Evaluation of Pedicled Descending Branch Latissimus Dorsi Mini Flap as an Immediate Reconstructive Technique Post Conservative Breast Surgery Regarding Cosmetic and Oncological Outcomes.

Abstract

Background: Oncoplastic surgery combines tissue displacement or volume replacement to improve aesthetics after partial mastectomy. It is now favored over mastectomy, especially for large volume defects, when followed by radiation. This study aimed to evaluate the use of the latissimus dorsi muscle mini-flap (LDMF) as a volume replacement technique for large breast defects following wide local removal in various quadrants of the breast and to assess its effectiveness in terms of aesthetic results, procedure-related complications, case satisfaction, and oncologic safety, including the flap’s ability to tolerate postoperative radiotherapy.

Patients and methods: This is a prospective cohort study including 25 cases who were admitted at Ain Shams University Hospitals within one year, from April 2023 until March 2024.  It was conducted on patients undergoing breast-conservative surgery. Patients with early breast cancer were enrolled and assigned either to neoadjuvant chemotherapy or to upfront surgery and immediate oncoplastic reconstruction according to the MDT evaluation of the cases. This is followed by close monitoring to outcomes in follow up visits. The EORTC-QLQ C30 and EORTC-QLO BR23 questionnaires and the Japanese Breast Cancer Society (JBCS) Cosmetic Evaluation Scale were the methods used to assess the quality of life and the cosmetic outcome, respectively.  Range of motion (ROMs) of bilateral shoulders was assessed by disabilities of the arm, shoulder and hand (DASH) questionnaire. Moreover, Vas (visual assessment score) and sensory preservation questionnaire were given for all participants. Three surgeon assessment questionnaire was given to doctors who were not involved in the surgery. Thereafter, data including operative time, early postoperative complications and aesthetic evaluation scores were collected and analyzed using appropriate computer based statistical methods.

 Results: Of the 25 candidates, sixteen patients (64%) had N1 disease, seventeen (68%) were estrogen receptor–positive, six (24%) were HERII-positive and two (10%) were triple negative. Sixteen patients (32%) received neoadjuvant chemotherapy, of which five (62.5%) had good pathological response, ten (62.5%) had poor response and one (0.06%) had no response. Eventually, Nine (56.25%) patient had upfront surgery, WLE (wide local excision) with SLN (sentinal lymph node) and immediate reconstruction, as their tumor was T1N0M0 with a pathology molecular subtype luminal A or their tumor size in relation to breast cup size was large. Of the sixteen patients who took neoadjuvant chemotherapy five had underwent targeted axillary therapy with SLN successful in three (60%) and conversion to ALND (axillary lymph node dissection) in two (40%). The other eleven patients (68%) underwent WLE and ALND with WBRT (whole breast radiation).  On the postoperative follow up visits, it was seen that the body image perception and nausea/vomiting score were significantly satisfying postoperatively whereas physical function score was not satisfying among the patients having shoulder pain and stiffness. Of the 25 patients, three (12%) had difficulty to resume to their daily activities and pain in shoulder. This was recorded during the 1-month follow-up; however, in the 3-month later visit none complained any difficulty in returning to their work (p=0.074). The mean operative time was 177 minutes, including the time needed for WLE and frozen section analysis. No significant relation between operative time in minutes and shoulder stiffness after angle of 150 degrees. Negative correlation between operative time and sensory preservation score (p=0.045). The median sensory preservation score was 8.00, with a range from 7.00 to 9.00; the median VAS score was 8.00, with a range from 8.00 to 9.00; and the median three-surgeon assessment score was 9.00, with a range from 8.00 to 9.00. Three patients (12%) had a complain of shoulder pain at side of operation. Of the 25 participants, five (20%) had wound infection and other 5 (20%) had seroma. Later on, wound infection was treated by antibiotics and daily dressing. Consequently, it wasn’t recorded in the 1-month follow up visit, which was statistically significant (P=0.018). Minor bleeding was recorded postoperatively in one (0.04%) patient. Adjuvant radiotherapy showed no affection to flap viability.

Conclusion: The LDMF as a volume replacement procedure post BCS (brest conservative surgery) offers an effective and safe oncoplastic option for early breast cancer patients particularly those with lateral breast tissue masses, post chemotherapy, weather was with good response or poor one, and patients with large defects left behind after removal of masses with size range of two to five centimeters in small to average sized breasts. Our study revealed manageable minimal postoperative complications, good patient satisfaction scores and agreeable cosmetic outcomes throughout the follow-up visits. Longer operative time affected patient’s sensory recovery but improved surgeon ratings. Larger studies are needed to validate results and reduce complications.