Latissimus dorsi flap reconstruction

What the operation is

A latissimus dorsi flap uses the latissimus dorsi muscle — a large, broad muscle on the upper back — together with overlying skin and fat, to reconstruct the breast after mastectomy. The flap is rotated under the skin from the back to the chest while remaining attached to its original blood supply (a pedicled flap), so no microsurgery is required.

The technique has been used for decades and remains a useful option in several specific situations. The volume of tissue alone is usually not enough to recreate a natural-sized breast; for that reason, a latissimus dorsi flap is typically combined with an implant placed underneath the muscle to provide volume, with the muscle and skin providing soft-tissue coverage and shape.

A variant — the extended latissimus dorsi flap — takes a larger paddle of skin and fat without an implant, suitable for smaller-breasted patients.

When latissimus dorsi is offered

The latissimus dorsi flap is considered when:

Implant-based reconstruction alone is not advisable — for example after radiotherapy, where the chest skin has limited blood supply and is unlikely to tolerate an implant on its own. The latissimus dorsi muscle brings well-vascularised tissue into the chest to allow safe implant cover.
Microsurgical autologous reconstruction (DIEP, PAP) is not feasible — for medical reasons, anatomical reasons, or where microsurgical capability is not available at the chosen hospital.
A specific area of the chest needs additional soft-tissue coverage — for example after a previous failed reconstruction or for patients with very thin chest-wall skin.
Salvage of a problematic implant reconstruction — the latissimus muscle can be used to cover an exposed implant or to provide soft-tissue support to a previously failed reconstruction.

It is less often the first choice for primary autologous reconstruction in patients who can have DIEP, because DIEP avoids both an implant and a back scar. The decision is individual.

How the operation works

The flap is raised through an incision on the upper back, usually placed horizontally so it can be hidden under the strap of a bra. The skin paddle is sized to match what is needed at the chest — sometimes a thin ellipse, sometimes a larger oval.

The latissimus dorsi muscle, together with the overlying skin and fat, is freed from 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 flap is then rotated under the skin of the side of the chest to the front of the chest, where it is positioned in the mastectomy cavity.

When an implant is part of the reconstruction, it is placed underneath the latissimus muscle at the same operation. The skin paddle from the back forms an island in the centre of the new breast — for skin-sparing or nipple-sparing mastectomies, the skin paddle may be very small or even buried (de-epithelialised), with the original breast skin envelope providing the visible surface.

The back wound is closed in layers, with drains placed to manage the fluid (seroma) that almost always collects at the donor site for several weeks.

What the operation involves

Anaesthetic: general anaesthetic.
Length of operation: typically 3–4 hours for unilateral; longer for bilateral or when combined with extensive immediate reconstruction.
Hospital stay: typically 3–5 nights (sometimes shorter with enhanced-recovery pathways).
Drains: chest drain and back drain. The back drain is usually the slowest to come out — sometimes worn home for 1–2 weeks because seromas at the back donor site are common.
Sentinel lymph node biopsy is performed at the same operation if relevant.
Implant: when used, placed at the same operation; type and size is chosen pre-operatively in discussion.

Recovery

First week — in hospital initially, then at home with drains. Limited shoulder movement on the operated side. Pain relief is structured.
Weeks 2–4 — at home, with continued attention to the back wound. Drains usually removed. Driving usually resumes around 4–6 weeks, once shoulder movement is comfortable and an emergency stop can be performed.
Weeks 4–6 — desk-based work resumed. Continuing physiotherapy for shoulder and back range of movement.
Three months — most physical activity resumed. Some patients notice a reduction in shoulder strength and back power — particularly for movements that pull or push from the operated side — that is usually well tolerated but may be noticed in specific activities (climbing, swimming, certain weight exercises).
One year — most patients are at their final functional and cosmetic outcome.

A surgical bra is worn day and night for 4–6 weeks to support the new breast while it heals.

Functional impact — the latissimus question

The latissimus dorsi muscle contributes to powerful shoulder movements: pulling the arm down and back (as in swimming, climbing, or paddling a kayak), and helping stabilise the shoulder during heavy upper-body work. Removing the muscle for a flap means the shoulder loses that contribution.

For most patients, the functional impact is modest — the shoulder has multiple muscles contributing to the same movements, and other muscles compensate. Daily life is usually unaffected. Specific activities — competitive swimming, climbing, certain heavy lifting jobs — may be more noticeably affected.

If your work or your sport depends on strong latissimus function, this is an important conversation at consultation. For some patients, this consideration tips the balance towards DIEP (no muscle taken at all) or implant-based reconstruction (no donor site).

Seroma at the back donor site is the other common medium-term issue: a collection of fluid that develops in the cavity left by the muscle. Most are managed with simple aspiration in clinic over several visits, settling over a few months. A small minority need a more involved intervention.

Cosmetic outcome and what to expect

The reconstructed breast has soft-tissue cover from the latissimus muscle, with implant volume underneath in most cases. The result feels softer and more natural to the touch than implant-only reconstruction, particularly after radiotherapy.
The chest scar is similar to other reconstruction approaches — around the areola, vertically, or horizontally in the mastectomy line, depending on the mastectomy pattern.
The back scar is horizontal across the upper back, usually placed where it can be hidden by a bra strap. It is a long scar but in a position most patients find acceptable. Initially red and raised, it fades over 12–18 months.
Back contour is usually preserved well — the muscle is not visible from the outside in the way a missing breast is — but a careful eye may notice a slight flattening of the upper back on the operated side.
Symmetry with the other breast is good in most cases, particularly when an appropriately sized implant is used. Minor revisions for symmetry are not uncommon.

Common questions The questions patients ask first

Why a back flap when there are options that don’t need a separate site?

Because in some situations — particularly after radiotherapy, where chest skin alone cannot reliably support an implant — the additional well-vascularised tissue from the back is what makes a safe reconstruction possible. The back is also a useful donor site when DIEP and PAP are not feasible.

Is this an autologous reconstruction or an implant reconstruction?

Both, in most cases. The latissimus dorsi flap brings autologous tissue, but implant volume is usually needed to recreate breast size. The combination is sometimes called a “hybrid” reconstruction. The implant is part of the reconstruction in the same way it is for an implant-only reconstruction; revision and replacement considerations are similar.

Will I lose strength in my arm?

Most patients notice some reduction in pulling, climbing, or swimming strength — 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.

What is a seroma and why does it matter?

A seroma is a collection of clear fluid that develops at the donor site after the muscle has been moved. Latissimus dorsi reconstructions almost always produce a seroma at the back, which is managed with a drain initially and sometimes simple aspiration in clinic over the following weeks. It is the most common complication of this operation — so common it is expected as part of recovery rather than an unexpected event. Persistent or large seromas are uncommon but do occasionally need additional intervention.

Can I have latissimus dorsi reconstruction without an implant?

Yes, with the extended latissimus dorsi flap, which takes a larger paddle of fat and skin without using an implant. This is suitable for smaller-breasted patients where the flap volume alone is enough to match the contralateral breast. It avoids the implant-related considerations of the standard latissimus 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. It is also sometimes used when DIEP is suitable but the patient prefers a non-microsurgical approach, or where a hospital does not offer microsurgical reconstruction.