Latissimus Dorsi  Flap Stephen McCulley MBChB,FCS(SA)Plast, FRCS(Plast) Consultant Plastic Surgeon Nottingham, UK  Cairo, ...
Latissimus Dorsi (LD) Flap <ul><li>Available </li></ul><ul><li>Reliable </li></ul><ul><li>Versatile </li></ul><ul><li>LD f...
 
Surface Anatomy
Vascular supply Angiosomes and Venosomes
Layers in standard LD flap harvest
Layers in extended LD flap harvest
 
Standard LD and ELD flap
Latissimus Dorsi (LD) Flap <ul><li>Primary </li></ul><ul><li>Secondary </li></ul><ul><li>LD flap and implant </li></ul><ul...
Immediate Breast Reconstruction with no chance radiotherapy Extended LD flap LD flap/Implant  DIEP flap
IMMEDIATE RECONSTRUCTION  LD flap and implant
 
 
Left Mastectomy and Extended LD flap (no implant)
Immediate Breast Reconstruction with chance radiotherapy Extended LD flap  DIEP flap  LD flap/Implant
 
Radiotherapy change after LD flap
Delayed Breast Reconstruction DIEP flap  Extended LD flap  LD flap/implant
LD flap and implant and C/L implant
Difficulties <ul><li>May be insufficient skin </li></ul><ul><ul><li>LD flap </li></ul></ul><ul><ul><li>Mastectomy site poo...
Limited skin on flap and high scar
Pre-op   6 months   3 years
<ul><li>Mini-LD flap (secondary) </li></ul>
Autologous vs. LD/Implant <ul><li>Added tissue good for the breast and bad for the back </li></ul><ul><li>Increased cover ...
All LD flaps be extended? <ul><li>Probably  </li></ul><ul><li>How much fat to take when definitely using an implant debata...
Scar placement and planning <ul><li>Patient preferences </li></ul><ul><li>ELD or use of implant </li></ul><ul><li>Natural ...
Planning with relation to clothes
 
 
Planning with relation to flap volume requirements
Maximising volume
 
 
Planning with relation to skin requirements <ul><li>Plan from the front…..mark on the back  </li></ul><ul><li>Think about ...
Immediate and delayed LD  Reconstruction with large skin volumes available
X Y Z X – Y = Z  (ideally!)
 
 
 
Planning LD and Implant
 
 
Planning – Mastecomy to final result
What to do with nerve and tendon? <ul><li>Dividing the nerve looses flap volume (15-30%) </li></ul><ul><li>Leaving the ner...
 
 
 
 
 
 
Insetting of flap - Options <ul><li>Transpose & Rotate </li></ul><ul><ul><li>Most of the time </li></ul></ul><ul><li>Trans...
Optimising outcomes <ul><li>Must define breast base </li></ul><ul><li>Secure flap laterally </li></ul><ul><li>Ensure flap ...
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Folding of flaps
 
Insetting the skin paddle <ul><li>Try and place skin paddle from scar to crease where feasible </li></ul><ul><li>Not alway...
Secondary Extended LD flap  Left LD and implant and right  and nipple share reconstruction breast augmentation  (awaiting ...
 
Secondary correction with LD flaps
 
3 weeks post surgery
Failed TRAM flap salvaged with an Extended LD flap
 
 
Using bilateral implants in small breasted patients <ul><li>Useful to discuss in selected cases </li></ul><ul><li>When ver...
 
Delayed reconstruction with LD flaps and contralateral augmentation
Planning – Mastecomy to final result
Breast reduction/mastopexy <ul><li>Difficult to get a lot of ptosis in secondary cases </li></ul><ul><li>May allow an auto...
 
Implant selection <ul><li>Round vs Anatomical </li></ul><ul><li>Profile </li></ul><ul><li>Cohesivity </li></ul>
Implant selection <ul><li>Personally  I predominantly use round low cohesive implants particularly in primary LD flaps </l...
Round Low cohesive Moderate profile
Round High profile
MX on left and MM on right
Avoiding complications
Back wound problems and seromas -use of steroid
Infected implant after LD flap
Implant wrinkling after LD flap
Radiotherapy change after LD flap
Capsule formation after LD flap and implant
 
 
 
Thank you
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EASO2011 BRS 2 McCulley

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

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

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