Keywords Mammaplasty - Surgical flaps - Superficial back muscles
INTRODUCTION
The latissimus dorsi (LD) flap procedure is a widely used autologous breast reconstruction
method [1 ]
[2 ]. The size and location of the skin paddle of the LD flap necessary for reconstruction
vary by the extent and location of the incision: inner oblique, outer oblique, or
transverse designs are available. In 1983, Hokin [3 ] introduced an extended latissimus dorsi (ELD) flap procedure, which collects a large
quantity of tissue. In performing this procedure, an oblique design is used that is
parallel to the posterior axillary line—the commonly used method for the donor site.
This offers the advantage of easy flap collection. However, this also leaves a severe
postoperative scar and is highly likely to lead to donor site deformation ([Fig. 1 ]) [4 ]. Therefore, in recent years, a transverse incision on the bra line has been the
preferred method, as it leaves a less visible scar ([Fig. 2 ]).
Fig. 1. Long scar on the donor site
A patient who was operated on without an elongated axillary incision line.
Fig. 2. Less visible scar on the donor site
A patient who was reconstructed using an extended latissimus dorsi flap with an elongated
axillary incision line.
However, a transverse skin paddle design narrows the operative field. This causes
flap dissection and makes transferring the pedicle flap challenging, subsequently
leading to longer operation times. Furthermore, in cases where a defect is located
in the inferior medial quadrant, transferring the skin paddle for reconstruction becomes
more difficult.
Axillary lymph-node dissection procedures by general surgeons are commonly performed
while the patient is in a supine position. Usually, the incision is made horizontally
up to the lateral border of the pectoralis major, which is rather short. Therefore,
there are many challenges in isolating the pedicle of the LD and dissecting and transferring
the flap, which is necessary for the surgical reconstruction performed by plastic
surgeons.
To address the abovementioned issues, the authors elongated the axillary incision
that was made by general surgeons previously for lymph-node dissection from the lateral
position for immediate breast reconstruction after a mastectomy. We aimed to examine
the effectiveness of this innovation by investigating the operation time (in particular,
whether it was shortened) and the incidence of scar-related complications.
METHODS
The present study was approved by the Institutional Review Board of Pusan National
University Yangsan Hospital (IRB No. 05-2018-047).
The subjects’ medical records were retrospectively analyzed, and consent for the use
of medical records was received from the patients. We used an elongated axillary incision
for 89 patients who underwent immediate breast reconstruction with an ELD musculocutaneous
flap from July 2014 to December 2016. The incision was placed on the axillary fold
in the lateral position and was elongated by 1.5 cm posteriorly to the lateral border
of the LD ([Fig. 3 ]). We used a horizontal oval-shaped skin paddle along the bra line that had been
marked prior to surgery while the patient was in a sitting position.
Fig. 3. Efficacy of the elongated axillary incision line
(A-D) The incision was elongated by 1.5 cm posteriorly to the lateral border of the
latissimus dorsi.
Through the elongated axillary incision, the LD was detached sufficiently from the
adipose layer to the inferior angle of the scapula. The upper border of the LD was
separated from the teres major. Additionally, through the elongated axillary incision,
we secured ample space for the detachment and isolation of the LD flap pedicle.
Forty-five patients who underwent immediate breast reconstruction with the ELD flap
without the elongated axillary incision from January 2012 to June 2014 were used as
a control group.
Based on the medical records of the two patient groups, we examined whether there
was any statistically significant difference in operation times between the two groups,
as defined by the time the incision was made to the time the operation ended. Moreover,
we conducted a statistical analysis to identify whether patients’ body mass index
(BMI) or the weight of the removed breast tissue affected the operation time. We also
compared the length of the scar between the two patient groups. All of the procedures
were conducted by a surgeon in the plastic and reconstructive surgery department of
this hospital. Mann-Whitney tests were used to statistically analyze the data. We
considered a P-value of <0.05 to indicate statistical significance. All statistical
analyses for this study were conducted with MedCalc version 22.0 (MedCalc Software
bvba, Ostend, Belgium).
RESULTS
In the experimental group with elongated axillary incision, the operation time ranged
from 125 to 255 minutes (median, 175 minutes) and the length of the incision ranged
from 5 to 10 cm (median, 7.5 cm). In contrast, for the control group that did not
undergo elongated axillary incision, the operation time took between 142 and 340 minutes
(median, 205 minutes) and the length of the incision was between 5 and 8 cm (median,
6 cm). There was a statistically significant difference between the two groups (P<0.05)
([Table 1 ]).
Table 1.
Operation time and length of incision by patient group
Elongated incision (n = 89)
No elongated incision (n = 45)
P-valuea)
Values are presented as median (range).
a) Mann-Whitney test.
Total operation time (min)
175 (125–255)
205 (142–340)
< 0.001
Length of incision (cm)
7.5 (5–10)
6 (5–8)
< 0.001
The BMI of the patients and the weight of the removed breast tissue did not correlate
with the operation time (P>0.05).
There were no significant complications involving scarring in the axillary region
after the elongated incision. No cases required scar revision. Moreover, the scars
were not visible while in the upright standing position (shoulder adduction) and were
therefore well accepted by the patients. Moreover, no complaints about scar contracture
were reported.
DISCUSSION
For reconstruction of a medium-sized or smaller breast using autologous tissue after
total mastectomy, a transverse rectus abdominis myocutaneous flap or a deep inferior
epigastric perforator flap is used with an ELD flap. After partial mastectomy, an
ELD flap should be the primary choice, regardless of breast size [5 ]
[6 ]
[7 ]
[8 ]. Several factors should be considered when an ELD flap is used, including the scar
or deformation that will remain on the donor site and the extension of the operation
time due to changes in position during surgery.
The skin paddle designs of the ELD flap are diverse. The part of the breast that needs
reconstruction and the patient’s preferences regarding the location of the incision
scar may determine the choice in design [9 ]
[10 ]. Because the horizontal skin paddle design leaves a scar along the bra line, patients’
satisfaction with this design is high, and it recently has become an increasingly
popular choice.
The volume of the ELD flap is larger than that of the conventional LD flap. Therefore,
ample subcutaneous tunneling and pedicle isolation are necessary to allow for flap
rotation and transfer. However, in cases where a transverse skin paddle design is
used, the operative field is narrow and dissection from the scapular tip to the axillar
region is challenging. This leads to longer operation times and increased fatigue
of the surgeon.
Moreover, the axillary incision made during lymph node dissection by general surgeons
is performed in the supine position: the length of the incision is short, and the
incision is made to the anterior chest, toward the pectoralis major. Therefore, the
operative field is narrow for harvesting the flap and isolating the pedicle through
the axillary incision from the lateral position, which in turn increases the likelihood
that it will be necessary to make the skin paddle close to the axillary incision line
or to place it in an oblique position.
When the axillary incision performed by general surgeons is elongated to the lateral
border of the LD muscle by 1.5 cm posteriorly in the lateral position and parallel
to the axillary fold, dissecting the proximal part of the LD (between the inferior
angle of the scapula and the axillary region) becomes easier, even when using a skin
paddle parallel to the bra line, as previously mentioned. Moreover, as ample room
for pedicle isolation is created, the operative field is broadened. The teres major
muscle and the upper border of the LD can be easily detached, and separating the LD
and dissecting or shaping the muscle component may be easier; this also prevents bulging
deformities in the anterior axillary fold ([Fig. 4 ]). Furthermore, isolating a pedicle of 10 cm or longer becomes possible. This makes
the insetting of a flap far easier, regardless of the skin paddle direction.
Fig. 4. LD separation and pedicle isolation
(A, B) When the latissimus dorsi (LD) is made thinner by sculpting its proximal part
and sufficiently dissecting the tissues surrounding the pedicle, the bulging deformity
can be minimized and the breast can be reconstructed satisfactorily, including the
inner lower part.
As the authors gained more experience with this surgical technique, we were able to
make the skin paddle incision along the bra line even smaller; eventually, we left
a relatively short and even scar on the donor site, using only a horizontal, oval-shaped
skin paddle ≤3 cm wide and ≤12 cm long. Through the elongated axillary incision, a
tunnel connecting to the detached area was easily made. Additionally, sufficient space
was secured to transfer ELD flaps that weighed 300 g or more. Moreover, we were able
to minimize damage to the flap that could have occurred with the unnecessary use of
a retractor, thereby helping to prevent scar contracture on donor site. Overall, we
shortened the operation time from making the incision to end of operation by approximately
30 minutes.
The scar near the axilla was unnoticeable in shoulder adduction. There were no complications
such as contracture deformities. Moreover, no hypertrophic deformities were found
in the incision scar in the breast or in the axilla, which is partially deemed to
be an effect of radiation therapy. Patients with breast cancer are less likely than
aesthetic plastic surgery patients to report complaints about scarring, as long as
there is no discomfort or severe deformity, even if the scar is rather long.
A shortcoming of this technique is that an additional procedure is needed to elongate
the axillary incision. Moreover, handling the pedicle of the LD is easy through the
elongated incision, but there is a risk of damage, making careful and attentive detachment
necessary.
In conclusion, when performing breast reconstruction using the ELD flap, elongation
of the axillary incision, which secured a sufficient operative field, made it easier
to harvest and transfer the flap, and led to an even and horizontal scar on the donor
site and a shorter operation time.
Notes
Ethical approval
The study was approved by the Institutional Review Board of Pusan National University
Yangsan Hospital (IRB No. 05-2018-047) and performed in accordance with the principles
of the Declaration of Helsinki. Written informed consents were obtained.
Patient consent
The patients provided written informed consent for the publication and the use of
their images.
