Latissimus dorsi flap reconstruction uses skin, fat and muscle from the back to recreate the breast mound. This tissue is tunneled to the breast region while remaining attached, or pedicled, to its donor site, so the blood supply remains intact. In some cases, the latissimus flap can reconstruct a complete breast mound, but often it provides the muscle and tissue necessary to cover and support an implant. The addition of the flap to the expander/implant gives Dr. Kim more control over the aesthetic appearance of the reconstructed breast. As with abdominally-based flaps, the latissimus flap helps create a more natural breast shape, projection and feel as opposed to an expander/implant alone. The latissimus flap is taken from the area below the shoulder and behind the armpit. Because this is a region with less fatty tissue than the abdomen, this reconstructive modality does often necessitate the placement of an expander or implant in conjunction with the flap to achieve the desired breast size. Whether or not a prosthesis is required is based on individual patients’ anatomies, which Dr. Kim assesses upon initial consultation visit to his Chicago office. Latissimus reconstruction is particularly useful as a salvage reconstruction technique after radiation and as an alternative in patients for whom abdominal flaps are not advised.
If an expander is placed along with the flap, the patient will come into Dr. Kim’s office in the Galter Pavilion of the Northwestern campus in downtown Chicago for expander fills approximately every week or every other week. Typically, because both a latissimus flap and an expander are in place to recreate the breast mound, fewer expansion will be necessary to achieve the desired size than if a patient has an expander alone. Then, in a second surgery, the expander is removed and a permanent implant is placed, as with tissue expander/implant reconstruction.
Check out Dr. Kim’s original article entitled “The utility of the tabbed expander in latissimus dorsi reconstruction” here.
The latissimus flap procedure adds approximately two to three hours onto the mastectomy surgery, and Dr. Kim usually has his patients remain in the hospital for 23 hours total, meaning the procedure is outpatient. During surgery, he will place one or more drains to release any fluid that collects in the newly reconstructed breast in the days or weeks following surgery. Normal recovery time is about three to four weeks. During office visits both before and after this surgery, Dr. Kim communicates with his patients about his expectations for decreased lifting and other activity after surgery, as well as any other restrictions he may want to impose to facilitate smooth recovery.
Secondary procedures are typically done about three months after the latissimus dorsi flap reconstruction. This includes exchange of the expander for a permanent implant, nipple reconstruction and other revision procedures to improve breast symmetry. Ideal candidates for the latissimus flap reconstruction process are thin, have a small breast volume and have excess tissue in their lateral breast area and in their mid-back region.
As Dr. Kim will discuss during your personalized breast reconstruction consultation visit to his Chicago office, the latissimus flap modality is a good option for women with a paucity of abdominal tissue but who desire autologous reconstruction (use of their own tissue to rebuild a breast mound after mastectomy). A major upside to latissimus reconstruction is that the flap remains attached to its native blood supply on the back, so the flap failure rate is quite low (flap failures result from interrupted blood supply). This procedure is also ideal for women with prior radiation to the chest, as radiation thins the skin among other issues, so flap coverage supports and strengthens the compromised area. If a woman has undergone radiation prior to her mastectomy surgery, the latissimus flap can be performed immediately at the time of the mastectomy. Similarly, if a patient has undergone prior breast surgery and has scarring, Dr. Kim will often opt for the latissimus reconstruction. Here is an example of one of Dr. John Kim’s patients who had radiation treatment prior to her mastectomies, so he performed the latissimus reconstruction at the time of the breast removal:
For women experiencing wound healing issues (i.e., a tissue expander was placed at the time of the mastectomy and is poking through the skin, or the incision is not healing) a latissimus flap is a good option for providing enough supportive tissue to prevent loss of the expander and a reconstructive failure. Additionally, if a patient experienced a complication from a first attempt at reconstruction (i.e., infection or mastectomy flap necrosis, meaning tissue death), the latissimus flap is an ideal form of secondary, or salvage, reconstruction.
Dr. Kim also utilizes something called a minimally invasive latissimus flap after a patient has had a lumpectomy. He creates a small incision under the armpit, one that is normally quite small and unnoticeable. The goal is to fill the lumpectomy defect three dimensionally, as can be seen in his patient here:
Finally, plastic surgeon Dr. John Kim performs a latissimus procedure as a delayed revision of a lumpectomy defect for women who were treated with a lumpectomy months or years prior. Typically, these women have some scarring, dimpling or other noticeable defects that Dr. Kim is able to revise with a flap from her back, as with this particular patient:
Check out Dr. Kim’s article entitled “Latissimus Flap Breast Reconstruction” on eMedicine.com here for more on the latissimus reconstructive modality.
One disadvantage of this procedure is that it leaves patients with a scar on the back in addition to the mastectomy scar on the breast. Dr. Kim does his best to create the scar in the area covered by a bra strap. Additionally, some women report partial loss of strength or function on the side of their latissimus flap, making it hard to twist their upper bodies or lift certain things. Thus, it is generally a good idea to only have latissimus reconstruction on one side to avoid potential muscle issues on both sides. Women who are particularly active in golf, climbing, swimming, tennis or similar activities may want to consider a different reconstructive modality for their treatment.
For more information on latissimus flap breast reconstruction, please contact board-certified reconstructive surgeon Dr. John Kim at his Chicago office today.