Volume Replacement (Latissimus Dorsi Miniflap)

Volume Replacement Latissimus Dorsi Musculocutaneous Flap Reconstruction

The past 35 years has seen the adoption of breast conserving surgery as the most frequent type of breast cancer surgery. This however has focused attention on the inter-related problems of local recurrence and cosmetic outcome. Put simply the larger the resection the lower the local recurrence rate but the more common the cosmetic failure. Cosmetic failure is more frequent than normally realised - occuring in 50% of breast conserving procedures. Cosmetic failure is mostly related to volume loss from the surgery but this itself is determined by the size of the tumour, its position and the breast volume. Other treatments such as radiotherapy will also contribute to the consequent scarring.

One method of volume replacement is the Latissimus Dorsi Miniflap technique. This technique initially performed in the 1990s uses part of the latissimus dorsi muscle (LD) to replace the removed volume.

How the Procedure Works

Images by P Jack & A Falcinelli *

In the latissimus dorsi musculocutaneous flap (LDMF) procedure a flap is created using the tissue from your back. The procedure is performed via a single incision placed to the side of the breast so that it is not visible from the front or indeed from the back. The accompanying diagrams show this schematically.

Essentially the incision is made and the breast folded forward to allow removal of the breast tumour. Next the LD flap is freed up and bought around to the front of the chest. Its attachments other than for the its blood supply are divided and the flap the stitched into place and finally the incision closed.

The tissue making up the flap includes fat, the latissimus dorsi muscle, skin, and blood vessels and it is tunneled under the skin at the front of the chest.

If you have diabetes, circulatory problems, connective tissue disease, or if you smoke, then you may be ineligible for this procedure as the technique requires healthy blood vessels in order to maintain adequate blood supply to the tissue.

Images by P Jack & A Falcinelli *

Advantages of flap procedures such as the LDMF are that no implant is used and so no replacement or rupture can occur, meaning that your will not need surgery to replace implants. Usually the tissue in your reconstructed breast will behave similarly to the rest of your body tissues, in the sense that it can shrink or enlarge as you lose or gain weight.

Possible Problems

Problems which can occur with this technique include muscle damage or weakness in the back and, occasionally, the arms. These issues are rare and great care is taken during your surgery to reduce their likelihood. If you are an active rock climber, tennis player, or swimmer, then you may notice a small difference in your performance with the removal of this muscle, but in most cases the other muscles of the back become stronger to compensate for its absence.

Side-Effects and Recovery

Images by P Jack & A Falcinelli *

There are a number of other effects that you may experience if you undergo this type of breast reconstruction including seroma. This is similar to what happens if you graze your skin as you observe a clear fluid leaking from the area for a few days as the tissue heals.

As a large section of tissue is removed from the back to provide the skin flap your body will respond by leaking this serous fluid for a few days as your heal. Your surgeon will have inserted drains to help clear this fluid and in some cases you may require these drains to remain for a little longer, or need fluid that pools under the skin to be removed by a simple procedure using a syringe.

As with any surgery there is a risk of infection, which is usually treated with antibiotics. Keeping your wound clean and dry according to your surgeon's guidance will help to minimise this risk. Bleeding is also quite normal at the edges of your wounds, but on occasion the bleeding may form a haematoma under the skin which can become uncomfortable and dangerous. This may require draining using a syringe or, in rare cases, further surgery.

Reducing the Risk of Failure

Images by P Jack & A Falcinelli *

It is possible that your flap procedure may fail, requiring surgical removal of the dead tissue and further reconstruction. This is a very rare complication but one that you should discuss with your surgeon in order to understand the risks and what you can do to minimise them. The failure of a flap procedure is usually due to blood supply in the grafted tissue becoming dysfunctional, leading to the death of the tissue. Smoking, and certain circulatory conditions make this more likely to occur.

Initial Asymmetry

As your surgeon will usually make your reconstructed breast slightly larger than your remaining breast to compensate for the usual shrinkage that occurs as your heal, there is the possibility that a residual asymmetry exists after your recovery. If the asymmetry, or any bulging of the tissue, is pronounced then you may feel that further surgery to correct the appearance is desirable.

* Illustrations by Mr Peter Jack, Medical Artist, Teaching Support and Media Services, University of Southampton, for the operative diagrams, Miss A Falcinelli for illustrations.