This week, Dr. Kline, of The Center for Natural Breast Reconstruction, answers your question about breast reconstruction.Question: I had that flap reconstruction 4 years after my mastectomy. That was 8 years ago. I'm in constant pain from the pulling in my chest. I hate that I can no longer paddle my canoe or swim. I'm also having continued back problems that require the use of a chiropractor. Can this procedure be reversed? I did not have any radiation or chemotherapy.Answer: What type of flap did you have? It would be very unusual for a free tissue transfer (such as DIEP) to cause pulling, but not so unusual for pedicled flaps like a latissimus (or even a TRAM). If you did have a latissimus, it could quite possibly be revised to improve your symptoms. If you had a DIEP, it would require a little more investigation. Please let me know, and I'll try to give you a more precise answer. I'd also be happy to chat with you by phone, if you wish.Inquirer’s Response: I believe it was a latissimus. They used a portion of muscle from the side of my back, just a few inches lower than the armpit. The breast has also shifted slightly so that it isn't centered in the chest anymore and is closer to the armpit. In addition to the pulling pain in the chest, I'm having severe pain in the upper back, shoulders, and neck. I've also had recurring numbness and tingling in the hand and sharp pain shooting down my arm. The chiropractor says that the realignment of the muscle will mean a forever battle of trying to keep the spine aligned and not pinching the nerve. Having the latissimus procedure is a huge regret for me. I wish I'd just had an implant. The other breast just had a lumpectomy, rather than a full mastectomy. I have a small implant on that side that has never caused me any issues. I want to know if the latissimus can be reversed and have an implant put in.Answer from Dr. Kline:I’m sorry you’re having so much trouble. That actually isn’t the norm for latissimus flaps, but it certainly can happen, as you know.The latissimus can be transferred with or without dividing its motor nerve (thoracodorsal), and with or without dividing its attachment to the humerus (arm bone). If the breast is shifting away from the center, that’s an indication that it may still be attached to the arm bone. If you have spasms, or intermittent pulling pain, it could be because the nerve isn’t divided, and the muscle is still functioning. This doesn’t bother most people, but it definitely bothers some.Sharp pain shooting down your arm (especially the inside of the upper arm) could indicate compression of the intercostobrachial cutaneous nerve, which lies in that area. Offhand, I can’t think of an obvious anatomical explanation for your hand numbness and tingling, however.Three muscles, the pectoralis major, the teres major, and the latissimus dorsi all attach to your upper arm bone at about the same place, and all pull the arm towards your body, but they each pull from a slightly different angle. The latissimus is now rearranged to pull from the same angle as the pectoralis major. Usually, this does not cause a problem, but that’s not to say it never does.It’s not really practical to actually “reverse” a latissimus flap, in the sense of putting it exactly back where it was. The flap can certainly be removed, however, and it is not at all unreasonable to think that that might help your symptoms.In addition to perforator flap breast reconstruction, we also do implant reconstruction, but we shifted to placing the implant exclusively in front of the muscle about three years ago. This can result in some visible rippling, but it has multiple benefits, including lack of animation deformity when the muscle is contracted, less chance of the implant coming out of position, less damage to the pectoralis muscle, and less discomfort. Successful placement in front of the muscle is made possible by completely or nearly completely wrapping the implant in acellular dermal matrix (preserved skin, such as “Alloderm”), which heals to the tissue around it, and provides support.While it may often be a very prudent decision to travel to see surgeons with extensive experience for complex procedures such as perforator flaps (DIEP, sGAP, PAP, etc.), simply removing the latissimus and placing an implant (or a tissue expander initially, which can be safer) requires no unusual skill, so I would recommend that you first consult your previous plastic surgeon, or another in your geographic area. I would still be happy to speak with you about your situation, however, if you wish.Have a great weekend, and thanks for your inquiry.
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