Breast Reconstruction Using Back Muscle

Breast cancer is a terrible disease, but fortunately it can be treated with surgery. If you or someone you know has been affected by breast cancer, it’s important to understand all of your options for treatment, including reconstructive surgery.

Breast reconstruction is a procedure that uses tissue from other parts of the body to rebuild the breasts after mastectomy. There are several different types of reconstructive procedures available, including flap reconstruction (using tissue from another part of your body), implant reconstruction (using an implant), and autologous tissue transfer (using fat or skin grafts). All three methods can be used for primary reconstruction (after mastectomy), partial breast reconstruction (after lumpectomy), or full breast reconstruction (after mastectomy).

The most common type of flap reconstruction is DIEP flap surgery, which uses abdominal skin and fat as well as muscle and nerves from the lower abdomen to create a new breast mound. In transverse rectus abdominis myocutaneous flap (TRAM) surgery, tissue is taken from your lower abdomen and cut into a thin sheet; then it’s sewn into place over your chest wall with stitches that wrap around both sides

Breast Reconstruction Using Back Muscle

breast reconstruction using abdominal tissue

Breast reconstruction using body tissue

Breast reconstruction using body tissue

Your surgeon might be able to use your own body tissue to make a new breast during a mastectomy operation or some time afterwards. They call this a flap reconstruction.

Using body tissue to make a new breast

To do this your surgeon takes skin, fat, and sometimes muscle (a flap) from another part of your body and makes it into a breast shape. The flap needs a good blood supply, or the tissue will die. So the surgeon will leave the body tissue connected to its original blood vessels. Or they can cut the blood vessels and reconnect them to blood vessels under your arm or in your chest wall. 

If your surgeon leaves the flap connected to its own blood supply it is called a pedicled flap.

If they connect the flap to new blood vessels, this involves microsurgery and they call it a free flap.

Before your surgery, you may have a type of CT scan called a CT angiogram. This looks at the blood supply of the tissue that’s used to create the new breast.

Who has body tissue reconstruction?

Flap reconstruction methods might suit you if:

• you have large breasts
• you have had radiotherapy
• you had a radical mastectomy with removal of your chest muscle
• you have a tight mastectomy scar 
• you want a softer and more realistic result than a silicone implant might give 
• you are not able to have an implant

Who can’t have this type of surgery?

This type of surgery may not be suitable if you have diabetes, smoke, or are very overweight. 

Types of body tissue reconstruction

Your surgeon can reconstruct your breast by:

• using a flap from your back (latissimus dorsi flap) 
• using a flap from your abdomen (TRAM flap) 
• using just skin and fat from the abdomen (DIEP reconstruction)
• using just skin and fat from the buttock (SGAP or IGAP)
• using skin, fat and muscle from the thigh (TMG or TUG) 

Radiotherapy and flap reconstruction

If you have radiotherapy to a flap, this won’t affect it straight away. But it may cause changes to the reconstructed breast in the future. After about 10 years the flap might shrink, discolour, harden, or change shape. You might then need further surgery to create a flap from a different part of the body.

Using a flap from your back (latissimus dorsi flap)

The latissimus dorsi is a muscle in your back, under your shoulder blade. Its job is to move the arm into your side and backwards. Other muscles around the shoulder also do the same job.

Your surgeon uses the muscle, and the skin and fat covering it, to make a new breast. You might need to have an implant put in as well if you have larger breasts. Or you could have the other breast made smaller.

The surgeon tunnels the flap under the skin to the front of the body to make the new breast. This is called a pedicled flap. With this type of reconstruction, the flap keeps its original blood supply.

You will have a scar on your back, roughly 6 inches (15cm) long. You can choose to have the scar horizontally so you can hide it under your bra. Or you can have it diagonally if you don’t want it to show under backless clothes. You can discuss the position of the scar with your surgeon.

If you are having the reconstruction after your mastectomy, you will also have an oval scar on the reconstructed breast.

A latissmus dorsi flap operation takes less time to recover from than an operation using the abdominal muscles. You will be in hospital for about 4 days. It takes about 4 weeks to get over the surgery.

Using a flap from your abdomen (TRAM flap)

The rectus abdominis muscle is in your tummy (abdomen) and runs from your breastbone to your pubic bone. For a TRAM flap reconstruction the surgeon takes part of this muscle, with its skin, fat, and blood vessels. They move it to your chest wall to make a new breast.

The most common way of creating the new breast is called a free flap. Your surgeon completely cuts away the skin and fat from the abdomen. They then connect the flap’s blood vessels to blood vessels in the chest wall or armpit.

The surgeon will stitch up your abdomen in a similar way to having a tummy tuck.

After a TRAM flap

After the operation, you stay on bed rest for about 48 hours. You may have a tube draining urine from your bladder (a catheter) so you don’t have to get up. Your room will be kept very warm to encourage a good blood flow to the flap.

You will have a scar running across your abdomen (horizontally). If you have the reconstruction after you had your mastectomy, you will also have an oval scar on the reconstructed breast.

You might feel uncomfortable for a while after your abdominal operation. Recovery takes longer than for the back flap method and you will be in hospital for about a week. It will be about 7 weeks in all before you have recovered. But it takes another 6 months or more before your tummy is as supple as before.

Possible complications

There is a risk of blood clots blocking the blood vessels in the flap, which cuts off the blood supply and the flap tissue will die. This complication can be serious but is not very common.

After TRAM flap reconstruction, the abdominal muscle can be weaker. This increases your risk of having a hernia in the future. Sometimes surgeons fix a piece of mesh in place during the operation to help strengthen the abdominal wall. 

• Find out more about problems after breast reconstruction

Taking just skin and fat from the abdomen (DIEP reconstruction)

A DIEP reconstruction is very similar to abdominal muscle reconstruction. But the surgeon only takes skin and fat from the abdomen to make the breast shape. They leave the abdominal muscle in place as they remove the skin and fat along with the blood vessel that keeps the tissue alive.

DIEP stands for deep inferior epigastric perforators, which are the blood vessels used in the reconstruction.

The surgeon carefully teases out the blood vessel from the muscle. The advantage of this operation is that the abdominal wall is not so weakened, because the muscle is still there. So there is less risk of hernia afterwards.

With these flaps the surgeon uses microsurgery to join up the flap’s blood vessels to small blood vessels in the chest wall or armpit. As with the free TRAM flap, the blood supply can become completely blocked off with clots.

Some women may need to go back to the operating theatre within a few days to improve the blood supply. If the blood supply is cut off, the flap tissue dies and the reconstruction will fail, but this is rare.

Having a DIEP flap allows you to keep as much abdominal strength as possible. So you might want to have a DIEP reconstruction if your abdominal strength is very important to you. Do to talk to your surgeon about the benefits and risks of surgery and what is best for you.

Taking fat and skin from the buttocks (SGAP or IGAP)

Your surgeon might use microsurgery to move fat and skin from the buttock to create new breast tissue.

Taking tissue from the upper part of the buttock is a superior gluteal artery perforator flap (SGAP).

Taking tissue from the lower part of the buttock is an inferior gluteal artery perforator flap (IGAP).

Taking tissue from the buttock leaves a dent in that area and a small scar. Because the buttock tissue is often thicker than normal breast tissue it means your new breast can be a bit firmer than with other types of reconstruction.

These operations are more difficult than taking tissue from the back or abdomen and more likely to have complications. So this type of reconstruction is not commonly used and is generally for women who can’t have other types. Your surgeon might offer it if you are too slim to take tissue from the abdomen or if you have scarring from previous surgery in the abdomen or back.

Only a few surgeons in the UK can do this surgery and you might need to travel to a specialist hospital.

Taking fat, skin and muscle from the thigh (TMG or TUG)

Your surgeon might use microsurgery to move fat, skin and muscle from the upper part of the thigh.

Taking tissue from the outer part of the thigh is called a transverse myocutaneous gracilis flap (TMG), a lateral thigh flap, or a saddle bag flap.

Taking tissue from the inner part of the thigh is a transverse upper gracilis flap (TUG).

The operation leaves a dent in the thigh and a scar. 

These operations generally only give a small amount of tissue. So your surgeon might only consider them if you can’t have back or abdominal muscle reconstruction. Your surgeon may offer these operations if you are too slim to take tissue from the abdomen or if you have scarring from previous surgery in the abdomen or back.

Only a few surgeons in the UK can do this type of reconstruction and you may need to travel to a specialist hospital.

Reshaping the breast (lipomodelling)

Sometimes after surgery, the breast can look uneven. Surgeons can adjust the shape by injecting fat into the breast. They call this lipomodelling or lipofilling. 

This technique can improve the appearance of the breast by filling in dents after breast conserving surgery. It can also help to reshape the breast after breast reconstruction.

How you have lipomodelling

Surgeons remove fat from other parts of the body, for example, the hip or thighs. They do this by inserting a narrow tube (cannula) into the fat through a tiny cut (incision). They create suction using a vacuum pump or a large syringe. 

Your surgeon then injects the fat into the dents in the reconstructed breast to improve the shape. You usually have this as a day case, either under a general anaesthetic or local anaesthetic.

The scars from this procedure are small and often in an area where they can’t be seen.

Afterwards you may notice some bruising or have some pain around the areas where the fat was taken, these will gradually improve. Some fat is often absorbed into the body over time, so you may need to have this procedure more than once. 

Possible effects of injecting fat

Some surgeons have reported that injecting fat into the breast seems to reverse some of the side effects of radiotherapy. It seems to reduce thickening of the tissue in the radiotherapy area and reduce skin tightness. It might also lessen the appearance of blood vessels under the skin (telangiectasia). Some small research studies seem to support this finding. 

There are some theories about why the fat reverses these radiotherapy side effects. Surgeons think that stem cells in the transplanted fat tissue might stimulate healthy breast tissue to develop in the area. Or it may be because fat can create new blood vessels that increase the blood supply.

After reconstruction surgery

Looking after you wound

After surgery the wound is covered with a surgical dressing. Before you go home your nurse will give you instructions on caring for the wound. This will include showering the area and possible problems you should be aware of.

Bras and underwear  

Your bra can help to support the reconstruction. Your surgeon or breast cancer nurse may suggest you wear a soft supportive bra after your surgery. This may be day and night for a couple of weeks.

You may find that a bra that fastens at the front is more comfortable. If you have any swelling, you might need a slightly larger size than usual for a short time.

Your nurse may also suggest that you wear supportive underwear on your lower half. This is for women who have a reconstruction using muscle from their thighs, tummy, or buttock. This helps to reduce swelling and support the wound.

Do speak to your nurse or surgeon before your surgery. They may be able to suggest local places to buy these.

Exercise

After the surgery you need to do some exercises to get your arm and shoulder moving properly again. Your nurse or physiotherapist will show you what to do and explain when to do them.

• Exercises after reconstruction using back muscle

Follow up

This will vary, your nurse will let you know how often you will need follow up appointments. 

You will still have regular mammograms of your other breast. You will not need one for the reconstructed breast unless you have some remaining breast tissue.

Latissimus Dorsi Flap Breast Reconstruction Problems Years Later

Women who undergo a mastectomy to remove cancerous breast tissue often undergo reconstruction of one or both breasts. When it comes to breast reconstruction, the options are vast. A new breast can be made from tissue harvested from the patient’s back, stomach, buttocks, or anywhere else on the body. Doctors call this autologous reconstruction. A different alternative to metal-and-plastic implants are those made of saline or silicone gel. When autologous reconstruction is not enough, an implant may be used.

Three approaches to breast reconstruction were compared in a small study.

Repairing the Latissimus Dorsi Muscle Using a Flap

surgical reconstruction utilizing implants

Repair of the Deep Incision Endothelial Flap

and discovered the latissimus dorsi flap reconstruction resulted in the most significant decrease in shoulder function, strength, and mobility.

The study was printed in the journal Breast Cancer Research and Treatment in November of 2018. The functional shoulder biomechanics of women undergoing mastectomy for breast cancer: impact of reconstruction choice and radiation therapy inclusion” abstract.
Types of reconstruction compared
Reconstruction via latissimus dorsi flap: Your latissimus dorsi muscle is located in your back, just below your shoulder and behind your armpit. It’s the muscle that helps you do twisting movements, such as swinging a racquet or golf club. An oval flap consisting of skin, fat, muscle, and blood vessels is taken from the patient’s upper back and used to reconstruct the breast in a latissimus dorsi flap procedure. This flap is moved under your skin around to your chest to rebuild your breast. The blood vessels (artery and veins) of the flap are left attached to their original blood supply in your back. A latissimus dorsi flap is a muscle-transfer flap because it contains a substantial amount of muscle. Although the skin on your back usually has a slightly different color and texture than breast skin, latissimus dorsi flap breast reconstruction can look very natural.

Reconstructive surgery using the abdominal artery known as the deep inferior epigastric perforator (DIEP) flap. In a DIEP flap, fat, skin, and blood vessels — but no muscle — are cut from the wall of the lower belly and moved up to your chest to rebuild your breast. Using microsurgery, your surgeon will meticulously reconnect the flap’s blood vessels to your chest’s blood vessels. Due to the lack of muscle involvement, most women benefit from a quicker recovery after a DIEP flap and a reduced risk of abdominal muscle weakness. A DIEP flap is considered a muscle-sparing type of flap.

A saline (salt water) or silicone gel-filled implant is surgically positioned either submuscularly or subpectorally to reconstruct the pectoral muscle. Reconstructing the breast with an implant only necessitates incisions to be made in the chest, unlike flap reconstruction (and not a tissue donor site). Nonetheless, more than one treatment might be necessary. Implants can wear out and develop other issues, such as tightness of scar tissue around the implant, which may necessitate additional surgery in the future.

Latissimus Dorsi Flap Muscle Spasms

Surgical Treatment of the Polish Breast Syndrome
Aesthetic and Reconstructive Surgery of the Breast, by Kenneth C. Shestak, 2010.

Recovery from a Latissimus Dorsi Muscle Flap
In these cases, the latissimus dorsi muscle can be used to great effect in breast reconstruction. With the breast tissue envelope now thicker, an implant or tissue expander can be placed underneath it. A lateral axillary breast fold can be approximated by transferring a flap of the lastissmus dorsi muscle to the chest via a high axillary tunnel. Tiny incisions in the back and chest wall are all that’s needed to raise the latissimus dorsi muscle. The best way to transfer the pectoralis major muscle is through a high axillary tunnel cut to mimic its origin and lateral course. Inset along the para-sternal area mimics the true position of the sternal head of the pectoralis major muscle when the muscle is sufficiently mobilized (see Fig. 40.5C, D). A tissue expander is inserted under the muscle to stretch the tissue and change the shape of the skin and latissimus muscle so that an implant can be placed.

Watch video Buy book Latissimus Dorsi Syndrome
Authored by MD, JD, Steven D. Waldman in 2019’s Atlas of Common Pain Syndromes

Abstract
Myofascial pain syndrome is commonly caused by repetitive microtrauma to the latissimus dorsi muscle, which can occur during strenuous use of exercise equipment or tasks that require reaching forward and upward. Another potential trigger for latissimus dorsi myofascial pain syndrome is a direct blow to the muscle.

Myofascial pain syndrome is a type of chronic pain that can be localized or widespread. Physical examination findings of myofascial trigger points are considered diagnostic of myofascial pain syndrome. Pain from these trigger points is often felt in unrelated locations, despite their usually localized nature. Referred pain can be difficult to identify and may be misattributed to other organ systems, leading to unnecessary testing and prolonged recovery times.

See the Chapter
Buy the book Local and Regional Flap Reconstruction of Maxillofacial Defects
Third Edition of Maxillofacial Surgery, 2017; Michael R. Markiewicz, Rui P. Fernandes

Supply of Blood
The thoracodorsal artery and vein provide blood and oxygen to the latissimus dorsi muscle. One of the subscapular arteries’ last tributaries is the thoracodorsal artery. After the circumflex scapular artery branches off, it continues as the thoracodorsal artery. Before rotating the flap, it may be necessary to ligate the angular artery (which supplies the apex of the scapula) and a branch of the thoracodorsal artery (which supplies the serratus muscle). As expected, the thoracodorsal artery consistently divides into medial and lateral branches. Usually, the lateral branch will be the larger of the two. It runs parallel to the muscle’s lateral border, within 1–4 centimeters of that border. In most cases, the medial branch is 45 degrees farther upward than the lateral one. 134 Depending on the nature of the defect to be repaired, the flap can be divided along either vessel, or skin paddles can be oriented along either vessel.

Watch Chapter Buy Book STANDARD WORKHORSE CRASHES
Flaps and Reconstructive Surgery, by Günter Germann and Markus hlbauer, 2009.

Osteomusculocutaneous rib-latissimus-dorsi flap
From the midline to the posterior axillary line, the latissimus dorsi muscle covers the lower ribs. The thoracodorsal artery has blood vessel connections to the periosteal vessels of the ribs. If you want to join the flap to the ninth or tenth rib, you can do that. There is a skeletal length of around 12 centimeters. When lifting a flap, start distally and stop at the intercostal space below the ribs you’ve chosen. After that, the rib is cut in half lengthwise and the intercostal muscles are separated in the intercostal space. Splitting the rib cage open reveals the pleura. As a next step, the proximal end of the part is flipped so that the muscle remains attached. The osteomusculocutaneous flap is isolated on the thoracodorsal neurovascular pedicle by dividing the intercostal muscles proximal to the chosen ribs.

Mechanical instability reduces the rib’s viability as a vascularized graft donor. There isn’t much need for it because of the cortical bone structure and the inherent convexity.