What Is a Latissimus Dorsi Flap?

The latissimus dorsi flap breast reconstruction is a procedure that uses skin, fat, and muscle from the upper back (the flap) to rebuild the breast. It is one of several surgical options for breast reconstruction after cancer.

This surgery typically is done after a mastectomy (surgical breast removal). It is often performed along with the insertion of breast implants. The procedure gets its name from the donor site of the latissimus dorsi, a large, triangle-shaped back muscle. The donor site is then used to rebuild the shape of the breast.

A flap technique is a type of plastic surgery to repair or reconstruct part of the body.  A portion of muscle and skin connected to the original blood supply (arteries and veins) is moved to a new location. This procedure uses donor tissue from your own body, so it is an autologous (from the same person) tissue reconstruction.

The latissimus dorsi muscle (often shortened to “lats”) are important muscles on the back. At the basic level, they help bend your trunk to the side or help you to extend your spine (like a backbend).

They are activated by pulling motions like swinging a golf club, pull-ups, and rock climbing. These muscles also help when you need to breathe hard or deeply (they are accessory muscles for breathing).

After a latissimus dorsi flap reconstruction, your newly reconstructed breast will not look and feel exactly the same as your natural breast. Typically, a flap will look and feel more like natural breast tissue than having breast implants alone. You may elect to have additional surgery to create a nipple and areola.

This article discusses the latissimus dorsi flap for breast reconstruction. It describes the purpose, risks, and advantages of the procedure. It also explains what you might experience when undergoing this surgery.

Purpose of the Procedure

Your breast surgeon and plastic surgeon can work to determine the best surgical treatments and reconstruction surgery for your unique situation. It is necessary to meet with your plastic surgeon before having your reconstruction.

This gives you the chance to discuss your expectations, risks, and benefits of the procedure. The surgeon will generally do a breast examination so that your reconstructed breast can be re-created as accurately as possible.

How it Works

During a latissimus dorsi flap breast reconstruction, the surgeon releases an oval section of fat, muscle, and a small amount of skin from your back. It is then tunneled from your upper back to your chest. The blood vessels in the tissue from your back are left attached to their original blood supply so the tissue can survive in its new location.

The latissimus dorsi muscle is considered "expendable" and able to be borrowed without causing major harm. This is because the shoulder girdle muscle remains in place and is able to carry out the movements that the latissimus dorsi muscle would otherwise have.

If there is not enough tissue to fully create a new breast, a small breast implant may be used under the flap. The implant is selected to adjust breast size, shape, and projection. The flap provides added coverage over an implant and makes a more natural-looking breast than just an implant alone.

Advantages

It is notable that women who have had flap procedures have reported significantly greater satisfaction with their breasts, sexual well-being, and psychosocial well-being than women who underwent implant reconstruction, according to a 2018 study published in JAMA Surgery.

In one study, this type of flap has been shown to be safe for patients who are overweight or obese, as well. Researchers reported that the incidence of complications after latissimus dorsi flap reconstruction was not significantly different in these patients compared to those of a healthy weight.

Other benefits of a lat flap:

• While the transplanted skin has a slightly different color and texture than the surrounding tissue, it will be a close color match for your breast skin.
• The flap will feel warm and flexible like your normal tissue because it is your own skin and muscle.
• The flap may feel less "foreign" to you than an implant.

Are You a Candidate?

The latissimus dorsi flap may be a good option for women who have small- to medium-sized breasts. For women with large breasts, this procedure doesn't provide enough fat tissue to fully reconstruct a similar size breast.

Blood vessels will be moved and/or reconnected during a tissue flap procedure. If you smoke or have any conditions that affect your circulation—including uncontrolled diabetes, vascular disease, or connective tissue diseases like rheumatoid arthritis and scleroderma—you may not be a good candidate for this procedure. Smokers, including recreational drug users, may be asked to quit at least four to six weeks prior to surgery to promote better healing.

Candidates for latissimus dorsi flap can also include those who:

• Are very thin and do not have enough fatty tissue to use from the lower abdomen
• Have prior scars that may have damaged important blood vessels in other donor sites
• Have previously had radiation
• Have had previous flaps or implants that have failed and are seeking an alternative

For active people who participate in tennis, golf, yoga, pilates, or other sports, this type of reconstruction may not be the best option. Your surgeon will discuss different reconstruction options with you.

Timing

Breast reconstruction can be done at the same time as the mastectomy or it can be done later, after cancer treatment. If you are having a mastectomy and reconstruction at the same time (immediate reconstruction), your surgeon will remove your breast before your reconstruction, sparing as much skin as possible.

If you need radiation therapy to the underarm area or chest, you may need to wait before having a flap placed. Having a latissimus dorsi flap done before your radiation treatment is complete may limit a radiation therapist's ability to treat you properly. It can also affect the new flap, making it hard and aesthetically unpleasing.

Risks and Contraindications

The latissimus dorsi flap reconstruction is considered a major surgical procedure. Generally, the procedure takes longer than breast implant surgery. Healing will also take longer with a tissue flap procedure since you will have two surgical sites—the donor site on the back and the newly constructed breast.

After this surgery, you may have weakness in your arm and back muscles. Physical therapy can help you regain strength.

Though not a health risk, you should know that the procedure will leave a back scar. Typically your surgeon will attempt to take the skin graft from an area that will be covered by your bra strap.

While health risks from this surgery are rare, it is still important to be aware of them.

Surgical risks include:

• Bleeding
• Blot clots
• Surgical site infection
• Wound healing difficulties
• Fluid buildup, pain, or swelling in the breast or donor site

Rare, delayed problems may include:

• Necrosis, or tissue death, in part or all of the reconstructed breast: Necrosis can be treated with the removal of the dead tissue, but the affected tissue cannot be returned to good health. The risk of failure for the latissimus dorsi flap is less than 1%, though that is higher if you have had prior radiation therapy.
• Loss of or changes to nipple and breast sensation
• Problems at the donor site, including loss of muscle strength
• Changes or problems to the arm on the same side as the reconstructed breast
• Problems with the implant, including leakage, rupture, or scar tissue formation
• Uneven breasts
• The need for more surgery to fix problems that may arise

Rate of Complications

Flaps have more complications than breast implants alone in the time right after surgery. A 2018 study published in JAMA Surgery found higher complication rates within two years following surgery among women who underwent flap procedures compared with women who underwent implant procedures.

Rates of complications ranged from 36%–74% among the flap procedure group compared with a range of 27%–31% among the implant group.

However, the study authors point out that with additional years of follow-up, implant-based procedures are more likely than flap procedures to have increased complication rates. Also, often more surgery is needed years later to remove, modify, or replace implants.

Before Surgery

You should follow all instructions your surgeon gives you as you prepare for your procedure. This may include instructions regarding your diet, medications, and quitting smoking.

The American Society of Anesthesiologists recommends quitting smoking as soon as possible before your surgery.

Location and Timing

Latissimus dorsi flap reconstruction is performed in a hospital. Typically, the procedure will take three to four hours.

Post-surgery, you will be admitted to the hospital, where you will stay for three to four days as you begin healing.

What to Wear

You will likely be sore and have limited mobility after your procedure. Generally, there will be drains or bandages in the surgical areas for several days. Bring comfortable clothing that is easy to put on.

Pack things like loose or stretchy shirts that wrap or button up the front, as well as pull-on pants. Occasionally, you may have some drainage or bleeding, so bring clothes that wash easily.

Know, too, that you will need to heal before you can wear a bra or prosthesis. Your healthcare provider will provide specific information about how long you will need to wait.

Purchase a camisole for support and to secure any surgical drains that will be used as part of reconstruction surgery. The camisole is usually worn home from the hospital after surgery.

Food and Drink

You will be told when to stop eating and drinking prior to surgery. Often surgeons instruct patients not to have anything for eight to 12 hours beforehand.

Ask your healthcare provider if you should take your medications with water the morning before surgery. Sometimes, even a sip of water could force your healthcare provider to cancel or postpone your procedure.

Cost and Health Insurance

Federal law requires insurance companies that cover mastectomy for breast cancer to also cover breast reconstruction. Check with your insurance company to find out what your costs will be.

This surgery can be expensive. A JAMA Surgery study found that the median cost of the hospital stay is just under $23,000. Some people may face high deductibles or co-payments, depending on their insurance. Some insurance companies require a second opinion before they will agree to pay for surgery.

Insurance providers each have their own unique policies and procedures regarding precertification, predetermination, and authorization for medical procedures. When a patient has been diagnosed with cancer, this process is generally completed promptly by the insurance provider. However, in other non-immediate or delayed cancer cases, it could take up to six weeks for finalization.

Medicare coverage includes reconstructive surgery. Medicaid coverage varies in each state, so you will have to get information for your state.

Anesthesia

During surgery, you will have intravenous (IV) sedation or general anesthesia, so you will not be awake during your mastectomy or reconstruction.

Your surgeon and the anesthesiologist will need to be informed of all medications and supplements you are taking before your procedure.

During Surgery

To prepare for surgery, your plastic surgeon will use a marker to carefully plan for the incision that will create your skin flap. A pointed ellipse (oval-like shape) will be drawn over your latissimus dorsi muscle. This ellipse will become the skin flap that closes the incision for your reconstructed breast.

When the incision for the flap is closed, it will leave a 4-inch to 6-inch scar on your back. Most surgeons try to place the incision so the scar is covered by your bra strap.

Moving Muscle and Skin

Your plastic surgeon will make an incision along the skin markings, raising the skin and muscle flap. Often, the fat from the back stays connected and is moved as well. A tunnel will be created under your skin so that the flap can be relocated.

This latissimus dorsi tissue flap will go through the tunnel to the front of your chest. The surgeon will keep the donor tissue blood supply intact so the skin and muscle will continue to survive in their new location.

If the flap is completely removed and moved to the chest, the blood vessels must then be reattached. The skin will be positioned so that it fills in the area of skin that was lost during your mastectomy. If you need an implant, the muscle will be draped over it to create the new breast mound.

Closing Incisions

Your back incision will be closed, and a surgical drain may be placed in it to help remove excess fluid.

On your chest, the skin flap will be carefully joined to the mastectomy incision. If needed, scar tissue from your mastectomy may be removed in order to create a smoother skin texture at the new incision.

After Surgery

It is critical that you get enough blood flow to the flap to keep the tissue alive. Your blood flow will be closely monitored while you are in the hospital. If you have surgical drains, you will learn how to empty them and how to keep records of the fluid volume.

Tell your doctor or nurse if you have any pain so that you can get treatment for pain relief. Your surgeon may recommend that you wear a compression garment for up to eight weeks after surgery to keep swelling in check.

Do not plan to go back to work right after surgery. You will need to take it easy while you recover. Be sure to have someone around to help drive you and do any lifting. Also, be sure to go for your follow-up appointments so your surgeon can keep an eye on your incisions and dressings and remove your drains.

You can anticipate gaining normal function for activities, such as driving, in four weeks. It may take as long as a year or even more for the reconstruction to stabilize in its appearance.

Because the donor site on the back has plain skin, some women choose to have nipple and areola reconstruction for a breast that looks more typical. Should you choose to have that additional procedure, it is generally performed at about three to six months after the primary reconstruction.

The timing can vary considerably based on preference and the specific techniques used in both procedures. The reconstructed nipple does not have the same sensitivity as the original nipple, but it does provide for a more natural appearance. 

Summary

There are a wide variety of options in breast reconstruction, and a latissimus dorsi flap approach is one option. This flap is highly effective for many people, but it is not necessarily the best choice for everyone. Other reconstruction procedures using tissue taken from your abdomen (i.e., TRAM flap reconstruction, or DIEP flap) have become more popular over the years.

The latissimus dorsi flap breast reconstruction continues to be a viable option for both immediate and delayed reconstruction. Talk with your plastic surgeon and work together to find an approach that will give you the best possible results.

A Word From Verywell

Mastectomy can bring about major changes in the way a woman feels about her body. Even though the cancer is gone, the long-term changes to physical appearance can be challenging to cope with. Spending time with your healthcare team and understanding your personal options can make a big difference in how you adjust to the many life changes you are facing.