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Breast Surgery

Lipofilled Mini Dorsi Flap

An Efficient Less Invasive Concept for Immediate Breast Reconstruction

Piat, Jean-Marc MD; Tomazzoni, Gabriela MD; Giovinazzo, Vincenzo MD; Dubost, Valentine MD; Maiato, Anna Paula MD; Ho Quoc, Christophe MD

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doi: 10.1097/SAP.0000000000002237
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Abstract

Immediate breast reconstruction after mastectomy plays a major role in a woman's body image and has become a critical step in breast cancer treatment. There are multiple and diversified techniques already well established for achieving good esthetic outcomes, such as silicon-based implants and tissue expanders, autologous flaps that could be harvested as pedicled flaps or as free flaps, and the combination of different techniques in association or not with lipofilling. Autologous techniques with flap1,2 and fat grafting show excellent and natural long-term results. Traditional extended latissimus dorsi flap with lipofilling has been one of the main techniques used for a long time in our institute. However, to achieve excellent esthetic outcomes, this technique requires a large muscle harvest in addition to 1 or more lipofilling sessions to accomplish the planned volume of the reconstructed breast. Therefore, the lipofilled mini dorsi flap technique, performed in 1 single operation, seems to improve the traditional technique.

The aim of this article is to present the lipofilled mini dorsi flap reconstruction technique, as well as our experiences, and to evaluate the efficiency, satisfaction, tolerance, and long-term results, especially in the novel setting of immediate breast reconstruction.

MATERIALS AND METHODS

We performed breast reconstruction with a lipofilled mini dorsi flap in 72 patients over a period of 21 months, from May 2017 to January 2019. The inclusion criteria of this study were female patients with breast cancer who underwent mastectomy and immediate breast reconstruction with a lipofilled mini dorsi flap, which was performed in 59 patients. Over that same period, we performed late breast reconstruction with the lipofilled mini dorsi flap in 13 patients, and those cases were excluded from this study. The surgical technique was homogeneous because it was performed by the same surgical team. The authors analyzed both the efficiency and tolerance of the technique, and the outcomes were evaluated by the surgical team and the patients. The operative technique is detailed hereby.

Indications

The lipofilled mini dorsi flap is a versatile technique for breast reconstruction that can be indicated for a large number of patients. It requires a favorable pinch test of the ipsilateral thoracic wall, and donor sites for fat harvesting. For the majority of patients, the flanks, outer and inner thighs, and knees are donor sites for fat harvesting. For patients with higher BMI, we can also use the anterior abdomen for liposuction.

There are no restrictions due to age, comorbidities, and potential oncological treatment for this technique.

This procedure is feasible for immediate and late breast reconstruction, for small and medium sized breasts, as 1-stage technique. For large breasts, we recommend either contralateral breast reduction or further sections of lipofilling if the patient wishes a large volume.

Preoperative Marks

We performed preoperative marks on patients in a standing position. A complete preoperative clinical examination using the pinching test was performed to determine the width of the skin to harvest. The mastectomy incision line was delimited, and the surgeon placed himself laterally to the patient. After that, we marked the skin for harvest at the level of the mastectomy incision line and extended it laterally to the subaxillary region, approximately 5 cm behind the anterior edge of the latissimus dorsi, including the lateral excess of skin and subcutaneous adipose tissue. The preoperative skin marks and the mastectomy scar formed a single continuous line. The muscular portion was marked 10 cm below the skin, and we also marked the fat graft donor site for fat harvesting. For patients with breast hypertrophy or ptosis causing important asymmetry, we indicated a reduction mammoplasty of the opposite breast, which was performed in the same operation. The preoperative marks are shown in Figure 1.

FIGURE 1
FIGURE 1:
Preoperative marks on a patient previously treated with conservative surgery for breast cancer with indication for mastectomy during follow-up evaluation. (A) Frontal view. (B) Lateral view. (C) Dorsal view.

Surgical Technique

The surgery was performed under general anesthesia. The patient was placed in a supine position, slightly lateralized by a small cushion placed under the scapula, and the arm was positioned in flexion and abduction to clear the armpit (Fig. 2).

FIGURE 2
FIGURE 2:
Preoperative patient positioning.

The mastectomy was either subcutaneous (nipple sparing mastectomy) or with cutaneous conservation (skin sparing mastectomy) when an areola excision was necessary. The axillary oncological approach may be a sentinel lymph node biopsy or axillary dissection, with no different impact regarding the reconstruction technique. However, it is important to note that the thoracodorsal artery must be systematically identified.

Fat harvesting3 was performed by a second team simultaneously with the mastectomy from the previously marked areas. The collected fat sample was centrifuged for 20 seconds at 3000 revolutions per minute.4 This strategy improves the quality of the fat graft and readies it for transfer into the subdermal plane, which is performed before harvesting the muscle flap5–7 (Fig. 3).

FIGURE 3
FIGURE 3:
Fat grafting into the subdermal plane.

The dissection of the mini dorsi flap1 began with an incision in the previously marked skin until the fascia superficialis. The anterior dissection of the latissimus dorsi, below the subcutaneous tissue, was limited to an anterior muscle portion that was 5 cm wide and 12 cm long. The fat graft was injected into the muscle before releasing the flap, as shown in Figure 4.

FIGURE 4
FIGURE 4:
Fat grafting into the anterior portion of the latissimus dorsi.

The superior limit of dissection for the muscular flap was above the entry of the thoracodorsal pedicle into the muscle (Fig. 5). It meets the anterior portion of the dorsal muscle when it reaches the posterior edge, behind the skin portion of the flap. The superior detachment of the muscle was no longer necessary. We preserved approximately 80% latissimus dorsi muscle, as well as its tendon and the transversal branch of the thoracodorsal pedicle. This very limited muscle dissection led the surgical team to name it the “mini dorsi” flap.

FIGURE 5
FIGURE 5:
Superior limit of muscular dissection. The thoracodorsal artery is isolated.

The inferior section, followed by the posterior section of the lipofilled muscular strip, meets the superior limit of the dorsal muscle dissection. The mini dorsi flap, pedicled by the descending branch of the thoracodorsal artery, was rotated forward, maintaining its attachments with the thoracic wall at the level of the anastomosis between the vascular pedicle of the serratus anterior muscle and the descending branch of the thoracodorsal artery, avoiding traction to the thoracodorsal vascular pedicle. The mini dorsi lipofilled flap is shown in Figure 6.

FIGURE 6
FIGURE 6:
Mini dorsal lipofilled flap.

After the mini dorsi flap was prepared, we deepithelized its corresponding skin (Fig. 7). We performed additional fat grafting into the major pectoralis muscle, particularly into its upper internal area (Fig. 8). The flap was positioned as a natural prosthesis, with its muscular portion in the lower internal site of the breast and the deepithelized portion in the upper external site, as observed in Figure 9. Before closure, we placed 2 tubular drains: one anterior and another posterior. The immediate postoperative aspect is shown in Figure 10, and Figure 11 shows the final result 8 months after surgery.

FIGURE 7
FIGURE 7:
Deepithelizing the skin portion of the flap.
FIGURE 8
FIGURE 8:
Fat grafting into the major pectoralis muscle.
FIGURE 9
FIGURE 9:
Mini dorsi flap positioned as the new breast. The deepithelized portion occupies the upper external area.
FIGURE 10
FIGURE 10:
Immediate postoperative aspect.
FIGURE 11
FIGURE 11:
Postoperative aspect of the patient from Figure 10 in the 8th month of follow-up evaluation. (A) Frontal view. (B) Lateral view. (C) Dorsal view. (D) Preserved movement of the shoulder.

Postoperative Evaluation

Minimal pain was observed during postoperative follow-up, similar to the observations following a classic mastectomy. The arm abduction reached at least 90° at the immediate postoperative examination, and it was fully recovered in an average period of 1 month. When indicated, additional oncological treatment as chemotherapy or radiotherapy was performed as usual, with no delays observed that could be related specifically to the lipofilled mini dorsi flap technique.

The esthetic outcomes were evaluated by the surgical team and by the patients according to a scale of satisfaction: very satisfactory, satisfactory, moderately satisfactory, or unsatisfactory. Figures 12 and 13 show the final aspects of the lipofilled mini dorsi flap after nipple sparing mastectomy and skin sparing mastectomy, respectively.

FIGURE 12
FIGURE 12:
Lipofilled mini dorsi flap reconstruction after nipple sparing mastectomy. (A, B, and C) Preoperative marks. (D, E, and F) Postoperative aspect.
FIGURE 13
FIGURE 13:
Lipofilled mini dorsi flap reconstruction after skin sparing mastectomy and contralateral reductive mammoplasty. (A) Preoperative marks. (B and C) Postoperative aspect.

Evaluations of efficiency (minimized scarring, functional loss of the arm, and fat graft reabsorption) and tolerance (development of hematoma, infection, flap necrosis, and seroma) were also noted. We evaluated patients at least 3 months after surgery. Figure 13 shows a patient at 8 months after surgery, where one can note that not only was the breast volume well preserved but also the movement of the ipsilateral arm.

Statistical Analysis

Regarding the data processing, database double entry, review, and analysis were performed using SPSS, version 18.0 (SPSS Inc. Released 2009; PASW Statistics for Windows, Version 18.0. Chicago: SPSS Inc.).

Symmetric data are expressed as the mean and standard error of the mean (±SEM) or as the median and 95% confidence interval (95% CI). Categorical variables are described as absolute (n) and relative (n%) frequencies. The Shapiro-Wilk test was used to determine the normality of the data distribution.

Spearman coefficients (rS) were estimated for determining correlations among the assessed variables. The level of significance was set at 5% for all analyses.

RESULTS

We performed 72 lipofilled mini dorsi flaps for breast reconstruction. Fifty-nine (81.9%) cases were immediate reconstructions for nipple sparing mastectomy or skin sparing mastectomy.

The mean age of patients who underwent surgery was 58.8 years (±SEM = 1.85), and 30 (50.8%) patients were 60 years or older. The median body mass index (BMI) of patients was 23.7 (95% CI, 23.186–28.055), ranging from 18.8 to 40. Twenty-six (44.1%) patients underwent irradiation: 8 patients (13.6%) before surgery, 17 (28.8%) after surgery and 1 (1.7%) before and after surgery. Twenty-one (35.6%) patients received chemotherapy: 10 received neoadjuvant chemotherapy (16.9%), and 11 received adjuvant chemotherapy (18.6%). No interference with additional treatment was observed, causing no delay in treatment implementation.

The median weight of the breast was 329 g (95% CI, 313.17–532.08). The mean volume of fat injected was 277 mL (±SEM = 11.621). The median volume of fat grafted was 90 mL (95% CI, 85.99–117.76) in the subcutaneous tissue and 90 mL (95% CI, 76.45–94.80) in the inferior portion of the dorsal muscle, and the mean volume of fat graft injected in the pectoral muscle was 87.71 mL (±SEM = 6.669).

The mean duration of the procedure was 138 minutes (±SEM = 5.550 minutes). It was 135.14 minutes (±SEM = 5.615 minutes) when no plastic surgery was performed on the opposite breast, which corresponded to 54 cases (91.5%), and 170.5 minutes (±SEM = 8.500 minutes) when we performed esthetic surgery in the contralateral breast, which was in 5 (8.5%) cases.

There was 1 (1.7%) case of hematoma in the dorsi, with no need for surgical drainage.

There were no complications, such as infection or necrosis of the flap. We noticed seroma in 28 (47.5%) cases, with a median volume of 70 mL (95% CI, 55.24–122.26), and 1 (1.7%) infected lymphocele, which was drained.

The body mass index (BMI) was directly related to the postoperative dorsal seroma. The authors reported that greater BMI was associated with higher seroma volume (rS = 0.449, P = 0.016). There was no correlation among the other assessed variables or the frequency or intensity of postoperative complications (P > 0.05). The characteristics of the patients and procedure results are summarized in Table 1.

TABLE 1 - Patient Characteristics and Procedure Results
Variables Total (N = 59)
Age: mean ± SEM, y 58.83 ± 1.85
Age ≥ 60 yr, n (%) 30 (50.8)
Body mass index: md (95%CI), kg/m2 23.70 (23.19–28.06)
Weight of the breast: md (95%CI), g 329.00 (313.17–532.08)
Fat volume injected: mean ± SEM, mL 277.08 ± 11.62
Duration of the procedure: mean ± SEM, min 138.08 ± 5.55
Radiotherapy, n (%)
 Yes 26 (44.1)
 No 33 (55.9)
Chemotherapy, n (%)
 Yes 21 (35.6)
 No 38 (64.4)
n, absolute frequency; n%, relative frequency; SEM, standard error of mean; md, median.

Twenty-five (42.4%) patients evaluated their reconstruction as very satisfactory, 34 (57.6%) as satisfactory, and 0 (0.0%) as moderately satisfactory. The surgical team evaluated the result as very satisfactory in 31 (52.5%) cases, satisfactory in 25 (42.4%) cases, and moderately satisfactory in 3 (5.1%) cases. There were no cases reported either by the patients or the surgical team as unsatisfactory (Table 2).

TABLE 2 - Study Evaluation (Efficiency and Tolerance)
Variables Total (N = 59)
Hematoma, n (%) 1 (1.7)
Flap necrosis, n (%) 0 (0)
Infection, n (%) 1 (1.7)
Seroma rate, n (%) 28 (47.5)
Seroma ponction volume: md (95%CI), mL 70.00 (55.24–122.26)
Seroma surgery, n (%) 0 (0)
Patient's satisfaction, n (%)
 Very satisfactory 25 (42.4)
 Satisfactory 34 (57.6)
 Moderately satisfactory 0 (0)
 Unsatisfactory 0 (0)
Surgical team satisfaction, n (%)
 Very satisfactory 31 (52.5)
 Satisfactory 25 (42.4)
 Moderately satisfactory 3 (5.1)
 Unsatisfactory 0 (0)

DISCUSSION

The lipofilled mini dorsi flap offers quite interesting advantages in breast reconstruction in comparison with the traditional technique.

The less invasive nature of this technique is a very important aspect to note. Placing the patient in a single position, the lateral supine position, allows all steps of the surgery to be performed, including harvesting of the flap, which was harvested horizontally in continuation with the mastectomy scar. The small horizontal scar was not visible on the back of the patient, not even under the bra strap. Harvesting the skin horizontally enables correcting its natural excess, which often bothers patients after mastectomy. The restriction for this technique is an unfavorable pinch test showing that the patient does not have enough skin, which is important in the early stage of the procedure for subdermal lipofilling and will lead to excessive tension in the suture. The harvest of a minimum anterior latissimus dorsi muscular portion explains its less aggressive detachment and the very quick recovery observed in the follow-up evaluation. In our study, we did not observe any serious complications, such as flap necrosis or fat necrosis. Dorsal seroma, which is less frequently observed with the mini dorsi flap than after the traditional technique, was treated very simply during consultation through small-volume punctures. There were no cases of reoperation.

Lipofilling8,9 combined with this technique in a single operation enables one to obtain the necessary volume and adapt this volume to the patient. The fat graft10,11 takes place on all available layers: subdermal, the anterior latissimus dorsi muscular strip, and the major pectoralis muscle. According to a rigorous injection technique, this graft has a low risk of fat necrosis and presents many advantages. It provides an adaptable volume immediately, achieves excellent esthetic results, with a very natural appearance compared with other reconstruction techniques, and improves the quality of tissues, especially after radiotherapy.12,13 The lipofilled mini dorsi technique is particularly attractive for patients who want simple and natural breast reconstruction in a single operation. Usually, the traditional autologous dorsal flap technique is followed by further lipofilling sessions.14

According to the patients and the surgical team, the evaluation of the results was very satisfactory or satisfactory in over 90% of cases. The high level of satisfaction demonstrates the efficiency of the technique with a very esthetically pleasing result after a single operation. This type of reconstruction is well adapted to patients older than 60 years (50.8% of cases in this study) who do not want reconstruction with a prosthesis.

Free flaps play an important role in the breast reconstruction scenario.15,16 We believe that the mini dorsi flap technique is of great interest in centers where microsurgery is not performed or when the patient is not an eligible candidate for microsurgery. Donor sites other than the abdomen are privileged although there are articles showing minimal impact on the abdominal perforators after abdominal liposuction.17 In the event of contralateral breast reconstruction, we offer contralateral lipofilled mini dorsi flap, but the possibility of abdominal microsurgery is not excluded.

In our experience, a lipofilled mini dorsi flap is a quickly performed technique. The lateral supine position is simpler in execution than the traditional 2-step positioning: the supine position for the mastectomy followed by the lateral position for the flap harvest. Additionally, the fat harvest can be easily reached in this position. The low detachment to preserve the mini dorsal muscle helps to minimize the duration of the surgery. The oncological approach of the axilla during mastectomy allows the identification of the thoracodorsal vascular pedicle and increases the safety of harvesting the dorsal flap.

The lipofilled mini dorsi flap technique seems to be an interesting solution for immediate breast reconstruction. This technique can be utilized with any kind of oncological treatment, as there were no particular issues associated with neoadjuvant or adjuvant therapies. The literature reports very few failures of autologous latissimus dorsi flap cases associated with radiotherapy.18,19 The failure rate for patients who underwent immediate breast reconstruction with prosthesis and radiotherapy is between 20% and 30%.20–22

CONCLUSIONS

The lipofilled mini dorsi flap technique is an efficient, quick, elegant and less invasive solution that is easier to perform, with excellent long-term results for breast reconstruction procedures immediately after mastectomy. Lipofilling improves the flap volume in a natural way, therefore, reducing the latissimus dorsi dissection to a small anterior muscle portion. Postoperative follow-up is simpler and better tolerated than after the traditional extended latissimus dorsi flap technique.

This new technique may be associated with any additional oncological treatment. It is a very interesting option for patients who wish to have a natural breast appearance after reconstruction in a single operation. It is also a good strategy for elderly patients or even younger patients who do not want contralateral breast surgery or breast reconstruction with implants or tissue expanders.

In our experience, the lipofilled mini dorsi flap technique has become the primary choice for immediate breast reconstruction after mastectomy.

REFERENCES

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16. Reid AW, Szpalski C, Sheppard NN, et al. An international comparison of reimbursement for DIEAP flap breast reconstruction. J Plast Reconstr Aesthet Surg. 2015;68:1529–1535. doi:10.1016/j.bjps.2015.06.025. Epub 2015 Jun 29.
17. Salgarello M, Barone-Adesi L, Cina A, et al. The effect of liposuction on inferior epigastric perforator vessels: a prospective study with color Doppler sonography. Ann Plast Surg. 2005;55:346–351.
18. Kelley BP, Ahmed R, Kidwell KM, et al. A systematic review of morbidity associated with autologous breast reconstruction before and after exposure to radiotherapy: are current practices ideal?Ann Surg Oncol. 2014;21:1732–1738.
19. Brondi RS, de Oliveira VM, Bagnoli F, et al. Autologous breast reconstruction with the latissimus dorsi muscle with immediate fat grafting: long-term results and patient satisfaction. Ann Plast Surg. 2019 Feb;82:152–157.
20. Chetta MD, Aliu O, Zhong L, et al. Reconstruction of the Irradiated Breast: A National Claims-Based Assessment of Postoperative Morbidity. Plast Reconstr Surg. 2017;139:783–792.
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Keywords:

breast reconstruction; autologous reconstruction; latissimus dorsi flap; lipofilling; mini invasive; lipofilled mini dorsi flap

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