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The Breast 18 (2009) 126–129

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The Breast

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Original article

Immediate reconstruction using thoracodorsal adipofascial flap afterpartial mastectomy

Yuko Kijima*, Heiji Yoshinaka, Yawara Funasako, Koichi Kaneko, Munetsugu Hirata,Sumiya Ishigami, Shoji NatsugoeDepartment of Surgical Oncology, Breast and Endocrine Surgery, Kagoshima University Graduate School of Medical and Dental Sciences 8-35-1, Sakuragaoka,Kagoshima 890-8520, Japan

a r t i c l e i n f o

Article history:Received 7 September 2008Received in revised form3 December 2008Accepted 18 February 2009

Keywords:Breast cancerBreast conservative therapyCosmesisImmediate reconstructionThoracodorsal adipofascial flapOncoplastic surgeryFree dermal fat graft

* Corresponding author. Tel.: þ81 99 275 5361; faxE-mail address: ykijima@m3.kufm.kagoshima-u.ac

0960-9776/$ – see front matter � 2009 Elsevier Ltd.doi:10.1016/j.breast.2009.02.006

a b s t r a c t

BCT (breast conserving therapy) has become a standard strategy for breast cancer and ensures localcontrol and acceptable cosmetic results. However, an insufficient resection margin may increase localrecurrence if too much attention is paid to cosmesis. Here, we describe a simple technique for recon-struction of the defect on the outer upper part of the breast with early breast cancer using thoracodorsaladipofascial flap.

� 2009 Elsevier Ltd. All rights reserved.

Patients

Immediate reconstruction of surgical defects was performed infifteen patients with a solitary cancer lesion located in the upperouter-quadrant region using thoracodorsal adipofascial flap afterbreast conserving surgeries in the Department of Breast and Endo-crine Surgery at Kagoshima University Hospital, Kagoshima, Japanfrom February 2005 to June 2008. Mean patients age was 52 years(ranged, 23–72 years), the body weight and %IBW were 53 kg (range,45–71 kg) and 103% (range, 85–150%), respectively. In twelvepatients, lesions were diagnosed as malignant by fine needle aspi-ration biopsy, two were diagnosed by core needle biopsy, and twowere diagnosed by excisional biopsy. They all received no neo-adjuvant chemo- and hormonal therapy. Their contralateral breastsdid not receive any surgical treatment. Preoperatively the size of thetumor area which contained not only invasive component but alsointraductal one was examined using mammography, ultrasonog-raphy, enhanced computed tomography, and magnetic resonanceimaging. Eleven lesions were diagnosed as T1 and the other fivewere T2. The surgical margin measured and designed from the edge

: þ81 99 265 7426..jp (Y. Kijima).

All rights reserved.

of the lesion not only invasive component but also intraductalcomponent was 29 mm, with a range of 20–40 mm. The meanfollow up period was 23 months, with a range of 4–44 months.

Technique

With the patient supine and the ipsilateral arm free, allowingaccess to the axillary region, partial mastectomy, harvest of thor-acodorsal adipofascial flap and reshaping of the breast are per-formed. The thin pillow is put under the shoulder and that makesus easier to harvest lateral adipofascial flap. The curved incision isat the anterior axillary line. The tumor is removed with grossmargins of 20–40 mm in cylinder shape. In the patients who werediagnosed as having breast cancer only by fine needle aspirationbiopsy, no skin is removed unless leaving the skin would compro-mise the superficial margin. In the case who received core needlebiopsy or excisional biopsy preoperatively, these scars should becompletely removed with the gland. Fascia of the pectoral muscle iscompletely removed. Axillary lymph node dissection of sentinellymph node biopsy is performed via same incision.

The harvesting and implantation of the thoracodorsal adipo-fascial flap involve four steps: (1) harvesting a C-shaped flap ofsubcutaneous fat with fascia of latissimus dorsi muscle, (2) rotationof the flap to the medial defect, (3) trimming or gathering the flap

Fig. 1. Procedure for harvesting the C-shaped thoracodorsal flap and repair of the defect. (A) By the same skin incision upon the middle axillary line, we can do the partial resectionof the breast, axillary lymph node dissection, and get the adipofascial flap. (B) A C-shaped thoracodorsal adipofascial flap was harvested after local resection of the breast andaxillary lymph node dissection. (C) Attaching the fascia of the latissimus dorsi muscle to the adipose tissue makes the harvested tissue firm. (D) The flap is rotated to the medial sideto fill the defect. We sometimes roll or gather it to reconstruct to the breast mound.

Y. Kijima et al. / The Breast 18 (2009) 126–129 127

to adjust to the shape of the contralateral breast, and (4) fixing theflap to the edge of remnant gland (Fig. 1). Even if the patient is notobese, we can obtain an enough amount of fat. Attaching the fasciaof latissimus dorsi muscle to the adipose tissue makes the har-vested tissue firm. We roll, or gather it to reconstruct the breastmound and to adjust the size of the contralateral breast. Fixation tothe edge of the remnant gland was performed using PDS.

A continuous closed suction drainage tube was added to thesubcutaneous defect at the donor site and/or at the reconstructedbreast for several days after the operation.

Results

The mean total operative duration was 126 min (range, 90–160 min) which was containing of 38 min (range, 20–60 min) ofwaiting time for the intraoperative histological diagnosis where thesurgical margin was free from cancer lesion or not. The meanduration of the reconstructive process was 34 min (range, 15–45 min), and the mean blood loss for total process was 28 g (5–110 g). In all patients, closed suction drain was left in the place ofthe surface of the latissimus dorsi muscle for two days, and in thepatients we performed axillary lymphadenectomy it was left in

Fig. 2. 42-year-old lady with breast cancer located on upper outer-quadrant of the right brshaped thoracodorsal adipofascial flap was marked before surgery. (B and C) 6 months pos

axillary region for one week. As a postoperative complication, theminor skin necrosis was observed in three patients (18.8%), theformation of axillary seroma was in two (12.5%) in axillary defect.They were healed within a month after preservative treatment. Fatmelting was not observed in any cases, however, cystic formation inthe flap was detected by ultrasonography in three cases (18.8%),which were palpated relatively firmer than residual gland ornormal fatty tissue. There was no complain for sensory ormorbidity in the donor site.

Lymph node metastasis was detected in one patient. All lesionswere ductal carcinoma according to TNM histological classification.Eleven patients were diagnosed histologically as stage I accordingto TNM classification, four as stage II, and one as stage 0. In allpatients histological margins from not only invasive component butalso intraductal ones were over 10 mm, so postoperative radiationwere not added.

All patients were satisfied with their new breast becausesymmetry was obtained and the scar on the anterior axillary linewas completely hidden under the arm without any trouble on thedonor site.

Also, we could easily identify the rotated lateral chest adipo-fascial flap after surgery using ultrasonography. The existence of

east (Case 1). (A) A resected area of the breast with the gross margin as 3 cm and a C-t-surgery. The deformity of both breast and donor site is inconspicuous.

Fig. 3. 46-year-old lady with breast cancer located on upper outer-quadrant of the right breast (Case 2). (A) A resected area of the breast with the gross margin as 3 cm and a C-shaped thoracodorsal adipofascial flap was marked before surgery. (B and C) 6 months post-surgery. The cosmetic result was excellent.

Y. Kijima et al. / The Breast 18 (2009) 126–129128

the flap does not disturb the examination of the local condition ofthe residual gland by mammography and computed tomography.The calcification due to fat necrosis did not appear on mammog-raphy in these cases. There have been no cases that have to receiveadditional surgical treatment due to the local recurrence in thisseries.

Discussion

Although BCT rapidly became a first-line procedure for early-stage breast cancer and ensures local control and acceptablecosmetic results,1–3 removing a relatively large part of the wholebreast can thus have a considerable impact on poor cosmeticoutcome. BCT thus cannot always provide satisfactory cosmeticresults in patients with small breasts.

Deformity following BCT depends on the area of skin excised,the volume of subcutaneous and glandular tissue resected, devel-opment of postoperative fibrosis, scar contracture, and the effectsof radio and chemotherapy.2 Mild deformation can be correctedusing minor procedures such as transposition of local flaps, wideundermining, and conization of the residual breast tissue.2,3

Compared with Western females, the breasts of Asian women,including Japanese, are commonly too small to maintain symmetryeven after partial resection and need sometime to reconstructionby some kind of augmentation.4–6 In our previous study we havegotten the excellent cosmetic results after partial resection for theJapanese patients with not so large breast; using free dermal fatgraft for upper inter-quadrant defect and using inframammaryadipofascial flap of the anterior rectus sheath for lower defect,respectively.4,5 Although the defect of upper outer-quadrant areacan be repaired easier than one of the other area, the volumereplacements are sometime necessary.

Using latissimus dorsi muscle transposition, one of the mostpopular methods, sufficient breast tissue resection of tumor-freemargin can be achieved, with subsequent breast tissue deficiencyimmediately repaired using transposition.7,8 We can repair notonly breast defect but also axillary deformity after lymph nodedissection. However, one drawback of this technique is to needa sacrifice of healthy muscle. Ohuchi et al. reported immediatevolume replacement using lateral tissue flap which is removed

from latissimus dorsi fascia and maintained the vascular supplyby lateral thoracic vessels. They also reported that the breastcancer patients undergoing immediate volume replacement withthe lateral tissue flap showed better cosmetic outcome thanpatients who underwent breast reconstruction using the lat-issimus dorsi muscle flap.9 We have no experience to use thor-acodorsal perforator flap and lateral thoracodorsal flap to repairthe defect on this lower area of the breast immediately after thepartial resection of the breast for the treatment of breastcancer.10,11 Although it is difficult for us to write thoracodorsaladipofascial flap is superior to them we can only say that thistechnique might make it possible for general surgeon but noteven for plastic surgeon to reconstruct the defect on upper outer-quadrant of the breast safely and without any extra scars for thepatients with small breast and slim body. It might be importantfor us to compare and mention the results between the use of thisflap and the other flaps above.

In our procedure, we don’t have to mind to preserve thevascular supply of lateral thoracic vessels and only have to mindadhesion of the muscular fascia to the lateral subcutaneous fattytissue. We observed no large degeneration of the graft by ultra-sonographical examination after the operation, and good cosmeticresults were obtained without fat necrosis, volume loss, firmnessor contour irregularity (Figs. 2 and 3). However, because thelongest observation period is still 5 years we should be mined thelonger observation is necessary to say that this technique is moreexcellent not only in convenience but also in safety than otherones.

Conclusion

Immediate volume replacement using the thoracodorsal adi-pofascial flap at the time of BCT on the upper outer region can beuseful with good cosmetic effect, particularly for patients withsmall breasts, such as Japanese women.

Conflict of interest

None declared.

Y. Kijima et al. / The Breast 18 (2009) 126–129 129

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