Breast cancer is the most common cancer among women and accounts for 12% of all new cancer cases globally. Many patients undergo lumpectomy or mastectomy1,2, which can lead to emotional distress and hampers the quality of life. Breast reconstruction helps in improving mental health, body image, and overall well-being. There are various options for autologous breast reconstruction such as pedicled or free or muscle sparing transverse rectus abdominis muscle flap, deep inferior epigastric artery perforator flap, lateral intercostal artery based perforator flaps etc. The pedicled latissimus dorsi myocutaneous flap (LDMCF) is a reliable surgical option for reconstruction, used either alone or with implants. This technique utilizes the latissimus dorsi muscle and skin paddle for coverage, volume, and skin replacement. Its dependable blood supply from the thoracodorsal artery makes it suitable for patients with prior radiation3. Latissimus Dorsi Musculocutaneous Flap has generally been considered a workhorse flap in clinics for breast reconstruction. It is a reliable means for soft tissue coverage providing form & function during breast reconstruction with acceptable peri-operative & long term morbidities. LD Flap provides tissue volume as well as reliable vascular pedicles for reconstruction4-6.The latissimus dorsi flap, whether myocutaneous or myofascial, is a highly versatile reconstructive option used in head, neck, torso, and breast reconstruction surgeries, providing a versatile solution to a wide range of reconstructive challenges In postmastectomy breast reconstruction, the pedicled latissimus dorsi transfer is commonly used, and its application also extends to free functional muscle transfer for facial reanimation. Whether utilized as muscle alone or including skin, this pedicled flap can effectively address chest or neck defects without tension7-12. The latissimus dorsi muscle, is richly vascularized by the thoracodorsal vessels. This ensures flap viability

and enables its use as both a pedicled and free tissue transfer method. This flap provides an abundant source of pliable soft tissue, a quality often lacking in alternative flap options. Moreover, the myocutaneous version of the latissimus dorsi flap is designed to include skin and subcutaneous tissue, providing extra bulk as needed, thereby enhancing its versatility across various clinical scenarios13. With minimal absolute contraindications and remarkable versatility, this flap presents itself as an indispensable tool in the arsenal of reconstructive surgeons, offering effective solutions for complex defects. This approach is particularly advantageous for women with neck defects, avoiding potential breast deformities linked with pectoralis flap reconstruction. In extensive cases, surgeons may harvest a mega flap that includes the latissimus dorsi and parascapular soft tissue, along with the subscapular artery14,15, circumflex scapular, and thoracodorsal branches. These mega flaps may necessitate the inclusion of scapular bone, rib, and the serratus anterior muscle for reconstruction purposes. LDMF can be used for breast reconstruction for various indications. It also provides good contour and bulk. The complications associated with LDMF is minimal, thus making LD flap a good option for breast reconstruction16.

AIM:

To study the indications, outcomes & complications associated with pedicled LD musculocutaneous flap for breast reconstruction.

In this observational study, 30 patients of breast reconstruction were studied over a duration of 12 months who underwent LD flap coverage. All these patients were prospectively studied for LD flap reconstruction under different clinical scenarios.

All the potential risks and complications of surgery like bleeding, seroma, hematoma, flap necrosis and wound dehiscence were studied and the outcome of surgery was also studied. Patients undergoing breast reconstruction other than LD flap were excluded from this study.

Table 1: Age of patients:

The majority of patients (40%) were aged above 60 years, followed by 33.3% in the 40–60 year age group. Younger age groups were less represented, with only 6.6% under 20 years and 20% between 20–40 years.

Table 2: Age group distribution in mastectomy cases:

Immediate breast reconstruction was most common in patients over 60 years (12 cases), followed by 8 in the 40–60 years group and 5 in the 20–40 years group. Late reconstruction was rare, with only 1 case in the 20–40 years group and 2 in the 40–60 years group; none were reported in those over 60.

Table 3: Indications

Among 30 cases, immediate breast reconstruction was the predominant indication, accounting for 80% (24 cases), while late reconstruction comprised 13% (4 cases). Post- burn reconstruction was the least common, representing 7% (2 cases).

Table 4: Complications:

Among the reported complications, seroma was the most common, occurring in 13.33% of cases, followed by wound dehiscence seen in 3.33% cases. No cases of hematoma or flap necrosis or shoulder restriction was observed.

Although the DIEAP flap is nowadays, the preferred flap for autologous breast reconstruction due to its potential for superior aesthetic outcomes and less donor site morbidity, it carries significant chances of fat necrosis, abdominal bulging, scarring and skin flap necrosis besides being more complex microsurgical technique requiring more technical expertise. The pedicled latissimus dorsi flap has gained less prominence in recent years for breast reconstruction, it still holds significant value. We propose that the pedicled latissimus dorsi myocutaneous flap (LDMCF) remains a reliable option. It continues to offer reliable and superior outcomes in both primary and secondary breast reconstruction.

The majority of patients in the study were aged above 60 years, accounting for 40% of the total. This was followed by the 40–60 years age group, which comprised 33.3% of the participants. The 20–40 years age group made up 20% of the cases. Only a small proportion (6.6%) were below 20 years of age. Overall, older adults formed the largest group affected in this sample. In a study by Lee, J.H., Ryu17 the mean age of the patients in the mini LD flap and vertical LD flap groups was 45.4 (± 6.8) and 44.3 (± 13.1) years, respectively.

In our study, immediate breast reconstruction was most common in patients over 60 years, with 12 cases recorded. This was followed by the 40–60 years group with 8 cases, and the 20–40 years group with 5 cases. Late breast reconstruction was less frequent, seen in only 3 patients in total. It was performed in 2 patients aged 40–60 years and 1 patient aged 20–40 years, with none in those over 60 years. In a study by Doan and leandra18, immediate reconstruction was performed in 25.4% of cases, whereas delayed reconstruction was performed in 74.6% of cases.

In our study, the majority of reconstruction was performed as immediate breast reconstruction, accounting for 80% of the cases. Late breast reconstruction was less common, seen in 13% of patients. Post-burn reconstruction was the least

frequent indication, comprising only 7% of the total. These findings highlight that most procedures were planned as part of initial surgical treatment. Post-traumatic and delayed cases formed a smaller portion of the reconstructive interventions.

In our study, among the complications observed, seroma was the most common, occurring in 13.33% of cases, followed by wound dehiscence seen in 3.33%. No cases of hematoma or flap necrosis were reported. Overall, the complication rate was relatively low. Most complications were minor and manageable, with no life-threatening outcomes. In study by Kokosis G, Khavanin N, Nahabedian MY19 Complications included partial flap necrosis, wound dehiscence, seroma, and infection occurring in 4 of 28 patients of 1-stage LD alone, 2 of 7 (28.6%) patients of 1-stage LD + I, 5 of 8 (52.5%) patients of

2-stage LD + TE/I, and 4 of 15 (26.7%) patients of 3-stage LD + TE + I (P = 0.055). Reoperation rates were 10.7%, 14.3%, 25%, and 0% across the 4 cohorts, respectively (P = 0.295). The LD only cohort had a 14.3% surgical revision rate, compared with 42.9% in the 1-stage + I, 50% in the 2-stage + TE/I, and 33.3% in the 3-stage LD + TE + I (P = 0.135). The rate of contralateral symmetry procedures was 10.7%, 0%, 25%, and 6.7%, across the 4 cohorts, respectively (P = 0.410). In a study by Banys-Paluchowski M20, the most common complication was seroma (26%), followed by wound dehiscence (8%), surgical site infection (7%), partial skin and/or nipple necrosis of any size (7%) and hematoma requiring surgical evacuation (2%). 19% of all patients required seroma aspiration or drainage, mostly at the donor site and performed under ultrasound guidance in the ambulatory setting. Flap loss due to necrosis occurred in 2% of patients.

Pedicled LDMF is a simple, reliable and good versatile technique for breast reconstruction with minimal complications. The latissimus dorsi (LD) flap remains a valuable option for breast reconstruction, particularly in cases where other techniques are unsuitable or unavailable. Despite its reliability, patients must receive comprehensive counselling due to the possibility of delayed complications. The addition of implants can introduce further risks, including implant-related sequelae. However, advancements such as fat grafting for volume enhancement and scar correction have revitalized the role of the LD flap. These developments reaffirm its reliability, versatility and relevance in modern breast reconstruction.

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