Revisiting the Fleur-de-Lis Reconstruction of the Breast

Why Change a Good Thing? Revisiting theFleur-de-Lis Reconstruction of the BreastMarguerite E. Aitken, M.D., and Thomas A. Mustoe, M.D.Grand Rapids, Mich., and Chicago, Ill.

Although the latissimus flap is known for its simplicityand reliability, use of the fleur-de-lis pattern was plaguedby undesirable T-shaped donor sites and small breast vol-umes in thin patients. We report a modified technique foroptimal shaping of the standard latissimus with the suc-cessful application of a modified fleur-de-lis pattern. Be-cause a “wet” tumescent infiltration was utilized and largeamounts of subcutaneous fat were harvested, thesechanges permitted application to a wide variety of pa-tients, with generous breast volumes reducing the size ofthe implant placed and resulting in excellent donor-sitescars.

This is a retrospective cohort study of 53 delayed orimmediate reconstructions performed consecutively bythe principal author (M.E.A.) on 48 patients at a univer-sity-based, urban hospital. Each case was analyzed betweenApril of 1995 and February of 1999, with a follow-up from2.5 to 44 months. All patients underwent injection oftumescent solution into the subcutaneous plane and har-vest of large amounts of subcutaneous fat with the neu-rologically intact latissimus muscle. The last 25 recon-structions utilized the modified fleur-de-lis skin pattern,an inferiorly based vertical limb and replacement of skindeficiency in both axes.

Of 11 perioperatively irradiated patients, none re-quired skin grafting, whereas 6 percent of all native mas-tectomy flaps were grafted. There was one instance ofminor distal tip flap necrosis in a nonirradiated patient.No implants became infected or were extruded. Donorsites were without wound complications and unveiled a 16percent overall seroma rate.

Through selective addition of harvested tissue, thismodified technique, particularly the fleur-de-lis pattern,permits improved volume and projection in the inferiorpole. The T-shaped donor-site closure is not only accept-able, but is also desirable, with reduced wound tensionand minimization of dog-ear formation. With a relativepaucity of complications, this conceptually ideal modifi-cation is technically simple and aesthetically comparableto our transverse rectus abdominis muscle flapresults. (Plast. Reconstr. Surg. 109: 525, 2002.)

Historically, the standard latissimus flap hasbeen known for its advantages including reli-ability, easy patient recovery, good aestheticresults, and maintenance of volume over time(Fig. 1).1–6 For certain patient populations notsuitable for alternative reconstructive proce-dures, it is known to be an effective and favor-able option.7–9 Disadvantages of the flap, in-cluding the need for an implant, the high rateof seroma formation, and some limitations tothe aesthetic result when compared with thetransverse rectus abdominis muscle (TRAM)flap, have made it second choice for manyplastic surgeons.10,11 In 1991, McCraw andPapp introduced an important concept bychanging the crescent shape to a three-cornered skin paddle for improved distribu-tion of volume.12 They also incorporated largeamounts of subcutaneous fat, which precludedthe need for an implant and created the fullyautogenous fleur-de-lis latissimus flap.9 Thismodification made the latissimus flap availableto a population of patients with small to mod-erately sized breasts desiring autogenous re-construction, but was not universally acceptedbecause of undesirable T-shaped donor-sitescars and the difficulty in achieving adequatevolumes for symmetry.

We propose to revisit the fleur-de-lis patternusing a modified tumescent technique of localinfiltration allowing rapid elevation of flapsand including large amounts of subcutaneousfat. This modification has enabled us, throughthe distribution of greater amounts of tissue tothe inferior pole of the breast, to optimize

From the Department of Plastic and Reconstructive Surgery, Northwestern University Medical School; and the Department of General Surgery,Grand Rapids Medical Education & Research Center, Michigan State University Affiliate. Received for publication December 5, 2000.

Presented at the Annual Meeting of the American Society of Plastic Surgeons, in Los Angeles, California, October 14 through 19, 2000; andthe Michigan Academy of Plastic Surgeons, in Mackinac Island, Michigan, July 22 through 26, 2000.

525

breast contour and ptosis and minimize im-plant size. The flap design evolved from anoblique positioned elliptical flap into a modi-fication of the fleur-de-lis pattern borrowedfrom McCraw and Papp, to optimize not onlybreast contour but also the donor-site scar (Fig.2). Careful closure of this T-shaped donor siteeliminates excess tissue often found laterally,and the scar is easily hidden in the bra line.Despite the addition of the tumescent solution,the seroma rate is minimal, with a completeabsence of donor-site wound or serious flapcomplications. In either immediate or delayedreconstructions, our method has converted atechnically challenging breast reconstructionto a type of breast augmentation procedure,with results equally as impressive as our TRAMresults (Fig. 3). The purpose of this study wasto present and evaluate retrospectively the re-sults of 53 modified myocutaneous latissimus

dorsi breast reconstructions (25 using thefleur-de-lis pattern), operated on by the seniorauthor (M.E.A.), and to draw conclusions onthe basis of this experience about the useful-ness of this procedure.

PATIENTS AND METHODS

The office records of patients with the pre-operative diagnosis of absence of breast, un-dergoing either immediate or delayed latissi-mus dorsi flap reconstruction, with or withoutimplants, were reviewed. There were 53 con-secutive reconstructions performed on 48 pa-tients between April of 1995 and December of1998. Only the last 25 cases utilized the fleur-de-lis pattern of flap. The follow-up periodranged from 2.5 to 44 months. Results weredefined by evaluations of each patient’s condi-tion by the operating surgeon at every officevisit as recorded in the chart.

Patient Selection

The patients ranged in age from 30 to 67years (mean, 47.0 years). The majority of the

FIG. 1. Fifteen-year postoperative view of right latissimusdorsi flap speaks to the durability of the flap. (Above) An-terolateral view of right latissimus flap demonstrates the pre-served volume of the breast. (Below) Anterior view demon-strates failure of the old method to completely cover theimplant resulting in dimpling of the surface of the breast.

FIG. 2. Donor site of latissimus dorsi flap with the fleur-de-lis pattern, extensive subcutaneous tissue to be included inthe harvest, and alternative skin paddles to be individualizedto each patient. (Original illustration by Marguerite E. Ait-ken, M.D.)

526 PLASTIC AND RECONSTRUCTIVE SURGERY, February 2002

patients had modified radical mastectomies,whereas the causes of their deformities varied:breast carcinoma, severe breast irregularitiesresulting from prior silicone injections, priorleaking of silicone from silicone gel implants,and prior lost TRAM flap.

Operative Technique

The patient is initially prepared in the lateralposition on a bean bag. After the back isdraped out, the patient is placed supine andthe chest draped for the mastectomy. No fur-ther draping is needed during the procedure.At the completion of the modified radical mas-tectomy, the patient is placed in the lateralposition with inflation of the bean bag, havingbeen previously prepared sterile. Between 300and 1000 cc of a 1:1,000,000 solution of epi-nephrine is injected into the subcutaneousplane. A knife dissection is carried out just

above Scarpa’s fascia, leaving native flaps ap-proximately 1 cm in thickness (Fig. 3). Theregion that will form the inferior tendinousinsertion of the muscle is totally divided, butthe muscle is left innervated to maximize bulk.A modified fleur-de-lis pattern is used regard-less of whether the planned reconstruction isdelayed or immediate.

Closure of the T-shaped donor site in twoaxes pulls excess tissues from the lateral chestwall, minimizing bulk and eliminating dogears. A monofilament subcutaneous pullout su-ture is left in place for 2 months or longer toprevent scar widening. After the back closure iscompleted and the patient turned, the pecto-ralis muscle is elevated, allowing the latissimusmuscle to form the lateral portion of the im-plant pocket. Even in a thin patient, 150 to 200cc of volume from the latissimus muscle can beachieved. In a larger patient, two to three times

FIG. 3. (Left) Preoperative view of patient for left mastectomy and modified latissimus dorsi reconstruction,after right TRAM reconstruction. (Above, right) Anterolateral view at 12 months postoperatively from latissimusreconstruction illustrates preserved breast contour and ptosis. (Below, right) Oblique view compares right TRAMwith left latissimus dorsi flaps, suggesting either method can be successful in the preservation of normal breastcontour and ptosis.

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that volume is obtained, allowing for a verymodest sized implant (� 300 cc in all but thelargest of breasts). The inset is performed asshown in Figure 4. In the case of delayed re-construction, the wound contraction that ispart of the natural healing process leaves adeficiency in the transverse and the verticalaxes, centered around the location of the orig-inal nipple-areola complex. As the fleur-de-lisflap is inset, the skin volume is expanded in twodirections, optimizing contour and symmetry.In the immediate reconstruction, using a skin-sparing mastectomy,13–15 the vertical limb isdeepithelialized which, particularly in the thinpatient, allows more volume to be placed at theinferior pole, particularly emphasizing theptotic shape of the breast (Fig. 5).

All saline implants were anterior valve, tex-tured, and round, as contoured implants tendto overproject. The textured surface aids inpreventing implant displacement postopera-tively, which has not been a problem in thisseries.

RESULTS

In this study, 48 patients underwent 53 latis-simus dorsi myocutaneous reconstructions, 34immediate and 17 delayed, 28 conventionaland 25 modified, as described above, using thefleur-de-lis pattern. One patient with bilateral

reconstruction received silicone implants andone latissimus flap was placed beneath a previ-ous TRAM flap and therefore no implant wasused. Of the remaining reconstructions, onepatient did not opt for implants and the restutilized either saline-filled textured implants orexpanders (Table I).

Skin Necrosis

A recent European study of 111 patients un-dergoing latissimus dorsi reconstructionsfound a 6 percent rate of necrosis of one-tenthof the total latissimus flap area,16 whereas otherstudies cite a range of 4 to 7 percent.16–18 Onelarge study quoted complete loss of the latissi-mus flap in 1 of 125 patients.9 Our thresholdfor placing a split-thickness skin graft was rea-sonable at 3 cm in diameter, constituting amajor component of the flap. Whereas threepatients (6 percent) had native mastectomyflaps that required grafting, only one latissimusflap showed signs of distal tip necrosis and didnot warrant a split-thickness skin graft (TableII). No patient experienced complete latissi-mus flap loss or loss of the implant after necro-sis of the native mastectomy skin flaps (Figs. 6and 7).

As more women are diagnosed early withbreast cancer and opt for breast conservationtherapy with adjuvant radiation, more partial

FIG. 4. Inset of latissimus flap to mastectomy defect with excess subcutaneous tissue. (Left) Repair of the conventional defect(delayed mastectomy) with fleur-de-lis skin paddle replacing the lost tissue in both the transverse and vertical axes. (Right) Repairof the skin-sparing mastectomy defect allows the vertical limb in particular to be deepithelialized for greater volume in the inferiorpole. (Original illustrations by Marguerite E. Aitken, M.D.)


and complete breast reconstructions on irradi-ated tissue will occur. Despite reports of postir-radiation fibrosis, soft-tissue necrosis, edema,and contractures, studies show that the risk of

flap loss is not increased in patients undergo-ing perioperative adjuvant irradiation.19–21 Ofthe 53 reconstructions performed, 11 experi-enced either preoperative or postoperative ir-radiation therapy (21 percent). Of these, nonerequired a split-thickness skin graft to eitherthe latissimus flap or the native mastectomyflaps (Table II).

Seroma Rate

Seroma is understood to be caused by theshearing force of the moving scapular girdlethrough the latissimus donor site and the fail-ure of the overlying skin to adhere to the mus-culature below.10,11 The literature reports awide variation in rate of seroma, ranging be-tween 9 and 19 percent22–24 and, in some stud-ies using extended harvests, as high as 79 per-cent.25 Slavin has reported seroma formation isnot improved by the use of prophylactic largesuction drains,26 whereas others have at-tempted alternative techniques such as quiltingstitches.27,28 One recent study reports a signifi-cant decrease in seroma rate with the use ofknife dissection versus electrocautery dissec-tion.29 In our study, the most common compli-cation was a minor seroma, defined by aspira-tion one to two times from a nonpainfulswollen fluid collection or any aspiration of afluid swelling severe enough to cause the pa-tient concern. We found, using the tumescenttechnique and knife dissection, four patients tohave developed a minor seroma (8 percent),some observed to be associated with early ex-ercise.30 A minor seroma responded to one totwo aspirations of less than 75 ml of total fluid.A major seroma was one requiring more than

TABLE IPatient Profile and Complications

Age Groups

Total (%)30–39 40–49 50–59 60–67

Number of patients 10 22 16 5 53Reconstructive timing

Immediate 5 12 11 5 33Delayed 5 10 5 0 20

IrradiationPreoperative 2 5 1 0 8 (15)Postoperative 0 2 1 0 3 (6)

ComplicationsWound coverage with split-thickness skin graft

Native mastectomy flap 0 1 2 0 3Latissimus flap 0 0 0 0 0

SeromaMajor 1 2 1 0 4 (8)Minor 0 2 1 1 4 (8)

Deflation 1 1 1 0 3 (6)

FIG. 5. Two-month postoperative photograph after leftskin-sparing mastectomy and reconstruction with the modi-fied fleur-de-lis reconstruction. (Above) Anterior view of key-hole-type skin-sparing mastectomy incision. (Below) Donorsite with obliquely positioned T-scar.


two aspirations or surgical intervention. Fourpatients experienced a major seroma compli-cation (8 percent), none of which caused im-plant extrusion or required surgical correctionor any other measures such as sclerosingagents. No evidence of infection was foundsecondary to a seroma.

Implant Deflation

A recently published study of 171 implantpatients reports a 4 percent rate of expander

deflation over a 7-year period, with a breastirradiation rate of only 13 percent,31 and an-other large study (450 patients) reports a rup-ture rate of 3.5 percent.19 Our study founddeflation rates of expanders to be 6 percent,with a rate of chest wall irradiation of 21 per-cent and evidence of at least one faulty valve inthe expander (Fig. 8).

DISCUSSION

The latissimus flap was the predominantmethod of breast reconstruction in the 1970sbecause of its reliability and relative simplicity.With the advent of tissue expansion and theTRAM flap, the latissimus flap lost favor be-cause of the perception that it combines disad-vantages of both alternatives (i.e., donor-sitescars with their attendant morbidity and theneed for an implant). However, there are manylimitations of tissue expansion: difficulties inachieving and maintaining a natural teardropshape over time, the rippling and distortionseen with capsular contracture, and the in-creasing evidence of poor outcomes in the faceof irradiated tissues. It has been suggested thatflaps do not offer a protective role against ir-radiation32; however, our absence of complica-tions suggests either the ratio of flap to implantvolume was beneficial or the incidence too lowand therefore study size too small to show adifference. Some patients, particularly in olderage groups, do not want to endure the postop-erative recovery and potential morbidity of aTRAM flap, and others have risk factors thatmake them suboptimal candidates for a TRAMflap.

In recent years, other authors have discussedmethods to optimize the latissimus flap. Slavinet al. describe utilizing the latissimus for recon-struction of difficult partial defect contour ab-normalities to produce excellent aesthetic re-sults closely mimicking the opposite breast’steardrop shape.14,15,20 We have used a tumes-cent infiltration, extended the amount of sub-cutaneous tissue harvested, and routinely usedthe modified fleur-de-lis pattern with a smallimplant. This combination has produced out-standing contour with increased volume andfullness in the inferior pole of even the verythin patient. This is particularly evident in thedelayed reconstruction, where natural woundcontraction often leaves a significant skin defi-ciency in both the transverse and vertical axes,addressed by the flexibility of the fleur-de-lisshape in a one-stage procedure.

FIG. 6. (Left) Anterior and (right) anterolateral views ofpartial loss of native mastectomy flaps after right mastectomyand immediate modified reconstruction, resulting in a split-thickness skin graft, in a 64-year-old patient.

TABLE IIBreakdown of Patients According to

Perioperative Irradiation

Complication

PreoperativeIrradiation

(n � 8)

PostoperativeIrradiation

(n � 3)

No PerioperativeIrradiation(n � 42)

Flap necrosisMastectomy flap (%) 0 0 3 (6)Latissimus flap (%) 0 0 1 (2)

Infection 0 0 0


While improving the final shape of the inset,the flap donor site is also optimized. Althoughthe T-scar might seem a disadvantage on theback, we have had no donor-site breakdownand have minimized the tendency for dog-ears

through closure of the wound in the two axes,eliminating tension on the wound and againreducing the need for further surgical proce-dures. In addition, infiltrating with a modifiedsuperwet technique, dissection can be per-formed rapidly with a scalpel, avoiding the useof electrocautery, except for control of perfo-rators, subsequently minimizing the zone ofnecrosis produced by surgical dissection. De-spite this extensive dissection, there is no in-crease in seroma rate with this technique.

CONCLUSIONS

The latissimus dorsi myocutaneous flap re-mains a simple, reliable reconstructive option forpatients seeking optimal results with minimal re-covery time. For most patients, the modifiedfleur-de-lis pattern provides a symmetric, morenatural appearing reconstruction with easily hid-den scars and fewer subsequent operative proce-dures. This modified flap is no longer limited to

FIG. 7. Postoperative views after left mastectomy and im-mediate reconstruction with the modified latissimus dorsimyocutaneous flap. (Above) View at 2 weeks postoperatively.(Center) Necrosis of native mastectomy flaps with no involve-ment of the adjacent latissimus flap. (Below) One year later,after approximation of native skin to repair defect of losttissue and after nipple reconstruction and tattooing.

FIG. 8. (Above) Two weeks after right mastectomy and im-mediate latissimus dorsi myocutaneous reconstruction. (Be-low) Three weeks postoperatively, implant deflation is notedby the loss of volume in the upper outer quadrant and themaintained fullness in the lower pole of the breast.


a population of women with small to moderatelysized breasts. For either immediate or delayedreconstruction, the transfer of greater amountsof subcutaneous tissues from the back and theuse of a small implant improves the ease withwhich the appropriate shape can be achieved(Figs. 9 and 10). These modifications also dem-onstrate the utility of the latissimus flap and itsability to virtually eliminate implant exposure,even in the instance of significant mastectomyskin flap necrosis or in the face of irradiatedtissues.

Few surgeons would utilize only one optionfrom their armamentarium for breast reconstruc-tion. This reproducible technique has beenshown to have the same or fewer complicationsthan the standard latissimus flap, specifically re-garding the minimal seroma rate and the com-plete absence of donor-site wound or serious flapcomplications. We conclude that the latissimuswith the fleur-de-lis modification should be con-sidered a first-line option for all women consid-ering breast reconstruction, regardless of their

bra size, especially those reluctant to undergo aTRAM flap reconstruction. In our experience,the aesthetic results were far superior to our re-sults with tissue expansion, and in most casesapproached the results achieved with the TRAMflap. We now use this latissimus in about 75 per-cent of those patients undergoing implant recon-struction and, if anything, our enthusiasm for theflap is increasing.

Thomas A. Mustoe, M.D.Division of Plastic and Reconstructive SurgeryNorthwestern University Medical School707 North Fairbanks Court, Suite 811Chicago, Ill. [email protected]

REFERENCES

1. Bostwick, J., Vasconez, L. D., and Jurkeiwicz, M. J. Breastreconstruction after a radical mastectomy. Plast. Re-constr. Surg. 61: 682, 1978.

2. Bostwick, J., III, and Scheflan, M. The latissimus dorsi

FIG. 9. (Above) Preoperative and (below) postoperativeviews after left mastectomy and immediate modified myocu-taneous latissimus dorsi reconstruction.

FIG. 10. Postoperative views after right mastopexy and leftmastectomy with the delayed modified myocutaneous fleur-de-lis latissimus dorsi reconstruction. (Above) Ten days post-operatively. (Below) Six months after nipple reconstructionwith tattooing.


musculocutaneous flap: A one-stage breast reconstruc-tion. Clin. Plast. Surg. 7: 71, 1980.

3. Cohen, B. E., and Cronin, E. D. Breast reconstructionwith the latissimus dorsi myocutaneous flap. Clin.Plast. Surg. 11: 287, 1984.

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12. McCraw, J. B., and Papp, C. The fleur de lis autogenouslatissimus breast reconstruction. In C. Hartrampf(Ed.), Breast Reconstruction with Living Tissue. NewYork: Raven Press, 1991.

13. Kroll, S. S., Ames, F., Singletary, S. E., et al. The onco-logic risk of skin preservation at mastectomy whencombined with immediate reconstruction of thebreast. Surg. Gynecol. Obstet. 172: 17, 1991.

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27. Schwabegger, A., Ninkovic, M., Brenner, E., and Anderl,H. Seroma as a common donor site morbidity afterharvesting the latissimus dorsi flap: Observations ofcause and prevention. Ann. Plast. Surg. 38: 594, 1997.

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Revisiting the Fleur-de-Lis Reconstruction of the Breast

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