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N. Kumar et al.

Fig. 18.1 (a) Periareolar incision. (b) Disk of skin with two curvilinear lines from the lateral and medial edges. (c) Removal of specimen with NAC and de-epithelization of

continued posteriorly with taking gross negative margin around the tumor and deep up to the pectoralis muscle.

• After taking out the specimen, de- epithelization of the skin in inferolateral breast is done.

• The closure of the wound is started by incising the breast and inframammary fold along the medial edge of the de-epithelialized skin.

skin with shifting of skin disc at NAC region. (d) Closure of aps. (e) Final outcome

• The same incision is extended through the underlying glandular tissue to the chest wall.

• The lower outer quadrant of the breast is separated from the chest wall to allow superior and medial rotation.

• The skin disc with underlying glandular tissue is advanced to the central quadrant.

18 Grisotti Mastopexy (B-Flap Resection)

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133

• Skin disc to be positioned at original NAC site and the volume of the central breast is restored using glandular tissue from both the inferior and outer quadrants.

• The mound of central breast is made by suturing the transposed tissue to the surgical margin with absorbable sutures in multiple layers.

• The lower inner quadrant is undermined to facilitate the full- thickness approximation.

• Wound is closed in layers with burying the deepithelialized dermis below the skin surface.

• Nipple and areola reconstruction can be performed later.

18.4 Modications ofGrisotti Flap

Few modications of Grisotti ap have been described depending upon the site of dermoglandular mobilization.

18.4.1 Grisotti Flap with“E/3”

Modication

To overcome the tension at the suture line, Rovere etal. published minor modication in the technique. In this technique, a small tringle of skin is preserved at the supero-medial extremity of the dermal glandular ap. This modication gives gure “3” like shape of upper medial skin edge on the right side and shape “E” on the left side [1].

18.4.2 Superior Pedicle Based

Grisotti Flap

Recently, Chen etal. published modication in the conventional Grisotti ap. In this procedure, disk of skin was taken from the upper quadrant based on superior pedicle [2].

18.5 Complications

• Hematoma

• Wound infection

• Breast skin necrosis

18.6 Discussion

The retroareolar breast tumors have traditionally been treated surgically with mastectomy or central quadrant excision without any reconstruction. However, with the increasing trends of cosmetic outcomes with a special emphasis on patient reported outcomes, reconstruction of NAC is required. Many surgeons preferred to perform skin sparing mastectomy with reconstruction using an implant or autologous technique [3].

Grisotti ap is a simple, cosmetically acceptable and oncological safe approach for central quadrant tumors. Various modications of conventional Grisotti ap have been described in a patient with short NAC and inframammary distance that has allowed the surgeons to expend the indications of Grisotti ap.

References

1. della Rovere GQ, Pillarisetti RR, Bonomi R, Benson

J. Oncoplastic surgery for retro areolar breast can-

cer — a technical modication of the Grisotti ap.

Indian J Surg. 2007 Aug;69(4):160–2.

2. Chen Y, Chen Q, Dong J, Liu D, Huang L, Xie F,

et al. Modied Grisotti ap technique in centrally

located breast cancer: case report. Gland Surg. 2021

Sep;10(9):2867–73.

3. Malata CM, See IJL, Kazzazi F, Forouhi P, Di Pace

B.Combining the Grisotti ap with a secondary der-

moglandular pedicle for partial breast reconstruction

following contiguous central-inferior segment breast

cancer excision. Case Rep Plast Surg Hand Surg.

2021;8(1):203–7.

Volume Replacement: Latissimus

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Dorsi Mini-Flap (LDMF) forPartial Breast Reconstruction

S.V.S.Deo, NaveenKumar, andAshutoshMishra

19.1 Introduction

The latissimus dorsi ap (LD) is one of the most common, reliable, and versatile aps used in breast oncoplastic surgeries. The major drawbacks of latissimus ap (LD) are the formation of seroma, scarring, and poor wound healing at the donor site if large tissue is harvested [1]. The latissimus dorsi mini-ap (LDMF) is an alternative option for patients with large volume resections (30–40%), skin loss, prior bad lumpectomies. Nano and Gendy have recently published their experiences with the latissimus mini-ap and reported high patient satisfaction regarding psychological morbidity, cosmesis, and preservation of nipple sensation [2, 3]. A signicant proportion of breast cancer patients present in developing countries with a relatively larger mean tumor size and quite often end up with large volume resections. These patients sometimes are not suitable for simple oncoplastic techniques and LDMF is a good option in such situations. Recently, the indication of LDMF has decreased since the use of chest wall perforator aps has been increased. However, LDMF is still a viable option to reconstruct the breast. In this chapter, we have described the indications, techniques, and complications of LDMF.

19.2 Patient Selection

• Volume loss >30%

• Location: Outer and central quadrant tumors

• Large primary with poor tumor v/s breast ratio

• Small to medium breast size

• Presence of skin loss

• Not keen on contralateral procedures

• Reluctant for implant reconstruction

• Volume displacement not feasible

• Secondary reconstruction: In case of bad cosme-

sis with previous breast conservative therapy

19.3 Contraindications

• Suspicion of the damage pedicle in previous

surgeries such as thoracotomy or extensive

and radical axillary surgery

• Congenital absence of the LD muscle

• Large breast defects or patient with thin LD

muscle

19.4 Surgical Technique

19.4.1 Patient Position

S. V. S. Deo (*) · N. Kumar · A. Mishra Department of Surgical Oncology, DR BRA-IRCH, All India institute of medical sciences, New Delhi, India

https://doi.org/10.1007/978-981-99-5536-7_19

• Supine with sandbag under scapula and 30

degree rotation of upper body with arm free

and draped (Fig.19.1)

• Semi-lateral followed by Supine

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S. V. S. Deo et al.

19.4.2 Incision

Planning of incisions for breast as well as for harvesting the ap depending on the location of tumor and size of the defect. It can be done by

• Single incision: “S” shaped incision along ant axillary line

• Two incisions: Wide excision + trans-axillary ALND and LD muscle harvest

Fig. 19.1 Semi-lateral position for both resections of primary and harvesting the mini-LD ap at single stage

19.4.3 Surgical Approach

• Trans-axillary

• Conventional LD ap approach

19.4.4 Mini-LD Flap Variations

• Muscle ap only

• Myo-subcutaneous ap

• Myo-cutaneous ap

19.4.5 Steps ofProcedure: (Fig.19.2)

• The patient is positioned in the lateral decubitus position and secured with well-padded table attachments or a bean bag with the arm supported at 90°.

• Wide excision of the tumor with frozen section for margin assessment.

• Axilla is managed with sentinel lymph node biopsy (SLNB) or axillary lymph node dissec-

Fig. 19.2 (a) Margin positive diagnostic lumpectomy with bad surgical scar (b), incision and pedicle marking, (c) re- resection of primary site, (d) nal outcome after mini-LD ap

19 Volume Replacement: Latissimus Dorsi Mini-Flap (LDMF) forPartial Breast Reconstruction

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137

tion for clinically palpable or pathological node involvement. During ALND, extra care should be taken to preserve the LD pedicle.

• Assessment of defect for mini-LD planning and harvesting the ap.

• Harvest 30% more than volume required.

• Harvest subcutaneous fat and skin if volume requirement is more.

• For harvesting the ap, the anterior border of the LD muscle is usually identied rst. Muscle is raised all around without taking the slips of serratus anterior muscle.

• The thoracodorsal neurovascular pedicle is identied and preserved. Sometime, the serratus branch can also be preserved to allow retrograde perfusion of the ap in case the viability of thoracodorsal pedicle is in doubt.

• The posterior part of the tendon insertion into the intertubercular groove of the humerus may be divided to allow additional mobility to the ap if required.

• A high axillary tunnel is created for the transposition of the ap.

• Flap hemostasis is checked prior to transfer the ap in the breast wound, with care not to twist the pedicle.

• Check adequate room for the pedicle to avoid compression prior to the transfer. On occasions where additional reach is required, the humeral insertion can be divided partially or fully.

• Denervation—to avoid muscle twitching.

• In setting of the ap in breast wound. Fix the LD muscle to pec. Major and breast parenchyma.

• The donor site is closed primarily in layers over drain to prevent seroma.

19.5 Complications

• Early postoperative complications:

– Hematoma – Wound infection – Seroma – Partial or complete ap loss – Wound breakdown

• Late complications:

– Breast animation/twitching – Atrophy of the of the ap

19.6 Discussion

Latissimus dorsi mini-ap is a simple option for partial breast reconstruction. Raja M etal. evaluated the LDMF for partial breast reconstruction and found that the LDMF did not produce any major scarring within the breast and at the donor site [4]. Gendy etal. compared skin sparing mastectomy and LDMF for cosmetic, functional, and surgical outcomes on 106 patients. They found that the LDMF is an oncological safe, simple, and feasible option in a patient with a defect size of 20–30%. The postoperative complications were also less common in LDMF group in comparison with skin sparing mastectomy group [5].

Chest wall perforator aps such as thoracodorsal artery perforator (TDAP), lateral intercostal artery perforator (LICAP), and anterior intercostal artery perforator (AICAP) are the other reliable options for partial breast reconstruction. The advantage of the chest wall perforator aps is decreasing the donor site morbidity by preserving the muscle. Hamdi etal. compared chest wall perforator aps with LDMF and he noted a signicant reduction in the morbidity in the chest wall perforator group at donor site by maintaining a good functional outcome [6].

19.7 Conclusion

Latissimus dorsi mini-ap has been a traditional volume replacement option in a patients who required partial breast reconstruction. LDMF utilisation has come down with introduction of perforator aps. LDMF still has a place as a salvage ap in the eld of complex partial breast reconstruction.

References

1. Schwabegger A, Ninković M, Brenner E, Anderl

H. Seroma as a common donor site morbidity after

harvesting the latissimus dorsi ap: observations

on cause and prevention. Ann Plast Surg. 1997

Jun;38(6):594–7.

138

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S. V. S. Deo et al.

2. Nano MT, Gill PG, Kollias J, Bochner MA. Breast volume replacement using the latissimus dorsi miniap. ANZ J Surg. 2004 Mar;74(3):98–104.

3. Gendy RK, Able JA, Rainsbury RM.Impact of skinsparing mastectomy with immediate reconstruction and breast-sparing reconstruction with miniaps on the outcomes of oncoplastic breast surgery. Br J Surg. 2003 Apr;90(4):433–9.

4. Raja MAK, Straker VF, Rainsbury RM.Extending the role of breast-conserving surgery by immediate volume replacement. Br J Surg. 1997 Jan 1;84(1):101–5.

5. Gendy RK, Able JA, Rainsbury RM.Impact of skinsparing mastectomy with immediate reconstruction and breast-sparing reconstruction with miniaps on the outcomes of oncoplastic breast surgery. BJS Br J Surg. 2003;90(4):433–9.

6. Hamdi M, Van Landuyt K, Monstrey S, Blondeel P.Pedicled perforator aps in breast reconstruction: a new concept. Br J Plast Surg. 2004 Sep;57(6):531–9.

Chest Wall Perforator Flaps

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forPartial Breast Reconstruction

GeetaShetty

20.1 Introduction

The aim of oncoplastic breast surgery is to achieve a better aesthetic outcome, without compromising the oncological outcome, thus improving the quality of life [1, 2]. Several oncoplastic techniques are available depending on tumour characteristics, breast size, and location of tumour [3–6]. Oncoplastic techniques for high tumour to breast ratio can generally be classied into volume displacement or volume replacement techniques. The latter requires replacement of tissue into the tumour excision defect from a regional or distant site. Amongst a number of volume replacement techniques, using the local chest wall perforator aps is associated with low morbidity and better aesthetic outcome [7–12]. Chest wall perforator aps (CWPF) have facilitated the expansion of options of breast conserving surgery (BCS) in patients who would have otherwise been offered a mastectomy which has its known implication onto the women mental and physical well-being [13].

G. Shetty (*) Sandwell and West Birmingham NHS Trust, Birmingham, UK

Edge Hill University, Ormskirk, UK

Edinburgh University, Edinburgh, UK

Manipal Academy of Higher Education, Manipal, India

Kasturba Medical College, Mangalore, India

Nevertheless, mastectomy with reconstruction using silicone implants has been used for more than 40years, modications of the material have not reduced the complication rates including capsular contracture, which increases with radiotherapy [14]. Autologous total breast reconstruction carries its own risk including ap failure and donor site morbidities.

In patients with adequate lateral chest wall

and upper abdominal fasciocutaneous tissue, CWPF can be used with or without a skin island to replace the breast defect whilst maintaining its size and shape, thus avoiding the contralateral symmetrisation. This procedure allows excising a large volume of breast tissue of up to 40% without compromising the cosmetic outcomes [7, 8]. The excess tissue on the lateral aspect of chest wall offers the ability to replace like to like tissue into the breast without sacricing the muscle. Additionally, its proximity to the breast borders makes it an excellent choice and does not compromise future options of total breast reconstruction.

Although using a local ap with chest wall

perforators has been the domain for plastic surgeons for a while, Hamdi etal. rst reported classication, surgical technique, and outcomes of partial breast reconstruction based on intercostal artery perforator aps [4, 15–17]. The costal arch is formed between the branches of aorta posteriorly and the internal mammary artery anteriorly. These aps are based on the cutaneous perfora-

https://doi.org/10.1007/978-981-99-5536-7_20

139

140

Medial perf

rator

Dorsal perforator

rator

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G. Shetty

tors of this costal arch from lateral, medial, and anterior intercostal vessels (Fig. 20.1). The lateral thoracic artery (LTAP), a branch from the axillary artery along with lateral intercostal artery perforator (LICAP), can be used to reconstruct laterally situated breast excision defects (Fig.20.2) [4, 15, 18]. The anterior (AICAP) and

orator

Internal thoracic artery

Aorta

Fig. 20.1 Schematic diagram showing the costal arch and perforators

Fig. 20.2 Demonstration of anatomy of Lateral intercostal artery perforator, lateral thoracic artery perforator, and thoracodorsal artery perforator

Anterior perfo

Lateral perfo

medial perforators (MICAP) ap can be used to reconstruct lower half of breast tumours and could be extended to central and upper inner quadrant tumours.

20.2 Patient Selection

andPlanning

Chest wall perforator aps are versatile aps, suitable for outer half and lower half of breast tumours with a high tumour to breast ratio. This technique is ideal for small to moderate size breasts with none to small ptosis [12, 19]. The redundant tissue on the lateral aspect of the chest wall and upper abdomen is used to perform this procedure. This procedure can be performed in either immediate or delayed settings [20, 21]. In the immediate setting, wide local excision or tumourectomy is performed prior to dissecting the ap, which allows to assess the estimated defect and width & length of the ap.

Marking The patients are examined in the

standing or sitting position for LICAP and LTAP ap marking. The inframammary fold (IMF), mammary line, lateral mammary fold or anterior axillary line, mid and posterior axillary lines are marked. For a single stage procedure, wide local excision/tumourectomy is performed through the lateral mammary fold where feasible and is continued superiorly and inferiorly along the bra line or horizontally to form an elliptical incision. The handheld vascular Doppler is used to locate the perforators. The perforator vessels are typically located 1–2cm posterior to the lateral mammary fold and about 2–3cm anterior to the posterior axillary fold arising from third- seventh intercostal spaces (Fig.20.3). The LTAP vessels can be traced vertically along the mid axillary line and often is inconsistent in its location. In 10–15% of patients LTAP can be absent. The width and length of the ap is based on the estimated breast defect and the available donor skin facilitating adequate closure. The width & length ratio may vary anywhere between 1:2 and 1:5. The length of the ap can also vary, and up to 30cm of the ap can be harvested without vascular compromise [18].

20 Chest Wall Perforator Flaps forPartial Breast Reconstruction

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LTAP ap reconstructions, using a saline bag or sandbag placed beneath the scapula and another one beneath the pelvis to avoid traction or twisting. No intraoperative change of position is required. For additional access posteriorly, the patient can be positioned laterally with their arm extended at 90 degrees. A single dose of an antibiotic is given at the start of the procedure. For immediate setting, a single incision is often used for the wide local excision and reconstruction in most of the cases, irrespective of the type of perforator ap. The ap is de-epithelialised and raised from lateral to medial. Careful dissection is carried out nearer the perforators which are situated 2.5–3.5cm from anterior border of latissimus dorsi. The ap is dissected at the musculofacial plane, including the fasciocutaneous tissue until it ips over 180degrees into the cavity without any tension. When skin island is required, ap can be propelled either on LTAP or LICAP perforator. However, one has to make sure that the perforators are not twisted (Fig. 20.4). It is not prudent to isolate the vessels. The intraoperative handheld vascular Doppler can be used to

Fig. 20.3 Marking of lateral intercostal artery perforator ap

guide the perforators and dissection. The axillary procedure is performed through the same incision, if feasible, or through a separate incision.

The anterior and medial perforator aps are

Magnication lenses are not essential for this marked in the supine position. The inframammary fold, mammary line, and midline are marked. The medial perforators can be located around 2–3 cm lateral to the sternal edge and about 1–2 cm inferior to the IMF. The ap is marked in a crescent shape including the redundant upper abdominal tissue. The base of MICAP is formed medially. For the AICAP base is along the mammary line and ap extends on either sides of the marked perforator.

MICAP flap

LICAP flaps

141

LTAP

20.3 Surgical Technique

20.3.1 LateraI Intercostal Artery

Perforator andLateral Thoracic Artery PerforatorFlap

Patients are positioned in supine position with the arm extended. A lateral tilt is given for LICAP/

AICAP flap

Fig. 20.4 The positioning of lateral, medial, and anterior

intercostal artery perforator aps

• LICAP - Lateral intercostal artery perforator

• MICAP - Medial intercostal artery perforator

• AICAP - Anterior intercostal artery perforator

• LTAP - Lateral thoracic artery perforator

• TDAP - Thoracodorsal artery perforator

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Fig. 20.5 A 57-year-old with partial breast reconstruction with lateral intercostal artery perforator ap, 5months and 1year post-operation

G. Shetty

procedure. The skin and subcutaneous tissue from the lower and upper incision are mobilised to facilitate the closure of the wound. Extensive mobilisation of the lower incision may compromise future latissimus dorsi skin peddle. Figure20.5 demonstrates the 5months and 1year post- operative pictures for a lateral intercostal artery perforator ap.

20.4 Medial andAnterior

Intercostal Artery PerforatorFlap

Patients are operated on whilst in supine position with arm extended. Wide local excision is performed from the inframammary incision. For MICAP, the ap is raised from lateral to medial. For AICAP, the centre along the mammary line acts as a base and the ap is raised from both medial and lateral (Fig.20.6). As we approach the pedicle, careful dissection of fas-

ciocutaneous tissue is carried out with bipolar

forceps and/or scissors. The dermis is detached

from the lower incision for adequate mobility

of the ap. The ap is either propelled in

MICAP for inner quadrant tumour defects or

advanced in AICAP for 6 ‘o’ clock tumours

(Figs.20.4 and 20.6). Flap is de-epithelialised

before in setting in the cavity, unless skin ped-

dle is used. The lower incision is mobilised and

heavy sutures are used to raise the lower ap so

as to recruit the skin and subcutaneous tissue

from the abdomen, to recreate the inframam-

mary fold. Figure 20.7 demonstrates the pre-

operative and post-operative pictures for

anterior intercostal artery perforator ap.

A drain is placed at the donor site chest wall perforator ap reconstructions. The drains are managed post-operatively as per hospital protocol. Patients are discharged on the same day or next day as appropriate. They are reviewed in the clinic after the 1st week and the 3rd week of the primary surgery.

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