Managing the manifestations of a Lat Flap

I am a Manipulative and Sports Physiotherapist with a special interest in breast cancer rehabilitation. I am a breast cancer survivor, having undergone surgery and reconstruction in 2011. I have had a double mastectomy and a reconstruction using the “Lat Flap” method.

My greatest fear before my surgery was what should I expect? Even after the surgery, I still had many questions such as: “why am I feeling like this? Am I damaging myself? What can I do to feel better? Is the loss of a major back muscle going to be problematic? The great news is that I feel better now than before my surgery! I am completely pain free and stronger in my upper body than ever before. I would like to share with you some knowledge and tips to assist you in your recovery.

What is the Latissimus Dorsi muscle and how does it work?

The latissimus dorsi is a tissue flap procedure that uses muscle and skin from your upper back to create a new breast mound after a mastectomy. An ellipse of skin and your latissimus dorsi muscle is tunneled from your upper back to your mastectomy area to create your reconstructed breast. The Lat Dorsi inserts into the humerus and deep fascia of the arm.

It is important to go into such detail as this will explain more clearly the reason for some of the aches and pains one experiences while recovering.

The Lat Dorsi is an extensive muscle, which acts in combination with many other muscles to produce shoulder extension, adduction, and internal rotation. It also hyperextends the spine for lifting. It is most powerful in overhead activities such as swimming (downstroke), climbing and also walking with crutches (shoulder depression). The Lat also adducts the raised arm against resistance, and is very active in strong expiration, such as coughing or sneezing.

The Lat Muscle does not work independently. Instead, it works together with other back and shoulder muscles. It also has its own nerve and blood supply. This makes the Lat a very suitable muscle for reconstruction as not much function could be lost. The biggest problem that I have experienced, and seen in other patients who have undergone lat flap surgery, is their inability to stabilise the shoulder, which leads to neck and shoulder pain. The Lat Muscle depresses the shoulder blade and maintains good postural alignment.

The muscle is assisted by the serratus anterior and lower trapezius muscles and it is important that these two muscles are continually strengthened to maintain the shoulder blade in the neutral position.

There is a progressive series of exercises to improve scapula control, and these can be started in week two following surgery (even with a drain in). The exercises prescribed are dependant on the weaknesses which are assessed by the Physiotherapist and must be graded and progressed according to ability. The sooner one becomes accustomed to good habitual posture, the less discomfort and pain will be experienced.

Once control of the Scapula is achieved in the neutral position, it is important to progressively load the shoulder to be able to withstand the forces of daily living (eg. carrying shopping bags). The position of neutral scapula has to be demonstrated on the patient. Again progress is achieved through monitored exercise, gradually increasing the load by 10% per week.

It is also very important to stretch the shoulder capsule and the pectoralis muscles. The reason for this is that if this soft tissue is tight, the whole shoulder complex sits forward, the lower tip of the scapula tilts outwards and all stabilising muscle control is lost.

These gentle stretches can be started at six weeks post op. We need to restore full range of movement of the shoulder post operatively, and this is done relatively slowly.

Along with these specific shoulder regimes, a good program of core strengthening and cardio- vascular exercise is necessary.  These can also be started at six weeks post op, and should be done under strict guidance of a physiotherapist. I have found that by progressively strengthening the shoulder stabilisers and the rotator cuff, that full mobility is achieved.

Always consult with your physiotherapist, as they will be able to assess your strengths and weaknesses and prescribe the appropriate exercise accordingly.

Written by Kim Grosset