Inverted Deepithelialized Latissimus Dorsi Flap for the Correction of Lumpectomy Defects in the Irradiated Breast

David L. Abramson, MD Stephanie Cooper, MD Richard B. Wait, MD, PhD

Deformities following lumpectomy and radiation can provide reconstructive challenges for the plastic surgeon. With the increasing incidence of breast conservation therapy, these problems are likely to become more frequent in the future. The use of autologous tissue, particularly the latissimus dorsi, provides an excellent option for correcting these tissue deformities. We propose using an inverted latissimus with a deepithelialized skin paddle to correct these defects when there is no shortage of overlying skin. Additionally, this technique provides a softer texture to the entire radiated breast.

Abramson DL, Cooper S, Wait RB. Inverted deepithelialized latissimus dorsi for the correction of lumpectomy defects in the irradiated breast. Ann Plast Surg 1998;40:664-667

Breast conservation and adjuvant radiotherapy have become more prevalent during the past decades owing in part to greater physician and patient awareness, earlier detection, a younger population, as well as a more complete understanding of the pathophysiology of breast cancer. However, breast-conserving therapy can result in both aesthetic and functional problems. Authors report both acute and chronic changes following radiotherapy with varying frequency.1'2 Berrino and colleagues3 categorized the deformities following conservative surgery and radiation based on the nature of the tissue deficiency, size dis­crepancy between the breasts, and radiation skin damage. At a minimum the radiated breast appears somewhat smaller and usually more firm that the nontreated side. The addition of a local tissue deficiency or nipple-areola distortion can contribute to both aesthetic and psychological disturbances. Thus, plastic surgeons are faced with a new set of challenges in breast reconstruction: how to restore the contour and feel of the scarred, irradiated breast. This report describes a modified use of the latissimus dorsi musculocutaneous flap to correct a local defect while also creating a softer more natural feel to the irradiated breast.

Surgical Technique

Access for the procedure is through the existing lumpectomy scar. The incision is lengthened if necessary to provide access to the subcutaneous plane above the entire breast. The local tissue defect is identified and its size is determined. The entire subcutaneous plane is dissected to provide a pocket for the entire latissimus muscle. The patient is then moved to a lateral decubitus position and, using an Esmarch bandage, the location and size of the deepithelialized skin paddle is marked above the latissimus dorsi. The skin paddle is deepithelialized and the latissimus with the accompanying skin and subcutaneous tissue is harvested. When completely mobilized, the flap is inverted and then passed through a subcutaneous tunnel so that the paddle falls into the defect and the muscle is spread through the subcutaneous pocket. The donor site is closed in layers with a single closed suction drain and the patient is returned to a supine position. Bolster sutures are used to secure the latissimus at the medial border of the breast. The incisions are closed with no drain necessary at the recipient site.

Patient Report

A 69-year-old female underwent lumpectomy and axillary dissection followed by 5,940 cGy of radiotherapy in 1992 for stage I breast carcinoma. She had a residual a deformity at the superior aspect of the nipple-areolar complex that failed previous correction with local tissue (Figs 1A, B). This irradiated breast was also firm and considerably smaller than the contralateral side. This patient was not concerned with the size mis­match between the two breasts and was not interested in any symmetry procedure to the unaffected side. The only aspects of this deformity that the patient wanted corrected was the divot superior to the nipple that was causing nipple distortion. The patient underwent deepithelialized latissimus dorsi reconstruction and was discharged home on postoperative day 2 (Figs ID, E). The bolsters and drain were removed 1 week following surgery. The long-term result revealed near-complete correction of both the divot superior to the nipple as well as the distor­tion of the nipple-areolar complex (Fig lC). Additionally, the breast had a soft and supple tex­ture that was much more natural than the preoperative irradiated breast.

Discussion

The approach to reconstruction of partial mastectomy deformities may differ in technique, but the goals of a soft, supple, normal-appearing breast symmetrical with the other breast remain un­changed. The nature of the defect often dictates the type of procedure that can be performed to achieve the desired result. Tissue deficiency as well as the quality of the overlying skin are important considerations. Preoperative planning is consummate in choosing the most appropriate procedure. Clearly, if the overlying skin envelope is of poor quality, the proposed deepithelialized latissimus is not a viable option because addi­tional skin must be brought into the field. How­ever, we have used the latissimus dorsi with a small skin paddle to correct defects requiring additional skin while at the same time providing a softer, more supple appearance to the remain­der of the breast (Fig 2).
A variety of methods have been described for correction of these partial mastectomy defects in irradiated breasts. The goal is to achieve an aesthetic and more natural breast mound. In these patients, implants have afforded less than ideal results. Pearl and Wisnicki4 report the use of implants and latissimus and transverse rectus abdominis musculocutaneous (TRAM) flaps for reconstruction of lumpectomy defects. They noted residual distortion in the patients reconstructed with implants alone.4 Berrino and associates5 reported the largest series of recon­struction following conservative surgery. Their large experience is likely a result of the true quadrantectomy performed in Italy during this time period, and therefore their tissue require­ments may have been larger than those encoun­tered today. This series included 5 patients treated with latissimus musculocutaneous flaps and 4 patients treated with deepithelialized latis­simus dorsi flaps, although they did not describe their exact technique. Slavin and coworkers6 have also reported using latissimus musculocu­taneous flaps, with excess areas of the skin pad­dle deepithelialized and buried with the muscle. They report using various amounts of the muscle depending on the nature of the defect. Other options are certainly available, such as a pedicled TRAM. However, moving the TRAM into a localized defect may require removal of a significant amount of the remaining breast tissue or exten­sive contouring of the TRAM. In those patients in whom a substantial volume is required or de­sired, it would clearly be a better choice. A free tissue transfer is another alternative, although this technique in an irradiated field is not with­out its risks and complications. One other advan­tage of this procedure is a relatively short hospi­tal stay (2 days) compared with the alternative procedures that usually have slightly longer op­erative times and hospital stays.

Although Berrino5 and Slavin6 have used deepithelialized skin paddles for the correction of the subcutaneous defect, this excess tissue is above the muscle flap whereas the defect is actually below. We feel that by turning the flap over and placing the skin paddle directly into the defect, a more anatomic correction is obtained. In addition, because the muscle lies more superfi­cially, a smoother contour and more natural feel to the breast is achieved. Our patient had ele­ments of type I (distortion of the nipple-areolar complex), type IIB (subcutaneous tissue deficien­cy), and type III (breast retraction and shrinkage) breast deformities. In our patient the deepitheli­alized skin paddle filled the subcutaneous tissue deficiency, allowing release of the adherent scar and thereby correcting the distortion of the nip­ple-areolar complex. Additionally, by placing the entire latissimus muscle just below the skin cov­ering the entire breast, some volume is added and soft, viable tissue covers the fibrotic, irradiated breast and thus creates a softer, more natural feel.

References

1. Olivotto IA, Rose MA, Osteen RT, et al. Late cosmetic outcome  after  conservative  surgery  and  radiotherapy: analysis of causes of cosmetic failure. Int J Radiat Oncol Biol Physiol 1989;17:747-753
2. Petit JY, Lehman A, Mandlebrot L. Problems of breast reconstruction after conservative surgery. In: Bohmert HH, ed. Breast cancer: conservative and reconstructive surgery. New York: Thieme Medical Publishers, 1980:349-372
3. Berrino P, Campora E, Santi P. Postquadrantectomy breast deformities: classification and techniques of surgical correction. Plast Reconstr Surg 1987;79:567-572
4. Pearl RM, Wisnicki J. Breast reconstruction following lumpectomy and irradiation. Plast Reconstr Surg 1985;76: 83-86
5. Berrino P, Campora E, Leone S, et al. Correction of type II breast deformities following conservative cancer surgery. Plast Reconstr Surg 1992;90:846-853
6. Slavin S, Love SM, Sadowsky NL. Reconstruction of the radiated partial mastectomy with autogenous tissue. Plast Reconstr Surg 1992;90:854-867