The latissimus dorsi muscle is a long, flat muscle that runs diagonally from the side to midback. Reconstruction uses a flap of skin, soft tissue, and the latissimus muscle, which is relocated from the back to the breast region. However, unlike a TRAM that provides all the bulk necessary to create a breast mound, a latissimus flap has little fat and therefore is more often used to support and cover a breast implant in breast reconstruction. Most women are good candidates for a latissimus dorsi flap reconstruction. However, women who are very thin or who have pre-existing back or shoulder problems may not be good candidates for reconstruction with a latissimus dorsi flap. A latissimus dorsi flap may be performed bilaterally (on both sides). Women who have chronic illnesses that may impair healing, such as diabetes or connective tissue disorders such as lupus, may not be good candidates for any breast reconstruction with flap surgery. In addition, if you smoke, you are not a good candidate for reconstruction of any kind and will be advised to quit smoking before any reconstructive procedure and for many weeks following.
To quit smoking for life is in the best interests of your health. A latissimus dorsi flap reconstruction is performed under general anesthesia as an inpatient hospital procedure. The procedure will add two or more hours if performed at the time of mastectomy, or may take several hours if delayed following mastectomy. An elliptical incision in the back, just below the shoulder blade, is made. This allows your cosmetic surgeon to release the latissimus dorsi muscle from the midback and keep it attached to its original blood and nerve supply. A paddle of skin and tissue attached to the flap will remain in place. The flap is then rotated under the skin and soft tissue from the back to the front of the chest wall, in the region below the axilla (underarm). The muscle flap, tissue, and skin are positioned through the mastectomy incisions on the chest wall. The flap is fashioned to create a pocket for a breast implant using internal sutures.
The implant is placed, and the resulting incisions on the back and breast mound are closed. Depending on your specific situation, your cosmetic surgeon may place a tissue expander behind the latissimus dorsi flap instead of placing a breast implant, and subsequently replace the tissue expander with a permanent breast implant in a future procedure. You will awaken from surgery with a full breast mound in place, if a permanent breast implant has been placed, or with a partial breast mound if an expander is used. Thin, flexible tubes may be placed in your incisions to drain any excess fluid that collects. You will experience discomfort, swelling, and tenderness at the new breast site and in your back where the flap was taken. Medication can be used to control your discomfort. In addition, you may experience a stiff and sore back, and find it difficult to lie on your back or lean back for a few days following surgery. It is important to begin moving as instructed as soon as possible following surgery, to prevent blood clots from forming and to ease you into recovery. You will remain in the hospital for two to three days or more. Your release depends on your physical condition, the extent of the surgery, and your progress in healing.
All of the complications and risks associated with breast surgery and with surgery in general are possible. In addition, if infection should develop and is not treated immediately you risk necrosis (pathologic death of one or more cells), of loss of the skin flap, and perhaps even surrounding healthy tissue. Because a portion of your back muscle has been relocated, a latissimus dorsi flap procedure can result in an asymmetrical appearance of the back if performed unilaterally (on one side). In addition, weakness in the upper back is possible, as is developing shoulder pain because the muscles in the shoulder will compensate for any weakness in the mid- to upper-back. A latissimus dorsi flap may allow for some physical sensation in the breast; however, it will take some time to develop or for you to recognize. In addition, because the flap is likely covering a breast implant, all of the risks associated with the use of breast implants are possible. It is important to discuss incision placement on your back with your cosmetic surgeon prior to your latissimus flap reconstruction. The incision on the back will leave a straight line scar that could measure 6 inches or more. In some cases, the scar may be placed to be hidden under the back portion of your bra, and low enough that you may feel comfortable wearing fashions that reveal the upper portion of your back.
Within two to four weeks following a latissimus dorsi flap reconstruction, you may be ready to get back to a moderate daily routine. Exercise is an important part of your recovery, but it is important to follow the instructions that you are given by your cosmetic surgeon or a physical therapist very closely. Too little exercise may hinder your recovery, and too much may result in unnecessary injury. It is important to maintain your back strength for life. Although a latissimus dorsi flap itself does not hinder the methods used to monitor the reconstructed breast, continuous follow-ups as recommended by your doctor, oncologist, and cosmetic surgeon are your best defense to leading a healthy life and feeling whole.
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