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Reconstruction Methods -
Using the Back
Reconstructing a breast using your back (Latissimus Dorsi flap)
This is commonly used and can be done in a number of different ways. The three different methods are as follows.
- To move the muscle and some skin from the back and pass this into the breast. An implant is then placed behind the muscle to give bulk. This is the most common method. Standard Latissimus Dorsi flap.
- To move skin and muscle as before but also leave lots of fat on the muscle to give added bulk. This is then used to build the breast without the need for an implant. Extended Latissimus Dorsi flap.
- Only part of the breast is removed as with breast conserving methods and a part of the muscle (usually no skin) from the back is moved into the breast to fill the hole. Mini Latissimus Dorsi flap.
Latissimus dorsi flap showing the skin paddle taken
The muscle is much larger and is passed into the breast through the arm-pit carrying the skin and /or fat on its surface. The muscle then lines the breast and an implant placed below it. The skin will either be used as a paddle or simply a disc to replace the nipple area.
Standard Latissimus Dorsi flap
What can be good about this operation?
- Can give an excellent shape and be used for both primary and secondary reconstruction. Often allows more natural droop/shape compared implant reconstruction alone.
- Very reliable operation with flap failure being <1%
- Can be used more safely if radiotherapy used
- Commonly performed and regarded by many as the "workhorse" of breast reconstruction
What can be bad about this operation?
- Is still a major operation with 4-7 day hospital stay and 6-8 week recovery
- Can give some restriction and weakness in certain shoulder movements. (fairly unusual)
- Leaves a scar on the back which can feel tight
- Can get fluid collection in back (seroma) needing removal for few weeks
- Can get infection around implant and so loosing reconstruction. ~2%
- Is regarded by some as the worst of both worlds in that it is still a major operation (like a TRAM flap) but still has the problems of implants (like implant reconstruction)
My own opinion is that for the right patient this is an excellent operation with very good potential outcomes. I think it routinely gives better results than implant alone reconstruction at the price of a bigger operation. However, it does not have the potential advantages long term of an autologous (own body tissue) reconstruction.
Operation facts
- Average length of stay - 6 days
- Average length of surgery - 3-4 hours
- Time restricted to bed - 2 days
- Bladder catheter used - Yes
- Time to walking - 4 days
- Walking easily - 10 days
- Time to exercise - 4 weeks
- Time to full recovery - 2-3 months
- Time off work - 2-3 months
- Dressings - Back and breast
- How long for dressings - 2 weeks
- Bras and garments - Pressure garment 4 weeks
- Potential donor site problems -~5-10% - Stiffness shoulder, fluid collection, wound breakdown
- Potential reconstruction problems -~3% - Total failure, part failure, infection around implant
- Long term problems -Moderate. Can be implant firmness and poor symmetry to other side over years.
- Single or staged operations - Single
Extended Latissimus Dorsi flap
What can be good about this operation?
- Has many of the advantages of TRAM and DIEP flaps in that all the reconstruction is made of your own tissues.
- Seems to withstand radiotherapy very well.
- Very reliable with <1% failure rate.
- Infection if it occurs can be easily treated as there is no implant
What can be bad about this operation?
- Not suitable for many patients.
- Still a major operation (like the standard version).
- Tends to leave a hollow in the back (usually well tolerated as not seen).
- Tends to have more healing problems in the back.
- More difficult to judge size as it tends to shrink about 30% of volume over the first year.
(Only relavent to patients suitable for breast conserving surgery. Not for patients needing mastectomy)
What can be good about this operation?
- Can give good shape to the breast.
- Reliable.
- Leaves much of the original breast and therefore good sensation.
What can be bad about this operation?
- Does use up one of the major reconstructive tools if a mastectomy is planned for the future.
- Will require radiotherapy as with most breast conserving surgery.
- Relatively major surgery compared to simple breast reshaping.
