Latissimus Dorsi Flap Breast Reconstruction

Breast reconstruction is a surgical procedure often performed on female patients who have had a mastectomy. While many of these patients are able to have a breast implant reconstruction, there are some women who need to seek an alternative method of breast reconstruction. One of the best alternative procedures to implants is latissimus dorsi flap breast reconstruction.  It was the first reconstruction method ever developed in the late ’60s.

OVERVIEW

Usually, patients that have had a mastectomy had cancer or have a strong family history of breast cancer. Nearly 75% of the patients who had a mastectomy undergo the implant-based method of reconstruction and can often achieve excellent results. However, there is a subset of patients that cannot undergo an implant reconstruction, often because radiation was used following the mastectomy. It is this group of patients that the latissimus muscle technique works well for. The latissimus muscle is a fairly wide yet very thin muscle on the back. The latissimus dorsi flap procedure is unique in that a surgeon does not just use the muscle and the skin for the reconstruction but uses them in combination with an implant for the final reconstruction.

WHO IS A CANDIDATE?

1. Patients Who Have Had Radiation

Some patients wonder why a doctor needs additional tissue for reconstruction. In the typical implant method of reconstruction, the first step is to put in an expander which is essentially like a preliminary implant. The surgeon is recreating the space as well as creating an extra soft tissue envelope because the patient is deficient in skin after the mastectomy. It basically creates a pocket that is replaced a few months later with the final silicone or salt water-filled saline implant. But, in patients who had radiation after the mastectomy, the skin has a lot of fibrosis or scar tissue development in the chest so the skin often resists expanding. This is where the latissimus dorsi muscle and skin come in.

The latissimus flap method brings a small amount of skin with the entirety of the muscle from the back. It is important to remember that the muscle is thin and there is not enough bulk to make a breast mound with it alone, so an expander has to be inserted at the same time. The patient is scheduled for follow-up visits every few weeks so the surgeon can gradually add fluid to the expander and, several months later, the expander is removed and the final implant is put in place. 

The vast majority of patients who undergo latissimus flap breast reconstruction are women who would not qualify for the less invasive implant method of breast reconstruction, which is outpatient surgery. Most patients want the least invasive surgery and quickest recovery time. For patients that have undergone radiation treatment and do not have enough abdominal tissue to recreate the breast mound, or do not want the abdominal option in general, this procedure is an excellent choice that can provide excellent aesthetic outcomes. However, it does involve a longer recovery than the implant-based method, but less recovery time then the abdominal DIEP or TRAM flap method. 

2. Patients With Little Body Fat

The other group of patients that the latissimus flap is used for are those who have had a mastectomy and did not have radiation but are extremely thin. If an implant is used for these patients, the outline of the implant will be visible and the aesthetic outcome often is poor.  It is very difficult to camouflage the implant’s edges. If they wear a bathing suit, for example, the implant will show because of their limited body fat. For that reason, the latissimus flap procedure works well for patients who are very thin.

SURGERY AND HOSPITAL STAY

The surgery usually lasts about three to four hours and is longer if both sides are reconstructed. With a latissimus flap, patients can go home that night but most patients go home the next morning. Patients often take pain medications for three to seven days and return to work three weeks after the surgery. If their job is very physical, four to six weeks of recovery may be required.

COST

Breast reconstruction surgery for patients following mastectomy for breast cancer treatment or for patients who are at high risk for breast cancer are covered by insurance. This is mandated by “The Women's Health and Cancer Rights Act of 1998” law. However, the out-of-pocket costs vary depending on the patient’s individual insurance plan and contract terms. Patients should check with their insurance provider to learn what their out-of-pocket costs will be before the surgery.

NON-IDEAL PATIENTS

Anyone who is morbidly obese and has other health issues like heart failure or liver failure is not a good candidate for elective surgery, including latissimus dorsi flap breast reconstruction. Patients need to be in good overall health and able to withstand a three- to four-hour surgery, as well as the recovery associated with it. A body mass index (BMI) of 30 to 35 is acceptable and a BMI up to 40 may be considered depending on other health issues. Once a patient starts getting over a BMI of 40, they are not a good procedure candidate. The complications and risks increase significantly for these patients and a weight loss regime prior to reconstruction would be recommended to assure a safe outcome from surgery.

Patients that are active smokers are also not good procedure candidates. If they smoke, their lung function is affected after anesthesia and the latissimus flap may not have sufficient blood supply, reducing their body’s ability to heal their wounds. Quitting smoking would be mandatory prior to the reconstruction.

ESTABLISHING SYMMETRY

Almost all patients who have had a mastectomy on one side followed by breast reconstruction, need a breast lift, breast reduction, or breast augmentation on the other breast to establish symmetry. According to the women’s health care law passed in 1998, all of these in-office, follow-up procedures are covered by insurance. Even if a surgeon has to perform a breast augmentation on the unaffected side to match the reconstructed side, the procedure is also covered by insurance according to federal law.

SIDE EFFECTS

For about the first three months, there is a decreased range of motion in the shoulder following a latissimus dorsi flap breast reconstruction. There is also decreased strength in that arm for motions such as swimming and rowing. However, within nine months to a year patients will regain 95% of their previous shoulder range-of-motion as well as their strength.

In terms of long range side effects, patients who are very physically active or play competitive sports may not want to choose a latissimus reconstruction. For people who are less competitive but enjoy activities like hiking, running, yoga, and swimming, it does not impact them whatsoever in the long run. In the short run, they feel some initial weakness, but the body compensates after about a year.

RECOVERY TIME

One of the distinct advantages of latissimus procedure is a shorter recovery time compared with the abdominal based surgeries like a TRAM or DIEP flap procedure. With latissimus dorsi flap breast reconstruction, it is recommended that a patient takes two to three weeks off from work. With a TRAM flap or DIEP flap, most patients take six to eight weeks off from work.

The latissimus dorsi flap breast reconstruction procedure involves putting a drain in the back that remains in place for one to two weeks. Most patients take pain medications for about a week, in decreasing amounts as the week progresses. The procedure causes more discomfort than the expander method but less discomfort and recovery than a TRAM flap.   

After a patient is discharged, they need to take it easy for several weeks. There are physical restrictions and they are not allowed to do anything too strenuous. After about two to three weeks patients can return to work and start getting back to their exercise routine at six weeks.

SCARRING

The scar length on the back depends on how much non-radiated skin the patient needs to replace on the front of the chest. The scar is usually a straight scar on the mid back that is about five inches long. Patients who wear a swimsuit after this should not notice any visible concavity or deformity.

FINAL RESULTS

With most patients it takes about a year to see the final results of the procedure. The first step is the transfer of the muscle with the placement of the expander during the first surgery. About four months later, a surgeon does the conversion to the final implant as well as any necessary procedures on the other side to make the breasts symmetrical. Once the swelling goes down after that surgery, a nipple reconstruction is performed. Finally, about two months afterwards, the nipples are tattooed to provide the desired coloring. It’s generally a year-long process to see the final results. That timeframe applies for almost all other methods of reconstruction including the implant method, TRAM, or DIEP. 

ONE-TIME PROCEDURE

A patient only has one latissimus muscle on the right side and one on the left, so technically a patient could have a latissimus flap done on both sides. If a patient develops breast cancer in her right breast and has a latissimus flap on the right side and then comes back 10 years later with breast cancer in the left breast, she can still use the latissimus flap on the left side. It is a one-time procedure in terms of doing it once on each side.

FINAL THOUGHTS

Breast reconstruction using the latissimus muscle is ideal for patients who either do not have enough tissue for an implant-based procedure or do not want to have major surgery utilizing the abdominal based TRAM or DIEP flap. The first step in deciding which method is best for a patient is consulting with an experienced plastic surgeon. A skilled surgeon can determine if a patient has enough tissue for the implant method or if having a latissimus dorsi flap breast reconstruction procedure is the best choice for the patient’s individual needs and overall health. 

Written by Cosmetic Town Editorial Team- MA

Based off an exclusive interview with Dr. Isik in Seattle, WA