Latissimus Dorsi Flap Reconstruction Seems to Cause Biggest Loss in Shoulder Stability, Function

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Many, but not all, women who have mastectomy to treat breast cancer go on to have one or both breasts reconstructed. There are many ways to reconstruct a breast. Tissue from the back, belly, buttocks, or other part of the body can be used to create a new breast. Doctors call this autologous reconstruction. Saline or silicone gel implants are another option. In some cases, an implant is added after autologous reconstruction.

A small study compared three types of breast reconstruction:

  • latissimus dorsi flap reconstruction
  • implant reconstruction
  • DIEP flap reconstruction

and found latissimus dorsi flap reconstruction caused the greatest loss of shoulder function, strength, and mobility compared to the other two.

The research was published in the November 2018 issue of Breast Cancer Research and Treatment. Read the abstract of “The influence of reconstruction choice and inclusion of radiation therapy on functional shoulder biomechanics in women undergoing mastectomy for breast cancer.”

Types of reconstruction compared

  • Latissimus dorsi flap reconstruction: 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. In a latissimus dorsi flap procedure, an oval flap of skin, fat, muscle, and blood vessels from your upper back is used to reconstruct the breast. 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. Because the flap contains a significant amount of muscle, a latissimus dorsi flap is considered a muscle-transfer type of flap. 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.
  • DIEP flap reconstruction: DIEP stands for the deep inferior epigastric perforator artery, which runs through the abdomen. 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. Your surgeon carefully reattaches the blood vessels of the flap to blood vessels in your chest using microsurgery. Because no muscle is used, most women recover more quickly and have a low risk of losing abdominal muscle strength with a DIEP flap. A DIEP flap is considered a muscle-sparing type of flap.
  • Implant reconstruction: In implant reconstruction, an implant filled with saline (salt water), silicone gel, or a combination of the two is placed under the pectoral chest muscle. Using an implant to rebuild the breast requires less surgery than flap reconstruction, since it only involves the chest area (and not a tissue donor site). Still, it may require more than one procedure. It also may require additional surgery in the future, as implants can wear out and develop other issues, such as tightness of scar tissue around the implant.

Study results

The study included 34 women:

  • 10 had latissimus dorsi flap reconstruction
  • 10 had DIEP flap reconstruction
  • 14 had implant reconstruction

The women who had latissimus dorsi and DIEP flap reconstruction had radiation therapy after breast reconstruction.

About 22 months after reconstruction the women in the study put their arms into a robotic device to measure shoulder stiffness and strength in a variety of positions.

The results showed that women who had latissimus dorsi flap reconstruction were weaker in all shoulder positions compared to women who had the other two types of reconstruction. Women who had latissimus dorsi flap reconstruction also had more stiffness and less stability in their shoulders compared to women who had the other two types of reconstruction.

There were no differences in shoulder strength or stiffness between women who had DIEP flap reconstruction and women who had implant reconstruction.

Helping women make informed choices

“Our finding that the latissimus dorsi flap reconstruction objectively decreases shoulder strength is important because this will need to be communicated to women ahead of time and may affect the choice they make for procedures,” said Adeyiza Momoh, M.D., associate professor of plastic surgery at the University of Michigan Medicine and a surgeon on the research team. As a next step, biomechanical changes in the shoulder should be correlated to a patient’s actual experience or perception of function, to better understand clinical significance, Momoh said.

Deciding whether to have a breast reconstructed after surgery to remove breast cancer is a very personal choice. If you’ve been diagnosed with breast cancer and are planning your surgery, you may decide not to have reconstruction, but it can be helpful to consider all your options.

Here are some questions you might want to think about as you're making your decision about breast reconstruction:

  • Is it important to you to have a permanent breast shape? Some women prefer to wear a prosthesis instead of having reconstruction.
  • Is it important to you that your breasts look balanced when wearing a bra and bathing suits? Though you'll be able to see the difference between the rebuilt breast and your other breast when you're naked, reconstruction usually looks very natural when you're wearing a bra or bathing suit.
  • In your unique situation, will breast reconstruction involve several surgeries over a long period of time? For many women, the answer is yes.
  • Will your insurance pay for all the reconstruction procedures? Find out what your insurance company will cover.
  • Did you have a lumpectomy that gave your breast a very different shape than it originally had? If you had a large portion of tissue removed, you might want to have reconstruction to restore a more balanced look.
  • Do you have any other medical conditions that might affect your ability to heal after surgery? If you have diabetes, circulatory problems, or a bleeding disorder, it may take your body longer to heal from reconstruction surgery than someone who doesn't have these conditions.
  • Do you have a condition that might give you a distorted image of your body? If you've been diagnosed with anorexia or bulimia, you may have a hard time accepting how your body looks in general, which may make it hard to accept how your reconstructed breast looks.

There are advantages and disadvantages to both implant reconstruction and autologous reconstruction. Implant reconstruction is considered easier up front but usually requires another surgery after 10 or more years. Autologous reconstruction is a more involved surgery, with higher rates of complications and a longer recovery time, but offers better patient satisfaction, according to a number of studies. You will need to decide what is right for you and your unique situation.

For more information, including types of reconstruction, the timing of reconstruction, and questions to ask your breast surgeon and plastic surgeon, visit the Breastcancer.org Breast Reconstruction section.

To discuss with others facing reconstruction decisions, join the Breastcancer.org Discussion Board forum Breast Reconstruction.

Written by: Jamie DePolo, senior editor


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