All forms of breast reconstruction carry their own set of advantages and disadvantages; no technique is ideal in all cases. Universal goals in all forms of reconstructive surgery, however, should include, wherever possible, minimizing scars, shortening operative time, and decreasing hospital stay.23–27 This procedure has been described before16,17; however, we hoped to describe clearly our personal technique that requires no endoscopic equipment and no patient repositioning and that can be performed using instruments available to all plastic surgeons around the world. This procedure enables us significant savings in operating time, with the reconstructive surgeon able to start operating with a second team after completion of the first side. Also there are no added risks in turning an anesthetized patient prone. We have also demonstrated a significant reduction in the length of hospital stay, which reduces costs.
Today, importing large skin paddles from the abdomen or back is often not necessary due to the extended oncologically sound preservation of native breast skin. When used, skin paddles from these sites often have significant color mismatch and can produce a less than ideal aesthetic result. Today, we can also use the power of tissue expansion to grow more skin, particularly when the lower pole is covered with well-vascularized tissue. We believe that the avoidance of an imported skin paddle apart from the area of the nipple-areolar complex will give a better long-term result. The “scarless” latissimus dorsi allows this with no unsightly scar but enough laxity in the lower pole to allow faster and more predictable tissue expansion or even direct-to-implant coverage.
In this study, we did not formally assess function or deformity of the back. Only part of the muscle is taken in this technique, and future refinements may allow preservation of tendon and nerve function to the residual muscle. Anecdotally, the scarless group was certainly in no way more functionally compromised than the traditional group. The scarless group obviously had no scars, but some patients did have a minor residual contour deformity. In all cases, this was significantly less than that of the patients with the traditional flap. Formal physical therapy assessments of long-term function will be the subject of further studies.
We expected to encounter an overall decrease in pain in the scarless group, but this was not significantly different in the 2 groups. Longer term follow-up may show a decrease in the incidence of longer term chronic pain sometimes seen in latissimus dorsi flap donor sites.
One valid criticism of the technique is the lack of the ability to monitor the flap in traditional ways. It was certainly a dilemma when developing the technique but on balance it was felt that the extremely low risk of flap compromise was outweighed by the benefits of no scar, shorter operative time, and no repositioning. There are many examples of buried flaps in the plastic surgery literature: hemifacial atrophy, lymphedema surgery, omental flaps, and pressure sore reconstruction—to name a few. In this study, all 2-stage cases showed viable muscle at the time of implant exchange, and none of the direct-to-implant single stages showed any clinical signs that would suggest vascular flap compromise. The flap is fully islanded and can be stretched significantly across the midline, and so the inset is under very little tension. If using a tissue expander, the device can be left minimally filled if there is any concern. The flap is monitored clinically, that is, its swelling and tissue turgor. If one suspected vascular compromise postoperative, we would suggest duplex Doppler ultrasound evaluation to look for blood flow in the muscle; this has the added advantage of assessing for hematoma or seroma.
We see the great advantage in this technique for bilateral prophylactic mastectomy in young BRCA-positive women. We know that prophylactic mastectomy reduces lifetime cancer risk by 90%.28 However, there are barriers to undertaking this surgery. The diagnosis of BRCA gene mutation is invariably made at an age and time when relationships are in an early stage and body image is crucial. Patients’ decision to undergo a potentially lifesaving procedure can be easier if the procedure has no donor-site scars and can be done in a single stage through only a mastectomy or inframammary incision.
Submuscular tissue expansion evolved in an era of delayed breast reconstruction. It has the advantage of no donor scar and avoids the need for unsightly skin paddles. In the era of immediate reconstruction, however, there are disadvantages. First, dissection to strip serratus anterior off the chest wall ribs inferolaterally is difficult and often produces significant postoperative pain. Second, due to tightness and fragility of this lower pole coverage, rapid expansion cannot be done, often resulting in a wrinkled redundant skin in the ptotic breast. Third, due to the tightness of the lower pole, tissue expanders can be a little unpredictable. Expanders tend to migrate high and even rotate. If the expander is not fully submuscular, the final implant often shows rippling.
Scarless latissimus dorsi avoids many of these problems. The dissection required to provide lower pole muscular cover avoids the painful periosteal stripping associated with serratus anterior harvest, and tissue expanders or implants can be directly placed at the time of mastectomy and rapidly expanded in a more controlled manner due to the loose lower pole.
The recent advent of biologic ADM reconstructions has flooded the breast reconstruction market with the distinct advantage of no donor-site morbidity. It seems to be the “quick fix” of breast reconstruction and is an attractive option in bilateral reconstruction, especially in young and athletic women. The use of ADM, however, can be disastrous if the ADM becomes exposed or infected, and this may lead to reconstructive failure. Drains are often required for long periods of time due to increased seroma and infection rates. There is also an unknown entity found in ADMs that is variously referred to as the “red breast syndrome”28 and the additional unknown future risks of xenografts and allografts. ADM devices can be expensive and difficult to access in many parts of the world due to regulations covering the importation of human and animal tissue. We feel that this technique can be performed in parts of the world without access to ADM devices, mainly to provide “lifeboat” protection against the unpredictable risk of mastectomy skin necrosis. It also shares many of the attractive advantages of ADMs, namely, no donor scar, less operative time than traditional flaps, and shorter hospital stay. This study compared scarless latissimus dorsi reconstruction with traditional myocutaneous reconstruction, but in reality scarless latissimus dorsi reconstruction is probably closer in technique to ADM reconstruction. A future study comparing these 2 techniques more formally along similar lines would be helpful in demonstrating the advantages or disadvantages particularly in terms of function.
One of the patients in this series suffered some native skin necrosis as shown in Figure 9. The oncologic breast surgeon inadvertently holed out when thinning the tissue behind the nipple. Having a fully vascularized muscle coverage over the entire implant allowed me (M.L.) the confidence to treat this conservatively. Over 4 weeks, the eschar healed and lifted with a very acceptable final result. She had a small nipple graft and tattoo to complete her breast reconstruction. We would not have had this confidence for conservative management with an ADM deep to this necrotic skin.
Reconstruction with ADMs does have a number of advantages such as no donor-site morbidity, good control of the infra mammary fold, and lower pole projection. However, it is expensive, with the products ranging from $1500 USD to $3500 USD each (significantly more expensive in Australia). It is therefore not surprising to see many alternatives now being produced at much cheaper cost. Despite this laudable trend, the fundamental risks of infection and exposure remain, and not infrequently, their development is beyond the control of the reconstructive surgeon.
The scarless latissimus dorsi technique has no added cost apart from the implant or the tissue expander and fully covers the entire implant, allowing significant peace of mind should an area of native skin necrosis become apparent postoperatively.
Longer operating times and rolling an anesthetized patient also have inherent risks. These include venous thrombosis, pulmonary embolus, pressure sores, nerve injury, and airway compromise, not to mention surgeon fatigue.
During the standard bilateral latissimus dorsi harvest for breast reconstruction, the reconstructive surgeon can start operating only after both the mastectomies have been completed. This significantly adds to operating time, and the reconstructive surgeon is unproductive for some hours. By contrast, the scarless latissimus dorsi harvest allows reconstruction to begin after the first mastectomy is completed, and thus it significantly reduces operating time and therefore risk.
This method of breast reconstruction is relatively time effective, requires no patient repositioning, and uses standard breast instruments. It is safe, reducing the risk of exposed prosthesis if native skin necrosis occurs. It requires no endoscopic equipment, expensive ADM, or special training, and it is versatile, able to be used in both immediate and delayed reconstructions, and has particular advantage in prophylactic mastectomy and reconstruction.
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