Breast Reconstruction: Latissimus Flaps

A latissimus flap breast reconstruction uses the latissimus muscle from the back and some overlying skin to replace the areola and the nipple that are removed at the time of the mastectomy. The flap is tunneled underneath the armpit skin to reach the area of the breast, and so no microsurgery is required. The flap replaces the skin that is lost, but usually is not big enough to replace the volume of the breast. Therefore, latissimus flap breast reconstructions typically require an implant to achieve a symmetric volume to the opposite side. The extra skin and muscle help the healing of the chest, and so the overall complication rate for this flap tends to be low.

The procedure takes on average 3 hours to perform, and patients then have a mildly indented area on their back with a curved scar. Patients who undergo this flap do so often for some sort of previous wound healing problem for their chest. A prime reason to use this flap is due to previous radiation to the chest, and the patient not being a good candidate to undergo the TRAM flap. Patients with previous problems of a tissue expander or a TRAM flap breast reconstruction are often good candidates to undergo a latissimus flap. Finally, the extra tissue from the back tends to cover the edges of the implant, and the implant used is a smaller percentage of the breast reconstruction when compared to the implant used after tissue expansion without a flap. Therefore, on average, latissimus flap reconstructions look a bit better overall than do expander/implant reconstructions. Some women do not want to undergo TRAM flap procedures or do not have adequate abdominal fat, yet want their breast reconstruction to look a bit better than the average tissue expander reconstruction. These women often choose the latissimus flap.

Ideal Candidates for a Latissimus Flap

Patients with small breasts and a history of chest irradation are not good candidates for tissue expander breast reconstructions. The latissimus flap works well for them. Patients who want an implant reconstruction but live far from Chicago, or can't come to the office for weekly expansions, may also choose the immediate results of a latissimus flap breast reconstruction.

A and B cup breasts can usually be reconstructed in one sitting. Larger breasted women and women with large skin requirements for the chest may need a two step operative sequence. In step one, the latissimus flap is placed over a tissue expander. Because of the extra skin from the flap, the expander can be partially inflated at the time of the mastectomy. In the office, the expander is blown up to reach a symmetric size to the opposite breast. Then, just like an expander reconstruction without the flap, the expander is removed, the breast mound adjusted, and a final implant placed.

Advantages to Breast Reconstruction with a Latissimus Flap

• Dependable procedure.
• Three hours to perform the procedure after the mastectomy, 2-3 day hospital stay.
• No microsurgery.
• Relatively easy recovery at home.
• Loss of the latissimus muscle does not seem to cause any functional problems.

Disadvantages to Breast Reconstruction with a Latissimus Flap

• Long curved back scar.
• The drains in the back can need to stay in place a variable amount of time, 1-3 weeks.
• Still a need for an implant in most cases.
• May need two steps.

Risks of Latissimus Flaps:

• Implant infections can occur, but are rare.
• Unhappiness with the final appearance of the reconstruction. This is due to unrealistic expectations of the patient, or due to some difficulty with surgery.
• Patient counseling by the surgeon and a clear understanding of the goals of the reconstruction by the patient will keep this to a minimum.
• Implant malposition.
• Blood transfusions are rarely needed.
• Any operation can be associated with seromas, which are fluid collections under the skin. Drains are left at the time of surgery, and are removed about one week after surgery. The drains are placed to decrease the chances of a seroma. If a seroma is noted, a needle can be placed through the skin to drain the fluid collection. Seromas can often occur in the back at the site that the latissimus was removed.
• The nerve to the latissimus muscle is typically not divided. After the surgery, the latissimus muscle can sometimes contract or move. With counseling of the patient, this unwanted muscle contraction typically is not a problem.
• Most patients who undergo mastectomies develop a bad feeling in the skin of the armpit and sometimes down the arm. This is due to stretching or injury of nerves that exit the breast and go to these areas. It is a common complaint, and the affected area tends to get smaller and less bothersome over time.
• Patients who undergo mastectomies will need to be monitored to regain the motion of the shoulder. Some patients will need to go to a physical therapist to help this motion. This is not specifically caused by the latissimus flap.
• Any operation can be associated with the serious complication of a blood clot in the leg. Blood clots in the leg can dislodge and go to the lungs, making breathing painful or difficult. The approximate risk of this is 1 in 500. Blood thinners can be used to treat this complication.
• Any operation can be associated with the chance of death. The risk of death in an otherwise healthy patient is on the order of 1 in 10,000 cases.