Latissimus Dorsi Flap Breast Reconstruction

Quick answer: A latissimus dorsi flap, or LD flap, moves skin, fat and usually part of the broad back muscle to the chest while keeping the tissue attached to its original thoracodorsal blood vessels. The flap provides reliable, healthy soft-tissue cover after mastectomy. It may create a small breast on its own, but it is often combined with an implant, tissue expander or staged fat grafting for additional volume.

The LD flap has remained useful for decades because it is dependable and versatile. It does not require the tiny blood vessels to be disconnected and rejoined under a microscope as in a free DIEP flap. This makes it available in more hospitals and particularly valuable when chest tissue has been damaged by radiotherapy, when abdominal tissue is unavailable, or when a previous reconstruction needs rescue.

Reliability does not mean that the operation is minor. The chest and back heal at the same time, fluid can collect at the donor site and shoulder function needs active rehabilitation. Some people recover near-normal everyday function, while high-demand athletes and some long-term patients notice lasting weakness, tightness or discomfort. A balanced consultation should discuss both the strengths and the donor-site cost.

What is the latissimus dorsi muscle?

The latissimus dorsi is a large, flat, triangular muscle covering much of the middle and lower back. It runs from the spine and pelvis towards the upper arm. It helps pull the arm down and backwards, rotate it inward and stabilise movements used in climbing, rowing, swimming and pushing up from a chair.

The muscle's dominant blood supply is the thoracodorsal artery and vein, which enter near the armpit. During an LD flap operation, the surgeon keeps this vascular pedicle connected. The flap can therefore rotate from the back, through a tunnel beneath the armpit, to the front of the chest without microsurgical anastomosis.

What tissue is moved?

A traditional musculocutaneous LD flap includes part or most of the muscle with an overlying ellipse of skin and fat. The skin can replace missing breast skin; the muscle and fat provide vascularised cover and some volume. An extended LD flap includes additional back fat to create more volume. A muscle-sparing or mini-LD design may be considered for partial defects in selected anatomy.

The exact design depends on whether the breast skin and nipple were preserved, the amount of volume required, previous scars, radiotherapy and whether an implant will be used. The back scar is planned horizontally or obliquely, often where a bra can cover it, but scar position must be discussed while standing in the clothing you normally wear.

The LD flap procedure step by step

1. Preoperative markings. The breast footprint, fold, desired skin paddle and back donor area are marked. The surgeon also considers an implant pocket, symmetry procedure and previous axillary surgery.

2. Flap elevation. Through the planned back incision, the skin-and-fat paddle and required muscle are carefully separated while protecting the thoracodorsal vessels.

3. Creating the tunnel. A pathway is made beneath the skin from the back, around the side of the chest and under the armpit. It must be wide enough to prevent compression or twisting of the vascular pedicle.

4. Transferring the flap. The tissue is passed through the tunnel to the mastectomy area while remaining attached to its blood supply.

5. Adding volume when required. An implant or tissue expander may be placed beneath the flap. Alternatively, an extended flap is shaped without an implant, or fat grafting is planned as a later stage.

6. Shaping the breast. The flap is folded and secured to restore the lower curve, central mound and soft-tissue cover. The skin paddle is positioned where breast skin is missing.

7. Closing both sites. Drains are placed in the back and breast to reduce fluid collection. The back is closed in layers, often with internal quilting sutures to limit the empty space.

Operating time varies with immediate or delayed reconstruction, implant use, one or both sides and simultaneous mastectomy. A single-breast LD reconstruction is generally shorter than a free abdominal flap, but it still requires general anaesthesia and a coordinated inpatient recovery.

Main variations of the LD flap

LD flap with an implant

This is the most familiar version. The flap provides healthy cover over an implant, especially where mastectomy skin is thin or radiated. It can mask implant edges and reduce rippling compared with an implant under thin skin alone. Implant-related risks remain, including infection, capsular contracture, rupture, displacement and future implant surgery.

Extended autologous LD flap

Extra fat over and around the muscle is included to provide more volume without a permanent implant. This can suit a small or medium reconstruction when sufficient back tissue is available. It creates a larger donor area and can increase seroma and contour concerns.

Fat-augmented LD flap

Fat grafting is added during or after flap transfer. This can progressively replace the volume that would otherwise require an implant. It combines the dependable blood supply of the LD flap with the softness of grafted fat, while usually adding stages.

Mini-LD or muscle-sparing approaches

Smaller variants may repair selected partial defects or preserve more muscle. They are anatomy- and defect-specific and should not be assumed to offer the same volume or indications as a full LD flap.

When is an LD flap considered?

• There is insufficient abdominal tissue for a DIEP flap.

• Previous abdominal surgery or vessel damage makes an abdominal flap unsuitable.

• The chest has been radiated and needs healthy vascularised cover.

• A tissue expander or implant has become exposed, infected or repeatedly problematic.

• A shorter operation than free-flap microsurgery is preferred or medically appropriate.

• Microsurgical reconstruction is not available locally.

• A small-to-medium breast can be made from an extended or fat-augmented flap.

It may be less suitable after major back surgery, injury to the thoracodorsal vessels, extensive axillary surgery affecting the pedicle, severe shoulder dysfunction or a career/sport that relies heavily on powerful latissimus use. Vascular imaging is not routine for everyone but may be requested when prior surgery raises concern.

LD flap reconstruction and radiotherapy

Radiotherapy can make chest skin thinner, firmer and less well vascularised. Bringing a pedicled flap introduces healthy tissue and can create safer coverage than an implant under radiated skin alone. That is a major reason the LD flap remains important in secondary reconstruction.

Radiotherapy can still affect the final result, especially when an implant is present. Capsular contracture, firmness, distortion and unplanned revisions are more common in radiated implant-based reconstructions. When possible, timing is agreed in a multidisciplinary team: in some pathways reconstruction is delayed until radiotherapy is complete; in others immediate reconstruction is appropriate. The LD flap does not make radiotherapy risk disappear.

Advantages of the latissimus dorsi flap

• Reliable circulation. The thoracodorsal vessels remain attached, so complete flap loss is uncommon.

• Vascularised tissue for a difficult chest. Healthy muscle, fat and skin can support healing after radiation or failed reconstruction.

• No microsurgical vessel connection. The operation is technically different from a DIEP free flap and is more widely available.

• Flexible volume options. It can be combined with an implant, tissue expander or fat grafting, or designed as an extended flap.

• Useful rescue procedure. It can cover an implant and replace damaged skin when other methods have failed.

Limitations and donor-site effects

The unavoidable trade-off is surgery to the back. A long scar, contour hollow or fullness beside the scar may be visible. The broad area where tissue was lifted can produce a seroma, meaning a pocket of clear fluid. Drains and quilting sutures reduce the risk but do not eliminate it; repeated aspiration is occasionally needed.

Moving the muscle changes shoulder biomechanics. Other muscles compensate, and many patients recover good everyday strength and range. Prospective studies have shown substantial improvement over the first year. More recent long-term patient-reported research also indicates that some people have worse back and shoulder function than comparable DIEP-flap patients years later. The most truthful message is therefore not “there is no functional loss,” but “most daily function can recover well, with a real possibility of persistent symptoms or high-demand weakness.”

The muscle may contract after transfer, causing the breast to twitch or move when the arm is used. This is called animation deformity. Some surgeons divide the motor nerve during the original operation; others preserve it to limit muscle atrophy. Persistent animation can be treated with botulinum toxin or a later nerve procedure in selected cases.

Risks and possible complications

General surgical risks include bleeding, infection, delayed wound healing, blood clots and anaesthetic complications. Flap-specific problems include partial skin-paddle loss, pedicle compression, contour irregularity and rarely major flap loss. Back seroma is one of the most frequent donor-site issues. Numbness, tightness, chronic discomfort and shoulder weakness are possible.

When an implant is included, add implant infection, exposure, capsular contracture, malposition, rupture and the possibility of revision or replacement. Smoking, diabetes, obesity, previous radiotherapy and poor tissue quality can increase complications. Your personal risk profile is more useful than a single percentage taken from a mixed study.

Hospital stay and early recovery

Patients commonly stay in hospital for several days, although local enhanced-recovery protocols differ. Nurses check the flap skin, pain control, drains and arm movement. The back can feel tighter or more uncomfortable than the breast, particularly when lying down.

At home, drains remain until output falls to the team's threshold. Button-front clothing, pillows that avoid direct pressure on the back scar and help with shopping and housework are useful. Short walks are encouraged, but pushing, pulling, heavy lifting and sudden overhead reaching are restricted during early healing.

Week-by-week recovery guide

Weeks 1–2

Rest, walking and drain care are the priorities. Bruising, swelling and a pulling sensation from chest to back are expected. Shoulder movement follows the physiotherapy instructions; doing too little can cause stiffness, while aggressive stretching can stress the healing flap.

Weeks 3–6

Most people become more independent and gradually regain comfortable arm elevation. Desk work may resume during this phase if pain, fatigue and commuting allow. Drains are usually out, but a back seroma can appear later and should be reported.

Weeks 6–12

Strengthening and wider shoulder movement progress under guidance. More physical work and exercise return step by step. A supportive bra and scar care may begin once wounds are fully closed.

Months 3–12

Strength, endurance, scars and breast shape continue to mature. Some restrictions resolve quickly; others improve over a year. Persistent shoulder pain, winging, marked weakness or limited motion deserves specialist physiotherapy review rather than being accepted as inevitable.

Long-term result and possible revisions

The transferred tissue is permanent, but the reconstructed breast still changes with ageing and weight. An implant underneath does not age like living tissue and may need later surgery. Common refinements include fat grafting, scar correction, adjustment of the breast fold, implant exchange, surgery to the other breast for symmetry, and nipple-areola reconstruction.

Patient-reported studies show that many women remain satisfied with extended LD reconstructions over long follow-up. Satisfaction is individual and should be weighed alongside donor-site function and, when relevant, the maintenance burden of an implant.

LD flap versus DIEP flap

An LD flap comes from the back, remains attached to its blood supply and is generally a shorter operation. It often needs an implant or staged fat for enough volume and can affect shoulder/back function. A DIEP flap transfers abdominal skin and fat as a free flap, requires microsurgical vessel connection and usually provides more implant-free volume while preserving abdominal muscle. DIEP recovery is longer and involves the abdomen, but long-term satisfaction is often high.

The better option depends on anatomy, radiotherapy, prior operations, health, desired size, access to microsurgery and personal priorities. The LD flap is not merely a second-best reconstruction; for the right problem, its reliable pedicle and flexible soft-tissue cover are exactly the needed advantages.

Questions to ask during your consultation

• Will my flap need an implant, and what size?

• Could an extended or fat-augmented LD flap avoid a permanent implant?

• Where will the back scar sit in my usual bra or swimwear?

• How do you prevent and manage donor-site seroma?

• Will the thoracodorsal nerve be preserved or divided?

• How might the operation affect my work, swimming, climbing or other sport?

• What physiotherapy programme will I receive?

• How does radiotherapy change my complication and implant-revision risk?

Frequently asked questions

Does an LD flap always need an implant?

No. An extended flap or fat-augmented flap can sometimes provide enough volume for a small or medium breast. Many standard LD flaps do use an implant because back tissue alone is relatively thin.

Will I lose shoulder strength?

Temporary weakness and stiffness are expected. Most people regain useful everyday function with rehabilitation, but persistent symptoms and reduced high-demand performance are possible. Discuss your specific sport and occupation before surgery.

How long is recovery?

Light activities return over the first weeks, many desk-based workers return around four to six weeks, and heavier activity builds over several months. Recovery varies with implant use, one or both sides, complications and baseline shoulder health.

Why is fluid on the back common?

Removing the flap leaves a broad potential space where tissue surfaces can slide and produce fluid. Drains, compression and quilting sutures help. A swelling that develops after drain removal should be checked for seroma.

Can the LD flap be used after radiotherapy?

Yes. Bringing vascularised tissue to a radiated chest is one of its key indications. If an implant is used, radiotherapy-related capsule and revision risks still require careful discussion.

Can both breasts be reconstructed with LD flaps?

Bilateral reconstruction is possible, but donor-site impact, operating time, available tissue and shoulder function require careful assessment. Other autologous options may provide more volume with a different donor-site profile.

Planning the reconstruction around daily life

Decide what the back tissue needs to achieve

An LD flap can solve several different problems: replace damaged chest skin, cover an implant, rescue a failed reconstruction or provide part of the breast volume. Those goals should be separated during planning. When most volume will come from an implant, the flap's main role is durable vascularised coverage. In an extended or fat-augmented reconstruction, the surgeon relies more heavily on back fat and later grafting. The balance affects breast size, projection, operating time and the chance of future implant-related surgery.

Patients should understand where the skin paddle may remain visible and how the back scar is positioned in relation to a bra. The final scar depends on anatomy and the direction in which tissue must be moved; it cannot always be hidden completely. Photographs of healed results in people with a similar build are more useful than a single ideal example.

Document shoulder function before surgery

Baseline matters. Previous shoulder injury, neck problems, lymph-node surgery, radiotherapy, dominant-hand demands and work or sport can influence recovery. A physiotherapy assessment may document range of motion, strength and compensatory movement before surgery. This provides a starting point for rehabilitation and identifies patients who need extra support.

The latissimus muscle contributes to pulling, climbing, paddling and movements that bring the arm down and backwards. Other muscles usually compensate well for normal daily tasks, but the impact may be more noticeable for competitive swimmers, climbers, wheelchair users or people whose work involves repeated overhead or pulling effort. The relevant question is therefore not only whether the arm will move, but whether it will meet the individual's real physical demands.

Prepare for recovery in two anatomical areas

Healing occurs at both the breast and back. Before surgery, arrange help for lifting, shopping, children and household tasks; place frequently used objects below shoulder height; and discuss sleeping positions, drain care and clothing. Early walking is encouraged, while shoulder exercises progress according to the flap and wound protocol. Pushing through pain is not the same as effective rehabilitation, but prolonged protection can also contribute to stiffness.

After discharge, contact the team for increasing redness, fever, shortness of breath, a rapidly enlarging breast or back swelling, wound separation or a change in flap colour. A soft fluid collection on the back may be a seroma and can require assessment or aspiration. Later follow-up considers breast shape, implant behaviour where relevant, back contour, shoulder function and whether targeted fat grafting or scar treatment would add value.

Think beyond the first successful operation

An LD flap itself is living tissue, but a reconstruction containing an implant may still need implant surveillance or revision over a lifetime. Weight change and ageing affect the natural tissue, while radiation can continue to influence softness and capsule formation. Ask which parts of the reconstruction are expected to be durable, what symptoms should prompt review and what options remain if the breast changes. This long-term perspective is particularly important when the flap is proposed as a salvage operation after previous complications.

Evidence and further reading

This page expands on Dr. Foumani's article Latissimus Dorsi Flap Breast Reconstruction: A Reliable Option Using Back Tissue. See peer-reviewed research on long-term BREAST-Q outcomes, prospective shoulder recovery and long-term back and shoulder function.

Educational content based on the work and book Breast Reconstruction Explained by Dr. Mahyar Foumani, plastic and reconstructive surgeon specialising in breast reconstruction. Content updated 15 July 2026. This information does not replace an individual consultation.