Since Tansini described the latissimus dorsi (LD) myocutaneous flap in 1896, reconstructive surgeons have been using the flap for over 120 years (1). Its use in postmastectomy reconstruction was first reported by D’Este in 1912 (2), but only gained prominence after the flap was popularized by Olivari (3) and Mühlbauer (4) in the 1970’s. After that, the LD has become a workhorse flap for many reconstructive surgeons, for both immediate and delayed reconstructions, due to its ease of harvest and safety. Factors associated with its popularity include its direct dissection, versatility in orientation and design, and a consistent, reliable vascular pedicle.
The traditional drawbacks of this technique include a potentially insufficient volume that requires the combination of a prosthesis or expander, donor site complications, including dehiscence and seroma as well as joint discomfort (5-7). Additionally, the initial enthusiasm regarding LD use in breast reconstruction has been tempered over ensuing years by the advent of abdominally based pedicle and free tissue transfer options. Despite this, there are circumstances where the LD flap remains the primary option for salvage, for example in reconstructions with previous radiotherapy, implant infections, recurrent cancer after breast-conserving therapy, or in reconstructive failures (8-10).
Various techniques were designed to create an “extended” LD flap, with the aim of recruiting additional tissue to circumvent implant use. This first was described in 1987 by Hokin and Silfverskiold and included lumbar fat extensions. In 1994, Papp and McCraw modified the design to carry fat on the surface of the latissimus muscle, thus creating the total autogenous latissimus breast reconstruction (11-13).
With the increased comfort and experience with perforator flaps, many surgeons abandoned the LD flap and migrated to the abdominal donor site as the first option, even with the possibility preserving the entire LD muscle. Angrigiani first described the thoracodorsal artery perforator (TDAP) free flap in 1995 for postburn cervical resurfacing (14). The TDAP is a perforator flap based on the perforators that originate from the thoracodorsal pedicle. It offers a well-vascularized cutaneous flap that can be harvested in several dimensions. Raising the flap without sacrificing the muscle or the nerve is essential, and by sparing the muscle and the motor nerve, there is minimal muscle trauma and scarring which preserves the functional capacity of the upper extremity and limited dead space which significantly reduces the risk of seroma formation (Figure 1).
Hamdi et al. popularized the development of the TDAP flap for both oncoplastic breast reconstruction in the setting of breast conservation and as well as for breast reconstruction after mastectomy (15,16). Subsequently Brackley et al. described the use of combining an implant with the muscle-sparing TDAP flap for breast reconstruction (17). Later, Angrigiani et al. showed that the propeller TDAP flap can be designed obliquely reaching a length of more than 30 cm (18). In 2013, the concept was further advanced when the TDAP propeller flap was combined with an acellular dermal matrix (ADM) hammock technique for single stage implant breast reconstruction (19). Published literature described additional variations of the TDAP, termed the muscle-sparing LD (MSLD) flap, harvesting a small cuff of LD surrounding a thoracodorsal perforator to the overlying skin while leaving the rest of the muscle in place in order to preserve LD function (20,21).
In thin patients who are unsuitable for abdominal tissue transfer but have had radiation to the chest wall, many would favor incorporating additional non-radiated tissue to supplement an implant-based reconstruction. Some authors developed the scarless LD flap approach, which avoids taking a skin paddle using a muscle flap alone that can be harvested through a small lateral extension of the mastectomy incision. The procedure is usually combined with a tissue expander but may also be done in single stage with an implant (22-24).
Endoscopically harvested LD flap is another scarless technique in immediate partial breast reconstruction which is gaining popularity in recent times and can be done through the same incision used for the sentinel node dissection (25). Recently, some groups have started performing a minimally invasive LD muscle flap using robot-assisted approach, as this would offer a better three-dimensional view of the field with comfortable and precise dissection (26-29). The drawbacks of this approach are its learning curve and costs, but it is definitely a field that will develop in the years to come.
Recently, the LD flap has had a resurgence in popularity. High volume fat graft to improve flap volume, quilting sutures at the donor site, associated technology during surgery, dynamism prevention and the changing patterns of reimbursement for free tissue transfer have been implicated for this resurgence. The purpose of this article is to describe the current indications, the applications and their advancements as well as the areas of controversy and how to improve the results surrounding the use of total autologous and implant-enhanced LD and TDAP flaps in breast reconstruction. We present the following article in accordance with the Narrative Review reporting checklist (available at http://dx.doi.org/10.21037/abs-20-72).
The studies used in this work were obtained from Ovid MEDLINE, CENTRAL, computerized searches, and hand searches of reference lists and systematic reviews. The language was limited to Spanish and English, plus studies with more than 10 years of publication, with the exception of historical ones, were omitted.
Indications and patient selection
Patients who wish to avoid prostheses or additional surgery on the contralateral breast for symmetry, have a history of ipsilateral breast radiation, or have a high probability for adjuvant radiation are candidates for autologous reconstruction. In our group, we have the conviction of choosing the reconstructive method according to the contralateral breast, considering not only the symmetry of volume and shape but also the breast’s dynamic behavior and changes over time. Based on that assumption, we inform patients and reinforce the benefit in superior results and outcomes with autologous reconstruction. There are several reasons why an LD flap may be preferred over other reconstructive options (30).
The LD is first line for autologous breast cancer reconstruction for patients who are not eligible for an abdominal flap due to prior surgery, inadequate abdominal donor volume, or high-risk comorbidities such as diabetes, obesity, or tobacco use (31,32). Another scenario where the LD flap may be preferred is when microsurgical techniques are not available. Recent studies have found that very few patients have access to a specialist in microsurgery (33). Furthermore, microsurgical practice can be deterred by the length of the procedure and the associated poor reimbursement for free flaps for most health insurance carriers (34).
Pedicle TRAMs have become a popular alternative when microsurgery is not available; however, these flaps can have significant abdominal morbidity, especially in bilateral cases (35). LD flaps and their variants offer an excellent option for the patient seeking autologous reconstruction without microsurgery and also avoid donor site problems associated with pedicle TRAM. The LD flap is most commonly harvested as a pedicle flap with a lower index of fat necrosis in the obese population with fewer donor site complications compared to patients undergoing abdominal based flap reconstructions (36). In patients with a history of radiotherapy, the LD flap may be used to supply vascularized tissue to provide coverage for an implant obviating the need to lift an irradiated pectoralis major muscle, which can result in morbidity and an increase in associated capsular contracture. Contraindications to harvest of a pedicle LD flap include prior thoracic operations where the muscle has been damaged or if the pedicle has been ligated as can occur during an axillary dissection. We believe the indications for the TDAP flap are exactly the same as the LD; however, caution should be taken since the TDAP often provide less volume, has more restricted mobility for certain defects, and requires comfort and experience with perforator dissection (37).
Applications and possible combinations
As the indications for breast conservative surgery (BCS) and radiation expand for both breast conservation and in the setting of a total mastectomy, the use of the LD and TDAP flaps are also expected to increase. However, given the versatility of these flaps, their use in immediate and delayed reconstruction and for breast conservation and mastectomy reconstruction should be better defined.
Breast conservation surgery reconstruction
Traditionally, it was commonly accepted that partial mastectomy defects can be closed primarily without detriment, but the cosmetic result can be unpredictable and patients are often dissatisfied particularly after radiation (38,39). BCS may lead to varying amounts of volume deficits depending on the dimensions of the resected tissue, and 10–30% of patients will be dissatisfied with the final aesthetic result, especially when more than 20% of the breast volume is removed (40). With increasing trends towards BCS, so-called “oncoplastic” reconstruction of partial mastectomy defects is gaining more and more traction as it offers superior cosmetic outcomes and comparable risks of complications as foregoing reconstruction (41,42). Oncoplastic breast surgery has emerged with the concept of combining tumor excision with clear margins followed by immediate breast reconstruction using the remaining breast tissue with clear psychological benefits (43).
While oncoplastic techniques typically are based on volume displacement using breast tissue, volume replacement techniques are often needed following larger resections or in smaller-breasted patients with less remaining breast tissue. Multiple reconstructive algorithms based on different flaps have been proposed, such as the lateral intercostal artery perforator, the lateral thoracic artery perforator flap, the TDAP, and the LD Flap. The choice depends on the size and location of the defect, as well as the experience and preference of the surgeon. However, most favor using the lateral perforator-based flaps for lateral defects and the TDAP and LD for larger defects (14,44-46). Mericli et al. performed a retrospective study involving 47 women who underwent LD reconstruction following partial mastectomy and demonstrated an average BREAST-Q score of 4 out a maximum score of 5 for aesthetic satisfaction (47). In another recent study, Abdelrahman et al. compared aesthetic results of oncoplastic reconstructions between LD and TDAP and found that 80.9% of patients with an LD and 76.2% of patients with a TDAP were satisfied with their cosmetic results. None of the patients evaluated their outcome as “bad” (48) (Figure 2 and Video 1).
The surgical treatment for breast cancer has evolved tremendously over time as the radical mastectomy has largely been replaced with skin-preserving mastectomy and even nipple-sparing mastectomy except for advanced and locally aggressive cancers. However, in many centers, wide skin resecting mastectomies are still routinely performed with the immediate need for a flap with a greater skin paddle, especially in the presence of previous radiotherapy.
LD and TDAP associated with tissue expander (TE) and implants
While the LD flap is safe and reliable, it often does not provide sufficient volume except in small-breasted patients. In order to address this main drawback, the flap often needs to be supplemented with implants or, if not possible, a TE followed by an implant in either an immediate or delayed fashion. Both reconstructions may be a successful strategy when used in appropriately selected patients. Studies have demonstrated delayed two-stage reconstruction is safer than direct-to-implant (DTI) in high-risk patients with tobacco use, poorly controlled diabetes mellitus, prior breast irradiation, thin mastectomy skin flaps, or who are morbidly obese. One emerging technology that may be useful in limiting complications is the use of intraoperative tissue angiography. While there are associated costs, it can be a useful adjunct for assessing mastectomy flap viability and aid in intraoperative decision-making for DTI.
We strongly believe that the ideal patient for a DTI with a LD or TDAP flap is a patient who had previous breast augmentation and wants to maintain her volume or even less volume, has a minimal skin defect that does not require expansion, and has favorable anatomy. However, when the skin defect is large, the anatomy is distorted from an extensive resection, or the patient wishes to have a larger volume, we consider a two-stage reconstruction using a flap with an expander will provide a superior aesthetic benefit and a lower revision rate (Figures 3-6 and Video 2).
Cattelani et al. conducted a 7-year analysis of 59 consecutive women with recurrent breast cancer, previously treated with partial mastectomy and adjuvant radiation therapy, who then underwent completion mastectomy and reconstruction using an implant and LD flap. They reported 3.4% risk of major complications requiring implant removal and 6.8% minor complications, mostly partial flap necrosis managed conservatively (49). In another recent study with 366 patients and 484 breasts, Patrinely compared ADM versus LD flap with TE, and showed no statistically significant differences in complications, reoperation rates, patient satisfaction, or overall cosmetic outcomes (50). The current literature indicates a higher cost of reconstruction with ADM versus LD flap but a shorter surgery period and shorter postoperative stay period. However large-scale comparative studies are still lacking (51,52). The “skinless” LD technique is alternative option that would be suitable for patients with thin mastectomy skin flaps who are not candidates for free abdominal tissue but who have undergone prior radiation. Studies hypothesize the LD muscle would behave similarly to ADM and is an alternative in TE based breast reconstruction (22,23).
Using the LD has a greater advantage in the irradiated field as it enables all implants to be covered with healthy tissue, clearly reducing the degree of capsular contracture caused by the already irradiated pectoral major and also a positive impact in improving the quality of mastectomy flaps with a history of radiotherapy as well.
LD and TDAP for total autologous breast reconstruction with and without fat grafting
There are a wide variety of modifications that can be performed to the LD and TDAP flaps in order to complete a fully autologous reconstruction and is predominantly determined by the size and shape of the contralateral breast. There are numerous benefits to an autologous reconstruction, including the natural feel and appearance, a lower incidence of potential reoperations, and the absence of complications related to implants such as extrusion, capsular contracture, infection, poor cosmetic outcomes after radiation therapy and the recently suggested link to anaplastic large cell lymphoma with textured implants (53-55).
In 2013, Hanwright conducted a retrospective study of 12,986 patients of which 3,636 patients were obese, and demonstrated an increased risk of complications in autologous breast reconstruction compared to TE in patients with high BMI. Of all the autologous breast reconstructions, the LD flap had the lowest 30-day morbidity (56). In another study, Demiri demonstrated an increased risk of major complications in LD flaps with an implant, including implant extrusion and capsular contracture compared to LD flaps augmented with autologous fat (57). In light of these findings, it is possible to plan a completely autologous reconstruction using the LD flap even in patients with medium or even large contralateral breasts. When it is found during preoperative planning that the volume provided by the back is insufficient, the flap can be augmented with fat grafting immediately or in a staged fashion to achieve the necessary volume to achieve symmetry. Fat grafting is widely used in breast reconstruction today, in both small and large volumes (58); however, its safety was initially considered controversial, but is has now been proven to be an excellent adjunct in breast reconstruction (59-61). A recent study demonstrates fewer complications, shorter operative time and hospital stay in patients undergoing reconstruction with fat grafted LD flaps compared to abdominal free flaps in obese patients (62). In this study, lipofilling was performed through the LD flap including the muscle, skin paddle, pectoralis major and serratus muscles, and mastectomy skin flaps. Another study demonstrated similar findings with promising outcomes in immediate breast reconstruction (63) (Figures 7,8).
In the authors’ experience, immediate fat grafting into the mastectomy skin flaps should be performed with extreme caution, but can be performed safely in a delayed fashion. In the setting or prior radiation, we have found lipofilling of the LD flap to be a useful tool in reconstructing a breast using entirely autologous tissue. This can be performed with an expander in place where the entire volume of an expander is replaced with autologous fat thereby obviating the need for an implant. A contralateral reduction mammoplasty for symmetry can be performed simultaneously during the last round of fat grafting or in a separate operation. With the experience gained from combining implants, flaps and fat grafting, we were able to replace the volume of the expander for fat and the final removal of the expander with total autologous reconstruction in a second and eventual third surgery where we can also perform a contralateral symmetrization through a breast reduction (Figure 9 and Video 3).
Another very powerful tool for completing a total autologous reconstruction is the use of an extended LD and then enhance it with fat grafting in a second time, thereby reaching an even greater volume without the need for a prosthesis. We believe this is an excellent alternative for achieving a total autologous reconstruction especially in centers where microsurgery has not been developed.
Design and technical tips to minimize morbidity and enhance results
Although the LD and TDAP flaps can be designed in many orientations, we recommend designing the flap along the lines of tension of the back. In this way. The issues of scar appearance and surface contour of the back can be significantly improved. By beveling the skin flaps, the deeper fat layer can be left on the latissimus muscle and harvested with the LD flap, particularly superiorly and medially, to increase the volume and maximize the utility of the LD myocutaneous flap. Once the flap is released, the authors recommend to divide the tendon almost entirely after the pedicle is clearly identified to avoid injury to the pedicle. By dividing the tendon, this increases the mobility of the flap and also limits the animation of the muscle; however, we recommend preserving the anterior 10% of the insertion intact to prevent inadvertent traction on the pedicle when the flap is passed anteriorly (6). Despite almost completely dividing the tendon, contraction can still create significant distortion in the shape of the breast. For this reason, it is recommended that the thoracodorsal nerve also be divided during flap elevation. Some recommend resecting at least 4 cm of the thoracodorsal nerve (64). While we concur with resecting a segment of the nerve to avoid any animation deformity, we believe it should be performed by surgeons with knowledge in microsurgery techniques since there is a risk of injuring the vascular pedicle.
As for the design of the TDAP paddle, it is limited based on the location of the perforator, so the scar is often higher than that of a LD and often crosses the axillary line, which may be visible in some patients. The size of the flap that can be harvested is based on the size of the perforator but can be as large as the skin paddle taken with an LD flap. With respects to using the TDAP for breast reconstruction, the flap can be designed as a propeller flap or as a transposition flap by dissecting the perforator through the muscle to gain more mobility of the flap. The perforator can be skeletonized and dissected to the origin of the thoracodorsal pedicle in order to achieve the maximum mobility of the flap.
One of the hallmark studies performed by Hamdi et al. proposed an algorithm for pedicle perforator flaps in breast reconstruction. The authors’ algorithm is based on the quadrants of the reconstruction and recommended using lateral based flaps for lateral defect, while larger defects should be reconstructed with a TDAP flap. They advised starting the flap dissection inferior and laterally to identify the perforator. If the perforator is diminutive and inadequate, the authors recommend converting to a partial or traditional LD flap (65). Other authors have suggested using preoperative angiograms to determine the size of perforators to determine what type of flap to harvest (66-68).
The possibility of performing a TDAP flap is interesting, with a previously traumatized axillary region and without a thoracodorsal pedicle, as in this case the perforator is also fed by secondary circuits.
Donor site seroma is the most common complication following harvest of a LD flap. Some have recommended maneuvers such as quilting sutures (progressive tension sutures), fibrin sealant or both to minimize the risks of a seroma. Others advise limited use of the upper extremity (69,70). Flap ischemia is a rare complication given the robust vascular pedicle, and total flap necrosis is most likely secondary to inadvertent injury to the thoracodorsal vessels during flap harvest, tension on the pedicle during flap inset, or tractional or torsion on the pedicle during transposing the flap to breast. An extremely rare complication following LD harvest is a lumbar hernia (71,72). Other rare complications include limitation is the shoulder and upper extremity with measurable reductions in shoulder joint stability, strength, range of motion, and general functionality. The overwhelming majority of these complications improve and resolve after 6 to 12 months (73-75).
A number of retrospective studies have examined the impact of LD flap harvest on shoulder function. The results range from fatigue with overhead activities, to occupational problems. However, this may be difficult to distinguish from the sequelae of undergoing a total mastectomy with an axillary lymph node dissection and adjuvant radiation therapy. In a prospective study, De Oliveira et al. demonstrated that LD flap reconstruction had no impact on shoulder range of motion. Smoking, axillary cords, and an axillary node dissection were associated with significant functional morbidity and limited abduction (76). In 2013 the same author re-examined shoulder range of motion after immediate reconstruction with LD one year following reconstruction. Tissue adhesion and scar formation were associated with functional limitations; however, early implementation of physical therapy starting immediately after surgery resulted in no clinically significant functional morbidity (77). Despite the low risk of donor site morbidity, we believe it is very important to discuss all these possibilities, especially in the case of active, athletic patients. We have not had any patient with shoulder damage in our practice.
Some studies demonstrated that immediate breast reconstruction using a LD flap led to a decrease in muscle volume of up to 50% without radiotherapy and up to 69% after postoperative radiotherapy. Particular care should be taken in determining the size of an extended LD flap if the LD is thick or if it occupies a large portion of the flap (78,79). Some of these authors suggest using larger prostheses, but since the volume changes are not predictable, we prefer future corrections with fat transfer.
As for the morbidity of the TDAP, there are no concerns for hyper animation of the breast, shoulder pain or instability, loss of the contour by sacrificing the posterior pillar, or large seromas (80). However, there are potential complications that can occur as with any perforator cutaneous flap such as bleeding, infection, or delayed wound healing. Issues like partial flap loss and fat necrosis are more commonly secondary to poor perfusion that can occur from injury to the perforator or perhaps harvesting a flap that extend beyond the perforasome of the TDAP perforator.
The surgeon must be aware of the possibility of irregular images and structures while working with fat grafting, and therefore alert the patient. The experience will reduce complications, but certainly the most important thing is to know where to send the control images to be made and this center should have experience in interpreting those findings.
The LD and TDAP flaps represent workhorse flaps for breast reconstruction with limited risks of complications, and represent an attractive option for autologous reconstruction when the abdominal donor site is not usable or when microsurgical resources and experience are limited. Supplementation with an implant or autologous fat can help augment the flap volume to match the size and symmetry of the contralateral breast. In the authors’ experience, if resources and technical skills are available, a TDAP flap should be performed if there is adequate volume and a robust perforator is present. However, a LD is recommended for those with less experience in perforator flaps or when more volume is needed.
Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Breast Surgery for the series “Novel Innovations and Advancements in Breast Reconstruction”. The article has undergone external peer review.
Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at http://dx.doi.org/10.21037/abs-20-72
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Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/abs-20-72). The series “Novel Innovations and Advancements in Breast Reconstruction” was commissioned by the editorial office without any funding or sponsorship. EIC served as the unpaid Guest Editor of the series and serves as an unpaid editorial board member of Annals of Breast Surgery from Dec 2019 to Nov 2021. Dr. FF reports personal fees and non-financial support from Mentor, Johnson & Johnson, outside the submitted work. The other authors have no other conflicts of interest to declare.
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Cite this article as: Flaherty F, Chouhy E, Vizcay M, Chang EI. Revisiting the back as an option in breast reconstruction, from basic to cutting edge: a narrative review. Ann Breast Surg 2020;4:16.