Plastic Surgery Research Council
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PSRC 60th Annual Meeting
Program and Abstracts

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Muscle-Sparing Latissimus Dorsi Myocutaneous Pedicled Flaps with Extended Transversely Oriented Skin Paddles are a Reliable Alternative to Thoracodorsal Artery Perforator Flaps
Yin Kan Hwee, MD, Pedro Vieira, ME, Christopher Brooks, MD, Yoav Barnavon, MD.
Cleveland Clinic Florida, Weston, FL, USA.

Purpose
Thoracodorsal artery perforator (TAP) flaps were introduced two decades ago but have not gained widespread acceptance as they often require tedious dissection of small and inconsistent caliber perforators. The vascular anatomy of the pedicled descending branch muscle-sparing Latissimus Dorsi (MSLD) myocutaneous flap has been described. We report our experience in using extended transversely oriented (ETO) skin paddles in MSLD pedicled flaps for breast reconstruction.
Method
A retrospective review was conducted on patients who underwent MSLD myocutaneous pedicled flap breast reconstruction by the authors from January 2009 to July 2014, including patients who underwent intraoperative indocyanine green (ICG) angiography. Patient demographics and surgical outcomes were recorded. All revisions and autologous fat transfer procedures were noted. Pre-operative and post-operative photographs were used for analysis. Patients with at least 3 months of follow-up were included in the study.
Results
Fifty-three patients underwent a total of 81 MSLD pedicled flaps for breast reconstruction. The average age and BMI were 58 and 28, respectively. Twelve MSLD flaps were performed for immediate reconstruction, 34 flaps for delayed reconstruction, and 35 flaps for salvage of failed initial breast reconstruction.
The dimensions of the ETO skin paddles ranged from 7-9 cm vertically by 25-35 cm horizontally. Approximately 75 percent of the Latissimus Dorsi muscle width was routinely spared (Figure 1). Twenty patients had ICG imaging revealing adequate perfusion in all flaps. There were three distinct zones of perfusion noted within the ETO skin paddles (Figure 2). The best perfused Zone 1 was immediately over the muscle containing the perforators, the second best Zone 2 was lateral to the muscle, and the least well perfused Zone 3 was medial to the muscle but still had overall excellent viability.
There were no flap losses or major complications. Minor complications included wound infection with minimal wound edge necrosis (6/81; 7.4%), fat necrosis (3/81; 3.7%) and seroma (4/81; 4.9%). Additional procedures included implant placement (17/81; 21%), fat grafting (35/81; 43.2%) and nipple-areolar complex reconstruction (44/81; 54.3%). All patients were pleased with their reconstruction and had minimal donor site complaints.
Conclusions
MSLD myocutaneous pedicled flaps with ETO skin paddles are reliable alternatives to TAP flaps for breast reconstruction and have minimal donor site morbidity. Although Zone 3 was the least well perfused region of the ETO skin paddle seen on ICG imaging, this area medial to the muscle remained completely viable in all flaps.


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