Latissimus Dorsi (LD) flap Reconstruction

The latissimus dorsi (LD) flap has been used for breast reconstruction for many years and is a popular choice for reconstructing breasts, due to its reliability, durability and good cosmetic result. The flap may be used with and without a patch of skin overlying the muscle whose blood supply comes through the muscle.

Latissimus dorsi is a large, flat muscle in the back, which is moved to the site of the breast by swinging it around the ribcage so that it lies at the front of the body. Most people have no problems from the absence of this muscle in the back after the operation because the other back muscles become stronger to compensate. Only women who are active swimmers, rock climbers or tennis players notice a small change due to the back weakness.

The LD flap does not usually provide enough tissue to form the entire breast, so an implant will usually be required to provide more volume, placed behind the muscle to help match the size of the remaining natural breast.

Compared with implant-only reconstruction, the extra muscle covering the implant provides a more natural shape although the breast will still be slightly 'prouder' than a natural breast. Scars from this type of reconstruction are relatively inconspicuous. In addition to the breast scar, there is a scar on the back, which is horizontal (to hide under a bra-strap), or placed in a skin crease.

Latissimus Dorsi is a pedicled flap, meaning that the blood vessels supplying the 'flap' of muscle and overlying skin remain attached to the body and continue to supply the flap in the same way when it is moved to its new site. The tissue moved to create the breast is mainly the muscle itself, but some overlying skin and fat is also transferred.

This is particularly useful in immediate reconstruction, for which a circle of skin, the same size as the mastectomy hole can also be moved, allowing the surgeon to close all wounds without stretching the remaining natural breast skin. It also results in only one circular scar on the breast around the nipple. Other versions of the flap are larger and diamond shaped to add volume to the lower breast. Your surgeon and breast care nurse will discuss this with you.

After the operation, the blood vessels supplying the muscle run from the back of the armpit to the chest, along with a protective cuff of muscle. This results in a 'bulkier' area under the armpit on the reconstructed side. This will settle considerably over the first few months after the operation, as swelling subsides and the muscle cuff naturally thins, but will never disappear completely.

LD Flaps - What else do I need to know?

Recurrence of Breast Cancer There is no evidence that having a reconstruction increases the risk of cancer returning or delays the diagnosis of recurrence but also you should not allow reconstruction to interfere with treatment for the breast cancer and having a reconstruction will not stop a recurrence of the cancer, if it were to occur.

LD Flaps - Possible complications

• Seroma. This is so common it should be regarded as part of the operation and not a complication as such. When you suffer a graze, you will probably have noticed a clear fluid seeping from the raw area for a few days. This is a normal response to injury and is known as serous fluid. After this operation there is a large raw area under the skin of the back and the body responds in the same way, leaking serous fluid. Generally this lasts for only a couple of days and the drains remove the fluid, but it can continue for a few weeks. If this fluid continues to be produced after the drains are removed, it will collect under the skin and may become uncomfortable, but it can be easily and painlessly removed by sliding a needle through the scar on your back, taking the fluid off with a syringe.

• Infection. Superficial wound infection is easily treated with antibiotics. Infection of the implant are troublesome as, generally, the implant must be removed to fully treat the infection, and re-inserted at a later date.

• Bleeding. It is common to have a small degree of oozing at the wound edges, but it is possible to develop a collection of blood under the skin. If this happens it may need to be let out by returning to theatre and re-opening the wound.

• Flap failure. This is a very rare complication. Any flap needs a good blood supply and occasionally it does not get the supply it needs. In this case the flap will die. The dead tissue would need to be surgically removed, and further options for reconstruction would need to be discussed.

• Revision Surgery. After the muscle is moved from the back to the front, it changes size over the first 3 months. Your surgeon will probably create a reconstructed breast that is larger than the other one initially to allow for this shrinkage, but it is possible that when the size changes have occurred, your breasts are asymmetrical or slightly bulging under the skin of the flap. Your surgeon may recommend another small operation to improve the final outcome of your reconstruction.