Aesthetic Breast Reconstruction with Muscle-Sparing Latissimus Dorsi (MSLD) Flaps in Patients Undergoing Mastectomy

BACKGROUND: Mastectomy remains a common surgical treatment for therapeutic and risk-reducing indications. The muscle-sparing latissimus dorsi (MSLD) flap provides a reliable autologous reconstructive option in immediate, delayed, and salvage settings. Our technique incorporates cone shaping of the flap to enhance projection. We use fat grafting for additional volume and contour correction. To evaluate aesthetic outcomes with these procedures, we conducted a 10-year retrospective review. METHODS: Patients who underwent mastectomy with MSLD flap reconstruction between January 2016 and December 2025 were identified. Inclusion required a minimum of 3 months follow-up. Demographic, operative, and outcomes data were collected. Standardized pre- and post-operative photographs were reviewed to assess breast and donor-site aesthetics. RESULTS: A total of 515 patients (807 flaps) were included (mean age 56.2 ± 10.7 years; mean BMI 29.7 ± 6.1 kg/m2). Racial distribution was 44% White, 28% Black, 25% Hispanic, and 3% other; 5% were active smokers. Reconstruction was immediate in 45.8%, delayed in 24.3%, and salvage in 29.9%. SPY angiography was used in 100% of cases. The major complication rate requiring return to the OR was 1.55% (infection n=3; partial flap necrosis n=5). Neo-parenchymal mastopexy was performed in 11.5%. Secondary fat grafting was performed in 40% with a mean volume of 73 cc per breast. CONCLUSION: MSLD flap reconstruction demonstrates low complication rates and reproducible aesthetic outcomes. Intraoperative perfusion assessment confirms flap viability. Cone shaping and adjunctive fat grafting provide contour refinement and volume optimization. Strategic donor-site design facilitates favorable scar concealment, particularly in patients with prominent back rolls.