Dr. Leonora Gotseva, Alexandrovska University Hospital – Sofia
Introduction
Breast reconstruction in patients who have previously undergone radiation therapy poses a significant challenge due to the compromised tissue quality and the increased risk of complications associated with implant-based techniques. The flap from latissimus dorsi muscle It remains a reliable reconstructive method in cases of failed previous reconstruction, providing well-perfused tissue in the irradiated area.
Clinical case
We present a 43-year-old female patient with a recurrence of multifocal invasive lobular carcinoma of the right breast, luminal type A.
In 2020, the patient was diagnosed with G2 invasive lobular carcinoma of the right breast. A quadrantectomy with level I and II axillary lymph node dissection was performed.
Histological examination revealed multifocal invasive lobular carcinoma, consisting of 95% classic-type lobular carcinoma in situ and 5% microinvasive component. Eighteen lymph nodes were examined, with no evidence of metastatic involvement. The final pathological stage is pT1mi pN0 M0, R0.
From February 15, 2021, to March 30, 2021, the patient underwent adjuvant radiation therapy. Starting in April 2021, she was prescribed endocrine therapy with tamoxifen and goserelin.
In 2025, a local recurrence of the disease was diagnosed, histologically confirmed as invasive lobular carcinoma. Six courses of neoadjuvant chemotherapy were administered. Genetic testing identified a pathogenic mutation in the BRCA2 gene.
In April 2025, a bilateral subcutaneous mastectomy was performed, with immediate reconstruction using implants (A). Two months later, implant extrusion occurred on the side of the previously operated on and irradiated right breast, necessitating explantation (B).
Six months after the explantation, the patient was admitted for delayed reconstruction of the right breast using a flap from the latissimus dorsi muscle and the insertion of a new implant (B).
Operational Equipment
Following preoperative marking, a myocutaneous flap was harvested from the musculus latissimus dorsi. The flap was mobilized on the thoracodorsal vascular pedicle and transposed to the anterior chest wall through a subcutaneous tunnel. Reconstruction of the right chest defect was performed using well-vascularized autologous tissue. A new implant was placed. Active drains were inserted in the donor and recipient sites, and the surgical wounds were closed in layers.
Results
The early postoperative period proceeded without significant complications. Good blood supply to the flap was observed, along with a satisfactory volume of the reconstructed breast and symmetry (G). A stable soft-tissue cover was achieved in an area with a history of prior radiation therapy and unsuccessful implant-based reconstruction. Two months after reconstruction using a latissimus dorsi muscle flap, the result is excellent (D). Shaping of the areola-nipple complex is pending.
Discussion
Prior radiation therapy is one of the major risk factors for complications following implant-based reconstruction, including infection, capsular contracture, impaired healing, and implant extrusion. In such patients, the use of well-vascularized autologous tissues improves the quality of the soft-tissue coverage and reduces the risk of subsequent reconstructive failures.
The latissimus dorsi muscle flap is an established method for secondary reconstruction following radiation therapy and implant loss. In the presented case, it provided a reliable solution for a patient with a complex oncological history, including disease recurrence, a BRCA2 mutation, prior radiation therapy, and failed implant-based reconstruction.
Conclusion
Reconstruction using a latissimus dorsi muscle flap is an effective and safe method for breast reconstruction in patients who have undergone prior radiation therapy and experienced complications following implant-based reconstruction. The clinical case presented demonstrates the potential of autologous reconstructive techniques to achieve reliable functional and aesthetic outcomes in patients at high risk for reconstructive complications.
A) 14 SOD following a subcutaneous mastectomy
B) Implant extrusion 2 months after single-stage implantation;
C) 6 months after explantation;
D) 7 SOD following reconstruction of the musculus latissimus dorsi using a lambo graft;
D) 2 months after reconstruction using a flap from the musculus latissimus dorsi.
