Ann Thorac Surg 2006;82:752-755
© 2006 The Society of Thoracic Surgeons
How to do it
Use of the Extended V-Y Latissimus Dorsi Myocutaneous Flap for Chest Wall Reconstruction in Locally Advanced Breast Cancer
Evan Woo, MRCS (Edin), M Med (Surg)a,
Bien-Keem Tan, FRCS (Edin)a,*,
Heng Nung Koong, FRCS (Edin & Glasg)b,
Allen Yeo, FRCS (Edin), M Med (Surg)c,
Mun Yew Patrick Chan, FRCS (Edin)d,
Colin Song, FRCS (Edin)a
a Department of Plastic Surgery, Singapore General Hospital, Singapore
b Department of General Surgery, Singapore General Hospital, Singapore
c Department of Surgical Oncology, National Cancer Centre, Singapore
d Department of General Surgery, Tan Tock Seng Hospital, Singapore
Accepted for publication July 11, 2005.
* Address correspondence to Dr Tan, Department of Plastic Surgery, Singapore General Hospital, Outram Rd, Singapore 169608. (Email: bienkeem{at}singnet.com.sg).
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Abstract
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The extended V-Y latissimus dorsi myocutaneous flap described by Micali and Carramaschi provides an innovative method of closing large anterior chest defects after resection of breast cancer. The technique provides robust chest wall coverage that is able to withstand immediate postoperative radiotherapy. The aim of this article is to confirm the usefulness of the flap's design and describe modifications to the technique. The modifications to technique include: a curvilinear design that recruited more skin for closure in patients with wounds extending laterally or superiorly, routine transposition of latissimus dorsi insertion inferio-medially onto the chest wall to maximize pedicle reach, and the use of small split skin grafts or delayed primary closure if there was tension in closing. Twelve patients who underwent resection of locally advanced breast cancer had immediate chest wall reconstruction with the extended V-Y latissimus dorsi musculocutaneous flap. The V to Y design of the flap's cutaneous island allowed primary closure of chest wound and donor defect.
There were no instances of chest wound dehiscence. The chest wounds healed, allowing patients to undergo adjuvant radiotherapy in a mean time interval of 6 weeks after surgery.
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Introduction
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Despite the impetus towards early breast cancer detection and curative resection, we occasionally still see patients presenting with large, fungating tumors. Surgery is indicated as it provides local control of the disease and a better quality of life [1]. Presently the standard treatment of such tumors is a wide excision followed by skin grafting, or where the ribs or lungs are exposed, a muscle flap and skin grafting to close the wound [3]. These techniques do not provide robust wound cover that allows for postoperative chemotherapy and radiotherapy [1, 3, 4]. Often, patients are left with chronic weeping chest wounds after therapy. The extended V-Y latissimus dorsi (LD) myocutaneous flap described by Micali and Carramaschi [2] provides an innovative method of wound closure without a significant donor defect. The aim of this article is to confirm the usefulness of the flap's design and describe modifications to the technique. Between October 2001 and March 2004, 12 patients underwent immediate chest wall reconstruction using the extended V-Y latissimus dorsi (LD) myocutaneous flap design. The patients with advanced breast cancer (n = 9) underwent a simple mastectomy and axillary clearance, whereas those with local recurrence of breast cancer (n = 3) had a wide excision of the recurrent cancer. The mean age of the patients was 55 (range, 40 to 67) years. The mean defect size was 192 cm2 (range 10 x 8 cm to 20 x 20 cm).
Seven patients received a preoperative induction course of chemotherapy to shrink the tumors. In addition, preoperative radiation therapy was given to 2 patients. After surgery, 2 patients had chemotherapy and 6 had adjuvant radiotherapy to the chest within 6 weeks after the surgery. The clinical details of the patients are summarized in Figure 1.
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Technique
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Preoperatively, the approximate outline of the resection and the flap are marked out in consultation with the resection surgeon. This is done with the patient in standing position, which is anatomically correct for the flap design. Important anatomical landmarks, such as the inferior angle of the scapula and the proximal humerus, are displaced when the patient is in the lateral decubitus position; hence, marking the flap in the lateral position would be inaccurate. Moreover, the reduction in width of the chest in lateral decubitus also gives the illusion of a smaller wound and may cause an underestimation of the flap size.
First, the surface marking of the LD muscle is determined. Drawing the triangular skin paddle is described as follows. The wound is pictured as a square whose lateral, medial, superior, and inferior borders are as shown (Fig 2A). The flap is essentially a triangle whose base is the lateral border of the chest wound. This is also the leading edge of the flap. First, a line is drawn tangentially from the superior border of the wound to the inferior angle of the scapula, and it is extended toward the midline to meet the spine; this forms the superior side of the triangle. Then, another straight line is traced from the inferior border of the wound to meet the spine to form the apex, thus completing the triangle (Fig 2A). The apex can be extended 2 to 3 cm beyond the midline to facilitate closure of the back. This straight-cut triangular design is ideal for wounds confined to the anterior aspect of the hemi-chest. However, if the wound extends laterally or is massive, a curvilinear modification of this design is used as it captures a larger skin territory (Fig 2A).
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Fig 2. Schematic representation of the extended V-Y latissimus dorsi design and operative procedure. (A) Flap planning. The wounds are depicted by the squares. Straight-cut flap design is depicted by dotted lines, whereas the curvilinear design is depicted by dashed lines. Note how the curvilinear design recruits more skin area to provide cover for a more laterally situated wound. (B) The extended V-Y latissimus dorsi flap transposed anteriorly without disinsertion of the pedicle. Note how the transposition of the flap causes its long axis to be vertical. (C) The extended V-Y latissimus dorsi flap after disinsertion of the pedicle. Disinsertion allows the long axis of the flap to be horizontal, which is necessary for insetting. Note the sutures anchoring the insertion of the latissimus dorsi to the ribs indicated by the arrow. This prevents accidental avulsion of the pedicle.
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After resection, the patient is positioned in the lateral decubitus for flap harvest. The triangular skin island is outlined and incisions are deepened until the LD is reached. Once the LD muscle is visualized, the entire muscle is harvested in the usual fashion, making sure that the overlying skin paddle remains attached. Donor site skin and subcutaneous tissue are widely undermined to relieve tension during primary closure. The insertion of the LD to the proximal humerus is always detached and transposed to an antero-medial position on the chest wall. This increases the reach of the flap and aligns the long axis of the paddle horizontally (Figs 2B, 2C). The tendinous insertion is secured to the rib periosteum with 2-0 Vicryl (Ethicon, Somerville, NJ) sutures to prevent accidental avulsion of the pedicle. The thoracodorsal pedicle, owing to its length and its medial origin in the axilla, has a slack that can be paid out so that the entire muscle can be further shifted medially and anteriorly over the chest wall. In so doing, an additional 4 to 5 cm reach of the flap is obtained. The donor wound is closed primarily. The patient is then repositioned supine for the rest of the procedure. This switch is critical to ensure correct distribution of tension when the flap is inset.
Anteriorly, the flap is anchored to the underlying ribs to fix its final position and to prevent traction on the thoracodorsal pedicle. Closure is performed in layers after adequate subcutaneous undermining of the wound edges to reduce wound tension. Three suction drains are inserted, one to the chest wound, one to the donor site, and one to the axilla.
Patients are discharged between postoperative days 7 and 10 after chest and axillary drains are removed. Patients are instructed to keep the arm on the operated side adducted for 2 weeks to avoid tension on the wound and the flap pedicle. Thereafter, intensive physiotherapy is commenced to ensure good range of shoulder motion (Fig 3).
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Fig 3. Case 5 patient: a 66-year-old woman who presented with locally advanced breast tumor measuring 10 cm in diameter. (A) This chest wound was closed by the extended V-Y latissimus dorsi flap design. (B, C) Good range of motion can be achieved with intensive physiotherapy starting 3 weeks postoperatively.
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There was no necrosis of the skin island of the latissimus dorsi flap in any of the patients. One patient had a minor donor site wound breakdown that healed after treatment with dressings. Three patients required small split skin grafting as an adjunct to wound closure. One patient had secondary closure of the chest wound on postoperative day 5. Six patients had adjuvant chemotherapy or radiotherapy, or both, to the chest wall without compromise to the wound. The results are summarized in Figure 1.
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Comment
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The usefulness of the extended V-Y latissimus dorsi flap design is its ability to close a large defect without the expense of a donor wound. The leading portion of the flap closes the chest wound while its V-shaped tail closes the donor defect. Furthermore, unlike skin grafts, closure is not dependent on wound bed. Five patients had exposed ribs while 1 had an exposed lung after resection of the tumor.
The key to successful wound closure was correct distribution of wound tension. This was achieved by marking and insetting the flap in an anatomical position and not in the lateral decubitus position, transposition of the LD insertion antero-medially to afford additional reach, and a curvilinear flap design that recruited a larger skin paddle for massive wounds. Despite such measures, if there was still tension in wound closure, then delayed primary closure or small split skin grafts were used (see Fig 1). Skin grafting should be avoided as they tolerate radiotherapy poorly. However, if necessary, the muscular portions of the LD flap (anteriorly) or the serratus anterior muscle (posteriorly) are suitable beds for skin grafting as they are in the peripheral zone of radiotherapy.
Patients who have had previous axillary dissection may not be suitable candidates for this procedure due to scar entrapment or previous disruption of the thoracodorsal vessels. In 2 patients who had previous axillary clearance (patients 1 and 11), we had to ensure the integrity of the pedicle by intraoperative Doppler before proceeding with harvesting the LD. One limitation we encountered with these patients was that the pivot point of the flap was tethered down by scarring, thus limiting the reach of the flap. In these cases, the V-Y design had to have smaller dimensions. There was also a greater propensity toward usage of supplementary skin grafting. Some alternative methods that would have been considered if the pedicle was not dissectable would be the conventional LD flap design or the transverse rectus abdominis myocutaneous flap [5–7].
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Acknowledgments
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The authors would like to thank Jane Wong and Ho Ee Wee for their expert assistance in the reproduction of the diagrams and clinical pictures in this article.
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References
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- Drake DB, Oishi SN. Wound healing considerations in chemotherapy and radiation therapy Clin Plast Surg 1995;22(1):31-37.[Medline]
- Micali E, Carramaschi FR. Extended V-Y latissimus dorsi musculocutaneous flap for anterior chest wall reconstruction Plast Reconstr Surg 2001;107(6):1382-1390.[Medline]
- Bernstein EF, Sullivan FJ, Mitchell JB, Salomon GD, Glatstein E. Biology of chronic radiation effect on tissues and wound healing Clin Plast Surg 1993;20(3):435-453.[Medline]
- Miller SH, Rudolph R. Healing in the irradiated wound Clin Plast Surg 1990;17(3):503-508.[Medline]
- Cordeiro PG, Santamaria E, Hidalgo D. The role of microsurgery in reconstruction of oncologic chest wall defects Plast Reconstr Surg 2001;108(7):1924-1930.[Medline]
- Ramming KP, Holmes EC, Zarem HA, Lesavoy MA, Morton DL. Surgical management and reconstruction of extensive chest wall malignancies Am J Surg 1982;144(1):146-152.[Medline]
- Larson DL, McMurtrey MJ. Musculocutaneous flap reconstruction of chest-wall defectsan experience with 50 patients. Plast Reconstr Surg 1984;73(5):734-740.[Medline]
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Abstract
Introduction
