Traditionally, the latissimus dorsi flap has been harvested and transferred as a musculocutaneous flap in women requiring muscle and skin coverage of mastectomy defects with or without an implant. Many patients undergoing breast reconstruction after mastectomy with or without radiation do not require skin coverage. For these patients, the pure latissimus muscle flap in conjunction with an expander/implant is an acceptable and appropriate choice for breast reconstruction. This muscle-only flap allows for a more aesthetically pleasing scar at the donor site as well as eliminates the “skin paddle” scar on the anterior chest. The authors have also started harvesting the muscle-only flap from an anterior approach through the mastectomy defect, eliminating the need for an incision on the back. Utilizing the anterior approach for harvest of the latissimus muscle during an immediate breast reconstruction allows the patient to remain in the supine position, eliminating the need for an additional prep and drape and therefore reducing total operative time. The authors wish to present their 3 year experience using the latissimus dorsi muscle flap without a skin paddle in conjunction with a tissue expander/implant for breast reconstruction.

A retrospective chart review was performed at two hospitals of all patients who underwent breast reconstruction following mastectomy utilizing a latissimus dorsi muscle flap without a skin paddle in conjunction with an expander/implant by a single surgeon between October 2004 and May 2007. Data regarding the patients' age, history of radiation, and number of minor and major complications were recorded. The decision to use the latissimus muscle without a skin paddle was based on the presence or absence of adequate skin and muscle to provide coverage for the expander/implant at the time of reconstruction.

Between October 2004 and May 2007 forty nine latissimus muscle flaps without a skin paddle were performed on thirty three women ranging in age from 32-67 years. 17 reconstructions were immediate and 32 were performed in a delayed fashion. There were no major complications defined as death, MI, DVT, or pulmonary embolus. There were minor complications including seroma requiring aspiration: 27 (55 %), Capsular Contracture Requiring Revision: 4 (8%), Infection of Implant Requiring Removal: 2 (4%), and Hematoma requiring evacuation: 2 (4%).

The use of the latissimus dorsi muscle flap without a skin paddle in conjunction with an expander/implant is an excellent choice for breast reconstruction following oncological breast surgery. The only indication for using a skin paddle with the latissimus flap is the inability to close the wound primarily. In this study population, there was never a need for a skin paddle secondary to deficient skin, even in those patients who were radiated. The use of the latissimus muscle flap without a skin paddle yielded several advantages over the traditional latissimus dorsi myocutaneous flap. Aesthetic outcomes were improved by sparing these patients the anterior chest “skin paddle” scar, as well as reducing the size of the donor site incision.

In several cases of the anterior approach for harvest of the muscle flap the donor incision on the back and the need to turn the patient intraoperatively were eliminated. The hearty blood supply to the latissimus dorsi muscle from the thoracodorsal pedicle obviated the need for a skin paddle for flap monitoring purposes. In all cases the muscle was always large enough to achieve complete coverage of the tissue expander/implant at the time of operation. There were no instances of total flap loss or necrosis from ischemia and the minor complication rate was comparable to those figures in the current literature on the use of latissimus flaps in breast reconstruction.