Preoperative assessment takes into account all data obtained during a visit prior to the procedure. Particular attention should be paid to the function of the latissimus dorsi [1], which if good generally indicates that the thoracodorsal pedicle is intact. Some items are important: skin and fat that can be harvested in the laterodorsal region, and assessing dorsal adiposity by pinching the natural laterodorsal pad. The volume obtainable should be compared with the desired volume of the breast. If the estimated volume, after atrophy of the muscle, is inadequate when compared with the volume of the opposite breast, secondary lipomodeling should be included in the operative planning. Patients are informed that there will be a horizontal, curved dorsal scar. More and more in delayed reconstruction, the thoracic scar from the mastectomy continues to a dorsal scar to decrease length of this scar.

The reconstruction is designed (Fig. 27.1a) with the patient in a standing position [1]. She is asked to lean the bust sideways (Fig. 27.1b, c) in order to reveal the natural folds of the skin and fat. The dorsal skin paddle follows these lines, forming a crescent with a concave upper curve (Fig. 27.1c). The amount of skin available should be carefully assessed using the pinch test so that closure can be performed entirely free from tension. The medial extremity of the paddle lies between the inferior angle of the scapula and the spine, whereas the lateral extremity may extend a few centimeters beyond the anterior margin of the muscle, depending on the patient’s morphology. In delayed reconstructions with an important previous subaxillary dog ear from the mastectomy, it is useful to integrate the dog ear into the flap, to avoid a bigger dog ear after the abdominal advancement flap.

The patient is placed in a lateral decubitus position (Fig. 27.1d), with the arm in abduction to open the axillary hollow. Physiological saline infiltration is done in the dorsal area. This makes dissection under the fascia superficialis easier by making it more visible. The skin paddle is incised by a single cut down to the fascia superficialis (Fig. 27.1e, f). Dissection then follows the deep aspect of the fascia superficialis, taking care to leave the deep fat on the muscle (zone 2). The upper part of the undermined area reaches the inferior angle of the scapula. In the internal part, the fascia superficialis is undermined up to the trapezius. The whole area of fatty tissue (Fig. 27.1g) between the superior border of the latissimus dorsi, the trapezius, and the upper limit of undermining forms the surface of the scapular hinge flap (zone 3). Then, the flap is harvested with respect to the trapezius, teres major and rhomboid muscle. The cutaneous prolongation of the circumflex scapular pedicle should be carefully ligated. In the lower part, undermining should be a little wider than in the area of the latissimus dorsi to make it easier to release the muscle later. The lower limit lies a little above the iliac crests in order to harvest fat from the love handles (zone 5). In the medial part, the cutaneous perforators of the intercostal posterior arteries that lie above the transverse processes mark the limit. In the lateral part, dissection begins a few centimeters forward of the anterior margin of the latissimus dorsi in order to harvest fat in zone 4. The muscle is then separated at a deep level from the serratus anterior by starting at about 15 cm from the axilla, because dissection is easy there [1]. Submuscular undermining is continued by harvesting the deep fat (zone 6) and by carefully ligating or coagulating the accessory pedicles (Fig. 27.1h). When the latissimus dorsi has been completely undermined, its distal part is transected, from the deep part toward the surface, as horizontally as possible in order to include as much fat bulk as possible, in particular zone 5 of the flap. In the axillary region, the pedicle is then freed so that it can be transposed without tension or kinking, and the latissimus dorsi tendon is sectioned. The pedicle is approached posteriorly by releasing the teres major from the latissimus dorsi, in a distal to proximal direction. The origin of the latissimus dorsi pedicle (Fig. 27.1i) is identified by following the pedicle of the serratus anterior up to the Y-shaped bifurcation. The branch of the serratus anterior should be carefully preserved to ensure blood supply to the flap if there is a lesion of the thoracodorsal pedicle. To make flap transposition easier, the scapular angular artery is ligated. When the pedicle has been identified, a finger is passed under the tendon (between the pedicle and the tendon) to protect it during partial proximal section of the tendon. The flap is then ready (Fig. 27.1j) to be transposed to the breast area via a subcutaneous tunnel or directly if the thoracic/dorsal scar is to be continued. The donor site [8] is closed (quilting suture) after irrigation of the whole area of the undermining in order to obtain perfect hemostasis (one suction drain).

Positioning and modeling of the flap differ according to two situations: delayed breast reconstruction and immediate breast reconstruction.