Lattissimus Dorsi Flap

This patient underwent a left mastectomy and immediate, simultaneous breast reconstruction with an ELD flap and she also received a small breast implant in the right breast.

 

Lattissimus Doris and Breast Reconstruction

The latissimus dorsi is a large muscle found on the back which acts to pull the arm into the side and backwards. This muscle, together with a large piece of skin and fat overlying it, can be moved to the front of the chest. It is kept alive by maintaining its blood vessels intact. The skin and muscle are then tunnelled under the skin around the chest wall and into the breast pocketĀ  to create the new breast. If the opposite breast is quite large and there is insufficient tissue available on the back to match this volume, it is possible to include a breast implant beneath this flap to create a larger breast, however, if the patients choice is to avoid using an implant, the breasts can be made an equal size by reducing the size of the normal breast. It is also possible to tailor the scar on the back; the scar can be horizontally orientated to be hidden beneath the bra straps or can be obliquely orientated so that it is not visible beneath strapless or backless garments. This should be discussed with your surgeon.

The procedure is performed under a general anaesthetic and several drains are required postoperatively in the back and the newly reconstructed breast.

As a rough guide the operation takes about 4 hours, needs 4 days in hospital and takes about 4 weeks to recover.

In general, despite the latissimus dorsi being a large muscle, its transfer does not result in any noticeable functional deficits, as there are other, smaller muscles around the shoulder which do the same job.

This flap is almost always available for use, though occasionally the blood vessels supplying the latissimus dorsi muscle may have been damaged at the original mastectomy. Breast surgeons are very aware of the possible future need for breast reconstruction with this flap and attempt to preserve this vessel if at all possible.

Use of the Lattissimus dorsi flap does have some advantages and disadvantages

Advantages:

  • Simple: This procedure provides the simplest method of recreating a breast using living tissue. The single stage operation is much quicker and is far better tolerated by the patient than a TRAM flap.
  • Avoids Silicone Implant: When used alone it is free from the complications associated with a silicon prosthesis.
  • Postoperative Recovery: Recovery period is fairly short and the flap is very reliable and safe, because it remains attached to its original blood supply.

Disadvantages:

  • Reconstructing Moderate Size or Large Breasts: It is difficult to reconstruct a moderate sized or large breast due to the limited tissue available, though this may be overcome by either including a silicone prosthesis or tissue expander beneath the flap or by reducing the size of the normal breast.
  • Donor Site Scarring: The donor site scar on the back is more obvious than that of the TRAM flap, and produces characteristic hollowing on one side when viewed from behind.
  • Patch of Pale Skin: The skin from the back is thicker and paler than skin on the chest, resulting in an obvious patch of pale skin within the new breast.
  • Creating Symmetry: There is a higher incidence of operations on the normal breast to achieve symmetry.

Possible Complications

Generally latissimus dorsi breast reconstruction is a safe, reliable technique with few potential complications

  • Flap Failure: Because the flap is never detached from its blood supply it is very rare, less than 1%, for this flap to fail
  • Partial Flap Failure: In heavy smokers or patients with known circulatory disease, part of the flap may die resulting in scarring and a slightly smaller breast than desired.
  • Seroma: Despite the use of drains, it was quite common for fluid to collect beneath the scar on the patient’s back which could cause swelling and discomfort. More recent techniques have significantly reduced this complication and it is now seen very infrequently.

Postoperative Advice