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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.
PMCID: PMC3385318  PMID: 22783516
Breast reconstruction; Pedicled flap; Lymphedema
2.  Lumbar herniation following extended autologous latissimus dorsi breast reconstruction 
BMC Surgery  2013;13:16.
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.
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.
PMCID: PMC3671191  PMID: 23721459
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.  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.
PMCID: PMC2499534  PMID: 4051425
5.  Does Fibrin Sealant Reduce Seroma after Immediate Breast Reconstruction Utilizing a Latissimus Dorsi Myocutaneous Flap? 
Archives of Plastic Surgery  2012;39(5):504-508.
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.
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.
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.
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.
PMCID: PMC3474408  PMID: 23094246
Seroma; Fibrin tissue adhesive; Mastectomy
6.  CASE REPORT Simultaneous Latissimus Dorsi Myocutaneous Flap Transfer and Revision Total Knee Arthroplasty With Allograft Extensor Mechanism Reconstruction: A Case Report 
Eplasty  2012;12:e43.
Introduction: We present the case of a patient undergoing simultaneous reconstruction of a massive soft tissue deficit of the right knee along with total knee arthroplasty and allograft reconstruction of the extensor mechanism after multiple failed attempts to repair and revise the affected joint. Methods: A latissimus dorsi myocutaneous flap was transferred to fill the soft-tissue deficit of the right knee. During the same procedure, a previously placed antibiotic-cement spacer was removed and a new total knee prosthesis was implanted. What remained of the damaged extensor mechanism was excised and replaced with a cadaveric allograft. Results: The latissimus dorsi flap provided the necessary soft-tissue coverage of the revision. The new knee components and allograft extensor mechanism were satisfactorily implanted. One year after simultaneous reconstruction, the knee remains functional and free of infection. Discussion: Although current literature may have indicated conversion to arthrodesis or prophylactic soft-tissue repair prior to revision, simultaneous soft-tissue and extensor mechanism repair along with revision total knee arthroplasty have yielded promising results in this patient.
PMCID: PMC3432584  PMID: 22977678
7.  Immediate latissimus dorsi pedicle flap reconstruction following the removal of an eight kilogram giant phyllodes tumour of the breast: a case report 
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.
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.
PMCID: PMC3037889  PMID: 21276231
8.  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.
PMCID: PMC2884729  PMID: 20574487
Reconstruction; breast; conservation; deformity
9.  Aesthetic Improvements in Poland’s Syndrome Treatment with Omentum Flap 
Aesthetic Plastic Surgery  2010;34(5):634-639.
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.
Patients with Poland’s syndrome from a clinical database were identified and their outcomes were studied.
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.
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.
PMCID: PMC2948656  PMID: 20419302
Breast asymmetry; Breast contour; Anterior axillary pillar; Poland’s syndrome; Breast deformities; Omentum flap; Laparoscopically harvested omentum flap
10.  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
11.  Lumbar hernia after breast reconstruction☆ 
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.
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.
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.
Laparoscopic lumbar hernia repair with mesh is a safe and feasible way to manage an uncommon complication after breast reconstruction with a latissimus flap.
PMCID: PMC3785856  PMID: 23973897
Lumbar hernia; Breast reconstruction; Laparoscopy
12.  Superficial Vein Thrombosis 21 cm Distant From the Venous Anastomosis of a Free Flap Causing Intermittent Venous Congestion 
Eplasty  2009;9:e32.
Objective: Reconstructive surgeons are aware that deep vein thromboses can cause a free flap to fail; however, there are no reports in the literature regarding the incidence of free flap failure in the presence of superficial vein thromboses. Methods: A 38-year-old white male patient with poorly controlled type I diabetes mellitus presented with a chronically infected ulcer overlying an osteomyelitic right distal tibia. This region was reconstructed with a musculocutaneous latissimus dorsi free flap. Results: A superficial vein thrombosis was found 21 cm distant from the venous anastomosis of a free latissimus dorsi myocutaneous flap causing venous congestion. After early exploration, this flap was salvaged by resection of the compromised superficial venous system and the use of an interposition vein graft as no other suitable recipient vein was available. Conclusions: This case may serve as a reminder to explore early and be aware that the crux of a complication may be at a distance from the operative field. Consideration must be given to the possible need for interposition vein grafts when a suitable local deep or superficial recipient vein is not available in the lower limb.
PMCID: PMC2720018  PMID: 19718239
13.  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.
PMCID: PMC3318177  PMID: 22493623
Breast neoplasms; Breast conserving surgery; Onocoplastic; Volume replacement
14.  Is myocutaneous flap alone sufficient for reconstruction of chest wall osteoradionecrosis? 
OBJECTIVES: This study was carried out to determine whether the myocutaneous flap, alone, is sufficient to reconstruct a chest wall defect after osteoradionecrosis and provide satisfactory stability to the chest wall.
METHODS: This study involved five patients who were subjected to post-mastectomy radiotherapy as a treatment for breast cancer. Excision of the ulcer and all the necrotic ribs, with preservation of the parietal pleura and reconstruction with the latissimus dorsi flap, was done without the use of either an artificial prosthesis or autologous rib to reconstruct the chest wall defect.
RESULTS: Clinical and radiological follow-up showed no complications regarding respiratory impairment or pleural complications.
CONCLUSIONS: The use of myocutaneous flap in patients with chest wall defect following osteoradionecrosis is satisfactory to cover the chest wall defect and provide satisfactory stability to the chest wall.
PMCID: PMC3422918  PMID: 22634471
Osteoradionecrosis; Chest wall reconstruction; Latissimus dorsi flap
15.  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.
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).
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.
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.
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.
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
16.  Oncological outcome and patient satisfaction with skin-sparing mastectomy and immediate breast reconstruction: a prospective observational study 
BMC Cancer  2010;10:171.
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.
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).
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).
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.
PMCID: PMC2873394  PMID: 20429922
17.  Abdominal aorta as a recipient artery: Using a free latissimus dorsi myocutaneous flap to close hip and pelvic defects 
Free tissue transfer (FTT) is now a common procedure in many surgical centres around the world and it has shown well established results especially in the field of reconstructive surgery. The choice of FTT depends on the size of defect, nature of tissue, length of pedicle and donor site morbidity. Notwithstanding, FTT is complex and always depending on a sufficient recipient vessel.
Herein, we report a case in which the abdominal aorta was used as arterial recipient vessel for microvascular transfer of a free latissimus dorsi myocutaneous flap. It was utilized to reconstruct an extensive pelvic and hip defect following a massive gas gangrene with a prior debridement of other potential recipient vessels.
In this case, the patient had a large defect that demanded a choice of a large flap such as the free latissimus dorsi myocutaneous flap. The iliac system has been sacrificed during the debridement procedure together with other potential recipient vessels. In the presented case, arterial anastomosis of the free latissimus dorsi myocutaneous flap was performed to the distal part of the aorta without complications.
Using the abdominal aorta as a recipient arterial vessel seems to be a reliable alternative that should be considered in difficult reconstructive scenarios such as the “vessel-depleted” pelvis.
PMCID: PMC3537943  PMID: 23103629
Abdominal aorta; Free latissimus dorsi flap; Recipient vessel
18.  Oncoplastic breast surgery with latissimus dorsi myocutaneous flap for large defect in patients with ptotic breasts: is it feasible when combined with local flaps? 
The latissimus dorsi myocutaneous flap (LDMCF) is frequently applied to breast cancer patients for breast reconstruction. However, the LDMCF is considered inappropriate for patients with ptotic breast. The authors investigated combining LDMCF and two local flaps for large defects of the breast after partial mastectomy in patients with ptosis.
Nineteen patients with breast cancer underwent a partial mastectomy with immediate reconstruction. Reconstruction methods consisted of LDMCF, thoraco-epigastric flap, and inferior pedicled rotational local flap, referred to as a combined pedicle flap. The cosmetic results were self-assessed after chemotherapy and radiotherapy by a four-point scoring system.
Ptosis was graded as follows: two patients with grade 1, 10 patients with grade 2, and seven patients with grade 3. The mean tumor size was 2.7 cm and multifocality was identified in 11 patients (57.9%). The mean excised volume was 468.5 cm3 and the percentage of excised volume was 46.2%. The cosmetic results were excellent in five patients, good in seven patients, fair in six patients, and poor in one patient.
The combined pedicle flap, consisting of LDMCF, thoraco-epigastric flap, and inferior pedicled rotational local flap, allows good cosmesis in breast cancer patients with large breasts or ptosis despite a wide excision.
PMCID: PMC3974747  PMID: 24669908
Breast neoplasm; Ptotic breast; Latissimus dorsi myocutaneous flap; Combination of flap
19.  Reconstruction of a Severely Crushed Leg with Interpositional Vessel Grafts and Latissimus Dorsi Flap 
Archives of Plastic Surgery  2012;39(4):417-421.
We present a case of a near total amputation at the distal tibial level, in which the patient emphatically wanted to save the leg. The anterior and posterior tibial nerves were intact, indicating a high possibility of sensory recovery after revascularization. The patient had open fractures at the tibia and fibula, but no bone shortening was performed. The posterior tibial vessels were reconstructed with an interposition saphenous vein graft from the contralateral side and a usable anterior tibial artery graft from the undamaged ipsilateral distal portions. The skin and soft tissue defects were covered using a subatmospheric pressure system for demarcating the wound, and a latissimus dorsi myocutaneous free flap for definite coverage of the wound. At 6 months after surgery, the patient was ambulatory without requiring additional procedures. Replantation without bone shortening, with use of vessel grafts and temporary coverage of the wound with subatmospheric pressure dressings before definite coverage, can shorten recovery time.
PMCID: PMC3408290  PMID: 22872848
Limb salvage; Negative-pressure wound therapy; Vascular grafting
20.  Laparoscopic treatment of Poland’s syndrome using the omentum flap technique 
Clinics  2010;65(4):401-406.
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.
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.
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).
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.
PMCID: PMC2862663  PMID: 20454498
Poland’s syndrome; Omentum flap; Breast deformities; Laparoscopically harvested omentum flap; Breast asymmetry
21.  Long-term results of breast conservation and immediate volume replacement with myocutaneous latissimus dorsi flap 
Published long-term outcomes of oncoplastic breast-conserving surgery are scarce and, specifically, aesthetic outcomes assessed with an objective method have not previously been published.
A cohort of 41 patients treated with a quadrantectomny and immediate reconstruction using a myocutaneous latissimus dorsi flap were analyzed and their aesthetic outcomes were evaluated objectively by BCCT.core software.
At the end of a 58-month follow-up from the date of initial diagnosis, one patient (2.4%) developed an ipsilateral recurrence, six patients developed distant metastases and three patients died (7.3%) without ipsilateral recurrence, one of them presenting hepatic metastases at the time of the initial diagnosis. We were able to evaluate aesthetic results in 23 patients, 3 assessed as excellent, 12 good and 8 fair.
This oncoplastic volume replacement technique obtained a good local control and satisfactory and stable aesthetic results which have maintained unchanged after a long period of time.
PMCID: PMC3286394  PMID: 22142459
Oncoplastic breast surgery; long-term outcomes; cosmetic outcome and latissimus dorsi flap
22.  Efficacy of Quilting Sutures and Fibrin Sealant Together for Prevention of Seroma in Extended Latissimus Dorsi Flap Donor Sites 
Archives of Plastic Surgery  2012;39(5):509-513.
The extended latissimus dorsi flap is important for breast reconstruction. Unfortunately, donor site seroma is the most common complication of extended latissimus dorsi flap for breast reconstruction. Although using fibrin sealant in the donor site reduces the rate of seroma formation, donor site seroma remains a troublesome complication. The purpose of this study was to analyze the effectiveness of the combination of quilting sutures and fibrin sealant in the latissimus dorsi donor site for the prevention of seroma.
Forty-six patients who underwent breast reconstruction with extended latissimus flap were enrolled in the study. The patients received either fibrin sealant (group 1, n=25) or a combination of fibrin sealant and quilting sutures (group 2, n=21) in the extended latissimus dorsi donor site. Outcome measures were obtained from the incidence, volume of postoperative seroma, total drainage amount, indwelling period of drainage, and duration of hospital stay.
The incidence of seroma was 76% in group 1 and 42.9% in group 2 (P=0.022). We also found significant reductions in seroma volume (P=0.043), total drainage amount (P=0.002), indwelling period of drainage (P=0.01), and frequency of aspiration (P=0.043). The quilting sutures did not affect the rate of drainage, tube reinsertion, or hospital stay.
The use of quilting sutures combined with fibrin sealant on the latissimus dorsi flap donor site is helpful for reducing the overall seroma volume, frequency of aspiration, and total drainage amount.
PMCID: PMC3474855  PMID: 23094247
Mammaplasty; Surgical flaps; Seroma; Suture techniques
23.  Male Breast Cancer Originating in an Accessory Mammary Gland in the Axilla: A Case Report 
Case Reports in Medicine  2012;2012:286210.
Carcinoma of an accessory mammary gland is an extremely rare tumor. A 61-year-old male patient presented with a hard mass measuring 85 mm × 51 mm in the left axilla. Incisional biopsy histopathologically showed an adenocarcinoma compatible with breast carcinoma originating in an accessory mammary gland. Systemic examinations revealed no evidence of malignant or occult primary lesion in the bilateral mammary glands or in other organs. Neoadjuvant chemotherapy was performed for the locally advanced axillary tumor and reduced the tumor to 55 mm in size, and, then, he could undergo complete resection with a negative surgical margin in combination with reconstructive surgery to fill the resulting skin defect with a local flap of the latissimus dorsi muscle. The patient has presented with no metastatic lesion in four years since the operation. This unusual case shows that neoadjuvant chemotherapy is an effective and tolerated therapy for advanced accessory breast cancer in the axilla.
PMCID: PMC3522500  PMID: 23251170
24.  Reconstruction of through-and-through osteocutaneous defects of the mouth and face with subscapular system flaps. 
BACKGROUND: Major ablative surgery in the head and neck region may create composite defects involving the oral mucosa, bone and the overlying facial skin. The large surface area and the three-dimensional nature of these defects pose a difficult reconstructive challenge requiring adequate bone and large, positionally versatile skin flaps. PATIENTS AND METHODS: From September 1993 to May 2000, 19 patients with through-and-through osteocutaneous defects of the mouth and face were reconstructed with composite subscapular artery system flaps. The evaluated parameters included: (i) site and dimensions of the tissue defect; (ii) specific flap properties; and (iii) review of the recipient and donor site morbidity. RESULTS: 10 variants of scapular osteocutaneous flaps, eight latissimus dorsi with serratus anterior and rib osteo-myocutaneous flaps, and one combination of an osteocutaneous scapular and myocutaneous latissimus dorsi flap were used to reconstruct composite facial defects with mean dimensions of: skin 54.4 cm(2), mucosa 56.2 cm(2) and bone of 8.2 cm. Ischaemic complications occurred in three patients including one total flap failure and one failure of the bony component in previously irradiated patients. The third flap was successfully salvaged. No significant long-term donor site morbidity was noted. CONCLUSION: Composite flaps based on the subscapular artery system are a versatile reconstructive modality for large through-and-through defects of the mouth and face.
PMCID: PMC1963828  PMID: 15720908
25.  Sentinel lymph node biopsy in breast cancer patients undergoing skin/nipple-sparing mastectomy and immediate autologous reconstruction 
Oncology Letters  2010;1(1):99-101.
Immediate breast reconstruction following mastectomy is an effective treatment for breast cancer patients. Among several implant options, a latissimus dorsi myocutaneous (LDM) flap is used mainly due to the ease and minimal invasiveness of the procedure. The role of sentinel lymph node (SLN) biopsy with total mastectomy is evolving. Since SLN biopsy is not included in health insurance coverage in the treatment of patients in Japan, it is not generally performed as a separate procedure due to its cost. The present study reviewed the results of seven patients who underwent initial-staged SLN biopsy followed by planned mastectomy and LDM flap reconstruction. Two patients with positive SLNs showed macrometastases and underwent modified radical mastectomy with immediate reconstruction. In contrast, cases showing negative results for sentinel lymph nodes underwent total mastectomy. There were no false-negative cases among the SLN biopsy-negative cases. When an SLN is found to be positive on final pathology, the patient with reconstruction by LDM flap generally requires a potentially difficult reoperation on the remaining axillary nodes. When initial SLN biopsy is generally performed as a separate procedure in Japan, it will be an effective method for screening the axilla for patients who wish to undergo LDM flap reconstruction.
PMCID: PMC3436341  PMID: 22966264
sentinel lymph node biopsy; immediate breast reconstruction; skin-sparing mastectomy; nipple-sparing mastectomy

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