Consultant Oncoplastic Breast Surgeon
Royal Hampshire County Hospital
Using LD Miniflap is indicated if 20% up to 70% of the breast volume is excised and the patient does not want to have mastectomy with reconstruction and wants to stay the same breast size without the need for contralateral breast symmetrization. Usually this is appropriate in patients with breast up to C cup size, depending on the volume that needs to be replaced following excision.
Markup and Positioning
We start by marking the edges of the palpable tumour and the edges of the resection margin. Then the lateral border of the breast is marked by applying gentle pressure on the breast. This will be the incision site as this will be hidden in the axilla and will allow good access to resect the tumour and harvest the LD flap. The anterior border of the LD muscle, the tip of the scapula, the upper border of the LD muscle and the extent of muscle to be harvested is also marked.
Outline the key landmarks before starting as these will provide an essential roadmap for the procedure
The patient is positioned on the table in the lateral position with the shoulder abdected at 90 degrees and secured using a lithotomy strap. The patient is secured on table anteriorly and posteriorly and a soft pillow is put between the knees to prevent prolonged pressure on the bony prominences.
When draping, it is important to see the anatomical landmarks for the dissection to include the midline anteriorly, the tip of scapula and the upper border of the muscle posteriorly along with the area of the flap to be harvested posteriorly. Good access to the axilla is a must as the axillary dissection is critical in this.
Different people use different instruments and techniques for dissection. We use infiltration the whole field with mixture of 500 mls of saline mixed with 1:000 adrenaline and marcaine. For the dissection we use a large blade on a long knife handle for tumor resection along with hand held diathermy and bipolar scissors which are useful for harvesting the flap. Insulated retractors help protect the flaps and prevent diathermy burns on the skin edges. Good light is also important using either lighted retractors or headlight.
Invest in good equipment
After infiltration, make the skin incision along the lateral skin crease as marked preoperatively. First start dissecting the tumour both in the retro-mammary and subcutaneous planes until you get beyound the tumour. Resection is carried out and specimen x-ray is done to check if the radiological abnormality is excised with clear margins. We routinely send 4 radial tumour bed biopsies and then we ink the margins and excise them. If the bed biopsies are reported positive on frozen section analysis, this process is repeated.
In other units, instead of doing the frozen section they opt to have the wide local excision done and few days down the line when the histology is back then a LD miniflap is performed to fill the defect if the margins are clear.
Frozen section is essential for a one stage procedure, if this is not available then a two stage procedure is preferred
Axillary Dissection and Flap Harvest
On entering the axilla it is important to realise that the anatomy looks different in the lateral position. The structures are crowded and need to be separated by retracting laterally. The axillary vein is collapsed and is usually more superficial and it is easy to confuse the lateral thoracic vein with the subscapular vein. So careful dissection is essential, and nothing should be divided until all the key structures are identified.
Don’t divide anything in the axilla until all key structures are identified as the anatomical relations in the lateral position looks different
When harvesting the flap, we always start by dissecting the superficial surface followed by the deep surface off the serratus anterior and the intercostal muscles. The distal part is divided followed by the posterior surface. The fascial attachments to all the surrounding muscles especially the Teres Major are dissected and the tendon is divided to enable transposition of the whole flap into the defect and preventing an axillary bulge.
The flap is positioned in the wide local excision defect. When positioning the flap if there is tension on the branch to Serratus Anterior or if it is causing limitation on the flaps mobility then it can be divided. The tendon is sutured to the lateral border of the Pectoralis Major Muscle using 2/0 Vicryl and the flap is sutured in the defect with the tip folded.
There is no need to insert a drain in the breast but usually we insert a suction drain in the donor site. Some will quilt the donor site to decrease the incidence of seromas. The wound is closed in 2 layers with absorbable sutures.