Lateral Chest Roll Flap
Abstract
Introduction
The lateral chest roll flap is an often overlooked alternative in breast breast reconstruction and post bariatric breast augmentation. The lateral chest roll The Lateral intercostal artery perforator (LICAP) pedicled flap procedures have been widely used in the past to alleviate breast deformities which arise in post-bariatric patients. This pedicled flap provides ample material for an autogenous breast augmentation, and a significant source of central mound skin which is important in reconstruction. Additionally, donor site morbidity is minimal due to the fact that the donor site is the excess skin that is commonly present in post-bariatric patients.
More recently, it has been seen that a variation of this LICAP pedicled flap can be used not only in massive weight loss patients, but also in patients with post-mastectomy defects. The lateral chest roll flap, which is a transverse perforator flap based on the lateral intercostal artery, is a useful and reliable source of skin and volume for breast reconstruction in the post-mastectomy patient.
There are many benefits to the lateral chest roll flap that make it an excellent alternative to the available techniques in breast reconstruction. Because these lateral chest roll flaps are harvested without sacrificing underlying muscle, donor site morbidity is reduced. Consequently, because the lateral chest roll flap procedures do not involve the movement of muscle, they require a shorter post-operative recovery time and can be performed in outpatient surgical settings. Outpatient surgical centers are often preferred to traditional hospitals settings due to their size, quality and efficiency.
Methods
The database of patients undergoing breast reconstruction at Dr. Joel Aronowitz’s office was queried for breast cancer patients undergoing lateral chest roll flap between January 2005 and June 2013, and 21 patients were identified. A retrospective study was performed and the medical records of these 21 patients were reviewed. Medical information was extracted from the patients’ charts, including demographics, perioperative and post-operative outcomes.
Surgical Technique
The lateral chest roll flap is designed to follow the lateral chest roll (Fig 1) with the pedicle located at the lateral 10 cm of the inframammary fold. The skin/adipose flap is elevated at the muscle fascia level with care taken during the dissection to avoid injury to the long thoracic nerve and the cutaneous perforator branches entering the flap from the intercostal vessels (Fig 2). The cranial border of the flap is usually continued to join the mastectomy incision. The flap is rotated 180 degrees. The pivot point is reinforced with a multi-laminated porcine xenograft, Biodesign® (Fig 3). The xenograft is sutured to the lateral border of the pectoralis major and serratus muscle to provide support for the flap and prevent post-operative lateral migration of the flap (Fig 4). Surgical results were assessed for flap and donor site complications and lateral bulge.
Results
Patients’ characteristics are summarized in Table 1. 30 lateral chest roll flap procedures were performed on 21 patients between January 2005 and June 2013. The patients’ ages ranged from 43 to 83 years old, with a median age of 64 years old. All of the patients were diagnosed with breast cancer and seeking breast reconstruction post-mastectomy. The majority of the patients had undergone mastectomy (6 bilateral, 2 skin sparing bilateral, and 10 unilateral) prior to the lateral chest roll procedure. The remaining 3 had undergone lumpectomies. Only 6 of the 21 patients had undergone prior radiation therapy.
Of the 21 patients, 20 of them had their operations performed in outpatient surgical settings (Tower Outpatient Surgery Center). Only one patient underwent the operation in an inpatient setting and was discharged home on post-operation day number 3. Following surgery, only 4 patients were sent to aftercare facilities for an average of 1 day (3 for 1 day, and 1 for 2 days). The other 17 patients were sent home.
In all but two of the patients, simultaneous associated procedures were performed. Fat grafts were performed on 22 flaps in 16 patients. Implants were placed in 10 patients. Mastopexies were performed on 3 patients. Capsulectomies were performed in 7 patients. Symmetrizing breast reduction was performed on 7 patients. Results summarized in Table 2.
15 patients including 19 flaps had no complications and required no revisions. The most common complication in the remaining flaps was partial flap necrosis, which occurred in 6 flaps in 4 patients. There was a flap infection which required flap revision in one patient, and one patient developed a painful keloid which required revision.
Discussion
Breast reconstruction is a critical component in the treatment of breast cancer. In post-mastectomy patients, there often is a need for tissue transfer during breast reconstruction to create breasts that are symmetric and that have a natural contour and shape. For this reason, the use of autologous tissue in breast reconstruction has been in evolution since the 1970’s. There are a variety of accepted methods of breast reconstruction with autogenous tissue. Flaps commonly used include the Transverse Rectus Abdominis Myocutaneous flap (TRAM), the Deep Inferior Epigastric Perforator flap (DIEP) and the latissimus dorsi flap. However, there are serious limitations to these methods because they are all methods which involve the transfer of muscle. Free flaps are detached from the donor site along with their respective blood supply, which requires reattachment of the vessels. Such procedures entail much longer and more extensive operations, which further imply the need for aftercare. In contrast, in pedicled flaps the donor tissue is still attached to the donor site but is rotated to the new site, allowing the blood supply to the tissue to remain intact. The lateral chest roll flap, which is a transverse perforator flap based on the lateral intercostal artery, is an example of such a flap and presents distinct advantages in breast reconstruction.
Harvesting of the lateral chest roll flap is relatively simple and quick, and the dissection provides adequate perforator length to successfully rotate the flap 180°. The flap provides variable but reliable source of skin and volume for the central mound skin in implant reconstruction without sacrificing the underlying muscle. Due to the lack of muscle and/or blood vessel movement, the procedure is much less extensive and can be performed in an outpatient surgery setting. This also eliminates the need for long hospital stays or aftercare facilities, and overall the procedure is much less painful. Additionally, only a few incidents of minor complications were reported (partial flap necrosis, infection and scarring), all of which were revised in the outpatient surgical center.
This technique has demonstrated significant efficacy in the breast reconstruction of post massive weight loss patients. The donor site is the lateral continuation of the inframammary fold. Excess skin/fat roll is commonly present in this location in post-bariatric and post-mastectomy patients, therefore minimal donor site morbidity has been reported. Another benefit to the donor site is that it yeilds aesthetically pleasing results, the minimal scarring that occurs at the donor site can be easily hidden under a bra.
In conclusion, the introduction of the perforator flap concept to patients other than post-bariatric patients, specifically post-mastectomy patients, has the potential to result in significant progress in the field of reconstructive surgery. The lateral chest roll flap provides variable, but reliable source of skin and volume for reconstruction, and donor site morbidity is minimal. Finally, the simplicity of the procedure allows for it to be performed in outpatient settings with minimal to no aftercare requirements.
Table 2 Associated Procedures Performed Simultaneously
