The latissimus dorsi (LD) muscle is the largest muscle in your body and lies over your ribs on your back between your shoulder blade and hip. It can be moved from here to the front of your body to reconstruct your breast. This is known as an ‘LD flap’ or back flap reconstruction. Because it is using your own tissues this form of reconstruction is known as ‘autologous’. Sometimes the LD flap can be used alone, but more commonly it is combined with a breast implant to give enough size to the reconstructed breast.
If you have an LD reconstruction as an immediate procedure your surgeon will normally carry out a skin sparing mastectomy by making a cut around your nipple to remove the nipple and breast tissue but leaving the skin of the breast. There will be another elliptical cut along your back from which a skin paddle, with underlying fat and part of the latissimus dorsi muscle will be removed. This tissue is moved to the breast area in the front by tunnelling it under the skin below your armpit. It will still be attached to its blood supply. An implant is placed in the breast to fill the cavity and is covered with this muscle from the back. The skin that came with the muscle is trimmed and used to replace the nipple and areola skin that has been removed with the breast. When your back scar is closed it will form a straight line; your Surgeon will discuss with you where that will be but usually we try to get it running so that it is hidden within your bra line.
A breast reconstruction using an LD flap tends to give a more natural droop and feel than an implant reconstruction will and may withstand treatment such as radiotherapy better than an implant only reconstruction. The muscle is left partially attached near your armpit which helps to support its blood supply so it is a very safe flap which is unlikely to fail due to poor blood supply. In the rare instance that the flap does fail during the operation your Surgeon will tend to carry out an implant only reconstruction instead unless you have specifically asked us not to.
This type of surgery takes around 4 hours to complete and 4-6 weeks to recover from. You will need to have a blood thinning injection the night before surgery to help prevent problems with blood clots. You will have a urinary catheter placed when you are under anaesthetic to drain urine, and at least two tube drains will be left at the site of surgery to drain off any extra fluid that collects. The urinary catheter will be removed once you are up and about, and the other drains left until they are draining less fluid. You will be able to go home with the drains in place and a member of the Hospital at Home team will visit you to check on them. This surgery is quite painful for a few days, and you will be given a button that you can press to give yourself a small amount of strong painkiller into a vein, as well as tablet painkillers. Complications specific to this surgery are bleeding, which can occasionally require us to do a second operation to deal with it, and problems with the back wound. Most commonly there can be a collection of fluid, called a seroma, which develops under the skin of the back. This is harmless but may require us to drain it off for you which can be done simply in outpatients’ clinic. The flap has a very good blood supply, but rarely this can be insufficient and all or part of the flap may die off. This may require treatment with dressings for a prolonged period, or sometimes further surgery.
After an LD reconstruction you may notice fullness in your armpit where the muscle has been tunnelled through to the front. As time passes the muscle thins because it is not being used in the normal way so this fullness will become less obvious. The rest of the muscle also thins, making the reconstructed breast smaller; for this reason we tend to deliberately make it larger than the other side at first, with the aim of giving you a good match in the end. The muscle cannot work in the same way as before it was moved, so you may notice some loss of strength to the shoulder, particularly when pushing up to get out of the bath or out of a low chair. Over time other muscles should strengthen so you don’t notice too much weakness, but you may be advised against this form of reconstruction if shoulder strength is very important to you in your work or hobbies.
Often we will need to put a small silicone implant in underneath the LD flap in order to give a sufficient size to your breast reconstruction, the risks of having a breast implant placed are the same as listed under implant reconstruction. These include infection, which may require the implant to be removed, hard scar (capsule) formation, movement of the implant (migration) and rupture, although infection and capsule formation tend to be less likely after an LD reconstruction than after implant only reconstruction. In addition all patients having a breast implant placed should be made aware of the rare chance of Breast Implant associated Lymphoma that has been identified. This is a form of cancer that occurs very rarely (1 in 20,000 with a breast implant) and which looks to be readily treatable by removal of the breast implant and any scar tissue surrounding it. Please let your GP or Breast Team know if you experience any sudden swelling of a breast that has a breast implant in it.
Complications specific to this surgery are bleeding, which can occasionally require us to do a second operation to deal with it, and problems with the back wound. Most commonly there can be a collection of fluid, called a seroma, which develops under the skin of the back. This is harmless but may require us to drain it off for you which can be done simply in outpatients’ clinic. The flap has a very good blood supply, but rarely this can be insufficient and all or part of the flap may die off. This may require treatment with dressings for a prolonged period, or sometimes further surgery.