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Latissimus Dorsi Flap Technique

Delayed Breast Reconstruction


Case
21

Musculocutaneous LD Flap with Prosthesis Expander replacement by definitive implant 2 years ago.
(with Contralateral Augmented Due to local wound dehiscence and infection, the defini-
Mammaplasty) tive implant was removed last year.
Current diagnosis:
Patient: 41-year-old woman. Post infected implant removal.
Previous diagnosis: Current procedure:
Recurrent invasive ductal carcinoma at the right breast. Reconstructive procedure:
Previous procedure: Delayed right breast reconstruction with latissimus dorsi
Oncologic procedure: musculocutaneous flap with implant.
Right total mastectomy with sentinel lymph node biopsy Anatomical implant MX 470 g was selected.
2 years ago. Left breast augmented mammaplasty (with periareolar
She also had quadrantectomy and adjuvant radiotherapy 6 incision).
years ago. Round moderate profile 125 g was selected.
Reconstructive procedure:
Right breast immediate tissue expander reconstruction 2
years ago.

Figs. 21.1 and 21.2 Preoperative photography drawings


Left medium breast size, right mastectomy scar
The back LD flap skin island drawing measured is 6 12 cm. The final scar will be inside the bra

M. Rietjens et al., Atlas of Breast Reconstruction, 187


DOI 10.1007/978-88-470-5519-3_22, Springer-Verlag Italia 2015
188 Case 21 Latissimus Dorsi Flap Technique

Fig. 21.3 The illustration outlines the back donor site of LD flap

Figs. 21.4, 21.5, and 21.6 Patient was placed in lateral position
It is necessary to take care about the right arm, shoulders, neck, hips, and knees to avoid pressure injuries
Musculocutaneous LD Flap with Prosthesis (with Contralateral Augmented Mammaplasty) 189

Figs. 21.7 and 21.8 The right mastectomy scar incision and cutaneous flap dissection

Figs. 21.9, 21.10, and 21.11 From the lateral part of the mastectomy site, the thoracodorsal vessels were dissected and identified
190 Case 21 Latissimus Dorsi Flap Technique

Fig. 21.12 The anterior border of the LD muscle was identified, and
the tunnel was created along the axillary region

Figs. 21.13, 21.14, 21.15, and 21.16 The LD flap incision was made then the subcutaneous tissue around the skin island was included in order
to have more volume and better cosmetic results
Musculocutaneous LD Flap with Prosthesis (with Contralateral Augmented Mammaplasty) 191

Fig. 21.17 The anterior border of LD flap was found, and this is the
anterior limit of this flap dissection

Figs. 21.18, 21.19, and 21.20 Then the LD flap was detached from its inferior insertion

Figs. 21.21 and 21.22 Medial border of the LD was dissected from the paraspinous fascia
It is important to identify and isolate the trapezius muscle from the medial and superior border
192 Case 21 Latissimus Dorsi Flap Technique

Figs. 21.23, 21.24, 21.25, 21.26, 21.27, 21.28, and 21.29 LD flap superomedial dissection
Identify the tip of the scapula and teres major muscle. Then the LD flap was dissected free from them

Figs. 21.30, 21.31, and 21.32 The LD flap was transposed to the anterior chest wall
The donor site closure
Musculocutaneous LD Flap with Prosthesis (with Contralateral Augmented Mammaplasty) 193

Figs. 21.33 and 21.34 Temporary closure of anterior thoracic wall that allows changing position of the patient from the lateral decubitus to
supine position

Fig. 21.35 Illustration of placed LD flap at the anterior thoracic wall


194 Case 21 Latissimus Dorsi Flap Technique

Figs. 21.36 and 21.37 The left breast superior periareolar incision and deepithelization

Figs. 21.38 and 21.39 Glandular tissue was dissected straight toward the pectoralis muscle

Figs. 21.40, 21.41, and 21.42 Subfascial plane was created for prosthesis implantation
Musculocutaneous LD Flap with Prosthesis (with Contralateral Augmented Mammaplasty) 195

Figs. 21.43 and 21.44 View the subfascial pocket

Figs. 21.45 and 21.46 Round prosthesis placement on the left breast

Figs. 21.47 and 21.48 Glandular closure


196 Case 21 Latissimus Dorsi Flap Technique

Fig. 21.49 LD flap was spread over the right thoracic wall

Figs. 21.50 and 21.51 Complete undermining of the mastectomy skin envelope to create space for prosthesis and LD flap
Musculocutaneous LD Flap with Prosthesis (with Contralateral Augmented Mammaplasty) 197

Figs. 21.52 and 21.53 LD muscle was sutured at the superior inner part of the breast

Figs. 21.54 and 21.55 LD flap was set free at the lower lateral part to allow the placement of the prosthesis
198 Case 21 Latissimus Dorsi Flap Technique

Figs. 21.56, 21.57, 21.58, and 21.59 After prosthesis placement, the LD flap was transferred to cover the prosthesis
Musculocutaneous LD Flap with Prosthesis (with Contralateral Augmented Mammaplasty) 199

Figs. 21.60 and 21.61 Skin closure

Figs. 21.62 and 21.63 Immediate final result

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