Muscle-sparing Latissimus Dorsi: A Safe Option for Postmastectomy Reconstruction in Extremely Obese Patients

Abstract

Background: Postmastectomy reconstruction in obese patients has a significant risk of complications and poor outcomes after implant-based and autologous methods. Here we present 22 consecutive patients with Class III obesity [body mass index (BMI) > 40 kg/m2] who underwent reconstruction with a muscle-sparing latissimus dorsi (MSLD) flap. Methods: A chart review of a single surgeon experience with 22 consecutive patients with Class III obesity who underwent postmastectomy reconstruction with an MSLD flap was performed. Demographics, operative details, outcomes, and complications were evaluated. Results: Twenty-two patients underwent 29 mastectomy and MSLD reconstructions. There were no flap failures. The average BMI was 47.2 kg/m2, including 12 patients with BMI > 50 kg/m2. Seven breasts demonstrated partial nipple and or mastectomy flap necrosis. There was 1 (3.4%) donor site dehiscence that healed with outpatient wound care and 1 (3.4%) seroma that required multiple aspirations in the office. The average operative times were 178 and 420 minutes for unilateral and bilateral mastectomy and immediate reconstructions, respectively. The average hospital length of stay was 0.56 and 1.3 days for unilateral and bilateral surgeries, respectively. Conclusions: These results demonstrate the utility of the MSLD flap in reconstructing the very obese. Operative times and lengths of stay compare favorably with conventional latissimus dorsi flap and abdominal-based microvascular free tissue transfer reconstructions. While our complication rates were higher than historically seen for patients with normal BMIs, there were no instances of flap failure, making this a viable reconstructive option for these very high-risk patients.

Updated Trends and Outcomes in Autologous Breast Reconstruction in the United States, 2016–2019

“…Of course, not all patients are suitable candidates for DIEP flap–based reconstruction and must use alternative forms of ABR. For example, previous studies have proposed the pedicled LDM flap, which does not require microsurgical techniques, as a safe option for high-risk patients, for patients who require salvage breast reconstruction, and for patients who have undergone postmastectomy radiation and may be predisposed to wound healing complications and necrosis 25–29 . In line with these prior inquiries, we observed reduced LOS among LDM reconstructions, plausibly due to avoidance of microvascular anastomosis and shorter operating times, despite elevated complication rates (wound dehiscence and necrosis, predominantly) likely related to patient comorbidities 30,31 .…”

Modified Incision for Muscle-sparing Latissimus Dorsi to Increase Flap Perfusion in the Morbidly Obese

“…Although certainly valid for most patients, the morbidly obese (Fig. 1) require large flap volumes for total breast reconstruction, 5 and sufficient vascularization may not be present without inclusion of the most proximal, robust perforators. These perforators, however, are located close to the pivot point, which would make flap positioning challenging, as the arc of rotation is limited.…”

Immediate Breast Reconstruction Using the Goldilocks Procedure: A Balance between More Surgery and Patient Satisfaction

“…In high-risk patients who desire an optimal result, first-stage Goldilocks mastectomy followed by second-stage implant or flap works reliably well in our hands. 2,3 This strategy makes it possible to offer reconstruction to patients who were previously denied surgery and improve the outcomes of those patients who were recommended a delayed reconstruction. For these women, their most significant risk of complication is mastectomy flap healing, and by decoupling this from implant or flap placement, we can improve outcomes (Fig.…”