Latissimus Dorsi Flap

What is a Latissimus Dorsi flap breast reconstruction?

In this type of flap reconstruction, the surgeon uses a large muscle in your back, the latissimus dorsi, to reconstruct your breast. The latissimus dorsi is located just beneath your shoulder blade and behind your armpit, and is the muscle that helps you do things such as lifting, twisting, swimming and playing tennis.

This procedure involves moving an oval flap of skin, fat, muscle and blood vessels from your back to your chest to form a new breast “mound”. The flap is moved under your skin and put into position on your chest. An implant is usually (although not always) required under the flap to make your breast large enough to match your remaining breast and achieve the desired shape, size and projection.

How is this surgery performed?
During latissimus dorsi flap reconstruction surgery, an incision is made in your back near your shoulder blade. Then, an oval section of skin, fat, blood vessels, and muscle is slid through a tunnel under the skin under your arm to your chest and formed into a breast shape. The blood vessels are left attached to their original blood supply in your back. If any blood vessels do have to be cut, they are matched to blood vessels in your chest and carefully reattached under a microscope. If you're also receiving an implant, the surgeon will insert that as well.

Who is a good candidate for this surgery?

women with small-medium sized breasts
women who do not have enough donor tissue in their abdomen to have a TRAM or DIEP flap reconstruction
women who have had previous flaps that failed and need a secondary alternative

women who do not have access to plastic surgeons that can perform the microsurgery that other free flaps require.

Who is not a good candidate for this surgery?

women who have scarring on their back from previous surgeries.
women who do not want a breast implant – implants are usually needed to recreate sufficient breast size.
women with very large breasts, or who are very overweight.

women who smoke. Reconstruction techniques which use tissue flaps that rely on a supply of blood may not be suitable for women who smoke as smoking greatly increases the risks of complications. Stopping smoking, as well as any nicotine replacement therapy, at least a month prior to the operation may mean that you can be considered for this procedure.

women with additional health issues who are not suited to a longer anaesthetic and the additional stresses of a longer recovery.

Women who are active in the gym, tennis court or rock climbing, as you will have weakness in some over head activity and shoulder exercises. For most women this is not noticeable and doesn’t affect their daily activities.

Advantages

What are the potential advantages of this type of surgery?

Latissimus dorsi should last you for life.
It may require a small breast implant, in addition to your own tissue.
The transplanted skin will be a close color match for your breast skin.
Your reconstructed breast will feel warm and somewhat flexible.
As this type of procedure uses your own body tissue, a more natural looking breast can be achieved than when using implants alone.

New method

Scarless latissimus dorsi
The scarless latissimus dorsi breast reconstruction procedure allows the patient’s muscle flap to effectively be harvested without scars on the patient’s back. Go to page

Disadvantages

What are the potential disadvantages of this type of surgery?

The Latissimus Dorsi method is considered a major procedure, and you will be in surgery longer than a patient who is getting breast implants only.
Healing will also take longer with a tissue flap procedure, since you will have two surgical sites and two scars.
Afterward, many women may experience weakness in the arm and back muscles and need physical therapy.
There is a risk of developing infection at the surgical sites and experiencing trouble healing. The risk of failure for the latissimus dorsi is less than 1%. A very experienced plastic surgeon can try to prevent complications and flap failure.
You may also experience some loss of strength or function in your back or shoulder, making it hard to lift things and to twist. This will improve over time, particularly if a course of physical therapy is included in your recovery plan.
Your new breast will have a slightly different texture and colour and so may not completely match the remaining breast
The possibility of a small bulge developing under your armpit where the muscle was tunnelled under the skin.
A latissimus dorsi flap reconstruction does leave a scar on your back, but most surgeons will aim to ensure the scar can be covered by a bra or swimwear.

After latissimus dorsi flap reconstruction surgery
You'll be moved to the recovery room after surgery, where hospital staff members will monitor your heart rate, body temperature, and blood pressure. If you're in pain or feel nauseated from the anesthesia, tell someone so you can be given medication.

You'll then be admitted to a hospital room. The nursing staff will check your new breast every hour to monitor the warmth, colour, tightness and blood flow. The room may be warmed or you may have a heated blanket to assist with circulation. You will have a catheter to drain urine until you are able to walk to the bathroom, usually either on the 2nd or 3rd day, and you will have several drains from the incision sites in place to remove excess blood and fluid. The drains will usually be removed 2-8 days after surgery, depending on their output.

Once you have recovered from the operation and all is progressing well with your new breast, you will be encouraged to shower and begin to move about. Nursing and physiotherapy staff will assist you in regaining mobility, and can provide advice on exercises and activities that can be done to improve your recovery and strength. You are likely to be in hospital for 4-5 days.

On leaving the hospital, your surgeon will give you specific instructions on post-operative care, including; caring for your surgical sites, medications to use, symptoms or concerns to look out for during the recovery period and when follow up is required.

How long is this operation?
This procedure is performed under general anaesthetic and usually takes around 4-6 hours.

What is the estimated hospital stay?
The hospital stay for latissimus dorsi flap is typically 4-5 days.

Where can this surgery be performed?
Latissimus dorsi breast reconstruction can be performed at most major public hospitals and private hospitals. Ask your surgeon where they can perform this surgery.

Who should do this surgery for me?
This surgery is a technique that most plastic surgeons are able to perform.

What stages are involved?

The initial latissimus dorsi flap operation may take around 2-4 hours, with a 4-6 week recovery period.
You may be interested in the final touches of either nipple reconstruction or 3D nipple tattooing. You may also consider whether you need to reduce, lift or reshape the other breast, to improve symmetry with the reconstructed breast. Your surgeon will advise if this is recommended and this procedure is often done at the same time as nipple reconstruction. Sometimes surgical revisions are also required to correct any minor irregularities. A breast lift and nipple reconstruction is usually a day procedure and takes around 1-2 hours.

What is the expected recovery time?
It can take 4-6 weeks to recover from latissimus dorsi reconstruction surgery and to resume normal activities.

What are the risks?

Like all surgery, latissimus dorsi flap surgery has some risks. Many of the risks associated with latissimus dorsi flap surgery are the same as the risks for mastectomy. If you've had an implant inserted along with latissimus dorsi reconstruction, there are also risks related to implant reconstruction. However, there are some risks that are unique to latissimus dorsi flap reconstruction.

Tissue breakdown
In rare instances, the tissue moved from your back to your breast area won't get enough circulation and some of the tissue might die. Doctors call this tissue breakdown “necrosis.” Some symptoms of tissue necrosis include the skin turning dark blue or black, a cold or cool-to-the-touch feeling in the tissue, and even the eventual development of open wounds. You also may run a fever or feel sick if these symptoms are not addressed immediately. If a small area of necrosis is found, your surgeon can trim away the dead tissue. This is done in the operating room under general anesthesia or occasionally in a minor procedure setting. If most or all of the flap tissue develops necrosis, your doctor may call this a “complete flap failure,” which means the entire flap would need to be removed and replaced. Sometimes the flap can be replaced within a short timeframe, but in most cases the surgical team will remove all the dead tissue and allow the area to heal before identifying a new donor site to create a new flap.

Lumps in the reconstructed breast
If the blood supply to some of the fat used to rebuild your breast is cut off, the fat may be replaced by firm scar tissue that will feel like a lump. This is called fat necrosis. These fat necrosis lumps may or may not go away on their own. They also might cause you some discomfort. If the fat necrosis lumps don't go away on their own, it's best to have your surgeon remove them. After having mastectomy and reconstruction, it can be a little scary to find another lump in your rebuilt breast. Having them removed can give you greater peace of mind, as well as ease any discomfort you might have.

Muscle weakness
In some cases, you may have some weakness in your back, shoulder, or arm after latissimus dorsi flap breast reconstruction because some of your back muscle has been moved to your chest. You may have partial loss of strength or function that makes it hard to lift things and twist. This can affect your ability to perform certain swimming, golf, or tennis stokes, or turn and manipulate objects. If you have muscle weakness that is problematic and persistent, talk to your doctor to see if you can work with a physical therapist on these issues. Also, ask about exercises you can do to help strengthen the area.

Fluid under the back wound (seroma)
This is the most common problem which occurs with this type of surgery. Seromas usually get better with time and as the body heals, but sometimes they need to be drained by the surgeon, or another skilled health professional.

Recovery advice

It can take about 4-6 weeks to recover from latissimus dorsi reconstruction surgery. Because you've had surgery at two sites on your body (your chest and your back), you might feel worse than someone who had mastectomy alone and it will probably take you longer to recover. You'll have to take care of two incisions: on your breast and your back. You may need to arrange for help to take care of the incision on your back. You also may be healing from axillary node dissection (an incision under your arm where lymph nodes were removed) if your doctor recommended it.

If you have had a tissue expander inserted, you will need to see your doctor regularly over several weeks or months to have the expander filled until the desired shape and size have been achieved for the implant. A support bra may be worn to help reduce swelling and support the reconstructed breast.

You may be prescribed painkillers, antibiotics and anti-inflammatory drugs when you are first discharged from hospital. It is vital to use these as prescribed to successfully manage any pain and to reduce the risk of infection.

Post-operative recovery can take longer if complications occur, so it is important to get adequate rest, make sure you follow your surgeon’s directions and exercise within the limits of comfort – if you feel any pain or pulling, especially around the wound sites, stop.

Follow your doctor's advice on when to start stretching exercises and your normal activities. You usually have to avoid lifting anything heavy, strenuous sports, and sexual activity for about 4 weeks after latissimus dorsi flap reconstruction. It’s worth having a short course of physical therapy with a qualified breast cancer physical therapist to strengthen and maintain range of motion in your shoulder. Ask your doctor for recommendations.

It can take up to twelve months to completely heal and for scars to fade and for you to get a good indication of how your new breast will settle into your body. You might feel further surgery to refine the shape of your new breast mound is necessary, but it is a personal choice. Revision surgery can take place anytime from three months post-surgery. Your surgeon may also recommend a breast lift or reduction on the other breast to create better symmetry. When you have achieved the desired symmetry and shape, you may like to consider the finishing touch of reconstructed nipples or 3D nipple tattoos.

Reviewed by:

Dr Pouria Moradi
MBBS BSc (Med)
MRCS (Eng) FRACS (plas)

Reference sources:

Breastcancer.org:

http://www.breastcancer.org/treatment/surgery/reconstruction/types/autologous/lat-dorsi
Cancer Research UK:
http://www.cancerresearchuk.org/about-cancer/type/breast-cancer/treatment/surgery/reconstruction/breast-reconstruction-using-body-tissue
Australian Society of Plastic Surgeons:
http://www.plasticsurgeryfoundation.org.au/patient-information/procedures
Cancer Australia:
http://canceraustralia.gov.au/affected-cancer/cancer-types/breast-cancer/treatment/breast-reconstruction/types/
Randwick Plastic Surgery: Patient Information Sheets
http://www.randwickplasticsurgery.com.au
Better Health Channel:
http://www.betterhealth.vic.gov.au/bhcv2/bhcmed.nsf/pages/B10lite_en