Latissimus dorsi skin and muscle flap explained

Dr Johan van Heerden details the breast reconstruction technique: latissimus dorsi skin and muscle flap.

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History of latissimus dorsi skin and muscle flap

The latissimus dorsi skin and muscle flap (LDF) was originally described in 1906 by Iginio Tansini. It fell from favour but was rediscovered in 1970 and until today remains a very useful source of autologous (obtained from your own body) tissue for various reconstructive needs.

Why use LDF in breast reconstruction?

Flaps were and will always be part of the armamentarium of breast reconstruction. The LDF not only is very close to the breast region, but it is also a flap that can supply well vascularised muscle, skin and fat, which can all be exploited to improve the vascularity, skin coverage, and volume in breast reconstruction.

LDF can be used on its own or in combination with expanders or implants. 

It’s not necessary to use the LDF in every patient, but when skin coverage or blood supply is compromised to the breast area, the LDF is a reliable lifeboat to use.

Specific scenarios

With lumpectomies (removal of tumour and breast tissue), the resulting volume loss can be replaced with the LDF, and in the modern era, there are multiple variations like perforator skin and fat LDF, that can be used to replace the volume loss, without the use of implants or expanders.

With mastectomies (removal of tumour, breast tissue, sometimes including the nipple, areola, and lymph nodes) where there is large skin loss or after radiotherapy, the LDF can be used in combination with expanders or implants to recreate the breast mound.

It’s also possible to use this flap in the immediate or delayed setting.

In bilateral mastectomies (removal of both breasts), the flaps can be used from both sides if indicated.

Is there a downside to LDF?

The latissimus dorsi muscle is a large and strong upper limb muscle. The loss is significant, but fortunately the remaining muscles around the shoulder girdle compensates for the loss, and most patients will not recognise the loss of the muscle, except in a few instances where a patient participates in professional sport, like mountaineering or swimming.

The additional donor site pain and sometimes seromas (body fluid accumulation) can add to the morbidity of breast reconstruction surgery. Hospitalisation duration and risk for bleeding may also be increased due to more extensive surgery.

During the procedure, you will need to be turned on your side to elevate the flap, and this adds significant additional theatre time to the procedure.

In conclusion

As always, it’s essential to discuss the indications and options with your plastic surgeon during consultation. Remember to ask your surgeon for pre-and post-op photos. 

It’s my opinion that the LDF should be used for more complicated second stage procedures, and the extent of surgery discussed in detail with the patient. 

The LDF is often used in practice and will remain one of the most reliable and predictable sources of autologous tissue to use alone or in combination with implants in specific breast reconstructive scenarios.