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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1054_Библиотеки_им_академика_М_И_Перельмана
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25 Skin Sparing Mastectomy andNipple Areola Sparing Mastectomy
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Fig. 25.3 (continued)
(b) Upper periareolar
(c) Upper periareolar with lateral extension
(d) Lower periareolar with inferior extension
(e) Incisions crossing the nipple areola complex.
(a) Trans areolar
(b) Trans nipple
(f) Inframammary incision (g. 25.4).
(g) Batwing mastopexy incision.
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S. V. S. Deo and S. ManojGowda
c
Fig. 25.4 (a) Incision for nipple areola sparing mastectomy by inframammary approach (b) Technique for mastectomy
(c) Post mastectomy with resected specimen (d) Final outcome after implant reconstruction
25.8 Skin Reducing Mastectomy
(SRM)
SRM is a type IV SSM (Fig.25.1), which involves
reduction of excessive skin envelope. This is
indicated in patients with severe ptosis (Areola to
IMF distance >8cm). Oncologic and prophylactic indications are same as those of SSM and
NSM.
25.9 Mastectomy Technique
After selecting the incision for conservative mastectomy, the dissection should be carried out
along the mastectomy plane. The thickness of the
d
ap depends on body mass index and habitus of
the patient. The thickness usually ranges from 2
to 5 mm and will be very thin close to the
NAC.The plane of dissection in various types of
mastectomies is shown in Fig.25.5.
Skin retraction should be performed using skin
hooks. The skin aps must be handled gently and
try to avoid using retractors where possible. Using
ngers of non-dominant hand to apply traction and
counter traction is very useful during dissection.
When using the peri-areolar incision for mastectomy, the opening will be small and thus elevating the skin aps in a centripetal fashion and
moving the skin opening like a moving window
to dissect peripheral parts of breast will improve
the vision for dissection.
25 Skin Sparing Mastectomy andNipple Areola Sparing Mastectomy
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189
abc
Fig. 25.5 Plane of dissection in various mastectomies. (a) Modied radical mastectomy, (b) Skin sparing mastectomy,
(c) Nipple sparing mastectomy
NSM through inframammary incision is challenging when you get close to the NAC, due to
minimal skin thickness in this area. Care should
be taken not to damage the skin, as it may complicate the situation in case of reconstruction
using an implant. In authors experience, dissecting on either side of NAC rst and then approaching the NAC area will make this step easier.
During raising the aps, it is important to not
violate the infra mammary fold (IMF). After raising the skin aps, the mammary gland should be
mobilised from the deep plane behind the posterior lamina of the supercial fascia. If NSM is
planned, complete removal of retro areolar breast
tissue should be done. If available an intraoperative frozen section of this retro areolar tissue
should be done to look for any tumour tissue. If
frozen report comes back as positive, NAC
removal should be considered.
The viability of skin ap is assessed clinically
and the skin edges are trimmed if the vascularity
is not good. Various other techniques have been
described to assess the skin ap viability and
uorescein angiography using indocyanine green
is most sensitive and specic among them in predicting skin ap necrosis after CM [4] (Fig.25.6).
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S. V. S. Deo and S. ManojGowda
c
Fig. 25.6 (a) Visualisation of skin ap using spy camera after intravenous injection of indocyanine Green. (b) Area of
low perfusion as seen on Spy camera. (c) Excision of low vascular area
25.10 Complications
and also in gene mutation carriers willing for risk
reducing surgery. Various types of conservative
Complications after conservative mastectomies
can be either minor, which can be managed conservatively or major, which require surgical intervention to treat the complication.
mastectomies have been described. Surgical
training and experience is a key determinant of
success in this eld. However oncological principles should not be violated at the cost of cosmetic outcomes and these procedures should be
Minor Major
1. Cyanosis/ hypo
pigmentation of NAC
2. Localised infection
1. NAC ischemia
2. NAC necrosis
3. Flap necrosis
4. Bleeding/hematoma/
seroma
5. Reconstruction related
complications
25.11 Conclusions
Conservative mastectomies have emerged as a
major surgical option for a signicant number of
breast cancer patients unsuitable or refusing BCS
carried out in multidisciplinary settings only.
References
1. Galimberti V, Vicini E, Corso G, et al. Nipplesparing and skin-sparing mastectomy: review of
aims, oncological safety and contraindications.
Breast. 2017;34:S82–4. https://doi.org/10.1016/j.
breast.2017.06.034.
2. Toth BA, Lappert P. Modied skin incisions for
mastectomy: the need for plastic surgical input
in preoperative planning. Plast Reconstr Surg.
1991;87(6):1048–53.
3. Carlson GW, Bostwick J, Styblo TM, et al. Skinsparing mastectomy: oncologic and reconstructive
25 Skin Sparing Mastectomy andNipple Areola Sparing Mastectomy
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191
considerations. Ann Surg. 1997;225:570–8. https://
doi.org/10.1097/00000658- 199705000- 00013.
4. Newman MI, Samson MC, Tamburrino JF, Swartz
KA. Intraoperative laser-assisted indocyanine
green angiography for the evaluation of mastectomy aps in immediate breast reconstruction. J
Reconstr Microsurg. 2010;26:487–92. https://doi.
org/10.1055/s- 0030- 1261701.
Dissection Guide forLatissimus
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Dorsi Breast Reconstruction
SankaranNarayanan andKirtiKatherineKabeer
26
26.1 Introduction
Breast reconstruction succeeding treatment of
breast cancer has become an integral part of rehabilitation. The latissimus dorsi ap (LD) has been
the workhorse following breast cancer surgery, as
full breast reconstruction following mastectomy,
resurfacing procedure for locally advanced breast
cancer (LABC) or as partial reconstruction following liberal wide local excision (WLE).
Reconstruction can be done simultaneously with
the initial surgery (immediate) or later once adjuvant cancer treatment has been completed
(delayed). LD reconstruction can be done using
muscle only (autologous ap) or combined with
implants.
The pedicled myocutaneous latissimus dorsi
ap (LDMF) was the rst autologous reconstruction used for breast reconstruction. This procedure was rst described by Iginio Tassini in 1906
and lost popularity until it was re-described about
70years later by Olivari in 1976 [1, 2]. Schneider
etal. in 1977 revisited the description of the ap
further [3]. In 1978, Bostwick et al. described
using a skin island harvested and the ap [4].
Many variations of the ap were developed over
the years. One such variation illustrated by Papp
and McCraw was initially in 1983, where the deepithelialised skin ap overlying the LDMF to
add to the volume, and in 1985, it modied it further to include the fat on the surface of the LDMF
[5]. The extended LDMF was described in 1983
by Hokin and Silfverskiold, including the lumbar
fat extensions to increase volume [6]. The use of
the LDMF declined with the advent of the TRAM
ap but regained popularity due to the comorbidities associated with using the rectus abdominis muscle in the TRAM ap.
Several features that make the LD aps robust
are their vascularity, good aesthetic outcomes and
minimal donor site morbidity [7]. An added advantage is the rarity in developing functional sequelae
such as weakness and shoulder dysfunction [8].
Over the years, LDMF has progressively used
along with prosthetic devices such as tissue
expanders and implants where larger volumes for
reconstruction are required.
S. Narayanan (*)
University Hospital of North Midlands NHS Trusts,
Stoke-on-Trent, UK
K. K. Kabeer
Kauvery Hospital, Chennai, India
MGM Cancer Institute, Chennai, India
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
S. V. S. Deo (ed.), Breast Oncoplasty and Reconstruction,
https://doi.org/10.1007/978-981-99-5536-7_26
26.2 Anatomy andFunction
The latissimus dorsi (LD) muscle is the largest
muscle on the posterior trunk. Most of the muscle
is directly under the subcutaneous tissue except
the superior and medial portions, resting deep to
the trapezius muscle. It takes its origin from the
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third or fourth ribs, the iliac crest, spinous processes of the lower sixth and seventh thoracic,
lumbar and superior sacral vertebrae and the inferior angle of the scapula [9]. It inserts into the
intertubercular groove of the humerus as a broad
tendon. It joins with the bres of the teres major
as it passes towards the axilla forming the posterior axillary fold. It takes its dominant blood supply from the thoracodorsal artery and vein.
Mathes and Nahi describe the LDMF as a type V
receiving its dominant supply from the
thoracodorsal artery and segmental circulation
from branches of the posterior intercostal and
lumbar arteries [10]. The thoracodorsal nerve
arises from the brachial plexus from the C6, C7
and C8 roots.
The latissimus dorsi muscle function is to
extend, adduct and internally rotate the shoulder
joint. It also helps with extension and lateral exion of the lumbar spine (Figs.26.1 and 26.2).
S. Narayanan and K. K. Kabeer
Fig. 26.2 Illustrates the origin and insertion of the latissimus dorsi muscle
26.3 Immediate LDMF
Reconstruction
Fig. 26.1 Demonstrating the vascular anatomy to the
latissimus dorsi muscle
The decision of an immediate reconstruction following mastectomy is to be made between the
patient and the surgeon, keeping in mind the biological behaviour of the tumour and patient characteristics. It is essential to consider the stage of
the disease at the time of diagnosis and treatment
and the consequences it may have on adjuvant
therapy.
Advantages of immediate reconstruction are
single-stage surgery reducing multiple procedures and anaesthesia, reduced cost and perhaps
better cosmesis [11]. Literature suggests that
those undergoing immediate reconstruction cope
better psychologically when compared to a
26 Dissection Guide forLatissimus Dorsi Breast Reconstruction
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195
cohort having delayed reconstruction. However,
some nd the reconstruction is overwhelming
and may opt to have the cancer surgery initially
and consider reconstruction at a later date.
26.4 Delayed LD Reconstruction
The LD ap is a good option for reconstruction in
the delayed setting for several reasons, one of
them being the prevention of a microvascular surgery with a well-vascularised ap that provides
sufcient perfusion even to radiated skin [12]. A
disadvantage is the requirement of larger aps
and skin paddles, leading to more visible scarring
to the patient.
26.4.1 Indications forLDMF
• Autologous reconstruction following simple
mastectomy, skin-sparing and nipple-sparing
mastectomy.
• Women with sufcient back fat and tissue not
suitable for other types of autologous
reconstruction.
• Obese patients who are unsuitable for other
types of autologous aps and older patients.
• Partial reconstruction following large wide
local excision.
• Delayed reconstruction in those who had
radiotherapy (RT) following mastectomy.
complication and morbidity due to implant extrusion and capsular contracture [12]. For the
patients who received postoperative radiotherapy,
these complications are exacerbated. This could
also affect the aesthetic outcome of the procedure
[11].
Reconstruction can be done as a single-stage
procedure where the implant is placed at the initial surgery. A TE (Tissue expander) can be set
behind the overlying aps to replace the permanent implant in delayed or two-stage reconstruction cases.
An alternative to using prosthetic devices to
add volume is delayed fat grafting. This is usually done at least 3–6months following the initial
surgery [12].
26.4.3 LDMF inResurfacing
Surgeries andasSecondary
Procedures
• Following wide excision for chest wall
resections
• Augment decient skin aps over an implant
• Failed implant-based reconstructions
• Severe radiation changes
• Poland syndrome
26.5 Advantages
andDisadvantages
oftheLDMF
26.4.2 Contraindications forLDMF
• Previous posterior lateral thoracotomy.
• Injury to the thoracodorsal nerve during axillary node dissection (ANC).
• Comprised blood supply due to previous surgery (damage to the thoracodorsal pedicle).
The LD ap may be used as a pure autologous
ap or in conjunction with a prosthetic device
(tissue expander (TE) or implant) to add to more
volume, particularly in big breasted women or
lean women with insufcient ap volume. This
cohort of patients develops higher postoperative
The latissimus dorsi ap produces good cosmesis, lower infection rates than implant-based
reconstruction and lower rate of capsular contracture. The option of using a skin paddle where
required, avoidance of microsurgery, quicker
recovery compared to abdominal aps are added
benets. It also serves as a good option for partial
mastectomy defects. Its longevity, reliable vascular pedicle and ease of harvesting the ap make it
popular [12]. The long-term functional loss associated with the LD muscle is minimal.
The disadvantages of this procedure or the
prolonged surgical time compared to implant
only surgeries and potential donor site morbidity.
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S. Narayanan and K. K. Kabeer
It, at times, may not provide sufcient volume,
requiring the use of a prosthetic device or fat
grafting to add to the volume.
26.6 Pre-operative Assessment
Before surgery, it is essential to gather information such as past medical history, signicant
comorbidities, state of the local tissue, donor site
and the contralateral breast. Assessment of the
latissimus dorsi muscle is usually carried out
with the patient sitting or standing position while
requesting them to adduct their arm. This
manoeuvre helps assess the viability and contractility of the muscle in patients who have had previous axillary surgery. It is also essential to
determine the volume obtained and can be done
by pinching the laterodorsal pad to gauge the
thickness. In those undergoing delayed reconstruction, acquire the previous operation notes,
tumour details and adjuvant treatments received.
They should be offered for immediate or delayed
nipple reconstruction and explained contralateral
symmetrising procedures where required.
It is vital that all patients undergoing reconstruction, immediate/delayed or for resurfacing
or as a secondary procedure, should have clinical
photographs and be discussed at the local multidisciplinary team meeting. All patients need to
have support, mainly from the breast care nurses,
for emotional support. A detailed informed and
written consent is imperative, and it is advisable
to go through risks and benets and hand over the
written consent to the patient before surgery.
the superior border of the breast and the lateral
edge of the breast. It is ideal for planning the
mastectomy incision at this stage. We then proceed to the markings posteriorly delineating the
surface of the latissimus dorsi muscle. This starts
superiorly the tip of the scapula, inferiorly the
junction of the posterior and middle thirds of the
iliac crest and laterally the posterior midline.
Finally, the appropriate skin paddle and orientation of the skin pattern is to be marked.
The skin paddle marked over the surface of
the LD is shaped elliptically, allowing tensionfree closure. The lay of the skin paddle can either
be transverse, horizontal or oblique. The dimensions of the paddle should correlate with the
amount of skin required to reconstruct the breast.
In immediate reconstruction, where is skinsparing mastectomy is performed, the harvested
skin paddle is de-epithelialised, adding to the
bulk of the ap. In the delayed setting, a wider
area of skin paddle may be required. The paddle
may be as long as 20 cms and should not exceed
a length of 8–10 cms. Commonly, the lie of the
incision is along the bra line making the scar
inconspicuous (Figs.26.3 and 26.4).
26.7 Surface Marking
Markings are performed pre-operatively with the
patient in an upright position. Start with the basic
breast markings anteriorly comprising the sternal
notch, the midline, bilateral inframammary fold,
Fig. 26.3 Surface marking showing a peri areolar incision and area of dissection for mastectomy
poster
axillar
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197
Tip of scapula
Trapezius
ior
y line
Fig. 26.4 Surface marking for the latissimus dorsi ap
harvest. The elliptical line marks the incision for the LD
ap
Midline
26.8 Technique
The patient is initially positioned in a supine
position with arms at 90°. The mastectomy is carried out, creating the breast pocket and dissection
of the axilla. Standard mastectomy going along
breast planes superiorly up to the second intercostal space, medially to the lateral border of the
sternal edge, inferiorly to the inframammary
crease and laterally to the midaxillary line (just
short of the anterior border of the LD). Where
required, a sentinel lymph node biopsy or axillary node clearance Is completed preserving the
thoracodorsal pedicle and its branches to the
latissimus dorsi and serratus anterior.
In unilateral latissimus dorsi, muscle harvest
is to be done with the patient positioned in the
lateral decubitus. The pressure points such as the
hips, knees exhilarate elbows should be wellpadded and placed. Ensure that the arm is not
abducted more than 90° to prevent injury to the
brachial plexus and shoulder joint.
If the patient has a bilateral reconstruction
using the latissimus dorsi, they will be placed in
the prone position.
The incision on the back is placed over the
previously marked skin paddle. Dissection is
carried out below the thoracolumbar fascia. Some
surgeons prefer to leave a bit of deep adipose tissue over this layer. Dissection is carried laterally
to separate the LD from the serratus anterior,
superiorly to the teres major muscle and the trapezius muscle, inferiorly to the thoracolumbar
fascia along the iliac crest. The LD pedicle is to
be always under vision. Finally, the muscle is
transected at its origin and insertion. There are
two schools of thought when it comes to transecting the thoracodorsal nerve. Some believe transecting the nerve may lead to atrophy and reduce
bulk, whereas some believe that transecting the
nerve will prevent postoperative contraction of
the muscle. The ap is now completely mobilised
and transposed into the breast cavity through the
axilla without twisting the pedicle.
The donor site is closed before repositioning
the patient. A suction drain is placed into the cavity, and the wound is closed in two layers comprising closure of the Scarpa’s fascia using
absorbable sutures brackets 3–0 Vicryl, 3–0 PDS
and subcuticular with absorbable sutures.
Occlusive dressing is applied, and the patient
placed in a supine position with an arm out at 90°
on both sides.
The ap setting into the breast pocket should
be done with care to recreate the breast anterior
axillary fold avoiding tissue bulk in the axilla and
medial deciency. Securing the muscle to the
chest wall medially and superiorly helps in maintaining the position of the ap.
In delayed reconstruction, mainly when a previous subpectoral expander or implant-based
reconstruction has already been attempted, the
pectoralis muscle could be left with the mastectomy ap or dissected off and put back onto the
chest wall. However, in patients who have
received radiotherapy, those with thin mastectomy aps or tobacco smoke can leave the pectoralis muscle with the mastectomy ap. In
situations where there is a lower pole deciency,
the skin paddle of the LD could be used to create
the inframammary fold. This requires careful
planning so it could be matched with the contralateral IMF.This also applies to those who have a
delayed LD reconstruction with a previous simple mastectomy.
Split ap elevation is well established and
valuable in reconstructing partial defects. Once
the anterior border of the LD is identied, the lat-
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