Prof. Fabio Santanelli di Pompeo

Latissimus Dorsi Flap

Breast Reconstruction

About Latissimus Dorsi Flap

The reconstructive procedure entailing the rotation of the Latissimus Dorsi flap to the anterior chestwall, was developed and described for the first time at the end of the XIX century by an Italian physician, Iginio Tansini, to reconstruct tissues defects of the thorax. The technique has been widely used, along the XX century, to restore thoracic wall defects following tumor resection, until it has been described in detail for breast reconstruction.

Breast reconstruction with Latissimus Dorsi muscle flap, as well as DIEP flap, is a procedure that allows for the use of the patient’s own tissues, although it requires the use of a prosthesis or one or more fat transfer. This technique can be indicated, instead of the DIEP flap, in skinny patients with an insufficient amount of abdominal adipose tissue to reconstruct an appropriate breast mound. When patient’s treatment program includes radiotherapy, it is suggested to perform this procedure as “delayed”, to avoid capsule contracture around the prosthesis due to radiation.

Latissimus Dorsi is an irregularly trapezoidal muscle, which originates from the lumbar vertebrae and gradually tapers reaching the axilla. It is used alone with an overlying skin island to reconstruct a small breast, or in combination with a fat transfer or prosthesis for a larger breast.

A similar procedure to the Latissimus Dorsi, using the same tissues from the posterior thoracic wall, is the adipo-cutaneous TAP (Toracodorsal Artery Perforator). It is perfused by the same vessels but spares the whole muscle and, to achieve the required volume, it is possible to insert a prosthesis or autologous fat tissue through lipofilling.

The Procedure

In the Latissimus Dorsi procedure, lasting two hours and half, the muscle is rotated from the posterior thoracic wall to the anterior, together with an overlying ellipse of skin and fat, to reintegrate tissues resected and to reconstruct the breast mound. Prosthesis is usually positioned under the pectoralis muscle and is completely covered by the Latissimus Dorsi muscle, hence is protected all around by a thick layer of tissue. It is important to remember that, in case of small breast size, it is possible to use the Latissimus Dorsi flap without prosthesis, eventually increasing breast volume afterwards with small adipose transplants (lipofilling) harvested from different body areas. Recent trends in breast reconstruction with Latissimus Dorsi goes towards the totally “autologous” option (patient’s own tissues) with fat transfer but not prosthesis, as first described by Prof. Fabio Santanelli di Pompeo di Pompeo. Once again, if necessary, a skin area is transposed together with the Latissimus Dorsi muscle and used to reconstruct the breast mound previously resected by the general surgeon.

With this procedure, it is possible to achieve a small/medium breast cup and, if contra-lateral breast is consistently larger than the reconstructed, it can be either reduced during the same operation with a reduction mammaplasty, or the correction can be delayed to a second stage. The new Nipple and Areola complex is always reconstructed in a second delayed operation.

Results

This procedure entails the use of an amount of healthy tissue from the back, allowing for the reconstruction of a small/medium breast mound, much softer and with a more natural drop if compared with what is obtained with the expander and prosthesis technique. With the Latissimus Dorsi flap the incidence of foreign body “capsule contracture” is much lower than with the expander technique, or completely absent if the reconstruction uses only “autologus” tissues, without prosthesis.

Two scars result from this procedure: an elliptically shaped one on the breast mound and a second horizontal on the posterior thoracic wall at the level of the bra belt and easily hidden by it. Is indeed in this area that the flap to reconstruct the breast mound was harvested.

Sometimes the scar can be placed vertically on the lateral aspect of the thoracic wall, being easily hidden by the arm.

Frequently Asked Questions

Q: When is breast reconstruction with Latissimus Dorsi flap suggested?

A: Whenever there is not enough abdominal tissue to harvest a DIEP flap.

Q: Is it an immediate or a delayed reconstruction?

A: As for any other breast reconstruction technique, it depends on the needs of the general surgeon and on the need to undergo radiotherapy. In this case, it is necessary to procrastinate reconstruction until therapy is over, since radiation on prosthesis and overlying tissues might produce a strong foreign body reaction.

Q: What kind of scars will result after the procedure?

A: An elliptical scar in the inframammary fold and a horizontal scar on the back, along the bra line, so it may be concealed. Sometimes it is possible to make a vertical incision along the side of the chest, resulting in a vertical scar in this site.

Q: Harvesting a Latissimus Dorsi flap will produce what kind of drawbacks on my back and on my movements?

A: The Latissimus Dorsi muscle participates in upper limb movements and, in the movement of the limb from a higher to a lower position, i.e. adduction, as it happens in wall-climbing. The procedure will decrease the ability to make such movement of almost 3%-5%, thus it will not impair the use of the limb. Whether it affects posture or not is still under debate, however it is noticeable that other, more important, groups of muscles are responsible for maintaining back posture. Few patients refer persistent pain.

Q: If a prosthesis is inserted, what is the reason for using the Latissimus Dorsi muscle?

A: It is a quite legitimate question. The reason is mostly the final aesthetic appearance of the breast, being more natural-like and pleasant than a breast reconstructed with expander and prosthesis; indeed, tissue is included to obtain a nice, natural-like ptosis of the new breast. Moreover, if one has undergone radiotherapy, the use of the Latissimus Dorsi muscle, not being irradiated as much as the Pectoralis Major, improves body tolerance to the prosthesis.

Q: Will I need to replace the implant in the future?

A: Almost certainly, although latest generation prostheses are more durable, with a lifespan of up to 20 years. Anyway, in any breast reconstruction in which a prosthesis is used, its replacement will sooner or later be necessary.

Q: Will I lose breast skin’s sensibility?

A: Tactile sensibility of the breast reconstructed with Latissimus Dorsi flap is slightly lower if compared with the reconstruction with DIEP flap, and is not nearly comparable to the skin sensibility resulting after reconstruction with expander and prosthesis.

Q: With TDAP flap, will I lose Latissimus Dorsi muscle function?

A: Absolutely not! Despite the use of the Latissimus Dorsi vascular pedicle, the muscle belly and its innervation will be respected.

Q: With TDAP flap, will I need a drainage tube?

A: Yes, but only to the anterior mammary region, while it is not necessary at all to the posterior donor area of the flap.

About Latissimus Dorsi Flap

The reconstructive procedure entailing the rotation of the Latissimus Dorsi flap to the anterior chestwall, was developed and described for the first time at the end of the XIX century by an Italian physician, Iginio Tansini, to reconstruct tissues defects of the thorax. The technique has been widely used, along the XX century, to restore thoracic wall defects following tumor resection, until it has been described in detail for breast reconstruction.

Breast reconstruction with Latissimus Dorsi muscle flap, as well as DIEP flap, is a procedure that allows for the use of the patient’s own tissues, although it requires the use of a prosthesis or one or more fat transfer. This technique can be indicated, instead of the DIEP flap, in skinny patients with an insufficient amount of abdominal adipose tissue to reconstruct an appropriate breast mound. When patient’s treatment program includes radiotherapy, it is suggested to perform this procedure as “delayed”, to avoid capsule contracture around the prosthesis due to radiation.

Latissimus Dorsi is an irregularly trapezoidal muscle, which originates from the lumbar vertebrae and gradually tapers reaching the axilla. It is used alone with an overlying skin island to reconstruct a small breast, or in combination with a fat transfer or prosthesis for a larger breast.

A similar procedure to the Latissimus Dorsi, using the same tissues from the posterior thoracic wall, is the adipo-cutaneous TAP (Toracodorsal Artery Perforator). It is perfused by the same vessels but spares the whole muscle and, to achieve the required volume, it is possible to insert a prosthesis or autologous fat tissue through lipofilling.

The Procedure

In the Latissimus Dorsi procedure, lasting two hours and half, the muscle is rotated from the posterior thoracic wall to the anterior, together with an overlying ellipse of skin and fat, to reintegrate tissues resected and to reconstruct the breast mound. Prosthesis is usually positioned under the pectoralis muscle and is completely covered by the Latissimus Dorsi muscle, hence is protected all around by a thick layer of tissue. It is important to remember that, in case of small breast size, it is possible to use the Latissimus Dorsi flap without prosthesis, eventually increasing breast volume afterwards with small adipose transplants (lipofilling) harvested from different body areas. Recent trends in breast reconstruction with Latissimus Dorsi goes towards the totally “autologous” option (patient’s own tissues) with fat transfer but not prosthesis, as first described by Prof. Fabio Santanelli di Pompeo di Pompeo. Once again, if necessary, a skin area is transposed together with the Latissimus Dorsi muscle and used to reconstruct the breast mound previously resected by the general surgeon.

With this procedure, it is possible to achieve a small/medium breast cup and, if contra-lateral breast is consistently larger than the reconstructed, it can be either reduced during the same operation with a reduction mammaplasty, or the correction can be delayed to a second stage. The new Nipple and Areola complex is always reconstructed in a second delayed operation.

Results

This procedure entails the use of an amount of healthy tissue from the back, allowing for the reconstruction of a small/medium breast mound, much softer and with a more natural drop if compared with what is obtained with the expander and prosthesis technique. With the Latissimus Dorsi flap the incidence of foreign body “capsule contracture” is much lower than with the expander technique, or completely absent if the reconstruction uses only “autologus” tissues, without prosthesis.

Two scars result from this procedure: an elliptically shaped one on the breast mound and a second horizontal on the posterior thoracic wall at the level of the bra belt and easily hidden by it. Is indeed in this area that the flap to reconstruct the breast mound was harvested.

Sometimes the scar can be placed vertically on the lateral aspect of the thoracic wall, being easily hidden by the arm.

Frequently Asked Questions

Q: When is breast reconstruction with Latissimus Dorsi flap suggested?

A: Whenever there is not enough abdominal tissue to harvest a DIEP flap.

Q: Is it an immediate or a delayed reconstruction?

A: As for any other breast reconstruction technique, it depends on the needs of the general surgeon and on the need to undergo radiotherapy. In this case, it is necessary to procrastinate reconstruction until therapy is over, since radiation on prosthesis and overlying tissues might produce a strong foreign body reaction.

Q: What kind of scars will result after the procedure?

A: An elliptical scar in the inframammary fold and a horizontal scar on the back, along the bra line, so it may be concealed. Sometimes it is possible to make a vertical incision along the side of the chest, resulting in a vertical scar in this site.

Q: Harvesting a Latissimus Dorsi flap will produce what kind of drawbacks on my back and on my movements?

A: The Latissimus Dorsi muscle participates in upper limb movements and, in the movement of the limb from a higher to a lower position, i.e. adduction, as it happens in wall-climbing. The procedure will decrease the ability to make such movement of almost 3%-5%, thus it will not impair the use of the limb. Whether it affects posture or not is still under debate, however it is noticeable that other, more important, groups of muscles are responsible for maintaining back posture. Few patients refer persistent pain.

Q: If a prosthesis is inserted, what is the reason for using the Latissimus Dorsi muscle?

A: It is a quite legitimate question. The reason is mostly the final aesthetic appearance of the breast, being more natural-like and pleasant than a breast reconstructed with expander and prosthesis; indeed, tissue is included to obtain a nice, natural-like ptosis of the new breast. Moreover, if one has undergone radiotherapy, the use of the Latissimus Dorsi muscle, not being irradiated as much as the Pectoralis Major, improves body tolerance to the prosthesis.

Q: Will I need to replace the implant in the future?

A: Almost certainly, although latest generation prostheses are more durable, with a lifespan of up to 20 years. Anyway, in any breast reconstruction in which a prosthesis is used, its replacement will sooner or later be necessary.

Q: Will I lose breast skin’s sensibility?

A: Tactile sensibility of the breast reconstructed with Latissimus Dorsi flap is slightly lower if compared with the reconstruction with DIEP flap, and is not nearly comparable to the skin sensibility resulting after reconstruction with expander and prosthesis.

Q: With TDAP flap, will I lose Latissimus Dorsi muscle function?

A: Absolutely not! Despite the use of the Latissimus Dorsi vascular pedicle, the muscle belly and its innervation will be respected.

Q: With TDAP flap, will I need a drainage tube?

A: Yes, but only to the anterior mammary region, while it is not necessary at all to the posterior donor area of the flap.

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Healing is a process that can be considered complete when, finally, you might recognize yourself into your own body, despite unavoidable changes...

In the last decades Plastic Surgery, has become part of the oncologic treatment protocol, as the importance of the reconstructive stage following resection of a diseased body part has been universally recognized. Concerning breast tumor, most advanced hospitals set up a “Breast Unit”, multidisciplinary functional unit composed by different specialists who cooperate to offer to the patient the best opportunity available from medical science, to contrast tumor disease and return to normal life.

There are several breast reconstructive procedures, even though expander and prosthesis is the most known. This web-site is dedicated to women undergoing mastectomy and willing to know all reconstructive opportunities. Main goal is to present “autologous” procedures using live tissues from the patient itself as a sort of “auto-transplant”. Advances in vascular microsurgery and in peri-operative patient care have allowed for outstanding steps forward to restore the female body image.

Once all aspects have been taken into proper consideration, a woman should be assisted during choice with broad information, evaluating pro and cons among any surgical procedure, so she can decide what is best for her.