Preoperative evaluation and markings

While the patient is awake and standing or sitting upright, the reconstructive surgeon uses a provocative maneuver to evaluate the contractility of the LD muscle (Fig. 5.1). The patient adducts her arm; as the LD muscle contracts, the reconstructive surgeon palpates and marks the muscle’s anterior border. The tip of the scapula, posterior iliac crest, and midline are also marked to further delineate the muscle’s topography (Fig. 5.2). If the patient has a history of lymph node sampling and the LD muscle does not contract when the patient adducts her arm, the thoracodorsal nerve may be injured or transected, and the adjacent thoracodorsal vascular pedicle may also be injured.

Fig. 5.1 Forced adduction of the shoulder enables palpation and marking of the latissimus dorsi muscle’s anterior border.

Fig. 5.2 Topography of the latissimus dorsi muscle. Key landmarks include the tip of the scapula, the iliac crest, the posterior midline, and the muscle’s anterior border.

If the breast reconstruction requires a skin island, the reconstructive surgeon can design and transpose a template of the size, shape, orientation, and location of the anticipated skin island onto the skin that overlies the LD muscle. The location of the anticipated skin paddle is critical in determining the relative location of the muscle and skin island in the reconstructed breast during inset. The template should also reflect the 90–110° of rotation the flap will undergo from the patient’s back to her chest during the reconstruction (Fig. 5.3). Attaching the template to a towel and using the axilla as a pivot point can help the surgeon confirm the flap will reach its intended final location. To ensure that the flap donor site can be closed primarily, the reconstructive surgeon should pinch together the anticipated incision lines. In most patients, primary closure without significant tension can be performed if the skin island is less than 10 cm wide. If a skin island is not required for breast reconstruction, the reconstructive surgeon can harvest the LD flap through a small incision in the posterior axilla and use endoscopy to limit the number of incisions made on the patient’s back.

Fig. 5.3 Preoperative markings for bilateral immediate breast reconstruction with latissimus dorsi myocutaneous flaps and tissue expanders after skin-sparing mastectomy. The skin paddle is designed to rotate easily into the mastectomy defect, taking into consideration that 90–110 degrees of rotation will occur.

Positioning

For unilateral breast reconstruction, an LD flap is commonly harvested and the donor site closed while the patient is in a lateral decubitus position. The patient who undergoes immediate breast reconstruction is usually in a supine position during mastectomy, and the reconstructive surgeon can confirm the integrity of the thoracodorsal vascular pedicle and start the anterior dissection of the LD flap from this approach; the patient can then be placed in the lateral decubitus position for flap harvest and donor site closure. Following donor site closure, the patient is then repositioned in the supine position for implant placement, flap inset, and breast symmetry and shape examination.

For bilateral breast reconstruction, LD flaps can be efficiently harvested while the patient is in the prone position; however, care must be taken to avoid direct pressure on the mastectomy skin flaps while the patient is prone. Judicious use of padding can prevent breast skin flap compression.

Flap elevation