What Is a Latissimus Dorsi Flap?

What to expect when undergoing this breast reconstruction procedure

woman consulting doctor about the latissimus dorsi flap breast reconstruction procedure
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The latissimus dorsi flap breast reconstruction is a procedure that uses skin, fat, and muscle from the upper back (the flap) to rebuild the breast shape after a mastectomy. Though some tissue flaps are used by themselves to reconstruct the breast, the latissimus dorsi flap is often used in conjunction with a breast implant. The procedure gets its name from the latissimus dorsi, the large, triangle-shaped back muscle that gives the attached tissue and fat an adequate blood supply.

The newly reconstructed breast will not look and feel exactly the same as your natural breast, but tissue flaps generally look more natural and behave more like natural breast tissue than breast implants alone. You'll need additional surgery to create a nipple and areola.

Latissimus dorsi flap breast reconstruction is also known as autologous tissue reconstruction.

Purpose of Procedure

During a latissimus dorsi flap breast reconstruction, an oval section of fat, muscle, and a small amount of skin is tunneled from your upper back to the mastectomy area to rebuild your chest. The blood vessels of the flap are left attached to their original blood supply in your back.

The lat muscle is considered "expendable," as its functions are preserved in its absence by the shoulder girdle muscle, according to a review article on the procedure published in 2018.

If there's not enough tissue to create a new breast, a small breast implant may be used under the flap to adjust size, shape, and projection. The flap provides added coverage over an implant and makes a more natural-looking breast than just an implant alone.

Advantages

Though reconstruction procedures using tissue taken from your abdomen (i.e., TRAM flap reconstruction, DIEP flap) have become more popular over the years, latissimus dorsi flap breast reconstruction continues to be a viable option for both immediate and delayed reconstruction because it offers solutions for a variety of patients. This includes those who:

  • Are very thin and don't have enough donor tissue in the lower abdomen
  • Have prior scars that may have damaged important blood vessels
  • Have previously had radiation
  • Have had previous flaps that have failed and are seeking an alternative

This "workhorse" flap was even shown in a 2013 study to be safe for overweight and obese patients. Researchers reported that the incidence of both flap and donor-site complications after latissimus dorsi flap reconstruction was not significantly different in overweight and obese patients compared to those of a healthy weight.

Other plusses:

  • While the transplanted skin has a slightly different color and texture, it will be a close color match for your breast skin.
  • The flap will feel warm and flexible like your normal tissue because it is your tissue.
  • Because the flap is a transplant, it may also feel less "foreign" to you than an implant.

The muscle used is one that is "replaced" by other muscles, so the majority of women report that they, after surgical recovery, adapt comfortably and are able to do the important physical activities that they were able to do before surgery.

It's notable that women who had flap procedures also reported significantly greater satisfaction with their breasts, sexual well-being, and psychosocial well-being than women who underwent implant reconstruction, according to a 2018 study published in JAMA Surgery.

Disadvantages

The latissimus dorsi flap reconstruction is considered a major surgical procedure, and you'll be in surgery longer than someone who's getting breast implants alone.

Healing will also take longer with a tissue flap procedure since you'll have two surgical sites and two scars. Afterward, it's not unusual to experience weakness in the arm and back muscles and need physical therapy.

Be aware that another 2018 study published in JAMA Surgery found higher complication rates within two years following surgery among women who underwent flap procedures compared with women who underwent implant procedures. Rates of complications ranged from 36 percent to 74 percent among the flap procedure group compared with a range of 27 percent to 31 percent among the implant group.

However, the study authors point out that with additional years of follow-up, implant-based procedures are more likely than flap procedures to have increased complication rates. Also, more surgery is often needed years later to remove, modify, or replace implants.

Are You a Candidate?

Before your mastectomy, your doctor will recommend that you meet with a plastic surgeon. You should consult with one who is experienced in breast reconstruction after a mastectomy procedure. Your breast surgeon and plastic surgeon can work to determine the best surgical treatments and reconstruction surgery for your unique situation.

The latissimus dorsi flap may be a good option for women who have small- to medium-sized breasts, as they don't have a lot of fat on the part of the back the tissue is harvested from.

Blood vessels will be moved and/or reconnected during a tissue flap procedure, so if you smoke or have any conditions that affect your circulation including uncontrolled diabetes, vascular disease, or connective tissue diseases like rheumatoid arthritis and scleroderma, you may not be a good candidate for any type of autologous tissue transplantation. Smokers may be asked to quit for four to six weeks prior to surgery.

When It Is Done

Breast reconstruction can be done at the same time as the mastectomy or after treatment.

If you're having a mastectomy and reconstruction at the same time (immediate reconstruction), your general surgeon will first remove your breast, sparing as much skin as possible. It's a good idea to talk with your plastic surgeon before having a mastectomy. This gives you the chance to have measurements and pictures taken of your natural breasts, so your reconstructed breast can be recreated as accurately as possible.

If you need radiation therapy to the underarm area or chest, however, it is worth waiting; having a latissimus dorsi flap done before treatment is complete severely limits a radiation therapist's ability to treat you properly.

Risks and Contraindications

It's important to have an idea of what to expect of surgery to rebuild the breast, including recovery, risks associated with surgery, and problems that may arise later down the road.

While most of these risks are rare, it's still important to be aware of them.

Surgical risks include:

  • Anesthesia problems, including allergic reaction
  • Bleeding
  • Blot clots
  • Surgical site infection
  • Wound healing difficulties
  • Fatigue
  • Fluid build-up in the breast or donor site with pain and swelling

Some problems that may occur later on, though they are rare, include:

  • Necrosis, or tissue death, in part or all of the reconstructed breast: Necrosis can be treated, with the dead tissue being removed, but the affected tissue cannot be returned to good health. The risk of failure for the latissimus dorsi flap is less than 1 percent, though that is greater if you've had prior radiation therapy.
  • Loss of or changes to nipple and breast sensation
  • Problems at the donor site (where the flap was removed to be used for the reconstructed breast), including loss of muscle strength
  • Changes or problems to the arm on the same side as the reconstructed breast
  • Problems with the implant, including leakage, rupture or scar tissue formation
  • Uneven breasts
  • The need for more surgery to fix problems that may arise

A very experienced plastic surgeon can try to prevent complications and flap failure.

Though not a health risk, you should know that the procedure will leave a back scar, but your surgeon will attempt to take the skin graft from an area that will be covered by your bra strap.

Making Your Decision

When meeting with your surgeon, be sure to discuss all of your options in detail: their pros and cons, anesthesia required, recovery, and follow-up. Ask your surgeon to show you pictures of other women who have had the procedure (this is commonly done; ask for both the best and worst results the surgeon has). You can also ask to speak to women who've had the surgery as well.

Before Surgery

You should follow any instructions your surgeon provides on preparing for your latissimus dorsi flap. This may include information on diet, medications, and quitting smoking.

Location and Timing

Latissimus dorsi flap reconstruction is performed in a hospital. The procedure will take three to four hours. Post-surgery, you'll be admitted to the hospital and stay three to four days to begin healing.

What to Wear

You'll likey be sore and have a limited range of motion (plus drains and bandages) after your procedure, so bring comfortable clothing that's easy to put on, including loose or stretchy shirts that wrap or button up the front, as well as pull-on pants.

Know, too, that you will need to heal before you can wear a bra or prosthesis; your doctor will provide specific information about how long you'll need to wait. Purchase a camisole for support and to secure any surgical drains that will be used as part of reconstruction surgery. The camisole is usually worn home from the hospital following surgery.

Food and Drink

You will be told when to stop eating and drinking prior to surgery, but typically you'll be instructed not to have anything for eight to 12 hours beforehand. Unless you've been told that it's OK to take your medications with water the morning before surgery, avoid doing so. Even a sip of water could force your doctor to cancel or postpone your procedure.

Cost and Health Insurance

Federal law requires insurance companies that cover mastectomy for breast cancer to also cover breast reconstruction. Check with your insurance company to find out what your costs will be.

This surgery can be expensive. Without health insurance, breast reconstruction with "flap" techniques can run as high as $50,000 per breast; some people may face high deductibles or co-payments. Some insurance companies require a second opinion before they will agree to pay for surgery.

Insurance providers each have their own unique policies and procedures regarding precertification, predetermination, and authorization for medical procedures. When a patient has been diagnosed with cancer, this process is generally completed promptly by the insurance provider, however, in other non-immediate or delayed cancer cases, it could take up to six weeks for finalization.

Medicare coverage includes reconstructive surgery and prostheses, breast forms that fit into your bra and that you may need before or during the reconstruction. Medicaid coverage varies in each state, so you'll have to get information for your state.

Anesthesia

You'll have intravenous sedation or general anesthesia, so you won't be awake during your mastectomy or reconstruction. Talk to your surgeon and the anesthesiologist beforehand about which type of anesthesia works best for you, and be sure he or she is informed of all medications and supplements you are taking.

During Surgery

Prior to surgery, your plastic surgeon will use a marker to carefully plan for the incision that will create your skin flap. A pointed ellipse (oval-like shape) will be drawn over your latissimus dorsi muscle. This ellipse will become the skin flap that closes the incision for your reconstructed breast.

When the incision for the flap is sutured closed, it will leave a four-inch to six-inch scar on your back, however, most surgeons try to place the incision so the scar is covered by your bra strap.

Moving Muscle and Skin

Your plastic surgeon will make an incision on the skin markings, raising the skin and muscle flap. A tunnel will be created under your skin so that the flap can be relocated. This latissimus dorsi tissue flap will go through the tunnel to the front of your chest, keeping its blood supply intact. This ensures that the skin and muscle will continue to live in their new location.

If the flap is completely removed and moved to the chest, the blood vessels must then be reattached with the use of a microscope. The skin will be positioned so that it fills in the area of skin that was lost during your mastectomy. If you need an implant, the muscle will be draped over it to create the new breast mound.

Closing Incisions

Your back incision will be closed, and a surgical drain may be placed in it to help remove excess fluid.

On your chest, the skin flap will be carefully joined to the mastectomy incision. If needed, scar tissue from your mastectomy may be removed in order to create a smoother skin texture at the new incision.

After Surgery

Blood flow to the flap is critical and will be closely monitored while you're in the hospital. If you have surgical drains, you'll learn how to empty those and keep records of the fluid volume.

Report pain if you have any so that it can be treated. Your surgeon may recommend that you wear a compression garment for up to eight weeks after surgery to keep swelling in check.

Don't plan to go right back to work—you'll need to take it easy while you recover. Be sure to have someone around to help drive you and do any lifting. Also, be sure to go for your follow-up appointments so your surgeon can keep an eye on your incisions and dressings and remove your drains.

People heal at different rates, so recovery times vary. Because you've had surgery at two sites on your body, you might feel worse than a person would after mastectomy alone, and it will probably take you longer to recover.

You can anticipate gaining normal function for activities, such as driving, in three to six weeks. It may take as long as a year or even more to see the final result.

Nipple and areola reconstruction, should you choose to have it, is performed at about three to six months after the primary reconstruction, though that timing can vary considerably based on surgeon and patient preference, as well as the specific techniques used in both procedures. The reconstructed nipple doesn't have the same sensitivity as the original nipple, but it does provide for a more natural appearance. 

A Word From Verywell

There are a wide variety of options in breast reconstruction, and a latissimus dorsi flap approach, although highly effective, is not necessarily the best choice for all patients. Talk with your plastic surgeon and work together to find an approach that will give you the best possible results.

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