BREAST SURGERY
Use of a Vertical Muscle-Sparing Latissimus Dorsi
Flap in Implant-Based Breast Reconstruction Without
Position Change
Hyung Chul Lee, MD,* Hyun Ho Han, MD, PhD,† and Eun Key Kim, MD, PhD†
Background: The use of various latissimus dorsi (LD) flap types in combination
with implants is a safe and reliable 1-stage breast reconstruction method. How-
ever, 1 or more positional changes are generally required during the procedure.
We designed a vertical skin paddle that was centered along the midaxillary line
and harvested the required LD muscle amount based on the thoracodorsal artery
descending branch, thereby completing flap elevation, inset, and donor-site clo-
sure in the supine position following skin-sparing mastectomy.
Methods: Between July 2017 and September 2017, we enrolled patients who
underwent breast reconstruction using the vertical muscle-sparing LD (ms-LD) flap
with an implant. The vertical ms-LD flap was selected when the nipple-areolar
complex could not be spared or when adjuvant radiation therapy was anticipated.
Results: Eleven patients were enrolled in the study. All patients underwent skin-
sparing mastectomy (with excision of the nipple-areolar complex for oncological
reason). The mean mastectomy specimen weight was 402.3 g. The average flap
length and width were 15.2 and 5.5 cm, respectively. The mean implant size was
290 mL. The average operative time was 112 minutes. All surgical procedures were
performed in the supine position, and the flap reached the most medial part of the
breast without any tension in all cases. The mean follow-up length was 87 days,
and no complications such as infection, partial flap loss, or donor-site seroma
were observed.
Conclusions: Vertical ms-LD flaps can be harvested and utilized in direct-to-
implant reconstructions when a skin paddle (or banking) is required, or when
acellular dermal matrix use is precluded, or when additional soft tissue coverage
is mandatory in high-risk patients not requiring intraoperative position changes.
This technique can shorten the operation time and may reduce donor-site morbid-
ity and associated complications.
Key Words: breast reconstruction, direct-to-implant reconstruction,
muscle-sparing LD
(Ann Plast Surg 2018;81: 152–155)
T he use of a latissimus dorsi (LD) flap, muscle-sparing LD (ms-LD)
flap, or thoracodorsal artery perforator (TDAP) flap combined with
direct-to-implant (DTI) procedures is a safe and reliable technique for
1-stage breast reconstructions.1–3 These methods are specifically useful
when the patient undergoes preoperative irradiation or when adjuvant ra-
diation therapy is anticipated. In the case of nipple-areolar sacrifice or a
mastectomy flap that is too thin, a skin paddle can also be included. How-
ever, at least 1 position change (or, more commonly, 2 position changes)
is generally required during an immediate LD flap breast reconstruction.
Received December 15, 2017, and accepted for publication, after revision March 15, 2018.
From the *Department of Plastic Surgery, Korea University Anam Hospital, Korea
University College of Medicine; and †Department of Plastic Surgery, Asan
Medical Center, University of Ulsan, College of Medicine, Seoul, Korea.
Conflicts of interest and sources of funding: none declared.
Reprints: Eun Key Kim, MD, PhD, Department of Plastic Surgery, Asan Medical
Center, University of Ulsan, College of Medicine, 88, Olympic-ro 43-gil,
Songpa-gu, Seoul 05505, South Korea. E-mail: nicekek@korea.com.
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0148-7043/18/8102–0152
DOI: 10.1097/SAP.0000000000001489
152 www.annalsplasticsurgery.com
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
In the present study, we designed a vertical skin paddle centered
along the midaxillary line and harvested the required LD muscle amount
based on the thoracodorsal artery descending branch and thereby per-
formed flap elevation, inset, and donor-site closure in the supine position
following skin-sparing mastectomy. Here, we report the technical consid-
erations and early outcomes associated with this method.
MATERIALS AND METHODS
We enrolled patients who underwent breast reconstruction using
the vertical ms-LD flap with an implant in the period July to September
2017. Patients who needed breast reconstruction but did not have
enough abdominal tissue or who were reluctant to using abdominal
based flap were candidate for LD-based breast reconstruction. Among
them, patients who underwent skin-sparing mastectomy or who needed
adjuvant radiation therapy were all included in the study. The study was
approved by the institutional review board of Asan Medical Center
(S2017-2062-0001) and was conducted in accordance with the Declara-
tion of Helsinki.
Operative Technique
Avertical skin paddle centered along the midaxillary line was de-
signed after identifying the anterior margin of the LD muscle. A posi-
tioning cushion was then inserted under the scapula with the patient
in the supine position, with the arm abducted. After completion of the
skin-sparing mastectomy, an anterior skin incision was made, and the
anterior margin of the LD muscle was identified. After thoracodorsal
artery descending branch was identified, a posterior skin incision was
made, and the required muscle amount was included in the flap. The
musculocutaneous flap was then elevated superiorly toward the superior
margin of the muscle, but elevation was stopped before the thoracodorsal
vessel bifurcation if possible. The flap was then transferred into the breast
via a subcutaneous tunnel. The upper part of the implant was positioned
beneath the pectoralis major muscle. The inferior part of the implant was
covered using the posterior part of the LD muscle. The skin paddle was
used to replace the excised nipple-areolar complex, and the remaining
part was de-epithelialized and buried to augment soft tissue coverage
(Fig. 1). The positioning cushion was removed prior to donor-site closure.
Symmetry was confirmed with the patient in the sitting position after per-
manent implant insertion. Finally, the flap was sutured into position.
RESULTS
Patient demographics and operative findings are summarized in
Table 1. We enrolled 11 patients in the study. The mean patient age was
47 years. All patients underwent skin-sparing mastectomy (with the
nipple-areolar complex excised for oncological reason). The mean mas-
tectomy specimen weight was 402.3 g. The mean length and width of
the flap were 15.2 and 5.5 cm, respectively. The mean size of the im-
plant was 290 mL. The average operative time was 112 minutes. All
surgical procedures were performed in the supine position as described
(Fig. 2), and in all cases the flap could reach the most medial part of the
breast without any tension (Fig. 3). The mean length of follow-up was
Annals of Plastic Surgery • Volume 81, Number 2, August 2018
Annals of Plastic Surgery • Volume 81, Number 2, August 2018 Vertical Muscle-Sparing LD Flaps With Implants

FIGURE 1. A, Intraoperative images after transfer of the flap to

the breast (oblique view). B, Anterior view.

87 days (range, 41–140 days), and no complications such as infection,

partial flap loss, or donor-site seroma were observed.
DISCUSSION
The use of an LD flap in DTI reconstruction is simple and safe,
particularly in high-risk patients. With advances in perforator flap sur-
gery, ms-LD (and nerve-sparing LD) flaps or TDAP flaps are commonly
used to decrease functional morbidity and donor-site complications. Kim
et al4 reported that the ms-LD flap had a low complication rate and fewer
donor-site functional and esthetic deficits compared with extended LD
flap breast reconstruction. No seromas were observed in our patients
probably because of lesser dissection and smaller dead space associated
with our technique. The skin paddle design also has been refined from
nonstandardized to transverse or propeller type.2,5–7
Although the use of ms-LD flaps has been well described by
other studies, we think that the most important point of this study is re-
duction of position change by using this design. Using LD, ms-LD, or
TDAP flaps for immediate breast reconstruction typically requires at
least 1 positional change. According to our previous results, the mean
FIGURE 2. A, Intraoperative images with the patient in the
supine position. After skin-sparing mastectomy and flap
elevation (lateral view). B, Anterior view. C, After implant
insertion and the flap coverage (lateral view). D, Anterior view.
operation extended LD flap breast reconstruction time was 206 minutes,
which was significantly longer than in this study (P = 0.016). Positional
change and additional draping are thought to be important reasons
causing this difference. Gust et al8 reported the use of an LD flap with
a tabbed expander in the lateral position without intraoperative posi-
tional change. Direct-to-implant reconstruction, however, requires sym-
metry confirmation in the sitting position, which can be hardly
achieved in the lateral position. Bittar et al9 reported elevating the LD
flap using an anterior approach; however, their incision technique was
different from ours and did not include a skin paddle.
The versatility of the LD flap in the general reconstructive field
was well reported by Kim et al,10 who could virtually harvest the flap in
any position. We too could harvest the ms-LD flaps using a vertical skin

TABLE 1. Patients' Demographics and Operative Findings

Mastectomy Flap Implant Operation

Patient Age, y Weight, g Dimension, cm2 Size, mL Time, min
1 50 405 15  4.5 270 120
2 55 264 14  4.5 160 92
3 47 427 15.5  5 270 119
4 57 454 16  5 300 128
5 64 407 15  6 120 125
6 30 150 13  5.5 215* 135
7 27 610 17  6 370 110
8 57 441 16.5  6 300 111
9 48 631 17  6 460 95
10 35 200 13  5.5 255* 110
11 47 437 15  6 360 85
Average 47 402.3 15.2  5.5 290 112
The mean volume of the implant was 290 mL, and the mastectomy specimen
weighed 402.3 g on average. The mean size of the flap was 15.2  5.5 cm2.
*Patients 6 and 10 received simultaneous augmentation mammoplasty on the
contralateral side with a 140-mL implant. FIGURE 3. The flap coverage of the most medial part of
the breast.

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Lee et al
FIGURE 4. A, Images of the patient 1 month after the operation (anterior view). B, Oblique view. C, Lateral view. D, Lateral view
with the arm flexed.
paddle in the supine position following mastectomy, thus expediting the
total operative procedure.
This flap has some potential pitfalls. The skin paddle dimension
is smaller than that of the classic LD flap, with an average width of ap-
proximately 5.5 cm. The total flap volume is also insufficient for
autologous-only reconstructions. A vertical scar line runs against the re-
laxed skin-tension line, although it can be hidden under the arm (Fig. 4).
Active prevention of hypertrophic scarring is essential, particularly in
Asian patients. When patients were asked about the scar, most of them
replied that they were generally satisfied. With the evolution of the op-
erative techniques, in the latter patients, we placed the incision not
higher than the inframammary fold level and designed the skin paddle
to be as short as possible. It can help to prevent contour deformities
and “dog ear” appearances above the incision around the axilla and to
increase the arc of rotation.
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Annals of Plastic Surgery • Volume 81, Number 2, August 2018
To conclude, vertical ms-LD flaps can be harvested and utilized
in DTI reconstructions when a skin paddle (or banking) is required,
when acellular dermal matrix use is precluded, or when additional soft
tissue coverage is mandatory in high-risk patients not requiring intraop-
erative positional changes. Our technique shortens the operation time
and may reduce donor-site morbidity and associated complications.
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Open. 2014;2:e140.
© 2018 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery • Volume 81, Number 2, August 2018
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Vertical Muscle-Sparing LD Flaps With Implants
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