Local Flap (LD) Reconstruction
What is Latissimus Dorsi Breast reconstruction surgery?
This is a breast reconstruction technique that involves transferring the back muscle (latissimus dorsi muscle) through the armpit and moving it to the breast pocket. The muscle remains attached to its blood supply and it is simply transferred from the front of the body to the back, pivoting on its blood vessels. This type of flap is called a pedicled flap. The latissimus dorsi muscle covers a substantial part of the back and is a ‘climbing muscle’ used by athletes. Removal of the muscle does not affect day-to-day activities, though some patients notice a slightly stiff shoulder.
There are two standard types of this operation:
- Taking the muscle and skin and then using an implant or fat transfer to build up volume on the breast.
- Taking the muscle and skin alone. It is not always possible to match the flap exactly to the other breast, particularly if the normal breast is droopy or excessively large. In these cases it would be best to have a breast uplift (mastopexy) or reduction in addition to the reconstruction.
This operation is particularly suitable if you are going to have or have had radiotherapy, as a pure implant based reconstruction is associated with a high rate of complications. The other advantage of adding muscle to any reconstruction is that it gives a more natural appearance than a pure implant based reconstruction.
What does the operation involve?
The LD muscle is transferred from your back through to your breast with a piece of overlying back skin. This skin paddle is orientated horizontally, so that you are left with a horizontal scar on your back that can be hidden by a bra or bikini. The muscle and skin are kept alive by carefully preserving their blood supply, which enters into the flap from vessels in the armpit. If you are having an immediate breast reconstruction with a skin-sparing mastectomy, then a small circular area of skin from your back will be used to replace your nipple and areolar. The remainder of the breast skin will be preserved and the flap will sit underneath this replacing the breast tissue that was removed by the mastectomy.
If you have already had or are having a full mastectomy (which takes all the breast skin) then the skin will be replaced with a leaf shaped area of skin from your back.
If you are having an implant then this will be placed underneath the LD flap. The flap is sutured into position.
Your incisions will be closed with a dissolvable suture that does not need removing. You will have waterproof glue based dressing, which will gradually dissolve at about 3 weeks. You can shower as soon as you want and do not need any dressing changes
A tube (called a drain) will drain off any excess blood or body fluid from your back.
What are the risks and side effects of surgery?
Having surgery should be a very positive experience. Complications are infrequent and usually minor. However, no surgery is without risk and it is important that you are aware of these potential problems.
Scar – scars tend to settle remarkably well, however some people heal with thick scars and this can make them more noticeable.
Bruising and swelling – bruising and swelling is very common and may take several weeks to settle.
Haematoma – this can happen if a bleed occurs under the skin, allowing a large blood clot to form. If this does occur, it is likely to happen within four to six hours of surgery. Any increase in swelling or pain should be reported immediately so that treatment can be given. Sometimes patients need to have this blood removed with another short operation.
Infection – on the rare occasion where infection occurs, the breast implant may have to be removed to allow this to settle. The implant will be replaced once the infection has settled. You will be given antibiotics to cover you during the postoperative period and hopefully this will prevent infection.
Seroma – this is a collection of clear fluid under the skin, which sits in a pocket. This spontaneously reabsorbs over the course of a couple of weeks, although it can be drained with a needle if it feels tight. Vary rarely a surgical procedure may be required if it does not reabsorb.
Wound healing problems – this is rare but can happen if the skin is under tension or the blood supply to the flap has been damaged in any way. These healing difficulties can range from minor problems, such as small areas of wound separation, to major issues, such as total flap loss. Although very rare, this situation may require a skin graft to close the wound, meaning more surgery. People who have diabetes, smoke, are obese or elderly are at an increased risk of delayed healing.
Rotation/displacement – occasionally implants can sit in the wrong position or move position in the post-operative period. This may need a further procedure to return the implants to the correct position.
Dog-ears – these are prominences of soft tissue found where the scar stops. In most cases these settle over the course of 3 months. However a small local anaesthetic procedure may be required to remove any excess that remains.
Twitching of your breast reconstruction – as the latissimus dorsi is a muscle patients can occasionally experience twitching of the muscle. If this occurs then a short procedure may be needed to divide the nerve to the LD flap
Numbness, reduced sensation or oversensitivity – this can occur around the scars. This is usually temporary, but occasionally these changes can remain to some degree.
Rupture – implants are medical devices, and as such they can fail. If an implant is known to have ruptured then it should be removed. The ruptured implant is contained within the capsule of scar tissue so it will not spill out into your breast tissue.
I only use implants that carry a lifetime guarantee from the manufacturer. Should the implants require replacement in future years, this guarantee only covers the cost of the replacement implants but not the cost of surgery.
Capsular contracture – as a response to any foreign body (such as a breast implant), the body makes a capsule of scar tissue to surround it. Sometimes this capsule can shrink and contract (capsular contracture). If this happens, it can make the breasts feel abnormally hard and it may require further surgery to remove the capsule. The risk of this is approximately 20% after 10 years but can be higher if radiotherapy has been given.
DVT/PE – following any surgical procedure it is possible to develop a blood clot in your legs, which could potentially break off and move to your lungs. If the blood clot is large enough it could prove fatal. In order to reduce any risks of this we give you special stockings to wear in bed and a blood thinning injection if you are not mobile.
All the risks will be discussed in detail at your consultation. However, if you have further questions or concerns, do not hesitate to ask. Decisions about surgery should never be rushed.
What happens after the operation?
When you wake up from the anaesthetic, you will have a drain coming under your arm to remove any fluid collecting in your back. You will have dissolvable sutures with a glue and tape dressing.
You will need to wear a support bra to help shape your breast and support you as you are healing. You should purchase this before your operation and I can guide you in your consultation.
The drain will be removed at about 3 days after your operation and you should expect to be in hospital for about 5 days.
Before you leave the hospital, you will be given a follow up appointment to see the nurses at a week to check your wounds. I would normally see you at 4 weeks or sooner should you have any problems.
What is the estimated time for recovery, absence from work and return to usual activities?
Recovery times vary from one person to another but most patients return to work at 3-4 weeks. You can start driving at 2 weeks, commence gentle exercise at 4 weeks and return to the gym at 6 weeks.
LD Breast Reconstruction Support Bras (PDF)
Pre and Post-Operation Instructions (PDF)
I hope you find this information useful. If you have any questions or require a little more information then please do not hesitate to contact me.