Introduction

The psychological impact of breast loss on the mental health of women undergoing treatment for breast cancer is immea-surable. Breast reconstruction is an integral component of comprehensive breast cancer treatment, providing physical and psychological benefits.

The advent of reconstructive techniques using alloplastic materials has enabled broader access to reconstruction for many women. Despite the technological advances in the development of tissue expanders and implants, reconstruction with these materials may result in complications, including capsular contracture, rupture, infection, and loss of esthetic outcome, which may compromise patients’ quality of life.

Autologous reconstruction provides several advantages, including greater naturalness, consistency, and long-term maintenance of results. Multiple studies comparing autolo-gous and alloplastic reconstructions demonstrate the advan-tages of flap-based techniques with respect to quality of life and durability of outcomes.

The latissimus dorsi musculocutaneous flap was first described by Tansini,¹ and it became widely-adopted in the 1970s in association with implants for volume augmen-tation. Subsequent modifications in flap design, dissection technique, and incorporation of fat grafting enabled breast-volume reconstruction using the flap in isolation, without the need for implants.

In 2016 at our institution, Arruda proposed a modification to the flap design, incorporating the cutaneous portion located anteriorly to the anterior border of the muscle. This new design expanded the indications for total breast reconstruction. The modified flap was named TLLD, reflecting the combination of the thoracolateral flap and the latissimus dorsi flap.

Objective

The current study aims to describe the anatomical character-istics of the TLLD flap, the technical aspects of the surgical dissection, the complications, and the main indications.

Methods

The present descriptive study was based on a review of data obtained from a prospectively-maintained database and the medical records of patients who underwent breast recon-struction using the TLLD flap at Instituto do Câncer do Estado de São Paulo (ICESP) from 2017 to 2023.

Flap design

With the patient in the standing position, anatomical land-marks are delineated, including the inferior border of the scapula, the posterior axillary line, and the posterosuperior iliac spine. The flap axis corresponds to the projection of the inframammary fold. The cutaneous component extends from the dorsal midline to the midmammary line, following the specific indication in each case. A bidigital pinch test deter-mines the appropriate width of the cutaneous portion of the flap (►Fig. 1).

Fig. 1 - Aspect after removal of an infected tissue expander following radiation therapy.

Fig. 1 - Aspect after removal of an infected tissue expander following radiation therapy.

Dissection technique

With the patient in lateral decubitus, infiltration is per-formed using an anesthetic solution containing epinephrine at a concentration of 1:100 thousand throughout the planned incision area. Flap elevation is initiated superiorly in the plane superficial to the muscle, with creation of a subcutaneous tunnel toward the breast when indicated. The segment located anteriorly to the border of the latissimus dorsi muscle is dissected in the subfascial plane. Dissection then proceeds distally until an adequate amount of muscular tissue is obtained, according to the requirements of each case. Following division of the distal portion, dissection continues along the deep surface of the muscle toward the vascular pedicle. After ligation of the branch to the serratus anterior muscle, the main pedicle is isolated, and the thor-acodorsal nerve is divided. The humeral insertion is subse-quently released, and the flap is rotated into the breast region (►Figs. 2-3). The inset is performed using absorbable sutures. The donor site is closed with the aid of adhesion sutures using VICRYL 2-0 (Ethicon Inc.). A #15 Blake drain (Ethicon Inc.) is placed in the reconstructed breast and axillary tunnel. The tendinous portion of the muscle is secured to the lateral chest wall to protect the vascular pedicle (►Fig. 4).

Fig. 2 - Preoperative marking. Abbreviation: TLLD, thoracolateral latissimus dorsi muscle flap.

Fig. 2 - Preoperative marking. Abbreviation: TLLD, thoracolateral latissimus dorsi muscle flap.

Fig. 3 - De-epithelialized flap.

Fig. 3 - De-epithelialized flap.

Fig. 4 - Late postoperative status.

Fig. 4 - Late postoperative status.

Results

Between 2017 and 2023, 95 patients underwent reconstruc-tion using this technique. They had a mean age of 43.5 (range: 34-75) years, and a mean body mass index (BMI) of 32.8 (range: 22.5-34.2) kg/m². In total, 12 patients were smokers, and 83 were non-smokers. Overall, 75% of the patients presented with at least 1 comorbidity, including arterial hypertension, diabetes, hypothyroidism, and cardiac conditions.

Most reconstructions were performed in the delayed setting (70%), whereas 30%, at the time of mastectomy. The main indications for the technique were recurrent capsular contracture, expander/implant infection, rupture, desire to change the reconstructive method, failure of another autol-ogous flap, and comorbidities precluding the use of an abdominal flap, such as morbid obesity.

A total of 15 patients (16%) underwent fat grafting of the flap, with injected volumes ranging from 90 to 200 mL. The de-epithelialized area was total in 54 cases (56%) and partial in 41 (44%). Flap dimensions ranged from 22 to 49 cm in length and from 8 to 18 cm in width.

Eleven patients developed complications, including do-nor-site seroma (2 cases), epidermolysis (3 cases), wound dehiscence (2 cases), wound infection (1 case), and vascular compromise (3 cases), including one case of venous conges-tion and one case of partial necrosis (4 × 2 cm).

Discussion

Despite its description in the early twentieth century,^1,3 the latissimus dorsi flap was popularized for breast reconstruc-tion by Bostwick et al.² in 1978. Numerous modifications have since been described, expanding its indications.

Its consistent anatomy and robust vascularization enable its application in various breast and thoracic reconstructive scenarios. It may be used as a muscular, musculocutaneous, or osteomyocutaneous flap.

Following its initial description in breast reconstruction, several authors introduced modifications aimed at increas-ing flap dimensions and volume. In 1987, Hokin and Silfver-skiold⁴ proposed the inclusion of the lumbar fascia. In 1996, Germann and Steinau⁵ reported inclusion of the scapular fascia and fat. In 1998, Papp and McCraw⁶ described enlarge-ment of the cutaneous component using an anchor-shaped incision. In 1995, Angrigiani et al.⁷ presented the extended thoracodorsal artery perforator flap, incorporating the scap-ular and lumbar fasciae. In 2012, Tame and Ledo⁸ described the dorsum-epigastric flap, expanding the limits of the cutaneous portion while reducing the muscular component used. In 2019, Koonce et al.⁹ incorporated indocyanine green angiography and defined vascular territories within the cutaneous portion. In 1996, Barnett and Gianoutsos¹⁰ reported the use of fat grafting for volumetric augmentation, thereby eliminating the need for implants.

The design modification described in the present study encompasses the lateral thoracic region, incorporating the cutaneous portion of the lateral thoracic flap (Holmström and Lossin, 1986).¹¹ The extent of the muscular component is variable and depends on individual patient requirements. The tendinous portion located near the posterosuperior iliac spine should not be included because it has relatively limited vascularization, represents a suboptimal recipient bed for fat grafting, and increases the risk of lumbar hernia.¹² In addi-tion to volumetric enhancement of the flap, mobilization of tissue from the lateral region may improve regional body contour in obese patients or those with excess lateral skin and adiposity.

The dimensions of the cutaneous portion, the volume of the adipose pad, and the possibility of fat grafting enabled fully-autologous reconstruction, achieving natural results with breast symmetry. The indications for the flap include immediate and delayed reconstructions requiring volume and/or cutaneous coverage. Among the procedures per-formed, 36 patients underwent removal of an expander or implant with replacement by the flap due to infection, rupture, exposure, or capsular contracture. The contraindi-cations are consistent with those of the traditional latissimus dorsi flap, and they include prior thoracic surgeries with incisions within the flap territory and previous ligation of the vascular pedicle.

The advantages of the TLLD flap include rapid dissection, technical simplicity, avoidance of a microsurgical procedure, adequate flap volume, and reduced donor-site morbidity compared with pedicled abdominal flaps. The main disad-vantage is the presence of a dorsal scar; however, this scar is linear and positioned at bra level, according to the flap design. Other disadvantages, such as decreased shoulder strength and flap atrophy, are well established in the literature.

A subgroup warranting particular attention consists of patients with morbid obesity, who, due to specific characteristics such as increased breast volume, ptosis, and elevated intra-abdominal pressure, are poor candi-dates for reconstruction using either alloplastic materials or abdominal flaps. Flap use enables total reconstruction of large and ptotic breasts without the risks of abdominal hernia or complications associated with alloplastic materials.

In the present study, the overall complication rate was of 32%. The complications were either minor, including epi-dermolysis, wound dehiscence (a single case required resu-turing under local anesthesia), wound infection, and donor-site seroma (8%), or major, such as vascular compromise (5%). No flap loss occurred. These findings are consistent with those of previously-published studies that report complica-tion rates of up to 34.9%.

According to Pirro et al. (2017),¹³ patients undergoing breast reconstruction with autologous tissue report greater satisfaction with the breast outcomes compared with alloplastic reconstruction after the application of the BREAST-Q. This satisfaction is attributed to more durable and predictable results, improved outcomes in patients with complex cases and/or undergoing radiation therapy, and absence of anaplastic large cell lymphoma risk.

Conclusion

The TLLD flap is an option for immediate or delayed autolo-gous breast reconstruction. It represents an additional sal-vage alternative in patients with prior reconstructive failure, infection related to alloplastic materials, or recurrent capsu-lar contracture.