LD reconstruction may be autologous (entirely your own tissue) or combined with an implant. This reconstruction uses skin / fat and muscle from your back to replace breast tissue. This option may be used for ladies who don’t have enough tissue for a free flap but in whom an implant-only reconstruction is not advised. In terms of complexity and recovery it sits between free flap and implant based reconstruction. It is unlikely that a lady who does not have enough tissue elsewhere to allow free flap reconstruction will have enough tissue for an autologous procedure and therefore it is often combined with a small implant.
Latissimus Dorsi Flap
The Latissimus Dorsi is a large flat muscle covering much of the back and inserting onto the upper arm. It is involved in arm movement and also helps to stabilise the shoulder. As there are lots of muscles in the same region that perform similar functions, the muscle can be moved with fat and skin with blood vessels. The tissue that is moved is called a flap. The blood supply comes through the axilla (armpit area) so the muscle does not need to be detached from its blood vessels (unlike free flaps) but is instead passed through the axilla to the chest wall. Depending on your requirements the tissue is either used to fully re-create the breast, or is sutured into place to allow an implant to be placed behind it.
The LD can be performed at the time of mastectomy (immediate reconstruction) or a period of months or years after your mastectomy (delayed).
The loss of the LD in the back and upper arm is not noticed by many ladies, however, a reasonable proportion of ladies describe persistent shoulder pain and early fatigue of the shoulder following this surgery. You may not wish to pursue this as an option if you have certain occupations or hobbies such as swimming or horse riding.
The LD gives a good cosmetic result however the volume may be limited if you are slim and you may require additional procedures to achieve a desired volume. This may either be an implant or fat transfer.
Who is a Good Candidate?
Provided you are in good health with no significant medical problems the LD flap can be used for breast reconstruction in most ladies. If you have enough fat and laxity elsewhere to allow free flap reconstruction I would usually recommend a DIEP or TUG, however, women may choose an LD over another options for a variety of reasons.
Who is not a Good Candidate?
Ladies with significant health issues will not be appropriate for LD reconstruction. In some cases the biology of your cancer makes it inappropriate to consider immediate breast reconstruction however, a delayed breast reconstruction can be discussed once you have completed treatment.
What to Expect at Consultation
At your initial consultation I will take a full medical history including all the details of your cancer diagnosis, treatments so far and any intended additional treatments. I will also ask about lifestyle and family support. I will examine you and assess your chest wall, breast size, and tissue to assess which reconstructive options are available to you. Depending on this assessment I may or may not be able to offer you a LD reconstruction. If I think an alternativr procedure is also available I will discuss all of your options.
Following our consultation you will have further opportunities to discuss your options with your breast care nurse and make a decision. You will be able to discuss your proposed surgery helping you to understand and consider the options open to you and what support is available to you. Some patients, for whom the surgery is urgent, have only a short period of time in which to decide on what is the best procedure for them. Although I will explain everything to you it can be difficult to absorb all the relevant information at one visit therefore you may have more questions for your breast care nurse and of course we can always arrange a further consultation if you feel it is necessary.
I always see patients a second time before booking surgery give you an opportunity to ask any additional questions. At this stage I will also go through the consent process in the clinic.
Preparing for LD Reconstruction
Following your consultation and the decision for surgery, your health will be and you may need some tests that will be arranged if required.
You should stop aspirin and anti-inflammatory medications at least a week before surgery. It will assist if you stop taking any herbal remedies, homeopathic or complementary medicine not prescribed by your GP. Some of these tablets can cause excessive bleeding during surgery. They should be stopped at least 3 weeks before surgery but can be resumed when you are discharged. If there is any change in your health prior to your surgery date you should let me know. Your health and general well being are my primary concern when I am treating you therefore if you are unwell for any reason it may be necessary to postpone surgery. Smoking is detrimental to this type of surgery therefore you are advised to stop smoking for at least 6 weeks prior to embarking on surgery.
Items you should bring to hospital:
- Slippers
- Dressing Gown
- Nightclothes
- Post-op bra
- Toiletries
Your bra will need to be supportive and without wires, ideally with a front fastening. If you need guidance this can be discussed with your breast care nurse. The bra is worn from the day of surgery, day and night for 6 weeks. This gives your reconstructed breast support.
Please do not bring in any jewellery and remove rings from the operated side because your hand is prone to swelling after the operation.
What to Expect on The Day of Surgery
You will need to come to hospital starved and ready for a general anaesthetic. On the day of surgery I will draw some markings on you to be used as a guide for surgery. You will also see the anaethetist who will discuss the anaesthetic and post-operative pain management plan.
What to Expect After Surgery
Surgery generally takes two to four hours. You should expect to be in hospital for 1-3 days. You will return to the ward around an hour after surgery and be encouraged to eat and drink. I encourage you to mobilise as soon as possible as this helps to open your airways up following the long anaesthetic. A nurse will monitor the flap regularly for any sign of compromise. If any problems with blood flow to the flap or other problems such as bleeding occur it would be necessary to return you to theatre to investigate the cause. You will feel swollen and bruised and you will be given appropriate painkillers. You will have drains in the back and also in the breast. You will need to wear a support bra immediately and day and night for six weeks.
You will have some tape dressings on the wounds and will put the bra on before getting out of bed to support the reconstruction.
During your hospital stay our physiotherapists will see you on several occasions. The aims of physiotherapy following breast reconstruction are to prevent you developing breathing problems such as chest infections, to help get you mobile again, to help you regain strength and movement in your shoulder and arm and to advise you on returning to your normal daily activities.
Your physiotherapist will show you some exercises you can do for your lower body to prevent stiffness and aching in your joints. Moving your feet and ankles helps your circulation and relieves pressure on your heals.
Following LD breast reconstruction there is a small risk you will develop a stiff shoulder. This is because the surgery is in close proximity to the shoulder joint, alters the dynamics of the joint, causes swelling in the area and you will inevitably be a bit reluctant to move your arm.
Your physiotherapist will advise and guide on which shoulder exercises to do and when. You should usually start these exercises the day after surgery. You will probably feel tightness, pulling and discomfort when you do the exercises. This is normal however if it is very painful please discuss this with your physiotherapist.
What to Expect on Discharge
You will have all your dressings checked on the day of discharge, which is usually 1-3 days after surgery. At this stage you will still not be using the arm on the operated side for any lifting or carrying and you may still feel a little weak. You should have another adult at home with you most of the time for the first week after discharge. You will be seen again in the dressings clinic approximately one week following discharge.
It is normal to feel tired after major surgery so do not over exert yourself for the first few weeks at home. You may find simple tasks such as getting washed and dressed leave you feeling tired. Try to get plenty of rest and always balance periods of activity with periods of rest. Build up your stamina by going for a walk everyday, increasing the distance you walk each time. Continue to do the shoulder exercises that you have been given in hospital and begin any new exercises as directed. You should continue the exercises until twelve weeks after your operation.
Scar Management
Scar tissue is vital to the healing process however scars can tighten, limit movements and become uncomfortable. Massage helps to encourage the scar tissue to form in the correct lines and make a more functional rather than restrictive scar. Massage also makes the scar less sensitive and prevents adhesions.
To massage apply a small amount of simple un-perfumed moisturizing cream to the scar. Use the thumb or index finger to massage in small circular motion along the scar. Use a firm pressure and massage several times a day. Only start the massage once the wounds are fully healed (nurses will provide you with guidance on this).
Returning to Normal Activities
There are no strict rules for when you return to work, driving or sports and this will depend upon you as an individual, how you heal and the nature of your work or hobbies. I will give you guidance in the clinic, the following information gives you a generalized idea of what to expect.
Two weeks after your operation you can use the arm on the affected side for light activities eg lifting a full kettle or brushing your hair. Over the next 4 weeks you can build up the use of this arm by doing light household activities such as dusting and preparing light meals. At 6 weeks after the operation you should have returned to most normal daily activities such as carrying shopping and hoovering.
Return to Work
This will depend on the type of work you do. For office jobs or other non-physical work you can probably return at 6 weeks although you may find you tire easily and therefore it may be appropriate to negotiate reduced hours for the first couple of weeks. If your work is physical and involves heavy lifting you could return on light duties if possible at 8 weeks post-operatively but you should not do any heavy lifting until at least 12 weeks post-operatively. When you return to work you will need to gradually build up your strength so may benefit from a phased return.
Return to Driving
You should avoid driving for 4-6 weeks after surgery. You should not return to driving until you feel 100% alert and able to react in an emergency. You must have regained full shoulder movement before attempting to drive. You must always wear your seatbelt when in the car.
Return to Sport
Provided you have healed you can return to sports at 4 - 6 weeks but you should start with less vigorous activities and gradually build up your level of activity. You will be unfit and will need to build slowly. You should not participate in contact sports or raquet sports until 3 months after your surgery.
Psychological Support
We know that this may be a difficult time for you. It often helps to talk to family and friends about how you are feeing. The team is here to offer support. If you feel that you need some additional support after discharge your breast care nurse will be your first point of contact. If it is felt necessary you will be offered the opportunity to meet one of our psychotherapy and counseling team for additional support. You are also welcome to request this if you feel in need of additional support.
Outpatient Clinics
- Dressing Clinic
You will be given a dressing clinic appointment approximately one week after you go home. At this appointment a nurse will clean the wounds, re-dress them if required and organise additional appointments if required. - Consultant Clinic
I will see you 6 weeks after your operation and check the reconstructed breast and make sure all is going well.
If you have had an immediate reconstruction you will be seen by the Breast Surgeon 2-3 weeks after surgery to discuss your results and additional treatments that you may be offered. You may be referred to see an oncologist to discuss radiotherapy or chemotherapy.
Potential Risks and Complications of LD reconstruction
In the vast majority of cases, surgery is a success. There is a very small risk of failure of the flap due to damage to the blood vessel or the blood vessel being constricted by structures in the axilla. We monitor you most closely during the first few hours following the operation so that any problems can be picked up and dealt with immediately.
In addition to the risk of flap loss other early complications include bleeding or haematoma that may require return to theatre, infection, delayed wound healing, seroma (a collection of tissue fluid) and post-operative pain. Potential complications also include those related to having a general anaesthetic such as cardiac or respiratory compromise, blood clots in the leg (DVT) or the lung (PE).
If an implant is required for volume the additional risks associated with an implant include infection, rotation, capsular contracture and ALCL. In the case of infection or extrusion (due to wound breakdown) it is necessary to remove the implant and allow the infection to be cleared and the tissues to settle for 3-6 months before having a new implant. Medium term complications include formation of a seroma, which is a collection of tissue fluid next to the implant. This normally self-resolves but on rare occasions may require drainage by a radiologist. In ladies who have had anatomical (tear drop shaped) implants, there is the potential for implant rotation. Rarely this may require re-operation to re-orientate the implant.
The bodies’ natural processes will wall off any foreign material in the body, including implants. A capsule (or internal scar) of tissue forms around the implant. This process usually has occurred by around 6 weeks post-op. The capsule can gradually thicken and get tighter with time and when this happens it is called capsular contracture. It can cause a change in the shape / position and size of the breast and in the later stages it may cause pain. This process is very patient dependent and occurs much more rapidly in some ladies and never in others. The most common reason for requiring further surgery to the breast after augmentation is to treat capsular contracture.
Recently there has been much interest in a type of lymphoma that is associated with breast implants. Breast Implant-Associated Anaplastic Large-Cell Lymphoma (BI-A ALCL) is a type of lymphoma that develops in the capsule of breast implants in some ladies. There is currently much research going on to assess the true incidence and cause of this lymphoma. The reported rates vary from 1 in 1000 in certain types of implants to 1 in 10 000. The actual incidence is as yet truly unknown. The condition most commonly presents with unilateral swelling of a breast associated with a fluid collection around it. It usually presents at least a year after augmentation but more commonly later than this. Diagnosis involves sending the fluid for special tests. The treatment is to remove the implant and the surrounding capsule. In very rare cases some ladies have required chemotherapy.
You will feel swollen and bruised for the first few weeks in both the breast and the back, this settles down over a period of a few weeks. You will experience numbness at both sites which will recover slowly over many months but is unlikely to fully recover. The scars will be red/pink initially but should fade over time. In rare cases patients develop abnormal thickened scars, which may require additional treatment
Occasionally some areas of the flap do not quite have enough blood supply and small areas of fat become necrotic forming a firm hard lump in the reconstructed breast. This usually settles with time but can take 1-2 years. In very rare cases fat necrosis requires excision.
In the long-term there may be a degree of asymmetry requiring “touch-up” surgery or contralateral symmetrising surgery (see following section). In a few cases there may be a mild contour defect in the back, which is usually amenable to correction at the same time as additional procedures.
Additional Procedures
The entire process of breast reconstruction may take many months and you will often require additional procedures to achieve the final result. Other procedures that may be offered to you are;
Nipple-Areolar Reconstruction & Tattoo
Nipple reconstruction is typically offered at least 3 months after your breast reconstruction. It is a local anaesthetic, day-case procedure that takes around 30 minutes. It involves lifting an area of skin on the flap and suturing it to create a prominence. It does not give any colour to the nipple / areola and to achieve this you will require a tattoo.
Nipple tattooing can be done once the scars in the area are mature (no longer pink). It is a simple outpatient procedure that takes around 40 minutes. A coloured semi-permanent pigment is applied using a small needle. The area is then covered with a dressing and you will be advised when to remove it. It can fade with time and may need a top-up from time to time.
Lipofilling / Autofat Injection
This involves taking fat from other areas of the body (by liposuction) and injecting it into the reconstructed breast to fill out any contours / dips in the reconstructed breast or to give additional volume. Usually 50% of the fat is absorbed so the procedure may need repeating.
Liposuction
Occasionally to reconstruction is too large or has fullness in one area. You may be offered liposuction to correct this.
Excess Skin (Dog Ear) Excision
Occasionally at the end of a scar excess skin can form a prominence that has the appearance of a dog’s ear. Often these settle with time but if appropriate they can be removed under local anaesthetic.
Reduction Mammaplasty
After reconstruction there may be a difference in the size of the breasts as the natural breast is larger. If this is the case it can be reduced to match the reconstructed side. This is usually a day-case procedure but you may require one night in hospital.