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The Breast 22 (2013) 667e672

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The Breast

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Original article

Breast reconstruction with the denervated latissimus dorsimusculocutaneous flap

Pawel Szychta a,b,*, Mark Butterworth a, Mike Dixon c, Dhananjay Kulkarni c, Ken Stewart a,Cameron Raine a

a Plastic and Reconstructive Surgery Department, St John’s University Hospital, Howden Road West, Livingston, West Lothian, EH54 6PP, United KingdombDepartment of Oncological Surgery and Breast Diseases, Polish Mother’s Memorial Hospital-Research Institute, Lodz, PolandcBreast Surgery Department, Western General Hospital, Edinburgh, United Kingdom

a r t i c l e i n f o

Article history:Received 7 July 2012Received in revised form8 November 2012Accepted 6 January 2013

Keywords:Breast reconstructionLatissimus dorsiDenervationInnervationMuscle atrophyVolume lossFlap

* Corresponding author. Tel.: +44 79 05 33 88 84.E-mail address: szychta@yahoo.pl (P. Szychta).

0960-9776/$ e see front matter � 2013 Elsevier Ltd.http://dx.doi.org/10.1016/j.breast.2013.01.001

a b s t r a c t

Objective: To analyze clinical implications of the thoracodorsal nerve division in the latissimus dorsimusculocutaneous flap breast reconstruction.Patients and methods: Prospective cohort study was conducted on 29 patients. Breast reconstruction withlatissimus dorsi musculocutaneous flap was performed unilaterally in 20 patients or bilaterally in 9women (38 breasts). Thoracodorsal nerve was divided during reconstruction of 20 breasts (group 1) andwas preserved for 18 breasts (group 2). Height, width, projection, area of the covering skin and volume ofthe reconstructed and healthy breasts were measured on the 3D images of the anterior chest wall, taken6 weeks and 6 months postoperatively with the Di3D 3D camera. Data regarding tissue consistency,painfulness and animation of the reconstructed breast, symmetry of both breasts and overall satisfactionafter the surgery were collected at 6 months.Results: The reconstructed and healthy breasts decreased in volume in group 1 (�45.85 cm3 �48.41 cm3, p ¼ 0.0004; �29.13 cm3 � 14.98 cm3, p ¼ 0.0009) and in group 2 (�31.5 cm3 � 25.35 cm3,p ¼ 0.0001; �15.4 cm3 � 21.96 cm3, p ¼ 0.0537). There were no differences in decrease in volumebetween groups 1 and 2 (p > 0.05).Respondents in group 1 in comparison to group 2 showed similar satisfaction of the tissue consistency ofthe reconstructed breast (p > 0.05) and the level of symmetry between both breasts (p > 0.05), gavelower scores for painfulness (p < 0.0001), animation (p < 0.0001) and higher scores for the overallsatisfaction about the reconstructed breast (p ¼ 0.0001).Conclusion: We suggest that division of the thoracodorsal nerve during latissimus dorsi musculocuta-neous flap breast reconstruction is a useful undertaking to minimize unnatural animation of thereconstructed breast.

� 2013 Elsevier Ltd. All rights reserved.

Introduction

At present, modern techniques for breast reconstruction aim torecreate a symmetric breastwith good esthetic shape and contours.1

It is well recognized that the incorporation of a patient’s own tissuesin breast reconstruction gives more favorable esthetic outcomes inthe majority of patients when compared to implant-only tech-niques.2 The latissimus dorsi musculocutaneous flap is an excellentsource of well vascularized autologous tissue for use in breastreconstruction with a complication rate of around 9%, including

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seroma formation, infection, partial flap necrosis and liponecroticpseudocysts.3 Favorable aspects of the surgical technique includea high rate of good esthetic results with symmetrical, naturallooking breasts, relatively short procedure and prompt recovery incomparison to the use of freeflaps.4 The technique is appropriate forawide groupof patients including very thinwomen, those unwillingto use the abdominal tissue, patients at high risk for free abdominalflaps with obesity, diabetes, hypertension or tobacco smokers.5,6 Itcan act as a salvage procedure for those with partial flap necrosisafter free abdominal flap breast reconstruction or in cases of cancerrecurrence after conservative surgery.7 Early descriptions of thetechnique limited the volume available to recreate an adequatebreast mound.8 This issue was overcome by introducing theextended latissimus dorsi musculocutaneous flap technique.4 The

P. Szychta et al. / The Breast 22 (2013) 667e672668

drawbacks of this surgical technique areweakening of the shoulder,a donor site scar on the back and animation of the reconstructedbreast.9

The above mentioned last adverse effect e unwanted animationof the reconstructed breast e could potentially be avoided by cut-ting the thoracodorsal nerve during the surgery; however therewould be a theoretical risk of atrophy of the denervated musclewhich could lead to a decrease of the reconstructed breast volume.The thoracodorsal nerve is a branch of the posterior cord of thebrachial plexus, and is made up of fibers from the posterior di-visions of all three trunks of the brachial plexus. It follows thecourse of the subscapular artery, along the posterior wall of theaxilla to the latissimus dorsi muscle, inwhich it may be traced as faras the lower border of the muscle. It carries motor fibers andsupplies latissimus dorsi on its deep surface. The skin on the la-tissimus dorsi muscle is supplied mainly by dorsal primary di-visions from the sixth to twelfth thoracic nerves.10 There is still nodefinite standard concerning the surgical management of thethoracodorsal nerve. Presently, many surgeons leave the thor-acodorsal nerve intact during breast reconstruction which can giverise to unwanted movement.

The aim of the study was to analyze the clinical implications ofthoracodorsal nerve division during latissimus dorsi muscu-locutaneous flap breast reconstruction.

Patients and methods

The prospective cohort study was conducted from September2010 until September 2011 following approval of the South EastScotland Research Ethics Committee 10-S1101-33. For the study weincluded 29 patients, who had breast reconstruction in theDepartment of Plastic and Reconstructive Surgery in St John’sHospital in Livingston or in the Department of Breast Surgery in theWestern General Hospital in Edinburgh, Great Britain. Breastreconstruction with latissimus dorsi musculocutaneous flap wasperformed unilaterally in 20 patients or bilaterally in 9 women(38 breasts). In all patients the extended latissimus dorsi flaptechnique was used.11 In 31 cases implants were added to increasevolume of the reconstructed breasts. The thoracodorsal nerve wasdivided for 14 patients in reconstruction of 20 breasts done by onesurgeon (group 1) and it was preserved for 15 patients in recon-struction of 18 breasts performed by three surgeons (group 2)(Figs. 1 and 2).

Fig. 1. 3D scan of patient after breast reconstruction with the denervated latissimus

Patients had 3D scans taken of the anterior chest wall 6 weeksand 6 months after the surgery with the Di3D 3D camera. Use of 3Dimaging has been previously extensively validated for assessmentof the breast shape and size.12,13 Height, width, projection, area ofthe covering skin and volume of the reconstructed and healthybreasts were measured from the 3D scans. Subsequently, the dif-ference in parameters between the reconstructed and healthybreasts 6 weeks and 6 months after the surgery was calculated for:height, width, projection, area and volume. The degree of asym-metry for area and volume of both breasts used the equation:a ¼ (l � r)/(l þ r)*100 and the results were presented as percentage(from 0% e no asymmetry to �100% e total asymmetry).

A survey of five questions was conducted at 6 months after thesurgery to investigate: (a) tissue consistency of the reconstructedbreast in relation to the normal breast tissue, (b) painfulness, (c)animation of the reconstructed breast, (d) symmetry of bothbreasts and (e) overall satisfaction level after the surgery. The an-swers were scored from 1 (very weak) to 5 (very good).

The significance of differences between the variables wasassessed with statistical tests. The KolmogoroveSmirnov test wasused to evaluate the normality of the groups. Differences betweenindependent parametric variables were assessed with t-test forindependent samples. Differences between dependent parametricvariables, such as comparing values of parameters in the samegroup between 6 weeks and 6 months after surgery were checkedwith t-test for dependent samples. Correlations were assessed withPearson’s test. Probabilities of less than 0.05 were accepted assignificant.

Surgical technique

During the preoperative consultation an intact thoracodorsalnerve is indicated if the patient can adduct the arms againstresistance, using the functional innervated latissimus dorsi muscle.Preoperative markings are undertaken with the patient standingmaking note of the projected breast ‘footprint’. On the back themarkings include the borders of the muscle, including: medial lineand posterior axillary line, iliac crest and the tip of the scapula. Wefavor a transverse skin ellipse leaving a scar in the bra line however,the skin paddle can be in any of the 3 popular locations, i.e. uppertransverse, vertical and lower transverse.7,14

The surgical technique for extended latissimus dorsi flap harvestis well described.15e18 Under general anesthesia the patient is placed

dorsi musculocutaneous flap; (a) state after 6 weeks, (b) state after 6 months.

Fig. 2. 3D scan of patient after breast reconstruction with the innervated latissimus dorsi musculocutaneous flap; (a) state after 6 weeks, (b) state after 6 months.

P. Szychta et al. / The Breast 22 (2013) 667e672 669

in the lateral position. After incision to themargins of the skin islandthe dissection of the muscle is performed distally in the planeimmediately under the superficial layer of thoracolumbar fascia(SLTLF), thus the deep layer of fatty tissue is harvested alongwith themuscle. The deep thoracic fascia acts as a fascial layer that separatesthe fatty tissue of the back into two layers. The superficial fatty layeris the thicker layerwith themore compact and dense fat. The deeperlayer is thinner and more areolar.15 Fat can be also harvestedextending from themuscle edge, particularly along the superior andmedialmuscle borders.19 The design of the extended latissimus dorsimusculocutaneous flap includes the additional volume of the para-scapular and scapular fat, in addition to the lumbar fat.20 These fadpads, if present, can be added to the flap to increase its volume.21 Themedial and inferior origins of the muscle are then divided and theflap is dissected from the posterior chest wall.

When raising the latissimus dorsi flap, the identification of thevascular pedicle is helpful to ensure that it is intact and has notbeen injured during the previous sentinel node biopsy, axillarynode dissection or the current procedure. Thoracodorsal nervecourses with the vascular pedicle and thus can be identified anddivided. The thoracodorsal nerve is usually identified as it passesunder the insertion of the muscle. This can be complicated in casesof excessive local scarring. In this study the thoracodorsal nervewas divided (group 1) or left intact (group 2).

After raising the flap a subcutaneous tunnel is created high inthe axilla and tissue is transferred to the mastectomy defect alongwith the skin island. Suction drains are used.

The patient is rotated into the supine position to complete thereconstruction. The muscle is inserted into the margins of themastectomy defect. The inframammary fold can be recreated bysuturing the skin flaps after mastectomy to the anterior chest wall.3

Breast implants are placed if required. The use of breast implantsunder the muscle to increase the volume of the breast can improvethe esthetic outcome, resulting in smooth, gentle contours alongthe medial, superior and lateral edges of the reconstructed breast.After placing a suction drain the wound is closed in layers withdeep quilting sutures.

Results

The objective assessment with use of 3D camera of the resultsafter breast reconstructionwith latissimus dorsi musculocutaneousflap, in relation to the surgical management with the thoracodorsalnerve (nerve dissected in group 1 and nerve left intact in group 2),is presented in Table 1.

Patients enrolled to group 1 were age 47.05 � 7.07 years andwomen included to group 2 were aged 48.77� 9.52 years (t ¼ 0.63,

p > 0.05). In group 1 the patients had the following comorbidities:severe obesity (1/14), aniridia (1/14), hypertension (1/14) and hy-pothyroidism (1/14). In group 2 the patients had the followingcomorbidities: discoid lupus erythematosus (1/15), anisometropicamblyopia (1/15), hypertension (1/15), psioriasis (1/15), hyperthy-roidism (1/15), asthma (1/15), depression (1/15) and hypothyroid-ism (1/15). The complications observed in group 1were: seroma (3/14), infection (3/14) and skin necrosis (1/14). Total incidence ofcomplications in group 2 was 5/14 (35% patients). The complica-tions observed were: seroma (4/15), skin necrosis (3/15) andinfection (1/15). Total incidence of complications was 6/15 (40%patients).

In group 1, the reconstructed breasts were similar in shape tothe healthy ones in all parameters 6 weeks and 6 months after thesurgery, including height (6 weeks: p > 0.05; 6 months: p > 0.05),width (p > 0.05; p > 0.05), projection (p > 0.05; p > 0.05), area(p > 0.05; p > 0.05) and volume (p > 0.05; p > 0.05). Similarly, ingroup 2 both, the reconstructed and healthy breasts had symmet-rical shape, measured 6 weeks and 6 months after the operationand described by: height (6 weeks: p > 0.05; 6 months: p > 0.05),width (p > 0.05; p > 0.05), projection (p > 0.05; p > 0.05), area(p > 0.05; p > 0.05) and volume (p > 0.05; p > 0.05).

In the observed period of 18weeks the reconstructed andhealthybreasts in group 1 changed in shape, described by difference inmost of parameters: height (�1.55 mm � 2.72 mm, p ¼ 0.0198and �5.38 mm � 5.58 mm, p ¼ 0.0013), width (�4.25 mm �5.58 mm, p ¼ 0.0030 and �6.50 mm � 4.99 mm, p ¼ 0.0078), pro-jection (�3.40 mm � 3.44 mm, p ¼ 0.0003 and �2.75 mm �5.80 mm, p > 0.05), area (�0.11 dm2�0.15 dm2, p ¼ 0.0041and �0.25 dm2�0.14 dm2, p ¼ 0.0013) and volume (�45.85 cm3 �48.41 cm3, p ¼ 0.0004 and �29.13 cm3 � 14.98 cm3, p ¼ 0.0009). Incontrast, in group 2 both, the reconstructed and healthy breasts didnot change significantly in shape during the observed period, con-sidering most of linear parameters: height (�0.39 mm � 5.07 mm,p > 0.05 and �1.90 mm � 7.64 mm, p > 0.05), width (�0.72 mm �4.82 mm, p > 0.05 and �1.20 mm � 4.57 mm, p > 0.05) and pro-jection (�1.67 mm � 3.74 mm, p > 0.05 and 1.60 mm � 3.20 mm,p > 0.05). In group 2, after 18 weeks of follow up we observed dif-ferences only in spatial parameters: area (�0.1 dm2 � 0.11 dm2,p ¼ 0.0010 and �0.13 dm2 � 0.14 dm2, p ¼ 0.0164) and volume(�31.5 cm3 � 25.35 cm3, p ¼ 0.0001 and �15.4 cm3 � 21.96 cm3,p ¼ 0.0537).

In both groups, we found no correlations in the change ofany parameters in time between the reconstructed and healthybreasts (p > 0.05). Width decreased more in the reconstructedbreasts in group 1 than in group 2 (�4.25 mm � 5.58 mmand�0.72 mm � 4.82 mm, p ¼ 0.0453). However, change in height,

Table 1Outline of changes in time of shape of the reconstructed and healthy breasts (delta), correlation of changes in time of parameters (delta) between the reconstructed and healthy breasts and degree of asymmetry between thereconstructed and healthy breasts of the areas of the covering skin and the volumes, in relation to groups 1 and 2, assessed 3 weeks (6 W) and 6 months (6 M) after the surgery using the 3D camera; t(i) e t-test for independentsamples, t(d) e t-test for dependent samples, ns e non-significant.

Parameter Differences between the reconstructed and healthy breasts within a group Difference inreconstructedbreast ingroup 1 vs. 2

Group 1 Group 2

Reconstructed breast Healthy breast Difference Correlation Reconstructedbreast

Healthy breast Difference Correlation

t(d) p r p t(d) p r p t(i) p

Changes ofbreasts shapein time

Height (mm) 6 W 160.50 165.50 �0.68 ns 147.11 145.60 0.15 ns 2.13 0.03926 M 158.95 160.13 �0.16 ns 146.72 143.70 0.3 ns 1.93 nsdelta �1.55 (�0.96%) �5.38 (�3.25%) 3.29 0.0029 0.63 ns �0.39 (�0.26%) �1.90 (�1.30%) 0.63 ns �0.09 ns �0.89 ns

Height(Change in time)

t(i) 2.55 5.2 0.33 0.79p 0.0198 0.0013 ns ns

Width (mm) 6 W 179.85 180.25 �0.04 ns 169.22 163.30 0.54 ns 1.42 ns6 M 175.60 173.75 0.2 ns 168.50 162.10 0.62 ns 0.95 nsdelta �4.25 (�2.36%) �6.50 (�3.60%) 0.99 ns �0.57 ns �0.72 (�0.42%) �1.20 (�0.73%) 0.26 ns 0.37 ns �2.07 0.0453

Width (Changein time)

t(i) 3.41 3.69 0.64 0.83p 0.0030 0.0078 ns ns

Projection (mm) 6 W 61.30 57.81 0.86 ns 54.44 58.70 �1.08 ns 2.34 0.02466 M 57.90 55.06 0.74 ns 52.78 60.30 �2.04 0.0512 1.78 nsdelta �3.40 (�5.54%) �2.75 (�4.75%) �0.37 ns �0.15 ns �1.67 (�3.06%) 1.60 (2.72%) �2.32 0.0282 0.09 ns �1.48 ns

Projection(Change in time)

t(i) 4.42 1.34 1.89 �1.58p 0.0003 ns ns ns

Area (dm2) 6 W 3.68 3.57 0.33 ns 3.28 3.34 �0.16 ns 1.58 ns6 M 3.57 3.32 0.78 ns 3.18 3.21 �0.08 ns 1.51 nsdelta �0.11 (�2.98%) �0.25 (�7.00%) 2.26 0.0326 �0.68 ns �0.10 (�3.04%) �0.13 (�3.89%) 0.6 ns �0.59 ns �0.27 ns

Area (Changein time)

t(i) 3.26 5.15 3.95 2.94p 0.0041 0.0013 0.0010 0.0164

Asymmetry ofareas (%)

6 W 3.68�3.83

1.88 ns

6 M 6.79�2.68

2.41 0.0283

Volume (cm3) 6 W 834.40 1017.88 �1.72 ns 680.67 737.70 �0.45 ns 1.79 ns6 M 788.55 988.75 �1.95 ns 649.17 722.30 �0.59 ns 1.68 nsdelta �45.85 (�5.49%) �29.13 (�2.86%) �0.95 ns �0.53 ns �31.50 (�4.62%) �15.40 (�2.08%) �1.68 ns 0.04 ns �1.12 ns

Volume (Changein time)

t(i) 4.24 5.5 5.27 2.22p 0.0004 0.0009 0.0001 0.0537

Asymmetry ofvolumes (%)

6 W �8.16�5.91

�0.41 ns

6 M �8.90�6.79

�0.39 ns

p value in bold when less than 0.05.

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projection, area and volume in the observed period of time wassimilar in groups 1 and 2 (p > 0.05).

In group 1 the degree of asymmetry between the reconstructedand healthy breasts increased in time for area (asymmetry of areas 6weeks after surgery ¼ 3.68%, asymmetry of areas 6 months aftersurgery ¼ 6.79%) and volume (asymmetry of volumes 6 weeks aftersurgery ¼ �8.16%, asymmetry of volumes 6 months aftersurgery ¼ �8.90%). In contrast, in group 2 the degree of asymmetrybetween the reconstructed and healthy breasts decreased afterthe observed period for area (asymmetry of areas 6 weeksafter surgery ¼ �3.83%, asymmetry of areas 6 months aftersurgery¼�2.68%) and increased for volume (asymmetryof volumes6 weeks after surgery ¼ �5.91%, asymmetry of volumes 6 monthsafter surgery ¼ �6.79%). The degree of asymmetry was similar ingroups 1 and 2 for area at 6 weeks after surgery and for volume 6weeks and 6 months after operation (p > 0.05), whereas higherasymmetry was seen in group 1 for area at 6 months after breastreconstruction (p ¼ 0.0283).

The subjective evaluation of the outcomes in patients’ opinion isshown in Table 2. Women in groups 1 and 2 scored similar level ofsatisfaction concerning the tissue consistency of the reconstructedbreast in comparison to the healthy one (p > 0.05) and the level ofasymmetry between both breasts (p > 0.05). However, respondentsin group1 gave higher scores in comparison to group2 for pain in theoperated area (4.65 and 2.72, p < 0.0001), animation of the recon-structed breast (4.80 and2.17, p< 0.0001) and for overall satisfactionwith their reconstructed breast (4.60 and 3.22, p ¼ 0.0001).

Discussion

Breast reconstruction is performed to increase the quality of lifein patients who require mastectomy which, although essential insome individuals, is also a disfiguring procedure.22 Increase inquality of life can be achieved not only by recreating symmetricalbreasts, but also by eliminating any potential long-term side effectsof the surgery.

Some authors recommend leaving the thoracodorsal nerveintact claiming that this structure is essential to preserve flap vol-ume and maintain long term symmetrical results.23 In their opin-ion, division of the nerve would cause atrophy of the muscleleading to significant decrease in volume and an adverse impact onthe esthetic outcome. The prevalence of this opinion was alsoboosted by the difficulties in finding the nerve in some patients,especially following radiotherapy.24We share the opinion that stateafter radiotherapy can make the dissection of tissues more chal-lenging due to enhanced fibrosis.

Previous reports have confirmed flap atrophy, however this hasbeen observed in both innervated and denervated flaps.23 In thisreport flap thickness was measured 12 months following surgeryand no significant differences were found between the innervatedand denervated muscle flaps. The possible reason in both instanceswas lack of stimulation provided in normal conditions by

Table 2Patients’ opinion concerning features of the reconstructed breast in groups 1 and 2,assessed 6 months after surgery; t(i) e t-test for independent samples, ns e non-significant.

Parameter describing thereconstructed breast

Group 1Mean

Group 2Mean

Difference

t(i) p

Consistency 4.30 3.78 1.58 nsPain 4.65 2.72 6.28 <0.0001Animation 4.80 2.17 10.44 <0.0001Symmetry 4.15 4.22 �0.26 nsOverall satisfaction 4.60 3.22 4.50 0.0001

p value in bold when less than 0.05.

movement. In our study we assessed the shape and size of thewhole breasts 6 weeks and 6 months after the surgery and founda decrease in volume of the reconstructed breasts of 45.85 dm3

(�5.49%) for the denervated flap group, which was similar to thebreasts where the flaps remained innervated (decrease in31.50 dm3, �4.62%) (p > 0.05). Indisputably, in our study patientsgave similar scores for the symmetry of the reconstructed breastsafter dividing or preserving the thoracodorsal nerve (4.15 of 5 and4.22 of 5, respectively, p > 0.05).

The well-known drawbacks of the latissimus dorsi breastreconstruction are painfulness in the operated area and twitchingof the muscle.25 Usually, the symptoms do not decrease in time andcause significant discomfort for the patients. In extreme cases pa-tients withdraw from the social life as they are embarrassed by theanimation of the breast. The muscular contraction deformities canbe treated with botulinum toxin type A however the result is un-predictable and temporary.26 The procedure of delayed divisionof the thoracodorsal nerve is well recognized, offering relief topatients complaining of tightness and muscle activity after inner-vated latissimus flap breast reconstruction. In the study of Halperinet al., 41% patients after primary breast reconstruction with latis-simus dorsi muscle were later subjected to a delayed division ofthoracodorsal nerve because of active twitching of the muscle anda feeling of tightness.27 In our study patients subjected to primarydivision of the thoracodorsal nerve during breast reconstructiongave significantly more favorable scores for both, painfulness (4.65vs. 2.72, p < 0.0001) and animation of the reconstructed breast(4.80 vs. 2.17, p< 0.0001). Division of the thoracodorsal nerve at thetime of the primary procedure would minimize the need for sec-ondary surgery to achieve this end. Moreover, scarring after pri-mary surgery can make secondary division of the thoracodorsalnerve more risky and difficult.

Breast reconstruction aims to create symmetrical breasts how-ever, the appearance of the breasts is not the only factor to influ-ence the patients’ satisfaction following surgery.28 Adverse effects,such as painfulness and breast animation, can diminish the pa-tients’ satisfaction with an otherwise good esthetic result. In ourstudy, the overall satisfaction after latissimus dorsi breast recon-struction with the denervated flap was higher (4.60 of 5) than withthe innervated one (3.22), p ¼ 0.0001.

Limitations of the study included relatively small groups ofpatients. Five patients had implant inserted which could also addbias to the results. The observation lasted 18 weeks and thus wasrelatively short for the long-term assessment of the surgical out-comes. Nevertheless, our report presents clinically valuable dataconcerning the preferred surgical management of the thor-acodorsal nerve.

In conclusion, our data supports the routine division of thethoracodorsal nerve during latissimus dorsi musculocutaneous flapbreast reconstruction to reduce the incidence of troublesome un-natural breast movements.

Ethical approval

Approval of the NHS Lothian Research & Development Com-mittee: 2010/SJ/PS/02 and the South East Scotland Research EthicsCommittee: 10-S1101-33.

Funding source

None.

Conflict of interest statement

None.

P. Szychta et al. / The Breast 22 (2013) 667e672672

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