Oncoplastic volume replacement with latissimus dorsi myocutaneous flap in patients with large ptotic breasts. Is it feasible?

BACKGROUND: Oncoplastic breast conservative surgery has evolved as a safe alternative to the standard mastectomy in the treatment of early breast cancer. The procedure involves tumour resection with an adequate safety margin and either breast reshaping with volume displacement procedures (large or ptotic breasts) or volume replacement with latissimus dorsi myocutaneous flap (LDF) (small to medium sized non-ptotic breasts). A contra lateral mastopexy procedure is usually necessary with the volume displacement oncoplastic surgery, a procedure that is often rejected by a significant number of patients. This limits the choice of the reconstruction of breast defects in such patients to autologous tissues i.e. LDF.

AIM: Aim is to evaluate the feasibility of volume replacement oncoplastic breast conservative surgery with latissimus dorsi myocutaneous flaps for patients with large ptotic breasts. This involves testing the oncologic safety in terms of adequate safety margin, the complications rate and the final cosmetic outcome. The loco regional recurrence rate will be recorded and compared with oncoplastic volume displacement for similar sized breast defects.

PATIENTS AND METHODS: A group of 50 female patients with early breast cancers (T2) who presented to the department of surgery at the National Cancer Institute, Cairo, Egypt in the period between January 2004 and November 2009 were included in the study. Bilateral soft tissue mammography was carried out in all patient groups and was used to annually follow up the patients. All patients were detected with T2 N0 breast cancer by both clinical and radiological examinations. All patients underwent partial mastectomy and reconstruction with LDFs.

RESULTS: The average age at presentation was 46.5±9years and the range was 26-65years. Most of the patients were subjected to partial mastectomy in 30 patients (60%), excision of a single quadrant from the four major quadrants was carried out in 15 patients (30%) where skin sparing wide local excision was carried out in only five patients (10%). The safety margin ranged from 1.1 to 3.2cm with an average of 1.8±0.5cm. There was no total flap loss in any patient where as we reported partial flap loss in two patients. Nipple and areola sloughing were reported in two patients, wound infection in five patients, haematoma in four patients, seroma in 16 patients, and donor site morbidity in six patients. The vast majority of patients were either satisfied (score >3 out of 5) (62%) or very satisfied (score 4 or more) (18%) with the results of reconstruction.

CONCLUSION: The results of the current study showed the feasibility and the versatility of volume replacement oncoplastic surgery in patients with large ptotic breasts with myocutaneous flaps. The adequacy of safety margin and the acceptable complications rate as well as the comparable local recurrence rate to volume displacement oncoplastic surgery, make it a suitable alternative in a subset of patients who object an immediate contra lateral mastopexy procedure.