Latissimus Dorsi Breast Reconstruction (LD Flap)

Latissimus Dorsi Breast Reconstruction (LD Flap)

General Surgery
Name of procedure: Latissimus dorsi breast reconstruction (LD Flap)

It has been recommended that you have a breast reconstruction. The aim of breast
reconstruction is to produce a replacement breast with a satisfactory appearance both
in and out of clothes, avoiding the need for an external prosthesis to be worn in the
bra.

This operation involves using the large latissimus dorsi (LD) muscle – a large muscle
that lies in the back just below the shoulder blade. The skin, fat and muscle are
removed from the back to form a flap. This flap is then turned and brought round to the
front of the body to lie on the chest wall and form a new breast shape. Some of the
skin on the flap is used to form the new skin of the reconstructed breast while the fat
and muscle form the volume of the breast. The blood vessels of the flap remain
attached. The scar on the breast will vary depending on your shape. The scar on the
back is usually horizontal and hidden along the bra line, or it can be diagonal.

Some women have a combination of an LD flap and implant reconstruction. The
implant gives more volume to the breast. The flap covers the implant. Occasionally, the
surgeon moves a large amount of fat with the LD muscle. This is called an extended
LD flap. It may be done so an implant is not needed.

The latissimus dorsi muscle helps to bring your arm into your side and backwards. You
use it when lifting something down off a high shelf, or pulling something towards you.
You also use the muscle when you push down to raise your body up, such as out of a
bath or chair. Other muscles can also do some of the things that the latissimus dorsi
muscle does. So after this type of surgery you will still be able to move your arm
normally. You might find there are specific activities that you don’t have quite the same
strength for on the side of the surgery. This will depend on your lifestyle and any
hobbies or sports.

This leaflet explains some of the benefits, risks and alternatives to the operation. We
want you to have all the information you need to make the right decision.

We recommend that you read this leaflet carefully. You and your doctor will also need
to record that you agree to have the procedure by signing a consent form, which your
health professional will give you. Please ask your surgical team about anything you do
not fully understand or want to be explained in more detail.

Benefits of the procedure
The aim of your surgery is to reconstruct a breast shape following a mastectomy. The
cosmetic results achieved from the surgery can have an extremely positive effect on a
woman’s confidence, self-image and self-esteem.

Serious or frequent risks
Everything we do in life has risks. There are some risks associated with this type of
surgery. The general risks of surgery include problems with:
 the wound (for example, infection); and
 blood clots (for example, in the legs or occasionally in the lung).

Those specifically related to breast surgery include problems with the following:
 Scarring
 There will be scarring on the front of your chest where the reconstructed
breast shape is attached to your chest wall. There will also be a scar on your
back where the LD muscle is taken from. Initially these scars will be bright
pink but they should fade over time.

 Bruising
 Bruising is very common after surgery and will usually resolve after a few
weeks.

 Breast sensation
 It is unlikely that you will have any sensation in your reconstructed breast.

 Seroma
 A collection of fluid may develop around your back wound. If this is a small
amount nothing will need to be done as it will disperse naturally. If the pocket
of fluid causes discomfort it may need to be drained using a needle and
syringe. This may need repeating several times over the following weeks
until your wound has healed.

 Bleeding
 2-4% of women having breast surgery (with or without reconstruction) will
have a secondary bleed, normally within 24 hours of their operation. This is
generally obvious as there is a tender swelling which comes up rapidly with
very obvious associated bruising. This collection of blood under the wound is
called a haematoma. If you think you may have a haematoma please call
your GP or breast care nurse and arrange for an urgent review as most
patients developing this complication will need to have another small
operation performed within the next few hours or days to stop the bleeding,
wash out the clot and prevent any pressure on the overlying skin.

 Infection
 You may be prescribed a course on antibiotics after your surgery.

 Minor skin burn.
 Due to heat conduction used to stop bleeding during surgery.

 Muscle twitching
 You may have some involuntary muscle twitching of your reconstructed
breast.

 Capsular contraction
 If an implant has been used as part of your reconstruction there is a slight
risk of scar tissue developing around it causing it to change shape and feel
firmer. This can happen several years after surgery and may be treated by
removing the implant and replacing it with a new one.

 Loss of LD Flap
 This may be due to compromised blood supply to the new breast however it
is an extremely rare occurrence.

 Shoulder weakness
 You will have some weakness in your back and shoulder. This will improve
over time. You should regain full shoulder strength for most activities 6 to 12
months after surgery.

Most women can return to daily activities without any problems, including sports such
as swimming and tennis. Having LD flap surgery can affect your ability to take part in
some sports, such as:
 Rowing
 Rock climbing
 High-level competitive racquet sports

Most people will not experience any serious complications from their surgery. The
risks increase for elderly people, those who are overweight and people who already
have heart, chest or other medical conditions such as diabetes or kidney failure. As
with all surgery, there is a risk that you may die.

You will be cared for by a skilled team of doctors, nurses and other health-care
workers who are involved in this type of surgery every day. If problems arise, we will
be able to assess them and deal with them appropriately.

Other procedures available
Other types of breast reconstruction such as implant only reconstruction or an
abdominal flap reconstruction may or may not be suitable for you. If you wish to
discuss this further, please speak to your Breast Care Nurse of Surgeon who will be
able to advise as to which type of reconstruction is best for you.

Preparing for Surgery
Before you come into hospital there are some things you can do to prepare yourself for
your operation and reduce the chance of difficulties with the anaesthetic.

a) If you smoke, it may not be appropriate for you to have an immediate
reconstruction but if your surgeon does consider it safe to proceed you are
advised to give up for at least six weeks before the operation and at least three
weeks after. Smoking reduces the amount of oxygen in your blood and increases
the risks of breathing problems during and after an operation. It also increases the
risk of complications with your wound and the healing process and specifically
increases the risk of complications with breast reconstructive surgery. Using a
vaporiser instead of smoking may help the lung and breathing issues but does not
significantly reduce the risk of post-operative wound problems.
b) If you are overweight, many of the risks of anaesthesia are increased. Reducing
your weight will help, although this may not be possible if you are having an
urgent operation for cancer.
c) If you have loose or broken teeth or crowns that are not secure, you may want to
visit your dentist for treatment. The anaesthetist will usually want to put a tube in
your throat to help you breathe. If your teeth are not secure, they may be
damaged.
d) Please stop taking the contraceptive pill one month before surgery. This is to
reduce the risk of a blood clot (deep vein thrombosis) but remember to use
alternative means of contraception.
e) Continue to take any other normal medicines up to and including the day of your
surgery. If we do not want you to take your normal medication, your surgeon or
anaesthetist will explain what you should do.
f) It is important to let us know, before you are admitted, if you are taking any
anticoagulant (blood thinning) drugs (for example, warfarin, aspirin or clopidogrel
or rivaroxaban). These will need to be stopped but other drugs may need to be
used instead. This should all be explained to you in the pre-operative assessment
clinic if not before.
g) If you are taking Tamoxifen tablets please stop these four (4) weeks before your
surgery and recommence 4 weeks later.

Your pre-operative assessment
Before you are admitted for your operation, you may be required to attend for a preoperative assessment, to ensure that you are fit for surgery. It is important that you
attend for this appointment to avoid delaying your surgery.

Not all patients require a detailed pre-operative assessment and a health
questionnaire is used to determine which patients require a full assessment. The
health questionnaire may be on paper or on a tablet/computer. The information
required includes all medical conditions, regular medications, allergies to medications
and your previous anaesthetic history. The information you give will be reviewed by the
pre-operative assessment team. If you require further assessment you will be given an
appointment to attend the pre-operative assessment clinic.

At the clinic, the nursing staff will confirm the medical information you have previously
given and some further tests may be required, such as a blood test, X-ray, heart or
lung test. If a more detailed assessment or discussion is required you may see an
anaesthetist prior to your admission for surgery. This may require an additional
appointment.

If you are taking prescribed medicines please bring a copy of your repeat prescription
to your appointment and a copy of the operation consent form (if you were provided
with a copy at your out-patient appointment).
Following your assessment, the staff will provide you with written information regarding
preparation for your surgery and a point of contact. It is important that you follow the
fasting instructions given on your admission letter.

On the day of your operation
It is important that you carefully follow the instructions we give you about eating and
drinking which will be detailed on your admission letter. You must not eat anything for
at least 6 hours before your operation. This is to make sure your stomach is empty
when you have your anaesthetic, because any food or liquid in your stomach could
come up into the back of your throat and go into your lungs while you are being
anaesthetised. Please refrain from chewing gum. Please note Drinks containing fats
(e.g. tea or coffee with milk) and sweets all count as food.

You can drink water or a drink without fats in it (e.g. black coffee) until 2 hours before
your operation. You may also have small sips of water to take tablets.

We will need to know if you don’t feel well and have a cough, a cold or any other
illness when you are due to come into hospital for your operation. Depending on your
illness and how urgent your surgery is, we may need to delay your operation as it may
be better for you to recover from this illness before your surgery.

Being admitted to the ward
You will usually be admitted on the day of your surgery. You will be welcomed on to
the ward and your details checked. We will fasten an armband containing your hospital
information to your wrist. You will usually be asked to continue with your normal
medication during your stay in hospital, so please bring it with you.

Your anaesthetic
Your surgery will usually be carried out under a general anaesthetic. This means that
you will be asleep during your operation and you will feel nothing.

Your pre-surgery visit by the anaesthetist
The anaesthetist will come to see you and check again the information you supplied at
your pre-operative assessment. They will also be interested in any problems you with
moving your neck or opening your mouth; and any loose teeth, caps, crowns or
bridges. Your anaesthetist will discuss with you the different methods of anaesthesia
they can use. After talking about the benefits, risks and your preferences, you can then
decide together what is best for you.

Your anaesthetic
When it is time for your operation, a member of staff will take you from the ward to the
operating theatre. They will take you into the anaesthetic room and the anaesthetist
will get you ready for your anaesthetic. To monitor you during your operation, your
anaesthetist will attach you to a machine to watch your heart, your blood pressure and
the oxygen level in your blood.

General anaesthetic
General anaesthesia usually starts with an injection of medicine into a vein. A fine
tube (cannula) will be placed in a vein in your arm or hand and the medicines will be
injected through the tube. Sometimes you will be asked to breathe a mixture of gases
and oxygen through a mask to give the same effect. Once you are anaesthetised, the
anaesthetist will place a tube down your airway and use a machine to ‘breathe’ for
you. You will be unconscious for the whole of the operation and we will continuously
monitor you. Your anaesthetist will give you painkilling drugs and fluids during your
operation. At the end of the operation, the anaesthetist will stop giving you the
anaesthetic drugs. Once you are waking up normally, they will take you to the recovery
room.

What to expect after surgery?
We commonly use local anaesthetic injections around the ribs and into the chest wall
at the time of your surgery. This can give good long lasting pain relief in the first 6
hours after your operation. We may also give you tablets, suppositories or injections to
make sure you have enough pain relief.

Pain relief after surgery
Once you are comfortable and have recovered safely from your anaesthetic, we will
take you back to the ward. The ward staff will continue to monitor you and assess your
pain relief. It is important that you report any pain you have as soon as you experience
it.

Side effects of having an anaesthetic include drowsiness, nausea (feeling sick),
muscle pain, sore throat and headache. After your surgery, you will need to rest until
the effects of the anaesthetic have worn off. You will have a drip in your arm to keep
you well-hydrated.

We will encourage you to get out of bed and move around as soon as possible, as this
helps prevent chest infections and blood clots. You will usually continue to have blood
thinning injections every day whilst you are in hospital to help prevent blood clots. You
should continue to wear the white thromboembolic deterrent (TED) stockings at home
until you are fully mobile.

Your surgical team will assess your progress and answer any questions you have
about the operation.

Leaving hospital

Length of stay
Please expect 3-5 days hospital stay after your operation.

Bra
You will require a well-fitting supportive bra (no underwire) to wear day and night for
support for 6 weeks following your surgery. It is suggested that your bra is one full cup
and 1 width larger than expected to allow for swelling after your surgery. You will need
to bring your bra into hospital with you. Please do not spend too much money on bras
as it can be hard to estimate the correct size.

An alternative for women whose breasts are expected to be different in size for a
period of time, is a stretchy crop top.

Your breast care nurse can advise you on bras.

Medication when you leave hospital
Before you leave hospital, the pharmacy will give you any extra medication that you
need to take when you are at home. It is useful to be prepared in advance by stocking
up on paracetamol and ibuprofen if you can normally take these drugs without
problems.

Recovery
How long it takes for you to fully recover from your surgery varies from person to
person. It can take up to 3 months. After you return home, you will need to take it easy
and should expect to get tired to begin with.

Stitches
Your wound will be closed with dissolvable stitches and covered with paper stitches
(steri- strips). Please keep the steri-strips in place until your out-patient’s appointment
(7 to 10 days later). Your nurse or doctor will remove them then.

Drain
You will have a small plastic tube (drain) coming out of a small hole in the skin near
the operation site. This will usually drain fluid (which is part of the healing process) into
a vacuum sealed bottle. We will remove this tube when you no longer need it. This
may be in for 1 week or longer. It is likely to stay in longer if you are having an implant
as part of your reconstruction. You are likely to continue on oral antibiotics while you
have the drain in. You can go home with the drain in and a district nurse will be
booked to come out to you and check on it.

Personal hygiene
You will need to keep your wound dry until your out-patient appointment when your
dressings and/or drain will be removed.

Infection
Please contact your GP or Breast Care Nurse if you notice any signs of infection such
as, redness, wound discharge or have a temperature.

Exercise
It is important to rest as much as possible for the first few weeks following surgery and
limit your arm movements to shoulder height only for two weeks.

Sex
You can continue your usual sexual activity as soon as you feel comfortable.

Driving
You should not drive until you feel confident that you could perform an emergency stop
without discomfort – probably at least four weeks after your operation. It is your
responsibility to check with your insurance company that you are fully insured after
your operation.

Work
How long you will need to be away from work varies depending on: how quickly you
recover; whether or not your work is physical and whether you need any extra
treatment after surgery. You may be able to return to work in 4-6 weeks if you do not
need any further treatment and if you do not have any complications after your
surgery. Please ask us if you need a medical sick (FIT) note for the time you are in
hospital and for the first two weeks after you leave.

Emotional support
It is not uncommon to feel a bit ‘down’ after any operation so do ask your doctor or
breast care nurse if you feel you need more psychological support. Some find
treatment for cancer a frightening experience so please tell your nurse or doctor about
any concerns that you have.

Outpatient appointment
Before you are discharged we will give you a follow-up appointment to come to the
outpatient department, or we will send it to you in the post.

Contact details
If you have any specific concerns that you feel have not been answered and need
explaining, please contact the following.

Worcestershire Breast Unit
Telephone – 01905 760261 (ext. 36711)
Email – wah-tr.breastcarenursingteam@nhs.net

If your symptoms or condition worsens, or if you are concerned about anything,
please call your GP, 111, or 999.

Patient Experience
We know that being admitted to hospital can be a difficult and unsettling time for you
and your loved ones. If you have any questions or concerns, please do speak with a
member of staff on the ward or in the relevant department who will do their best to
answer your questions and reassure you.

Feedback
Feedback is really important and useful to us – it can tell us where we are working well
and where improvements can be made. There are lots of ways you can share your
experience with us including completing our Friends and Family Test – cards are
available and can be posted on all wards, departments and clinics at our hospitals. We
value your comments and feedback and thank you for taking the time to share this with
us.

Patient Advice and Liaison Service (PALS)
If you have any concerns or questions about your care, we advise you to talk with the
nurse in charge or the department manager in the first instance as they are best
placed to answer any questions or resolve concerns quickly. If the relevant member of
staff is unable to help resolve your concern, you can contact the PALS Team. We offer
informal help, advice or support about any aspect of hospital services & experiences.

Our PALS team will liaise with the various departments in our hospitals on your behalf,
if you feel unable to do so, to resolve your problems and where appropriate refer to
outside help.

If you are still unhappy you can contact the Complaints Department, who can
investigate your concerns. You can make a complaint orally, electronically or in writing
and we can advise and guide you through the complaints procedure.

How to contact PALS:
Telephone Patient Services: 0300 123 1732 or via email at: wah-tr.PALS@nhs.net

Opening times:
The PALS telephone lines are open Monday to Friday from 8.30am to 4.00pm. Please
be aware that you may need to leave a voicemail message, but we aim to return your
call within one working day.

If you are unable to understand this leaflet, please communicate with a member of
staff.

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