Technique #3: Latissimus Flap

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Latissimus Dorsi (BACK) Muscle and Implant Reconstruction

This technique, as are the others, is a technique for replacement of both skin and breast mound volume. The skin is replaced not by expansion as in the previously mentioned technique but by bringing skin and muscle from an adjacent area. In this case the skin is brought from a portion of the back, usually in the area starting in the back part of the underarm and coursing for a variable distance down towards the upper part of the hip bone. Occasionally this may be removed from a mid-portion of the back as shown in other brochures. This skin does not have blood supply of its own and can only be moved if blood supply is moved with it. This blood supply is provided by the underlying muscle called the latissimus dorsi muscle. Once the skin and overlying muscle have been replaced,this technique requires breast fill replacement by an implant and thus has the setbacks associated with implant placement as mentioned previously. The skin and muscle unit, once cut free from the back, pivots around to the front of the chest where it is sewn to the chest wall muscle-the pectoralis major. The implant is then placed behind this muscle envelope.

Advantages and Disadvantages of Latissimus Flap Breast Reconstruction

Advantages

The advantages of this operation is that it is a single operation for breast skin and breast mound replacement. This can be done as an immediate reconstruction at the time of mastectomy or can be performed as a delayed procedure. Because of the additional muscle coverage which the latissimus muscle provides for the implant this tends to create a softer breast than does tissue expansion technique.

This technique also develops a breast which may have more ptosis or droop to it than the tissue expanded breast. It is therefore a better technique for mimicking a more mature breast. This amount of droop can be achieved easier, however it is limited by the amount of skin that can be replaced.

In addition to being an easier procedure to perform and recover from than the one which will be discussed subsequently the blood supply to this flap is extremely healthy.

It is rare to have complications with the skin healing following reconstruction with this type of technique. For this reason it can be described as being a more durable flap, than the next reconstructive technique. It is a good technique for bilateral reconstruction.

Disadvantages

The disadvantages of this procedure involve the removal of skin and muscle from the back. As far as the skin, the only resulting negative effect is the additional placement of a second scar in the area just beneath the arm on the flank or possibly across the back.

Although techniques will be used to keep the scar to its shortest possible length and width, due to the constant respiratory motions and locations on the flank this scar has a tendency to widen. Often it is necessary to take a fairly wide piece of skin as well as a long piece of skin to replace skin removed at time of mastectomy. The length of the scar will be determined by the length of the mastectomy incision and the widening of the scar will be determined primarily by techniques of closure and the constant motion in the chest region.

The functional loss of the underlying muscle usually is of no consequence in normal daily activity or normal nonprofessional sports related activity. There may be a fullness beneath the arm where the blood supply and thinner portions of the muscle are moved from the back to the front of the chest for reconstruction. Some patients may prefer the DIEP flap reconstruction technique to avoid these concerns. It takes tissue from the lower abdomen instead of the back, preserving the muscle and offering abdominal contouring benefits.

This fullness will usually disappear with time, however, this may take six to twelve months to decrease in size. The muscle having a finite bulk will also be missed not only functionally but also cosmetically. This will give a relatively concave appearance to the outer portion of the back when viewed from directly behind. The skin once removed from the back and rotated to the front portion of the chest will be devoid of its sensory nerve supply. For this reason the patch of skin which now exits in the breast (in the area of the skin removed at the time of mastectomy) will have no sensation. Although this may be a nuisance at first this is usually adapted to quickly and has no usual long-term consequences.

The patch of skin brought from the back will also usually be of slightly lighter color than the more reddish color of the upper breast skin. For this reason this patch is placed in an area which will be covered by a swimsuit or bra.

This procedure is more difficult to perform and will entail longer operative time as compared to the tissue expansion reconstructive technique.

In addition, time to recover is longer (4-6 weeks) and this technique will add one to three days of additional stay to your hospitalization.

Breast Reconstruction Timing with Latissimus Flap

This procedure can be done at the time of the mastectomy; however, the combined mastectomy and back muscle reconstruction may be associated with blood loss requiring blood transfusion. As a delayed procedure this may allow time for self blood donation, however if done immediately this may not be an option and although attempts will be made to eliminate the need for a transfusion, if health and safety require transfusion, one will be given.

This muscle and skin flap rarely has enough bulk by itself to provide adequate volume for most reconstructive needs. Therefore an implant is usually required. You should review the implant related concerns as discussed earlier in Technique #1.

This is a one-step procedure used for unilateral or bilateral reconstruction. It can be used to create a more mature, more ptotic or larger breast mound. The longer recovery and second scar are two of the drawbacks. As with the first technique, this operation requires and implant.