This is a common plastic surgical technique for breast reconstruction which involves transferring the back muscle (latissimus dorsi muscle) under the skin in the armpit area and moving it to the breast pocket. The muscle covers a substantial part of the back and is a ‘climbing muscle’ used by athletes. Removal of the muscle does not affect an individual in day to day activities, though some patients notice a slightly stiff shoulder. The muscle transfer is done with a piece of overlying back skin and the exact orientation of this will be discussed by your surgeon. Orientation of the skin depends on the position of excess tissue as well as the type of clothes you wear. Aside from the orientation of skin there are two standard types of this operation:
- Taking the muscle and skin piece and then using an implant or expander to build up volume on the breast.
- Taking the muscle and skin piece with a layer of extra fat on the back with or without using an expander or implant.
Option 1 is the more common variant practised by myself, but I shall discuss this with you in detail. The muscle transfer is particularly suitable if you are going to have or had radiotherapy, as a pure implant based reconstruction is associated with a high rate of complications. The other advantage of adding muscle to any reconstruction is that it gives a more natural appearance than a pure implant based reconstruction.
If I use a definitive implant under the breast, then this stays permanently. If an expander is used than you need another operation to change the temporary expander for a definitive implant. The two stage approach is sometimes necessary when the tissues on the breast are very tight and scarred. The expander is slowly increased in size by filling it up with saline. When it reaches an acceptable size, the expander is eventually removed and replaced with a definitive implant under the muscle.
The results are generally excellent with high satisfaction rates. In this description I shall take you through the operation, hospital stay, recovery and the complications. Once you have met me for the initial consultation, I would be quite happy to see you again for a second consultation, so that you can clarify any of your doubts.
It is advisable to stop smoking for 4 weeks and stop contraceptive pill and hormone replacement therapy for 4 weeks prior to the procedure. On the day of the operation, the surgeon will do skin markings over the breasts. The procedure is done under general anaesthetic and takes a few hours to perform. The actual time taken varies on the type of procedure or whether it involves a simultaneous mastectomy and armpit gland removal. While you are in hospital you will have blood tests, fluids through a drip and pain killers. The stitches are all dissolving in nature. At the end there is a fairly bulky dressing on the breasts. There are a couple of drains on the back and a drain or two on the front of the chest. You will feel bruised and swollen after the operation and this settles in due course. Because it is a flap based reconstruction, you will be closely monitored to make sure that the flap is healthy. A urinary catheter is frequently inserted at the time of surgery, to monitor urine output. This is subsequently removed. We take precautions to prevent clots in your calves by putting on stockings and giving you a blood thinning injection. The hospital stay is conventionally 5-7 days and depends on recovery and drain removal.
You will normally have some physiotherapy and a visit from the breast care nurses who will advice you on postoperative care, exercises and bra wear.
Recovery After Surgery
At discharge the dressing stays on and you will need to attend the dressing clinic in a weeks time. The dressing will then be removed and the nurse will assess you for expansion if you have an expander. You should avoid smoking for 4 weeks after the procedure. The recovery is individual, but most patients get back to work and driving in 4 weeks time. Aerobics and more vigorous exercise, especially with implants under the muscle should be done only around 3 months after the procedure.
Overall results are excellent but there are some well know limitations, risks and complications which you should be aware about.
- I cannot promise you the ultimate cup size and there is wide variation among bra manufacturers.
- Breasts are asymmetrical and this difference will persist after surgery.
- Breasts are never static and will change with age, weight changes and pregnancy.
- Scars heal well but can become rarely lumpy.
- Infection can occur which may require antibiotics and implant removal.
- It is very common to have a collection of straw coloured fluid in the back. This may necessitate aspiration with a needle.
- You can get a dish like deformity in the back, due to the muscle transfer.
- Bleeding straight after surgery may necessitate a return to theatre.
- Implants can rupture and then need to be replaced.
- Occasionally silicone leakage can result in lumps in the breast, which are harmless.
- Occasionally one can feel the implant edge and occasional ripples.
- Tear drop shaped implants can occasionally rotate or get displaced to the side.
- Implants always develop a capsule of scar tissue around them, but in some it can become quite hard and painful and may require further treatment. Capsule formation is more common if you have had radiotherapy.
- The life expectancy of implants is unknown, though manufacturers have suggested that they last for 10 years. It is frequent to see patients who have had implants for much longer.
- Clots in the calf and clots going to the lung are known to occur after any operation.
- Silicone is completely safe and has no relationship to breast cancer or any connective tissue disorder. This matter has been ratified in USA and in a wide ranging study in the UK (Department of Health, UK).
- The flap is a very robust muscle, but uncommonly one can have flap failure, then the flap needs to be removed.
- The muscle can occasionally twitch on shoulder movement.
- It is common to have dog ear on the back scar and this may require revision in the future.
- May feel lumpiness in the armpit, which is basically the muscle flap passing from the back to the front of the chest.
- Stiffness of shoulder can result, and you will be advised on exercises.
- If you have radiotherapy after the flap procedure, the final appearance is even more unpredictable, as tissues have a variable response and there is considerable scarring.
- Nipple reconstruction and tattooing are recommended procedure which can make a big difference to the appearance of the breast.
- Mastopexy (breast lift) procedure on the normal breast may be necessary to give good symmetry.