Breast Reconstruction with Latissimus Dorsi Flap: Improved Aesthetic Results after Transection of Its Humeral Insertion

BREAST

Breast Reconstruction with the Latissimus DorsiFlap: Women’s Preference for Scar Location

Steven Bailey, M.D.Michel Saint-Cyr, M.D.

Kathy Zhang, B.Sc.Ali Mojallal, M.D.

Corrine Wong, M.R.C.S.Da Ouyang, B.Sc.

Munique Maia, M.D.Song Zhang, B.Sc., Ph.D.

Rod J. Rohrich, M.D.

Dallas, Texas

Background: Refinements made in latissimus dorsi breast reconstruction haveimproved the aesthetic appearance of the breast without changing the donor-site location. The optimal location for donor-site placement, from a patient’sperspective, is still unknown. The purpose of this study was to assess women’spreference for the latissimus dorsi donor-site location; the reasons for donor-sitechoice; and the correlation between donor-site location preference and factorssuch as, age, body mass index, body image, and clothing options.Methods: Two hundred fifty women between the ages of 20 and 80 years weresurveyed. Participants analyzed patients’ pictures and ranked the scar locationsfrom most desirable to least desirable. The reason for preference and additionalfactors were assessed. The data were then collected and analyzed using con-tingency tables with p � 0.005.Results: The low and middle transverse donor sites were the most preferredsites, 54 percent and 22 percent, respectively. The most common reasons forchoosing a donors site were ability to conceal the scar in a low-back top andcontour improvement. Women younger than 50 years were more concernedabout the ability to conceal the scar (64 percent). Women older than 50 yearswere focused on contour improvement (40 percent) and concealing the scarwhile clothed (42 percent) (p � 0.05). No direct correlation with age, body massindex, body image, or clothing options was seen.Conclusions: Women overwhelmingly prefer the low and middle transverse scarlocations. Physicians should consider using these locations primarily in suitablepatients, as this may improve overall patient satisfaction following breastreconstruction. (Plast. Reconstr. Surg. 126: 358, 2010.)

Breast reconstruction remains one of themost common procedures performed byplastic surgeons worldwide. Use of the latis-

simus dorsi flap for breast reconstruction hasmaintained a strong popularity because of its easeof harvest, reliability, and ability to provide addi-tional prosthetic coverage. The latissimus dorsiflap has undergone several variations1–5 since itsdescription by Tansini in 1896.6 The impetus forthese changes grew mainly from an enhancedunderstanding of the vascularity and neural sup-ply of the latissimus dorsi muscle.7,8 The abun-dant blood supply of the muscle allows for greatvariation in latissimus dorsi skin paddle designand harvest.9 –11 The main variations can be de-scribed as anatomical (e.g., split latissimus dorsi,

extended latissimus dorsi, muscle-sparing latissimusdorsi) and orientation of the skin paddle: transverse,oblique, or vertical. Although variations in skin pad-dle location can offer similar aesthetic results forbreast reconstruction, the effect on the final appear-ance of the back is variable. Some latissimus dorsiflap skin paddle designs leave scars that are large anddisfiguring despite an aesthetically pleasing breastreconstruction.

Increased patient education and awarenesshas resulted in not only the expectation of a pleas-ing breast reconstruction but also a pleasing do-nor site. The purpose of this study was to examinewhether women perceive the scar location as im-portant and to determine whether women have apreference for the latissimus dorsi skin paddle scar

From the Department of Plastic Surgery, University of TexasSouthwestern Medical Center.Received for publication September 6, 2009; accepted Janu-ary 15, 2010.Copyright ©2010 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e3181de1b41

Disclosure: The authors have no financial inter-ests in this research project or in any of the tech-niques or equipment used in this study.

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location. Characteristics such as age, body massindex, body image and fashion style, and ethnicitywere examined to determine whether there was acorrelation between these factors and the latissi-mus dorsi flap donor-site scar preference.

PATIENTS AND METHODSTwo hundred fifty women between the ages of

20 and 80 years were surveyed, including 50 womenwith a history of breast cancer. With a 96 percentparticipation rate, the total sample size was 240 sub-jects. The women who participated in the study weresampled within a 15-mile radius of the University ofTexas Southwestern Medical Center. This covered adiverse population within the 879–square mile areaof Dallas County. The participants were not incen-tivized. The women were grouped into the followingage categories: 20 to 29, 30 to 39, 40 to 49, 50 to 59,and older than 60 years. These groups were similarin number. The distribution of participants was asfollows: 20 to 29 years, n � 46; 30 to 39 years, n � 32;40 to 49 years, n � 44; 50 to 59 years, n � 70; and60 to 79 years, n � 48. The sample characteristics arelisted in Table 1.

Picture PanelThe survey used three picture panels. The first

panel consisted of photographs of a patient’s back,with red lines delineating the variations of the latis-simus dorsi donor-site locations (Fig. 1). The secondpanel consisted of a patient’s photographs showing the variation of the latissimus dorsi donor-site loca-

tion (Fig. 2). To reduce bias and to control for dis-traction caused by scar quality, the pictures werechosen by a panel of physicians to ensure similar scarquality. The patient’s photographs were then re-touched using Photoshop (Adobe Systems, Inc., SanJose, Calif.) software to remove blemishes and scarsother than the donor-site scar.

Survey MethodThe survey consisted of a 15-question, multi-

ple-choice questionnaire with boxes for optionalwritten responses, to gather information such asage, ethnicity, height, weight, fashion choices,preference of scar location, importance of scarlocation, and other factors that may influence thechoice of latissimus dorsi donor site. Participantswere told specifically to assess the donor-site lo-cation and not the scar, as healing characteristicsvary from person to person. The survey used anelectronic platform (Verity TeleForm; Verity, Inc.,Sunnyvale, Calif.) that allowed handwritten re-sponses to be recorded electronically. The re-

Table 1. Sample Characteristics

Characteristics No. (%)

SexFemale 240 (100)

Age20–29 years 46 (19)30–39 years 32 (13)40–49 years 44 (18)50–59 years 70 (29)60–79 years 48 (20)

EthnicityAfrican American 51 (21)Asian 35 (15)Caucasian 115 (48)Hispanic 25 (10)Other 14 (6)

BMINormal (�25) 108 (45)Overweight (25–29.9) 69 (29)Obese (�30) 56 (23)Not reported 7 (3)Average 26

History of breast cancerYes 50 (21)No 190 (79)

BMI, body mass index.

Fig. 1. (Above) The red lines delineate the transverse scar lo-cations, upper, middle, and lower. (Below) The red lines delin-eate the vertical and oblique scar locations.

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sponses were confirmed manually and then tab-ulated using Microsoft Excel v.2003 (MicrosoftCorp., Redmond, Wash.). The data were then pro-cessed using SAS software (SAS Institute, Inc.,Cary, N.C.) provided by the Biostatistics Depart-ment at the University of Texas Southwestern bymeans of support provided by National Institutesof Health grant NIH5ULIRR024982-02. Contin-gency tables were conducted for all variables witha value of p � 0.05.

RESULTSThe majority of women noted that the location

of the latissimus dorsi flap donor site was impor-tant (66 percent). Of all women surveyed, 54 per-cent preferred the lower transverse scar location,followed by 22 percent of women who preferredthe middle transverse donor-site scar location(Fig. 3). Overall, 32 percent of women stated thatthe most important factors were the ability to con-

Fig. 2. (Above, left) The location of the upper transverse scar. (Above, right) The location of the middle transverse scar. (Center,left) The location of the lower transverse scar. (Center, right) The location of the vertical scar. (Below) The location of theoblique scar.

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ceal the scar in a low-back top or swimwear, fol-lowed by 30 percent who wanted contour improve-ment (Fig. 4). It was also noted that womenyounger than 50 years were concerned primarilywith concealing the scar with clothing options,whereas women older than 50 years were con-cerned with both clothing options and contour ofthe back (Fig. 5). The independent factors of age,body mass index, ethnicity, body image, and cloth-ing options were also evaluated to assess correla-tion to donor-site location choice. The indepen-dent factors of age, body mass index, ethnicity,body image, and clothing options showed no sig-nificant correlation with scar location. The resultsare summarized in Table 2.

DISCUSSIONBreast reconstruction has had long history in

plastic surgery, but traditionally, the focus has been

on the aesthetic result of the breast.12 Throughoutthe literature, there are multiple examples of aes-thetic evaluation of the breast following latissimusdorsi–based breast reconstruction,13–15 but evalua-tion of the donor site is relatively scarce. When as-sessing the donor site of the latissimus dorsi flap, themajority of articles focus on functional loss andmorbidity of the donor site.16–21 It would seem thatthe only incision that matters is the incision on thebreast. This study takes a different approach be-cause it specifically analyzes the basic question ofwomen’s preference for a latissimus dorsi donor-site incision/location.

The participants in this study made their de-cisions in a slightly different manner than mostpatients undergoing breast reconstruction. Thedecision of donor-site location was based on layknowledge and the picture panel. Although thisstudy in no way advocates that surgical decisions

Fig. 3. Overall results for latissimus dorsi flap scar location preference.

Fig. 4. Reasons stated for choosing a latissimus dorsi flap scar location.

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should be made in a vacuum without surgical con-sultation, the latissimus dorsi flap lends itself wellfor this type of comparison because the variationsin skin paddle harvest carry a relatively similar risk,benefit, and complication rate. Although somemay view the lack of surgical consultation as a

confounder, it is well known that patients under-going surgical procedures are often inundatedwith information and that, despite an adequateinformed consent process, patients’ understand-ing of the procedure and risk and benefits is oftenvariable.22 The lack of surgical consultation should

Fig. 5. Comparison of women’s reasons for preference and age older than 50 yearsand younger than 50 years.

Table 2. Latissimus Dorsi Scar Location Preference Summary Stratified by Age, Body Mass Index, Ethnicity,Body Image, and Clothing Options

VariablesUpper

Transverse (%)Middle

Transverse (%)Lower

Transverse (%) Vertical (%) Oblique (%)

Age20–29 years 23 21 44 3 1030–39 years 22 22 50 6 040–49 years 5 9 59 5 2350–59 years 11 29 49 4 760–79 years 4 23 67 0 6

BMI�25 14 22 53 2 925–29.9 7 23 55 6 9�30 17 20 50 2 11

EthnicityCaucasian 13 19 56 4 7African American 11 23 53 2 11Hispanic 8 20 64 0 8Asian 18 29 41 3 9Other 7 21 50 0 21

Body imageHigh 13 20 54 4 9Medium 17 31 45 5 2Low 5 18 59 0 18

Clothing optionsHalter top 33 22 22 0 22Low-back top 7 20 65 0 8Open-back top 18 15 48 13 8Contour while clothed 11 28 46 4 11Other 10 20 60 0 10

BMI, body mass index.

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not be considered as a confounder for latissimusdorsi donor-site preference.

Another difference between the participantsin this study and cancer patients is that the ma-jority of participants were not facing the real pos-sibility of losing one or more breasts to cancer.This was a concern; however, all women in thisstudy were given specific instructions and theywere placed in a scenario where they had breastcancer and would need a mastectomy and breastreconstruction. In addition, 50 subjects with a historyof breast cancer were surveyed and their preferenceof donor site was similar to that of the women with-out breast cancer (Figs. 6 and 7). These results areapplicable to breast cancer patients.

In this study, women overwhelmingly pre-ferred the low transverse latissimus dorsi donorsite over the other orientations of the skin paddle(54 percent). Factors such as age, body mass in-dex, ethnicity, clothing options, and fashionchoice were assessed to distinguish their impact onchoice. It was anticipated that women of differentages, ethnicities, body mass indexes, body images,and fashion preferences would choose differentdonor sites. This was not found to be the case. Inthis study, participants from a diverse sample pop-ulation chose the lower transverse and middletransverse scar locations as their first and secondmost preferred locations.

Fig. 6. Latissimus dorsi scar location preference of women with a history of breast cancer.

Fig. 7. Latissimus dorsi scar location preference of women without a history of breast cancer.

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Considering the overall scar location prefer-ence, each flap has key advantages and disadvan-tages that surgeons need to understand well tooptimize outcomes (Table 3). The high transversescar location, defined as a scar location on theback above the level of the inframammary fold,offers a straightforward flap dissection and allowsfor recruitment of additional periscapular tissue.Care should be taken when harvesting additionalperiscapular tissue, as this may lead to severe con-tour deformity. The middle transverse scar loca-tion, defined as a scar location at the level of theinframammary fold, offers an easy flap dissection,and its location is well hidden in the bra line.Additional tissue can also be recruited to reducethe need for a prosthesis. However, patients witha scar in this location cannot conceal their scar inclothing with an open-back design. The low trans-verse scar location, defined as a scar location be-low the level of the inframammary fold, is associ-ated with a slightly more tedious dissectionbecause of its lower placement in the back. Nev-ertheless, the lower position allows it to be con-cealed in a variety of clothing options and im-proves contour, especially when flaps areharvested bilaterally in the mid to lower lumbarregions. When harvesting additional tissue in thelow lumbar region, care should be taken to alsoinclude subcutaneous tissue superior to the flap’sskin paddle to include additional perforators andincrease the vascularity of the flap. The verticaland vertical oblique donor-site locations give ex-cellent exposure for dissecting the pedicle and canprovide a large skin paddle but leave a scar ori-entation that is perpendicular to the natural adi-pocutaneous tissue rolls along the back. This maycreate unsightly rippling with later weight gain(Figs. 8 and 9).

CONCLUSIONSWomen do consider the location of the latis-

simus dorsi donor-site scar an important aspect ofbreast reconstruction. In addition, women in thisstudy also had a definite preference for the scarlocation, with three-fourths of the women choos-

ing the lower and middle transverse scar locations.Although factors such as age, ethnicity, body massindex, body image, and clothing options were notfound to independently correlate with the choiceof donor-site location, this study showed thatwomen younger than 50 years were more con-cerned about trying to conceal the donor-site scarin clothing, whereas women older than 50 yearswere concerned about concealing the scar andimproving the contour of the back. Therefore,during the preoperative consultation, surgeonsshould carefully and thoughtfully discuss the pa-tient’s goals to conceal the donor-site scar or im-prove contour. In summary, surgeons should con-

Table 3. Advantages and Disadvantages of Various Latissimus Dorsi Flap Harvest Techniques

Scar LocationDifficulty ofDissection

Vascularity ofSkin Paddle

Arc ofRotation

Ability to HarvestAdditional Tissue

Upper transverse Low Medium Medium LowMiddle transverse Low Medium Medium MediumLower transverse Medium Medium-low High MediumVertical Low Medium Medium MediumOblique Low Medium Medium Medium

Fig. 8. This image shows a patient who underwent breast re-construction with a latissimus dorsi flap performed at an outsidehospital using a vertically oriented skin paddle design, perpen-dicular to the soft-tissue rolls of the back. Note rippling and dim-pling that occurs lateral to the donor-site scar following surgery.This effect is accentuated over time and with increased weightgain and is secondary to the tethering of the donor scar, which isperpendicular to the natural orientation of the back’s natural adi-pocutaneous tissue rolls.

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sider the low transverse and middle transverse scarlocations to maximize patient satisfaction follow-ing latissimus dorsi–based breast reconstruction,as these locations were the most preferred scarlocations for women.

Michel Saint-Cyr, M.D.Department of Plastic Surgery

University of Texas Southwestern Medical Center1801 Inwood Road

Dallas, Texas [email protected]

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5. Monticciolo DL, Ross D, Bostwick J III, Eaves F, Styblo T.Autologous breast reconstruction with endoscopic latissimusdorsi musculosubcutaneous flaps in patients choosing breast-

conserving therapy: Mammographic appearance. AJR Am JRoentgenol. 1996;167:385–389.

6. Maxwell GP. Iginio Tansini and the origin of the latissimusdorsi musculocutaneous flap. Plast Reconstr Surg. 1980;65:686–692.

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8. Wong MT, Lim AY, Coninck CD, Kumar PV. Functional unitswithin the latissimus dorsi muscle based on Sihler technique.Ann Plast Surg. 2007;59:152–155.

9. Tobin GR, Schusterman M, Peterson GH, Nichols G, BlandKI. The intramuscular neurovascular anatomy of the latissi-mus dorsi muscle: The basis for splitting the flap. Plast Re-constr Surg. 1981;67:637–641.

10. Ruetschi MS, LeWinn LR, Chaglassian TA. Variation of la-tissimus dorsi skin island design for postmastectomy recon-struction. Ann Plast Surg. 1981;6:171–178.

11. Millard DR Jr. Variations in the design of the latissimus dorsiflap in breast reconstruction. Ann Plast Surg. 1981;7:269–271.

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13. Tomita K, Yano K, Matsuda K, Takada A, Hosokawa K. Es-thetic outcome of immediate reconstruction with latissimusdorsi myocutaneous flap after breast-conservative surgeryand skin-sparing mastectomy. Ann Plast Surg. 2008;61:19–23.

14. Thomson HJ, Potter S, Greenwood RJ, et al. A prospectivelongitudinal study of cosmetic outcome in immediate latis-simus dorsi breast reconstruction and the influence of ra-diotherapy. Ann Surg Oncol. 2008;15:1081–1091.

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16. Lam DG, Choudhary S, Cadier MA. Latissimus dorsi donor-site quilting: Less is more? Plast Reconstr Surg. 2000;105:2271.

17. Russell RC, Pribaz J, Zook EG, Leighton WD, Eriksson E,Smith CJ. Functional evaluation of latissimus dorsi donorsite. Plast Reconstr Surg. 1986;78:336–344.

18. Spear SL, Hess CL. A review of the biomechanical and func-tional changes in the shoulder following transfer of the la-tissimus dorsi muscles. Plast Reconstr Surg. 2005;115:2070–2073.

19. Buntic RF, Horton KM, Brooks D, Lee CK. The free partialsuperior latissimus muscle flap: Preservation of donor-siteform and function. Plast Reconstr Surg. 2008;121:1659–1663.

20. Tomita K, Yano K, Matsuoka T, Matsuda K, Takada A,Hosokawa K. Postoperative seroma formation in breast re-construction with latissimus dorsi flaps: A retrospective studyof 174 consecutive cases. Ann Plast Surg. 2007;59:149–151.

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Fig. 9. This image shows a patient who underwent breast re-construction with a latissimus dorsi flap performed at an outsidehospital usingtwodifferentscarorientations, vertical on therightand oblique transverse on the left. Note how the incision on theleft side follows the natural tissue rolls and results in a nice sil-houette postoperatively compared with the vertical incision onthe right, which results in tethering and rippling of the soft tissueof the back.

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