title: Two-Stage Latissimus Dorsi Flap with Implant for Unilateral Breast Reconstruction: Getting the Size Right.
abstract: BACKGROUND
  The aim of unilateral breast reconstruction after mastectomy is to craft a natural-looking breast with symmetry. The latissimus dorsi (LD) flap with implant is an established technique for this purpose. However, it is challenging to obtain adequate volume and satisfactory aesthetic results using a one-stage operation when considering factors such as muscle atrophy, wound dehiscence and excessive scarring. The two-stage reconstruction addresses these difficulties by using a tissue expander to gradually enlarge the skin pocket which eventually holds an appropriately sized implant.
  
  
  METHODS
  We analyzed nine patients who underwent unilateral two-stage LD reconstruction. In the first stage, an expander was placed along with the LD flap to reconstruct the mastectomy defect, followed by gradual tissue expansion to achieve overexpansion of the skin pocket. The final implant volume was determined by measuring the residual expander volume after aspirating the excess saline. Finally, the expander was replaced with the chosen implant.
  
  
  RESULTS
  The average volume of tissue expansion was 460 mL. The resultant expansion allowed an implant ranging in volume from 255 to 420 mL to be placed alongside the LD muscle. Seven patients scored less than six on the relative breast retraction assessment formula for breast symmetry, indicating excellent breast symmetry. The remaining two patients scored between six and eight, indicating good symmetry.
  
  
  CONCLUSIONS
  This approach allows the size of the eventual implant to be estimated after the skin pocket has healed completely and the LD muscle has undergone natural atrophy. Optimal reconstruction results were achieved using this approach.
authors.affiliation: Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital, Singapore.
authors.forename: Jiajun
authors.initials: J
authors.lastname: Feng
authors.affiliation: College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
authors.forename: Cleone I
authors.initials: CI
authors.lastname: Pardoe
authors.affiliation: Hull and East Yorkshire Trust, England, Yorkshire, UK.
authors.forename: Ashley Manuel
authors.initials: AM
authors.lastname: Mota
authors.affiliation: Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital, Singapore.
authors.forename: Christopher Hoe Kong
authors.initials: CH
authors.lastname: Chui
authors.affiliation: Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital, Singapore.
authors.forename: Bien-Keem
authors.initials: BK
authors.lastname: Tan
keywords: Breast; Radiotherapy; Reconstructive surgical procedures; Surgical flaps; Tissue expansion