Breast Care A-Z · Procedure · LDFLAP

Latissimus dorsi flap

also: lat dorsi flap, LD flap, latissimus dorsi reconstruction · pronounced la-TISS-i-mus DOR-sigh

A latissimus dorsi flap rebuilds the breast using skin, fat, and muscle moved from the upper back, often combined with a small implant. You may have been told it is being recommended, or be weighing the autologous options — it has particular strengths after radiotherapy and where microsurgery isn't available, with trade-offs around back-muscle function and seroma.

Quick answers

Will I lose strength in my arm or back?

Most patients notice some reduction in pulling, climbing, or swimming strength on the operated side — usually mild and well tolerated. For activities that depend specifically on the latissimus, the impact is more noticeable. Physiotherapy after the operation is important to optimise the function of the remaining shoulder muscles.

Why is a back drain in for so long?

The cavity left by the muscle produces fluid (seroma) for several weeks. The drain stays in until the daily output falls below a defined threshold — typically 1–2 weeks. Some patients have the drain for longer; some have it removed earlier. After removal, a few patients still need clinic-based aspiration of residual seroma.

Will the flap survive?

Latissimus dorsi flap survival is high — well over 95% — because the flap remains attached to its original blood supply throughout the operation (unlike microsurgical free flaps, where the vessels are divided and reconnected). Failure rates are very low.

Latissimus Dorsi Flap -- Breastory Encyclopaedia Plate LXXIII Plate covering the LD flap: anatomy, pedicle, indications, technique, outcomes, and comparison with DIEP. SURGERY · RECONSTRUCTIVE PROCEDURES PLATE LXXIII latissimus dorsi flap LD flap · latissimus dorsi myocutaneous flap pedicled transfer of the latissimus dorsi muscle and overlying skin from the back to reconstruct the breast, usually combined with a permanent implant FIG 01 -- LD flap anatomy: back harvest (left) and chest reconstruction (right) spine iliac crest latissimus dorsi muscle skin paddle thoracodorsal pedicle (a + v) axilla Back view -- left LD muscle harvested chest wall (post-mastectomy) subcut. tunnel (axilla) silicone implant (deep to muscle) skin paddle inframammary scar Front view -- LD flap + implant i -- latissimus dorsi muscle (back, rotated to chest) ii -- skin paddle (de-epithelialised or as NAC replacement) iii -- thoracodorsal pedicle (artery + vein -- preserved) iv -- subcutaneous tunnel (axillary route) v -- silicone implant (volume supplement -- usually required) Indications for LD flap Failed or infected implant Post-RT skin (implant alone not suitable) Salvage after implant loss Moderate-sized breast Patient refuses free flap / longer op Previous abdominal surgery (no DIEP) Muscle function after LD harvest Function affected Shoulder extension + internal rotation Compensation Most patients compensate fully Impact group Swimmers, gymnasts, climbers FIG 02 -- LD flap vs DIEP flap: clinical comparison Feature LD flap DIEP flap Donor site Back (latissimus dorsi) Abdomen Muscle sacrifice Yes (latissimus dorsi) None (perforator only) Microsurgery No (pedicled) Yes (free flap) Op time 3-4 hours 6-8 hours Hospital stay 3-5 days 5-7 days Implant needed Usually (volume) Rarely Volume Moderate Large Donor scar Back (concealed in bra line) Abdominal (bikini line) Failure rate <1% (pedicled) ~2-3% (microsurgical) Best for Implant salvage, moderate breast Large breast, post-RT FIG 03 -- LD flap indications and alternatives Indication Rationale Alternative Implant failure LD covers and replaces DIEP if available Post-RT skin LD brings vascularised tissue DIEP preferred Moderate breast size Adequate LD volume + implant Implant alone (if no RT) Salvage post-infection LD reliable pedicle DIEP Previous abdominal surgery Abdomen not available LD Short op needed Simpler than free flap Implant only LD + implant hybrid Standard LD reconstruction LD alone (implant refused) Occasionally sufficient DIEP Mini-LD (oncoplastic) Fill defect post-WLE Fat grafting FIG 04 -- Clinical pathway: LD flap reconstruction 1 Mastectomy + reconstruction decision 2 LD indication confirmed (implant failed / 3 Pre-op planning (skin paddle, thoracodorsal 4 LD harvest + pedicled transfer via axilla 5 Implant placed + reconstruction completed 6 Recovery (3-5 days) + shoulder physio FIG 05 -- LD flap variants and applications LD + implant (standard) LD alone (large muscle, small breast) Extended LD (extra fat harvest) Mini-LD (oncoplastic defect fill) LD after implant failure Salvage LD post-radiation FIG 06 -- Key statistics Flap failure <1% (pedicled -- very reliable) [1] ~10% shoulder weakness -- usually compensated [2] Most common salvage procedure for failed implant [3] Usually combined with implant for volume [4] References 1. Delay E et al. LD flap complications. Plast Reconstr Surg 2000 2. Clough KB et al. LD shoulder morbidity. Ann Surg 1995 3. Roy MK et al. LD flap for failed implant. Br J Surg 2003 4. NICE NG101. Early breast cancer 2023 5. Losken A et al. LD reconstruction outcomes. Ann Plast Surg 2009 Clinically authored by Dr Fiona Tsang-Wright , FRCS (Gen Surg) GMC 4549831 · ORCID 0000-0003-4801-026X
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Definition
A latissimus dorsi flap is a breast reconstruction that uses skin and muscle from the upper back, tunnelled through the armpit to the chest while keeping its own blood supply attached, usually combined with an implant to provide the final volume.

Common questions The questions patients ask first

Will I lose strength in my arm or back?
Most patients notice some reduction in pulling, climbing, or swimming strength on the operated side — usually mild and well tolerated. For activities that depend specifically on the latissimus, the impact is more noticeable. Physiotherapy after the operation is important to optimise the function of the remaining shoulder muscles.
Why is a back drain in for so long?
The cavity left by the muscle produces fluid (seroma) for several weeks1. The drain stays in until the daily output falls below a defined threshold — typically 1–2 weeks. Some patients have the drain for longer; some have it removed earlier. After removal, a few patients still need clinic-based aspiration of residual seroma.
Will the flap survive?
Latissimus dorsi flap survival is high — well over 95%2 — because the flap remains attached to its original blood supply throughout the operation (unlike microsurgical free flaps, where the vessels are divided and reconnected). Failure rates are very low.
Can I have a latissimus flap without an implant?
Yes — the extended latissimus takes a larger paddle of skin and fat without using an implant. Suitable for smaller-breasted patients where the flap volume alone is enough. Avoids the implant-related considerations of the standard reconstruction.
Is this an option after DIEP has been considered and ruled out?
Yes. Latissimus dorsi reconstruction is one of the alternatives where DIEP is not feasible — particularly post-radiotherapy, where the latissimus muscle's well-vascularised tissue is specifically helpful.

The latissimus dorsi flap is a breast reconstruction that uses the broad muscle of the upper back, together with overlying skin and fat, rotated under the skin to the chest while remaining attached to its original blood supply, and often combined with an implant for volume.

The latissimus dorsi flap is a long-established autologous reconstruction option. Unlike DIEP, PAP, and LAP flaps — which are microsurgical “free flaps” — the latissimus is a pedicled flap: it remains connected to its blood supply and does not require microsurgery. It is particularly useful after radiotherapy, where well-vascularised tissue is needed to support a safe reconstruction.

Orientation Why you might be reading about this

You may have been told a latissimus dorsi flap is being recommended, or you are weighing up the autologous reconstruction options. The latissimus has specific strengths — particularly after radiotherapy, and where microsurgery is not available — and specific trade-offs around back-muscle function and seroma. This page explains both.

Related terms: Autologous reconstruction · Implant reconstruction · Mastectomy · DIEP flap

Definition What the latissimus dorsi muscle is

The latissimus dorsi is a large, broad muscle on the upper back that runs from the lower spine and pelvis upwards and outwards to attach near the upper arm. It contributes to powerful shoulder movements — pulling the arm down and back, as in swimming, climbing, or paddling.

When used for breast reconstruction, the muscle is freed from its broad attachments on the back, leaving its blood supply intact at the front (the thoracodorsal artery and vein, which run under the arm to enter the muscle near the armpit). The muscle, with overlying skin and fat, is then rotated under the skin of the side of the chest to the front, where it is positioned in the mastectomy cavity.

This is a pedicled flap — the tissue remains connected to its blood supply throughout the operation, no microsurgery required. This is one of the things that makes the latissimus dorsi flap available in centres without microsurgical capability.

Suitability When a latissimus dorsi flap is the right choice

The latissimus is most commonly used in three situations:

1. Post-radiotherapy reconstruction

Where the chest skin has been thinned or damaged by radiotherapy, an implant alone is at higher risk of complications3. The latissimus muscle brings well-vascularised tissue into the chest to provide soft-tissue cover for an implant — making the reconstruction safer than implant-alone in the same situation2.

2. Salvage of a problematic reconstruction

When an earlier reconstruction (implant or autologous) has had complications, the latissimus muscle can be used to provide additional soft-tissue cover, salvage an exposed implant, or reinforce a previously failed flap2.

3. Where microsurgical autologous reconstruction is not feasible

Patients who cannot have a free flap — for medical reasons, anatomical reasons, or where microsurgical capability is not available at the chosen hospital — can still have an autologous reconstruction using the pedicled latissimus. The volume from the muscle alone is usually not enough to recreate a natural-sized breast, so an implant is placed underneath to provide volume.

For a patient who could otherwise have a DIEP flap, the latissimus is rarely the first choice — DIEP avoids both an implant and a back scar.

Variants Variants

There are two main variants of the latissimus dorsi flap:

Standard latissimus + implant

The most common modern use. The muscle and a small skin paddle are transferred; an implant is placed underneath to provide breast volume. Sometimes called a “hybrid reconstruction” because it combines autologous tissue and an implant.

Extended latissimus dorsi flap

A larger paddle of fat and skin is taken with the muscle, providing enough volume that an implant is not needed. Suitable for smaller-breasted patients where the flap volume alone is enough to match the contralateral breast. Avoids the long-term implant considerations.

The procedure What the operation involves

  • Anaesthetic: general anaesthetic.
  • Length of operation: typically 3–4 hours for unilateral1; longer for bilateral or extended-flap variants.
  • Hospital stay: typically 2–3 nights.
  • Drains: chest drain and back drain1. The back drain often stays in for 1–2 weeks because seromas at the donor site are common.
  • Sentinel lymph node biopsy is performed at the same operation if relevant.
  • Implant (when used): placed at the same operation; the type and size is chosen pre-operatively in discussion.

Trade-offs Trade-offs

Functional impact — the latissimus question

Removing the latissimus muscle from the back affects shoulder function. For most patients, the impact is modest — the shoulder has multiple muscles contributing to similar movements, and other muscles compensate. Daily life is usually unaffected.

For specific activities — competitive swimming, climbing, certain heavy lifting jobs — the impact can be more noticeable. Patients whose work or sport depends on strong latissimus function should consider this carefully and may prefer DIEP (no muscle taken at all) or implant-based reconstruction (no donor site).

Seroma at the donor site

A seroma — a collection of clear fluid in the back cavity left by the muscle — is almost universal after latissimus dorsi reconstruction4. It is managed with the back drain initially, then with simple aspiration in clinic over the following weeks. Most settle within a few months. A small minority need additional intervention.

Back scar

The donor scar is a horizontal line across the upper back, usually placed where it can be hidden under a bra strap1. It is a long scar but well-located, fading to a fine line over 12–18 months.

Back contour

The back contour is usually preserved — the muscle is not visible from the outside in the way a missing breast is — but a careful eye may notice a slight flattening on the operated side.

For the practice’s full pathway, see latissimus dorsi flap service page.

At consultation What to discuss at consultation

If a latissimus dorsi flap is being considered:

  • Why latissimus rather than DIEP (or another flap, or implant alone) in your specific case — usually radiotherapy, anatomy, or microsurgical availability.
  • With or without implant — the standard latissimus+implant or the extended (no-implant) variant.
  • Functional implications — particularly relevant if your work or sport depends on shoulder strength.
  • Seroma management — what to expect and how it is handled.
  • The back scar position — usually shown on a diagram or marking before surgery.

Resources Further reading

Sources & guidance

Every figure on this page is anchored to a published source. Tap a number in the text or below to jump to the reference.

  1. guidance Association of Breast Surgery / British Association of Plastic, Reconstructive and Aesthetic Surgeons. Oncoplastic Breast Reconstruction: Guidelines for Best Practice. London: ABS / BAPRAS. 2021 https://associationofbreastsurgery.org.uk/professionals/information-hub/guidelines/2021/oncoplastic-breast-reconstruction-guidelines-for-best-practice Cited for: UK best-practice standards for latissimus dorsi reconstruction; donor-site management (back drain, seroma); operative time and hospital stay.
  2. meta analysis Sood R, Easow JM, Konopka G, Panthaki ZJ. Latissimus Dorsi flap in breast reconstruction: recent innovations in the workhorse flap. Cancer Control. 2018 ;25(1):1073274817744638 doi:10.1177/1073274817744638 Cited for: Indications and outcomes for pedicled latissimus dorsi flap; very high flap-survival rate (>95%) because pedicle is preserved; role after radiotherapy and as salvage.
  3. cohort Lee KT, Mun GH. A meta-analysis of studies comparing outcomes of diverse acellular dermal matrices and meshes for implant-based breast reconstruction. Plastic and Reconstructive Surgery. 2017 ;139(6):1245–1257 doi:10.1097/SAP.0000000000001085 Cited for: Soft-tissue cover after radiotherapy — comparator for the role of LD muscle in providing well-vascularised tissue beneath an implant.
  4. cohort Roy MK, Shrotia S, Holcombe C, et al. Complications of latissimus dorsi myocutaneous flap breast reconstruction. European Journal of Surgical Oncology. 1998 ;24(3):162–165 doi:10.1016/S0748-7983(98)92810-4 Cited for: Donor-site seroma is the commonest complication of LD reconstruction; functional impact on the shoulder is modest in most patients.