Breast reconstruction with donor tissue from the back—an evolution towards customized reconstructive solutions guided by innovative surgery and patient wishes

The boomerang latissimus dorsi (bLD) flap is the most recent addition to a growing armamentarium of LD flap designs for breast reconstruction (1). Now joining the previously introduced LD flap techniques based on the difference in skin island design; the traditional horizontal, vertical, and extended LD (eLD) utilized for breast reconstruction (2). Baumholtz et al. first introduced the boomerang design in the literature in 2002; they extended the traditional horizontal skin island in which the medial part of the flap was elongated vertically in the medial part of the back in close proximity to and along with the vertebra (3). Kim et al. apply a boomerang design similarly in order to harvest as much volume from the back as possible, however the design is altered as the horizontal and vertical skin islands is placed in the mid-axillary line along the anterior border of the LD muscle instead of its lumbar portion (1). This may turn out to be an advantage as the skin in the lateral part of the thorax around the mid-axillary line is thinner and more pliable than the thick skin closer to the vertebra. The vascularity is probably more reliable along the anterior muscle border including the descending branch of the thoracodorsal artery along with its perforators. However, a recent cadaver study by Elzawawy et al. showed that the vascularity of the LD muscle is much more variable than anticipated (4). It seems that the typical type 5 vascular pattern is only present in 20% of cases. Thus, maybe this should be taken into consideration in the preoperative planning of flap design including the boomerang design to avoid vascular problems. A design based on the vascular branching pattern of the thoracodorsal vessels and perforators targeted by preoperative color Doppler ultrasonography (5,6). The boomerang design includes areas where excess skin can be found by pinch test; the usual location is often horizontally below the scapula and vertically and posteriorly to the mid-axillary line. The design proposed by Kim et al. is therefore sensible if you want to harvest as much tissue as possible, with the least tension for subsequent closure (1).

A major drawback for the traditional musculocutaneous LD flap in breast reconstruction is the limited upper pole fullness. It is therefore not a clear first choice for total autologous breast reconstruction unless combined with fat transplantation or an implant to fill up the breast volume with the additional burden of more operative corrective procedures. Fat transplantation frequently requires repeated procedures in order to obtain or maintain sufficient volume (7). Implants can be used for augmentation, however, one has as much control over an implant as a housecat and they are equally as reliable, with plans on their own. The boomerang design enables the surgeon to fold the flap in the shape of an implant to create projection and fill both the upper and lower pole as opposed to the traditional flap, which mainly covers the inferior, and lateral half of the breast most often leaving the upper pole empty. The boomerang design may potentially provide patients with an alternative for autologous breast reconstruction without the addition of an implant, which is often necessary to obtain sufficient volume for reconstruction, when using the traditional LD techniques.

We mentioned that the vascularity of the tissue along the anterior border of the LD muscle is more reliable than the posterior part that crosses over to the lumbar and paraspinal angiosomes, which probably makes the addition of a vertical portion more attractive. Iginio Tansini, who pioneered the use of the LD flap, revised his original horizontal design to a vertical design of the LD flap for reconstruction of the breast (8). The scar on the other hand is rather visible and does not hide anatomically at all. Experience gained from body contouring procedures using lateral mid axillary incision have been largely dissatisfying due to the vulnerable anatomy of cutaneous nerves running laterally causing painful scarring.

A drawback to the use of any type of LD flap, including the bLD flap is donor site morbidity, when the entire LD muscle is included in the design. Involvement of larger portions of the muscle seem to increase the risk of donor site morbidity (9-11). Our studies amongst others have shown the eLD to be associated with more donor site morbidity of the shoulder and arm and more seroma formation, compared to the other types of LD flaps; classic LD flaps, and muscle sparing LD (MS-LD) flaps, not to mention the propeller thoracodorsal artery perforator (TDAP) flaps and the classic TDAP flap (12). In our practice, we have taken the benefits of the vascularity and available tissue to evolve a reliable propeller tap flap and a MS-LD flap that has a boomerang shape along the anterior border of the LD muscle upwards towards the axilla. This allows for an easy dissection and reduces the lateral bulk formation, as the superior portion of the flap is included in the lateral part of the reconstruction, Figure 1. The paper by Kim et al. seems to be a natural evolution of the LD flap in experienced hands, we agree with the authors conclusions so far and commend their efforts (1). The question that remains, whether the donor site morbidity measures up to the possible benefits/morbidity associated with the other reconstructive options? This remains to be tested over time with larger studies and longer follow-up. Until more is known about the bLD, patients need to be well informed about the possible benefits and potential limitations. However, multilobed designs of LD-flaps is gaining popularity for customized reconstruction of defects as shown in another recent study by Zhang et al. (13). However, we must be aware, that the donor site scar does matter to patients as shown in a study by Rha et al., and it seems patient with a vertical scar is more satisfied than patients with other types of scars (14).

Figure 1 Muscle sparing latissimus dorsi flap with cranial boomerang shape designed to reduce lateral bulk.

Overall, new innovative techniques are inspiring and at the same time, it also reminds us, that we have to consider all options prior to reconstruction of our patients. First and foremost, we have to ask the patients, what they want and what they expect regarding the reconstruction and the possible donor site(s) (14). In doing so we have to consider and examine the vascularity of the planned donor site and in doing so, evaluate the possible reconstructive options (4). Reconstructive options which seem to evolve towards more customized solutions (13).

We congratulate the authors on their innovative approach utilizing a maximum of the available donor tissue from the back to achieve a satisfying one-stage autologous breast reconstruction. It is an intriguing thought to examine in future studies whether a boomerang design can be raised without the entire LD muscle, as a muscle-sparing variant or even as a perforator-based boomerang TDAP, propeller or classic? It is almost bound to follow, Figure 2.

Figure 2 Illustration of suggestions for design of: (A) boomerang thoracodorsal artery perforator flap and (B) boomerang muscle sparing latissimus dorsi flap.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Gland Surgery. The article did not undergo external peer review.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-23-325/coif). JBT serves as an unpaid Honorary Editor-in-Chief of Gland Surgery from November 2022 to October 2024. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated or resolved.

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References

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