Breast reconstruction using latissimus dorsi muscle for a woman
following mastectomy for breast cancer: a case report
Name: Jeries Wesam Ajlan Mdanat
Year of studies: 3 of 6
Home University: Jordan University Of Science And Technology, Jordan
Tutor(s): MUDr. Matêj Patzelt, Ph.D. , MUDr. Tomàš Herma
Department, Hospital, University, City, Country: Surgery-Plastic Surgery, Fakultní
nemocnice kràlovské Vinohrady, Prague, Czech Republic
Introduction
Breast cancer is a serious epidemiological issue in the Czech Republic; approximately 7,200 new
cases of breast cancer are diagnosed each year, corresponding to more than 133 cancers per
100,000 women in the Czech populatio. The Czech Republic experiences an average of 1,600
breast cancer deaths per year, representing an average of 30 breast cancer deaths per 100,000
women in the country.
The chart above shows the basic epidemiological data on breast cancer in the Czech Republic in
the period 1977–2018. [1]
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The majority of women with breast cancer undergo surgery, often with breast-preserving
procedures, such as lumpectomy or aplastic breast surgery. The use of these techniques has
increased, but 25% of breast cancer females still require a mastectomy. The majority of patients
will receive adjuvant chemotherapy and radiation therapy.
More than 80% of women who undergo mastectomy are interested in reconstruction of the breast
after the initial treatment. The ability of patients to overcome psychological trauma in the wake
of the primary diagnosis and treatment has been shown to be improved by reconstruction of the
breast.
An implant is used to reconstruct patients who do not receive adjuvant radiotherapy. Patients
who have received radiotherapy prior to treatment are more likely to undergo an autologous
reconstruction.
There are several ways women can have their breasts rebuilt. There are implants that can be used
to rebuild the breasts. Autologous tissue from elsewhere in the body can be used to rebuild them.
Sometimes both implants and autologous tissue are used to reconstruct the breast.
The surgery to reconstruct the breasts can be done at the time of the mastectomy (which is called
immediate reconstruction) or after the mastectomy incisions have healed. Months or even years
after the mastectomy, delayed reconstruction can happen months or even years after the
mastectomy.
If the nipple and areola were not preserved during the mastectomy, they may be recreated in a
final stage of breast reconstruction.
Sometimes, breast reconstruction surgery also involves removing the other, or contralateral,
breast to ensure that the two breasts are identical in size and form [6].
The most commonly utilized autologous reconstruction is a deep inferior epigastric perforator or
transverse rectus abdominis myocutaneous flap. This may not be possible for all patients because
some do not have enough tissue and some have had previous surgery to the abdomen, or the
patient does not wish to have an operation on the abdomen. The most commonly employed
technique is a pedicled latissimus dorsi flap with an overlying skin island.
Alternative autologous flaps for breast reconstruction are available. The LD flap is closely
related to the thoracodorsal artery perforator (TDAP) flap, which consists of skin and
subcutaneous fat. It is raised from the same area and on the same vessels as the LD flap, but does
not include muscle. Other flaps, such as the transverse myocutaneous gracilis flap from the thigh
or the superior gluteal artery perforator flap from the buttocks, require microsurgical expertise.
[2]
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Patient
The patient is a 78-year-old female presenting to the operating room for breast reconstruction
using a pedicled latissimus dorsi muscle flap following a mastectomy of the right breast due to
breast cancer. She is alert and oriented, with stable vital signs. The patient has a well-healed
mastectomy site on the right chest, with no signs of infection or dehiscence. She reports mild
discomfort in the surgical area but denies any significant pain. The patient has a history of
hypertension, which is well-controlled with medication, and no known allergies. Her
preoperative evaluation indicates that she is a good candidate for the reconstruction procedure,
and she has been thoroughly informed about the surgery, potential risks, and expected outcomes.
The patient is anxious but optimistic about the reconstructive surgery, expressing a desire to
regain a sense of normalcy and body image post-cancer treatment. She has complied with all
preoperative instructions, including fasting and medication adjustments, and is accompanied by
her daughter, who will provide postoperative support.
Treatment
Autologous breast reconstruction aims to recreate the sensation of a natural, soft breast that is
symmetrical and of a comparable size and position as the contralateral, natural breast.
The flap is marked while the patient is in a standing position, and the skin paddle is marked
overlying the latissimus dorsi muscle on the patients back. The surgeon's pre-operative
measurements regarding the amount of skin needed to restore the breast's surface and the amount
of skin available for a primary closure of the donor area determine the size of the paddle.
During the dissection of the flap, the thoracodorsal vessels are explored first to ensure that they
have not been damaged during previous surgery, such as axillary lymph node dissection. Such
damage will make the reconstruction impossible. The thoracodorsal nerve, which is usually
transected to prevent involuntary muscle contractions of the breast, is preserved throughout the
procedure. The flap is tunnelled through the axilla and moved to the anterior side of the thorax to
be shaped into the new breast after dissection.
The LD flap is often paired with a silicone implant, which is inserted into the muscle to attain a
satisfactory volume. A tissue expander and skin expansion can be used to provide adequate skin
coverage of the correctly sized implant.
For some patients with smaller breasts, the muscle flap alone can be enough to achieve a
complete reconstruction. Correcting the opposite breast is often necessary to maintain a perfect
symmetry.
The procedure can be performed either immediately following a mastectomy or, more frequently,
as a postponed one after the completion of any planned postoperative treatment.
The patient is scheduled for a reconstruction of the nipple, including areolar tattooing, after the
operation.
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Discussion
After breast reconstruction with an LD flap, two types of complications dominate: The first is a
seroma at the donor site on the back, and the second is a possible impairment in shoulder
function following the muscle's insertion.
A donor-site seroma is the most commonly reported complication in the current literature with
rates varying from 6-72% [3]. The frequency of seroma appears to be linked to the timing of the
reconstruction, as higher rates were observed in patients who underwent primary reconstructions
than in those who underwent secondary reconstructions.
Developing a donor-site seroma results in further visits to the outpatient clinic for aspiration and
a higher probability of infection.
Seroma formation was prevented by several techniques. One point in common for these
techniques is to minimize the pocket created at the donor site of the latissimus dorsi muscle in
the back. There are tools to prevent seroma formation, such as fibrin glue and quilting sutures. In
the future, this topic should be further investigated in prospective randomised studies.
Third, it's possible to make supportive clothing that prevents seroma. The purpose of the
garments is to apply pressure to the donor site on the back without jeopardizing the donor vessels
while minimising seroma formation. Current literature does not describe the use of pressure
garments for this purpose [4].
The effects of the latissimus dorsi muscle removal on shoulder function and range of motion
remain unclear. Despite the initial description of this method more than a century ago and its
enduring popularity over the past thirty years, there is no conclusive evidence to support these
claims. The removal of a muscle of this size must result in a significant decrease in the ability to
perform shoulder movements to which the latissimus dorsi muscle contributes.
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The consensus is that the synergistic actions of the shoulder joint compensate for the missing
muscle when it comes to shoulder mobility and performing daily activities.
Several individuals have reported a decrease in shoulder strength, but the degree of this decline
varies. To achieve a better understanding of the mechanical changes in the shoulder following
the removal of the latissimus dorsi muscle, prospective studies where the patients’ shoulder
strength is tested pre- and post-operatively should be performed [5].
The choice of autologous breast reconstruction remains safe. Future focus-points for this
procedure could include prevention of donor-site seroma as well as improvement of the clinical
pathway and post-operative regimen.
Summary
Breast reconstruction following mastectomy is a critical component in the holistic treatment of
breast cancer, significantly aiding in the psychological and physical recovery of patients. This
report highlights the case of a 78-year-old female undergoing reconstruction with a pedicled
latissimus dorsi muscle flap after a right mastectomy. This technique is particularly
advantageous for patients who have received radiotherapy, providing a natural and symmetrical
breast reconstruction [Link] meticulous preoperative planning and surgical execution were
pivotal in achieving optimal aesthetic results. Postoperative care focused on managing potential
complications such as donor-site seroma and shoulder function impairment. Despite these
challenges, the latissimus dorsi flap remains a preferred method due to its reliable outcomes,
emphasizing the need for continued advancements to enhance patient recovery and satisfaction.
My Inclusion in the Exchange
I am so grateful that I had the opportunity to witness firsthand the transformative power of
plastic surgery. I learned intricate techniques in reconstructive and cosmetic procedures, gaining
invaluable hands-on experience under the mentorship of skilled surgeons. The rotation
illuminated how plastic surgery not only enhances aesthetics but also profoundly impacts
patients' lives by restoring function and confidence after trauma or illness. This immersive
experience broadened my clinical skills, deepened my understanding of patient care, and
solidified my passion for a field that combines artistry with medical precision to make a tangible
difference in people's lives.
IFMSA Czech Republic, Senovážné náměstí 24, 110 00 Prague 1, Czech Republic
Literature
[1] MU IL. MAMO [Internet]. MAMO. [cited 2024 Jul 18]. Available from:
[Link]
[2] Breast reconstruction using a latissimus dorsi flap
after mastectomy [Internet]. [Link]. [cited 2024
Jul 18]. Available from:
[Link]
latissimus-dorsi-flap-after-mastectomy
[3] Miranda BH, Amin K, Chana JS. The drain
game: Back drains for latissimus dorsi breast
reconstruction. Journal of plastic, reconstructive
& aesthetic surgery. 2014 Feb 1;67(2):226–30.
[4] Shin IS, Lee DW, Lew DH. Efficacy of
Quilting Sutures and Fibrin Sealant Together for
Prevention of Seroma in Extended Latissimus
Dorsi Flap Donor Sites. Archives of Plastic
Surgery. 2012;39(5):509.
[5]de Oliveira RR, do Nascimento SL, Derchain SFM, Sarian LO. Immediate Breast Reconstruction with
a Latissimus Dorsi Flap Has No Detrimental Effects on Shoulder Motion or Postsurgical Complications
up to 1 Year after Surgery. Plastic and Reconstructive Surgery [Internet]. 2013 May 1 [cited 2023 Aug
7];131(5):673e. Available from:
[Link]
[Link]
[ 6] National Cancer Institute. Breast Reconstruction After Mastectomy [Internet]. National Cancer
Institute. [Link]; 2017. Available from: [Link]
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IFMSA Czech Republic, Senovážné náměstí 24, 110 00 Prague 1, Czech Republic
