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BREAST RECONSTRUCTION WITH
LATISSIMUS DORSI FLAP

Reconstructive surgery:
This document has been conceived under the authority of the French Society of Plastic, Reconstructive and Aesthetic Surgery (SOFCPRE).

DEFINITION

Mastectomy is the removal of the mammary gland, a certain amount of skin and the areola.

It is unfortunately necessary in some forms of breast cancer.

The demand of breast reconstruction after mastectomy is completely legitimate.

The reconstruction by latissimus dorsi flap uses skin harvested from the back, the latissimus dorsi muscle (thin and extended muscle of the back) and often one prosthesis to recreate the breast volume.

This reconstruction is supported by health insurance.

OBJECTIVES

This surgery aims to restore the volume and contour of the breast with skin and muscle taken from the back. An implant is often needed to complete the internal reconstruction whenever the transferred volume is insufficient.

This technique applies mainly to cases where the residual skin of the chest is insufficient or weakened by radiation and cannot, by itself, protect an internal prosthesis.

This is not a one-time breast reconstruction, because also comprises, according to the wishes of the patient, a reconstruction of the areola and nipple, and possibly an operation in the opposite breast to improve symmetry.

ALTERNATIVES

Breast reconstruction is never mandatory. The use of an external prosthesis can be significant enough for some women. Reconstruction remains a personal choice.

There are also other techniques providing tissue from another part of your body (rectus of the abdomen). These techniques have their own advantages and drawbacks.

PRINCIPLES

The procedure is usually done after complementary treatments that were necessary have been done; it is called secondary reconstruction.

The mastectomy scar is reused as approach in case of reconstruction; although it can sometimes be improved, it is impossible to make it completely disappear.

The intervention consists in placing skin and latissimus dorsi muscle taken from the back in the chest.

The latissimus dorsi muscle is a thin, extended muscle of the back region whose function is not essential for the gestures of everyday life. The area of living skin is maintained by the intermediary of the muscle flap to which it adheres, and the whole is transferred, forward, to the thoracic region.

This flap is slid under the skin of the lateral wall of the chest and inserted between the mastectomy scar and the inframammary fold as an insert.

The implantation of an internal prosthesis under the skin and muscle is usually used for the restoration of a sufficient volume.

In the area where the skin was removed, the residual scar is usually horizontal and concealable by the strap of the bra.

The symmetrisation of the other breast and the reconstruction of the nipple-areola complex are most often realized subsequently, when the volume of the reconstructed breast has stabilized.

Breast reconstruction does not affect the oncologic surveillance.

THE IMPLANTS

There are several manufacturers and several types of breast implants.

The implants or prostheses are all made in a silicone elastomeric envelope that can be smooth or somewhat rough (textured) to reduce the risk of forming a shell or capsule.

This prosthesis can be filled, either with saline (salt water) or silicone gel that has a consistency closer to that of the mammary gland.

There are several types of implants: rounded, more or less projected, or anatomical, whose projection is greater in the lower pole, simulating a natural breast.

BEFORE THE OPERATION

A pre-operative assessment is performed in accordance with the usual requirements.

An autotransfusion can be proposed (taking your own blood and reserving it several weeks before surgery) to minimize the transfusion risks.

The anaesthetist will be seen for consultation at the latest 48 hours before surgery.

In all cases, the surgeon should check the breast imaging (mammography, ultrasound) of the other breast, if the last review of control is not recent enough.

No medication containing aspirin should be taken within 10 days preceding the intervention.

It is possible that the anaesthetist may prescribe anti-embolism stockings (prevention of phlebitis) that you should wear before the intervention until you leave the hospital.

Stopping smoking is essential. It could be a cause of delay or failure of healing.

TYPE OF ANAESTHESIA AND HOSPITAL STAY

Type of anaesthesia:

This is a classic general anaesthesia during which you sleep completely.

Hospital stay:

Hospitalization for several days is usually required. The discharge will be conditioned to the removal of drains.

THE PROCEDURE

The intervention can take three to four hours. By the end of surgery, a bandage shaped like a bra is made up in.

 

POSTOPERATIVE CARE AND FOLLOW-UP

The postoperative course is generally quite painful at the back for a few days and may require strong painkillers.

These painkillers will be replaced later by less powerful analgesics prescribed on demand.

Swelling (edema), ecchymosis (bruising) of the reconstructed breast is possible in the postoperative period.

Wearing a bra (night and day) is necessary for several weeks. The change of dressings will be regularly performed.

Consideration should be given to a recovery period of at least four weeks. It is advisable to wait one to two months to resume sport activities. Swimming is possible and can be started earlier.

THE RESULT

The reconstruction by a latissimus dorsi flap immediately restores volume and shape usually allowing the patient to wear low-cut dressings.

The final result is not acquired right from the start. The breast may appear a little too rigid with a pulling sensation in the back.

The appearance of the reconstructed breast will gradually evolve. It takes two to three months so that your surgeon can appreciate the result and in particular the symmetry.

It is at this stage when an eventual retouch is possible.

In some patients, the psychological integration of the reconstruction can be difficult and a period of ambivalence of at least six months is often necessary. The medical and family environment plays an important role in this period during which the patient needs to be reassured.

The goal of this surgery is to provide a clear improvement but we cannot claim the perfection. If your wishes are realistic, the obtained result should give you great satisfaction.

DISAPPOINTING RESULTS

It is unfortunately impossible to reconstruct a breast perfectly symmetrical to the other.

It will always remain a certain asymmetry of the breasts, whether of the:

volume: the base of the breast will never be perfectly identical. Weight changes may accentuate this difference.

shape: lying down, the prosthesis does not spread like the normal breast.

height: non-reconstructed breast will undergo the normal evolution towards the ptosis, accentuating the asymmetry.

colour: there is frequently a small difference giving an aspect of patch.

and palpation: the patient can feel the prosthesis because of the low thickness of the covering tissues. In addition the sensitivity of the paddle of skin will never be perfect.

The scars will be closely monitored and it is frequent that they become pink and swell during the first post-operative month. Beyond, they generally fade over time, to become barely visible. They cannot however completely disappear.

The scars can sometimes stay a little too visible and present different unsightly aspects (hyper-pigmentation, thickening, retraction, adhesion or enlargement) that may require specific treatment.

In this regard, we must not forget that if the surgeon performs the sutures, the scar itself is the result of the patient.

POSSIBLE COMPLICATIONS

Breast reconstruction with a latissimus dorsi flap is a quite heavy surgery, which involves the risks inherent to any surgical act.

However, the surgical aftercare is generally quite simple. Nevertheless, complications can occur, some of general order, inherent to any surgery, others loco-regional, more specific of the reconstruction of the breast with implants or flaps.

We must distinguish the risk of complications related to the anaesthesia from those related with the surgery.

Regarding the anaesthesia

A consultation at least 48 hours before your hospitalization is required.

During this consultation, the anaesthetist will explain you the risks of general anaesthesia and will present the different ways to manage post-operative pain.

Regarding the surgery

By choosing a competent and qualified Plastic Surgeon, with experience in this type of intervention, you will limit these risks, although they will not disappear completely.

Fortunately, real complications are infrequent after breast reconstruction with latissimus dorsi flap. In practice, the majority of interventions occur without any problem and the patients are generally satisfied with the result.

Complications, however, must be known and understood. So, it can be observed:

A serous effusion (lymph drainage): it is the most common complication. A pocket of fluid forms in the site of the new breast or at the donor site in the back. Depending on its importance, it can reabsorb spontaneously or require a puncture or a surgical revision.

Skin necrosis: the undermining creates a risk of skin suffering, because to the fineness of its vascular network. This risk is increased by the reconstruction, especially if the sutures are done under tension. This risk is much higher in patients after radiotherapy or in smokers. The risk is proportional to the intensity of smoking. The necrosis may need a reoperation to remove all dead tissue. It can lead to infection, and the extreme, the failure of reconstruction.

Infection: Infection is a risk present during any surgical procedure. Treatment requires antibiotic treatment and sometimes adapting a second operation for drainage, or removal of the implant.

Haematoma: the hematoma is a risk inherent to any surgical procedure. It can occur despite all the attention given by the surgeon intraoperatively. This complication may need early revision surgery.

The placement of an internal prosthesis for breast reconstruction adds its own complications:

Formation of a capsular contracture: the formation of a capsule around the implant is constant. In some cases, the capsule contracts causing a sensation of tightening, sometimes painful. This contraction can sometimes cause a visible deformation of the breast that is at the same time globular and becomes firmer. In recent years this risk has been substantially reduced owing to the use of new implants, but remains completely unpredictable for each patient. It will be higher if radiotherapy has been administered on the prosthesis itself.

Waves and folds: when the skin covering the prosthesis is fine, it may reveal that the envelope of the prosthesis in the form of waves or folds.

Displacement of the implant: a displacement of the implant is always possible under the effect of muscle contractions. It is not advisable to perform excessive pectoral muscle exercises in the post-operative period. Revision surgery may be necessary.

The traumatic rupture or deflation by external manoeuvres: the risk is real in a severe trauma, or at an excessive compression during a mammogram. The replacement of the prosthesis is then necessary.

Wear and aging of the implant: it is essential to understand that no prosthesis can be implanted for life. Indeed, prosthesis has their aging and life span necessarily limited.

Over time, the envelope gradually wears away, which may cause leakage of contents with varying consequences:

With a prosthesis filled with saline, there, in case of breakage, sagging breast usually occurs within hours or days, corresponding to a deflation of the prosthesis.

With a prosthesis pre-filled with silicone gel, the clinical diagnosis is less obvious. With the gel with important cohesiveness, now more commonly used, you are protected from a rapid diffusion of silicone gel outside of the prosthesis. Because of the very gradual nature of the gel migration outside of the prosthesis, the clinical signs corresponding to the tearing of a prosthesis pre-filled with silicone gel are most often delayed as a deformation of the breast or the appearance of a capsular contracture.

The period of onset is unpredictable.

Digital mammography makes the diagnosis of such a failure.

The late nature of clinical signs testifying the wear of a prosthesis pre-filled with silicone gel reflects the obligatory character of a regular clinical monitoring of breast reconstruction by your surgeon.

Whether the wear and tear is from a prosthesis of serum or gel-filled, in both cases, we must proceed with the replacement of the prosthesis.

There is no quantifiable risk of autoimmune disease with silicone gel.

The presence of the implant can sometimes complicate the interpretation of mammograms. It is necessary to tell the radiologist so that the technique is adapted.

All things considered, the risks must not be overestimated, and the very great majority of cases, if reconstructive surgery is done correctly, it will give a very appreciable result, even if the scarring is inevitable.

You can be assured that if you are operated on by a qualified Plastic Surgeon, he/she will have the experience and skill required to avoid these complications, or to treat them successfully if necessary.

These are the facts that we wish to bring to your attention, to complement what you were told during the consultation.

Our advice is for you to keep this document and to read it and think it over carefully after your consultation.

Once you have done this you will perhaps have further queries, or require additional information.

We are at your disposal should you wish to ask questions during your next consultation, or by telephone, or even on the day of the operation, when we will meet in any case, before the anaesthesia.


"Copyright", © "All Rights Reserved" SOFCPRE, any reproduction, even partial, of these texts is prohibited without permission from the French Society of Plastic Reconstructive and Aesthetic Surgery. A copy or reproduction by any means whatsoever, including photocopying, photography, screen capture, copy, paste, recording or otherwise, constitutes an infringement punishable under the Act of March 11, 1957 on the protection of copyright.
Authorization for reproduction of March 10, 2009, for: MCEI (www.chirurgiens-plasticiens.info).


This factsheet has been designed under the auspices of the French Society of Plastic Reconstructive and Aesthetic Surgery (SOF.CPRE) as a complement to your first consultation; to try to answer any questions you can ask yourself if you intend to use a surgical lipo-filling.

The purpose of this paper is to bring you all the information necessary and essential for you to make your decision with full knowledge of the facts. So is it advisable to read with the greatest attention.