Late results and current indications of latissimus dorsi breast reconstructions.

One hundred and fifty latissimus dorsi flaps were used in 145 patients out of a series of 483 breast reconstructions performed from 1977 to 1988. There were few immediate complications and a durable, good cosmetic result was obtained in two-thirds of the 103 cases reviewed after at least one year. The main reasons for dissatisfaction with long-term results were capsular contracture (grades III and IV) and upper displacement of the implant. The rate of these late complications was 30%, the same as found in the simpler subpectoral reconstruction. However, prostheses with a thick outer envelope induced only 10% of severe capsular contracture. Reconstructions with autologous tissue are currently replacing latissimus dorsi flap reconstructions unless local or general conditions contraindicate such major surgery or when the patient lacks motivation.

[Reduction of mammaplasty scars: from a short inframammary scar to a vertical scar]. / Réduction des cicatrices de plastie mammaire: de l'ancre courte à la verticale.

A better understanding of the vascular anatomy of the breast has drastically reduced the risk of postoperative necrosis in breast reduction. Scars however remain a major concern, and techniques to reduce these have often been considered to be less satisfactory in terms of the shape and stability of the result. Our experience with more than 1,000 breasts operated on between 1984 and 1989 with a short inframammary scar technique has proved the contrary. The next step was to eliminate the inframammary scar, as proposed by Lassus, and to leave just a periareolar scar and a lower vertical scar which does not cross the inframammary fold. One hundred and four breasts, in sixty four patients--17 to 60 years old--have been operated on according to this vertical technique between April and September 1989. Twenty seven cases of ptosis correction in seventeen patients, and seventy seven reductions in forty seven patients, with a median excision weight of 460g, have been performed. By means of an individualized preoperative drawing and several technical devices, the results have proved that vertical mammaplasty is an excellent technique particularly indicated for women with elastic skin and a firm gland. Recent experience with liposuction at the beginning of the operation, has given new possibilities for breast modelling. In fatty juvenile hypertrophies, liposuction alone may even be adequate to reduce the volume, retaining a satisfactory shape for the breast with minimal scarring.

Innervation of the rectus abdominis muscle: implications for rectus flaps.

The usefulness of leaving lateral strips of the rectus abdominis muscle in place during a transverse rectus abdominis musculocutaneous (TRAM) flap procedure is questioned. Since textbooks do not agree on the course of the intercostal nerves in the rectus fascia and no precise description is given of the exact site of penetration of the nerves in the rectus muscle, six fresh cadavers were dissected. It has been observed that the nerves enter the deep face of the muscle in its middle portion. Lateral parts of the muscle are consequently denervated during a transverse rectus abdominis musculocutaneous flap, which preserves them. This has been confirmed by CT scan of the abdominal wall in 10 patients 2 to 37 months after a transverse rectus abdominis musculocutaneous flap. In these patients, a progressive fibrosis and disappearance of the remaining muscle could be demonstrated. It is concluded that a partial taking of the rectus abdominis muscle does not preserve its muscular function.

[Analysis of 163 latissimus dorsi muscle flaps]. / Analyse de 163 lambeaux de grand dorsal.

During the last 9 years, 163 latissimus dorsi flaps (LTD) were used in our department for different kinds of reconstructions. The indications for raising this flap were various. The pedicled flap (129 cases) provided an adequate solution for breast reconstruction (109 cases). As a free tissue transfer (34 cases) the LTD flap was mainly used for head and neck reconstruction (12 cases) after removal of infiltrating tumours. In the lower limb (12 cases) this myocutaneous flap remained an ultimate solution for coverage of open fractures, exposed osteosynthesis material and for treatment of chronic osteomyelitis. The authors further stress the constant anatomy and the ease of dissection. Removal of the muscle leaves minimal functional donor deficits. The high success rate of 95% as a pedicled flap and of 94% as a free flap highlight the reliability of the LTD flap and advocate its use for "all seasons".