The Latissimus Dorsi Myocutaneous Flap for Breast Reconstruction: Still a Good Competitor in 2014?

During my 33-year career in plastic surgery the Latissimus Dorsi myocutaneous (LD) flap remained a widely used workhorse in breast reconstruction. However, this flap must compete with highly sophisticated transfers as the DIEP and other free flaps . In the presentation, I wish to analyze how the application of the LD- flap in breast reconstruction progressively evolved from the 20th to the 21st century. As a reconstructor , I remain of the opinion that a surgeon should be able to provide all options and that he acts as a physician and not merely as a technician. The training in plastic surgery should therefore not focus on one type of reconstruction applied regardless of age, history, general medical or physical condition, body image or wishes of the patient. During the last 25 years, the indications for the use of the different types in the breast reconstruction, from implant to pedicled and free flaps, are determined according to well-defined criteria, taking into account the original tumor type and degree of aggressiveness of the cancer and involvement of the axillary nodes, the age of the patient, and the period in life of the patient, the other medical problems , the sequellae of the therapies ( chemo- and radiotherapy) used in the treatment of the breast cancer, the body image and the requirements of the patient. Since 1995, the progression in the use of the LD flap (N=307) in my practice, has been characterized by the development of a standard biodimensional design, adapted to the physical properties of the patient and the mastectomy, also taking in account the aesthetic units of the future breast, the change of the orientation of the remaining scar in the donor area, from horizontally extending over the back to vertically under the arm, the use of an all in one implant ( Allergan style 150), the remodeling using lipofilling or the lipofilling of the LD-matrix to produce a final autologous reconstruction without an implant for slim or, on the opposite, obese patients ( BMI 35-40). In future, we will have to think also in plastic surgery minimally invasive. The LD flap will in my opinion fulfill this condition.