Journal of Plastic, Reconstructive & Aesthetic Surgery
No need to cut the nerve in LD reconstruction to avoid jumping of the breast: A prospective randomized study☆
Introduction
Breast reconstruction with a pedicled myocutaneous latissimus dorsi (LD) flap is a widely used safe reconstruction method with minimal donor-site morbidity.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 It is an appropriate method for a wide group of patients, including very thin women in whom abdominal tissue is not available, or for patients with co-morbidities such as diabetes and smoking that present a higher risk for abdominal flap procedures. It has been found that patients generally express a preference for autologous material and an excellent aesthetic result when choosing the type of breast reconstruction.12 However, autologous tissue combined with an implant has been found less popular when compared with autologous tissue alone. Short operation time has been preferred over a long operation. Short-term and long-term complication rates are also found important by the patients. Based on these findings, extended LD flap reconstruction, for example, offers the advantages of autologous tissue, while operation times are shorter when compared with those of free-flap breast reconstruction, and long-term complications associated with the use implant material are avoided.
It is controversial if surgical denervation by transecting the thoracodorsal nerve should be performed or not. Some surgeons consider that resection of the thoracodorsal nerve may lead to pedicle injury, especially in delayed breast reconstruction.9, 13, 14 It has been assumed that, after denervation, the LD muscle will significantly atrophy and, thus, lose its volume.7, 14, 15, 16 In a previous study, we have showed that denervation of the LD flap causes more significant myofiber atrophy than when the flap is innervated.17 However, marked atrophy was also observed in the innervated flaps, which can be explained by the inactivity of the muscle. The completely detached LD muscle is no longer stretched between the origin and insertion. Interestingly, it was also shown that there was no significant difference in the LD flap thickness between the denervated and innervated groups. This was explained by more pronounced fatty tissue infiltration in denervated flaps. It seems that the volume and consistency of the flap remain more or less the same regardless of whether the thoracodorsal nerve is cut or not. Currently, some surgeons believe that the discomforting signs and symptoms from muscle contraction can be avoided if surgical denervation is performed.3, 6, 13, 18
In this prospective, randomized study, the aim was to examine the functional and aesthetic effects of both innervation and denervation of the LD flap, in association with complete division of the LD tendon, in delayed reconstruction.
Section snippets
Patients
Delayed unilateral breast reconstructions with a pedicled myocutaneous LD flap were performed during the years 2007–2008. The research protocol was accepted by the ethical committee of Tampere University Hospital. Written informed consent was obtained from the patients.
Twenty-eight patients were randomized into two groups: denervated group (n = 14) and innervated group (n = 14). The average age of the patients was 53 years (range 41–62 years). Average time after primary mastectomy was 2.8 years
Results
The results of patients' evaluation of the twitching, pain and tightness of the breast 12 months after LD flap breast reconstruction are presented in Table 1. In the innervated group, seven patients had minor twitching and seven had no twitching at all. Those patients who had minor twitching did not find it discomforting. In addition, they did not feel that the breast was markedly distorted because of the muscle contractions. Several patients in the innervated group mentioned that the breast
Discussion
The treatment of thoracodorsal nerve during breast reconstruction with LD flaps has been discussed and there are opinions both in favour of and against transecting the nerve. Some authors prefer leaving the thoracodorsal nerve intact in order to preserve flap volume and maintain long-term symmetrical results, particularly when the LD muscle is raised extended with surrounding fat tissue16, 17, 20, 21 or following radiotherapy.22 However, it has been shown histologically, immunohistochemically
Conflict of interest/funding statement
None of the authors have a financial interest to declare in relation to the content of this article.
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Presented at the 21st European Association of Plastic Surgeons (EURAPS), Manchester, United Kingdom, 27–29 May 2010.