Extended Latissimus Dorsi Flaps

The latissimus dorsi is a large quadrilateral muscle on the back.

The latissimus dorsi is a large quadrilateral muscle on the back.

The extended latissimus dorsi flap (ELD) involves harvesting the fat surrounding the muscle and gives more volume than the standard flap, which uses the muscle alone.

The standard flap is suitable to fill a partial breast defect following a wide local excision but when it is used as to reconstruct the breast following mastectomy, an implant is always required beneath the flap to give sufficient volume. The extended flap can be used without an implant to reconstruct a small breast (around a B cup). For a larger breast reconstruction, an implant may be needed, or alternatively, fat injections can be performed at a later stage to increase the size of the reconstructed breast.

The benefit of using your own tissue rather than an implant is that the look and feel of the breast is more natural than with an implant alone and there are none of the limitations and complications associated with implant surgery. The operation is always done under a general anaesthetic and the average length of hospital stay is 5 days.

This lady has had a left mastectomy for breast cancer and an immediate reconstruction with an extended latissimus dorsi flap from her back with no need for an implant. She has gone on to have a nipple reconstruction and fat grafting to her reconstructed breast. The result is shown at 1 year following the original surgery.

This lady has had a right mastectomy for breast cancer and immediate reconstruction with an extended latissimus dorsi flap from her back and no need for an implant. She has gone on to have a left balancing breast reduction, fat grafting to her right reconstructed breast and a right nipple reconstruction. This is the result 2 years following her original surgery.

Breast Reconstruction – Breast Implants Limitations & Complications

  • Bleeding

    Occasionally, bleeding may occur that can form a collection (haematoma) that would require a return to the operating theatre, this can happen in the back or the breast.

  • Seroma

    This may occur in the back and will require drainage if it is problematic.  This is a simple procedure that can be performed in the outpatient department.  The incidence of seroma has been significantly reduced with the use of quilting sutures.

  • Infection

    This can occur in the breast or the back.  This can usually be treated with antibiotics, as long as an implant has not been used.  Infection in the presence of an implant may result in removal of the implant.

  • Wound breakdown

    The wound on the back may be slow to heal or after an immediate reconstruction, the mastectomy skin flaps may breakdown and occasionally require skin grafting.  If an implant has been used and it becomes exposed following a wound breakdown, it will need to be removed.  An implant can be replaced after things have healed and settled for a few months.  Wound breakdown is much more common in smokers and overweight patients (BMI over 30).

  • Fat necrosis

    This may happen in the reconstructed breast and will present as hard lumps.  This can be alarming for a patient who has had breast cancer and it is helpful to reassure the patient as to the benign nature of this condition.  Small areas may resolve spontaneously, while larger areas may need surgical excision.

  • Asymmetry

    The reconstructed breast is often more pert than the normal breast.  Asymmetries can be addressed by augmenting the reconstructed breast or by performing a mastopexy (uplift), reduction or augmentation to the opposite breast.

  • Shoulder dysfunction

    There may be stiffness of the shoulder following this operation, which usually responds to physiotherapy.  Long-term weakness is usually only noticed by patients requiring to pull themselves up with their arms, eg rock climbers or when climbing ladders.

  • Flap loss

    Total flap loss is possible but very rare.  There may be partial flap loss resulting in some of the skin going black, which could require a second operation to remove the dead tissue.

  • Muscle twitching

    This occasional occurs and is due to the fact that the nerve to the latissimus dorsi muscle may be left intact when raising the flap.  Rarely, a second operation is required to go back and divide the nerve.

What is the difference between a latissimus dorsi flap and an extended latissimus dorsi flap?

A latissimus dorsi flap (LD flap) is a muscle flap taken from the back. The traditional LD flap is used to drape over an implant when doing a breast reconstruction and the flap itself does not carry much volume and so an implant is always needed. An extended latissimus dorsi flap (ELD) involves harvesting extra fat from the back when raising the muscle and this carries more volume with it. This means that it is possible to reconstruct a smaller breast with an ELD flap alone and no implant, or if an implant is used, then there is more tissue to cover it.

An ELD flap is more technically demanding than an LD flap and there are more potential complications with the donor site on the back, but in my view it is superior to the LD flap and so I almost always use an ELD flap for breast reconstruction. The only time I use an LD flap is if I were resurfacing the chest wall for an advanced cancer and so I would be more interested in simply obtaining cover for the chest rather than providing volume to recreate a breast.