Back and shoulder function after delayed breast reconstruction with a latissimus dorsi flap: a disputed topic

The latissimus dorsi (LD) flap was first described in 1897 as a method of covering mastectomy defects. Following further refinement and advancement, this flap has been utilized for a variety of purposes, notably as an option in autologous breast reconstruction (ABR). The introduction of the deep inferior epigastric perforator (DIEP) flap, however, has lowered rates of breast reconstruction with LD flaps in those patients preferring ABR. Still, LD flap breast reconstruction remains an option for patients who have insufficient abdominal tissue volume, inadequate abdominal vasculature, or prior history of abdominal surgery (1). It is also a method to salvage failed breast reconstruction that has previously used other techniques, including the DIEP flap. Furthermore, patients undergoing LD flap breast reconstruction have been demonstrated to have positive patient-reported outcomes that are comparable to DIEP, free transverse rectus abdominis myocutaneous (TRAM), and pedicled TRAM flaps when examined together (2).

Although the LD flap should be considered a reliable and safe option for ABR, it is not without its disadvantages. In order to complete this reconstructive method, the LD muscle—which is primarily involved in the movement of the upper extremity and considered to be an accessory muscle of respiration—must be sacrificed. The sacrificing of this muscle raises concerns for donor site morbidity and led to the development of the thoracodorsal artery perforator (TDAP) flap. Harvesting of the pedicled TDAP flap for breast reconstruction reduces the morbidity drawback of the LD flap, sparing the latissimus muscle while also providing acceptable functional and aesthetic results (3). A 2008 study from Hamdi et al. demonstrates that the utilization of the pedicled TDAP flap does not affect LD muscle strength, suggesting that there is minimal surgical sequelae following this surgical alternative (4). Moreover, when using the Disability of the Arm, Shoulder and Hand (DASH) questionnaire as an outcome measure, patients who underwent the TDAP flap in the setting of implants were shown to have less donor site functional morbidity when compared to patients who underwent the LD flap with implants, scoring significantly lower on the questionnaire (5).

Similar to the reasoning for the development of the TDAP flap, other surgical and non-surgical methodologies have evolved to address the donor site morbidity following LD flap breast reconstruction. Refinement of LD flap harvest emphasizing the utilization of a muscle-sparing technique was created to combat the morbidity associated with the original technique. A modification of the muscle-sparing technique, originally described in 2010, was also demonstrated to preserve muscle function and had utility in a population of active patients who underwent complete breast reconstruction (6). Although LD flap harvest sacrifices the LD muscle, Park et al. show that postoperative physical therapy could improve shoulder mobility and patient-reported DASH scores (7). Furthermore, research has explored the relationship between thoracodorsal innervation to the LD muscle following LD flap harvest and shoulder function. While multiple studies put forth the idea that thoracodorsal nerve preservation versus division does not impact breast reconstruction outcomes, this idea is still argued within more recent literature (8,9). Despite concerns of donor site morbidity, the LD flap remains a workhorse flap used for various reconstructions, laying the foundation for Löfstrand et al.’s research (10).

Previous studies have examined the impact of LD flaps on patients’ upper extremity function. In a 2019 randomized controlled trial examining shoulder-related morbidity in patients who undergo delayed breast reconstruction using LD flaps when compared to TDAP flaps, Rindom et al. demonstrated significant differences in postoperative patient-reported shoulder-related pain between the two cohorts. Using the Constant Shoulder Scale (CSS) to objectify shoulder function, patients in the LD cohort experienced worse shoulder-related pain and had greater hindrance to their ability to perform activities of daily living than the TDAP cohort (11). Furthering the idea that LD muscle flap harvest negatively impacts shoulder functionality, a prospective observational study (n=20) of shoulder motor and sensory deficits following delayed LD flap reconstruction found a significant decrease in isometric shoulder strength for both adduction and extension at 12 months postoperatively (12). In contrast, Cattelani et al. used the DASH to objectively assess patients’ functional long-term outcomes after LD breast reconstruction (13). Of the 59 patients included in this study, over 70% reported that they experienced no disability of their upper limb, with the remaining 17 reporting that they experienced only minimal disability. Cattelani et al.’s findings are consistent with a 2013 clinical trial that showed while shoulder range of motion is decreased at the one-month postoperative timepoint, longer term assessment does not associate LD breast reconstruction with detrimental effects on shoulder kinematics (14).

The conflicting findings of the impact of LD breast reconstruction on patients’ physical function demonstrate that there is a lack of consensus regarding the impact of LD breast reconstruction on shoulder and donor site morbidity. Steffenssen et al.’s 2019 systematic review and meta-analysis on the topic of functional shoulder impairment following LD breast reconstruction establishes that the evidence presented in existing literature suggests that some impairment in shoulder function occurs after this surgical option. As noted by the few systematic reviews on this topic, however, the current literature addressing this question is limited by multiple factors, including confounding variables, varying reconstructive pathways and methodologies, limited sample sizes, and follow-up times (3,15). Moreover, Steffenssen et al. note that there is an inadequate amount and quality of research to definitively conclude how LD breast reconstruction impacts shoulder and donor site morbidity. This necessitates further nuanced and high-quality investigations to not only be able to better answer the question of how LD breast reconstruction impacts shoulder and back function but also to identify predictors of poor outcomes in patients undergoing this reconstructive option.

This is the gap in literature that Löfstrand et al. attempt to fill in their research. Through 135 and 118 patients who underwent breast reconstruction with an LD flap or DIEP flap, respectively, Löfstrand et al. demonstrate that LD patients are less satisfied with the function of their shoulder and back when compared to DIEP patients (10). It is important to note that this study was conducted in a population of patients who underwent delayed reconstruction, in which the majority were irradiated prior to reconstruction, and who had a median follow-up time of 7 years post reconstruction, as this can all impact patient-reported outcomes. To assess patient outcomes regarding the shoulder and back, the authors utilized both the validated LD domains of the BREAST-Q and the Western Ontario Shoulder Osteoarthritis Index (WOOS) (16).

Overall, LD patients scored lower on both the BREAST-Q and WOOS when compared to DIEP patients. On the BREAST-Q, specifically, LD patients reported significantly lower satisfaction with back and shoulder function regarding shoulder pain, difficulty doing activities with arms outstretched, experience of a pulling feeling in the back, and difficulty carrying heavy objects. When individually analyzing the subdomains of the WOOS, LD patients reported significantly decreased percentages of normal function in all domains (i.e., physical symptoms and pain, sport/recreation/work, lifestyle and social functioning) except in the category of emotional well-being where the percentage of normal function was comparable between the two patient cohorts. The WOOS score differences, however, were not clinically significant, not meeting the minimal clinically important difference of 12.3 (17). Löfstrand et al. also established predictors of poor patient-reported outcomes on both the BREAST-Q and WOOS through the performing of regression analysis. The authors found that axillary surgery and axillary radiotherapy were predictive of worse outcomes on the BREAST-Q, whereas older age at the time of reconstruction was associated with lower reported scores on the WOOS.

Importantly, Löfstrand et al.’s data cover a median time of 7 years. As the survivability of breast cancer increases, the long-term outcomes of breast reconstructive procedures continue to increase in importance (18). Prior studies regarding shoulder and back function following LD breast reconstruction suggest that function recovers to near baseline levels over time (15). The findings of Löfstrand et al.’s work contradict the notion that long-term shoulder function returns to baseline. LD patients report lower scores than DIEP patients over this median 7-year follow-up period, suggesting that impairment continues to exist years after reconstruction. Future studies should investigate this further as the current study does not directly assess this relationship and only allows for inferences to be made.

Regarding the assessment of functionality and morbidity, Löfstrand et al.’s study is unique in its utilization of the WOOS, a tool previously used to examine health-related quality of life in patients with osteoarthritis of the shoulder and has proven its utility in other diagnoses. Unlike the DASH, which assesses the entire upper extremity and potentially could allow for the conflating of shoulder morbidity with other functional aspects of the upper limb, the WOOS is shoulder-specific and likely has more relevance to LD breast reconstruction. Furthermore, the use of the LD domains of the BREAST-Q is important as it not only allows for the specific examination of back and shoulder function in a manner that other studies utilizing PROs have been unable to do but also continues to center the patient experience as an important outcome of breast reconstruction. Finally, Löfstrand et al.’s findings in LD breast reconstruction patients are strengthened by the study’s use of a seemingly similar control cohort of DIEP patients.

When compared to previous literature, Löfstrand et al.’s findings are consistent with work from Woo et al. which demonstrated that reconstruction with an LD flap was a significant risk factor for the development of shoulder morbidity, defined as a restricted range of motion greater than 30° in comparison to the contralateral non-operated side, when compared to the DIEP flap (19). Similarly, Löfstrand et al.’s results are supported by an analysis of the shoulder morbidity of 10 irradiated LD flaps, 14 two-stage subpectoral implants, and 10 irradiated DIEP flap breast reconstruction patients. Examination of these patients demonstrated that those who underwent LD flaps had significant weakness when vertically adducting their shoulder when compared to patients who underwent DIEP flap reconstruction (20).

Conflicting with Löfstrand et al.’s results, Cattelani et al. showed that very few patients experience shoulder morbidity—when measured using the DASH questionnaire—following LD flap breast reconstruction (13). In their study, Garusi et al. showed that patients undergoing LD flaps had minimal DASH-related disability overall, with extension being more impacted than adduction by flap harvest (21). Interestingly, while the 2019 systematic review and meta-analysis from Steffenssen et al. acknowledged that existing literature on the topic of shoulder function following LD flap harvest suggests that this reconstructive method harms shoulder morbidity, they report that this impact was minimal and that few patients experience a major impact on shoulder function (15). It is also important to note that more historical data examining shoulder function outside of the context of breast reconstruction determined that sacrifice of the latissimus muscle has little impact on the functionality of the shoulder (22). This conclusion that these studies put forward directly conflicts with the findings of Löfstrand’s study, but the historical findings may not be relevant in the context of breast reconstruction.

As the authors indicated, a major limitation to the study is the lack of critical variables, like body mass index (BMI). Patients with higher BMI may be more likely to opt for DIEP reconstruction as they have available abdominal tissue (23). Although one of the studies from our group has found that BMI may not be a critical factor in autologous reconstruction, patients who underwent LD flaps were not included in this work, making the results irrelevant to these patients. BMI may still play a role in LD flap reconstruction, and we believe that it should be controlled for in the regression model. Moreover, this study is limited by the lack of preoperative BREAST-Q scores. In unpublished data, we have demonstrated that postoperative BREAST-Q scores are significantly influenced by preoperative scores. While Löfstrand et al. found differences between the LD and DIEP cohorts postoperatively, this study is not able to capture if these differences also existed in the preoperative period or how preoperative scores influence postoperative outcomes in the two cohorts. We believe that the study could have also been strengthened if LD vs. DIEP was included in the regression model. Multivariable regression models help to predict the impact of predictor variables on the outcome while controlling for several variables and inclusion of reconstructive modality in the model would have strengthened the authors’ findings (24). Lastly, at least at our institution, LD flaps are rarely chosen as the first option for breast reconstruction. It is often utilized after an implant or abdominal-based ABR failure. As the authors note, they use LD flaps to also salvage reconstruction. Therefore, there is an inherent difference in the two cohorts. The LD cohort may be primarily composed of patients who experienced a reconstructive failure, which can lead to pain, psychosocial symptoms, and worsened mental health (25). Thus, the lower BREAST-Q and WOO scores in the LD cohort may be a reflection of the reconstructive failure, rather than donor site morbidity.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Gland Surgery. The article has undergone external peer review.

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