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• Fig. 9.7 Breast repair after a partial mastectomy in a 41-year-old woman with a 36DD bra size who presented with a T2N0 (stage IIA) invasive ductal
carcinoma in the upper-inner quadrant of the right breast (Zone 1). (A) Preoperative views. Inverted T skin pattern markings and the inferomedial
dermoglandular pedicle in preparation for repair with the breast reduction technique. (B) Intraoperative views showing the tumor resection, which
was performed through an access incision along the superior limb of the inverted T pattern. (C, D) Intraoperative views showing the de-epithelialized
inferomedial dermoglandular pedicle and after creation of both the dermoglandular pedicle and the inverted T skin flap, which in certain zones (Zones
2 and 7) can serve as separate reconstructive components. (E) During radiation therapy, showing the boost to the tumor bed and whole-breast treatment. (F) Postoperative view 10 months after repair showing how the retained medial wedge of breast tissue filled the defect in Zone 1. The surgeon
can plan for contralateral breast reduction using the same inferomedial dermoglandular design. (G) Postoperative view 1 month after contralateral
breast reduction for symmetry.
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A
C
B
D
• Fig. 9.8 Unexpected deformity after partial mastectomy. (A, B) A 34-year-old woman who presented 2
weeks after a right partial mastectomy with significant concerns regarding cosmetic outcome. (C) Intraoperative view of exploration of blood supply to dermoglandular pedicle before performing Kronowitz
Inverted-T Mammoplasty. (D) Intraoperative view showing the blood supply was adequate to perform a
delayed repair before radiation therapy using an inferomedial dermoglandular pedicle. (E, F) Postoperative
views.
CHAPTER 9 Mastopexy Techniques
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Although oncoplasty varies in the United States, some
recommendations include that, whenever feasible, oncoplasty before whole breast radiotherapy is preferable because
it has the lowest complication rate and allows for the simplicity of using the remaining breast tissue, which maintains the color and texture match of the repaired breast.6
An important question is whether or not the oncoplastic
repair be performed immediately at the time of the partial
mastectomy or delayed after the partial mastectomy but
before the radiotherapy. Unfortunately, not all surgeons
have access to reliable intraoperative tumor margin assessment, but most patients do undergo preoperative mammography and ultrasonography that can assist the breast
reconstructive surgeon in determining the most appropriate timing for repair. Patients with no or localized microcalcications by mammography and those with unifocal
tumors may be reasonable candidates for immediate repair
at the time of partial mastectomy. However, those patients
with diuse microcalcications by mammography or those
with multifocal tumors by ultrasound will probably benet
from waiting (delayed before radiotherapy) until the nal
pathology margin assessment and then perform the dermoglandular oncoplasty. In summary, immediate repair before
radiotherapy in patients with D-cup-sized breasts or larger
can best be accomplished using dermoglandular oncoplasty.
Concentric displacement, vertical oncoplasty, or inverted-T
Oncoplasty are extremely versatile and can be routinely used
in most patients who undergo breast conserving surgery.
References
1. Kronowitz SJ. State of the art and science in postmastectomy
breast reconstruction. Plast Reconstr Surg. 2015;135(4):755e–
771e.
2. Kronowitz SJ, Kuerer HM, Buchholz TA, Valero V, Hunt KK.
A management algorithm and practical oncoplastic surgical techniques for repairing partial mastectomy defects. Plast Reconstr
Surg. 2008;122(6):1631–1647.
3. Losken A, Hamdi M. Partial breast reconstruction: current perspectives. Plast Reconstr Surg. 2009;124(3):722–736.
4. Losken A, Styblo TM, Carlson GW, Jones GE, Amerson BJ. Management algorithm and outcome evaluation of partial mastectomy
defects treated using reduction or mastopexy techniques. Ann Plast
Surg. 2007;59(3):235–242.
5. Kronowitz SJ, Robb GL. Breast reconstruction and adjuvant therapies. Semin Plast Surg. 2004;18(2):105–115.
6. Kronowitz SJ, Feledy JA, Hunt KK, Kuerer HM, Youssef A,
Koutz CA, Robb GL. Determining the optimal approach to
breast reconstruction after partial mastectomy. Plast Reconstr Surg.
2006;117(1):1–11. discussion 12-4.
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Local Flap Techniques for Oncoplastic
Breast Reconstruction
JAUME MASIA AND JORDI RIBA VILCHEZ
Introduction
Recently, standardization of population screening and
advances in diagnostic techniques have allowed for earlier
detection of breast cancer, which allows breast cancer diagnosis to occur when the relative tumor burden is low. Earlier
detection often allows for tumor excision via breast conservation, which includes appropriate ablation with maximal
breast preservation. Breast conservation therapy (BCT)
implies a therapeutic-surgical approach to the tumor based
on the partial mastectomy in conjunction with adjuvant
radiotherapy directed toward the tumor bed. is strategy
is proven to be a treatment comparable to mastectomy in
terms of overall survival for early stage cancer.
In patients with early stage breast cancer, there are several
resection techniques that can be performed, the purpose of
which is to make sure that margins are oncologically safe and,
in addition, to achieve aesthetically acceptable results. Even
with this approach, the fact remains that approximately onethird of patients will subjectively report a negative outcome
related to the ablated breast.2 e breast asymmetry or the
modication of the location and/or shape of the nipple–areolar complex (Fig. 10.1) are the most frequent reasons accounting for this dissatisfaction. e location of the tumor and
subsequent partial mastectomy defect can aect outcomes
because certain areas are better able to tolerate the resection.
e standardization of this approach has a direct consequence,
which is that the number of patients with partial volumetric
decits is increasing. Plastic surgeons are now confronted
with a variety of patients with partial mastectomy defects following radiotherapy, which has been a signicant source of
psychosocial discomfort and distorted body image. For these
and other reasons (Table 10.1), this increase in the number of
patients with breast distortion following breast conservation
alone (Fig. 10.2) has aroused major interest in the development and use of local techniques for breast reconstruction.
Currently it is dicult to estimate the percentage of
women treated with BCT who will end up undergoing
reconstructive surgery, either immediate or delayed, given
1
the multitude of factors aecting this decision (Table 10.2).
Before surgery, a multidisciplinary approach is highly recommended, in conjunction with the oncoplastic surgeon
and the oncologist, to agree on the treatment to be applied,
which will certainly aect the indications for reconstruction.
Oncoplastic Surgery: Displacement
Techniques versus Local Flaps
e oncoplastic techniques are born with the dicult function
of combining an oncologically safe resection with an aesthetically satisfactory postsurgical result for the aected woman.
ere exist multiple oncoplastic techniques, generally
described according to the size and location of the tumor;
thus, each case will be unique in that there will be an optimal treatment strategy based on the breast and tumor characteristics. However, the selection of each technique will
depend on the expertise of the surgeon, and the indication
for each procedure will be determined by the size of the
defect in relation to the size of the breast before surgery.
• Fig. 10.1 Case A: Nipple–areolar complex distortion due to a previous
lumpectomy on right breast.
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TABLE
Factors that Promote the Increase of Interest
10.1
and Use of Local Reconstructive Techniques
Improvement in oncologic detection methods → major % of
tumor detection in early stage cancer status
Consolidation of breast-conserving therapy → lesser
volume resections
Substitution of “whole breast radiotherapy” for radiotherapy
focused on the tumor bed (major availability for local tissues in good conditions)
“Replace like with like” concept
Development of microsurgical techniques and perforator
flap surgery
Presence of lipofilling as an additional procedure to local
techniques
• Fig. 10.2 Case A: Postoperative image. Position and appearance of
nipple–areolar complex are highly improved after local flap coverage.
e oncoplastic techniques can be dierentiated into two
large groups depending on the type of tissue handling that
is carried out. Broadly speaking, patients with large and/or
ptotic breasts will benet from oncoplastic techniques based
on the mobilization of breast tissue (volume displacement
techniques) that, in some cases, will improve the aesthetic
appearance of a woman’s breast. On the other hand, women
with small breasts or who do not want an intervention on
the contralateral breast will require a volume contribution
through the use of local aps incorporating the principles of
volume replacement.
• Volume displacement techniques: oncoplastic tech-
niques based on mobilization after resection of the
remaining breast glandular tissue toward the lumpec-
tomy bed.
Upon resection and mobilization of the tissue itself with-
out adding new volume, the nal size of the breast will
be smaller than that of the contralateral breast. For
this reason, to avoid residual breast asymmetry, these
techniques should be accompanied by mastopexy or
reduction mammaplasty procedures of the contralateral breast.
ese are techniques with a relatively simple learning
curve by applying well-known concepts for the plastic
surgeon, with a seemingly predictable end result. In
addition, they allow the reconstruction of the defect
without requiring anything other than the breast tissue, so the creation of new donor defects is avoided.
e inclusion of a plastic surgeon in designing the
skin pattern for the oncologic resection can minimize
the creation of new scars and optimize scar location;
thus, the same incisions made for the tumor extirpation can be used for the oncoplastic reconstruction.
Despite optimal planning and execution, complications
can occur and usually are due to excessive glandular mobilization that may lead to steatonecrosis that
could mask a potential recurrence. Along the same
lines, alteration of the normal breast architecture as
well as mobilization of the original tumor bed may
add to the complexity and diculty of oncologic
follow-up; however, this contention has not been scientically proven.
TABLE
Factors that Condition the Possibility of Partial Breast Reconstruction with Local Flaps
10.2
Logistic Factors Patient Factors Oncologic Factors
Availability of plastic surgeon/oncoplastic
surgeon in the reference hospital
Knowledge of oncoplastic techniques
by the plastic surgeon/oncoplastic
surgeon
Existing information in relation to breast
partial reconstruction techniques
Personal decision of the patient, oriented by
plastic surgeon/oncoplastic surgeon
Breast size before the surgery Oncologically safe margins, defect size in
Comorbidities Radiotherapy: need of adjuvant
Possibility to perform breast-conserving
therapy (tumor size and location)
relation to the breast size
radiotherapy, type of radiotherapy
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• Local ap reconstruction: oncoplastic techniques based
on the use of pedicled local aps for the supply of volume
from nearby tissues, without using the gland itself.
When recruiting regional tissue, donor areas adjacent to
the defect will be required, which, in addition to those
used for oncologic resection, will generate new scars.
ere are several dierent local aps that are available to
correct partial mastectomy defects that will depend on
the chosen donor area and on the type of ap to be
mobilized to the defect zone. ese include fasciocutaneous aps or musculocutaneous aps. In general,
these techniques are indicated for women with small
breasts and large tumors because there is not enough
glandular tissue to perform volume displacement
techniques.
In certain cases, if the same amount of previously re-
sected tissue is provided and an adequate inset of the
ap is made, an acceptable symmetry between both
breasts can be achieved without the need to perform a
symmetrization procedure on the contralateral breast.
For this reason, these techniques are also indicated for
women who do not want an intervention on the contralateral breast; however, the ability to achieve optimal
symmetry in these cases is less predictable because it will
depend on the postoperative settling of the ap and how
it will respond to the possible adjuvant treatment. Unlike volume displacement techniques, the normal architecture of the breast or the tumor bed is not modied.
Local Flaps for Breast Reconstruction
Introduction, Indications, and
Contraindications
Despite the standardization of perforator free aps as a gold
standard for breast reconstruction, local coverage options
like pedicled aps should not be underestimated, because
their use has shown to be eective in women with lumpectomy and mastectomy sequelae.
ere is a wide range of local possibilities for the restora-
tion of breast defects, from techniques based on axial vessels
(for example, latissimus dorsi [LD] musculocutaneous ap)
to techniques based on perforating vessels (for example, thoracodorsal artery perforator [TDAP] ap, etc.).
erefore, local aps are a therapeutic alternative that
should be included in the surgical arsenal of any plastic surgeon specializing in breast reconstruction, because they may
turn out to be the indication of choice in certain cases, presenting a series of benets as follows:
• Concept of replacing “like with like”: the skin texture,
thickness, and color will always be more similar to those
of the original breast, if the tissue used for the reconstruction is adjacent to it.
• Shorter duration surgeries: pedicle aps do not require
dissection of recipient vessels, a vascular anastomosis,
or the use of microsurgical dissection techniques and/or
special material (except perforator aps).
• Pedicle aps have an expedited learning curve (except for
perforator aps).
e surgical technique of these aps is based on rotation/
transposition of the tissues near the breast area such that the
breast quadrant with the defect to be reconstructed will play
a denitive role when deciding on the various ap options
available. us, taking into account that the vast majority
of these pedicle aps are based on the excess dermal adipose
tissue present in the axillary or dorsal region, the defects
located at the inferolateral quadrant will be those with the
greatest accessibility for coverage by pedicled aps. On the
other hand, defects located at medial mammary quadrants
will pose a surgical challenge and will have to be approached
using less conventional aps. e majority of local pedicle
aps such as the LD musculocutaneous ap or its analog in
perforator surgery, the TDAP ap, are ideally suited for lateral breast defects and less likely to reach when confronted
with a medial breast defect.
Before breast reconstruction with local aps, it is nec-
essary to complete a full assessment of the patient and
anticipated breast defect, and to preoperatively plan the
reconstruction using a free or pedicle ap. e risks and
benets as well as the pros and cons must be evaluated. By
performing this assessment preoperatively, the likelihood
of success will be enhanced, and the risk of reconstructive failure can be minimized. is fact is more evident in
delayed reconstructions, in which there are prior scars in
the vicinity of the proposed ap (i.e., axillary node excision that may compromise the ability to use local aps). In
other cases, especially in patients whose oncologic resection
was performed years before the standardization of BCT, the
larger breast deformities in the setting of prior radiotherapy
may actually be indications for completion mastectomy
with total breast reconstruction with a free tissue transfer
rather than attempt a partial reconstruction prone to morbidity. us, there is a sequence of established indications
and contraindications that will indicate or rule out breast
reconstruction with local aps in cases where it is required
(Table 10.3).
Types of Local Flaps
As previously mentioned, there are dierent alternatives for
breast reconstruction with local aps.
ey can be classied depending on two principal
criteria:
a. Depending on the tissue recruited for subsequent mobi-
lization
• Dermal-fat aps
• Fasciocutaneous aps
• Musculocutaneous aps
b. Depending on the ap vascularization
• Random pattern vascularization
• Vascularization through perforator vessels
• Vascularization through axial vessels
Some of these aps are more versatile than others and can
adapt to the needs of each specic case. On the other hand,
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TABLE
other aps will need specic indications that will be detailed
throughout the chapter. Until recently, the most globally
accepted option for breast reconstruction with locoregional
autologous tissue was the LD musculocutaneous ap. With
the development and standardization of oncoplastic techniques and perforator surgery, new local alternatives appear
that are applicable to breast reconstruction.
alternative of the use of LD ap, presenting several advantages. e primary advantage is the preservation of the LD
muscle, which, apart from avoiding the morbidity associated with its sacrice, allows the patient and the surgeon
to maintain it as a reconstructive option in case of a local
recurrence.
as there is no subsequent muscular atrophy that decreases
the overall volume of the ap. ese aps also can be combined with volume displacement techniques or with fat
Indications and Contraindications for Local Flaps in Breast Reconstruction
10.3
Indications Contraindications
Preference for autologous reconstruction, in patients
who do not want to undergo long surgeries
Partial breast reconstruction (lumpectomies,
quadrantectomies), especially in small- to
medium-sized breasts
Autologous breast augmentation (contralateral breast) Relative: defects in medial quadrants → difficulty to achieve coverage
Correction of breast deformity after partial necrosis of
the previous free flap
Absolute: previous surgical procedures, especially in axillary region or in
the donor zone for the local flap
Relative: “whole breast radiation” radiotherapy, axillar radiotherapy → in
these cases it is preferable to perform the reconstruction with healthy
tissue by a free transfer, not affected by regional radiotherapy damage
through traditional flaps. It is possible to perform less frequent flaps
(IMAP, AICAP)
Relative: globally distorted breast (large previous resection + radiotherapy)
→ It is better to complete mastectomy and proceed to free flap
reconstruction
• It is relatively simple to perform and does not require use
of microsurgical techniques.
• Intraoperative time is short, without need of positional
changes.
• It does not include LD muscle, and its dissection does
not aect the thoracodorsal pedicle, for which we maintain the rest of local reconstructive options intact in
us, random and perforator aps are a relatively simple
case they would be necessary, avoiding the need for new
donor areas on the dorsal area.
• It has a lesser complication rate (except for unpredictable
ap necrosis) and shorter hospital stay and less postoperative pain. is helps initiate the postoperative adjuvant
therapy without delays, if necessary.
e use of these local aps is most useful in the set-
In addition, its denitive result will be more predictable
ting of immediate reconstruction. As mentioned, possible limitations in the setting of delayed reconstruction
include prior scars or incisions that can limit ap design
and applicability.
inltration techniques in case the defect to be covered is
extensive.
Rhomboid Flap
Dermal-fat ap is indicated for the reconstruction of small
Random Pattern Flaps
e random pattern aps are adipocutaneous aps in which
the vascularization is not based on an axial pedicle but on
the perforators irrigating the subdermal network. Unlike
the conventional perforator aps, in the random aps any
perforator is dissected under direct visualization, so the viability of its distal ends will be unpredictable. To minimize
the risk of ap necrosis, it is important to emphasize that
its indication will be limited to small-sized defects, preferably at the level of lateral quadrants of the breast. Larger
defects would be better to reconstruct with perforator aps
in which the visualization and microsurgical dissection of
the perforator will provide greater security in terms of ap
survival and will have a lower necrosis rate than the random
aps. Even so, its use should not be underestimated, considering that they have a series of advantages with respect to
the rest of local aps:
defects on the lateral quadrants of the breast.
It is especially useful for the coverage of defects in which
direct closure implies generating aesthetically unacceptable
“dog ear” deformations or when their correction requires
increasing the scar length too much along the breast surface.
To ensure a correct cosmetic result, the ap should
include a sucient amount of fat, so it should be avoided in
extremely thin women.
e markings are done in the supine position, transforming the lumpectomy defect into a rhomboid or diamondshaped defect, as in the Limberg ap, so that, after excision,
one of these resection margins constitutes one of the lateral
borders of the ap (Fig. 10.3).
During its dissection, it is necessary to extend the dissection to the muscular fascia to allow a correct axis of rotation
and closure of wounds without tension; otherwise, distal tip
necrosis of the ap may occur. e likelihood of total ap
necrosis is rare.3
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Subaxillary Flap
e subaxillary based random pattern ap is an ecient
therapeutic alternative for the reconstruction of small- to
medium-sized defects of the superior-lateral quadrant of
the breast. It is important to note that the base of the ap,
which will be located at the superior aspect of the defect,
must be at least 6–8 cm wide. e markings for this ap will
be guided by using the pinch test in the subaxillary region,
because it recruits redundant skin and fat at that level without causing a distortion in the adjacent breast contour. For
this reason, this ap is not indicated for thin patients with
quadrantectomy defects because the tissue available at the
subaxillary level is equivalent to a maximum of 25% of
the total breast volume. If there is no need for cutaneous
contribution, the ap can be de-epithelialized and buried
to only ll volume in the lateral mammary quadrants, as
described by Chatuverdi in 2004.4 Similar to other random pattern aps, the same incisions used for lymph node
surgery or lumpectomy will correspond to the lateral margins of the ap; thus, cooperation between the oncoplastic
• Fig. 10.3 Rhomboid flap technique for breast reconstruction. In J
Breast Health 2015; 11(4):186–191, by Menekse E.
surgeon and the plastic surgeon is highly recommended at
the time of operation to delineate the incisions appropriately and to facilitate the technical aspects corresponding to
the tumor excision, lymph node resection, and oncoplastic
reconstruction.
e harvesting of the ap does not require positioning
the patient in lateral decubitus, but it will be necessary to
keep the arm abducted at 90 degrees to easily reach the muscular fascia and allow for the correct rotation of the ap.
Once the ap has been harvested, the arm must be closed
beforehand to avoid tension on the incisions and ensure a
correct remodeling of the breast contour.
Lateral Thoracodorsal Flap
is fasciocutaneous ap with random vascularization pattern could be considered as a specular image of the subaxillary ap but inferiorly based. erefore, it will be indicated
for small- to medium-sized defects at the level of inferiorlateral breast quadrants. Initially described by Hölstrom in
the mid-1980s, the design resembles an “ax” or “wedge”
shape, with an approximately 7-cm wide base, located in
the lateral continuation of the inframammary fold. Posteriorly, the axis of the ap will be traced toward the lateral
thoracic region, where the dermal-fat excess at that level will
be included in the design, being that this was previously
checked by pinch test (Figs. 10.4 and 10.5). In general, the
dimensions of the ap do not exceed 7–9 cm of basis and
15–18 cm of length. Despite being a random ap, its main
vascularization is derived from intercostal branches; therefore, during the dissection of this ap, two fundamental
aspects to ensure its viability must be accounted for:
• Avoid performing undermining in the lateral region of
the inframammary fold during oncologic resection.
• Include the fascia of the m. serratus anterior in the ap.
e donor site can be closed in a direct fashion with a
horizontal scar that will be concealed below the brassiere. In
case the contributed volume is insucient, combined techniques with tissue expander or implant placement have been
• Fig. 10.4 Lateral thoracodorsal flap for breast reconstruction. In Plast Reconstr Surg 2006; 117:1699,
by Mendonça A.
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• Fig. 10.5 Lateral thoracodorsal flap for breast reconstruction. In Plast Reconstr Surg 2006; 117:1699,
by Mendonça A.
71
described, although its use is not widespread. Used for years
for delayed breast reconstruction, the use of this ap in the
immediate reconstruction of defects secondary to BCT was
recommended without resulting in a higher rate of ap or
donor site complications.5 When complications did occur,
they occurred during the rst days of hospitalization and
did not delay the start of adjuvant therapy. Recently, due to
the standardization of microsurgical techniques and better
knowledge of the perforators present on the lateral thoracic
region, the TDAP or lateral intercostal artery perforator
(LICAP) perforator aps have been imposed as a more eective and safe alternative to the lateral thoracodorsal ap.
Musculocutaneous Flaps
LD Flap
e use of musculocutaneous LD ap for breast reconstruction was described in mid-1970s, when it gained popularity
due to its relative simplicity and consistent vascularization.
In addition, various studies demonstrated that its use, combined with implants in patients who had previous radiotherapy, resulted in a better aesthetic outcome and in a
signicant decrease of the rate of complications compared
with patients reconstructed with breast implants only. us,
the LD musculocutaneous ap became quickly regarded as
the workhorse ap for breast reconstruction. Since then, the
LD ap has remained a reliable rst-level option for both
delayed and immediate reconstruction, either as a single
procedure or combined with implant placement. However,
with the emergence of perforator aps, indications for its
use have been decreasing with the aim to reduce the functional morbidity associated with removal of the LD muscle
(Fig. 10.6).
Flap Characteristics
Vascularization: e LD represents a type 5 ap (according
to Mathes and Nahai classication) based on the thoracodorsal artery that is a branch of the subscapular artery
that arises from the axillary artery. When the thoracodor-
sal artery penetrates into the muscle (about 8–12 cm af-
ter the bifurcation of the subscapular artery), it divides
in two principal branches: one vertical branch of major
caliber and another horizontal. Between them, there ex-
ist various interconnections that allow irrigation to the
whole muscle. e classic LD ap is based on the vertical
branch of the thoracodorsal pedicle.
Vessel diameter: 2–4 mm (artery), 2–5 mm (vein)
Pedicle length: 7–12 cm
Approximate maximum dimensions of skin paddle:
25 × 15 cm
Intraoperative position: Requires positional changes.
• Flap harvesting: lateral decubitus with the arm ab-
ducted at 90 degrees, and elbow exed at 90 degrees.
• Adaptation of the ap to the defect and breast remodeling: supine decubitus.
Preoperative Preparation
Ideally, the markings have to be performed in the same
position in which the ap will be harvested (e.g., with the
arm and elbow in abduction and exion of 90 degrees,
respectively).
After proper positioning, the most relevant anatomical
landmarks should be marked: free margin of the LD muscle
(anterior limit), lower scapular ridge (upper limit), dorsal
midline and spinous processes (posterior limit), and postero-superior iliac crest (lower limit). is serves to delineate
the muscular topography on the dorsal surface. e cutaneous paddle of the ap can be oriented in a variety of fashions
(longitudinal, transverse, oblique); however, it is the horizontal design that will allow the scar to remain concealed
under the line of the brassiere. In addition, placing the scar
such that it is parallel to the resting skin tension lines will
allow a better quality postoperative scar. e amount of the
skin that can be included in the ap must be predicated on
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• Fig. 10.6 Latissimus dorsi musculocutaneous flap for breast reconstruction. In Prestige Institute website,
2017, by Tamburrino J.
the ability to close the gap created by harvesting the skin
paddle. is can be estimated by using a pinch test. In general, a cutaneous island of 12 cm in width permits a direct
closure. Unless there is a history of previous axillary surgeries
(a fact that may contraindicate surgery), the LD ap vascularization is constant and established, so there is no need for
computerized tomographic angiography before surgery. In
patients who have had prior axillary surgery and who have
poor to absent function of the LD muscle, damage to the
thoracodorsal pedicle and nerve must be suspected. In those
cases, preoperative imaging tests should be considered.
Surgical Technique
Following the surgical markings, patients will be placed in
a supine or decubitus position. e lateral-decubitus position will allow for the partial mastectomy and reconstruction to be performed without further position change. is
positioning is appropriate for immediate and delayed reconstruction. e rst step with the reconstruction is to identify
the thoracodorsal pedicle anteriorly with the patient still in
the supine position, especially if axillary lymph node biopsy
has been performed during the same procedure. e benet
of this approach is to ensure that the thoracodorsal vessels
are intact and patent.
Once the initial portion of the surgery has been completed and the dimensions of the partial mastectomy defect
are known, the patient is placed in lateral decubitus position. e cutaneous island is incised and the dissection proceeds to the level of the muscular fascia. e dissection is
continued suprafascially in the direction to the anatomical
limits of LD muscle, with the intention to expose the muscle surface needed for reconstruction. Preferably the portion
of muscle perfused by the vertical branch of the thoracodorsal pedicle is selected because it is a larger caliber vessel and
presents a more constant course than the horizontal branch.
e muscular remnant that is not necessary for the reconstruction will be preserved in its natural site; thus, only a
portion of the muscle is harvested.
Following exposure of the LD muscle, medial and inferior origin of the muscle is released using electrocautery and
elevated in a distal to proximal direction. It is important to
remain in the same plane to avoid lifting of the trapezius (in
its most medial region) or the serratus anterior (in its uppermost region) muscles. is is facilitated by paying attention to
direction of the muscle bers. Once the tendinous insertion of
the LD muscle is identied, it can be partially or completely
divided according to the range of mobility required to cover
the defect. In case of complete division, care must be taken
not to load the entire weight of the ap onto the pedicle, as
irreversible spasm or even avulsion of the pedicle may occur.
In cases where the thoracodorsal pedicle was not identied at the onset of the operation, it is important to identify and preserve the vessel at its entrance to the muscle. In
patients in whom a greater arch of movement of the ap is
required, dissection of the pedicle in the proximal direction
will be necessary, although the need to reach its origin at
the level of the subscapular artery is uncommon. During
dissection of the pedicle, the authors’ preference is to divide
the thoracodorsal nerve. Although this will cause more pronounced muscle atrophy (up to 30%), dividing it prevents
dynamic contraction of the muscle when it is in its new
location. is contraction can be annoying and unsightly
for the patient. In contrast to dividing the nerve, the vascular branch of the serratus anterior is usually preserved in
cases where it does not prevent a correct rotation of the ap.
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