Algorithm for Autologous BreastReconstruction for Partial Mastectomy DefectsJoshua L. Levine, M.D., Nassif E. Soueid, M.D., and Robert J. Allen, M.D.New Orleans, La.

Background: The use of lateral thoracicskin and fat for breast reconstruction is ad-vantageous because it does not require theuse of muscle transfer, and the donor-siteincision is well hidden under the arm. Inpatients with redundant skin at the thoracicflank, use of this tissue has the added ben-efit of removal of an unsightly roll. Thelateral thoracic skin and fat flap can beharvested using microsurgical techniquebased on three different pedicles: the tho-racodorsal artery perforators; a direct cu-taneous branch of the thoracodorsal, axil-lary, or lateral thoracic arteries; and thelateral thoracic intercostal perforating ves-sel.Methods: The authors describe the tech-niques for harvest of lateral thoracic tissuebased on each of the pedicle options. A caseis then presented to illustrate each option,and an algorithm is suggested for decidingwhich pedicle to use.Results: The authors have used lateralthoracic tissue for partial breast reconstruc-tion for a variety of defects. In this report,the authors review the results of three il-lustrative cases.Conclusions: Partial breast reconstruc-tion may be required for patients afterbreast-conserving therapy or after breast re-construction by other methods. Lateralthoracic tissue can be safely transferred tocorrect defects in treated or reconstructedbreast, or to obtain symmetry. Knowledgeof the vascular anatomy to this region is

helpful in understanding the pedicle op-tions when harvesting this tissue. The au-thors present an algorithm for determiningwhich pedicle is most appropriate for thetransfer of lateral thoracic tissue for partialbreast reconstruction. (Plast. Reconstr.Surg. 116: 762, 2005.)

Breast reconstruction with the use of adja-cent tissues from the axillary and lateral tho-racic region is advocated in this article as anoption for the surgeon, especially in patientswho have excess and redundant tissues at thissite. The ease of harvest and versatility of theflaps described makes them attractive.

The use of lateral thoracic skin and subcuta-neous tissue for breast reconstruction has ad-vantages for several reasons. Proximity to thebreast makes it an excellent choice for a localflap. It is similar in color and texture to thebreast, and the donor-site scar is well hiddenunder the arm. A large volume of skin andsubcutaneous fat can be harvested without vio-lating any muscle. Also, in some patients, re-moving this axillary tissue, which may be anunsightly, redundant roll, has an added cos-metic benefit. Lateral thoracic soft tissue canbe used for breast reconstruction with or with-out an implant, or for autologous breast aug-mentation by deepithelializing the flap andplacing it behind the breast.

A lateral thoracodorsal fasciocutaneous flaphas been described for immediate breastreconstruction.1 This tissue can also be har-

From the Division of Plastic and Reconstructive Surgery, Louisiana State University. Received for publication June 18; 2004; revised February15, 2005.

DOI: 10.1097/01.prs.0000176892.38430.8a

762

vested based on several different pedicles: mus-culocutaneous perforating vessels through thelatissimus dorsi; direct cutaneous branches ofthe thoracodorsal, axillary, or lateral thoracicvessels; and intercostal musculocutaneous per-forators. These options are outlined below,along with a case that illustrates each. We pro-pose an algorithm for deciding which vascularpedicle should be used in a given situation.

THORACODORSAL ARTERY PERFORATOR FLAP

Since its description in 19062 and reintro-duction in the 1970s, the latissimus dorsi myo-cutaneous flap has been a mainstay for breastreconstruction.3 An adipocutaneous flap basedon the thoracodorsal perforating vessels wasdescribed in 19954 and has been used forbreast reconstruction.5 The thoracodorsal ar-tery perforator flap can be used in place of thelatissimus dorsi myocutaneous flap and has thedistinct advantage of complete muscle sparing.

The thoracodorsal branch of the subscapu-lar artery, after giving off a branch to the ser-ratus anterior, travels along the lateral under-surface of the latissimus dorsi muscle. Itbifurcates into a horizontal (medial) and ver-tical (lateral) branch.6 Both branches give offan approximately equal number of cutaneousperforators.7 A large skin paddle can be de-signed over any of these perforators, providedthat the selected vessels are of adequate diam-eter. There is a great deal of flexibility withrespect to the orientation of the skin paddle.4

Case 1A 42-year-old woman presented who had undergone a

lumpectomy, axillary dissection, and radiation therapy of theright breast for breast cancer 7 years previously. Two yearslater, she had a recurrence in the right breast for which sheunderwent a right completion mastectomy and a left pro-phylactic mastectomy. She underwent reconstruction withbilateral expanders, which were ultimately replaced with im-plants. She had several complications on the right (irradi-ated) side resulting in explantation. She was referred forbilateral breast reconstruction with autologous tissue andunderwent bilateral superficial inferior epigastric artery freeflap reconstruction. She developed fat necrosis in the rightbreast flap, which a plastic surgeon in her hometown treatedwith excision of the firm area and placement of a salineimplant. She subsequently developed complications with theimplant and required three more operations and ultimateexplantation. At this time, the patient returned to us for anautologous augmentation/reconstruction of her smaller re-constructed right breast (Fig. 1).

The lateral thoracic tissue was marked lateral to the breastwith the 7-cm base of the flap at the anterior axillary line asdescribed by Holmstrom and Lossing.8 Thoracodorsal per-forating vessels are identified with a handheld Dopplerprobe. The triangular design follows the curve of the ribs

laterally. An intercostal perforating vessel was also identifiedat the base of the flap.

The patient was placed in the supine position with a bolsterunder the right lateral back. The arm was abducted at 90degrees. Flap dissection was begun lateral to the anterioraxillary line in a subfascial plane. Thoracodorsal perforatorswere identified under loupe magnification and preserved(Fig. 2, above). The two thoracodorsal perforators were dis-sected down through the fibers of the latissimus dorsi muscleto the thoracodorsal artery. The thoracodorsal artery wasthen freed from surrounding tissue and from the thoracodor-sal nerve (Fig. 2, center). Dissection was continued to the baseof the flap, at which point the capsule from the prior implantwas encountered at the lateral edge of the pectoralis muscle.Significantly, because of scar tissue from prior operations, theintercostal perforator was not present. The flap was com-pletely isolated on its thoracodorsal artery perforator pedicleand passed between the fibers of the latissimus dorsi muscle.The flap was then deepithelialized. A space was created be-tween the reconstructed breast and the pectoralis fascia, andthe flap was turned over, passed into this space, and anchoredwith a 2-0 Vicryl stitch (Ethicon, Inc., Somerville, N.J.) (Fig.2, below). A drain was placed and the defect was closed pri-marily (Fig. 3).

LATERAL THORACIC FLAP (AXILLARY FLAP)

Axillary and lateral thoracic tissue can deriveits blood supply in part from one or more directcutaneous branches from the lateral thoracic ar-tery, the axillary artery (accessory lateral thoracicartery), or the thoracodorsal artery5 (or rarelyfrom the subscapular artery).9 Any of these ves-sels, when present, are excellent candidates forthe basis of skin transfer for reconstruction, andtheir use as pedicles for free transfer of axillarytissue has been described.10–12 There are vary-ing reports as to the consistency of these ves-sels. In a study of 100 cadaveric dissections ofthe subscapular-thoracodorsal artery system,Roswell et al. found a direct cutaneous branchfrom the thoracodorsal artery in 47 percent of

FIG. 1. Patient after bilateral superficial inferior epigas-tric artery reconstruction and subsequent problems leadingto asymmetry.

Vol. 116, No. 3 / AUTOLOGOUS BREAST RECONSTRUCTION 763

subjects and from the subscapular artery in 7percent.9 Allen, et al. repeated this study on 20cadavers in 2003 and found a direct cutaneousbranch from the thoracodorsal artery in 55percent of cadavers.9

As with the thoracodorsal artery perforator,the skin and subcutaneous fat for transfer areisolated on the cutaneous vessels. The pedicleis then freed from surrounding tissue andtransferred into position as described below.

Case 2A 48-year-old woman who had undergone a lumpectomy,

axillary dissection, radiation, and chemotherapy of the rightbreast for cancer presented with a deformity of the inferiorpole of the right breast (Fig. 4). The skin paddle was designedsimilar to that in case 1. The width of the base was 7 cm andthe length was 16 cm, extending over the latissimus dorsimuscle. Dissection was started laterally at the apex of the flapand continued in a subfascial plane toward the anterior ax-illary line. As the dissection proceeded anteriorly, no ade-quate thoracodorsal perforators were identified. Just anteriorto the edge of the latissimus dorsi muscle, a direct cutaneousbranch off of the thoracodorsal artery was identified andpreserved. This pedicle was deemed adequate to perfuse theentire flap. The flap was completely elevated off of the un-derlying muscle (Fig. 5, above). An island flap was created bytransecting the medial skin bridge. A subglandular dissection

FIG. 2. (Above) Two thoracodorsal artery perforators wereidentified and preserved. (Center) The thoracodorsal arteryperforator is dissected through the muscle, and the thora-codorsal nerve is preserved. (Below) The flap is turned overand secured behind the breast flap. The perforating vesselsare seen passing into the flap.

FIG. 3. The defect is closed primarily and the drain isplaced.

FIG. 4. A 48-year-old patient after lumpectomy and radi-ation therapy.

764 PLASTIC AND RECONSTRUCTIVE SURGERY, September 1, 2005

and scar contracture release was then performed to create apocket for the flap. The flap was then deepithelialized andflipped over. The flap was then placed in the retromammaryspace to reconstruct the inferior pole and augment the breast(Fig. 5, below). A mastopexy was performed on the contralat-eral breast for symmetry. The patient did well postoperatively,with no complications.

INTERCOSTAL PERFORATOR FLAP

Lateral thoracic skin and subcutaneous tis-sue has been used as a fasciocutaneous flap foraxillary and breast reconstruction.1,8,13 Basingthe flap on an intercostal perforator that entersthe flap’s base at the anterior axillary line al-lows the surgeon to create a reliable flap oflarge dimensions that can dramatically aid inbreast reconstruction. This tissue can be usedas a rotation flap with or without an implant, orit too can be used as a turnover flap to augmentthe lower pole as described below.

Case 3A 61-year-old patient was treated for breast cancer with

bilateral mastectomy and tissue expander reconstruction 4years previous to presenting to us. She had several implant

exchanges for recurrent, severe, grade IV capsular contrac-tures; pain; extreme firmness; and poor shape and symmetry.We performed a bilateral superficial inferior epigastric arteryflap reconstruction. Postoperatively, the patient’s right re-constructed breast was smaller than the left, and the patientrequested better symmetry. The flap was designed similar tothose in cases 1 and 2. The intercostal perforators were iden-tified in the fifth interspace at the anterior axillary line witha Doppler probe (Fig. 6). The flap was lifted from lateral tomedial off of the underlying latissimus. Dissection proceededposterior to anterior until the intercostal perforators wereidentified (Fig. 7). The skin at the base of the flap was thentransected, and the flap was deepithelialized and the retro-mammary space developed. The flap was then turned over,placed into the pocket, and sutured in place.

DISCUSSION

Various breast abnormalities can result inpartial breast defects. Women who are diag-nosed with early-stage breast cancer are in-creasingly being treated with breast-conserva-tion therapy. Breast-conservation therapyinvolves lumpectomy and sentinel node biopsywith or without axillary node dissection, andradiation therapy. This has resulted in a varietyof breast deformities that ultimately requirefurther treatment. In fact, 20 to 30 percent ofpatients who have breast-conservation therapyhave a poor or mediocre cosmetic result, withdeformity and asymmetry as a result of lumpec-tomy and radiation fibrosis.14,15 The indicationsfor breast-conservation therapy are expandingto include more advanced disease,16,17 and asmany as 71 percent of patients treated for cos-metic sequelae after breast-conservation ther-apy will ultimately seek partial breastreconstruction.18 In addition, with the increas-ing popularity of breast augmentation and withthe young age at which many breast augmen-tations are performed, plastic surgeons are see-

FIG. 5. (Above) The flap is elevated off the latissimus dorsimuscle. (Below) The flap is used to reconstruct the lower pole.

FIG. 6. Intercostal perforators were identified at the baseof the flap at the anterior axillary line (X).

Vol. 116, No. 3 / AUTOLOGOUS BREAST RECONSTRUCTION 765

ing an increasing number of patients with whatVan Landuyt et al. have called the “augmenta-tion cripple,” the patient who has failed cos-metic augmentation with repeated infections,hematomas, or sever capsular contractures.19

Many of these patients are looking for an au-tologous solution to their breast deformity.

Most partial breast defects require a moder-ate amount of volume for reconstruction, andmany do not require skin. These defects havetraditionally been handled with a latissimusdorsi myocutaneous flap. We have found thatthe lateral thoracic skin and subcutaneous tis-sue is an ideal candidate for these defects.Taken from the natural redundancy of tissue atthe lateral thorax, the scar is well hidden underthe arm, and there is often an added cosmeticbenefit to removing what sometimes is an un-sightly roll. The scar is approximately 15 cmand concealed in the bra line. In addition,seromas seen with the latissimus myocutaneousflap is not noted to be a frequent problem.This flap can be used to recruit tissue with orwithout a skin island for augmentation or re-construction.

ALGORITHM

The three cases presented in this report il-lustrate the variety of options that are availablefor reconstruction with tissue in the axillaryand lateral thoracic region. The vascular anat-omy of this area has been studied extensively.An algorithm for choosing a vascular pediclecan be described based on knowledge of thisanatomy and preoperative Doppler planning.The triangular flap is designed with its base atthe anterior axillary line. The base of the flap ismarked with a 6- to 8-cm vertical height, cen-

tered directly over an interspace. If the tissue isneeded for reconstructing the inferior pole,and if the use of a skin paddle is anticipated,the fifth interspace is chosen. If the tissue isneeded for augmentation and thus flap deepi-thelialization is planned, the flap is centeredover the fourth interspace. The superior andinferior incisions of the triangular flap aremarked on the lateral thorax. The flap curvesslightly upward overlying the contour of theribs, coming to a point over the latissimusdorsi. The length of the flap is usually 15 cm. Ahand-held Doppler probe is used to locate thethoracodorsal perforating vessels at the lateraledge of the latissimus dorsi and the intercostalperforator at the base of the flap.

Pedicle Option I

Starting the dissection lateral to the anterioraxillary line, the skin and subcutaneous fat isincised down to the lateral latissimus dorsi.The dissection continues medially in a subfas-cial plane. Under loupe magnification, the tho-racodorsal perforators are identified near thelateral edge of the latissimus dorsi. If they areadequate for flap perfusion, they are preservedand dissected down through the muscle fibersto the thoracodorsal artery. The thoracodorsalnerve is preserved and the flap is then passedthrough the opening on the muscle. The tho-racodorsal vessels are freed proximally asneeded to mobilize the flap into position.

Pedicle Option II

If the thoracodorsal perforating vessels aredeemed to be inadequate for any reason, thedissection is continued anteriorly. The nextoption for flap perfusion would be direct cuta-neous branches of the axillary, thoracodorsal,or lateral thoracic vessels. If direct cutaneousvessels are available, this option is advanta-geous in that dissection does not involve thelatissimus dorsi. This pedicle can also be freedby dissecting the cutaneous branch to its parentvessel. This allows good mobilization of the flap.

Pedicle Option III

If neither of the first two options seems ad-equate, the intercostal perforating vessels pro-vide an excellent option. They are very consis-tent and reliable, and very capable of carryingthe flap. In patients who have had extensivesurgery in this area, however, these vessels aresometime not available. Based on the intercos-tal perforators, this flap can be rotated 90 de-

FIG. 7. Intercostal perforators at the base of the flap.

766 PLASTIC AND RECONSTRUCTIVE SURGERY, September 1, 2005

grees as described by Holmstrom and Lossing13

or deepithelialized and turned over.

CONCLUSIONS

All of these options make the lateral thoracicarea a versatile donor site with a myriad of possi-bilities for flap perfusion. The use of this tissuehas advantages, including complete muscle pres-ervation, a well-hidden scar, and removal of re-dundant lateral thoracic tissue. Knowledge of thevascular anatomy and preoperative Dopplerplanning provide the surgeon with several perfu-sion options, making this a safe and reliable pro-cedure. It can also be performed in approxi-mately 1 hour. An algorithm for the use of lateralthoracic tissue is presented. Lateral thoracic tis-sue should be considered as a donor site for avariety of breast reconstruction defects.

Nassif Elias Soueid, M.D.330 Julia Street, Apt. 203New Orleans, La. 70130boballen@diepflap.com

PREFERENCES

1. Krupp, S. Thoracic fascio-cutaneous flap (in French).Helv. Chir. Acta 58: 69, 1991.

2. Tansini, I. Coverage of the anterior chest wall followingmastectomy (in Italian). Guz. Mal. Ital. 57: 141, 1906.

3. Schneider, W. J., Hill, H. L., Jr., and Brown, R. G. La-tissimus dorsi myocutaneous flap for breast recon-struction. Br. J. Plast. Surg. 30: 277, 1977.

4. Angrigiani, C., Grilli, D., and Siebert, J. Latissimus dorsimusculocutaneous flap without muscle. Plast. Reconstr.Surg. 96: 1608, 1995.

5. Khoobehi, K., Allen, R. J., and Montegut, W. J. Thora-codorsal artery perforator flap for reconstruction.90th Annual Scientific Assembly of the Southern Med-ical Association, Baltimore, Maryland, November 20–24. South. Med. J. 89: 1996.

6. Strauch, B., and Yu, H.-L. Atlas of Microvascular Surgery:Anatomy and Operative Approaches. New York: Thieme,1993. P. 490.

7. Heitmann, C., Guerra, A., Metzinger, S. W., Levin, L. S.,and Allen, R. J. The thoracodorsal artery perforatorflap: Anatomic basis and clinical application. Ann.Plast. Surg. 551: 23, 2003.

8. Holmstrom, H., and Lossing, C. The lateral thora-codorsal flap in breast reconstruction. Plast. Reconstr.Surg. 577: 933, 1986 .

9. Roswell, A. R., Davies, D. M., Eisenberg, N., and Taylor,G. I. The anatomy of the subscapular-thoracodorsalarterial system: Study of 100 cadaver dissections. Br. J.Plast. Surg. 537: 574, 1984.

10. Harii, K., Torii, S., and Sekiguchi, J. The free lateralthoracic flap. Plast. Reconstr. Surg. 62: 212, 1978.

11. Baudet, J., Guimberteau, J. C., and Nascimento, E.Successful clinical transfer of two free thoraco-dorsalaxillary flaps. Plast. Reconstr. Surg. 558: 680, 1976.

12. Boeckx, W. D., De Coninck, A., and Vanderlinden,E. Ten free flap transfers. Plast. Reconstr. Surg. 57:707, 1976.

13. Holmstrom, H., and Lossing, C. Lateral thoracodorsalflap: An intercostal perforator flap for breast recon-struction. Semin. Plast. Surg. 16: 53, 2002.

14. Amichetti, M., Busana, L., and Caffo, O. Long-termcosmetic outcome and toxicity in patients treated withquadrantectomy and radiation therapy for early-stagebreast cancer. Oncology 52: 177, 1995.

15. Rkose, M. A., Olivotto, I. A., Cady, B., et al. Conservativesurgery and radiation therapy for early breast cancer:Long-term cosmetic results. Arch. Surg. 124: 153, 1989.

16. Calais, G., Berger, C., Descamps, P., et al. Conservativetreatment feasibility with chemotherapy, surgery andradiotherapy for patients with breast carcinoma largerthan 3 cm. Cancer 74: 1283, 1984.

17. Scholl, S. M., Fourquet, A., Asselain, B., et al. Neoad-juvant versus adjuvant chemotherapy in premeno-pausal patients with tumors considered too large forBreast conserving surgery: Preliminary results of a ran-domized trial: S6. Eur. J. Cancer 30: 645, 1994.

18. Clough, K. B., Cuminet, J., Fitoussi, A., et al. Cosmeticsequelae after conservative treatment for breast can-cer: Classification and results of surgical correction.Ann. Plast. Surg. 41: 471, 1998.

19. Van Landuyt, K., Hamdi, M., Blondeel, P., and Monstrey,S. Autologous breast augmentation by pedicled per-forator flaps. Personal communication.

Vol. 116, No. 3 / AUTOLOGOUS BREAST RECONSTRUCTION 767