Autologous breast reconstruction with latissimus dorsi flap and fat grafting is an excellent option for patients who want autologous breast reconstruction but are not good candidates for DIEP flap reconstruction. This technique reconstructs the breasts using skin and fat from your back and the entire latissimus dorsi muscle in addition to additional fat harvested via liposuction from your abdomen and/or thighs. Unlike a DIEP flap, the latissimus flap does not require microsurgery, reducing your OR time and your time spent in the hospital after surgery. For the correct patient, this type of reconstruction can produce breast aesthetic results that match those of a DIEP flap. A breast mound of reasonable size and natural consistency is generally able to be achieved in most patients.

Overview & Why Choose Dr. Chang

Autologous Reconstruction with Latissimus Dorsi Flap 

  • Patients Undergoing Mastectomy – The latissimus flap is a good option for the majority of patients undergoing mastectomy. Patients can choose, to an extent, if they would like to remain roughly the same size, smaller than, or larger than their pre-operative breast size. The size of the reconstructed breasts is limited by the amount of skin and fat you have in the mid-outer portion of your back and how much excess fat you have in your abdomen, flanks, thighs, arms, etc. for fat grafting.

  • Patients Who Need Radiation Therapy – Patients who need or have had radiation therapy are best treated with staged autologous breast reconstruction. In the first stage, a tissue expander is used to maintain some of the breast pocket during the radiation period. Because radiation induces so much scarring, latissimus flap reconstruction is an excellent option because most of the radiation-damaged tissues are replaced with completely healthy abdominal tissue.

  • Patients Who Have Failed Implant-Based Breast Reconstruction – Patients who have failed implant-based breast reconstruction for any reason may benefit from reconstruction with a latissimus flap.

  • Patients Who Have Failed DIEP Flap Reconstruction – While the DIEP flap is Dr. Chang’s first-line option for autologous breast reconstruction, the latissimus flap is an excellent option if the DIEP flap did not work.

  • Patients Who Have Failed Implant-Based Breast Reconstruction – Patients who have failed implant-based breast reconstruction for any reason may benefit from reconstruction with a DIEP flap.

  • Patients Who Are Poor DIEP Flap Candidates – Although DIEP flap reconstruction is Dr. Chang’s preferred option for autologous breast reconstruction, not all patients are good candidates. Patients with multiple abdominal surgeries, open abdominal surgeries, or certain surgeries like abdominoplasties (tummy tuck) or liposuction may be at higher risk of DIEP flap failure. Those prior surgeries not only cause scar tissue but also could have been associated with direct injury to the blood vessels that would perfuse the DIEP flap. Those patients may consider reconstruction with the latissimus flap instead. Patients with a history of blood clots and/or conditions that make you hypercoagulable are at higher risk for anastomosis failure of the microsurgical part of the free flap as well potentially life threatening DVTs. Patients who are morbidly obese are at higher risk of abdominal donor site problems including abdominal bulges. These patients may be better suited with latissimus reconstruction instead of DIEP flap reconstruction.

  • Healthy Patients – Healthy, non-smoking patients without major medical conditions that would make surgery or general anesthesia unsafe are candidates for this surgery. Conditions that pre-dispose to increased complications such as diabetes, vascular disease, autoimmune conditions, immunodeficiencies, etc. are still candidates for surgery but require additional pre-operative counseling and optimization. Certain conditions—namely blood clots, hypercoagulable disorders, and bleeding disorders—will require more thorough discussion with Dr. Chang and your primary care provider to determine if proceeding with latissimus reconstruction is safe for you.

  • Realistic Expectations – Dr. Chang views surgery as a partnership between the patient and him. It is important trust and confidence go both ways. Together, we will discuss your goals and if we can reasonably achieve those goals based on your anatomy.


Who Is a Candidate for Latissimus Dorsi Flap?

  • Medical Evaluation – Dr. Chang will review your medical conditions, medications, prior surgeries, and personal and family history of breast diseases, masses, and cancers. Some patients may be referred to their primary care doctor or a specialist to ensure you are medically optimized for a safe surgery under general anesthesia and post-operative recovery. 

  • Breast Examination – Dr. Chang will perform a physical examination of your breasts. This will include measurements of the size, location, and symmetry of the breasts and nipple-areolar complexes. Dr. Chang will assess the skin quality, the weight/volume of excess breast tissue relative to your desired size, and the positions of the nipple areolar complexes to help determine the best surgical approach.

  • Back Examination – Dr. Chang will perform a physical examination of your back. This will include assessing the skin quality and excess, location and type of fat excess, and muscle quality.

  • Clinical Photographs – Clinical photographs from multiple views will be taken of your breasts and back. These photos are used to plan for your individualized surgery and compare before and after surgery. No photographs will be published online without your written consent.



Pre-Operative

Incisions are made in your mid-outer back over the central aspect of your latissimus dorsi muscle. The final scar will be hidden in one of the normal skin folds of your back. The skin, fat, and latissimus dorsi muscle are all include in the flap. After exposing the entire latissimus muscle, it is divided from its bony attachments so that it can move freely into the breast. The motor nerve controlling the latissimus dorsi is identified and partially resected so as to prevent an animation deformity where your reconstructed breast moves when you move your arm. Liposuction of your body is performed to harvest fat that can be grafted into the flap and the mastectomy flaps. The latissimus flap is transferred into the breast pocket, secured with sutures, and aesthetically shaped. 

How Is Reconstruction with Latissimus Dorsi Flap Performed?

If you have any urgent concerns, you may call the office at any time. Otherwise, patients should expect follow-up visits at 1 week, 2 weeks, 1 month, and 3 months. At your 3 month appointment, we will discuss your planned revision surgery, generally between 6-12 months after your flap reconstruction.

Follow-Up Visits

Immediately after surgery, you will be admitted to the hospital for pain control. Once your pain is well controlled and you are able to stay hydrated and ambulate on your own, you may go home. For most patients, that is on post-op day 1 or 2. Depending on your occupation, you may return to work 2-4 weeks after surgery. You may resume light cardio exercises at 4 weeks after surgery. You should not lift anything heavier than 5 pounds or extend your arms extensively over your head for the first 4 weeks after surgery. You may resume all physical activities at 6-8 weeks after surgery. You should expect some drainage from the incisions and mild bruising around the incisions. You will be swollen, and it can take up to 3-6 months for the swelling to reside. Your incisions will take 2-4 weeks to completely heal, but the final scar will take 6-12 months to mature. Scar care will be discussed at your 1 month post-operative appointment.

Recovery Period

Local anesthetic (numbing medication) will be injected at your surgical sites to minimize your immediate post-operative pain. You should take acetaminophen and an NSAID around-the-clock, according to instruction, for the first 72 hours and then as-needed thereafter. You can purchase these over-the-counter. You will be given a small number of low-dose narcotic pain medications for breakthrough pain only for the first 72 hours.

Pain Management and Medications 

Your incisions will be dressed with surgical bandage strips and/or surgical skin glue. You will be wearing a comfortable surgical bra stuffed with gauze pads. The bra should be relatively loose. You should try to wear the surgical bra as much as possible but may remove to shower and to wash the bra. You may shower the day after surgery but cannot bathe or swim until instructed to do so. You will have drains in your breasts and back.

Dressings and Incision Care 

Post - Operative

  • Asymmetry – No one’s breasts are perfectly symmetric. While the goal is near-perfect symmetry, there will be some asymmetries in your reconstructed breasts.

  • Need for Revision Surgery – All patients undergoing latissimus flap reconstruction will be recommended for at least one revision surgery. The revision surgery helps achieve your desired breast size, position, contour, and symmetry. Sometimes, multiple, staged revision surgeries are needed.

  • Fat Necrosis – Not all of the fat that is grafted becomes re-vascularized and survives in its new location. Sometimes, the fat is just absorbed by the body, but in other cases, it forms hardened scar tissue. While not dangerous or cancer-predisposing, fat necrosis can be painful and uncomfortable. If large and bothersome enough, the fat necrosis must be removed surgically.

  • Mild Back / Upper Extremity Weakness – The latissimus muscle functions to pull your arms down and inward when raised above your shoulders. This is a function performed by multiple different muscles, not just the latissimus dorsi. When the latissimus muscle is used in breast reconstruction, it no longer performs its function to move your arm. For the vast majority of patients, this has no noticeable effect on you physically. Patients who may notice a difference are people who are competitive swimmers or gymnasts and patients who use crutches or wheelchairs.

  • Animation Deformity – The latissimus dorsi is a muscle that contracts. If the motor nerve to the latissimus is not cut or if it has multiple nerves, the muscle may still be contractile. This would result in part of your breast contracting with certain arm movements. The risk of this is greatly reduced by resecting the motor nerve.

  • Axillary Bulge – The latissimus flap is transferred from the back to the chest through the axilla. Sometimes, a portion of the flap remains in the axilla and adds volume there. If this bothers you significantly, it can be addressed during the revision stage.

  • Bleeding – Significant bleeding after surgery may require an urgent return to the operating room. Smaller collections of blood may be treated conservatively or managed with a small procedure in the office or the operative room.

  • Need for Blood Transfusion – Because DIEP flap reconstruction is a major surgery, blood loss is expected. Sometimes, patients will need a blood transfusion.

  • Unmet Expectations – Despite thorough pre-operative planning and discussions, you still may not be fully happy with your aesthetic results.

  • Poor Scarring – Everyone scars differently. The final scar takes 6-12 months to mature. In rare cases, hypertrophic scars or keloids may form and may require secondary revision.

  • Wound Healing Issues – There may be small areas where the incisions do not fully heal. In these cases, the wounds will be allowed to heal on their own with dressing changes. Severe cases may require a secondary revision procedure.

  • Infection – Infections are managed with antibiotics. In severe cases, you may need an additional procedure.

  • Seroma – Fluid collections may develop in the chest. Small ones will be absorbed by the body, but larger ones will need to be aspirated in the clinic.



Risks of Latissimus Flap Reconstruction

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