, 17, 18, 19, 20 However, recommendations for its use in previous unsuccessful LDMF reconstruction are limited.8, 9, 10, 11, 12, 13, 14 This retrospective observational study included 12 patients with previous total failed breast reconstructions. In this sample, there was no set algorithm applied to determine who underwent secondary and tertiary reconstructions and the method employed.

The most common

Conclusion

The results of this study demonstrate that the free CL–LDMF is a reliable technique and should be considered in cases of tertiary reconstructions. We believe that in selected patients, especially those without the available donor-site areas, free CL–LDMF has advantages and should be another tactic in the tool kit of plastic surgeons dealing with failed breast reconstruction.

Conflict of interest statement

All authors did not have any financial and personal relationships with other people or organizations that could inappropriately influence (bias) their work.

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