Latissimus Dorsi Myocutaneous Flap in Immediate Reconstruction after Salvage Mastectomy Post-Lumpectomy and Radiation Therapy

Adjuvant radiation therapy (ART) is a local treatment, complementary to breast-conserving surgery, applied to the majority of early breast cancers. The risk of local relapse in these patients is estimated to be between 0.5% and 1% per annum. The absolute number of patients who require a breast reconstruction having had prior radiation is growing. Performing breast reconstruction after salvage mastectomy (SM) for recurrent cancer represents an authentic challenge due to the increased complication rate in patients with prior radiation, particularly when implant-only reconstructions are analyzed. For this reason, autologous flaps are considered the best resource to mitigate such undesired drawbacks. After 40 years from the introduction of the latissimus dorsi myocutaneous flap (LDMF) in breast reconstruction,1,2 its use experienced continuously changing considerations in the evolving scenario of autologous flap-based reconstructive techniques. Analyzing the early series of LDMF associated to implant, although with biased and limited studies, some authors observed a high capsular contracture rate3,4; for this reason, the procedure failed to reach widespread use in primary breast reconstruction. In the meantime, the pedicled transverse rectus abdominis myocutaneous (TRAM) flap gained fast popularity, obtaining a soft, natural-shaped breast even without use of implants. Because TRAM flap complications seemed nonnegligible, both for their incidence and functional burden, the microsurgical free deep inferior epigastric perforator (DIEP) flap and gluteal free flaps were generated with the purpose to obviate the abovementioned problems.5 During this tumultuous evolution in breast flap reconstruction, LDMF remained relegated to a sporadic role, but continued to be a good option in reconstruction after SM in breasts with prior radiation, even primarily used when abdominal flaps are not feasible.6,7 Whether free or pedicled, autologous abdominal-based flap breast reconstruction, although suitable for patients undergone ART, is not appropriate for thin or severely obese patients (body mass index >30)8,9 and sometimes, because of the longer recovery time and the additional scar at the donor site, it is refused even by the eligible ones. Moreover, neither elderly patients nor those with comorbidities or having had prior abdominal surgery are good candidates for DIEP flap reconstruction. In this very complex landscape, LDMF now seems to resurrect from its own ashes, never completely defeated, thanks to its versatility, safety, and adaptability to almost all kinds of patients with few contraindications. The LDMF probably might maintain a definite not negligible role, once redefined in its modern path. Recent series in the literature reported, for implant-assisted LDMF, an acceptable capsular contracture rate ranging from 3% to 6%.10–13 The utility of this procedure for immediate reconstruction after SM for cancer recurrence in breasts with prior radiation remained viable across decades, and a meta-analysis of Fischer in 2016 demonstrated the advantages of LDMF-assisted reconstruction over implant-only in this setting.14 In fact, implant reconstructive procedures without autologous tissue were burdened by intolerable rates of major complications, unpleasant aesthetic results, and failures discouraging their use in such patients.15,16 A well-vascularized soft muscular flap has a favorable interaction with a field that has undergone ART, obtaining an improvement of the overhanging skin and exerting a protective role against the undesired reactions of the surrounding tissues to the implant presence. The majority of studies analyzed the staged expander-LDMF/implant, most commonly used in delayed reconstruction after SM in the setting of previous ART.6 However, when feasible, 1-step breast reconstruction after mastectomy represents the better approach, both for patient expectation and for the economic effectiveness. By paying attention to some technical details, LDMF can allow definitive reconstruction with just 1 operation. With the intention to contribute to the definition of the actual role of LDMF, we analyzed the recent literature and critically reviewed our institutional experience with this procedure as applied to immediate implant-assisted reconstruction after SM in patients previously treated with ART.