Preoperative photographs of a 60-year-old female.

A new, one-step breast reconstruction technique has appeared that promises fewer surgeries, less scar tissue, and a good aesthetic outcome. The procedure, called the single-stage anterior approach latissimus flap reconstruction, has been developed by Sami M. Bittar, MD, FACS, a board-certified plastic and reconstructive surgeon in Chicago, and is especially beneficial to cancer patients, according to Bittar.

The typical two-stage breast reconstruction begins with a process to expand the muscles to cover the implants. The patient undergoes surgery, which typically requires a 1- to 2-day hospital stay, for the expander to be inserted.

Following surgery, the patient comes into the office once or twice a week for 6 to 8 weeks, so that fluid can be injected into the expander, allowing the muscles to gradually be expanded. A second surgery removes the expanders, inserts a permanent implant, and adjusts the resulting pocket. Patients who require chemotherapy must wait for the treatment to be complete before proceeding with a permanent implant.

TALKING POINTS

The single-stage anterior approach latissimus flap reconstruction offers several advantages to patients:n Emotional, physical, and financial stress associated with two surgeries is reduced, as only one surgery is required.

  • Chemotherapy can proceed as needed, without interruption.
  • Patients can resume their normal lives and activities more quickly.
  • Scarring on the back is reduced.
  • Discomfort associated with the expansion process is eliminated.
  • It offers a more favorable aesthetic outcome when compared with the two-stage approach.

Bittar’s procedure uses the pectoralis muscle as well as the latissimus muscle in the back. However, Bittar harvests the latissimus muscle from the front instead of the back using the same mastectomy incisions, which eliminates the need for extra incisions in the back. Ample muscle coverage and skin eliminates the need for expansion, which allows a permanent implant to be inserted and the breast to be reconstructed in a single step.

Bittar is humble and altruistic about his procedure. “I like it not because of publicity,” he says, “nor do I care about financial gain. I am a firm believer that this procedure is a great contribution to breast reconstruction.”

After earning his degree in medicine from Damascus University School of Medicine, Bittar completed his general surgery residency training at The Western Pennsylvania Hospital, followed by fellowships in plastic and reconstructive surgery at Rush-Presbyterian-St Luke’s and in microsurgery at Southern Illinois University School of Medicine. In addition, he is board-certified by the American Boards of General Surgery, Hand Surgery, and Plastic and Reconstructive Surgery.

PSP: WHAT INSPIRED YOU TO DEVELOP THIS APPROACH?

Sami M. Bittar, MD, FACS: Over my career, most of my practice has been in breast reconstruction. In addition, for the last 23 years I’ve been doing this on a daily basis. I’ve slowly arrived to this procedure doing a breast reconstruction directly after a mastectomy with one stage.

The same 60-year-old patient 2.5 months after bilateral mastectomies, with bilateral anterior approach latissimus flaps and 550-cc high-profile silicone implants.

Traditionally, patients go through two stages to do a breast reconstruction with implants. The first stage would be using a tissue expander. This is what I used to use, and which most surgeons still do. We go under the pectoralis muscle, which is the front muscle. There is a muscle on the side called the serratus muscle. We elevate the pectorals and the serratus, place the expander—which is an empty implant—and close the skin. We wait for the wound to heal and, in about a week or so, start bringing [the patient] into the office once or twice a week.

Then, through the skin and through the port of the expander we inject normal saline, which is saltwater, trying to stretch the skin and the muscle—this is standard in breast reconstruction surgery. We might have to stop the expansion if the patient must go through chemotherapy. After they finish chemo and after the expansion, we wait for a couple of months, bring her back, and put her under anesthesia again. Every time a patient goes through surgery, they have an emotional, physical, and financial toll. So, you go through a second procedure to finish the reconstruction.

I have done the two-stage reconstruction for years. The outcomes were not very pleasing to me, most of the time.

There are surgeons who use the latissimus muscle, which is the muscle from the back. We know the reconstructions are better with the latissimus. Usually, the patient has to turn on their side and you make an incision on the back, take an island of skin from the back, and transfer to the front. Then, use the muscle and skin to reconstruct the breast.

PSP: AND YOU ARE SAYING THAT ALL OF THAT IS NOT NECESSARY?

Bittar: Yes. I can harvest the muscle from the front. That is the whole point about this procedure. The latissimus flap reconstruction has been known for years, but the way I harvest the latissimus muscle is very different. You can harvest it from the same incision, and use it to cover the implants.

The same patient 7 months after surgery.

We now have enough skin and muscle to cover the implants. We can use whatever implant we want. And if any procedure needs to be done on the other side, we can attend to that at the same time—be it augmentation, reduction, lift, or whatever needs to be done if the patient so desires. This way, the patient does not have to go back to the OR. Therefore, it saves the patient financially, emotionally, and physically

It is a good procedure for the patient, for the health care industry, but most importantly for me in that the outcome is definitely better because of the use of the latissimus muscle. The procedure may take some learning curve, but it is definitely the best procedure to go through for the patient.

PSP: CAN YOU TALK ABOUT COMPLICATIONS?

Bittar: In any procedure you have the possibility of complication, to oversimplify it. If you have two procedures, then you have the possibility of two sets of complications. The most common thing we see after this procedure is seroma.

PSP: SO, YOU BELIEVE YOUR PROCEDURE COMPARES FAVORABLY?

Bittar: Yes. Some people say the one-stage procedure may be a more involved procedure, but that is not the case for surgeons who have been doing it for a while. It is very efficient. It does not take more than 20 to 30 minutes.

Patients may think that the use of the latissimus muscle might affect the function or the strength of the back. This has been studied by the British, who compared 60 patients before and after taking the latissimus for other reasons. They found it would not decrease the function significantly for the average person—unless they are a competitive athlete.

We use two muscles, the pectoralis and serratus, in the two-stage reconstruction. The serratus is an important muscle. In this procedure, we do not use the serratus muscle; we use the pectorals and latissimus, and studies have shown that the latissimus does not reduce the function.

In conclusion, I think patients and doctors need to be aware of the one-stage reconstruction. No one should have to go through the agony of the pain, emotion, and additional cost if the outcome is at least the same or, especially, is more favorable.


Jeffrey Frentzen is the editor of PSP. He can be reached at plasticsurgery@allied360.com.