Immediate nipple areolar complex reconstruction over latissimus dorsi skin paddle flap in bilateral periareolar mastectomy & reconstruction

Background: Today, conservative mastectomies allow preservation of skin and nipple-areolar complex with oncologic safety. In those cases where nipple-areola complex (NAC) must be sacrificed, the latissimus dorsi (LD) musculocutaneous flap can be considered as an effective method for immediate breast reconstruction with simultaneous NAC reconstruction over the LD skin paddle. The skin color of the dorsal flap, dermal thickness, and preservation of the fat under the thoracic fascia and its perforator vessels allows a safe and acceptable reconstruction with two surgical steps and satisfactory outcomes. Methods: A retrospective analysis of 12 patients who underwent bilateral skin sparing mastectomy (SSM) by periareolar approach and immediate NAC reconstruction over the LD skin island flap was performed between January 2013 and June 2019. The use of an expander/implant is included in the overall surgical strategy for breast reconstruction. Mean follow-up was 32.2 months. Results: In this limited series of 12 patients (24 procedures), the mean age was 57 years and patients selected with no comorbidities. As complications, seroma at the dorso was the most common. We also experienced one back wound dehiscence. No reinterventions were needed. Success in NAC reconstruction was 100%. A thin donor-site scar remains in the back, designed with a ‘banana’ pattern. The flap rotates completely to the breast because of the muscle insertion partial release, and the volume provided by the flap is increased by keeping the deep layer of fat attached to the muscle. This maneuver effectively softens the contours of the reconstructed breast. NAC reconstruction over the LD skin paddle maintains the projection over time thanks to the latissimus dorsi flap (LDF) dermis thickness. Breast animation is minimized by sectioning the thoracodorsal nerve, and the consistency and quality of the result are improved by using a staged tissue expander/implant strategy. Minimal complications were observed. Conclusions: With advancements in surgical technique by conservative mastectomies and improvements by immediate NAC reconstruction over the LD skin island flap, outstanding results obtained can be outstanding using the LDF in bilateral breast reconstruction when NAC must be sacrificed.