Definition & Overview
Mastectomy is one of the most common treatment options offered to women diagnosed with breast cancer. Recent advancements in surgical techniques and improved understanding of the nature of this disease have allowed the option of saving as much breast tissue as possible. However, the remaining tissue would have to be reconstructed for the patient to regain the form and shape of the original breast or something close to it. This procedure significantly improves the quality of life of breast cancer patients who have to deal with the removal of a significant part of their physical anatomies. One method of breast reconstruction is the use of latissimus dorsi flap.
Flap surgery refers to using a type of tissue taken from a donor site, which is then surgically transplanted into the recipient site. There are several types of flaps used in reconstruction surgery. These include:
- Local flaps, or tissues that are cut and stretched over to fill a defect or wound
- Regional flaps, which are moved to the recipient site without losing their connection from the donor site
- Distant flaps, where tissue is taken from a distant donor site; only a tubed flap connects the donor and recipient sites
Latissimus dorsi flap, which is sometimes referred to as myocutaneous flap, is one of the most common flaps used in reconstructive surgery. Apart from breast reconstruction, it is also used in repairing the chest wall as well as in head and neck surgery. The latissimus dorsi is a broad muscle found in the back, extending from the lower part of the armpit to the lower portion of the iliac crest. It is involved in the rotation and movement of the arm, as well as in pulling the shoulder in and out.
Who Should Undergo and Expected Results
The use of latissimus dorsi in breast reconstruction can be indicated by patient preference. If the patient wishes to use the back muscle to reshape and give form to the breast, the surgeon can harvest a part of this muscle for transplantation.
In some cases, breast reconstruction using this muscle is a result of the inability to use the transverse rectus abdominis muscle, which is taken from the stomach. For very thin patients or those who had repeated surgery on the stomach, using the muscle in the back is a good option for breast reconstruction. Patients who wish to get pregnant after their cancer treatment can also opt to use the back muscle to preserve the abdominal wall.
Breast reconstruction using latissimus dorsi has a good success rate. In most cases, the flap is able to successfully fill out the spaces left by the removed tissue. There is also lowered incidence of necrosis or cell death with the use of this type of flap. Most patients are satisfied in terms of achieving near-normal breast form, volume, and shape. Symmetry between two breasts is also achieved with this technique.
How is the Procedure Performed?
Prior to the surgery where the flap is taken, the patient is asked to stand up, and the area where the muscle tissue will be taken is marked. The patient is then made to lie down with the shoulder abducted at 90 degrees. The patient is also placed under general anaesthesia. The surgeon makes an incision, reaching below the skin layer. The posterior end of the muscle is cut. Any affected blood vessels are also cut and ligated to prevent excessive bleeding. The muscle is then freed from its connection to the underlying tissue and is tethered only to the armpit.
A pedicle that will connect the transferred muscle layer from the donor to the recipient site is kept intact. This is to ensure that the flap will receive enough blood supply while it is trying to establish its own connection at the recipient site. The incision is then closed using sutures and the patient is placed in a supine position to proceed with the reconstruction surgery. The breast is made sterile. The surgeon makes an incision over the previous incision made during the original mastectomy. The flap is then positioned into the chest wall and over the reconstruction site. In some cases, the flap may be stretched out to cover most of the defect left by mastectomy. The back incision is then closed using absorbable sutures.
The flap is then sutured to the chest wall. A suction drain is also placed in the surgical site and in the axilla to collect any accumulated fluid.
The breast may be applied with topical antibiotics and covered with layers of dressing.
Possible Risks and Complications
Infection in both the donor and recipient sites is one possible complication of this procedure. There is also a risk of excessive bleeding during surgery.
Hematoma, or the collection of blood in the surgical site, can also occur. This complication, however, typically resolves itself after a day or two.
Despite the presence of drainage tubes, there is still the possibility that fluid will accumulate at the surgical site. This condition is termed seroma and is quite common after breast reconstruction with latissimus dorsi flap.
There is also a risk of skin flap necrosis. When the transplanted flap fails to get an adequate blood supply, cell death occurs. This may require the surgeon to repeat the surgery.
In some cases, patients report the development of keloids or hypertrophic scars on both the donor and recipient sites. There is also a slight possibility of pulmonary complications, such as the development of an embolus that could travel and block the blood vessels going into the lungs. This could lead to shortness of breath and pain.
- American Society for Plastic and Reconstructive Surgeons: “Breast Reconstruction.”