Latissimus dorsi flap reconstruction: What to expect
While there are several reconstructive options available, latissimus dorsi flap reconstruction is a good option for many women who are not candidates for other reconstructive procedures.
In this article, we take a look at what happens in latissimus dorsi flap reconstruction, including what women can expect from the surgery and who may benefit from it most.
What is latissimus dorsi flap reconstruction?
The latissimus dorsi is one of the largest muscles in the body. Situated below the shoulder and behind the armpit, the muscle allows a person to move in a twisting motion, such as when swinging a racket or golf club.
Women who have had a breast removed may choose to have breast reconstructive surgery.
In a latissimus dorsi muscle myocutaneous flap (LDMF) reconstruction, surgeons take a large flap of skin, containing some, fat, muscle and blood vessels from this area of the back.
One of the most reliable flaps used in reconstructive surgery, it is known for its use in chest wall surgery and reconstruction after breast removal. It is particularly effective because of its proximity to the chest and because of the blood vessels that keep blood circulating.
During latissimus dorsi flap reconstruction surgery, the surgeon makes an incision in the back near the shoulder blade and passes the oval section of skin, fat, blood vessels, and muscle through a tunnel under the skin and arm to the chest. Once in place, the mass is sculpted into a breast shape.
The blood vessels remain attached to their original blood supply in the back. If any of these blood vessels are severed during the procedure, the surgeon matches them to blood vessels in the chest and uses a microscope (microsurgery) to reattach them.
In most cases, the surgeon will also place an implant in the breast to achieve the desired shape, size, and projection. The entire surgical procedure lasts between 3 and 4 hours.
What to expect
It is important for people to follow any instructions that their doctor gives them at the pre-operative appointment. Some instructions may include having blood tests, a chest X-ray, or a test to check the electrical activity of the heart called an electrocardiogram (EKG).
Before surgery, most people will need to stop taking aspirin, blood thinners, anything with vitamin E, and any nonsteroidal anti-inflammatory medications (NSAIDs). Additionally, taking a stool softener will help with constipation that often results after the surgery because of the narcotics used.
Additionally, a woman should prepare for surgery by:
- Stopping smoking. Smoking can add complications to the surgery, and some surgeons will refuse to operate on a smoker. A woman should quit smoking as soon as breast cancer is diagnosed to help eliminate potential risks.
- Preparing the home for recovery. This may include preparing a bed with supports and pillows, moving the bed and other essentials to the ground floor to avoid stairs, and putting things, such as medicines and other important objects within easy reach.
- Preparing for comfort after surgery. This may include getting looser fitting clothes, finding a caregiver, and having sandals available to wear, as these are easier to put on than regular shoes.
The most important preparation is asking a doctor about what to expect and preparing for a lengthy recovery.
Who should have latissimus dorsi flap reconstruction?
Though a good option for some women, latissimus dorsi flap reconstruction is not the only option available.
A latissimus dorsi flap reconstruction does have some advantages, such as being close to the donor site as well as the blood vessels it requires. Perhaps, the ideal candidate for this surgery is a woman who has small or medium-sized breasts, as there is limited fat in the latissimus dorsi flap.
This type of reconstruction is a good option for women who may not be suitable for other types of reconstructive surgery. Some reasons why a woman may not be an ideal candidate for other treatments include:
- previous flaps have failed, so a secondary method is needed
- there is not enough tissue in other parts of the body, particularly the abdomen, to use in the reconstruction
- they do not have access to a qualified plastic surgeon who can perform the microsurgery that latissimus dorsi flaps require
Side effects and recovery
Latissimus dorsi flap reconstruction has risks similar to other reconstruction surgeries. Some of the most common areas of concern are:
- Partial loss of strength or movement that makes it hard to lift things and twist. In cases where both breasts need to be reconstructed, the latissimus dorsi flap is not the best choice as this may result in muscle weakness on both sides of the body.
- Many women need an implant along with a latissimus dorsi flap. Some women feel that the implant feels firmer than the tissue in front it.
- The fat in the latissimus dorsi flap is firmer than other body fat. As a result, the reconstructed breast will feel firmer than the other breast.
Women tend to be moved to a recovery room after surgery, and will probably remain there for some time. During this recovery period, hospital staff members will monitor the woman's heart rate, blood pressure, and body temperature.
It is not uncommon for women to feel pain or sick from the anesthesia. Medications are available to treat both of these conditions, however.
Once cleared from the recovery room, the woman will move to a standard hospital room, where she will remain for around 4 days. The length of time the woman stays in the hospital, however, depends on how well she is healing.
Before going home, a doctor will provide the woman with instructions, medications, and ideas on what to expect.
It is important to be aware of the partial loss of strength after reconstruction, and to consider this during recovery.
A doctor will also provide some care tips on how to care for:
- surgical drains
Full recovery time will vary from woman to woman. A typical recovery will take about 4 weeks.
It is important for women who have undergone this procedure to remember that they have two areas to take care of - the breast reconstruction and the back. Both will need close attention to prevent any complications, such as infection by the incision sites.
Other types of reconstruction
There are many additional options for breast reconstruction following breast removal or other procedures on the breasts.
Two of the more common reconstruction methods using flaps are:
Deep inferior epigastric artery perforator (DIEP) flap
DIEP is a newer flap technique. A surgeon uses the skin and fatty tissue from the lower abdomen to reconstruct a breast. The muscles are left intact.
The procedure has a slimming effect to the lower abdomen, which some women view as an added benefit. However, it is best for women to follow their doctor's recommendation for the best method of reconstruction.
Transverse rectus abdominis muscle (TRAM) flap
TRAM is another technique that uses a tissue flap obtained from the lower abdomen. In this case, unlike the DIEP, the surgeon removes skin, fatty tissue, and muscle to reconstruct the breast.
There are two different methods for completing a TRAM. One method involves leaving the flap connected to its original blood supply, but moving it to the chest using a tunnel under the skin. The other method involves disconnecting the flap and moving it to the chest before reattaching it to the blood supply.
Additional options for reconstruction include:
Superior gluteal artery perforator tissue (SGAP) flap
In a SGAP flap reconstruction, the tissue comes from the top of the buttocks. The surgeon removes the tissue from the buttocks and uses it to create the shape of the breast. Women will be left with a scar on both the buttocks and breast.
Transverse upper gracilis tissue (TUG) flap
The TUG flap is tissue located in the upper thigh near the groin and the gracilis muscle, which is inside the upper leg. During this procedure, the surgeon reconstructs the new breast from the tissue flap removed from the leg.
This procedure is ideal for women with small breasts as it requires less volume to make the breast appear natural. The scar on the thigh is well hidden because of the location.
After the reconstruction, the gracilis muscle will not work very well, but few women report significant effects on their comfort or function from this change.
Each procedure has its benefits and drawbacks. Not all options are right for everyone, so it is important that women discuss with their doctor which option suits them best.