Single-Stage Latissimus Dorsi Breast Reconstruction Using Spectrum Devices

Outcomes and Technique

Colton Boudreau, MSc; Kaitlin S. Boehm, MD, Med; Aevan MacDonald; Jason Williams, MEd, MD, FRCSC

Disclosures

Plast Reconstr Surg Glob Open. 2021;9(5):e3282 

In This Article

Methods

Institutional approval was obtained from the Nova Scotia Health Authority Research Ethics Board (File no. 1024677). Patients undergoing an LD myocutaneous flap with Spectrum implant device (Mentor, Irving, Tex.) by a single surgeon at an academic, tertiary hospital were retrospectively identified by billing codes. All oncologic resections were performed by general surgeons. All patients, unilateral or bilateral, immediate or delayed reconstructions were included from June 2009 to September 2019.

Electronic medical records for each identified patient were reviewed to determine the type of reconstruction (unilateral/bilateral, immediate/delayed), initial procedure date, implant fill volume during initial surgery, and any intraoperative incidents. Surgical implant records were utilized to obtain the size and model of Spectrum implant. All postoperative clinic and procedure notes were reviewed chronologically until port removal. The following information was collected for each patient undergoing breast reconstruction: volume of expansion, date of drain removal, and complications (wound dehiscence or delayed healing, mastectomy flap necrosis, minor/major infection, seroma, return to the main operating room for any reason, including implant exchange).

All data extracted were stored in a secure Microsoft Excel file (version 16.16.3, Redmond). All statistical analyses were also performed using Microsoft Excel.

LD Reconstruction Technique

The first stage of the reconstruction is to establish the breast pocket. Unilateral reconstructions are typically performed in lateral decubitus, whereas bilateral cases require flap harvest in prone followed by inset in supine positions. In an immediate reconstruction, any modifications to the pocket size or shape following mastectomy are performed using cautery. In delayed reconstructions, the pocket is dissected subcutaneously to define the breast footprint (using contralateral side as a guide, or, in bilateral cases, to achieve symmetry). In cases where preoperative radiation has been performed, the pocket dissection is slightly larger to allow for softer transition between the breast footprint and surrounding tissues. The LD flap is then raised using a skin paddle oriented horizontally such that the scar falls under the bra line (Figure 1A). Once the skin paddle is defined, the skin overlying the LD is raised subcutaneously. If there is sufficient subcutaneous fat immediately caudal to the skin paddle, this can be kept on the underlying muscle and tapered down to the muscle. Once transposed, this fat will contribute to a soft and full upper pole. The free edge of the LD is identified at the tip of the scapula and traced toward midline. Cautery is used to dissect through the LD along the midline followed by inferior border (along the posterior superior iliac spine). While lifting the flap laterally, dissection is slowed to ensure that the serratus remains attached to the chest wall. This landmark is identified based on the direction of the muscle fibers. The serratus branch of the thoracodorsal pedicle is identified and traced proximally to dissect the pedicle. The senior author does not cut the thoracodorsal nerve. There have been no concerns regarding animation deformity to date. The muscle does show some mild atrophy, however, which has been found to contribute to a smooth transition from breast to chest wall tissue. Once the pedicle is dissected, a subcutaneous pocket to the anterior chest is developed (Table 1). Special attention is given to ensure the tunnel is wide enough to avoid any pressure on the pedicle.

Figure 1.

Example of bilateral immediate breast reconstruction. A, Preoperative markings for the bilateral LD flaps. Preoperative (B) and postoperative images (C) of single-stage bilateral immediate breast reconstruction with skin-sparing mastectomy, latissimus dorsi flaps, Spectrum implants, and nipple reconstruction with tattooing in a patient desiring a large final breast size.

On the anterior chest, the periphery of the LD muscle is sutured to the chest wall along the medial, superior, and lateral borders using 3–0 Vicryl to define the breast pocket (Table 1). The breast/chest wall skin is sutured to the flap in a multi-layer closure. A small subcutaneous pocket on the inferolateral chest wall is made for the port (Table 1). Spectrum implants are prepared and inserted as recommended by Mentor (Mentor, Irving, Tex.). The LD muscle is then sutured to the chest wall along the inferior border. The implant is inflated with normal saline to maximally fill out the breast skin and flap. Operative time, excluding mastectomy (if performed), is <2 hours for a unilateral reconstruction (patient in lateral decubitus) and 4 hours for bilateral cases (including position change from prone to supine).

Expansion is usually started 2 weeks postoperatively and continued weekly on an outpatient basis until final size and shape are achieved (See Table 1 for more technical pearls).

Port Removal Technique

Consent to perform the expansion port removal under local anesthetic is obtained. The patient is brought to a minor procedures room and placed in a supine position with her ipsilateral arm to the port extended laterally. This allows access to the port on the lateral chest wall. The port is palpated and marked, then 9 cm3 of 1% lidocaine with 1:100 000 epinephrine with 1 cm3 of bicarbonate is injected to anesthetize the overlying skin. The area is prepared using chlorhexidine solution and field sterility established with the use of sterile towels. A small, straight-line incision is made in the skin and electrocautery used to dissect down to the port. Once identified and freed from surrounding tissue, the port tubing is gently pulled until it is free from the implant. Of note, when pulling the port, make sure the connector is free of scar to remove the entirety of port tubing from the implant. If this is not done, the connector on the port tubing can pull apart, thereby not sealing the internal valve and leading to deflation (Table 1). For more information regarding this, visit Mentor's website for instructions on how to use the port system (https://www.e-ifu.com/franchise-landing/V0G000000000212/product-family/V0F000000000271).

The incision is closed using deep dermal 3–0 Monocryl followed by a 4–0 Monocryl running subcuticular suture. A simple steri-strip and mepore dressing is placed.

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