ABSTRACT
ABSTRACT: Nipple-sparing mastectomies (NSMs) have become a common surgical approach in the management of invasive breast cancers and ductal carcinoma in situ, and as a risk-reducing approach in genetically predisposed patients. The current standard of care in the management of positive nipple margin after NSM is total excision of the nipple-areola complex. In this article, we aimed to present a case series describing a novel approach to positive nipple margins with nipple-only excision and immediate nipple reconstruction using areolar flaps in patients who underwent NSM for noninvasive tumors. We conducted a retrospective review of patients who underwent NSM and were found to have positive nipple margins and underwent subsequent nipple excision with immediate areolar flap reconstruction. We identified 6 patients who underwent NSM and were found to have nipple margins-5 for ductal carcinoma in situ and 1 for invasive ductal carcinoma. These patients underwent nipple excision with immediate reconstruction using "sickle" flaps. We concluded that if nipple excision and immediate reconstruction with areolar sickle flaps can be performed, it results in good aesthetic outcomes without compromising oncologic results.
Subject(s)
Breast Neoplasms , Carcinoma, Intraductal, Noninfiltrating , Humans , Female , Nipples , Esthetics , Genetic Predisposition to DiseaseABSTRACT
The muscle-sparing latissimus dorsi (MSLD) flap is a modification by Saint Cyr of the traditional latissimus dorsi flap. While the flap is commonly based on the thoracodorsal artery pedicle, flap design based on reversed flow from the serratus branch has also been well documented. Uncertainty over the availability of adequate arterial inflow to support a pedicled MSLD flap is a potential concern in secondary breast reconstruction for previous surgery may have compromised the thoracodorsal pedicle and/or its branches. Herein, we describe how the MSLD flap can be utilized for breast reconstruction in such cases, even when the thoracodorsal artery and its serratus branch are found to have be ligated, by relying on reversed flow via the intercostal arteries. We present three female patients we were able to use the MSLD flap for reconstruction based on reversed flow via the descending branch of the thoracodorsal artery supplied by intercostal perforators. All patients had satisfactory aesthetic outcomes with a minimum of 6 month's follow-up.
Subject(s)
Breast Neoplasms/surgery , Mammaplasty/methods , Superficial Back Muscles/transplantation , Surgical Flaps , Adult , Female , Humans , Mastectomy/methods , Middle Aged , Salvage Therapy/methods , Treatment OutcomeABSTRACT
BACKGROUND: The authors report their experience using extended transversely oriented skin paddles in muscle-sparing latissimus dorsi pedicled flaps for breast reconstruction as an alternative to thoracodorsal artery perforator flaps. METHODS: A retrospective review was conducted of patients who underwent muscle-sparing latissimus dorsi flap pedicled breast reconstruction from January of 2009 to July of 2014 with at least 3-month follow-up. Surgical outcomes and complications were analyzed. RESULTS: Fifty-three patients underwent a total of 81 muscle-sparing latissimus dorsi pedicled flaps for breast reconstruction. Extended transversely oriented skin paddles ranged from 7 to 9 cm vertically by 25 to 35 cm horizontally and were perfused by a strip of latissimus dorsi muscle that was approximately 25 percent of the total muscular volume. Twenty patients had indocyanine green angiography revealing three distinct zones of perfusion in the extended transversely oriented skin paddles. The area of earliest perfusion (designated zone 1) was directly over the muscle containing the perforators. The second best area of perfusion (zone 2) was lateral to the muscle (toward the axilla). The last and relatively least well-perfused area (zone 3) was medial to the muscle (toward the spine). Zone 3 still had adequate viability. There were no flap losses. Minor complications included wound infection [six of 81 (7.4 percent)], fat necrosis [three of 81 (3.7 percent)], and seroma [four of 81 (4.9 percent)]. CONCLUSIONS: Muscle-sparing latissimus dorsi pedicled flaps with extended transversely oriented skin paddles are reliable alternatives to thoracodorsal artery perforator flaps for breast reconstruction. Three zones of perfusion were delineated in the extended transversely oriented skin paddles on indocyanine green imaging, and all three zones were viable. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
Subject(s)
Breast Neoplasms/surgery , Mammaplasty/methods , Postoperative Complications/ethnology , Superficial Back Muscles/transplantation , Aged , Aged, 80 and over , Female , Humans , Mammaplasty/adverse effects , Mastectomy/adverse effects , Middle Aged , Myocutaneous Flap/transplantation , Organ Sparing Treatments/adverse effects , Organ Sparing Treatments/methods , Perforator Flap/transplantation , Postoperative Complications/etiology , Reproducibility of Results , Retrospective Studies , Treatment OutcomeABSTRACT
Our experience in the use of muscle-sparing latissimus dorsi (MSLD) flaps for breast reconstruction is presented. The procedure was performed on 83 patients by the senior author over an 8-year period. Of the 83 patients reviewed, a total of 126 MSLD flaps were done for immediate (26) or delayed (100) breast reconstructions. Preoperative and postoperative photographs were taken of all patients, and complications as well as ancillary procedures were recorded. The MSLD flap is shown to be a versatile option for breast reconstruction in a variety of clinical settings, with minimal complications and satisfactory aesthetic results.
