cancer treatment - breast reconstruction - LD
(latissimus dorsi) flap reconstruction.This is another common method of reconstructing the breast. The operation takes about three hours and involves a stay in hospital of 4 to 6 days. It usually needs a small breast implant to achieve enough volume to match the other breast. It can be done either at the same time as the mastectomy operation, or at any time after this. It produces a natural looking breast reconstruction. The appearance is better than that from an implant or expander reconstruction, but is generally not as good as that from a TRAM reconstruction.
The operation
The LD operation involves taking muscle from the back and moving it to the breast area. The muscle is draped around an implant to give a natural result. Sometimes fatty tissue is also taken from the back, which can avoid the need for an implant.
The LD muscle is a sheet of muscle which lies on the back extending down the length of the spine. It is supplied with blood from an artery in the axilla and so can be rotated easily to the front of the body.
The muscle and a patch of skin are taken from the back, leaving a horizontal scar. A tunnel is created beneath the skin between the back and the mastectomy site, and the tissue is passed through this. It is then cut and shaped to match the normal breast on the other side, and held in place with internal sutures. The skin is cut to fit the area of skin removed for the mastectomy.
The wound in the back is closed with layers of sutures.
During the operation, a small amount of your blood is temporarily removed. Clotting factors are separated out and are used during the operation to help stop bleeding and to help the layers of tissue ‘stick’ to each other. The blood is then re-transfused back into your circulation (auto-transfusion).
You will be asked to wear intermittent compression stockings during and after the operation. These squeeze the legs at intervals and help to prevent clots in the leg veins (deep vein thrombosis). You will also have a urinary catheter placed during the operation. This will be removed one to two days after the operation when you are more mobile.
Three to four soft suction drains will be placed in your breast and back. These drain away the excess fluids produced. They are normally removed 2 to 4 days after surgery.
(a) The reconstruction is difficult to perform just under the pectoralis muscle.
(b) The latisimuss dosis muscle is brought around from the back and form a more complete layer of muscle as it is stitched to the pectoralis muscle over the implant.
After the operation
After surgery, the room will be kept warm and there will be warm padding over the reconstructed breast. This keeps the blood vessels supplying the reconstructed breast open and improves the chances of it surviving.
You will be encouraged to move around and walk after your operation. You may also be given some physiotherapy exercises to improve the depth of your breathing. You will also need some physiotherapy to improve your arm movements after your mastectomy and axillary surgery. Although the LD muscle is quite large, there are very few noticeable problems after it has been moved. You may find some weakness on that side when carrying heavy objects or when lifting things above your head.
It is normal after any operation to have some pain or discomfort around your wounds. This is likely to continue for a few weeks, but will get better. During your operation, you will be given local anaesthetic around the wounds and a combination of painkillers. This will mean that the level of discomfort you experience is much reduced. After surgery, you will be given further painkillers and you will also be given a supply when you go home. Occasionally, pain continues for longer, or needs more pain relief. If this happens, please discuss it with your doctor as further pain relief can easily be given.
Complications
Any operation can have complications including bleeding and infections. You will be given a course of antibiotics to reduce the chances of infection. Fluid collections (seromas) are very common after an LD reconstruction. These often require needle drainage under local anaesthesia. This may be done under ultrasound guidance.
Because tissue is moved from one part of the body to another, it is important that its blood supply is not harmed in any way. If the blood supply is damaged, part or all of the flap may necrose (die). Loss of all or most of the flap is extremely rare, but loss of a small amount of tissue is less uncommon. This can result in lumpiness or hardening of the reconstructed breast. This is much less likely to happen after an LD flap than a TRAM flap.
If the blood supply to the skin edges is impaired, areas of skin may also necrose. This can happen either in the breast area or around the abdominal wound. Normally, this can be managed with dressings and will heal. Sometimes, a small area of tissue may need to be removed.
