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1.  Improvement of Upper Extremity Lymphedema after Delayed Breast Reconstruction with an Extended Latissimus Dorsi Myocutaneous Flap 
Archives of Plastic Surgery  2012;39(2):154-157.
Lymphedema is a common complication after mastectomy in breast cancer patients. Many treatment options are available, but no treatment results in a complete cure. We report a case of lymphedema that occurred after modified radical mastectomy in a breast cancer patient who showed objective improvement after delayed breast reconstruction with an latissimus dorsi myocutaneous flap. A 41-year-old female patient with left breast cancer had undergone modified radical mastectomy with axillary lymph node dissection and postoperative radiotherapy 12 years previously. Four years after surgery, lymphedema developed and increased in aggravation despite conservative treatment. Eight years after the first operation, the patient underwent delayed breast reconstruction using the extended latissimus dorsi myocutaneous flap method. After reconstruction, the patient's lymphedema symptoms showed dramatic improvement by subjective measures including tissue softness and feeling of lightness, and by objective measures of about 7 mL per a week, resulting in near normal ranges of volume. At a postoperative follow-up after 3 years, no recurrence was observed. Delayed breast reconstruction with extended latissimus dorsi myocutaneous flaps may be helpful to patients with lymphedema after mastectomy. This may be a good option for patients who are worried about the possibility of the occurrence or aggravation of secondary lymphedema.
doi:10.5999/aps.2012.39.2.154
PMCID: PMC3385318  PMID: 22783516
Breast reconstruction; Pedicled flap; Lymphedema
2.  Laparoscopic treatment of Poland’s syndrome using the omentum flap technique 
Clinics  2010;65(4):401-406.
OBJECTIVE
For patients with Poland’s syndrome, a transverse skin fold in the anterior axillary pillar, infra-clavicular depression and an anomalous breast contour are the most uncomfortable disfigurements. This study aims to demonstrate that superior aesthetic results can be achieved by using a laparoscopically harvested omentum flap to treat this condition.
METHODS
From a prospectively maintained clinical database of patients undergoing a laparoscopic omentum flap procedure for breast reconstruction, all of the patients with Poland’s syndrome were identified and their outcomes were studied.
RESULTS
Thirteen consecutive patients with Poland’s syndrome were treated and evaluated regarding breast contour, reconstruction of the anterior axillary pillar and filling of the infra-clavicular depression. Implants were employed beneath the flap in 76% of cases to improve symmetry. In 23% of cases, a contra-lateral mastopexy was performed, and in 15% of cases, a breast implant was used. The consistency of the flap is similar to natural breast tissue and only a small incision in the breast fold is needed. The majority of patients (85%) were female, with a mean age of 26 (18–53). The flap is extremely malleable, adapts to irregular surfaces, and has a long vascular pedicle. Additionally, its removal does not leave a scar at the donor site as the removal of muscular flaps does. For example, the removal of the latissimus dorsi flap causes a deformity in the dorsal contour. The mean operative time was 201 minutes (80–350) and the mean hospital stay was 2.3 days (1–5).
CONCLUSIONS
The outcomes of these patients revealed that the omentum flap technique provided superior amelioration of the deformities caused by Poland’s syndrome when compared with other reconstructive options.
doi:10.1590/S1807-59322010000400009
PMCID: PMC2862663  PMID: 20454498
Poland’s syndrome; Omentum flap; Breast deformities; Laparoscopically harvested omentum flap; Breast asymmetry
3.  Latissimus Dorsi Myocutaneous Flap for Breast Reconstruction: Bad Rap or Good Flap? 
Eplasty  2011;11:e39.
Objective: This article serves to review latissimus dorsi myocutaneous flap as an option for breast reconstruction postmastectomy. Since the introduction of the latissimus dorsi myocutaneous flap in the late 1970s, its use has always been as a secondary technique, particularly after the development of the transverse rectus abdominus myocutaneous flap in the 1980s. Methods: A literature review of the history of latissimus dorsi myocutaneous flap utilized for breast reconstruction as well as a review of our institution's experience with latissimus dorsi myocutaneous flap and tissue expander placement was performed. Results: There remains a paucity of published studies investigating latissimus dorsi myocutaneous flap for breast reconstruction. Most studies have small numbers and do not utilize tissue expanders. More recently several small studies have been published that show acceptably low complication rates with aesthetically pleasing outcomes when latissimus dorsi myocutaneous flap is employed with a tissue expander. At our institution, we have employed latissimus dorsi myocutaneous flap with tissue expander placement for both delayed and immediate reconstruction with subsequent replacement with a permanent implant with a capsular contraction rate of 10.5%. Our data and others more recently published demonstrate very acceptable capsular contracture rates and aesthetic outcomes, particularly when an expander is utilized. Conclusion: The latissimus dorsi myocutaneous flap remains an excellent choice for breast reconstruction with a low risk of complications.
PMCID: PMC3196917  PMID: 22031843
4.  Correction of Poland's Syndrome: Case Report and Review of the Current Literature 
Breast Care  2013;8(2):139-142.
Summary
Background
Poland's syndrome, a rare congenital anomaly, consists of unilateral absence of the pectoralis major muscle, ipsilateral brachysyndactyly, and occasionally associated other malformations of the anterior chest wall, mamilla, and mamma.
Case Report
In the case of a 32-year-old woman, marked hypoplasia of the right breast and the right nipple, malformation of the right upper limb with brachysyndactyly and microdactyly were noted, all present since birth. This paper describes the surgical technique and possible complications of reconstruction of the chest wall deformity with a solid silicone implant and a latissimus dorsi flap. The current literature on the topic is reviewed.
Conclusion
The surgical method with autologous material and implants is a sufficient technique for chest wall reconstruction and gives a good long-term result in case of Poland's syndrome.
doi:10.1159/000350778
PMCID: PMC3683949  PMID: 24419214
Poland's syndrome; Breast hypoplasia; Breast reconstruction; Malformation
5.  Delayed two-stage breast reconstruction with implants: The authors’ recent experience 
In Poland, because breast cancer detection is delayed, patients usually undergo amputation or breast reconstruction. Surgeons believe that delayed reconstruction yields better aesthetic results compared with immediate reconstruction after mastectomy. Reconstruction is achieved by using either the patient’s own tissues or a tissue expander, which is later exchanged for a prosthesis/expandable implant. The two-stage reconstruction method (expander and prosthesis) is considered to be optimal because the implant position can be corrected. This study evaluated the aesthetic results of 54 patients who underwent the two-stage breast reconstruction method.
BACKGROUND:
Presently, breast cancer detection is delayed in Poland and, thus, the only other option for patients is amputation and breast reconstruction (immediate or delayed). Reconstructive methods are based on using the patient’s own tissue (pedicled or free myocutaneous flaps) or implants (a tissue expander, which is later exchanged for a prosthesis or an expandable implant).
OBJECTIVE:
To evaluate the aesthetic results of a delayed two-stage breast reconstruction with the use of implants (expander and prosthesis) in patients who have previously undergone cancer-related mastectomy.
METHODS:
From 2006 to 2009, 54 patients (34 to 65 years of age) underwent reconstruction at least one year after their mastectomy and adjuvant chemotherapy; three women also received x-ray therapy. All women underwent a two-stage treatment with a tissue expander, which was later exchanged for a prosthesis.
RESULTS:
Outcomes of the surgery (evaluated by the physician and the patient at least six months after all stages of reconstruction) were found to be very good in 42 patients and good in 12 patients. After amputation and x-ray therapy in two cases, a fistula developed, which necessitated implant removal.
CONCLUSIONS:
After amputation, breast reconstruction with implants (expander and prosthesis) provides good aesthetic results. The method is mildly burdening to the patient and does not cause severe scarring. Symmetrization of the second breast is often recommended; however, the cost is not covered by the national health system. In principle, earlier x-ray therapy disqualifies the application of implants. Dividing reconstruction into two stages (expander and prosthesis) allows for possible correction of prosthesis placement.
PMCID: PMC3269328  PMID: 22942657
Breast implant; Breast reconstruction; Delayed; Prosthesis; Tissue expander; Two stage
6.  Combined serratus anterior and latissimus dorsi myocutaneous flap for obliteration of an irradiated pelvic exenteration defect and simultaneous site for colostomy revision 
Background
Usually, several surgical methods are used, with re-suturing, free skin grafting and local flaps, for the reconstruction of wall defects after abdominoperineal resection. However, or larger defects, free flaps have been preferred because they can provide a large area of well-vascularized soft tissue, which is suitable for defect repair. We present the case of a large abdominal wall defect, which was treated with a free combined serratus anterior and latissimus dorsi myocutaneous flap, resulting in a successful outcome.
Case presentation
A 38-year-old female originally had squamous cell carcinoma of the cervix uteri, and had undergone radical hysterectomy and oophorectomy followed by radiotherapy. She had a recurrence of the cervical cancer after 13 years, and underwent pelvic exenteration. However, the mid-abdominal wound developed dehiscence and an abdominal full-thickness defect communicating with the pelvic cavity. Furthermore, the adhered colon developed necrosis, which drained stools into the pelvic cavity, resulting in chronic peritonitis. During surgery, the empty pelvic cavity was filled with a combined serratus anterior and latissimus dorsi myocutaneous flap to prevent chronic peritonitis, to create a new stoma in the skin paddle of the flap for the necrotic colon, and to separate the pelvic cavity from the drained stools. The patient could walk in the absence of abdominal hernia formation and relapse of infection.
Conclusions
A combined serratus anterior and latissimus dorsi myocutaneous free flap was applied to cover the raw surface and reinforce the abdominal wall and to fashion a new colostomy, as well as successfully filling the pelvic cavity with a large muscle body and long vascular pedicle. This is the optimal method for reconstructing severe abdominal wall defects that have many complications.
doi:10.1186/1477-7819-12-319
PMCID: PMC4213489  PMID: 25335529
7.  Lumbar herniation following extended autologous latissimus dorsi breast reconstruction 
BMC Surgery  2013;13:16.
Background
Reconstructive breast surgery is now recognized to be an important part of the treatment for breast cancer. Surgical reconstruction options consist of implants, autologous tissue transfer or a combination of the two. The latissimus dorsi flap is a pedicled musculocutaneous flap and is an established method of autologous breast reconstruction.
Lumbar hernias are an unusual type of hernia, the majority occurring after surgery or trauma in this area. The reported incidence of a lumbar hernia subsequent to a latissimus dorsi reconstruction is very low.
Case presentation
We present the unusual case of lumbar herniation after an extended autologous latissimus dorsi flap for breast reconstruction following a mastectomy. The lumbar hernia was confirmed on CT scanning and the patient underwent an open mesh repair of the hernia through the previous latissimus dorsi scar.
Conclusion
Lumbar hernias are a rare complication that can occur following latissimus dorsi breast reconstruction. It should be considered in all patients presenting with persistent pain or swelling in the lumbar region.
doi:10.1186/1471-2482-13-16
PMCID: PMC3671191  PMID: 23721459
8.  Aesthetic Improvements in Poland’s Syndrome Treatment with Omentum Flap 
Aesthetic Plastic Surgery  2010;34(5):634-639.
Background
There are many techniques that can be used to reconstruct anomalous breast volume in Poland’s syndrome, but repair of the stigmatizing deformities such as the transverse skin fold in the anterior axillary pillar, infraclavicular depression, and anomalous breast contours continues to be a challenge. This study aimed to demonstrate the superior results of laparoscopically harvested omentum flap to achieve these aesthetic improvements.
Methods
Patients with Poland’s syndrome from a clinical database were identified and their outcomes were studied.
Results
In 15 consecutive patients with Poland’s syndrome, the breast contour, the anterior axillary pillar, and the infraclavicular depression were treated with omentum flap and evaluated. Silicone implants were used beneath the flap in 80% of cases to improve symmetry. Flap consistency was similar to that of the natural breast and only a small incision in the breast fold was needed. The flap is extremely malleable, adapts to irregular surfaces, and has a long vascular pedicle. It does not leave a scar at the donor site as muscular flaps do. The omentum can repair small irregularities in breast contour, achieving a natural result different from all other flaps. Due to its malleability, it is possible to reconstruct even the extension to the axillary pillar, which is impossible with all other techniques.
Conclusions
The omentum flap technique is a means of repairing the deformities caused by Poland’s syndrome and improves the aesthetic result with outcomes that seem superior to any other reconstructive option.
doi:10.1007/s00266-010-9513-y
PMCID: PMC2948656  PMID: 20419302
Breast asymmetry; Breast contour; Anterior axillary pillar; Poland’s syndrome; Breast deformities; Omentum flap; Laparoscopically harvested omentum flap
9.  A Simple Algorithm for Immediate Postmastectomy Reconstruction of the Small Breast—A Single Surgeon's 10-Year Experience 
Eplasty  2012;12:e55.
Introduction: Immediate small breast reconstruction poses challenges including limited potential donor site tissues, a thinner skin envelope, and limited implant choice. Few patients are suitable for autologous reconstruction while contralateral symmetrization surgery that often offsets the problem of obvious asymmetry in thin and small-breasted patients is often unavailable, too expensive, or declined by the patient. Methods: We reviewed 42 consecutive patients with mastectomy weights of 350 g or less (the lowest quartile of all reconstructions). Indications for the mastectomy, body mass index, bra cup size, comorbidity, reconstruction type, and complications were recorded. Results: A total of 59 immediate reconstructions, including 25 latissimus dorsi flaps, 23 implant-only reconstructions, 9 abdominal flaps, and 2 gluteal flaps, were performed in 42 patients. Of the 42 mastectomies, 4 were prophylactic. Forty-three percent of patients had immediate contralateral balancing surgery. The average mastectomy weight was 231 g (range, 74-350 g). Seven percent of implant-based reconstructions developed capsular contracture requiring further surgery. One free transverse rectus abdominus myocutaneous flap failed because of fulminant methicillin resistant staphylococcus aureus septicaemia. Discussion and Conclusion: Balancing contralateral surgery is key in achieving excellent symmetry in reconstruction small-breasted patients. However, many patients wish to avoid contralateral surgery, thus restricting a surgeon's reconstructive options. Autologous flaps, traditionally, had not been considered in thinner women because of inadequacy of donor site tissue, but in fact, often, as with larger-breasted patients, produce superior cosmetic results. We propose a simple algorithm for the reconstruction of small-breasted women (without resorting to super-complex microsurgery), which is designed to tailor the choice of reconstructive technique to the requirements of the individual patient.
PMCID: PMC3521473  PMID: 23308302
10.  Does Fibrin Sealant Reduce Seroma after Immediate Breast Reconstruction Utilizing a Latissimus Dorsi Myocutaneous Flap? 
Archives of Plastic Surgery  2012;39(5):504-508.
Background
The most common complication of latissimus dorsi myocutaneous flap in breast reconstruction is seroma formation in the back. Many clinical studies have shown that fibrin sealant reduces seroma formation. We investigated any statistically significant differences in postoperative drainage and seroma formation when utilizing the fibrin sealant on the site of the latissimus dorsi myocutaneous flap harvested for immediate breast reconstruction after skin-sparing partial mastectomy.
Methods
A total of 46 patients underwent immediate breast reconstruction utilizing a latissimus dorsi myocutaneous island flap. Of those, 23 patients underwent the procedure without fibrin sealant and the other 23 were administered the fibrin sealant. All flaps were elevated with manual dissection by the same surgeon and were analyzed to evaluate the potential benefits of the fibrin sealant. The correlation analysis and Mann-Whitney U test were used for analyzing the drainage volume according to age, weight of the breast specimen, and body mass index.
Results
Although not statistically significant, the cumulative drainage fluid volume was higher in the control group until postoperative day 2 (530.1 mL compared to 502.3 mL), but the fibrin sealant group showed more drainage beginning on postoperative day 3. The donor site comparisons showed the fibrin sealant group had more drainage beginning on postoperative day 3 and the drain was removed 1 day earlier in the control group.
Conclusions
The use of fibrin sealant resulted in no reduction of seroma formation. Because the benefits of the fibrin sealant are not clear, the use of fibrin sealant must be fully discussed with patients before its use as a part of informed consent.
doi:10.5999/aps.2012.39.5.504
PMCID: PMC3474408  PMID: 23094246
Seroma; Fibrin tissue adhesive; Mastectomy
11.  The Role of Latissimus Dorsi Myocutaneous Flaps in Secondary Breast Reconstruction After Breast-Conserving Surgery 
Eplasty  2013;13:e28.
Objective: Secondary reconstruction after breast-conserving surgery is generally challenging because of the nature of irradiated tissue. The aim of this study was to validate the use of latissimus dorsi myocutaneous (LDM) flaps for secondary breast reconstruction after breast-conserving surgery. Methods: Fifteen consecutive patients who underwent secondary reconstruction with an LDM flap after breast-conserving surgery were included in the study. The esthetic outcome in comparison with the contralateral breast was evaluated by observer assessments consisting of 7 criteria. In addition to comparing pre- and postoperative scores for each criterion, factors affecting overall esthetic outcome were analyzed. Results: There was no major recipient- or donor-related complication. In 13 patients, the skin paddle of the LDM flap was exposed to the skin surface. In all patients, overall esthetic scores increased postoperatively. Age, period between breast-conserving surgery and LDM flap, body mass index, or preoperative breast size did not affect the overall esthetic outcome. Tumors in the lower quadrants tended to result in poorer esthetic scores, especially in breast shape and scar (P = .04 and .02, respectively). Conclusions: Given their high vascularity and moderate flap volume, LDM flaps could be a reliable option for secondary breast reconstruction after breast-conserving surgery. Although exposure of skin paddle to the skin surface is inevitable in most cases, esthetic improvement could be achieved, including the breast scar. On the contrary, immediate reconstruction would certainly be more desirable, especially in cases of tumors in the lower quadrants.
PMCID: PMC3681253  PMID: 23837111
12.  Breast reconstruction after failed conservation. 
We report our experience of using latissimus dorsi myocutaneous flaps after failed conservation for breast carcinoma. Twenty-nine patients were treated by two methods of reconstruction. Seventeen patients with central recurrent tumours and three patients with radiation necrosis of the breast were treated by total mastectomy and latissimus dorsi reconstitution with silicone implant. Nine patients underwent latissimus dorsi reconstruction with preservation of the nipple for recurrent peripheral tumours. After a mean follow up period of 20.2 months no local recurrences have been observed but a longer period of follow-up is necessary to evaluate the likely long term recurrence rate.
Images
PMCID: PMC2499534  PMID: 4051425
13.  Oncological outcome and patient satisfaction with skin-sparing mastectomy and immediate breast reconstruction: a prospective observational study 
BMC Cancer  2010;10:171.
Background
The management of early breast cancer (BC) with skin-sparing mastectomy (SSM) and immediate breast reconstruction (IBR) is not based on level-1 evidence. In this study, the oncological outcome, post-operative morbidity and patients' satisfaction with SSM and IBR using the latissimus dorsi (LD) myocutaneous flap and/or breast prosthesis is evaluated.
Methods
137 SSMs with IBR (10 bilateral) were undertaken in 127 consecutive women, using the LD flap plus implant (n = 85), LD flap alone (n = 1) or implant alone (n = 51), for early BC (n = 130) or prophylaxis (n = 7). Nipple reconstruction was performed in 69 patients, using the trefoil local flap technique (n = 61), nipple sharing (n = 6), skin graft (n = 1) and Monocryl mesh (n = 1). Thirty patients underwent contra-lateral procedures to enhance symmetry, including 19 augmentations and 11 mastopexy/reduction mammoplasties. A linear visual analogue scale was used to assess patient satisfaction with surgical outcome, ranging from 0 (not satisfied) to 10 (most satisfied).
Results
After a median follow-up of 36 months (range = 6-101 months) there were no local recurrences. Overall breast cancer specific survival was 99.2%, 8 patients developed distant disease and 1 died of metastatic BC. There were no cases of partial or total LD flap loss. Morbidities included infection, requiring implant removal in 2 patients and 1 patient developed marginal ischaemia of the skin envelope. Chemotherapy was delayed in 1 patient due to infection. Significant capsule formation, requiring capsulotomy, was observed in 85% of patients who had either post-mastectomy radiotherapy (PMR) or prior radiotherapy (RT) compared with 13% for those who had not received RT. The outcome questionnaire was completed by 82 (64.6%) of 127 patients with a median satisfaction score of 9 (range = 5-10).
Conclusion
SSM with IBR is associated with low morbidity, high levels of patient satisfaction and is oncologically safe for T(is), T1 and T2 tumours without extensive skin involvement.
doi:10.1186/1471-2407-10-171
PMCID: PMC2873394  PMID: 20429922
14.  MR imaging of the reconstructed breast: What the radiologist needs to know 
Insights into Imaging  2012;3(3):201-213.
Objective
The objective is to review the different types of breast reconstruction following cancer surgery and describe expected imaging appearances and complications seen in the reconstructed breast.
Methods
Surgical management of breast cancer often entails lumpectomy or mastectomy. When mastectomy is performed, patients often opt for breast reconstruction. Most facilities do not routinely image the reconstructed breast with mammography.
Results
However, many of these women are imaged with screening breast MRI for evaluation of the contralateral breast, or they may develop a clinical problem that warrants a diagnostic evaluation with MRI. In this article, we will review the more commonly encountered types of breast reconstruction, which include implants, tranversus rectus abdomnis flap, latissimus dorsi flap, deep inferior epigastric perforator flap, and gluteal flaps. Each of these types of reconstruction has different appearances on MR. We will also discuss potential complications that can be seen in the reconstructed breasts, including fat necrosis and recurrence.
Conclusion
Radiologists will better understand the different types of breast reconstruction after mastectomy and their normal imaging appearance on MRI. Radiologists will be more aware of how to recognize complications related to surgery as well as how to determine whether recurrence is present.
Main Messages
• The different surgical techniques used in breast reconstruction are discussed.
• Describes the normal magnetic resonance imaging appearance of the breast after reconstruction.
• Identify MR imaging features of benign sequelae and recurrence following breast reconstruction.
doi:10.1007/s13244-012-0150-7
PMCID: PMC3369124  PMID: 22696083
Breast; MRI imaging; Surgery; Types of breast reconstruction; MRI imaging of reconstructed breast
15.  The Scarless Latissimus Dorsi Flap Provides Effective Lower Pole Prosthetic Coverage in Breast Reconstruction 
Background:
The evolution of surgical breast cancer treatment has led to the oncologically safe preservation of greater amounts of native skin, yet we are still often using flaps with large skin paddles, thereby resulting in significant donor-site scars. This explains the increasing appeal of acellular dermal matrix reconstructions. Acellular dermal matrices can, however, have significant problems, particularly if there is any vascular compromise of the mastectomy skin flaps. We have developed a method of raising the latissimus dorsi flap through the anterior mastectomy incisions without requiring special instruments or repositioning. This can provide autologous vascularized cover of the prosthesis.
Methods:
A clear surgical description of the scarless latissimus dorsi flap harvest is provided, and our results of a retrospective cohort review of 20 consecutive patients with 27 traditional latissimus dorsi breast reconstructions were compared with those of 20 consecutive patients with 30 scarless latissimus dorsi breast reconstructions.
Results:
Operative time, length of stay, and complication rates were reduced in the scarless group. Patients Breast-Q scores were equivalent in each group. The aesthetic assessment was good/excellent in 77% of both groups; however, subscale assessment was better in the scarless group. This was statistically significant (P = 0.0).
Conclusions:
Breast reconstruction using the scarless latissimus dorsi flap is time effective, requires no patient repositioning, and uses standard breast instrumentation. It is safe and versatile while reducing the risk of exposed prosthesis if native skin necrosis occurs. It is a vascularized alternative to acellular dermal matrices.
doi:10.1097/GOX.0000000000000089
PMCID: PMC4174076  PMID: 25289340
16.  Immediate Partial Breast Reconstruction with Endoscopic Latissimus Dorsi Muscle Flap Harvest 
Archives of Plastic Surgery  2014;41(5):513-519.
Background
Currently, breast conservation therapy is commonly performed for the treatment of early breast cancer. Depending on the volume excised, patients may require volume replacement, even in cases of partial mastectomy. The use of the latissimus dorsi muscle is the standard method, but this procedure leaves an unfavorable scar on the donor site. We used an endoscope for latissimus dorsi harvesting to minimize the incision, thus reducing postoperative scars.
Methods
Ten patients who underwent partial mastectomy and immediate partial breast reconstruction with endoscopic latissimus dorsi muscle flap harvest were reviewed retrospectively. The total operation time, hospital stay, and complications were reviewed. Postoperative scarring, overall shape of the reconstructed breast, and donor site deformity were assessed using a 10-point scale.
Results
In the mean follow-up of 11 weeks, no tumor recurrence was reported. The mean operation time was 294.5 (±38.2) minutes. The postoperative hospital stay was 11.4 days. Donor site seroma was reported in four cases and managed by office aspiration and compressive dressing. Postoperative scarring, donor site deformity, and the overall shape of the neobreast were acceptable, scoring above 7.
Conclusions
Replacement of 20% to 40% of breast volume in the upper and the lower outer quadrants with a latissimus dorsi muscle flap by using endoscopic harvesting is a good alternative reconstruction technique after partial mastectomy. Short incision benefits from a very acceptable postoperative scar, less pain, and early upper extremity movement.
doi:10.5999/aps.2014.41.5.513
PMCID: PMC4179355  PMID: 25276643
Mammaplasty; Endoscopes; Surgical flaps
17.  Reconstruction of the Breast Conservation Deformity 
Seminars in Plastic Surgery  2004;18(2):89-96.
The era of breast conserving treatment of early-stage breast carcinoma has created reconstructive challenges for the plastic surgeon. Although good to excellent cosmetic outcomes occur in the majority of patients, a significant number could benefit from additional reconstructive measures. Because of the need for continuing surveillance following breast-conserving therapy, estimated at 5–10% after fifteen years, plastic surgeons should choose techniques that do not interfere with the detection of recurrent breast carcinoma. Myocutaneous flaps-in particular, the latissimus dorsi and transverse rectus abdominis—have fulfilled the reconstructive needs of these patients by providing well-vascularized soft tissue. Postoperative radiological evaluation has demonstrated that these flaps are radiolucent, unlike breast implants that can obscure accurate mammographic interpretation.
Myocutaneous flaps have been used for both immediate and delayed reconstruction of post-breast conservation deformities. The delayed approach offers the benefit of an established contour deformity that usually involves cutaneous, parenchymal, and nipple-areolar components. Moderate overcorrection of the defect has been advocated in anticipation of ongoing postradiation wound contraction and fibrosis. Immediate reconstruction of lumpectomy and partial mastectomy defects permits wider initial excision of the breast lesion, but can be compromised by positive histological margins. Long-term results suggest stability of the aesthetic outcome following reconstruction of delayed deformities.
doi:10.1055/s-2004-829043
PMCID: PMC2884729  PMID: 20574487
Reconstruction; breast; conservation; deformity
18.  Immediate latissimus dorsi pedicle flap reconstruction following the removal of an eight kilogram giant phyllodes tumour of the breast: a case report 
Introduction
Phyllodes tumors account for less than 1% of breast tumors in women, and giant phyllodes tumors are those that are larger than 10 cm in diameter. Removal of such large tumors places a huge burden on the surgeon to reconstruct a breast that is aesthetically acceptable by the patient. We report what may be the largest giant phyllodes tumor and, most likely, the first latissimus dorsi flap used to cover such a large defect caused by the resection.
Case presentation
We report the case of a 36-year-old Malaysian woman who presented with a three-year history of gradually increasing swelling of the left breast, with skin changes. Examination revealed a huge, globular, lobulated mass measuring 400 mm by 350 mm. The patient had a mastectomy with an immediate latissimus dorsi pedicled myocutaneous flap reconstruction. The breast weighed 8.27 kg, and ex vivo, the tumor measured 280 mm by 250 mm by 180 mm. Histopathologic analysis confirmed the diagnosis as a giant phyllodes tumor. At 12-month follow-up, the patient reports no complications and is satisfied with the aesthetic outcome.
Conclusion
Giant phyllodes tumors are very rare tumors that can reach up to 40 cm in diameter. Reconstruction of such a defect is a great challenge, and we report what we believe is the first latissimus dorsi flap to cover successfully a defect of approximately 400 mm by 350 mm.
doi:10.1186/1752-1947-5-44
PMCID: PMC3037889  PMID: 21276231
19.  Sternoclavicular Joint Infection: Classification of Resection Defects and Reconstructive Algorithm 
Archives of Plastic Surgery  2012;39(6):643-648.
Background
Aggressive treatment of sternoclavicular joint (SCJ) infection involves systemic antibiotics, surgical drainage and resection if indicated. The purpose of this paper is to describe a classification of post resectional SCJ defects and highlight our reconstructive algorithm. Defects were classified into A, where closure was possible often with the aid of topical negative pressure dressing; B, where parts of the manubrium, calvicular head, and first rib were excised; and C, where both clavicular, first ribs and most of the manubrium were resected.
Methods
Twelve patients (age range, 42 to 72 years) over the last 8 years underwent reconstruction after SCJ infection. There was 1 case of a type A defect, 10 type B defects, and 1 type C defect. Reconstruction was performed using the pectoralis major flap in 6 cases (50%), the latissimus dorsi flap in 4 cases (33%), secondary closure in 1 case and; the latissimus and the rectus flap in 1 case.
Results
All wounds healed uneventfully with no flap failure. Nine patients had good shoulder motion. Three patients with extensive clavicular resection had restricted shoulder abduction and were unable to abduct their arm past 90°. Internal and external rotation were not affected.
Conclusions
We highlight our reconstructive algorithm which is summarised as follows: for an isolated type B SCJ defect we recommend the ipsilateral pectoralis major muscle for closure. For a type C bilateral defect, we suggest the latissimum dorsi flap. In cases of extensive infection where the thoracoacromial and internal mammary vessels are thrombosed, the pectoralis major and rectus abdominus cannot be used; and the latissimus dorsi flap is chosen.
doi:10.5999/aps.2012.39.6.643
PMCID: PMC3518009  PMID: 23233891
Sternoclavicular joint; Infectious arthritis; Surgical flap
20.  Oncoplastic volume replacement techniques according to the excised volume and tumor location in small- to moderate-sized breasts 
Gland Surgery  2014;3(1):14-21.
Background
In the treatment of cancer patients with small breasts, breast-conserving surgery (BCS) with adjuvant radiotherapy has become popular. In Korean women, many of whom have small- to moderate-sized breasts, the removal of an adequate volume of tissue during breast cancer surgery may compromise the cosmetic outcome and sometimes cause unpleasant results. In such cases, oncoplastic volume replacement techniques can be valuable.
Methods
Between January 2007 and December 2013, 213 women underwent 216 BCSs with various oncoplastic volume replacement techniques selected according to the volume of breast tissue excised. When the excised volume was <150 g, regional flaps such as a lateral thoracodorsal or thoracoepigastric flap, or perforator flaps such as an intercostal artery perforator (ICAP) flap or a thoracodorsal artery perforator (TDAP) flap were used. When the excised volume was >150 g, a latissimus dorsi (LD) myocutaneous flap was used.
Results
The mean age was 45.7 years, and the mean follow-up interval was 11.3 months. The mean excised volume was 148.4 g. The oncoplastic volume replacement techniques used included 22 lateral thoracodorsal flaps, 8 thoracoepigastric flaps, 29 ICAP flaps, 20 TDAP flaps, and 137 LD myocutaneous flaps. Postsurgical complications occurred in 30 cases, including 1 case of congestion and 26 cases of seroma in LD myocutaneous flaps, and 3 cases of fat necrosis in ICAP flaps. Most of the patients were satisfied with the cosmetic outcome.
Conclusions
Oncoplastic volume replacement techniques according to the excised volume and tumor location are reliable and useful for the correction of breast deformity after BCS, especially in patients with small- to moderate-sized breasts.
doi:10.3978/j.issn.2227-684X.2014.02.02
PMCID: PMC4115780  PMID: 25083489
Breast neoplasms; breast reconstruction; mammaplasty; surgical flaps
21.  Oncoplastic breast surgery: indications, techniques and perspectives 
Gland Surgery  2013;2(3):143-157.
Breast-conservation surgery (BCS) is established as a safe option for most women with early breast cancer. Recently, advances in oncoplastic techniques have reduced surgical trauma and thus are capable of preserving the breast form and quality of life. In spite of the most BCS defects can be managed with primary closure, the aesthetic outcome may be unpredictable. Oncoplastic reconstruction may begin at the time of BCS (immediate), weeks (delayed-immediate) or months to years afterwards (delayed). With immediate reconstruction, the surgical process is smooth, since both procedures can be associated in one operative setting. Additionally, it permits wider excision of the tumor, with a superior mean volume of the specimen and potentially reducing the incidence of margin involvement. The oncoplastic techniques are related to volume displacement or replacement procedures including local flaps, latissimus dorsi myocutaneous flap and reduction mammaplasty/masthopexy. Regardless of the fact that there is no consensus concerning the best approach, the criteria are determined by the surgeon’s experience and the size of the defect in relation to the size of the remaining breast. On the basis of our 15-year experience, it is possible to identify trends in types of breast defects and to develop an algorithm for immediate BCS reconstruction on the basis of the initial breast volume, the extent/location of glandular tissue ressection and the remaining available breast tissue. The main advantages of the technique utilized should include reproducibility, low interference with the oncologic treatment and long-term results. Surgical planning should include the patients’s preferences, and chiefly addressing individual reconstructive requirements, enabling each patient to receive an individual “custom-made” reconstruction.
doi:10.3978/j.issn.2227-684X.2013.08.02
PMCID: PMC4115743  PMID: 25083476
Breast reconstruction; conservative breast surgery; partial mastectomy; oncoplastic; reduction mammaplasty; local flaps; outcome; complications
22.  Surgical Techniques for Personalized Oncoplastic Surgery in Breast Cancer Patients with Small- to Moderate-Sized Breasts (Part 2): Volume Replacement 
Journal of Breast Cancer  2012;15(1):7-14.
Oncoplastic breast surgery has become a popular choice of treatment for breast reconstruction after mastectomy. There are two different techniques in oncoplastic surgery depending on the volume of the excised breast tissue. One is the volume displacement procedure, which combines resection with a variety of different breast-reshaping and breast-reduction techniques; the other is the volume replacement procedure in which the volume of excised breast tissue is replaced with autologous tissue. In this study, current authors performed various volume replacement techniques based on the weight of the excised tumor and its margin of resection. We used a latissimus dorsi myocutaneous flap for cases in which the resection mass was greater than 150 g, and for cases in which the resection mass was less than 150 g, we used a regional flap, such as a lateral thoracodorsal flap, a thoracoepigastric flap, or perforator flaps, such as an intercostal artery perforator flap or a thoracodorsal artery perforator flap. In the patients with small to moderate-sized breasts, when a postoperative deformity is expected due to a large-volume tumor resection, the replacement of non-breast tissue is required. Many of whom have small breasts, oncoplastic volume replacement techniques in breast-conserving surgery allow an extensive tumor excision without concern of compromising the cosmetic outcome and can be reliable and useful techniques with satisfactory aesthetic results.
doi:10.4048/jbc.2012.15.1.7
PMCID: PMC3318177  PMID: 22493623
Breast neoplasms; Breast conserving surgery; Onocoplastic; Volume replacement
23.  Lumbar hernia after breast reconstruction☆ 
INTRODUCTION
Lumbar hernia is a rare complication that can occur after breast reconstruction using a latissimus dorsi flap. The defect occurs within the superior lumbar triangle and may result in visceral incarceration.
PRESENTATION OF CASE
We report a 61-year-old female who presented with a left sided lumbar bulge and pain 7 years following a modified radical mastectomy and latissimus dorsi flap reconstruction. Computed tomography demonstrated a lumbar hernia with incarcerated colon. The patient underwent a successful laparoscopic repair with prosthetic mesh underlay.
DISCUSSION
Lumbar hernias may be congenital, secondary to trauma or prior surgery. Imaging studies assist in excluding soft tissue tumors, infections, hematoma or abdominal wall denervation atrophy, which may also present as a lumbar bulge. Repair may be performed in an open, laparoscopic or retroperitoneoscopic approach.
CONCLUSION
Laparoscopic lumbar hernia repair with mesh is a safe and feasible way to manage an uncommon complication after breast reconstruction with a latissimus flap.
doi:10.1016/j.ijscr.2013.06.008
PMCID: PMC3785856  PMID: 23973897
Lumbar hernia; Breast reconstruction; Laparoscopy
24.  Reconstruction with a 180-degree Rotationally Divided Latissimus-dorsi-musculocutaneous Flap after the Removal of Locally Advanced Breast Cancer 
Summary:
This study described a technique for reconstruction of a large lateral thoracic region defect after locally advanced breast cancer resection that allows for full coverage of the defect and primary closure of the flap donor site. The authors performed reconstruction using the newly designed 180-degree rotationally-divided latissimus-dorsi-musculocutaneous flap in a 42-year-old woman for coverage of a large skin defect (18 × 15 cm) following extensive tissue resection for locally advanced breast cancer. The latissimus-dorsi-musculocutaneous flap, consisting of two rotated skin islands (18 × 7.5 cm each) that were sutured to form a large skin island, was used for coverage of the defect. The flap was sutured without causing excessive tension in the recipient region and the donor site was closed with simple reefing. No skin grafting was necessary. The flap survived completely, shoulder joint function was intact, and esthetic outcome was satisfactory. Quick wound closure allowed postoperative irradiation to be started 1 month after surgery. The technique offered advantages over the conventional pedicled latissimus-dorsi-musculocutaneous flap, but the flap was unable to be used, when the thoracodorsal artery and vein were damaged during extensive tissue removal. Detailed planning before surgery with breast surgeons would be essential.
doi:10.1097/GOX.0000000000000190
PMCID: PMC4229276  PMID: 25426400
25.  Variation in the insertion of the latissimus dorsi & its clinical importance 
Journal of Orthopaedics  2013;10(1):25-28.
The latissimus dorsi is the larger, flat, dorso-lateral muscle on the trunk, posterior to the arm, and partly covered by the trapezius on its median dorsal region. Origin of the latissimus dorsi is from spinous processes of thoracic T7–T12, thoracolumbar fascia, iliac crest and inferior 3 or 4 ribs, inferior angle of scapula and insertion on floor of intertubercular groove of the humerus. We have studied 50 cadavers in the different medical colleges in which we found 2% case of anterior and posterior slip of the muscle fibers with their extension up to the pectoralis major and teres major respectively. Usually, latissimus dorsi involve in extension, adduction, transverse extension also known as horizontal abduction, flexion from an extended position, and internal rotation of the shoulder joint. It also has a synergistic role in extension and lateral flexion of the lumbar spine. The latissimus dorsi may be used for the tendon graft surgeries. Tight latissimus dorsi has been shown to be one cause of chronic shoulder pain and chronic back pain. Because the latissimus dorsi connects the spine to the humerus, tightness in this muscle can manifest as either sub-optimal glenohumeral joint function (which leads to chronic shoulder pain) or tendinitis in the tendinous fasciae connecting the latissimus dorsi to the thoracic and lumbar spine. Latissimus dorsi used for pedicle transplant rotator cuff repair reconstruction of breast, face, scalp and cranium defect. The extra slip of the latissimus dorsi may puzzle any transplant operations. We as anatomist discuss the clinical implication of the extra slip of latissimus dorsi.
doi:10.1016/j.jor.2013.01.002
PMCID: PMC3768243  PMID: 24403744
Latissimus dorsi; Slips

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