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| Dr. Joel Aronowitz |
Abstract
Introduction
The lateral chest roll flap is an
often overlooked alternative in breast breast reconstruction and post bariatric
breast augmentation. The lateral chest roll The Lateral intercostal artery
perforator (LICAP) pedicled flap procedures have been widely used in the past
to alleviate breast deformities which arise in post-bariatric patients. This
pedicled flap provides ample material for an autogenous breast augmentation,
and a significant source of central mound skin which is important in
reconstruction. Additionally, donor
site morbidity is minimal due to the fact that the donor site is the excess
skin that is commonly present in post-bariatric patients.
More
recently, it has been seen that a variation of this LICAP pedicled flap can be
used not only in massive weight loss patients, but also in patients with
post-mastectomy defects. The lateral chest roll flap, which is a transverse
perforator flap based on the lateral intercostal artery, is a useful and
reliable source of skin and volume for breast reconstruction in the
post-mastectomy patient.
There
are many benefits to the lateral chest roll flap that make it an excellent
alternative to the available techniques in breast reconstruction. Because these
lateral chest roll flaps are harvested without sacrificing underlying muscle,
donor site morbidity is reduced. Consequently, because the lateral chest roll
flap procedures do not involve the movement of muscle, they require a shorter
post-operative recovery time and can be performed in outpatient surgical settings.
Outpatient surgical centers are often preferred to traditional hospitals
settings due to their size, quality and efficiency.
Methods
The database of patients undergoing
breast reconstruction at Dr.
Joel Aronowitz’s office was queried for breast cancer patients undergoing
lateral chest roll flap between January 2005 and June 2013, and 21 patients
were identified. A retrospective study was performed and the medical records of
these 21 patients were reviewed. Medical information was extracted from the patients’
charts, including demographics, perioperative and post-operative outcomes.
Surgical
Technique
The lateral chest roll flap is designed to
follow the lateral chest roll (Fig 1) with the pedicle located at the lateral
10 cm of the inframammary fold. The skin/adipose flap is elevated at the muscle
fascia level with care taken during the dissection to avoid injury to the long
thoracic nerve and the cutaneous perforator branches entering the flap from the
intercostal vessels (Fig 2). The cranial border of the flap is usually
continued to join the mastectomy incision. The flap is rotated 180 degrees. The
pivot point is reinforced with a multi-laminated porcine xenograft, Biodesign®
(Fig 3). The xenograft is sutured to the lateral border of the pectoralis major
and serratus muscle to provide support for the flap and prevent post-operative
lateral migration of the flap (Fig 4). Surgical results were assessed for flap
and donor site complications and lateral bulge.
Results
Patients’ characteristics are summarized
in Table 1. 30 lateral chest roll
flap procedures were performed on 21 patients between January 2005 and June
2013. The patients’ ages ranged from 43 to 83 years old, with a median age of
64 years old. All of the patients were diagnosed with breast cancer and seeking
breast reconstruction post-mastectomy. The majority of the patients had
undergone mastectomy (6 bilateral, 2 skin sparing bilateral, and 10 unilateral)
prior to the lateral chest roll procedure. The remaining 3 had undergone
lumpectomies. Only 6 of the 21 patients had undergone prior radiation therapy.
Of
the 21 patients, 20 of them had their operations performed in outpatient
surgical settings (Tower Outpatient Surgery Center). Only one patient underwent
the operation in an inpatient setting and was discharged home on post-operation
day number 3. Following surgery, only 4 patients were sent to aftercare
facilities for an average of 1 day (3 for 1 day, and 1 for 2 days). The other
17 patients were sent home.
In
all but two of the patients, simultaneous associated procedures were performed.
Fat grafts were performed on 22 flaps in 16 patients. Implants were placed in
10 patients. Mastopexies were performed on 3 patients. Capsulectomies were
performed in 7 patients. Symmetrizing breast reduction was performed on 7
patients. Results summarized in Table 2.
15
patients including 19 flaps had no complications and required no revisions. The
most common complication in the remaining flaps was partial flap necrosis, which
occurred in 6 flaps in 4 patients. There was a flap infection which required
flap revision in one patient, and one patient developed a painful keloid which
required revision.
Discussion
Breast reconstruction is a
critical component in the treatment of breast cancer. In post-mastectomy
patients, there often is a need for tissue transfer during breast
reconstruction to create breasts that are symmetric and that have a natural
contour and shape. For this reason, the use of autologous tissue in breast reconstruction
has been in evolution since the 1970’s. There are a variety of accepted methods
of breast reconstruction with autogenous tissue. Flaps commonly used include
the Transverse Rectus Abdominis Myocutaneous flap (TRAM), the Deep Inferior
Epigastric Perforator flap (DIEP) and the latissimus dorsi flap. However, there
are serious limitations to these methods because they are all methods which
involve the transfer of muscle. Free flaps are detached from the donor site
along with their respective blood supply, which requires reattachment of the
vessels. Such procedures entail much longer and more extensive operations,
which further imply the need for aftercare. In contrast, in pedicled flaps the
donor tissue is still attached to the donor site but is rotated to the new
site, allowing the blood supply to the tissue to remain intact. The lateral
chest roll flap, which is a transverse perforator flap based on the lateral
intercostal artery, is an example of such a flap and presents distinct
advantages in breast reconstruction.
Harvesting
of the lateral chest roll flap is relatively simple and quick, and the
dissection provides adequate perforator length to successfully rotate the flap
180°. The flap provides variable but reliable source of skin and volume for the
central mound skin in implant reconstruction without sacrificing the underlying
muscle. Due to the lack of muscle and/or blood vessel movement, the procedure
is much less extensive and can be performed in an outpatient surgery setting.
This also eliminates the need for long hospital stays or aftercare facilities,
and overall the procedure is much less painful. Additionally, only a few
incidents of minor complications were reported (partial flap necrosis,
infection and scarring), all of which were revised in the outpatient surgical
center.
This
technique has demonstrated significant efficacy in the breast reconstruction of
post massive weight loss patients. The donor site is the lateral continuation
of the inframammary fold. Excess skin/fat roll is commonly present in this
location in post-bariatric and post-mastectomy patients, therefore minimal
donor site morbidity has been reported. Another benefit to the donor site is
that it yeilds aesthetically pleasing results, the minimal scarring that occurs
at the donor site can be easily hidden under a bra.
In
conclusion, the introduction of the perforator flap concept to patients other
than post-bariatric patients, specifically post-mastectomy patients, has the
potential to result in significant progress in the field of reconstructive
surgery. The lateral chest roll flap provides variable, but reliable source of
skin and volume for reconstruction, and donor site morbidity is minimal.
Finally, the simplicity of the procedure allows for it to be performed in outpatient
settings with minimal to no aftercare requirements.
Table 2 Associated
Procedures Performed Simultaneously
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