Comparative study of endoscopic surgery and traditional open surgery of latissimus dorsi flap harvesting for breast reconstruction_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

FENG Yu ¹ , LUO Guilin ¹ , LIANG Faqing ^2,3 ,  ZHANG Donglin ¹ ,  DU Zhenggui ^2,3

1. Department of General Surgery, The Fourth People’s Hospital of Sichuan Province, Chengdu 610016, P. R. China;
2. Department of General Surgery, West China Hospital, Sichuan University, Chengdu 610041, P. R. China;
3. Breast Disease Research Center, West China Hospital, Sichuan University, Chengdu 610041, P. R. China;

Corresponding author：

ZHANG Donglin, Email: zoomail@126.com; DU Zhenggui, Email: docduzg@163.com

Keywords：

latissimus dorsi muscle flap; breast reconstruction; endoscope; open surgery

DOI：

10.7507/1007-9424.202411035

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Objective To compare the surgical data, safety, cosmetic outcomes, and quality of life of patients underwent a single axillary incision endoscopic nipple-sparing mastectomy and immediate breast reconstruction with endoscopic harvesting of latissimus dorsi muscle flap (abbreviation as the “endoscopic group”) and traditional open surgery of latissimus dorsi muscle flap harvesting for breast reconstruction after mastectomy (abbreviation as the “traditional open group”). Methods The patients were collected, who underwent latissimus dorsi breast reconstruction at the West China Hospital of Sichuan University and the Fourth People’s Hospital of Sichuan Province from January 2021 to June 2024 from a prospective maintenance database, and then were assigned into an endoscopic group and a traditional open group according to the surgical method. Their basic information, information relevant operation, postoperative complications, and patient reported outcomes (BREAST-Q scale) score were compared between the two groups. Results A total of 73 patients were collected, including 23 patients in the endoscopic group and 50 patients in the traditional open group. There were no statistically significant differences in the age, body mass index, breast sagging, tumor location, tumor N stage, pathological type, adjuvant therapy, etc. between the patients of two groups, except for a higher proportion of T4 stage patients in the open group as compared to the endoscopic group (P＜0.001). A longer size of latissimus dorsi muscle flap was harvested in the endoscopic group as compared with the open group (P=0.002). There were no statistically significant differences in the total surgical complications, major complications, minor complications, and implant-related complications between the patients of two groups (P>0.05). The most common complication in the patients of both groups was back seroma, 21.7% (5/23) in the endoscopic group and 22.0% (11/50) in the traditional open group. The total length of incisions in the endoscopic group was significantly shorter than that in the traditional open group (P<0.001), and the points of the breast satisfaction (P=0.045), back satisfaction (P<0.001), and sexual well-being (P=0.028) of the patients in the endoscopic group were significantly higher than those in the traditional open group. The major complications did not happen in the endoscopic group, but happened in 2 cases in the open group (1 patient due to ischemic necrosis of the latissimus dorsi muscle and 1 patient due to breast infection resulting in implant removal). During the follow-up period, 3 (6.0%) patients had distant metastasis (all were lung metastasis) in the traditional open group, and there was no local or regional recurrence, distant metastasis, and specific death of breast cancer in the endoscopic group. Conclusions The results of this study suggest that, for patients who have skin invasion but who desire breast reconstruction or have failed by prosthetic breast reconstruction (such as skin flap necrosis), traditional open surgery of latissimusdorsi flap harvesting for breast reconstruction is worth choosing. However, for breast cancer patients who do not need additional skin breast reconstruction, endoscopic latissimus dorsi breast reconstruction has greater advantages in cosmetic effect, and it is safe and effective.

1.	Adams WP, Lipschitz AH, Ansari M, et al. Functional donor site morbidity following latissimus dorsi muscle flap transfer. Ann Plast Surg, 2004, 53(1): 6-11.
2.	Marín-Gutzke M, Sánchez-Olaso A. Reconstructive surgery in young women with breast cancer. Breast Cancer Res Treat, 2010, 123 Suppl 1: 67-74.
3.	Yang CE, Roh TS, Yun IS, et al. Immediate partial breast reconstruction with endoscopic latissimus dorsi muscle flap harvest. Arch Plast Surg, 2014, 41(5): 513-519.
4.	Sood R, Easow JM, Konopka G, et al. Latissimus dorsi flap in breast reconstruction: Recent innovations in the workhorse flap. Cancer Control, 2018, 25(1): 1073274817744638. doi: 10.1177/1073274817744638.
5.	Berthet G, Faure C, Dammacco MA, et al. Tolerance of latissimus dorsi in immediate breast reconstruction without implant to radiotherapy. J Plast Reconstr Aesthet Surg, 2018, 71(1): 15-20.
6.	Winocour S, Tarassoli S, Chu CK, et al. Comparing outcomes of robotically assisted latissimus dorsi harvest to the traditional open approach in breast reconstruction. Plast Reconstr Surg, 2020, 146(6): 1221-1225.
7.	Toesca A, Peradze N, Galimberti V, et al. Robotic nipple-sparing mastectomy and immediate breast reconstruction with implant: First report of surgical technique. Ann Surg, 2017, 266(2): e28-e30. doi: 10.1097/SLA.0000000000001397.
8.	Lai HW, Chen ST, Tai CM, et al. Robotic- versus endoscopic-assisted nipple-sparing mastectomy with immediate prosthesis breast reconstruction in the management of breast cancer: A case-control comparison study with analysis of clinical outcomes, learning curve, patient-reported aesthetic results, and medical cost. Ann Surg Oncol, 2020, 27(7): 2255-2268.
9.	Lai HW, Chen ST, Lin SL, et al. Technique for single axillary incision robotic assisted quadrantectomy and immediate partial breast reconstruction with robotic latissimus dorsi flap harvest for breast cancer: A case report. Medicine (Baltimore), 2018, 97(27): e11373. doi: 10.1097/MD.0000000000011373.
10.	Eo PS, Kim H, Lee JS, et al. Robot-assisted latissimus dorsi flap harvest for partial breast reconstruction: comparison with endoscopic and conventional approaches. Aesthet Surg J, 2023, 44(1): 38-46.
11.	Missana MC, Pomel C. Endoscopic latissimus dorsi flap harvesting. Am J Surg, 2007, 194(2): 164-169.
12.	Losken A, Schaefer TG, Carlson GW, et al. Immediate endoscopic latissimus dorsi flap: risk or benefit in reconstructing partial mastectomy defects. Ann Plast Surg, 2004, 53(1): 1-5.
13.	Serra-Renom JM, Serra-Mestre JM, Martinez L, et al. Endoscopic reconstruction of partial mastectomy defects using latissimus dorsi muscle flap without causing scars on the back. Aesthetic Plast Surg, 2013, 37(5): 941-949.
14.	Kim DG, Kim JS, Lee JS, et al. The usefulness of endoscopic harvesting of the latissimus dorsi flap for breast reconstruction using a single-port and CO₂ gas insufflation technique. Aesthetic Plast Surg, 2021, 45(6): 2681-2690.
15.	Iglesias M, Gonzalez-Chapa DR. Endoscopic latissimus dorsi muscle flap for breast reconstruction after skin-sparing total mastectomy: report of 14 cases. Aesthetic Plast Surg, 2013, 37(4): 719-727.
16.	Ahmed YS, Abd El Maksoud WM. Combined endoscopy-assisted muscle-sparing latissimus dorsi flap harvesting with lipofilling enhancement as a new volume replacement technique in breast reconstruction. Breast J, 2022, 2022: 7740439. doi: 10.1155/2022/7740439.
17.	Liang F, Wen N, Xie Y, et al. Subversion of endoscopic breast reconstruction surgery: nipple-sparing mastectomy and immediate reconstruction with a latissimus dorsi flap/latissimus dorsi flap and implant through a single axillary incision. Ann Surg Open, 2021, 2(3): e082. doi: 10.1097/AS9.0000000000000082.
18.	Qiu J, Wen N, Xie Y, et al. Novel technique for endoscopic-assisted nipple-sparing mastectomy and immediate breast reconstruction with endoscopic-assisted latissimus dorsi muscle flap harvest through a single axillary incision: a retrospective cohort study of comparing endoscopic and open surgery. Gland Surg, 2022, 11(8): 1383-1394.
19.	Feng Y, Wen N, Liang F, et al. Endoscopic nipple- or skin-sparing mastectomy and immediate breast reconstruction with endoscopic harvesting of the latissimus dorsi flap: A preliminary experience of an innovative technique. Breast J, 2022, 2022: 1373899. doi: 10.1155/2022/1373899.
20.	Du Z, Zhou Y, Chen J, et al. Retrospective observational study of breast reconstruction with extended latissimus dorsi flap following skin-sparing mastectomy. Medicine (Baltimore), 2018, 97(31): e10936. doi: 10.1097/MD.0000000000010936.
21.	Regnault P. Breast ptosis. Definition and treatment. Clin Plast Surg, 1976, 3(2): 193-203.
22.	Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6 336 patients and results of a survey. Ann Surg, 2004, 240(2): 205-213.
23.	Pusic AL, Klassen AF, Scott AM, et al. Development of a new patient-reported outcome measure for breast surgery: the BREAST-Q. Plast Reconstr Surg, 2009, 124(2): 345-353.
24.	Spear SL, Baker JL Jr. Classification of capsular contracture after prosthetic breast reconstruction. Plast Reconstr Surg, 1995, 96(5): 1119-1124.Spear SL, Baker JL Jr. Classification of capsular contracture after prosthetic breast reconstruction. Plast Reconstr Surg, 1995, 96(5): 1119-1124.
25.	Nam SB, Oh HC, Choi JY, et al. Volumetric change of the latissimus dorsi muscle after immediate breast reconstruction with an extended latissimus dorsi musculocutaneous flap. Arch Plast Surg, 2019, 46(2): 135-139.
26.	Chang HP, Fan KL, Song SY, et al. The traditional versus endoscopic-assisted latissimus dorsi harvest in oncoplastic surgery: A long term comparison of breast volume, aesthetics, and donor site outcomes. Asian J Surg, 2020, 43(12): 1165-1171.
27.	Clemens MW, Kronowitz S, Selber JC. Robotic-assisted latissimus dorsi harvest in delayed-immediate breast reconstruction. Semin Plast Surg, 2014, 28(1): 20-25.
28.	Houvenaeghel G, El Hajj H, Schmitt A, et al. Robotic-assisted skin sparing mastectomy and immediate reconstruction using latissimus dorsi flap a new effective and safe technique: A comparative study. Surg Oncol, 2020, 35: 406-411.

1. Adams WP, Lipschitz AH, Ansari M, et al. Functional donor site morbidity following latissimus dorsi muscle flap transfer. Ann Plast Surg, 2004, 53(1): 6-11.
2. Marín-Gutzke M, Sánchez-Olaso A. Reconstructive surgery in young women with breast cancer. Breast Cancer Res Treat, 2010, 123 Suppl 1: 67-74.
3. Yang CE, Roh TS, Yun IS, et al. Immediate partial breast reconstruction with endoscopic latissimus dorsi muscle flap harvest. Arch Plast Surg, 2014, 41(5): 513-519.
4. Sood R, Easow JM, Konopka G, et al. Latissimus dorsi flap in breast reconstruction: Recent innovations in the workhorse flap. Cancer Control, 2018, 25(1): 1073274817744638. doi: 10.1177/1073274817744638.
5. Berthet G, Faure C, Dammacco MA, et al. Tolerance of latissimus dorsi in immediate breast reconstruction without implant to radiotherapy. J Plast Reconstr Aesthet Surg, 2018, 71(1): 15-20.
6. Winocour S, Tarassoli S, Chu CK, et al. Comparing outcomes of robotically assisted latissimus dorsi harvest to the traditional open approach in breast reconstruction. Plast Reconstr Surg, 2020, 146(6): 1221-1225.
7. Toesca A, Peradze N, Galimberti V, et al. Robotic nipple-sparing mastectomy and immediate breast reconstruction with implant: First report of surgical technique. Ann Surg, 2017, 266(2): e28-e30. doi: 10.1097/SLA.0000000000001397.
8. Lai HW, Chen ST, Tai CM, et al. Robotic- versus endoscopic-assisted nipple-sparing mastectomy with immediate prosthesis breast reconstruction in the management of breast cancer: A case-control comparison study with analysis of clinical outcomes, learning curve, patient-reported aesthetic results, and medical cost. Ann Surg Oncol, 2020, 27(7): 2255-2268.
9. Lai HW, Chen ST, Lin SL, et al. Technique for single axillary incision robotic assisted quadrantectomy and immediate partial breast reconstruction with robotic latissimus dorsi flap harvest for breast cancer: A case report. Medicine (Baltimore), 2018, 97(27): e11373. doi: 10.1097/MD.0000000000011373.
10. Eo PS, Kim H, Lee JS, et al. Robot-assisted latissimus dorsi flap harvest for partial breast reconstruction: comparison with endoscopic and conventional approaches. Aesthet Surg J, 2023, 44(1): 38-46.
11. Missana MC, Pomel C. Endoscopic latissimus dorsi flap harvesting. Am J Surg, 2007, 194(2): 164-169.
12. Losken A, Schaefer TG, Carlson GW, et al. Immediate endoscopic latissimus dorsi flap: risk or benefit in reconstructing partial mastectomy defects. Ann Plast Surg, 2004, 53(1): 1-5.
13. Serra-Renom JM, Serra-Mestre JM, Martinez L, et al. Endoscopic reconstruction of partial mastectomy defects using latissimus dorsi muscle flap without causing scars on the back. Aesthetic Plast Surg, 2013, 37(5): 941-949.
14. Kim DG, Kim JS, Lee JS, et al. The usefulness of endoscopic harvesting of the latissimus dorsi flap for breast reconstruction using a single-port and CO₂ gas insufflation technique. Aesthetic Plast Surg, 2021, 45(6): 2681-2690.
15. Iglesias M, Gonzalez-Chapa DR. Endoscopic latissimus dorsi muscle flap for breast reconstruction after skin-sparing total mastectomy: report of 14 cases. Aesthetic Plast Surg, 2013, 37(4): 719-727.
16. Ahmed YS, Abd El Maksoud WM. Combined endoscopy-assisted muscle-sparing latissimus dorsi flap harvesting with lipofilling enhancement as a new volume replacement technique in breast reconstruction. Breast J, 2022, 2022: 7740439. doi: 10.1155/2022/7740439.
17. Liang F, Wen N, Xie Y, et al. Subversion of endoscopic breast reconstruction surgery: nipple-sparing mastectomy and immediate reconstruction with a latissimus dorsi flap/latissimus dorsi flap and implant through a single axillary incision. Ann Surg Open, 2021, 2(3): e082. doi: 10.1097/AS9.0000000000000082.
18. Qiu J, Wen N, Xie Y, et al. Novel technique for endoscopic-assisted nipple-sparing mastectomy and immediate breast reconstruction with endoscopic-assisted latissimus dorsi muscle flap harvest through a single axillary incision: a retrospective cohort study of comparing endoscopic and open surgery. Gland Surg, 2022, 11(8): 1383-1394.
19. Feng Y, Wen N, Liang F, et al. Endoscopic nipple- or skin-sparing mastectomy and immediate breast reconstruction with endoscopic harvesting of the latissimus dorsi flap: A preliminary experience of an innovative technique. Breast J, 2022, 2022: 1373899. doi: 10.1155/2022/1373899.
20. Du Z, Zhou Y, Chen J, et al. Retrospective observational study of breast reconstruction with extended latissimus dorsi flap following skin-sparing mastectomy. Medicine (Baltimore), 2018, 97(31): e10936. doi: 10.1097/MD.0000000000010936.
21. Regnault P. Breast ptosis. Definition and treatment. Clin Plast Surg, 1976, 3(2): 193-203.
22. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6 336 patients and results of a survey. Ann Surg, 2004, 240(2): 205-213.
23. Pusic AL, Klassen AF, Scott AM, et al. Development of a new patient-reported outcome measure for breast surgery: the BREAST-Q. Plast Reconstr Surg, 2009, 124(2): 345-353.
24. Spear SL, Baker JL Jr. Classification of capsular contracture after prosthetic breast reconstruction. Plast Reconstr Surg, 1995, 96(5): 1119-1124.Spear SL, Baker JL Jr. Classification of capsular contracture after prosthetic breast reconstruction. Plast Reconstr Surg, 1995, 96(5): 1119-1124.
25. Nam SB, Oh HC, Choi JY, et al. Volumetric change of the latissimus dorsi muscle after immediate breast reconstruction with an extended latissimus dorsi musculocutaneous flap. Arch Plast Surg, 2019, 46(2): 135-139.
26. Chang HP, Fan KL, Song SY, et al. The traditional versus endoscopic-assisted latissimus dorsi harvest in oncoplastic surgery: A long term comparison of breast volume, aesthetics, and donor site outcomes. Asian J Surg, 2020, 43(12): 1165-1171.
27. Clemens MW, Kronowitz S, Selber JC. Robotic-assisted latissimus dorsi harvest in delayed-immediate breast reconstruction. Semin Plast Surg, 2014, 28(1): 20-25.
28. Houvenaeghel G, El Hajj H, Schmitt A, et al. Robotic-assisted skin sparing mastectomy and immediate reconstruction using latissimus dorsi flap a new effective and safe technique: A comparative study. Surg Oncol, 2020, 35: 406-411.

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