Secondary Logo

Journal Logo

Endoscopic Thoracodorsal Neurectomy for Correction of Animation Deformity following Latissimus Dorsi–Based Breast Reconstruction

DeFazio, Michael V. M.D.; Pittman, Troy A. M.D.

Plastic and Reconstructive Surgery: October 2015 - Volume 136 - Issue 4 - p 573e–574e
doi: 10.1097/PRS.0000000000001577
Viewpoints
Free

Department of Plastic Surgery, Medstar Georgetown University Hospital, Washington, D.C.

Correspondence to Dr. Pittman, Department of Plastic and Reconstructive Surgery, Georgetown University Hospital, 3800 Reservoir Road, 1-PHC, Washington, D.C. 20007, troy.a.pittman@gunet.georgetown.edu

Back to Top | Article Outline

Sir:

Painful muscular contractions, involuntary twitching, tightness, and/or dynamic displacement of the breast affect a high percentage of patients (41 percent) undergoing innervated latissimus dorsi–based breast reconstruction.1 These sequelae can limit physical activity, jeopardize satisfaction, and diminish quality of life for individuals who have otherwise achieved a favorable aesthetic result. Studies evaluating the impact of surgical denervation of the latissimus dorsi muscle demonstrate significantly reduced pain and animation; comparable preservation of volume, shape, and symmetry; and improved satisfaction following thoracodorsal neurectomy.2,3 It is therefore our preference to perform primary nerve resection during immediate or delayed breast reconstruction, which is readily accomplished through an open axillary or dorsal approach and eliminates the need for a second-stage procedure.

Nevertheless, plastic surgeons must also be familiar with treatment strategies for patients who present with secondary contractile deformities. In such cases, chemical denervation with botulinum toxin type A offers a temporary solution; however, results with this approach are unpredictable, and the need for repeated injections over time increases the risk of implant leakage and/or rupture.4 Alternatively, delayed proximal resection of the thoracodorsal nerve may offer the best available option for symptomatic relief. Although high success rates have been reported using an axillary approach (90 percent), sectioning of the latissimus dorsi muscle to access the thoracodorsal nerve is excessively destructive and may alter muscle tropism and contour without guaranteeing successful denervation.1 Furthermore, scarring and/or fibrosis, which are often encountered during secondary revisions, increase the risk and complexity of dissection and the need for more extensive incisions.4

In this communication, we propose a minimally invasive, endoscopic approach to thoracodorsal neurectomy that minimizes incisions, bypasses axillary scarring, and eliminates dynamic abnormalities through selective denervation of the latissimus dorsi muscle. With the patient in lateral decubitus position, endoscopic visualization of the thoracodorsal neurovascular hilus is achieved using carbon dioxide insufflation (10 mmHg) through a 3-mm trocar inserted along the posterior axillary line. Two additional trocars placed distal to the dorsocaudal border of the latissimus dorsi permit unobstructed dissection through the nonirradiated, dorsal submuscular plane. Once identified on the undersurface of the muscle, the thoracodorsal nerve is isolated proximal to the point of divergence from the vascular pedicle and clipped (Fig. 1). Proximal resection of at least 4 cm of extramuscular nerve is then performed under endoscopic guidance, following confirmation of latissimus dorsi contraction on nerve stimulation (Fig. 2).

Fig. 1

Fig. 1

Fig. 2

Fig. 2

It is important to note that both muscular reinnervation and incomplete/distal nerve transection may contribute to compromised results and/or persistent animation.4 Technical error can be prevented through segmental resection of the main thoracodorsal nerve trunk—proximal to the neurovascular hilus—using a dorsal approach to avoid injuring the latissimus dorsi muscle and any structures embedded within the scarred axillae. As recommend by Schroegendorfer et al., at least 4 cm of thoracodorsal nerve is resected to achieve permanent sufficient denervation.5 We routinely clip the proximal/distal ends to prevent nerve sprouting and/or aberrant regeneration from adjacent nerve fibers. As with other minimally invasive techniques, improved scarring, reduced pain, and earlier postoperative recovery can be expected following endoscopic thoracodorsal neurectomy for correction of latissimus dorsi–based contractile deformities.

Back to Top | Article Outline

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

Michael V. DeFazio, M.D.

Troy A. Pittman, M.D.

Department of Plastic Surgery

Medstar Georgetown University Hospital

Washington, D.C.

Back to Top | Article Outline

REFERENCES

1. Halperin TJ, Fox SE, Caterson SA, Slavin SA, Morris DJ. Delayed division of the thoracodorsal nerve: A useful adjunct in breast reconstruction. Ann Plast Surg. 2007;59:23–25
2. Kääriäinen M, Giordano S, Kauhanen S, et al. The significance of latissimus dorsi flap innervation in delayed breast reconstruction: A prospective randomized study-magnetic resonance imaging and histologic findings. Plast Reconstr Surg. 2011;128:637e–645e
3. Szychta P, Butterworth M, Dixon M, Kulkarni D, Stewart K, Raine C. Breast reconstruction with the denervated latissimus dorsi musculocutaneous flap. Breast. 2013;22:667–672
4. Paolini G, Longo B, Laporta R, Sorotos M, Amoroso M, Santanelli F. Permanent latissimus dorsi muscle denervation in breast reconstruction. Ann Plast Surg. 2013;71:639–642
5. Schroegendorfer KF, Hacker S, Nickl S, Vierhapper M, Nedomansky J, Haslik W. Latissimus dorsi breast reconstruction: How much nerve resection is necessary to prevent postoperative muscle twitching? Plast Reconstr Surg. 2014;134:1125–1129
Back to Top | Article Outline

GUIDELINES

Viewpoints, pertaining to issues of general interest, are welcome, even if they are not related to items previously published. Viewpoints may present unique techniques, brief technology updates, technical notes, and so on. Viewpoints will be published on a space-available basis because they are typically less timesensitive than Letters and other types of articles. Please note the following criteria:

  • Text—maximum of 500 words (not including references)
  • References—maximum of five
  • Authors—no more than five
  • Figures/Tables—no more than two figures and/or one table

Authors will be listed in the order in which they appear in the submission. Viewpoints should be submitted electronically via PRS’ enkwell, at www.editorialmanager.com/prs/. We strongly encourage authors to submit figures in color.

We reserve the right to edit Viewpoints to meet requirements of space and format. Any financial interests relevant to the content must be disclosed. Submission of a Viewpoint constitutes permission for the American Society of Plastic Surgeons and its licensees and assignees to publish it in the Journal and in any other form or medium.

The views, opinions, and conclusions expressed in the Viewpoints represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.

©2015American Society of Plastic Surgeons