Perfusion Zones of Extended Transverse Skin Paddles in Muscle-Sparing Latissimus Dorsi Myocutaneous Flaps for Breast Reconstruction

Abstract

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.

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

“…18 There is a frequent requirement for donor site revisions for scar cosmesis after poor wound healing, which is far less common for the back scar after LD or MSLD harvest. 9 , 27 – 33 Additionally, as these surgeries utilize both lower abdominal sites, they make a future contralateral abdominally based reconstruction, for patients only committing to upfront unilateral surgery, impossible. This necessitates a significant consideration for upfront bilateral surgery if the patient may desire or require contralateral mastectomy and reconstruction in the future.…”

Optimizing Aesthetics in Reconstructive Breast Surgery Using Muscle-Sparing Latissimus Dorsi Flap in Radiated and Nonradiated Patients

“…4,5,25 However, placement of the skin paddle transversely relative to the MSLDF pedicle will make the very distal end of the skin paddle behave as a random portion and may lead to minor skin necrosis. Koonce et al 26 looked at the zones of perfusion of an extended transverse skin paddle in MSLDF and reported 3 zones of perfusion with all zones showing good viability, with zone 3 (toward the spine) having relatively the slowest perfusion. The perfusion zones may relate to the statistically significant increased number of distal tip epidermolysis noted in the MSLDF cohort.…”

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

“…The MSLD with a transverse skin island for breast reconstruction was described without explicit perforator identification, relying on a 4-7 cm strip of LD for blood flow. [1][2][3][4] In most clinical scenarios, this strategy works well and simplifies dissection. Morbidly obese patients have flap volumes significantly larger than the average patient, likely requiring more blood flow.…”

“…Transverse skin paddles were designed to harvest areas of abundant fat and to facilitate rotation into the breast regardless of perforator location. [1][2][3][4] After definitive surgical identification of the anterior edge of the LD and confirmation that the preoperatively identified perforators were in the appropriate location, we committed to our superior incision with a generous cuff of additional skin and fat overlying the anterior edge of the LD to incorporate the most proximal musculocutaneous and septocutaneous perforators 6 (Fig. 2).…”

“…The muscle-sparing latissimus dorsi (MSLD) flap is a less invasive approach for breast reconstruction. [1][2][3][4] This flap includes the descending branch of the thoracodorsal artery (TDA), which provides perforators for blood flow. The MSLD skin incision has been described as independent of perforator location as multiple perforators arise from the TDA beginning 6-10 cm from the posterior axillary fold.…”