Immediate breast reconstruction is an excellent complementary treatment for patients with ductal carcinoma in situ and early-stage invasive breast cancer . The latissimus dorsi myocutaneous flap with prosthesis has been considered to be an effective and aesthetic method of immediate breast reconstruction following skin-sparing mastectomy [6, 7]. There have also been reports of refinements to the latissimus dorsi flaps which include harvesting subcutaneous fat to avoid implants; however, these were following mastectomy -. Although wide local excision can produce significant deformity of the breast, little has been reported on using lattisimus dorsi to restore breast contour in these cases. Latissimus dorsi flaps are usually raised using a separate incision in the back and tunneling the pedicled flap through the axilla to the front for reconstruction. The major disadvantages to this technique are a separate, long scar in the back, a need to change the position of the patient for the posterior dissection and a contour defect in the back . Avoidance of a posterior scar has been described in skin sparing mastectomy [9, 10]. There are also previous reports recommending the use of single axillary incision for reconstruction following quandrantectomy, although an additional pad of fat was not utilized [3, 4]. One of the methods to minimize the scar may be endoscopically harvesting the latissimus dorsi, although a previous report found no additional advantage to this technique .
Our modification of the technique offers the advantage of a single incision for axillary clearance as well as harvesting the fat with the muscle flap. Sometimes, depending on the site of the primary it is possible to also do the segmentectomy through the same incision. The scar does not extend posteriorly and is completely concealed with the arm in the normal anatomical position (Figure 3). Additionally, a thick pad of fat along with the muscle can triple or quadruple the bulk for filling the breast defect (Figure 5). This permits generous, uncompromised wide clearance of the tumor with minimal or no deformity. Although there is no scar posteriorly, there is a visible depression in the area from which muscle and fat have been removed. Since the lattissimus dorsi myoadipose flap has a dual blood supply it is quite robust and can tolerate the usual radiotherapy which follows wide local excision of a breast carcinoma. Denewer et al. have been able to further increase the bulk of the flap by adding part of serratus anterior and overlying fat to fill mastectomy defects . This would be of value for large defects such as those produced by nipple-sparing mastectomy.
Thus far, we have used this flap to fill defects in any portion of the breast except the infero-medial quadrant. For supero-medial lesions, an additional circumareolar incision is used to provide adequate clearance of the primary lesion (as in our case 3). A recent study reported that immediate reconstruction following partial mastectomy using lattisimus dorsi flaps had a higher complication rate than using local tissue . However, we believe that increasing the vascularity by preserving the dual blood supply, improving its mobility by division of the lattisimus dorsi tendon and augmenting its bulk by utilization of the overlying fat would significantly minimize the complications associated with this procedure.
Satisfactory oncologic outcomes have been assessed by histologic margins of the primary lesion and the number of axillary nodes retrieved. Much longer follow up would be needed to assess the overall oncologic outcomes.
In summary, immediate breast reconstruction following segmentectomy, by raising a latissimus dorsi myoadipose flap from the same incision used for axillary clearance offers excellent cosmetic and oncologic results.