Pre-Operative Information – Latissmus Dorsi Muscle (LD) flap and insertion of implant surgery

This information is for patients who are having an operation to reconstruct one or both breasts by moving tissue from one part of the back area (the donor site), to the breast (the recipient site), and insertion of an implant under the muscle once moved It explains the procedure, reasons for having it, what is involved and any significant risks that there may be.

What is a LD?

A common method used to reconstruct one or both breasts is to use tissue from the back area and move the tissue around to reconstruct the breast. The Latissmus Dorsi muscle flap means the vessels; muscle, fat and overlying skin are transferred. An implant is placed under the muscle when it has been moved to increase the size of the breast reconstructed.
It is a procedure taking about 4 to 6 hours to perform. This operation will result in a back scar and a reconstructed breast mound anterially.

What are the reasons for having an LD flap?

It is used for the reconstruction of one or both breasts after a cancer has been removed.

What preparation do you need?

You will have had an opportunity to discuss the operation with the surgeon at your outpatient appointment. If you have questions after this please contact his secretary at the hospital where you saw him. Alternatively you can ring the Plastic Surgery Liaison team on 020 8725 0473 Monday to Friday 08.00 to 17.00.
Eat a well balanced diet. Nutrition is essential for wound healing. It is important to make sure you are getting all the recommended food types and amounts.
Smoking has a poor effect on healing and will directly affect the success of this surgery. We advise you to take steps to give this up before the operation. Smoking is likely to cause the flap to fail. Nicotine patches should not be used during the peri-operative period.
We advise you to make arrangements for help at home during your recovery. This will be for at least 2 weeks although some activities need to be reduced for 4 to 6 weeks. This varies according to the individual and you should discuss your requirements with the medical or nursing staff caring for you.
We recommend you bring some pajamas with a button up top. This will make access to the dressings easier after the operation.

Your admission

You will have this operation as an inpatient. The health service standards mean that operations must take place within a set time frame once your name has been placed on the waiting list. All operations take place at St. George’s Hospital irrespective where you saw the surgeon in the first place.
We will send you a letter with details of the date and time of your admission to hospital, plus information leaflets about coming into hospital.
Please telephone the contact name and number on the admissions letter you will receive to check that a bed is available for you before coming to the hospital.
Your stay in hospital will vary according to the nature of the operation and your recovery period. It will be at least a week in most cases.

What is involved?

You will have a general anaesthetic and will be asleep through the operation.
The number and size of incisions (cuts) vary from patient to patient; your surgeon will have discussed with you earlier what is best for you.
The cuts are sealed with stitches and covered with a dressing pad. The stitches are usually dissolvable but occasionally there will be some stitches that need removing at some time after the surgery.
You will leave the operating theatre with:

A drip – one or more small tubes attached to a needle inserted into a vein in your hand or arm so that medications and fluids can be given as necessary.
A drain – one or more small tubes that allow excess fluid and blood to drain away from the operation site into plastic bottles.
A catheter- a rubber tube going into your bladder automatically draining your urine. This allows careful monitoring of the levels of fluid in your body.
Wound dressings – this will include a dressing on the area to which the tissue has been transferred to and the area from which it has come.

After the operation

In most cases patients return directly to the ward following the operation. Sometimes patients require a short period in the intensive care unit or high dependency unit for careful monitoring. You may be attached to different pieces of equipment and have a dedicated nurse to look after you
The nurse will check your blood pressure, breathing, temperature and pulse regularly. In addition the flap will be inspected regularly to ensure its blood supply is progressing in a satisfactory way.
The area the flap has been transferred to and the place it has been moved from may be uncomfortable. Please tell the nurse when you feel pain at any time so that you can take painkillers. These can be given in different ways and this will be discussed with you at the time.
You will be offered something to eat and drink as soon as you feel like it. However, you are advised to avoid caffeine as this affects the blood vessels. This includes tea, coffee, certain soft drinks such as coke and chocolate.
The various tubes are likely to stay in place for at least 48 hours. Each one will be removed as your condition improves and the flap becomes more established.
Drains are usually removed when the fluid reduces and this varies considerably between patients and the type of surgery.
Stitches on the skin will be removed at various times after the operation depending on the surgeon’s instructions. This may include dissolvable stitches (that fade away naturally). Some stitches may be removed while you are still an inpatient in hospital. An appointment will be made for the removal of any stitches/clips at the Plastic Dressing Clinic (based at St. George’s Hospital) for any stitches that need removing after discharge from hospital.
The flap and the donor site from where the tissue has been transferred will be covered by dressings.

Are there any significant risks?

Bleeding – This can occur after any operation. Nursing staff will observe for signs of this. In rare cases the patient sometimes has to return to the operating theatre to have a bleeding problem resolved. If you experience bleeding after being discharged contact the ward. If this cannot be stopped with firm pressure over the wound for 15 minutes, you should return to St Georges Hospital Accident and Emergency Department.
Pain – Any operation will result in pain and you must inform the nursing staff when you have any level of discomfort this can be reduced. Painkillers will be given in a variety of ways and will be discussed with you by the nurses looking after you.
Swelling – The new breast(s) and donor site may swell. In most cases this will remain within acceptable limits. Nursing staff will monitor this to ensure that there is no underlying problem such as bleeding or that the swelling is not putting pressure on the flap. In some cases patients need to have stitches released to reduce such pressure or return to theatre to explore the problem.
Wound breakdown – small areas of the line of stitches may open up and produce fluid. This is not uncommon. It can occur on or around the flap and the donor site from which it has come. If this occurs dressings will be used to assist the body to heal. In some cases it may require additional surgery. This will be discussed with you at the time. If it occurs after you have been discharged you are advised to apply a simple dressing from a chemist. Then arrange to see your GP or make an appointment in the Plastic Dressing Clinic which ever is more convenient in terms of time and distance. If you choose to go to your GP, also then arrange an appointment in the Plastic Dressing Clinic so that any problems can be monitored.
Infection – this may be the wound or the implant - signs include redness, swelling and discharge from the wound and a raised temperature. This can be treated with antibiotics. If you notice any signs of infection once discharged please contact your GP immediately you notice any of the above signs and arrange to bring your appointment with the hospital forward. If you are unable to contact your GP, contact Caesar Hawkins Ward. Do not delay getting medical attention, as an infection can become life threatening if left untreated.

Specific risks include:

Operation failure – In very rare circumstances the operation may have to be abandoned before the flap is transferred. This may be due to technical reasons such as an inability to connect the blood vessels. Although disappointing, it is essential that the surgeon abandon the operation if he/she feels it is impossible to proceed.
Flap failure - The main problem at the recipient site is flap loss. There can be blockage at the site where the blood vessels have been connected. This may result in a complete or partial loss of the flap. This is monitored closely while you are in hospital. Treatment may include another operation to resolve the blockage in the blood supply. Smoking increases the chances of flap failure due to the effects of nicotine. Hence the reason why patients who smoked are advised to give up now. If you continue to smoke up until the operation you need to be aware that the risk of flap failure is high. You will not be able to smoke at the time of the operation or in the recovery period while healing occurs. It is important to note that if the flap survives by day 5 the outlook is very good. However, smoking increases the chances of problems for many weeks after this time and so must be avoided. In addition to smoking other high risk factors in flap failure and healing problems include hypertension, previous radiotherapy, obesity, poor nutrition and underlying medical conditions.
Partial flap failure – it is more common that only part of the flap does not survive. Usually this can be managed with dressings but may involve another operation.
Returning to theatre – This is a complex procedure. There is a possibility that the blood vessels (the artery or vein) may become blocked in the first few days after surgery. If this occurs you will need to return to surgery for unblocking of the vessels. This may be necessary in about 5% of cases.
Implant problems - It is important to remember that no implant (prosthesis) will remain with the same person for life. Problems will occur at some point although this can range from within the first few weeks to years. There are two types of implants used at this hospital. All have a silicone envelope but differ in the contents, one type contains silicone gel and the other type contains saline. Some concerns about the use of silicone have been raised in the press. To date the British Medical Association still authorizes the use of silicone. However, women have reported reactions to silicone including general symptoms and local problems associated with a ruptured or leaking implant. Both types of implants have the potential to leak and or rupture, but saline will be re-absorbed into the body and silicone will not. Therefore silicone has the potential to cause inflammatory reactions as a result, which may lead to further operations. If either type of implant ruptured, an operation would be needed to remove or replace it. Saline implants have been criticized for providing a less natural appearance in comparison to silicone implants. Your surgeon should discuss with you the options for you.
Capsular contraction

This can occur when the scar tissue develops around the implant. The breast becomes firm and hard. It can be uncomfortable or very painful. Occasionally, the implant may have to be removed and replaced.

Gel bleed

This is when small amounts of the gel within the implant leak out of the bag and into the surrounding tissues. There may be no symptoms associated with this and there is no way of monitoring it.

Rupture of the implant

This occurs when the bag splits and the contents move into the surrounding body tissues. The implant may deflate slightly or fully. If this happens you will need to arrange an outpatient appointment with your surgeon. This may mean another operation is needed.

Altered sensation - You can expect some loss of feeling in the area the tissue has been transferred to and from. This numbness usually fades in the following weeks. Occasionally this may last longer or may be permanent.
Scars – You will have scarring around the breast area and a lengthy scar on the back. Any scar can become red and lumpy and can take a minimum of 12 months to settle. There is a possibility that it will remain raised and very noticeable. If you have a partner it is important that you discuss this with them.
Extra skin lumps (dog ears) - These may be situated at the edges of the scar where the tissue has been removed from; they look like small pyramids of soft tissue that stick out. These can be reduced with surgery under a local anaesthetic at a later date once all the swelling has subsided. This will be discussed at the follow up outpatient appointment with the surgeon.
Seromas – This is a collection of fluid at the donor site from where the tissue has been removed. Inserting a needle and draining this fluid can treat it and this will be undertaken on the ward while you are an inpatient or at outpatient clinic appointments once you are discharged. Intermittent drainage of the fluid continues for as long as it keeps collecting there. This can range from a week to several weeks and varies considerably between individuals. You may be advised to wear a supportive garment to try to reduce the fluid collection. This will be discussed with you if required by the staff caring for you.
Functional problems due to the donor site – Using a LD flap can result in reduced strength of the muscles in that area. This may affect activities when the back muscle would be uses such as racket sports and climbing activities.
Additional operations – It is uncommon that this is the only operation that you will undergo to reconstruct the breast(s). Most patients will have additional operations which may include improving symmetry with the other breast, ‘tidying-up’ surgery for “dog ears” as indicated above, reconstruction of a new nipple and areola etc. The requirements for this are individual and you will need to discuss them with your surgeon.

What are the chances of the flap being successful?
In experienced hands the rate of tissue transfer survival is about ninety percent. Unfortunately, treatments such as radiotherapy increase the risk of patients having problems in the post-operative period with flap failure and wound healing problems. Your general health is a major influence on how well you will do with this surgery.

How long will I be in hospital?
Flap surgery is complex and the length of stay can be very variable. A typical stay about 1 week although it can be longer. Length of stay is dependent on the type of tissue transferred, complexity of the case and your recovery after the operation. Your progress will be discussed with you on a day-to-day basis.

Going home

Please make sure that you arrange for some one to drive you home. He/she should bring in a small cushion that you could put under your seat belt to protect your chest area on your journey home. You should have at least 2 weeks resting. This means you will need to arrange for someone else to do the housework, shopping, cleaning cooking, laundry and childcare.
Make sure you have any tablets or medicines plus advice on how and when to take them.
Make sure you have been given a future outpatient appointment and a copy of a letter for your GP.
Make sure you have telephone contact numbers at the hospital.

At home

The recovery period varies depending on your progress. Please make sure you discuss your individual issues with your surgeon or the nurses caring for you on the ward/clinic.
In general you need rest for at least 2 weeks following this operation. Do not expect to be able to manage on your own.
Do not lift anything heavy for 4 weeks. This means children, vacuum cleaners, pots, pans, full kettles, laundry and shopping bags.
Avoid any sports for at least 6 weeks.
Do not drive for 4 weeks or until the wounds have healed and you have no pain.
Do not return to work for at least 4-6 weeks. This will vary according to the type of job you do and your recovery. You should discuss this with the surgeon, or nursing staff caring for you.
Do keep moving around and take gentle exercise.
Do use the contact number below if you have any queries or concerns.

Please be realistic about what you expect as a result of this surgery and consider all the issues raised in this information sheet before finally deciding about having the operation.

Any further questions?

You can contact the Lead Clinical Nurse in Plastic Surgery directly.

Caesar Hawkins Ward: 020 8725 2020/21
(24-hour service)

Plastic Surgery appointment desk: 020 8725 3675
(for follow up and Plastic Dressing Clinic)

Lead Clinical Nurse in Plastic Surgery
During office hours: 020 8672 1255 and ask for bleep 6332
Answer phone: 020 8725 0473