Options for Breast Reconstruction

Overview

The latissimus dorsi flap has been used for breast reconstruction since 1906 and is still a popular choice for reconstructing a small to medium volume breast, due to its reliability, durability and good cosmetic result. Latissimus dorsi is a large, flat muscle in the back, which is moved to the site of the breast by swinging it around the ribcage so that it lies at the front of the body. Most people have no problems from the absence of this muscle in the back after the operation because the other back muscles become stronger to compensate.

This method does not usually provide enough tissue to form the entire breast, so an implant or expander will also probably be needed, placed behind the muscle to help match the size of the remaining natural breast. Compared with implant only reconstruction, the extra muscle covering the implant provides a more natural shape and helps to minimise any rippling caused by the implant; although the breast will still be slightly 'prouder' than a natural breast or one reconstructed using abdominal tissue.

Scars from this type of reconstruction are relatively inconspicuous. In addition to the breast scar, there is a scar on the back, which can be almost horizontal, to hide under a bra-strap, or almost vertical under and just behind the armpit, to hide under a low-back evening dress.

Latissimus Dorsi is a pedicled flap, meaning that the blood vessels supplying the 'flap' of muscle and overlying skin remain attached to the body and continue to supply the flap in the same way when it is moved to its new site. The tissue moved to create the breast is predominantly the muscle itself, but some skin can also be transferred to the new breast. This is particularly useful in immediate reconstruction, as a circle of skin, the same size as the mastectomy hole can also be moved, allowing the surgeon to close all wounds without stretching or distorting the remaining natural breast skin. It also results in only one circular scar on the breast, around the nipple.

After the operation, the blood vessels supplying the muscle run from the back of the armpit to the chest, along with a protective cuff of muscle. This results in a 'bulkier' area under the armpit on the reconstructed side. This will settle considerably during the first few months after the operation, as swelling subsides and the muscle cuff naturally thins, but will never disappear completely.

Latissimus Dorsi flap breast reconstruction offers good cosmetic results for women unable or unwilling to undergo abdominally-based breast reconstruction. It provides a reliable breast mound using tissue from the back, the absence of which is well tolerated in almost all women. Only women who are active swimmers, rock climbers or tennis players may have diffculty due to the back weakness.

Who is it suitable for

Women who would like a more realistic reconstruction than is possible with an implant alone
Women who would like to avoid large abdominal scars or risk reducing abdominal strength
Women without enough abdominal fat to create a breast to match the remaining natural breast
Women with small to medium volume breasts
Women with considerable previous abdominal surgery or abdominal radiation

Pros and Cons

Advantages

Reliable blood supply to reconstructed breast
Good symmetry and cosmetic result for small to medium volume breasts
Faster recovery than abdominal-based flaps
Provides skin to replace the nipple area in immediate reconstruction to allow only a single, circular breast scar around the nipple
No abdominal weakness after surgery

Disadvantages

Usually only suitable for up to B cup breasts
Most women will need an implant in addition to the muscle flap
Skin colour and breast texture is not as natural as abdomen-based reconstruction
Muscle weakness can affect people who rely heavily on back or shoulder strength (swimmers, rock climbers, golfers, tennis players, etc.)

Operation

The operation is carried out in two stages. Firstly, the patient is placed on her side and, while the breast surgeon undertakes the mastectomy at the front, the reconstructive surgeon makes an incision in the back and starts to free the latissimus dorsi muscle from the other tissues of the back. The pedicle (artery and vein to the flap) is identified in the armpit to avoid any inadvertent damage, and the muscle with its overlying piece of skin is lifted from the back, tunnelled through the armpit and swung round the ribcage to lie under the breast. The patient is then turned onto her back and the skin of the flap is trimmed to match the hole left by the mastectomy, the breast is compared to the unoperated side and the muscle is sutured to create the contour of the breast mound. If necessary, an implant is inserted. Drains are inserted in both the breast and the back wounds which are then closed, generally with dissolving sutures.

Complications you should be aware of

Infection – this ranges from a superficial wound infection, easily treated with antibiotics, to an infection of the implant if one is used. Implant infections are especially troublesome as, generally, the implant must be removed to fully treat the infection, and re-inserted at a later date
Bleeding – it is common to have a small degree of oozing at the wound edges, and you will have a couple of drains to remove any excess bleeding from inside the wound for the first few days after the operation. Although any bleeding points are cauterised during the procedure, it is possible that you may develop a collection of blood under the skin. Very occasionally, this can become infected or need to be let out by returning to theatre and re-opening the wound.
Seroma – this is a very common complication. When you suffer a graze, you will probably have noticed a clear fluid seeping from the raw area for a few days. This is a normal response to injury and is known as serous fluid. After this operation there is a large raw area under the skin of the back and the body responds in the same way, leaking serous fluid. Generally this lasts for only a couple of days and the drains remove the fluid, but it can continue for a few weeks. If this fluid continues to be produced after the drains are removed, it will collect under the skin and may become uncomfortable, but it can be easily and painlessly removed by sliding a needle through the scar on your back taking the fluid off with a syringe.
Flap failure – this is a very rare complication. Any flap needs a good blood supply and occasionally it does not get the supply it needs. In this case the flap will die. Often it can be salvaged by returning to theatre and identifying and eliminating the source of the blood flow inadequacy, but occasionally the surgeon is unable to save the flap. The dead tissue would need to be surgically removed, and further options for reconstruction would need to be discussed.
Revision Surgery – After the muscle is moved from the back to the front, it changes size over the first 3 months. Your surgeon will probably create a reconstructed breast that is larger than the other one initially to allow for this shrinkage, but it is possible that when the size changes have occurred, your breasts are asymmetrical or slightly bulging under the skin of the flap. Your surgeon may recommend another small operation to improve the final outcome of your reconstruction.
Recurrence – although this is not strictly a complication of the reconstruction, it should be mentioned that having a breast reconstruction must not interfere with treatment for the breast cancer and having a reconstruction would not stop a recurrence of the cancer, if it were to occur.