Preoperative considerations
See the list below:
Planning the flap harvest and inset requires an adequate assessment of the patient’s profile, particularly with respect to the anterior chest wall defect to be reconstructed. [25, 26] Repairing a segmental defect has significantly different ramifications than planning reconstruction after modified or radical mastectomy. A partial transfer of the latissimus dorsi muscle flap may suffice to fill a segmental defect. However, the same transfer is far from adequate for filling the subclavicular and anterior axillary loss noticed by patients who have undergone more involved procedures.
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In secondary reconstruction, the existing mastectomy scar may pose challenges to planning flap inset. Compared to an oblique mastectomy scar, a vertical or horizontal scar may be difficult to conceal or may compromise projection. Proper flap placement requires attention to breast symmetry with preservation of ptosis and contour of the inferior breast pole. If the flap position is too high, which may be imposed by inset into a vertical or horizontal incision, the bulk of the muscle is out of position to accomplish this goal. Sacrifice of the inferior breast skin flap or inset into an additional incision at the projected inframammary fold and placement of the skin flap into an inferior lateral position can guarantee inferior projection.
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When considering the latissimus dorsi for autogenous reconstruction, communication with the surgeon who performed the mastectomy is critical. Ligation of the neurovascular pedicle is not an uncommon complication of axillary dissection. In the preoperative assessment for delayed reconstruction, innervation can be tested indirectly by evaluation of isometric contraction of the muscle. To test muscle function, have the patient put both hands on her waist and push downward. Contraction of viable muscle is assessed by palpation of the lateral edge of the latissimus dorsi from the posterior axilla to the iliac crest and by contralateral comparison. Electrical stimulation or electromyography can be used for further evaluation of muscle function in ambiguous cases. If muscular contraction is not elicited by any of the above techniques, assume that muscle has been denervated, which results in an atrophic flap.
Posterior markings include identification of the muscle projection and, if used, isolation of the skin island. Orientation of the skin segment depends on the extent of the anterior chest defect and patient preference. Loss of the pectoralis major muscle after radical mastectomy results in significant tissue loss that leaves an undesired subclavicular space, with projection of the superior ribs through the skin. In this or similar situations, arranging the skin island in a horizontal pattern is beneficial. Orientations with oblique skin islands running perpendicular to the muscle fibers and fleur-de-lis patterns have also been described. The critical takehome message is that each breast reconstruction requires a careful consideration of skin island needs regarding scar issues.
See preoperative markings in the image below.
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Transposition of this skin island to an inferolateral location in the reconstructed breast causes most of the muscle to shift superiorly. This arrangement allows the muscle to reach the superior defect while still maintaining bulk in the inferior pole. After modified radical mastectomy in which the superior defect is less of an issue, an oblique skin island may be adequate. This orientation positions the medial portion of the skin island farther away from the pivot point so as to allow greater reach on the anterior chest.
The ultimate location of the back scar also is taken into account. Traditionally, the horizontal scar was favored because it can be camouflaged conveniently with the brassiere strap. The preoperative markings can be made with the patient wearing the brassiere to ensure proper placement. The oblique pattern results in a lower, less conspicuous scar. Oblique skin islands also can be planned to create scars along the relaxed skin tension lines of the back, which reduces the chance of hypertrophic scarring that is more common with horizontal scars.
The skin island should measure approximately 8 cm wide by 20 cm long. Wider islands tend to be difficult to close primarily. The shape is an ellipse with a slightly wider portion at the inferomedial pole. This distribution provides the widest piece to the inferior breast for creation of the lower curvature. The superolateral end of the ellipse should begin at the posterior axillary line below the tip of the scapula. This ensures a skin island location that is anterior to the muscle flap.
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