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EASO2011 BRS 2 McCulley
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  • Polglase
  • Christie-Phillips
  • Bramley
  • Clahson
  • McCance
  • Christie-Phillips
  • Polglase

Transcript

  • 1. Latissimus Dorsi Flap Stephen McCulley MBChB,FCS(SA)Plast, FRCS(Plast) Consultant Plastic Surgeon Nottingham, UK Cairo, March 2011
  • 2. Latissimus Dorsi (LD) Flap
    • Available
    • Reliable
    • Versatile
    • LD flap and implant
    • Extended LD (ELD) flap
    • Mini-LD flap
  • 3.  
  • 4. Surface Anatomy
  • 5. Vascular supply Angiosomes and Venosomes
  • 6. Layers in standard LD flap harvest
  • 7. Layers in extended LD flap harvest
  • 8.  
  • 9. Standard LD and ELD flap
  • 10. Latissimus Dorsi (LD) Flap
    • Primary
    • Secondary
    • LD flap and implant
    • Extended LD (ELD) flap
    • Mini-LD flap
  • 11. Immediate Breast Reconstruction with no chance radiotherapy Extended LD flap LD flap/Implant DIEP flap
  • 12. IMMEDIATE RECONSTRUCTION LD flap and implant
  • 13.  
  • 14.  
  • 15. Left Mastectomy and Extended LD flap (no implant)
  • 16. Immediate Breast Reconstruction with chance radiotherapy Extended LD flap DIEP flap LD flap/Implant
  • 17.  
  • 18. Radiotherapy change after LD flap
  • 19. Delayed Breast Reconstruction DIEP flap Extended LD flap LD flap/implant
  • 20. LD flap and implant and C/L implant
  • 21. Difficulties
    • May be insufficient skin
      • LD flap
      • Mastectomy site poor
    • Volume required by implant which can make symmetry difficult
    • “ Has disadvantages of both flaps and Implants together”
  • 22. Limited skin on flap and high scar
  • 23. Pre-op 6 months 3 years
  • 24.
    • Mini-LD flap (secondary)
  • 25. Autologous vs. LD/Implant
    • Added tissue good for the breast and bad for the back
    • Increased cover to implant still useful
    • ELD has better shape longevity and avoids implant replacement
    • ?more cost effective
  • 26. All LD flaps be extended?
    • Probably
    • How much fat to take when definitely using an implant debatable
  • 27. Scar placement and planning
    • Patient preferences
    • ELD or use of implant
    • Natural rolls on back
    • Volumes available
    • Obviously aim remains adequate well perfused tissue with minimal morbidity of donor site.
  • 28. Planning with relation to clothes
  • 29.  
  • 30.  
  • 31. Planning with relation to flap volume requirements
  • 32. Maximising volume
  • 33.  
  • 34.  
  • 35. Planning with relation to skin requirements
    • Plan from the front…..mark on the back
    • Think about skin paddle width and height
    • Try to plan secondary reconstruction as aesthetic unit
  • 36. Immediate and delayed LD Reconstruction with large skin volumes available
  • 37. X Y Z X – Y = Z (ideally!)
  • 38.  
  • 39.  
  • 40.  
  • 41. Planning LD and Implant
  • 42.  
  • 43.  
  • 44. Planning – Mastecomy to final result
  • 45. What to do with nerve and tendon?
    • Dividing the nerve looses flap volume (15-30%)
    • Leaving the nerve causes twitching
    • Leaving the tendon creates axillary fullness
    • Dividing the tendon gives more reach
  • 46.  
  • 47.  
  • 48.  
  • 49.  
  • 50.  
  • 51.  
  • 52. Insetting of flap - Options
    • Transpose & Rotate
      • Most of the time
    • Transpose only
    • Fold flap
    • Use Pectoralis Major
  • 53. Optimising outcomes
    • Must define breast base
    • Secure flap laterally
    • Ensure flap is in breast not axilla
    • Muscle cover medially without tension
    • Adequate skin
    • Adequate implant cover
    • (extended, use of PM)
  • 54.  
  • 55.  
  • 56.  
  • 57.  
  • 58.  
  • 59.  
  • 60.  
  • 61.  
  • 62.  
  • 63.  
  • 64.  
  • 65.  
  • 66.  
  • 67.  
  • 68. Folding of flaps
  • 69.  
  • 70. Insetting the skin paddle
    • Try and place skin paddle from scar to crease where feasible
    • Not always feasible with LD flap
  • 71. Secondary Extended LD flap Left LD and implant and right and nipple share reconstruction breast augmentation (awaiting tattoo)
  • 72.  
  • 73. Secondary correction with LD flaps
  • 74.  
  • 75. 3 weeks post surgery
  • 76. Failed TRAM flap salvaged with an Extended LD flap
  • 77.  
  • 78.  
  • 79. Using bilateral implants in small breasted patients
    • Useful to discuss in selected cases
    • When very small breasted can make symmetry easier to achieve
    • Beware
      • Now need more skin!
      • Thins tissue/implant palpability
  • 80.  
  • 81. Delayed reconstruction with LD flaps and contralateral augmentation
  • 82. Planning – Mastecomy to final result
  • 83. Breast reduction/mastopexy
    • Difficult to get a lot of ptosis in secondary cases
    • May allow an autologous reconstruction
  • 84.  
  • 85. Implant selection
    • Round vs Anatomical
    • Profile
    • Cohesivity
  • 86. Implant selection
    • Personally I predominantly use round low cohesive implants particularly in primary LD flaps
    • Anatomical implants or round in delayed LD flaps. Need to judge depending on opposite breast
    • Breast width fundamental as with augmentation
    • Projection again judged against opposite breast. Frequently low projection in primary reconstruction
    • Differential profiles useful when contralateral implants used
  • 87. Round Low cohesive Moderate profile
  • 88. Round High profile
  • 89. MX on left and MM on right
  • 90. Avoiding complications
  • 91. Back wound problems and seromas -use of steroid
  • 92. Infected implant after LD flap
  • 93. Implant wrinkling after LD flap
  • 94. Radiotherapy change after LD flap
  • 95. Capsule formation after LD flap and implant
  • 96.  
  • 97.  
  • 98.  
  • 99. Thank you