ORIGINAL ARTICLE
Oncoplastic volume replacement for breast cancer:
Early outcome and patient satisfaction following reconstruction with Latissmus dorsi (LD) flap versus Thoracodorsal artery perforators (TDAP) flap
Authors: Emad.M.Abd ElRahman,Mohammad.A,Balbaa, Ahmed. M.Nawar and Ahmed.A.ShoulahGeneral Surgery Department, Benha University and General Surgery Department, Menufia universityCorrespondence to: Emad.M.Abd ElRahman, Email: [email protected]
Back ground: Volume replacement oncoplastic breast techniques become one of the standard lines in strategy of treatment of early breast cancer because of better cosmetic out come and good patient satisfaction. Those techniques provide obvious decrease of the psychological impact on patient and in the same time resection of the tumor with safety margin to decrease the incidence of recurrence.

Aim: the current study aims at recording our experience in oncoplastic breast surgery by comparing the early outcome and patient satisfaction scale of both Latissmus dorsi (LD) flap and Thoracodorsal artery perforators (TDAP) flap
Methodology: From August 2016 till October 2018, a total of 42 adult female patients with early cancer breast who are eligible for conservative breast surgery and immediate breast reconstruction are allocated and divided in to two groups, group (A) where patients underwent immediate reconstruction using (LD) flap and group (B) that underwent reconstruction using (TDAP) flap. Follow up is designed for at least 12months for early outcome, patient satisfaction and shoulder functions.

Results: According to our scale evaluating outcome of latissmus dorsi (LD) flap and thoracodorsal artery perforators (TDAP) flap in 42 females with mean age of 40.95 ± 5.06 and 40.33 ± 5.25 years for group A and group B respectively. the safety margin was 17.52 ± 4.06 and 17.33 ± 3.17 mm in group A and group B respectively with no significant difference in flap dimensions, post operative complications or cosmetic outcome in both groups. there was significant difference between both groups as regards functional outcome of the shoulder at 3,6 and 12 months follow up.
Conclusion: Our study considers the TDAP flap as a good technique as (LD) flap as regards the post operative complications, cosmetic outcome, feasibility of technique, required equipment and finally early out come. There is still grey area that should be hit again and we are still in need for algorism for choosing the appropriate oncoplastic technique depending on the previous parameters
Keywords: Oncoplastic breast surgery LD flap, TDAP flap
Introduction
Breast cancer is a highly emotional topic. It is important for surgeons performing breast surgery to have a basic understanding of which patients are candidates for breast reconstruction and the reconstructive options.(1)
The main concept of oncoplastic breast surgery combines tumor excision with clear safety margin followed by breast reconstruction. Excision of more than 20% of the breast volume will increase the risk of worse cosmetic outcome. oncoplastic breast surgery includes either volume displacement or volume replacement techniques with clear shift towards immediate reconstruction for better psychological outcome.(2)
The aim of Breast reconstruction using different oncoplastic techniques is not just creating a mound on the chest wall but the symmetry with the contra lateral native breast is the main goal taking in consideration the size and shape of the other breast, location of the infra mammary fold, size, and color of the nipple-areola complex; and amount of breast ptosis.(3)
Advances in breast reconstruction techniques recommend immediate reconstruction over delayed reconstruction. many studies have shown a psychological benefit, cost-effectiveness, cosmetic advantage, and no increased risk for complications or oncologic risk with immediate breast reconstruction. (4)
Noguchi et al. (5) modified the original LD myocutaneous flap described by Tansini(6). Following tumor excision and axillary LNs clearance. Volume replacement by LD flap maintains the original shape and size of the breast with a balanced cosmetic outcome. It suitable for patients with small-to-medium sized breasts and those refusing contralateral surgery. Transposition of the LD flap will not interfere with subsequent mammogram, because the fatty tissue and the muscle are radiolucent. (7)
The Thoracodorsal artery perforator or TDAP flap is a fasciocutaneous flap based on a musculocutaneous perforator or perforators from the thoracodorsal vessel axis. The TDAP flap is well suited for extremity, head and neck defects.. A flap of dimensions 15 X 8 cm can be harvested on a single perforator. These dimensions allow for both primary closure of the donor site and avoidance of post-operative venous congestion in the flap. (8,9)
Complications, including partial or total flap loss, mastectomy flap loss, wound breakdown, infection, and problems related to the flap donor site like back seroma and hematoma can be encountered with any form of breast reconstruction and may cause delay in adjuvant chemotherapy. Complications are known to be higher in women who require adjuvant radiation therapy and, more commonly, with implant-based reconstructions. (10)
Patients and methods
The patients were recruited from the Department of General Surgery Faculty of medicine, in both Benha University and Menufia hospitals.
From August 2016 till November 2018, a total of 42 adult female patients with early cancer breast who were eligible for conservative breast surgery and immediate breast reconstruction are allocated and divided in to two groups, group (A) where patients underwent immediate reconstruction using (LD) flap and group (B) that underwent reconstruction using (TDAP) flap. Follow up is designed for at least 12 months for early outcome and patient satisfaction and functions of the shoulder.

The inclusion criterion were patients with T1,T2, DCIS who were eligible for breast conservative therapy and candidate and motivated for immediate reconstruction.
The exclusion criteria were Patients with locally advanced tumor, inflammatory breast cancer or metastatic disease. patients with collagen diseases like scleroderma or those with score >3 on American Society of Anesthesiologists (ASA) scale that prevent prolonged anesthesia were also excluded. Finally patient refusing breast reconstruction, inclusion with in the study or to sign informed consent were also excluded.

Follow up for early postoperative complications, patient satisfaction and range of shoulder movement was done for at least 12 months
The participants who agree to share in this clinical study gave informed consent after being fully informed about the technique and complications.. The study was conducted after approval of the committee of ethics in, Faculty of Medicine Benha and Menufeya University.

Preoperative assessment included full history taking, complete general and local assessment, bilateral mammography and tissue biopsy. Also full preoperative laboratory and metastatic work up was done
All patients were given sedative premedication and one shot of antimicrobial prophylaxis before surgery
Procedure
In LD flap Preoperative marking was done. Transverse elliptical was applied in the lateral decubitus position then dissection was done deep to the thoracodorsal facia till separation of the latismus dorsi muscle from the serratus anterior muscle, paraspinous muscles an trapezius. The LD muscle was then separated from the humerous after identification of the thoracodorsal artery. Subcutaneous tunnel for transfer of the flap where insetting in the defect was done. Finally closure of the donor site by direct suturing was applied.
In TDAP flap Using handheld Doppler preoperative marking of the site of the thoracodorsal artery perforator was done. After evaluation of volume deficit and location, the TDAP flap was designed in standing position with the arms at sides and hands on waist . It contained the point of previously localized artery within its center and the design of the flap must exceed the edge of the LD muscle. The flap width was designed with possibility of direct closure of the donor site. It is preferable to achieve a fine aesthetically acceptable scar than a skin graft in the donor area.
Two anatomical land marks were determined. The 1st point was related to the center of the flap and located 8cm below the posterior axillary fold and 2cm behind the lateral border of LD muscle. At this point the proximal skin perforator arises from the descending branch of the thoracodorsal artery and exits the LD muscle to pass in the SC tissue. The 2nd point was related to the site of thoracodorsal artery bifurcation and was located 3-6 cm below the inferior scapular tip and 1-4 cm medial to the lateral free margin of the LD muscle
The dissection was designed to be beveled to include a maximum of fat starting from the anterior side along the superficial plane till pulsation of the perforator was felt and could be easily observed using 4* magnification. Dissection was then continued till the anterior border of the muscle is reached. Tunnel was performed for flap insetting .The vascular pedicle was dissected until enough length was achieved to allow insetting of the flap in the breast defect without tension then the donor area was closed directly in two layers
Postoperative management included monitoring of the viability of flap, prophylactic anticoagulation in the form of I.V. heparin (5000IU/4hs) for 5 days, prophylactic antibiotic therapy for 3 days and monitoring of the drains.
Postoperative adjuvant therapy was planned for most our patients and the delivery time was determined to start 4 to 6 weeks postoperative to achieve maximum effect.

The esthetic outcome and patient satisfaction depended on the symmetry of both breasts, shape of the scar . keloid and finally the nipple areola complex. This was achieves through five point score (1= bad. 2=poor, 3= fair, 4= good and 5= excellent)
The functional out come of the shoulder was evaluated through shoulder pain and disability index (SPADI) where Functional activities were assessed with eight questions designed to measure the degree of difficulty an individual had with various activities of daily living that require upper-extremity use. The SPADI took 5 to 10 minutes for a patient to complete. SPADI is the only reliable and valid region-specific measure for the shoulder. To answer the questions, patients placed a mark on a 10cm visual analogue scale for each question. Verbal anchors for the functional activities are ‘no difficulty’ and ‘so difficult it required help’. The scores from both dimensions are averaged to derive a total score. Total disability score: _____/ 80 x 100 = ___% (11)

Figure (1) LD flap. a) Marking of flap, b) Incision and dissection, c) Full mobilization and tunnel formation, d) Insetting and e) Final esthetic outcome

Figure (2) TDAP flap. a) Marking of flap, b) Identification of Thoracodorsal artery, c) Full mobilization on vascular pedicle, d) Insetting and e) Final esthetic outcome
Results
The current study included 42 women with early breast cancer. For reconstruction following BCS they were divided into two groups, group A (LD flap) while group B (TDAP flap)
The mean age was 40.95 ± 5.06 and 40.33 ± 5.25 years for group A and group B respectively and the median was 41 and 40 for group A and group B respectively
Table (1): Comparison between the two studied groups according to tumor characteristics
Group A(n = 21) Group B(n = 21 p
No. % No. % Quadrant
UOQ
UIQ
LIQ
LOQ 10
4
3
4 47.6
19.0
14.3
19.0 9
5
2
5 42.9
23.8
9.5
23.8 1.000
Side
RT
LT 13
8 61.9
38.1 12
9 57.1
42.9 1.000
Size
T1
T2 7
14 33.3
66.7 6
15 28.6
71.4 1.000
Safety margin in mm
Min. – Max.

Mean ± SD.

Median 11.0 – 25.0
17.52 ± 4.06
18.0 12.0 – 23.0
17.33 ± 3.17
17.0 0.866
LN status
Negative
+ 1
+ 2
+ 3
+4 13
3
1
3
1 61.9
14.3
4.8
14.3
4.8 11
2
4
2
2 52.4
9.5
19.0
9.5
9.5 0.726
The mean dimension of the flap was 14.90 ± 1.97 and 14.62 ± 1.72 with mean time of operation 154.3 ± 11.54 and 155.7 ± 9.26 in group A and group B respectively.

Hospital stay was calculated from the day of the operation to the day of discharge The mean duration of hospital stay was 7.0 ± 1.22 and 6.71 ± 0.96 days in group A and group B respectively.

There was no total flap loss in both groups however Partial flap loss occurred in 1 patient (4.8%) and 2patients (9.5%) in group A and group B respectively but this didn’t delay adjuvant radiotherapy or chemotherapy.

Figure (3) Post operative complications

Figure (4) Patient satisfaction

Table (2):Comparison between the different studied periods according to shoulder functional disability
Shoulder functional disability 3 Months 6 Months 12 Months p
Group A(n = 21) Min. – Max. 15.0 – 58.0 9.0 – 28.0 2.0 – 16.0 ;0.001*
Mean ± SD. 28.10 ± 9.78 17.43 ± 5.66 5.62 ± 3.09 Median 26.0 16.0 5.0 Sig. bet. periods p1=0.002*, p2;0.001*, p3=0.001* Group B (n = 21) Min. – Max. 9.0 – 27.0 4.0 – 14.0 0.0 – 5.0 ;0.001*
Mean ± SD. 17.24 ± 5.36 7.57 ± 3.09 3.05 ± 1.47 Median 16.0 6.0 3.0 Sig. bet. periods p1=0.001*, p2;0.001*, p3=0.001* Table (3):Comparison between the two studied groups according to shoulder functional disability
Shoulder functional disability Group A(n = 21) Group B (n = 21) p
3 Months Min. – Max. 15.0 – 58.0 9.0 – 27.0 ;0.001*
Mean ± SD. 28.10 ± 9.78 17.24 ± 5.36 Median 26.0 16.0 6 Months Min. – Max. 9.0 – 28.0 4.0 – 14.0 ;0.001*
Mean ± SD. 17.43 ± 5.66 7.57 ± 3.09 Median 16.0 6.0 12 Months Min. – Max. 2.0 – 16.0 0.0 – 5.0 ;0.001*
Mean ± SD. 5.62 ± 3.09 3.05 ± 1.47 Median 5.0 3.0 Discussion
Oncoplastic breast surgery in treatment of breast cancer is an intermediate option between conventional breast conservative surgery and mastectomy. There is shift from delayed to immediate reconstruction and from implants to autologus tissue using volume replacement techniques. (12)
In The current study we evaluated the early outcome, esthetic outcome and shoulder function disability following LD flap (Group A) and TDAP flap (Group B) in 42 patient with early breast cancer with the mean age 40.95 ± 5.06 and 40.33 ± 5.25 years for group A and group B respectively and the median was 41 and 40 for group A and group B respectively
The current study revealed no involved surgical margins with safety margin 17.52 ± 4.06 and 17.33 ± 3.17 mm in group A and group B respectively. there was no significant difference in both groups and our results were comparable or even better than other reported studies evaluating safety margin in volume replacement oncoplastic surgery
Hamdi, et al. in 2008, (13) reported the mean dimension of the harvested TDAP flaps was 15. 32 ± 1.94. The flaps were successfully transferred with an average operative time of 190 min. (14)
The current study shows no significant difference in the mean dimension of the flaps that was 14.90 ± 1.97 and 14.62 ± 1.72 with mean time of operation 154.3 ± 11.54 and 155.7 ± 9.26 in group A and group B respectively. There is no significant difference in the hospital stay that was calculated from the day of the operation to the day of discharge The mean duration of hospital stay was 7.0 ± 1.22 and 6.71 ± 0.96 days in group A and group B respectively
By far the most common complication is seroma at the back donor site. Significant flap necrosis is unusual and is nearly always associated with either recognized or unrecognized injury to the vascular pedicle. Infection and hematoma occur with a frequency equal to other plastic surgical procedures. (15)
Judkins and singletary, 2009 (16) discussed the advantages and disadvantages results that occurred after immediate breast reconstruction utilizing TDAP flap in 100 patients with an average length of follow up was 20 months. The major complications were rare (1% partial necrosis and 1% total necrosis). The minor complications were represented mainly with dorsal seroma and this was the main drawback of the technique and occurred in 79% specially in obese patients . Donor site morbidity like wound infection and keloid occurred in 4% of cases. They reported that the level of patient satisfaction was high 87% of the patients were deeply satisfied, 10% were satisfied and only 3% were poorly satisfied. The aesthetic results have been judged excellent by surgeons in 85%, good in 12% and poor in 3% and no results judged bad. (17)
The current studies reported the post operative complications includes hematoma in 19.0 % of cases in group A while it was only 9.5 in group B but still insignificant. The seroma was 14.3% and 4.8 % in group A and group B respectively but still insignificant. Other complications like wound infection. Wound dehiscence and keloid were comparable in both groups.

There was no total flap loss in both groups however Partial flap loss occurred in 1 patient (4.8%) and 2 patients (9.5%) in group A and group B respectively but this didn’t delay adjuvant radiotherapy or chemotherapy.
The final cosmetic outcome in both groups depending on the symmetry, wound scar, and nipple and areola was comparable. It was found to be excellent in 23.8 % and 28.6%, good in 57.1% and 47.6, fair in 9.5% and 14.3% in group A and group B respectively. Finally it was poor in 9.5 % of patients in both groups. No patient evaluated his outcome to be bad.
M. Dejode etal (2011) (18) described in their study that LD muscle transfer have a sequale at the ipsilateral shoulder range of movement. However, the exact functional impairment is still a subject of debate. (19)
C.Garusi, etal (2016) (20) combined DASH score and objective evaluation of harvesting LD flap in breast reconstruction on the shoulder functions. Also the percentage of recovery. They demonstrated minimal disability in general and up to 80% recovery within 1year especially with sport practice. (21)
The current study reveals significant difference between LD flap and TDAP flap as regards the functional outcome of shoulder using SPADI. In group A&B respectively the mean functional disability was 28.10 ± 9.78 and 17.24 ± 5.36 at 3 months, 17.43 ± 5.66 and 7.57 ± 3.09 at 6 months . Finally it was 5.62 ± 3.09 and 3.05 ± 1.47 at 12 months follow up. The current study also shows inter periodic significant difference during follow up at 3, 6, and 12 months indicating improvement of the disability in functions of shoulder in both groups
Conclusion
Our study considers the TDAP flap as a good technique as (LD) flap as regards the post operative complications, cosmetic outcome, feasibility of technique, required equipment and finally early out come. There is still grey area that should be hit again and we are still in need for algorism for choosing the appropriate oncoplastic technique depending on the previous parameters
Declaration of conflicting interests
The authors declare no potential conflicts of interest with respect to the research, authorship and publication of this article
Financial disclosure
The authors receives no financial support for research project or in any techniques or equipment used in this study or in publication of this article
Acknowledgement
Authors thank librarian for providing initial literature search and support