Limberg Flap in Breast Oncoplasty for Carcinoma Breast Revisited—a Tertiary Cancer Centre Experience

Abstract

Limberg flap is currently not commonly used in breast oncoplasty. We present our experience with Limberg flap reconstruction in breast cancer patients who underwent breast conservation surgery. This study was conducted at a tertiary cancer centre in Kerala, India. We reviewed the records of patients with breast cancer who underwent Limberg flap reconstruction with breast conservation surgery from 1^st January 2020 to 31^st October 2021. Data collected included age, quadrant of tumour, side of tumour, T and N stage, status at surgery (primary or post neoadjuvant therapy), type of surgery, flap complications following surgery and breast deformity following surgery. Seventeen patients underwent Limberg flap reconstruction during the study period. The median age of the patients was 51 years. The commonest stage was cT1N0M0. Twelve patients underwent primary surgery and 5 post neoadjuvant chemotherapy. No patient had postoperative flap complications or breast deformity. Limberg flap is simple, versatile and robust and should be a part of the armamentarium of breast surgeons.

Introduction

Breast conservation surgery is the current gold standard in the treatment of breast cancer whenever feasible. In this surgery, the oncological safety and cosmesis go hand in hand. Breast oncoplasty procedures play an important role in breast reconstruction combining principles of oncology and plastic surgery. Oncoplasty includes both volume displacement and volume replacement procedures. Most commonly used technique of volume replacement in current practice is the perforator flap. Perforator flaps give excellent cosmesis but are complex and rarely undergo partial or complete necrosis. A local flap can replace a tissue defect functionally and cosmetically. The Limberg flap also known as rhomboid flap or rhombic flap one of the most commonly used local flaps [1]. It is a random-pattern local flap that relies on blood supply through the subdermal plexus. It is a useful technique that is simple for surgeons to design and perform. Limberg flap is commonly used in head and neck and pilonidal sinus reconstruction [2–4]. Earlier literature in breast conservation surgery with Limberg flap reconstruction consisted of large series of 200 cases [5]. However, with the advent and popularity of type 1 and 2 oncoplasty and perforator flaps, Limberg flap is currently not widely used in breast reconstruction. Current literature on Limberg flap in breast reconstruction is limited and restricted to case reports in an attempt to rejuvenate the flap [6–8].

In the lower quadrants of the breast, excision of the tumor without reconstruction can result in bird’s beak deformity [9]. Volume replacement using the robust and versatile Limberg flap results in excellent cosmesis with minimal morbidity as compared to other oncoplasty. Limberg flap technique is especially useful in lesions near the inframammary crease with close proximity to the skin. This study is a review of our experience with Limberg flap in breast conservation surgery.

Material and Methods

This retrospective review was conducted at a tertiary cancer center after receiving clearance from the institutional review board. Data was collected of women who underwent Limberg flap reconstruction during breast conservation surgery from 1^st January 2020 to 31st October 2021. Data collected included age, quadrant of tumor, side of tumor, T and N stage, status at surgery (primary or post neoadjuvant therapy), type of surgery, flap complications, and breast deformity following surgery. The primary site of tumor was tattooed in patients receiving neoadjuvant chemotherapy. The data was analyzed and is presented descriptively.The flap planning is depicted in Fig. 1. A rhomboid defect was created during the excision of the tumor with adequate margins such that the shorter diameter was in the craniocaudal direction. This diameter was extended equal to its length towards the inframammary crease and the remaining limb was drawn parallel to one of the lower sides of the rhombus. The defect after excision of tumor and the elevated flap are depicted in Fig. 2. The cosmesis on the first postoperative day is depicted in Fig. 3 and the long-term post-radiotherapy cosmesis is depicted in Fig. 4.

Fig. 1.

Design of the Limberg flap

Fig. 2.

Breast defect after excision of tumor with the elevated Limberg flap

Fig. 3.

Postoperative day 1 cosmesis following the Limberg flap

Fig. 4.

Post radiotherapy follow up of the Limberg flap

Results

Seventeen women underwent breast conservation surgery with Limberg flap reconstruction during the study period. The patient, tumor, surgery characteristics and the postoperative outcomes are depicted in Table 1. The median age of the women was 49 years. The tumor was located in the lower inner quadrant in the 14 patients and lower outer quadrant in 3 patients. The commonest stage at presentation was cT1N0M0. Twelve patients underwent primary surgery and 5 patients underwent surgery post neoadjuvant chemotherapy. Sentinel lymph node biopsy was done using blue dye technique in 9 patients. No patient had any postoperative flap complications or breast deformity in immediate postoperative period. The margins of excision of the primary tumor was negative in all the cases.

Table 1.

Patient, tumor, surgery characteristics and postoperative outcomes

Serial number	Age years	Side of tumour	Quadrant	cTNM stage	cT cm	Status at surgery	Surgery	pT cm	Flap complications	Breast deformity
1	42	left	Lower inner	T1N0M0	2	primary	BCS(SLNB)*	1.8	Nil	Nil
2	64	left	Lower outer	T2N1M0	4.5	primary	BCS#	4.2	Nil	Nil
3	47	left	Lower inner	T1N0M0	2	primary	BCS(SLNB)*	1.3	Nil	Nil
4	51	left	Lower inner	T1N2M0	2	Post NACT+	BCS#	1.9	Nil	Nil
5	44	right	Lower inner	T2N0M0	4	primary	BCS(SLNB)*	3.5	Nil	Nil
6	51	left	Lower inner	T1N0M0	2	primary	BCS(SLNB)*	1.6	Nil	Nil
7	64	left	Lower inner	T1N1M0	1.5	primary	BCS#	1	Nil	Nil
8	68	left	Lower inner	T1N1M0	1	Primary	BCS#	1.3	Nil	Nil
9	59	right	Lower inner	T2N2M0	3	Post NACT+	BCS#	2.8	Nil	Nil
10	31	right	Lower outer	T1N2M0	2	Post NACT+	BCS#	0.8	Nil	Nil
11	59	left	Lower inner	T2N1M0	4	Post NACT+	BCS#	2	Nil	Nil
12	51	right	Lower inner	T1N0M0	1.5	Primary	BCS(SLNB)*	1.1	Nil	Nil
13	50	right	Lower outer	T2N0M0	3.5	Primary	BCS(SLNB)*	3.3	Nil	Nil
14	36	left	Lower inner	T1N0M0	1.5	Primary	BCS(SLNB)*	1.1	Nil	Nil
15	59	left	Lower inner	T2N0M0	2.5	Primary	BCS(SLNB)*	2.8	Nil	Nil
16	55	left	Lower inner	T1N0M0	2	Primary	BCS(SLNB)*	1.6	Nil	Nil
17	56	Left	Lower inner	T2N2M0	4	Post NACT+	BCS#	3.8	Nil	Nil

Post NACT⁺, post neoadjuvant chemotherapy; BCS (SLNB)*, breast conservation surgery with sentinel lymph node biopsy; BCS^#, breast conservation surgery

Discussion

Russian surgeon Alexander Limberg first illustrated the rhomboid flap in 1945 and published it in English in 1966 [10]. This flap is a random transposition flap which requires a quadrilateral rhombus-shaped defect. In our cases, we utilized the fasciocutaneous tissue below the inframammary crease to create the Limberg flap. Breast conservation surgery in tumors of the lower quadrants may result in bird beak deformity. Many types of oncoplasty such as inverted T technique, J plasty, V plasty, and superior pedicle oncoplasty have been described for this region [9]. The common perforator flaps used in this region are based on the intercostal artery perforators such as AICAP (Anterior InterCostal Artery Perforator) and LICAP (Lateral InterCostal Artery Perforator) flaps [11]. These flaps are complex and time-consuming. The Limberg flap is a simple, versatile, robust, and is especially useful in lesions close to the inframammary crease. It is also useful in cases with skin loss during excision. The inframammary crease is reformed and gives very good cosmesis as depicted in Figs. 3 and 4. None of the patients had any flap complications. This is due to the robust design of the flap. In the large series by Silva et al., 45% of the tumors were in the lower quadrant [5].

This flap design can be used in any of the breast quadrants. However, there are simple oncoplasty techniques available for the other quadrants which will provide equivalent if not better cosmesis. In the lower quadrants, the oncoplasty would result in loss of ptosis. This would result in disparity between the two breasts as our patients are rarely willing for any reduction procedure in the opposite breast. Mokkapati et al., in their study on the breast anthropometry in Indian women concluded that nearly 81% of patients had ptosis and up to 40% had grade 3 ptosis [12]. This flap is more useful in ptotic breast with small defects. In non-ptotic breasts, oncoplasty and in larger lesions, intercostal perforator flaps or inverted T oncoplasty or J plasty would be a better option. Inverted T oncoplasty or J plasty are volume displacement techniques which can be carried out if there is adequate volume in the lower half of the breast to replace the excision volume. In ptotic breasts. these techniques reduce the ptosis on the operated side and cause disparity between the two breasts. A reduction mammoplasty may be required in the opposite side for symmetrization which may not be practically possible in low resource high volume centers and also due to patient’s unwillingness for surgery on the normal breast. There are economic constraints for such reduction mammoplasty procedure. The various intercostal perforator flaps (lateral, medial, and anterior) are also used in this site for volume replacement. As these flaps are larger in size, there is the risk of flap necrosis. They require some training and expertise whereas the Limberg flap is a simple, random flap based on basic geometry which can be practiced by all the surgeons.

The Limberg flap has its limitations. It is not very useful in large defects as the volume of the flap may not suffice. In women with very low body mass index, adequate bulk may not be present in the flap for good cosmesis. In such situations, the perforator flaps are a better option. The vertical limb of the Limberg flap extends onto the anterior abdominal wall and may not be cosmetically acceptable to some women. In our series, post radiation follow-up and long-term follow-up were not done as the patients are still undergoing adjuvant therapy or have recently completed radiotherapy. Objective assessment of the reconstruction using questionnaires was also not carried out. We plan to assess the post radiation and long-term cosmesis of the patients using objective questionnaires. We conclude that the Limberg flap is an extremely useful flap in T1 andT2 lesions in the breast near the inframammary crease.

Conclusion

Limberg flap is a very useful flap in oncoplastic reconstruction following breast conservation surgery. It is simple, robust, and versatile and should be a part of the armamentarium of the breast surgeons.