eMedicine Specialties > Plastic Surgery > Breast

Breast Reconstruction, Latissimus Flap: Treatment

Author: John YS Kim, MD, Assistant Professor, Department of Surgery, Division of Plastic Surgery, Northwestern Medical Faculty Foundation; Consulting Staff, Northwestern Plastic Surgery
Coauthor(s): Jamal M Bullocks, MD, Assistant Professor, Department of Surgery, Division of Plastic Surgery, Baylor College of Medicine; Arturo Armenta, MD, Staff Physician, Department of Surgery, Division of Plastic Surgery, Baylor College of Medicine
Contributor Information and Disclosures

Updated: Jun 15, 2009

Treatment

Preoperative Details

Preoperative Planning

Considerations

• Mastectomy defect
• Neurovascular pedicle integrity
• Previous radiation
• Contralateral breast size and shape
• Posterior scar location

Planning the flap harvest and inset requires an adequate assessment of the patient's profile, particularly with respect to the anterior chest wall defect to be reconstructed.¹⁹ Repairing a segmental defect has significantly different ramifications than planning reconstruction after modified or radical mastectomy. A partial transfer of the latissimus dorsi muscle flap may suffice to fill a segmental defect. However, the same transfer is far from adequate for filling the subclavicular and anterior axillary loss noticed by patients who have undergone more involved procedures.

In secondary reconstruction, the existing mastectomy scar may pose challenges to planning flap inset. Compared to an oblique mastectomy scar, a vertical or horizontal scar may be difficult to conceal or may compromise projection. Proper flap placement requires attention to breast symmetry with preservation of ptosis and contour of the inferior breast pole. If the flap position is too high, which may be imposed by inset into a vertical or horizontal incision, the bulk of the muscle is out of position to accomplish this goal. Sacrifice of the inferior breast skin flap or inset into an additional incision at the projected inframammary fold and placement of the skin flap into an inferior lateral position can guarantee inferior projection.

When considering the latissimus dorsi for autogenous reconstruction, communication with the surgeon who performed the mastectomy is critical. Ligation of the neurovascular pedicle is not an uncommon complication of axillary dissection. In the preoperative assessment for delayed reconstruction, innervation can be tested indirectly by evaluation of isometric contraction of the muscle. To test muscle function, have the patient put both hands on her waist and push downward. Contraction of viable muscle is assessed by palpation of the lateral edge of the latissimus dorsi from the posterior axilla to the iliac crest and by contralateral comparison. Electrical stimulation or electromyography can be used for further evaluation of muscle function in ambiguous cases. If muscular contraction is not elicited by any of the above techniques, assume that muscle has been denervated, which results in an atrophic flap.

Posterior markings include identification of the muscle projection and, if used, isolation of the skin island. Orientation of the skin segment depends on the extent of the anterior chest defect and patient preference. Loss of the pectoralis major muscle after radical mastectomy results in significant tissue loss that leaves an undesired subclavicular space, with projection of the superior ribs through the skin. In this or similar situations, arranging the skin island in a horizontal pattern is beneficial. Orientations with oblique skin islands running perpendicular to the muscle fibers and fleur-de-lis patterns have also been described. The critical takehome message is that each breast reconstruction requires a careful consideration of skin island needs regarding scar issues.

The ultimate location of the back scar also is taken into account. Traditionally, the horizontal scar was favored because it can be camouflaged conveniently with the brassiere strap. The preoperative markings can be made with the patient wearing the brassiere to ensure proper placement. The oblique pattern results in a lower, less conspicuous scar. Oblique skin islands also can be planned to create scars along the relaxed skin tension lines of the back, which reduces the chance of hypertrophic scarring that is more common with horizontal scars.

The skin island should measure approximately 8 cm wide by 20 cm long. Wider islands tend to be difficult to close primarily. The shape is an ellipse with a slightly wider portion at the inferomedial pole. This distribution provides the widest piece to the inferior breast for creation of the lower curvature. The superolateral end of the ellipse should begin at the posterior axillary line below the tip of the scapula. This ensures a skin island location that is anterior to the muscle flap.

Intraoperative Details

Operative Preparation

• Preparation for the operation includes the standard medical clearance and assessment of anesthetic risks.
• Once in the operating room, position the patient with pneumatic compression stockings after Foley catheterization. The preferred position is lateral decubitus because it allows exposure of both the anterior and posterior operating fields. This is useful for planning and enables room for the assistant to prepare the recipient site.
• In cases of immediate reconstruction, the general surgery team can perform the mastectomy at the time of flap harvest.²⁰ If this is not possible, then simply prepare and drape the patient in the lateral decubitus position after the mastectomy is complete.
• Once the patient is in position, take care to ensure that the dependent points of the patient are padded to prevent pressure necrosis. The ipsilateral arm should be flexed to 90°, partially abducted, and stabilized using a Mayo stand. This configuration concurrently gives maximal exposure of the axilla and adjacent thorax. Then prepare and drape the patient to isolate an operative field that does not obscure the necessary bony landmarks for dissection.

Intraoperative Details

• The procedure then begins by incising the skin island and dissecting through the subcutaneous tissue to the muscle. Bevel this tissue away to maximize the number of vascular perforators from the muscle to the skin island.
• Once into the subcutaneous tissue, continue this plane of dissection inferiorly to elevate the skin from the remainder of the muscle.
• Using electrocautery, skin elevation proceeds until visualization of the muscle's inferior and medial origins at the spinous processes and posterior iliac spine.
• In the lateral direction, identify the full vertical edge of the muscle and free it from the skin in this plane of dissection. Continue this action superiorly from the skin island at the tip of the scapula to the axilla to identify the superior origins of the muscle.

Flap elevation

• The next step is to release and elevate the muscle flap completely from its origin. This is accomplished by identifying the plane of dissection beneath the muscle that is superficial to the deep posterior muscles of the thorax. Starting laterally, the approximate location of the origin of fibers from the lower ribs is at a position that is one-third the distance of the muscle's insertion. In this area, the serratus anterior and external oblique lie deep to the muscle.
• An avascular plane can be created with careful dissection medially. This plane continues to the inferior points of origin overlying the serratus posterior inferior muscle. Once this point has been reached, transect the inferior origin of the muscle medial to lateral through the thoracodorsal fascia. With the muscle detached, elevate it and reflect it from the thorax from inferior to superior.
• At this point in the procedure, the medial and lateral rows of the segmental arteries that feed the muscle come into view. Clip and coagulate these perforators that arise from the lumbar and intercostal arteries to ensure hemostasis and to prevent postoperative hematoma.
• Once the muscle is reflected completely, detach the superior border of the muscle from the tip of the scapula. In this area, the teres major, serratus anterior, and rhomboids meet with the connective tissue of the superior origin of the latissimus dorsi. Completely detach all points of origin and tether the muscle to the axilla by its insertion and neurovascular pedicle.
• With the muscle reflected, using scissor dissection, isolate the pedicle and separate the thoracodorsal nerve. Further assess the integrity of the vascular anatomy and excise the nerve.

Flap transfer

• The anterior chest incision now is made to prepare flap inset. Position this incision using either the old mastectomy scar or creating a fresh curvilinear incision at the inframammary fold. With the anterior skin flap elevated in the subcutaneous plane, create an axillary tunnel to connect the anterior and posterior wounds. Creating this tunnel high in the axilla with the exact amount of space needed for the flap to pass through is essential. This prevents the implant from slipping to the back and replenishes the anterior axillary defect that remains after mastectomy.
• Bring the flap into position on the anterior chest by gently pushing it through the tunnel. Inset the transferred skin flap into its proposed position to ensure adequate reach without compromising the vascular pedicle.
  
  

  

  Latissimus dorsi breast reconstruction; flap inset.

  [ CLOSE WINDOW ]

  

  Latissimus dorsi breast reconstruction; flap inset.

• If additional length or mobility is needed, the flap can be extended either by dividing the muscle from its point of insertion or by ligating the thoracodorsal vascular branches to the serratus anterior. Before dividing these branches to the serratus, ensuring that perfusion is occurring through the primary thoracodorsal vessel and not through retrograde flow from these branches is imperative. Intraoperatively, a Doppler flow meter can aid in assessment of flow through the thoracodorsal trunk.
• Once a satisfactory length and position is achieved, close the back incision in 3 layers using absorbable sutures over drains.

Creation of the breast mound

• Attention now is directed at implant placement and molding of the breast mound. The flap can be placed into the anterior breast pocket and the entire wound covered with a sterile occlusive dressing while the patient is repositioned and draped in the supine position.
• Elicit further dissection from the lateral border of the pectoralis major to create a subpectoral pocket, which eventually is the location for the implant. This dissection should be limited to secure a permanent space for the implant, which prevents excessive movement of the implant.
• Position a temporary implant sizer into this newly created space to function as a template for the future permanent prosthesis. The sizer can be inflated and deflated with saline so that the proper implant size can be chosen based on comparison with the contralateral breast. Then replace the sizer with the implant of choice and bring the latissimus flap into position.
  
  

  

  Latissimus dorsi breast reconstruction; implant placement.

  [ CLOSE WINDOW ]

  

  Latissimus dorsi breast reconstruction; implant placement.

• If the pectoralis major muscle is insufficient to cover the implant completely or is too thin to ensure stability of the implant, the implant can be placed in a subcutaneous position covered with the latissimus flap.
• In primary reconstruction, the location of the inframammary fold easily is appreciated due to the immediacy of reconstruction, especially if the general surgery team is cognizant of its preservation. Regardless, proper alignment can be accomplished by suturing the structure into position using permanent suture. In situations in which the inframammary fold is recreated using the previously formed curvilinear incision, the skin island can be positioned in an inferolateral orientation. This allows the bulk of the muscle flap to provide ptosis and the inferior curvature of the breast.
• When an acceptable position is attained, suture the flap to the chest wall with absorbable sutures, ensuring security of the lateral border and implant fixation. Position a suction drain at the dependent portion of the wound and tunnel to exit though the axilla. Then close the skin island in two layers.

Alternative Procedures

Extended latissimus dorsi flap

Variations to this procedure are available to adapt this flap to larger reconstructive tasks. In patients in whom the volume defect is substantial, a variant of the standard flap can be used to supply an increased amount of tissue. Such reconstructive scenarios include irradiated anterior chest wall and breast with significant skin loss, large mastectomy scars, and desire for completely autogenous reconstruction. This situation may arise when planning reconstruction in robust women with small breasts, in whom an implant is not necessary to match the fullness of the contralateral breast.

In these circumstances, a fleur-de-lis skin island can be used, or simply greater amounts of adipose tissue and fascia can be included with the dissection of the standard skin island. The fleur-de-lis pattern consists of an inverted T-shaped island with 7-cm wings that increase the amount of soft tissue available for reconstruction. This pattern can be used to provide volumes up to 400 mL.

Another variation to the extended flap harvest is to excise the standard flap skin paddle with the inclusion of the parascapular and iliac subcutaneous tissue and fascia. This dissection begins superiorly to the teres major muscle and is carried inferiorly to the iliac crest. Chang et al recently reviewed an institutional experience of the extended latissimus dorsi flap.²¹ Their review revealed successful outcomes for varying volumes of reconstruction, negating the need for an additional prosthesis. However, the authors advise caution with the use of the extended flap in obese patients who are at higher risk for postoperative donor-site complications.

Small reconstructions

Conversely, correction of segmental defects does not use the entire muscle flap and may not require the use of a skin island. The posterior dissection is accomplished by harvesting the necessary muscle through a horizontal incision inferior to the scapula. Since the inframammary fold, nipple, and general breast shape are intact, these should be conserved. The anterior preparation is limited to a lateral breast incision or opening the previous breast wound. The flap then is brought into position either superficial to the pectoralis major beneath remaining breast tissue or deep to the elevated skin surrounding the defect. The former option may yield superior aesthetic results since it better prevents deformity of the superior slope of the breast.

Additionally, flap harvest can be accomplished using laparoscopic assistance. By incorporating the preexisting mastectomy scar, a feasible muscle flap can be attained without the addition of a posterior wound.

Postoperative Details

• Once the operation is complete, dress the breast with antibiotic ointment along the incisions.
• Wrap the superior chest wall with a loosely applied dressing, placing fluffed gauze at the inferolateral breast curvature and foam tape at the upper breast pole. This dressing is used to prevent implant migration during the immediate healing period and may be changed 48 hours postoperatively.
• The dressing then is changed each day for 2 weeks, after which the patient is encouraged to proceed with the use of a wireless brassiere.
• The suction drains usually are kept in place until they drain less than 30 mL in a 24-hour period.
• Physical therapy, for upper extremity strengthening and range-of-motion exercises, is begun within the first postoperative week.

Complications

• Implant contracture²²
• Implant rupture
• Hematoma
• Seroma
• Flap necrosis
• Hypertrophic scarring of donor site
• Infection

Most complications related to this procedure stem from issues related to the implant or to donor site closure. Implants alone carry the risk of displacement contracture and rupture. These risks mandate a thorough discussion with and acceptance by the patient preoperatively of the possibility of further operations to correct implant position. In addition, the patient should be warned that the implant will have to be replaced at some point in the future, since its viability is finite.

Inadequate hemostasis and postoperative drainage of chest wounds predisposes to hematoma and seroma formation. Conservative management of the drains postoperatively is best to prevent this complication. Although flap necrosis is a possible complication, actual problems with flap inset and wound healing are rare. These issues are more significant in the patient who has undergone irradiation.²³ Lastly, as with any wound under extremes of tension, the posterior donor site may tend to form hypertrophied scars. This can be avoided by creating an oblique incision or skin island to better distribute the opposing forces on the wound.

Generally, latissimus dorsi breast reconstruction is a safe procedure with a small risk of complication. Kroll compared his experience with the latissimus dorsi to implant and TRAM reconstruction.²⁴ He found that complications and reconstructive failure were considerably less using the latissimus dorsi versus expander with implant reconstruction and equal to those experienced with TRAM procedures. The safety of the procedure was demonstrated in Roy's review of 111 cases in which no life-threatening sequelae were identified.²⁵

• Search for CME/CE on This Topic »

• Breast Reconstruction, Refinements & Finishing Touches (Plastic Surgery)
• Breast Reconstruction, Free TRAM (Plastic Surgery)
• Breast Reconstruction, Other Free Flaps (Plastic Surgery)
• Breast Reconstruction, Bipedicled TRAM (Plastic Surgery)

• Mastectomy Overview
• Breast Lumps and Pain Overview
• Breast Cancer Overview
• Breast Self-Exam
• Cancer and Tumors Center
• Mastectomy Preparation

• Polyglactin Mesh Less Costly Than Aceullar Dermal Allograft for Breast Reconstruction
• Acellular Dermal Matrix Product Linked to Complications in Breast Reconstruction
• Immediate Postmastectomy Reconstruction Tied to Better Breast Cancer Survival

• Evolution of Breast Cancer Management in Ireland: A Decade of Change
• Quality of Life After Breast Cancer Surgery With or Without Reconstruction
• Satisfaction and Quality of Life in Women Who Undergo Breast Surgery: A Qualitative Study