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

Discussion

The increasing popularity of single-stage breast reconstructions has demonstrated economic benefit as well as improved patient experience, as only 1 procedure in the main operating room is required.[2,5] However, not all patients are suitable candidates for a purely implant-based or autologous tissue reconstruction using abdominal flaps and as such, the LD flap remains an option in the breast reconstruction algorithm.[2] Like many breast reconstruction surgeons, the senior author has adopted DTI reconstruction, given its many benefits (single-stage pre-pectoral, no donor site morbidity, etc). However, in the senior author's practice, there is still an important role for the LD flap, which offers enhanced reliability in certain patients. The typical patients for LD over a pure alloplastic reconstruction are often in the setting of previous radiation or those in need of soft tissue coverage but are not candidates or do not desire an abdominally-based surgery. LD with Spectrum devices represent approximately 15% of the senior author's reconstructions. With respect to preoperative radiation, in the senior author's practice, it is not an absolute contraindication to pure alloplastic reconstruction. However, the higher complication rate in these reconstructions is reviewed with the patient. The benefits of LD and abdominally-based reconstructions are also presented. Ultimately, the patient's goals and preferences dictate the eventual selection of reconstruction technique. That being said, it is the senior author's preference to do an abdominally-based or LD and Spectrum reconstruction in patients who have received preoperative radiation.

The technique reported in this study eliminates the most criticized disadvantages of using this flap—a return to the main operating room for tissue expander exchange for permanent implants. Other authors have described their use and outcomes using expander/implant devices for various types of breast reconstruction; however, this is the first in-depth look at a similar technique in LD reconstructions.[10]

Spectrum implants were designed to act as both tissue expanders and permanent implants. The expansion port is remote and often positioned inferiorly and outside the implant pocket on the lateral chest wall. The incidence of capsular contracture in our study was 7.1%, which is low compared with the 40% reported by Cordeiro et al[11] in 2-stage alloplastic reconstructions without radiation. No difference in capsular contracture rate between patients who received radiation therapy was found. Our infection rate was comparable to the literature at 1.8%.[10,12] As these devices are available with a smooth surface, the risk for development of breast-implant–associated anaplastic large-cell lymphoma (BIA ALCL) is low.[13] Furthermore, anecdotally, patients rarely complain about the texture of their LD reconstructed breasts (with saline-filled Spectrum devices) compared with their pure saline implant reconstruction counterparts. This is likely because the thickness of the overlying LD flap maintains a natural feel to the reconstructed breast. This was demonstrated by 2 patients in this cohort who opted for gel implants on contralateral breast that was augmented for symmetry. Neither patient reported significant differences between the sides, which the authors feel is likely due to the thickness of the overlying LD flap. In rare cases where rippling is present, it is typically mild, and some patients request exchange for a silicone implant (Figure 2). Despite the difference in fill between the (saline) Spectrum and gel implant in the symmetrized breast, patients did not report feeling significant differences. With respect to symmetrization (Table 6), patient preference dictates if the contralateral breast is operated on. In preoperative consultation, evaluation of the contralateral breast is performed and if there is an existing size or contour discrepancy or there will likely be one postoperative (eg, lack of upper pole fullness in ptotic breasts compared with reconstruction with a Spectrum), then this is reviewed with the patient. The augmented or reduced contralateral breast is targeted to match the patient's desired final size and shape. The flexibility of the Spectrum device in the reconstructed device allows postoperative adjustments to match the symmetrized breast.

Figure 2.

Example of rippling defect with the Spectrum device. Left delayed breast reconstruction with LD flap and Spectrum device with contralateral reduction mammoplasty, which demonstrated mild rippling, leading to patient requesting exchange for silicone implant. Arrows indicate areas of rippling.

Additional advantages of using the Spectrum implants (Mentor, Irving, Tex.) include the ability to tailor expansions to improve symmetry as tissues settle postoperatively, which, in our study, was achieved in an average of 4 expansions. Using Spectrum implants with LD flap reconstruction enables the surgeon to better match the mild ptosis (Figure 3) or accommodate patients' breast size preferences (Figure 1B). It is also advantageous for patients with a very tight breast pocket who could not fit even a small implant (such as the patient who had an ultimate fill volume of 120 cm3 in this cohort). The Spectrum device size is chosen preoperatively and confirmed intraoperatively, and is based primarily on base width of the breast more than the volume of the device. Volume adjustment postradiation therapy occurs rarely in a small minority of patients. From an economic perspective, LD reconstructions boast financial benefits. The cost of a Mentor tissue expander and permanent silicone implant in a 2-stage reconstruction is more than double that of a single-stage reconstruction with a Spectrum implant (Mentor, Irving, Tex.) for the devices alone, excluding additional expenses associated with a second operation. Previous studies have also shown that LD reconstruction has significantly less cost than abdominally-based free flap reconstruction.[14,15] The study by Marchac et al (2011) showed a 22% cost reduction for LD compared with DIEP in unilateral reconstructions. However, their average length of stay for LD with implant reconstructions was 5 ± 2 days compared with 1–2 days in our centre.[14] This difference would make the economic benefit of the LD even more apparent. This being said, the use of any implant likely necessitates another surgery in the long term. With an average age of 54 years in our patients, the number of additional ORs for an implant exchange will likely be modest.

Figure 3.

A, Preoperative appearance of breasts. B, Postoperative result showing similar ptosis between breasts following right immediate breast reconstruction with LD flap and Spectrum device with left symmetrization procedure with placement of Spectrum implant.

In an effort to avoid any complications surrounding the use of implants in LD breast reconstruction, some authors describe a purely autologous LD reconstruction using fat grafting.[4,5] High aesthetic and patient satisfaction outcomes have been described with lipofilling.[4,5] This technique, however, is resource intensive, as it often requires a second and occasionally third stage in the main operating room to achieve adequate volume to the reconstructed breast. Additionally, fat grafting alone may be insufficient to achieve an adequate volume in large-breasted patients.[5]

Our study is not without limitations. It is retrospective and a single-surgeon's experience from a single center. However, our outcomes were comparable to those published by others.[10] We did not specifically investigate patients' experience of the port removal under local anesthetic. Anecdotally, however, this was very well tolerated, and the additional small scar on the chest wall was not considered to be a problem by patients.

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