Dear Dr. Marga:
I have Stage III breast cancer and lymphedema. I have not had reconstruction and have been researching my options. I have seen three plastic surgeons in New York City and each have recommended a latissimus muscle flap and a breast implant.
I am very active and enjoy golf. I am not very excited about losing my latissimus muscle from my back so I have been doing some research on the internet for other options. I see that you have experience in TDAP flaps and discovered that you are a lymphedema therapist in addition to being a breast surgeon.
What do you recommend? Could I use a TDAP flap instead of losing my latissimus muscle?
I am also worried that this surgery may make my lymphedema worse. Should I abandon my desire to have normal breasts so I can better care for my arm?
Thank you for your time,
Thank you for your question regarding latissimus dorsi and TDAP flap breast reconstruction in patients with lymphedema.
You mentioned that you are a Stage III patient and I am assuming you had a mastectomy with an axillary lymph node dissection and irradiation as a part of your care…
In cases such as these, most patients are advised to avoid breast implants alone as implant failure in an irradiated field is exceedingly high (> 50% at 7 years). A traditional means to address this issue has been to add a latissimus dorsi (LD) muscle flap on top of a breast implant as a means to add tissue to the reconstruction site to avoid implant exposure and capsular contracture (scaring around the implant). This is the traditional teaching for plastic surgeons throughout the country.
Reconstructive surgeons with additional training in microsurgery may offer a thoracodorsal artery perforator (TDAP) flap over an implant as a means to preserve muscle function as no muscle is included in the TDAP flap and the LD and TDAP flap donor sites are nearly identical. More commonly they avoid implants all together for patients with a history of irradiation and offer a variety of soft tissue reconstructions that can be taken either from the abdomen, buttocks or thighs.
The bigger issue here is not whether to chose a LD flap (muscle) or a TDAP flap (fat and skin) but rather is that of adding an operation on your back given your history of lymphedema!
Breast cancer patients who suffer arm and/or trunk lymphedema are encouraged to seek long-term care with a Certified Lymphedema Therapist (CLT) for conservative management of their swelling. As a part of their care, most therapists in the United States include Vodder Method Manual Lymphatic Drainage (MLD) as one of the 4 major components of Complex Decongestive Therapy. Vodder Method MLD is a well-defined series of maneuvers where lymphatic fluid is directed out of an area of injury towards normal lymphatic pathways. For a breast cancer patient with arm lymphedema and a history of axillary lymphadenectomy (removal of any lymph nodes), breast surgery (lumpectomy or mastectomy) and irradiaiton, this would focus on moving fluid out of your arm posteriorly and though unaltered lymphatic pathways in your back… Therefore, I strongly oppose the use of the LD and TDAP flaps for patients as yourself as these operations destroy the major pathway for MLD for your already affected arm and or trunk. Further, I discourage the use of these flaps for “at risk” patients as the back would be their “salvage” drainage pathway should they go on to develop lymphedema later in life. Many may not know that the lifetime risk of lymphedema in a patient with an axillary lymph node dissection and irradiation reportedly is 50% or more.
I view the popularity of the use of the latissumus flap in breast cancer patients with prior irradiation as a symptom of the paucity of lymphedema education in traditional medical schools and residency training programs. Many surgeons and cancer providers alike lack even the most basic education related to Vodder method MLD and CDT.
So, the short answer to your question: Yes, a TDAP flap can be used over a breast implant in order to preserve muscle function.
The long answer: Don’t do it!
Even a TDAP flap may hinder your ability to drain your arm through your posterior trunk! And, breast implants in an irradiated field (with or without a flap) are simply a bad idea. Unplanned re-operation rates reported to the FDA far exceed 50% at 7 years for breast implant reconstruction in an irradiated field.
Go Natural! Seek out a qualified microsurgeon and a natural muscle-sparing breast reconstruction with a more remote donor site. Even better, seek out a surgeon with experience in lymphatic reconstruction! There are ways to make your lymphedema more manageable while reconstructing your breast!
Lastly, don’t forget to ask if your surgeon is a Certified Lymphedema Therapist!
MD-CLT is the new TLC!
We will be in San Francisco, May 12th 2012, hosting a “The Dr Is In” Event. Join us and learn more about natural breast and lymphatic reconstruction.
Marci, I hope this helps!