Pre-expanded Muscle-sparing Latissimus Dorsi Flaps for Reconstruction of Severe Scar Contractures on the Anterior Chest

Objective To investigate the utility of pre-expanded muscle-sparing latissimus dorsi flaps in the reconstruction of deformities secondary to severe scar contractures on the anterior chest.Methods The function of the latissimus dorsi was preserved with blood supply from the main or lateral branch of the thoracodorsal artery.The entire treatment period was divided into two stages,during which segmental latissimus dorsi flaps were pre-expanded in stage I and anterior chest scar deformities were reconstructed in stage II.During stage I,the musculocutaneous perforators arising from the lateral branch of the thoracodorsal artery were determined by ultrasound preoperatively;the flap design included the anterior segment of the latissimus dorsi supplied by the musculocutaneous perforators from the lateral branch;and a tissue expander was placed following flap dissection and then infused with saline intermittently for 4–6 months.In stage II,the chest scars were excised,and breast tissues were repositioned;the continuity of the medial branch of the thoracodorsal nerve to the muscle was preserved when reconstruction was performed using the segmental latissimus dorsi flaps supplied by the main or lateral branch of the thoracodorsal artery.Results From October 2010 to October 2019,21 patients(on 24 sides)underwent reconstructive procedures for extensive scar contractures on the anterior chest.All flaps survived,and their donor sites were sutured directly.During a follow-up of 3 months to 8 years,the flaps became soft and exhibited color similar to that of the adjacent tissues.The limited neck and shoulder movements improved,and postoperatively,all female patients were satisfied with the shape of their breasts.Additionally,neither apparent weakening on the adduction,internal rotation,or extension strength of the shoulder joint on the affected side nor marked depression deformity in the back was observed.Conclusion Pre-expanded muscle-sparing latissimus dorsi flaps with blood supply from the main or lateral branch of the thoracodorsal artery proved to be a desirable option for the reconstruction of extensive scar contractures on the anterior chest.

Natural History of Seroma Following the Immediate Latissimus Dorsi Flap Method of Breast Reconstruction

Background： The latissimus dorsi （LD） flap procedure remains a popular and useful breast reconstrtlction tool in China and Western countries, and donor site seroma formation is the main complication. This study was conducted in Chinese patients to determine whether stable cases of seromas would resolve without treatment. Methods： A retrospective review of 45 consecutive cases of immediate breast reconstruction with LD flap from April 2012 to February 2017 was conducted. The scope of the seroma was demarcated with a marker pen, and cases that remained stable over time （i.e. the size of the seroma did not increase） were observed without treatment. The measured outcomes included the incidence ofseromas, the volume and duration of postoperative wound drainage, and other demographic characteristics. Results： Twenty-four patients （53.3%） developed a seroma at the donor site. Of these, 21 patients （87.5%） did not require treatment, and the seroma resolved over time. The mean duration of a sustained serol-na was 6.8 ± 1.4 weeks （range： 4-9 weeks）. Conclusions： This study observed the scope and progression of the seromas and found that seromas at the LD donor sites resolved over time without treatnlent.

IMMEDIATE BREAST RECONSTRUCTION WITH LATISSIMUS DORSI MUSCULOCUTANEOUS FLAP: A SUITABLE OPTION FOR CHINESE WOMEN AFTER MASTECTOMY

Objective： To discuss the suitable immediate breast reconstruction modalities for Chinese patients by comparing the pedicled transverse rectus abdominis myocytaneous flap （TRAM） reconstruction with latissimus dorsi myocytaneous flap （LTD） reconstruction plus implants or not after mastectomy due to breast cancer. Methods： From Jan. 2000 to Jul. 2005, 74 staged 0-II patients （mean age 39） were performed immediate breast reconstruction with autologous tissue either using LTD flaps or pedicled TRAM flaps with supplemental implants when necessary after mastectomy due to breast cancer and the charts were reviewed. Results： The age, marriage and menses status did not affect the selection of modalities and the need of implants. In 74 patients, 62 cases （83.8%） were performed LTD reconstruction with 13 implants and 12 cases received TRAM with 1 implant. The difference in need of implants or not between the two modalities had no statistical significance （P=0.442, Fisher＇ exact test）. Aesthetic results judged as good or fair were in 88% patients and the cosmetic effects between LTD and TRAM groups or implant and non-implant groups had no differences. All reconstructions were successful, with 4.1% cumulative locoregional recurrence and 100% overall survival by following up to 66 months （median 9 months）. The DFS and RFS between the two modalities had no significant differences by log rank test. Conclusion： Immediate autologous tissue reconstruction makes it possible to regain the natural and symmetric contour of breast without increased local recurrence. The LTD flap reconstruction is a suitable option for most Chinese women as well as the pedicled TRAM flap.

Cost-effectiveness of one-stage versus two-stage breast reconstruction in the United Kingdom

Aim:Permanent expanders allow for breast reconstruction as a single stage.These prostheses are more expensive than conventional tissue expanders,but this excess cost is markedly offset as only one operation is required.However,if the revision rate is sufficiently high,then this effect is negated.We aim to compare costs of one-stage vs.two-stage reconstruction at a single center,taking into account explantation and unexpected admissions following complications.Methods:A retrospective review was carried out on all patients who underwent one-stage and two-stage reconstruction over a 5-year period by a single surgeon.A cost analysis was performed taking into account,explantation and additional admissions.Results:One hundred and forty-three one-stage and 45 two-stage procedures were included.The explantation rate for one-stage procedures is 36%,at a mean of 12.9 months postimplantation,the majority of which were exchanged for silicone implants to improve cosmesis.Four(9%)of the two-stage procedures were explanted a mean of 18 months postreconstruction.Overall,one-stage reconstructions were significantly more expensive than the two-stage group(P=0.016).Conclusion:There are many benefits of one-stage breast reconstruction.However,it does not appear to be cost-effective when additional admissions for explantation surgery are taken into account.

Poland＇s syndrome in women： 24 cases study and literature review

Background Since its first description in 1841, numerous variations and treatments of Poland＇s syndrome （congenital deficiency of the pectoralis major muscle associated with brachysyndactyly） have been reported. None of the reports, however, involved female Chinese patients. Methods A retrospective study of 24 female patients was conducted to guide the selection of methods of surgical reconstruction. The patients were divided into three groups according to the degree of thoracic tissue development. Type I （mild）： Limited tissue loss which can be treated with simple filling with autologous fat and/or an artificial breast implant. Type II （moderate）： Moderate thoracic tissue hypoplasia where the breast parenchyma can still offer adequate implant coverage. Mammoplasty using a latissimus dorsi muscular flap with an implant was performed in this group. The flap was used to fill the infraclavicular hollow, and the implant was placed in the dual-plane pocket. Type Ⅲ （severe）： Severe thoracic tissue hypoplasia, without sufficient parenchyma to offer implant coverage. A latissimus dorsi muscular flap was used to form a total submuscular pocket in which an implant was placed. Results The numbers of Type Ⅰ, Ⅱ, and Ⅲ patients were 15, 3, and 6, respectively. All of the flaps and injected fat demonstrated good survival. Satisfactory cosmetic results were exhibited during the follow-up period of 1 to 9 years. Conclusions Although this group of patients showed varied conditions, they can be roughly divided into three types according to the degree of thoracic tissue development. In our experience, this classification is simple and useful in choosing the breast reconstruction options.