Complication of Using Lattissimus Dorsi Myocutaneous Flap on Breast Reconstruction Surgery.
COMPLICATION OF USING LATTISSIMUS DORSI MYOCUTANEOUS FLAP
ON BREAST RECONSTRUCTION SURGERY: A CASE REPORT
Dewi Prima Christian, Putu Anda Tusta Adiputra, W. Steven Chr.
Subdivision of Surgical Oncology, Departement of Surgery
Faculty of Medicine, Udayana University – RSUP Sanglah
Denpasar
FOREWARD
Extensive clinical experience with the LDMF has documented the safety of the procedure of
breast reconstruction surgery. The flap has a good and vigorous blood supply and can be used
with minimal risk of flap necrosis, even in the smokers, diabetics, and patient with medical
illness. Significant flap necrosis is very unusual and is nearly always associated either recognized
of unrecognized injury to the vascular pedicle, as when the thoracodorsalis artery has been
ligated during the original mastectomy. Partial flap necrosis has been noted in up to 7 % of cases.
CASE REPORT
A 53 year old woman, suffered with a huge tumor on her left breast. Clinical investigations and
on biopsy examination was benign phyloides of the breast. Mastectomy was done and immediate
LDMF underwent to reconstruct the leaving defect of surgery. On the second day after surgery
LDMF was noted partial necrosis and tend to totally necrosis.
CONCLUSION
LDMF is common procedure to reconstruct the leaving defect after mastectomy. The cause of
necrosis may due to technical error and impact to vascular compromise. The vascular injury and
thrombosis during and after surgery may be responsible for the event of flap necrosis.
Key words: Mastectomy, LDMF, Necrosis, Vascular injury
1
COMPLICATION OF USING LATTISSIMUS DORSI MYOCUTANEOUS FLAP
ON BREAST RECONSTRUCTION SURGERY: A CASE REPORT
Dewi Prima Christian, Putu Anda Tusta Adiputra, W. Steven Chr.
Subdivision of Surgical Oncology, Departement of Surgery
Faculty of Medicine, Udayana University – RSUP Sanglah
Denpasar
(Danies C., 2006) The flap has a good and
vigorous blood supply and can be used with
minimal risk of flap necrosis, even in the
smokers, diabetics, and patient with medical
illness. Significant flap necrosis is very
unusual and is nearly always associated
either recognized of unrecognized injury to
the vascular pedicle, as when the
thoracodorsalis artery has been ligated
during the original mastectomy (Danies C.,
2006, Mendelson BC., 1983, De Mey A., et
al. 1991). Partial flap necrosis has been
noted in up to 7 % of cases (Danies C.,
2006, De Mey A., et al. 1991, Hokin JAB,
Silfverskiold KL, 1987, Barnett GR, et al,
1992).
FOREWARD
Reconstructive surgery in the cancer
patient endeavors to restore form and
function following ablative surgery (Jules
A., et al, 2006) Breast reconstruction is an
important component of breast cancer
management and should be a safe procedure
of appropriate complexity for the patient.
The use of the latissimus dorsi (LD)
myocutaneous flap as a primary method of
reconstruction has declined since the 1970s
and originally described by Tansini in 1906
for use as an axial musculocutaneous flap to
cover mastectomy defect ( Danies C., 2006)
Reconstructive surgery of the breast
cancer can be performed in the immediate or
delayed setting (Jules A., et al , 2006) The
timing of reconstructive surgery is
influenced by the tumor pathology, extent of
resection, adjuvant therapy, surgical
expertise, and patient preference. Successful
reconstructive surgery achieves restoration
of function and form with minimal donor
site deformity and consequent enhancement
of quality of life (Jules A., 2006)
Patient and Method
In our series patient of breast cancer
who has been reconstructed by Latissimus
Dorsi myocutaneous flap (LDMF) were
noted without any complication. But this
one patient of huge phyloides tumor of left
breast who underwent reconstructive surgery
with LDMF was noted serious complication
of the flap. A 53 year old woman, suffered
with a huge tumor on her left breast. Clinical
investigations and on biopsy examination
was benign phyloides of the breast.
Mastectomy was done and immediate
Extensive clinical experience with
the LDMF has documented the safety of the
procedure of breast reconstruction surgery
2
LDMF underwent to reconstruct the leaving
defect of surgery.
necrosis. Finally, the entire skin, fat excised
and just leave the muscle alone, and covered
with skin graft. The island of the flap was
harvested too extend, almost at the end of
the muscle.
Figure 2.
operation.
Mastectomy
defect
during
Figure 1a and 1b . Clinical figure of patient
with benign phyloide on the left breast.
Figure 3. Latissimus Dorsi myocutaneous
flap (LDMF) after surgery.
On the first day after surgery LDMF
was noted vascular compromised and there
is sign of the tissue necrosis at the end of the
flap. The skin color was changed become
blackish. Re explore of the flap was done at
the second day to evaluate the extension of
the vascular compromised. There is no
significant obstacle of the vascular bundle
that may cause diminished of the blood
supply to the flap. Debrided of the skin and
fat tissue was done and performing the
needle puncture decompressing of the skin
island of the flap to decrease the tension of
the tissue. The next day the whole skin of
the flap become darker and tend to be total
Figure 4. Donor site from posterolateral left
chest .
3
Although the LDMF procedure is
safe on the breast reconstructive surgery but
the surgeon still has awareness of the arising
of complication at any time. Knowing the
anatomy of donor site like LD component is
very important to finish reconstruction
successfully. Accurate preoperative marking
are vital to properly position the skin island
and should always be made with the patient
upright (Jules A., et al, 2006) Extensive
clinical experience with the LDMF has
documented the safety of the procedure of
breast reconstruction surgery. The flap has a
good and vigorous blood supply and can be
used with minimal risk of flap necrosis, even
in the smokers, diabetics, and patient with
medical illness.
Figure 5. Post operation day 1, necrosis at
the end of the flap and the skin color was
change become blackish.
Breast
reconstructive
surgery
complication may occur due to many
conditions, included using LDMF, where is
known has very good vascular and blood
supply. The procedure of LDMF may be
noted, not too extend the harvest of the flap
because will diminished of blood supply of
the flap tissue. Careful preoperative
planning including the design of a flap may
be more important than the actual harvest of
the flap (Geoffrey G., 2009) Significant flap
necrosis is unusual and is nearly always
associated technical error and more common
when the procedure is too extend. Total
necrosis of the skin island of LDMF will
occur when the harvest of the skin island at
the end of the LD muscle. The sign of the
vascular compromised will be noted on the
first day after surgery. Most common
complication of LDM flap is the forming of
seroma, beneath at the donor site (Gabriel
N., et al, 2010, Sameer A., et al, 2010,
Bostwick J, et al.1979).
Figure 6. Necrotic flap getting worse in a
couple of day and more dark than before.
Discussion
The Latissimus Dorsi muscle is the
largest and most superficial of the muscles
of the posterior chest wall. It is a broad, flat
muscle that extends from a wide area of the
origin over the posterolateral thorax. The
blood supply to the Latissimus Dorsi muscle
is constant arises from thoracodorsalis
vessel as the branch of axillary vessel.
4
Our patient revealed the vascular
compromised on the first day after
reconstructive surgery, and become worst on
the following day. The plan of reexploration of the flap immediately after it
recognized the present of vascular
compromised. Trying to decompression of
the tension tissue with needle, but it did not
improve. The next day the necrosis of the
skin island of LDMF was excised and skin
graft was done.
Figure 7c. Donor site from left femoral .
Conclusion
LDMF is common procedure to
reconstruct the leaving defect after
mastectomy. The cause of necrosis may due
to technical error and impact to vascular
compromise. The vascular injury and
thrombosis during and after surgery may be
responsible for the event of flap necrosis.
The LDMF was taken too extent, and may
cause diminished of blood supply of the flap
tissue. Planning prior reconstructive surgery
is very important to all surgeons to make all
things successfully.
Discipline and
experience of the surgeon on reconstructive
surgery may become more important than
just doing the harvest.
Figure 7a.
During second operation,
necrotomy of necrotic flap and debridement
of wound defect.
References
Barnett GR, Gianoutsos MP, 1996. The LD
added fat plaf for natural tissue breast
Reconstruction: Report of 15 cases. Plast
Reconst Surg; 97:63
Figure 7b. Skin graft on the defect.
Bostwick J, Nahai F, Wallace JG, et al.1979.
Sixty Lattissimus Dorsi Flaps. Plast Reconst
Surg; 63:31
Danies C. Hammond. 2006. Latissimus
Dorsi Musculocutaneous flap Breast
5
Reconstruction. In : Surgery of the Breast.
2nd. Scott L Spear. Lippincott Williams and
Wilkins:1: 601
Jules A. Feledy Jr., Mathew M. Hanasono,
Geoffrey L. Robb. 2006. Reconstructive
Surgery in the Cancer Patient. MD
Anderson Surgical Oncology Handbook. 4th
Ed. Lippincoot Williams and Wilkins.: 24
De Mey A., Lejour M., Declety A., et al.
1991. Late Result and current indication on
LD breast Reconstruction. Br J Plast Surg;
44:1
Mendelson BC., 1983. Lattissimus Dorsi
Breast Reconstruction and Result. Br J Surg;
70: 45
Gabriel N. Hortobagyi, Sonja Eva
Singletary, and Eric A Storm, 2010. Locally
Advanced Breast Cancer. In : Disease of the
Breast. 4th Ed. Ed by Jay R. Harris, Merc E.
Lippman, Monica Morrow, C.Kent Osborne.
Lippincott
Williams
and
Wilkins.
Philadephia. 752
Moore TS, Farrell LD, 1992. Lattissimus
Dorsi Myocutaneous Flap for Breast
Reconstruction: Longterm Result. Plast
Reconstr Surg.; 89: 666
Sameer A. Patel and Neal Stoddart Topham,
2010. Breast Reconstruction. In : Disease of
the Breast. 4th Ed. Ed by Jay R. Harris, Merc
E. Lippman, Monica Morrow, C.Kent
Osborne. Lippincott Williams and Wilkins.
Philadephia: 531-532
Geoffrey G. Hallock. 2009. In : Flap and
Reconstructive
Surgery.
Wei-Mardini.
Elsevier Inc: 3:16
Hokin JAB, Silfverskiold KL, 1987. Breast
Reconstruction without an Implant: Result
and complication using an extended LD
flap. Plast Reconst Surg; 79-58
6
ON BREAST RECONSTRUCTION SURGERY: A CASE REPORT
Dewi Prima Christian, Putu Anda Tusta Adiputra, W. Steven Chr.
Subdivision of Surgical Oncology, Departement of Surgery
Faculty of Medicine, Udayana University – RSUP Sanglah
Denpasar
FOREWARD
Extensive clinical experience with the LDMF has documented the safety of the procedure of
breast reconstruction surgery. The flap has a good and vigorous blood supply and can be used
with minimal risk of flap necrosis, even in the smokers, diabetics, and patient with medical
illness. Significant flap necrosis is very unusual and is nearly always associated either recognized
of unrecognized injury to the vascular pedicle, as when the thoracodorsalis artery has been
ligated during the original mastectomy. Partial flap necrosis has been noted in up to 7 % of cases.
CASE REPORT
A 53 year old woman, suffered with a huge tumor on her left breast. Clinical investigations and
on biopsy examination was benign phyloides of the breast. Mastectomy was done and immediate
LDMF underwent to reconstruct the leaving defect of surgery. On the second day after surgery
LDMF was noted partial necrosis and tend to totally necrosis.
CONCLUSION
LDMF is common procedure to reconstruct the leaving defect after mastectomy. The cause of
necrosis may due to technical error and impact to vascular compromise. The vascular injury and
thrombosis during and after surgery may be responsible for the event of flap necrosis.
Key words: Mastectomy, LDMF, Necrosis, Vascular injury
1
COMPLICATION OF USING LATTISSIMUS DORSI MYOCUTANEOUS FLAP
ON BREAST RECONSTRUCTION SURGERY: A CASE REPORT
Dewi Prima Christian, Putu Anda Tusta Adiputra, W. Steven Chr.
Subdivision of Surgical Oncology, Departement of Surgery
Faculty of Medicine, Udayana University – RSUP Sanglah
Denpasar
(Danies C., 2006) The flap has a good and
vigorous blood supply and can be used with
minimal risk of flap necrosis, even in the
smokers, diabetics, and patient with medical
illness. Significant flap necrosis is very
unusual and is nearly always associated
either recognized of unrecognized injury to
the vascular pedicle, as when the
thoracodorsalis artery has been ligated
during the original mastectomy (Danies C.,
2006, Mendelson BC., 1983, De Mey A., et
al. 1991). Partial flap necrosis has been
noted in up to 7 % of cases (Danies C.,
2006, De Mey A., et al. 1991, Hokin JAB,
Silfverskiold KL, 1987, Barnett GR, et al,
1992).
FOREWARD
Reconstructive surgery in the cancer
patient endeavors to restore form and
function following ablative surgery (Jules
A., et al, 2006) Breast reconstruction is an
important component of breast cancer
management and should be a safe procedure
of appropriate complexity for the patient.
The use of the latissimus dorsi (LD)
myocutaneous flap as a primary method of
reconstruction has declined since the 1970s
and originally described by Tansini in 1906
for use as an axial musculocutaneous flap to
cover mastectomy defect ( Danies C., 2006)
Reconstructive surgery of the breast
cancer can be performed in the immediate or
delayed setting (Jules A., et al , 2006) The
timing of reconstructive surgery is
influenced by the tumor pathology, extent of
resection, adjuvant therapy, surgical
expertise, and patient preference. Successful
reconstructive surgery achieves restoration
of function and form with minimal donor
site deformity and consequent enhancement
of quality of life (Jules A., 2006)
Patient and Method
In our series patient of breast cancer
who has been reconstructed by Latissimus
Dorsi myocutaneous flap (LDMF) were
noted without any complication. But this
one patient of huge phyloides tumor of left
breast who underwent reconstructive surgery
with LDMF was noted serious complication
of the flap. A 53 year old woman, suffered
with a huge tumor on her left breast. Clinical
investigations and on biopsy examination
was benign phyloides of the breast.
Mastectomy was done and immediate
Extensive clinical experience with
the LDMF has documented the safety of the
procedure of breast reconstruction surgery
2
LDMF underwent to reconstruct the leaving
defect of surgery.
necrosis. Finally, the entire skin, fat excised
and just leave the muscle alone, and covered
with skin graft. The island of the flap was
harvested too extend, almost at the end of
the muscle.
Figure 2.
operation.
Mastectomy
defect
during
Figure 1a and 1b . Clinical figure of patient
with benign phyloide on the left breast.
Figure 3. Latissimus Dorsi myocutaneous
flap (LDMF) after surgery.
On the first day after surgery LDMF
was noted vascular compromised and there
is sign of the tissue necrosis at the end of the
flap. The skin color was changed become
blackish. Re explore of the flap was done at
the second day to evaluate the extension of
the vascular compromised. There is no
significant obstacle of the vascular bundle
that may cause diminished of the blood
supply to the flap. Debrided of the skin and
fat tissue was done and performing the
needle puncture decompressing of the skin
island of the flap to decrease the tension of
the tissue. The next day the whole skin of
the flap become darker and tend to be total
Figure 4. Donor site from posterolateral left
chest .
3
Although the LDMF procedure is
safe on the breast reconstructive surgery but
the surgeon still has awareness of the arising
of complication at any time. Knowing the
anatomy of donor site like LD component is
very important to finish reconstruction
successfully. Accurate preoperative marking
are vital to properly position the skin island
and should always be made with the patient
upright (Jules A., et al, 2006) Extensive
clinical experience with the LDMF has
documented the safety of the procedure of
breast reconstruction surgery. The flap has a
good and vigorous blood supply and can be
used with minimal risk of flap necrosis, even
in the smokers, diabetics, and patient with
medical illness.
Figure 5. Post operation day 1, necrosis at
the end of the flap and the skin color was
change become blackish.
Breast
reconstructive
surgery
complication may occur due to many
conditions, included using LDMF, where is
known has very good vascular and blood
supply. The procedure of LDMF may be
noted, not too extend the harvest of the flap
because will diminished of blood supply of
the flap tissue. Careful preoperative
planning including the design of a flap may
be more important than the actual harvest of
the flap (Geoffrey G., 2009) Significant flap
necrosis is unusual and is nearly always
associated technical error and more common
when the procedure is too extend. Total
necrosis of the skin island of LDMF will
occur when the harvest of the skin island at
the end of the LD muscle. The sign of the
vascular compromised will be noted on the
first day after surgery. Most common
complication of LDM flap is the forming of
seroma, beneath at the donor site (Gabriel
N., et al, 2010, Sameer A., et al, 2010,
Bostwick J, et al.1979).
Figure 6. Necrotic flap getting worse in a
couple of day and more dark than before.
Discussion
The Latissimus Dorsi muscle is the
largest and most superficial of the muscles
of the posterior chest wall. It is a broad, flat
muscle that extends from a wide area of the
origin over the posterolateral thorax. The
blood supply to the Latissimus Dorsi muscle
is constant arises from thoracodorsalis
vessel as the branch of axillary vessel.
4
Our patient revealed the vascular
compromised on the first day after
reconstructive surgery, and become worst on
the following day. The plan of reexploration of the flap immediately after it
recognized the present of vascular
compromised. Trying to decompression of
the tension tissue with needle, but it did not
improve. The next day the necrosis of the
skin island of LDMF was excised and skin
graft was done.
Figure 7c. Donor site from left femoral .
Conclusion
LDMF is common procedure to
reconstruct the leaving defect after
mastectomy. The cause of necrosis may due
to technical error and impact to vascular
compromise. The vascular injury and
thrombosis during and after surgery may be
responsible for the event of flap necrosis.
The LDMF was taken too extent, and may
cause diminished of blood supply of the flap
tissue. Planning prior reconstructive surgery
is very important to all surgeons to make all
things successfully.
Discipline and
experience of the surgeon on reconstructive
surgery may become more important than
just doing the harvest.
Figure 7a.
During second operation,
necrotomy of necrotic flap and debridement
of wound defect.
References
Barnett GR, Gianoutsos MP, 1996. The LD
added fat plaf for natural tissue breast
Reconstruction: Report of 15 cases. Plast
Reconst Surg; 97:63
Figure 7b. Skin graft on the defect.
Bostwick J, Nahai F, Wallace JG, et al.1979.
Sixty Lattissimus Dorsi Flaps. Plast Reconst
Surg; 63:31
Danies C. Hammond. 2006. Latissimus
Dorsi Musculocutaneous flap Breast
5
Reconstruction. In : Surgery of the Breast.
2nd. Scott L Spear. Lippincott Williams and
Wilkins:1: 601
Jules A. Feledy Jr., Mathew M. Hanasono,
Geoffrey L. Robb. 2006. Reconstructive
Surgery in the Cancer Patient. MD
Anderson Surgical Oncology Handbook. 4th
Ed. Lippincoot Williams and Wilkins.: 24
De Mey A., Lejour M., Declety A., et al.
1991. Late Result and current indication on
LD breast Reconstruction. Br J Plast Surg;
44:1
Mendelson BC., 1983. Lattissimus Dorsi
Breast Reconstruction and Result. Br J Surg;
70: 45
Gabriel N. Hortobagyi, Sonja Eva
Singletary, and Eric A Storm, 2010. Locally
Advanced Breast Cancer. In : Disease of the
Breast. 4th Ed. Ed by Jay R. Harris, Merc E.
Lippman, Monica Morrow, C.Kent Osborne.
Lippincott
Williams
and
Wilkins.
Philadephia. 752
Moore TS, Farrell LD, 1992. Lattissimus
Dorsi Myocutaneous Flap for Breast
Reconstruction: Longterm Result. Plast
Reconstr Surg.; 89: 666
Sameer A. Patel and Neal Stoddart Topham,
2010. Breast Reconstruction. In : Disease of
the Breast. 4th Ed. Ed by Jay R. Harris, Merc
E. Lippman, Monica Morrow, C.Kent
Osborne. Lippincott Williams and Wilkins.
Philadephia: 531-532
Geoffrey G. Hallock. 2009. In : Flap and
Reconstructive
Surgery.
Wei-Mardini.
Elsevier Inc: 3:16
Hokin JAB, Silfverskiold KL, 1987. Breast
Reconstruction without an Implant: Result
and complication using an extended LD
flap. Plast Reconst Surg; 79-58
6