What is the purpose and procedure of a latissimus dorsi flap in reconstructive surgery?

Latissimus Dorsi Flap in Reconstructive Surgery

The latissimus dorsi (LD) flap is a versatile autologous tissue technique used primarily in breast reconstruction following mastectomy, providing both coverage and volume with acceptable donor-site morbidity and improved quality of life for patients. 1

Purpose of Latissimus Dorsi Flap

• Serves as a myocutaneous tissue flap that can replace relatively large volumes of breast tissue in reconstruction following mastectomy 1
• Provides both coverage and volume for complex anterolateral chest defects with relatively short surgery time 2
• Improves quality of life for patients who have undergone mastectomy by addressing cosmetic, body image, and psychosocial issues 1
• Can be used alone or in combination with implants (composite reconstruction) to achieve better symmetry and volume 1

Anatomical Considerations

• The LD flap utilizes the latissimus dorsi muscle from the back, which has a reliable blood supply from the thoracodorsal artery (TDA) 1
• The flap can be designed as a muscle-only flap or as a myocutaneous flap that includes both muscle and overlying skin 1
• In cases where the thoracodorsal artery is damaged, alternative blood supply can come from posterior intercostal artery perforators (P-ICAP) 2
• The thoracodorsal artery perforator (TDAP) flap variant allows preservation of the latissimus dorsi muscle, reducing donor site morbidity 3

Procedure Overview

1. Preoperative planning:

   • Patient selection and assessment of suitability for LD flap reconstruction 1
   • Consideration of factors such as smoking status and obesity, which are relative contraindications due to increased risk of complications 1

2. Surgical technique:

   • The LD muscle is harvested from the back, traditionally in lateral decubitus position, though dorsal decubitus positioning allows for simultaneous work by two surgical teams 4
   • The flap is elevated with its vascular pedicle (thoracodorsal vessels) 1
   • The muscle with or without overlying skin is tunneled to the anterior chest wall or breast area 1
   • The flap can be used alone or in combination with implants for optimal volume and symmetry 1

3. Timing options:

   • Can be performed as immediate reconstruction at the time of mastectomy 1
   • Can be performed as delayed reconstruction any time after mastectomy 1
   • May be preferred over implant-based reconstruction in patients who will undergo radiation therapy, as autologous tissue better tolerates radiation 1

Clinical Applications

• Primary breast reconstruction: Most common use, can be performed with or without implants 5
• Defect coverage: Used for covering defects after removal of large tumors 5
• Implant-to-flap conversion: When implant-based reconstruction has failed or is problematic 5
• Chest wall reconstruction: For complex anterolateral chest defects 2

Complications and Considerations

• Common complications:

  • Seroma (most common, occurring in approximately 26% of patients) 5
  • Wound dehiscence (8%) 5
  • Surgical site infection (7%) 5
  • Partial skin/nipple necrosis (7%) 5
  • Hematoma requiring surgical evacuation (2%) 5
  • Flap loss due to necrosis (rare, approximately 2%) 5

• Important considerations:

  • Radiation therapy may affect the cosmetic outcome but autologous tissue generally tolerates radiation better than implants 1
  • Smoking and obesity increase the risk of wound healing complications and partial or complete flap failure 1
  • The procedure may require additional surgeries on the contralateral breast to achieve optimal symmetry 1

Evolution and Alternatives

• The LD flap has been partially replaced by abdominal flaps (TRAM, DIEP) as the first choice for breast reconstruction, but remains valuable in specific clinical situations 5
• The thoracodorsal artery perforator (TDAP) flap represents an evolution that preserves the latissimus dorsi muscle function while providing similar coverage 3
• The perforator-based fasciocutaneous extension of the LD flap increases versatility for complex reconstructions 6

The latissimus dorsi flap continues to be an important option in the reconstructive surgeon's arsenal, particularly for patients who are not candidates for abdominal-based flaps or who require specific reconstructive solutions for complex defects.