Latissimus dorsi breast reconstruction is quite a mouthful and that is most probably why it is called lat flat breast reconstruction for short. Thankfully Dr Anton Potgieter expounds the surgery process in a much simpler form.
In a latissimus dorsi flap procedure an oval flap of skin, fat, muscle, and blood vessels from your upper back is used to reconstruct the breast.
The latissimus dorsi musculocutaneous flap (LDMF) was first used in 1896 by Italian surgeon, Iginio Tansini. It became popular for the management of mastectomy defects, but fell out of favour. In the 1970s it was ‘rediscovered’ for breast reconstruction, but its use declined once again in 1979 with the description of the TRAM (transverse rectus abdominis musculocutaneous) flap by Carl Hartrampf. More recently, with improvements in tissue expander and implant design, the LDMF has regained popularity as an alternative to the TRAM flap and has assumed an important role in reconstructive breast surgery.
Something about its anatomy
The latissimus dorsi is the largest and most superficial muscle of the back. It originates from the thoracic and lumbar spine, as well as the pelvis. The muscle fibres run over the tip of the scapula (shoulder blade), curve around the the side of the chest and insert into the humerus (of the upper arm). Its major blood supply is from the thoracodorsal artery which has a very consistent course, entering the muscle about 9 to 11cm below its insertion.
The physical after-effects of using the LDMF for a reconstruction are generally well tolerated by most women. There is little loss of function of the shoulder; weakness may be noticed during strenuous activity involving shoulder extension (pulling the shoulder back) and adduction (moving the shoulder down towards the chest wall).
The LDMF’s robust blood supply makes it very versatile allowing it to be used in patients who smoke and have medical illnesses such as diabetes. When used with an anatomical prosthesis, it can give a very pleasing result and it is a good option for partial volume defects after lumpectomy and radiation.
Elevation and relocation of a LDMF is straightforward. The skin island can be located anywhere in the large area between the tip of the scapula, the pelvis, the midline and lateral border of the back.
Orientation of the scar can be in any direction. It can be placed horizontally in order to be concealed in the bra line or obliquely to follow lines of resting tension in the back.
The LDMF can be used in both immediate and delayed breast reconstructions. In an immediate reconstruction, the procedure begins with the patient supine (lying on their back) and the mastectomy is performed by means of a skin sparing pattern with a general surgeon. In a delayed reconstruction, the previous mastectomy scar is opened and the area is prepared for the passage of the flap through the axilla and lateral border of the breast. Care is taken to preserve the lateral anatomy which ensures good shape and contour of the final result.
The patient is positioned in the lateral decubitus position (lying with their left side down and arm at 90 degrees to the chest wall) to carry out elevation of the LDMF. A fairly large amount of fat and muscle can be harvested in most patients in order to provide breast volume. Thin patients would need an alternate source of volume, such as an implant.
Once completed and ‘shaped’ all wounds are closed with buried absorbable sutures and drains are left in place. Drains are important with the LDMF donor site since this area can produce large amounts of serous fluid. Quilting sutures help to diminish the dead space and the drains help clear away the fluid which can accumulate.
Early recovery is difficult in the first two to three days, but comfort and range of motion improves quickly and by days 10 to 14 patients should be back to a normal level of activity. Strenuous activity will only be attainable at least four to six weeks after surgery and the utmost care ought to be taken at all times to avoid injury. There is considerable muscle swelling post-op which can take three to six months to resolve.