Flap reconstruction

Rebuilding with your own tissue

Two muscles make it possible to rebuild a breast without relying on an implant alone: the latissimus dorsi, in the back, and the rectus abdominis, in the abdomen. Both are transferred to the chest with the skin and fat that accompany them.

The choice between them depends on the anatomy of the donor sites and on what the patient has available: fat in the back, or an excess of skin and fat in the lower abdomen.

The latissimus dorsi flap

The latissimus dorsi is a large flat muscle of the back, fed by a vascular pedicle arising in the armpit. It has been used in breast reconstruction for a very long time, because it can remain pedicled on its artery and be transferred to the chest with a skin paddle 8 cm wide and 20 cm long.

It replaces the missing breast skin, especially where that skin is dystrophic, and brings a thick, richly vascularised muscle into the reconstructed breast. The scar is placed along the line of the bra strap, and transferring the muscle causes very little or no functional trouble.

With or without an implant

With an implant, the flap provides cover and additional shape. It is an alternative to implant-only reconstruction when the quality of the skin is genuinely poor and the volume to be rebuilt must be large.

Without an implant, the autologous latissimus dorsi technique uses the flap to the full extent of its possibilities, harvesting the skin and the fat of the back attached to the flap. Close to 400 cc of vascularised fat can thus be harvested in addition to the muscle and the skin. The flap is then shaped, and the skin more or less buried within the reconstructed breast. This technique requires the patient to have enough fat in the back.

The rectus abdominis flap

The rectus abdominis is a vertical muscle of the abdomen whose feeding artery runs beneath the lowest rib and beneath the breast. It can be harvested with a paddle of skin and fat taken between the navel and the pubis.

That vascularised mass of skin and fat is transferred to the chest and shaped to form a new breast. The muscle sheath is closed and reinforced with a non-absorbable mesh, and the abdomen is closed using an abdominoplasty technique.

The method is indicated for autologous reconstruction where the patient has a natural excess of skin and fat in the lower abdomen; it additionally improves the abdominal contour.

Recovery

It differs according to the donor site, and that is part of the choice.

For the latissimus dorsi, the hospital stay is 5 to 6 days, and a body-type compression garment is worn for one month. A lymphatic collection in the back is usual: it is aspirated at the office on two or three occasions.

For the rectus abdominis, the hospital stay is 6 days on average. An abdominal compression binder is worn for one month, and muscular exertion is allowed after three months.

Results with the latissimus dorsi are very natural, with a pleasant and reliable long-term appearance for a fully autologous reconstruction; a complement of lipomodelling may sometimes prove necessary. It is also a good technique for immediate reconstruction with preservation of the breast skin. Results with the rectus abdominis are durable, in terms of autologous reconstruction.

The DIEP, and why it is referred elsewhere

Rectus abdominis reconstruction can be performed as a so-called free microsurgical transfer, which has the advantage of preserving the muscle and taking only the main vessel within the flap. That operation is called the DIEP.

It is not performed by Dr Azencot. If you are a suitable candidate, he will direct you to a competent team. Saying what one does not do is part of the consultation.