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Chronic Back Pain After Latissimus Dorsi Breast Reconstruction

You’re not the only one who experienced prolonged back discomfort following latissimus dorsi breast reconstruction surgery. The muscle itself is the largest and strongest muscle in the human body, so it’s not surprising that it can cause trouble once it’s been cut or otherwise manipulated. Regrettably, there are several reasons why this type of surgery can result in chronic back pain.

The good news is that after this type of surgery, there are treatments for back pain—but only if you understand what is causing it and how to avoid it. In this exposition, we’ll also consider nerve pain after latissimus dorsi breast reconstruction and pros and cons of latissimus dorsi flap.

Chronic Back Pain After Latissimus Dorsi Breast Reconstruction

Reconstructive breast surgery is now recognized to be an important part of the treatment for breast cancer. Surgical reconstruction options consist of implants, autologous tissue transfer or a combination of the two. The latissimus dorsi flap is a pedicled musculocutaneous flap and is an established method of autologous breast reconstruction.

Lumbar hernias are an unusual type of hernia, the majority occurring after surgery or trauma in this area. The reported incidence of a lumbar hernia subsequent to a latissimus dorsi reconstruction is very low.

Case presentation

We present the unusual case of lumbar herniation after an extended autologous latissimus dorsi flap for breast reconstruction following a mastectomy. The lumbar hernia was confirmed on CT scanning and the patient underwent an open mesh repair of the hernia through the previous latissimus dorsi scar.

Lumbar hernias are a rare complication that can occur following latissimus dorsi breast reconstruction. It should be considered in all patients presenting with persistent pain or swelling in the lumbar region.

Breast reconstruction is an important part of the surgical treatment of breast cancer, and is usually performed following a mastectomy. Surgical options for reconstruction include implants, autologous tissue transfer or a combination of both. Autologous tissue transfer is often the preferred option as it can give a more natural appearance to the breast compared to implants alone [12]. The latissimus dorsi (LD) flap is an established method of autologous breast reconstruction with relatively few contraindications and complications [35].

Lumbar hernias are an unusual type of herniation of the postero-lateral abdominal wall. The majority of this hernia type is acquired, rather than congenital and occurs after surgery or trauma. The diagnosis is usually suspected on clinical grounds and confirmed by CT scanning [67].

Lumbar herniation after an LD flap is an uncommon complication that patients are not routinely warned about during the counseling and consent for the procedure. There have been very few published reports over the past 20 years regarding the incidence, detection and management of this complication [89].

We present the rare case of lumbar herniation following a latissismus dorsi reconstruction for breast cancer and the consequent diagnosis and treatment.

A 63-year old female with a past medical history of bronchiectasis was diagnosed with a grade 3 ductal breast cancer. She initially underwent breast conservation surgery in the form of a right wide local excision and sentinel lymph node biopsy. Due to the proximity of the carcinoma to the surgical resection margins she subsequently had a skin sparing mastectomy and extended autologous latissimus dorsi flap reconstruction.

On her first post-operative outpatient visit she had a large seroma in relation to the tumour site, which was drained in clinic. She was seen two weeks later and was found to have a large seroma over the back wound (LD site); this was aspirated and drained 650 mls serous fluid. On two consecutive outpatient visits at fortnightly intervals she had recurrent large seromas at the LD site. On each occasion these were aspirated and over a litre of serous fluid drained.

On her fourth visit, following aspiration of the seroma there was a residual fullness in the lower region of the LD donor site. On palpation this felt like a separate firm lump, clinically in keeping with a possible lumbar hernia. An urgent CT scan of the abdomen and pelvis confirmed the diagnosis of a lumbar hernia containing the majority of the small bowel and right colon (Figures 1 and 2). The CT scan also demonstrated an incidental finding of an enlarged polycystic liver.

figure 1
Figure 1
figure 2
Figure 2

She accordingly underwent an open repair of the lumbar hernia using the previous LD scar for access (Figure 3). Small bowel loops within the hernia sac were freed from adhesions and the small bowel and caecum reduced into the intra-abdominal cavity. The edges of the defect were closed with interrupted PDS, and a 30 × 30 cm onlay prolene mesh was used for reinforcement.

figure 3
Figure 3

Postoperative recovery was uneventful and she was commenced on adjuvant hormonal and herceptin therapy.

Discussion

Breast conservation surgery is an established method of treatment for early breast cancer. In the majority of patients this method of surgery, in combination with radiotherapy, provides effective oncological therapy and long-term survival as compared to mastectomy. However, over 30% women in the UK still require a mastectomy for the treatment of breast cancer. Reasons for mastectomy include large cancers, those directly behind the nipple, multi-focal cancers, patient preference and increasingly prophylactic mastectomies due to an improved understanding of the genetics of breast cancer.

Mastectomy is known to be associated with significant psychological consequences including a distorted body image, loss of self-esteem and sexual dysfunction. Breast reconstruction should be offered to virtually all women undergoing a mastectomy and is an integral part of the surgical treatment of breast cancer. The benefits of an immediate or delayed breast reconstruction are well recognized, for both emotional and physical well being [4]. Furthermore reconstruction techniques have been shown to be safe with minimal morbidity and no affect on local recurrence rates.

The aims of reconstructive surgery are to correct the anatomical defect after mastectomy and restore the shape and symmetry of the breasts. Surgical reconstruction options consist of implants, autologous tissue transfer or a combination of the two. In comparison to implants, autologous tissue transfer is considered to give a better aesthetic look.

The latissimus dorsi flap is a pedicled musculocutaneous flap, first used in the late 19th century to cover chest wall deformities following mastectomy complications. The current use of the latissimus dorsi flap was developed in the 1970s for breast reconstruction following mastectomy in patients with radiation damage to the skin and chest wall. There are relatively few absolute contraindications to latissimus dorsi breast reconstruction. Complications can be split into flap complications and donor site complications, the most common being mastectomy skin flap necrosis and donor site seroma.

Lumbar hernias are an uncommon type of hernia, only 20% present as a congenital condition, the majority are acquired following surgery, trauma or inflammation. Lumbar hernias typically are wide necked and therefore less likely to be prone to strangulation or obstruction. Lumbar hernias usually occur in 2 weak sites in the posterolateral abdominal wall – the superior (Grynfeltt-Lesshalft) and the inferior (Petit) lumbar triangles. However in large incisional defects the hernia can affect the entire lumbar region.

Due to its rarity there is no standardized surgical technique for lumbar hernia repair. When there is clinical suspicion of a lumbar hernia CT is recommended to get exact information on the size and content of the hernia and to plan for surgical repair.

Our patient had pre-disposing factors that in hindsight contributed to the development of a lumbar hernia, despite preservation of the lumbar fascia during the operation. The co-morbidities of bronchiectasis and a polycystic liver both reduced the intra-abdominal compartment size and increased the intra-abdominal pressure. This caused herniation of abdominal contents through a weakened area of the abdominal wall. On further questioning she admitted to a post-operative chest infection with associated coughing and had received oral antibiotics from her GP.

We currently do not routinely image seromas occurring in post-operative breast reconstruction patients. However there was clinical suspicion following recurrent aspiration, due to the residual fullness and the anatomical site of the seroma, that raised the suspicion of a lumbar hernia.

Lumbar herniation is a rare complication that can occur following LD breast reconstruction. It should be clinically suspected in patients with a persistent swelling or pain in the lumbar region and subsequent CT scanning should be performed. Surgical repair is recommended in suitable patients; due to the large size these hernias can reach and related patient discomfort. Pre-existing co-morbidities should be carefully considered in all patients undergoing breast reconstruction.

Consent

Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Series Editor of this journal.

Nerve Pain After Latissimus Dorsi Breast Reconstruction

Postoperative pain after breast reconstruction surgery with the latissimus dorsi flap is a common occurrence. Botulinum neurotoxin (BoNT) injection during surgery is effective in reducing postoperative pain. This study aimed to determine the most appropriate locations for BoNT injection. A modified Sihler’s method was performed on the latissimus dorsi muscles in 16 specimens. Nerves were found inside the muscle from the surgical neck on the inside of the humerus to a line that went through the middle of the iliac crest and the spinous process of T5.

The latissimus dorsi muscles were divided into medial, middle, and lateral segments with 10 transverse divisions to give 10 sections (each 10%). Intramuscular nerve arborization of the latissimus dorsi muscle was the largest in the medial and lateral part of the muscle, ranging from 40 to 60%, middle part from 30 to 60% and medial, middle and lateral part from 70 to 90%. The nerve entry points were at the medial and lateral parts, with 20–40% regarding the medial side of surgical neck of the humerus to the line crossing spinous process of T5 to the middle of iliac crest. These outcomes propose that an injection of BoNT into the latissimus dorsi muscles should be administered into specific zones.

Pros and Cons of Latissimus Dorsi Flap

Advantages

It is notable that women who have had flap procedures have reported significantly greater satisfaction with their breasts, sexual well-being, and psychosocial well-being than women who underwent implant reconstruction, according to a 2018 study published in JAMA Surgery.

In one study, this type of flap has been shown to be safe for patients who are overweight or obese, as well. Researchers reported that the incidence of complications after latissimus dorsi flap reconstruction was not significantly different in these patients compared to those of a healthy weight.

Other benefits of a lat flap:

  • While the transplanted skin has a slightly different color and texture than the surrounding tissue, it will be a close color match for your breast skin.
  • The flap will feel warm and flexible like your normal tissue because it is your own skin and muscle.
  • The flap may feel less “foreign” to you than an implant.

Other muscles take over the latissimus dorsi’s function after the surgery. The majority of people who have this procedure adapt comfortably and are able to do the important physical activities that they were able to do before surgery.

Risks and Contraindications

The latissimus dorsi flap reconstruction is considered a major surgical procedure. Generally, the procedure takes longer than breast implant surgery. Healing will also take longer with a tissue flap procedure since you will have two surgical sites—the donor site on the back and the newly constructed breast.

After this surgery, you may have weakness in your arm and back muscles. Physical therapy can help you regain strength.

Though not a health risk, you should know that the procedure will leave a back scar. Typically, your surgeon will attempt to take the skin graft from an area that will be covered by your bra strap.

While health risks from this surgery are rare, it is still important to be aware of them.

Surgical risks include:

  • Bleeding
  • Blot clots
  • Surgical site infection
  • Wound healing difficulties
  • Fluid buildup, pain, or swelling in the breast or donor site.

Rare, delayed problems may include:

  • Necrosis, or tissue death, in part or all of the reconstructed breast: Necrosis can be treated with the removal of the dead tissue, but the affected tissue cannot be returned to good health. The risk of failure for the latissimus dorsi flap is less than 1%, though that is higher if you have had prior radiation therapy.
  • Loss of or changes to nipple and breast sensation
  • Problems at the donor site, including loss of muscle strength1
  • Changes or problems to the arm on the same side as the reconstructed breast
  • Problems with the implant, including leakage, rupture, or scar tissue formation
  • Uneven breasts
  • The need for more surgery to fix problems that may arise

Rate of Complications

Flaps have more complications than breast implants alone in the time right after surgery. A 2018 study published in JAMA Surgery found higher complication rates within two years following surgery among women who underwent flap procedures compared with women who underwent implant procedures.

Rates of complications ranged from 36%–74% among the flap procedure group, compared with a range of 27%–31% among the implant group. However, the study authors point out that with additional years of follow-up, implant-based procedures are more likely than flap procedures to have increased complication rates. Also, often more surgery is needed years later to remove, modify, or replace implants.

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