Clinical Study about Latissimus Dorsi Based Breast Reconstruction at a Tertiary Health Centre in Mangalore, India.
The most common cancer among urban women in India is breast cancer.  The gold standard treatment of operable breast cancer is breast conservation surgery (BCS) or modified radical mastectomy with or without reconstruction. Mastectomy causes loss of body image and negatively impacts quality of life. For the rehabilitation of these patients, restoration of body image is an important step. [2,3] Breast reconstruction (BR) is done in a small percentage of patients due to cost, surgical training, and technical skill.
Recently, various options of BR are available. The options are autologous or implant-based reconstruction or combined approach. Autologous BR choices are TRAM, LD flap, DIEP (Deep Inferior epigastric) flap or Superior epigastric flap. Implant based reconstruction choices are silicone-filled or saline-filled expanders.  Each of these reconstructive methods has its benefits and drawbacks. The ideal breast reconstruction following a mastectomy should be a one-stage procedure; restore deficient skin; replace the contour of the absent pectoralis major muscle; restore the lost breast volume; replace the absent nipple-areolar complex, and match symmetrically and pleasingly the contour of the remaining breast.
In 1897 Iginio and Tansini first developed a workhorse flap that is LD flap to reconstruct the post-mastectomy defects.  Since then, there have been variety of advancements in the harvesting and inserting technique of LD Flap. McCraw and Pepp and delay and colleagues' modifications gave extra bulk of flap which was suitable for medium breast reconstruction without using an implant. 
Silicone breast implants were introduced in the 1960s and offered the first opportunity to provide a reconstruction of the breast following a mastectomy. During those times, extirpative surgery resulted in significant breast deformities due to the more radical approaches used, and the breast implants allowed for really nothing more than the recreation of a breast mound. In the late 1970s, the LD flap was reintroduced and combined with implant placement to provide notably improved results in breast reconstruction. [7,8] Rather than simply placing an implant beneath thin skin flaps, the latissimus muscle served to replace or even augment the pectoralis muscle to provide coverage of the implant. [9,10] This present clinical study was done to describe about latissimus dorsi based breast reconstruction (BR) at a tertiary health centre.
This retrospective study was conducted at a tertiary health care centre from Jun 2018 to Dec 2020. Patients work up were history, clinical examination, and metastatic workup. Patients considered as suitable candidates were further assessed for the option of reconstruction by LD flap, LD flap with an implant. Eligible desiring patients' were divided into the small, medium and large breasts (Based on subjective assessment and bulk of reconstruction required) and were willing to undergo BR were taken up for surgery. All the patients were fully explained about the procedure.
Small breast patients were offered LD flap, medium and large breast patients were offered LD flap + Implant. First, patients underwent MRM and special attention was paid to maintain the integrity of the thoracodorsal pedicle during the axillary dissection. Care was also taken not to disturb the inframammary fold as well the fascial attachment along the lateral chest wall.
For LD flap harvesting, patients were turned to lateral decubitus position with 90 [degrees] abducted shoulder. The incisions on the donor site were made down to the subdermal layer. The plane of dissection was kept along the subcutaneous plane just above Scarpa's fascia, maintaining a thickness of skin flap of at least 1 cm. Fat was harvested from the scapular and the iliac region as much as possible, to lift the largest possible flap in terms of volume. Then the flap was brought to defect through the axilla.
Implant size was measured based on the size of the contralateral breast size assessed and kept ready before mastectomy. Then LD harvesting was done from the above-mentioned method and placed above the implant. The flap was covering the implant all around. Immediate and delayed seroma aspiration, wound resuturing were recorded and complications related to recipients' site and donor site were assessed.
Cosmesis was assessed by two surgeons and recorded as excellent, good and fair. Patients expressed cosmesis assessment as very satisfied, satisfied and fair (patient's satisfaction). Data was compiled in MS Excel and checked for completeness and correctness. Then it was analysed.
Statistical analysis was done by the descriptive and casual analysis method.
Total number of mastectomies were 158 and breast reconstruction was done in 45 patients, with a percentage of 29%. The most common age group was less than 40 years (48.9%) and the majority was the premenopausal group (Table 1). The right breast was commonly presented with carcinoma and increased incidence of T4, N1 stage with a predominance of infiltrative ductal carcinoma (Table 2). In our study, surgical procedures done were Pates mastectomy (62.2%), skin-sparing mastectomy (26.7%), nipple-sparing mastectomy (6.7%) and radical mastectomy (4.4%). Radical or modified radical mastectomy was done by transverse or oblique incision whereas skin-sparing or nipple sparing mastectomy was done by Tennis bat-shaped incision (Table 3). Majority (91.1%) of the patients underwent immediate breast reconstruction. Reconstructive methods used in our study were autologous LD flap (71.1%), LD flap with silicone implant (28.9%) based on size of the contra lateral breast (Table 4). Most common type of reconstruction in our study was LD flap (71.1%).
Most common procedure related complication observed at donor and recipient sites was seroma followed by wound dehiscence. 5 patients developed partial flap loss and no patient had total flap loss (Table 5). Cosmetic status assessed by patients was rated as very satisfied, satisfied, and fair and a majority of patients were satisfied (66.7%). Surgeon's score assessed as excellent (15.6%), good (62.2%), and fair (22.2%) (Table 6).
The main aim of breast reconstruction is to create a soft, symmetric, sensible, aesthetically acceptable breast with minimum donor morbidity. The optimal method of BR should be soft, reliable and with no health risk. The breast reconstruction rate in India is lower compared to the west (80-90%). It is mainly due to patient education, cost, and surgeons training. The reconstruction rate in our study was 29% only. Immediate reconstruction advantages are better aesthetic result, psychological effect, lower cost and disadvantages are high risk of complications. Delayed reconstruction advantages are lower complication rate and disadvantages are less optimal result, high percentage of anxiety, depression and impairment of their sexual attractiveness and higher cost (2 operations, hospital stays). 
LD flap is one of the most reliable and versatile methods of BR. The aesthetic results from bulky LD reconstructions are superior to reconstruction with implants due to their more natural appearance, consistency, and durability. Autologous tissue can also withstand RT better. Functional impairment after LD flap harvest is also minimal and affects only very specific activities like rowing, cross country skiing or mountain climbing, but appears to have little effect on most other activities. One of the limitations of autologous LD flap is the volume of the harvested tissue and it is usually not possible to match the size of a large breast. Some workers have reported on the harvesting of superficial fibres of serratus anterior muscle along with overlying fat to increase the volume of the flap.  Lip modelling by Coleman fat transfer can also be another method to augment the flap volume.  However, an ideal patient for autologous LD reconstruction should have a small or medium size breast.
LD flap with implant--Among the currently available options, implant-based reconstruction is most commonly performed. However, they are expensive and have their aesthetic limitations. Implant-based reconstructions are usually round and natural ptosis is difficult to reproduce. Therefore, in approximately 60% of cases, it is necessary to perform a contralateral mammoplasty to improve the symmetry.  Another major drawback of implant-based reconstruction is capsular contracture, which occurs in at least 15% of patients after a follow up of 2 years.  In severe cases of capsular contracture, it may even be necessary to perform a surgical capsulotomy. 
Complications associated with LD flap; Implants are manageable. Donor site morbidity is another potential problem of this flap. Seroma collection and skin necrosis of the dorsal skin flaps have been variably reported by several authors. [16,17,18] Seroma formation is common after the harvest of the autologous LD flap. Several strategies have been suggested to reduce the incidence of post-operative seroma such as quilting sutures and injection of topical fibrin glue. [19,20] In our series, four patients (21%) had breakdown of suture line and two (10.5%) had partial necrosis of skin flaps. Delay et al. reported 3% incidence in 100 patients,  while Chang et al. reported 16% necrosis rate in 75 patients.  To avoid this complication, it is important that primary wound closure of the donor site should be relatively tense free and the width of the skin paddle should not exceed 6 cm.
In our study, 5 patients developed partial flap loss at the edges and were easily managed with debridement. As per literature, chemotherapy and radiotherapy increase the flap related complications, but in our study, majority received chemotherapy and radiotherapy and complications were minimal and manageable. Post-mastectomy radiation, irrespective of the method of reconstruction, increases the incidence of postoperative complications; however, this study demonstrates that an autologous flap offers a more favourable outcome in terms of morbidity than expander. 
Valid tools to assess aesthetic outcomes after breast reconstructive surgery are scarce. Several studies report aesthetic outcomes, in the form of an assessment by the patient, by the surgeon, or by an independent professional. [22,26] Some authors use questionnaires, whereas others use photographs to assess aesthetic outcomes. However, measures for the assessment of aesthetic outcomes of breast reconstruction vary widely between studies and are often ill-defined. We used assessment by a patient and two surgeons. Majority of the patients were satisfied. Reconstruction options can be given to economically poor patients as modified LD flap.
Immediate reconstruction of mastectomy defects can be offered to all interested patients. Autologous or implant-based reconstruction can be done safely with minimum morbidity. Latissimus dorsi flap-based breast reconstruction is a cost-effective, safe method and reliable in a tertiary health centre.
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Financial or other competing interests: None.
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Gopinathan S. (1)
(1) Department of Surgical Oncology, Father Muller Medical College, Mangalore, Karnataka, India.
Corresponding Author: Dr. Gopinathan S., Department of Surgical Oncology, Father Muller Medical College, Mangalore, Karnataka, India. E-mail: firstname.lastname@example.org
Submission 25-03-2021, Peer Review 29-05-2021, Acceptance 05-06-2021, Published 23-08-2021.
Table 1. Patients Characteristics Age No Percentage (%) < 40 Yrs. 22 48.9% 40-50 Yrs. 18 40.0% > 50 Yrs. 05 11.1%
Table 2. Tumour Characteristics Menstrual Status No Percentage Pre-menopausal 40 88.9% Post-menopausal 05 11.1% Table 2(a). Side Side No % Right 28 62.2% Left 17 37.8% Table 2(b). Stage T Stage No % T1 03 6.7% T2 05 11.1% T3 15 33.3% T4 22 48.9% N Stage No % N1 31 68.9 N2 12 26.7 N3 02 04.4 Table 2 (c). Histology Types No % IDC 37 82.2 ILC 03 06.7 COLLOID 03 06.7
Table 3. Primary Surgery Characteristics (a). Type of Incision for Mastectomy Incisions No % Transverse 25 55.6 Oblique 09 20.0 Tennis Shaped Table 3 (b). Type of Mastectomy Types No % Patey's mastectomy 28 62.2 Skin sparing mastectomy 12 26.7 Nipple sparing mastectomy 03 06.7 Radical mastectomy 02 04.4
Table 4. Reconstruction Characteristics, (a). Timing of Breast Reconstruction Timing No % Immediate 41 91.1 Delayed 04 08.9 Table 4 (b). Type of Reconstruction Types No % Small Medium Large Breast Breast Breast LD Flap 32 71.1 20 12 00 LD FLAP+ Implant 13 28.9 00 10 02
Table 5. Procedure Related Complications (a). Early Complications Complications LD Flap LD flap+ Implant Hematoma 01 01 Wound Infection 02 00 Fat necrosis 01 00 Reopen 01 01 Total flap loss 00 00 Partial flap loss 03 01 Seroma 08 04 Wound dehiscence 04 00 Table 5(b). Late Complications Complications LD Flap LD flap+ Implant Hypertrophic scar 01 02 Malposition 00 00 Capsular contracture 00 00 Table 5 (c). Secondary Procedure Procedures LD Flap LD flap+ Implant Scar revision 02 01 Redo flap 00 00
Table 6. Chemotherapy Status, (a). NACT Status Chemotherapy No % Received 25 55.6 Not received 20 44.4 Table 6. Chemotherapy Status (b). Adjuvant Chemo Chemotherapy No % Received 38 84.4 Not received 07 15.6
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|Title Annotation:||Original Research Article|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Article Type:||Clinical report|
|Date:||Aug 23, 2021|
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