Latissimus Dorsi Breast Reconstruction
Comments
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Ah, you misunderstood me. I gave that link because the study shows exactly what damage to the LD muscle means, and the thoracodorsal nerve is always cut in the LD breast reconstruction to stop breast animation and promote LD muscle atrophy.
The thread is pinned at the top of the "breast reconstruction" forum. This is the thread.
I am sorry for misunderstanding too. As this thread is about LD breast reconstruction, I assumed that your problems are due to a LD breast reconstruction.
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Oh I see. So you do have all the bad side effects without even having the reconstruction. I am so sorry!
But yes, that is what the "loaf" is, the muscle itself. And that study shows exactly what type of activities would be affected by the LD muscle being rendered unusable. Do you know if your surgeon cut the thoracodorsal nerve or not? Do you have any animation on your chest? As in, does anything move if you try to push on something with your arm?
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Ah. I had axillary web syndrome after the lymph node removal. Like a dozen supertightened piano strings that were going from the axilla to the base of the thumb and keeping my arm in a 90 degrees angle at the elbow. Nevertheless I didn't get "gentle" rubs or stretches or anything gentle for that matter. I had the scar tissue on the lymph vessels (that is what does the webbing) broken - a very painful procedure that I had to have several times a day. Because my insurance would only cover 15 PT sessions in a calendar year, the PT lady was kind enough to show my boyfriend how to do that. The scar tissue would tighten back within a couple hours and my arm would slowly get back in the 90 degrees angle, and then I had to go through the breaking the scar tissue thing all over again. Took about 2 1/2 weeks of this torture for the webbing to go away. It still has the tendency to come back once in a while and when it does I do stretches and preso-puncture.
But yes, you might want to ask if the nerve was cut or not. It has a great influence on the atrophy of the muscle, and only when the muscle atrophies does the "loaf" start shrinking.
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Thank you for the interesting conversation and information since my last post. PS warned me that I'd have some fluid build up and that she would take care of it when I see her in a few days so I'm not worried about her leaving it and having my body reabsorb. She was good about showing my husband what to look and feel for so there were no surprises over the Thanksgiving holiday.
I appreciate the information on the "loaf" as well. It is weird for me to let my arm rest by my side and to have something in my armpit. I understand that all this will continually change as the weeks and months go on (especially once I start getting some fills in my TE). But for now must keep telling myself: don't use right arm to carry/move stuff! (Good thing I'm left handed!)
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Oh, you're lucky! I am severely right handed and the BC was on the right, so that's where I had the ALND too.
Btw, about the "loaf", it's an easy way to make someone understand how you feel: fold a hand towel in two, length wise, then roll it, and put it under their armpit. Then tell them to walk around and do stuff like this. That worked wonders for me.
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I actually had my shoulder messed up because of that "loaf", due to the awkward position of the arm, I developed a mild shoulder impingement syndrome that affected my acromion process, with a mild bursitis in the subacromial process.
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seachain, my PS doesn't cut the thoracodorsal nerve when he does an LD flap. (Yes, indeed, that means I can make my foob jump on command!) He doesn't want the lat muscle to atrophy because it provides some of the volume for my left foob.
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That is fine, if you can live with the breast animation. I hated it with a passion.
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I don't think mine plans to cut the muscle either. What does that mean: breast animation?
I do need as much "volume" as I can get as the ps worries that he likely won't be able to stretch me out as much as we'd like.
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seachain, I don't love it, but the LD flap was literally my only option. I'll take foobs that move (the non-flap side does it too but not as much) over the way I looked flat.
Ruth, it's the nerve to the muscle that is sometimes cut not the muscle itself. Since the nerve and muscle still function, when I use my arm in a way that contracts the lat muscle, my foob moves. Both of them move whe I contract my pecs. It's a bit annoying, but I definitely consider it the lesser of evils.
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2Tabbies, I didn't notice any decrease in size after the PS cut the thoracodorsal nerve. I think the "atrophy" doesn't do much in terms of decreasing the size of the LD - which is stretched over the implant anyway. Even after the de-nervation you will still have some breast animation from the pectorals, but it will be greatly diminished - the implants won't be pushed towards your clavicles and that puckering at the bottom of the breast when the muscle is flexed will be greatly diminished,
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Ruth, the volume doesn't come as much from the LD itself, but from the implant. The LD is there to form a better pocket for the implant and better coverage.
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I recall the time when I was making my decisions about the LD Flap surgery and posters would periodically pop onto the thread with nightmare stories that scared the crap out of all the women on here who had enough to contend with. Had I listened to any one of them I would not have boobs today. Does anyone recall the woman who is now so disabled that she cannot slice a tomato? Did anyone else smell total BS? It's important to be well informed but it's also important to get your clinical and medical advice from your doctors. Yes, LD Flap surgery may have serious complications and so may every other stinkin' option women have for reconstruction. LD Flap surgery is actually one of the safer flap surgeries. My best advice to everyone on here: Do not assume everyone on here is real or has good intentions. Get to surgeons with a lot of experience with LD Flaps and get as many opinions as you need until you're comfortable. And get physical therapy whether you think you need it or not.
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seachain, I'm only going by what my PS said regarding volume. And he did use a significantly larger implant in the non-flap side so that foob would be as big as the one with the flap.
Warrior, yes, exactly. There's a chance of problems with any surgery. Everybody has to decide if it's worth the risk to them. If so, get an experienced surgeon and cross your fingers.
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Warrior Woman, allow me to come from the other end of the spectrum and remember when I was considering the LD flap option and several women here advised me not to, while a lot of others jumped in and said that they had no issues whatsoever, including the decisive one (I will not name names as she felt very guilty afterwards) who said that she can do exactly what she was doing before the surgery, involving a lot of fairly athletic activities. And here I am, on disability, with my cervical spine messed up and some of my remaining muscles on the back and especially on each side of the waist ripping open because they can't compensate for the missing LD. And looking forward to yet another surgery within the month to fix at least the "ripping apart muscles" part of this reconstruction, 6 years later down the road. All because the PS never tells you the whole truth, and it's always "there isn't enough evidence", while on the other hand there are innumerable studies on what happens when the LD is injured and they have to do surgeries to fix it in order to restore the body's normal function.
Would I chose to not have this surgery if I could go back in time, even with the risk of being flat for the rest of my life? In a heartbeat. I'd choose not having boobs over living in chronic pain, not being able to even open jars by myself, and not being able to work and having to survive on SSD and SSI.
I very much doubt that telling people that LD flap reconstruction "is the safest" does anyone any service. Of all the reconstruction techniques, it's the one that has the heaviest effects on the normal body function. It is the "safest" only in terms of complications of the reconstruction itself, the one with the least death of tissue due to the fact that the LD has strong blood vessels that are moved with the muscle insuring thus the survavibility of the tissue. That is all.
The "safest" in terms of no complications regarding body functioning is the newest fat grafting technique. The next is the one-step implant with Alloderm sling. The next, is the regular TE to implant transition. All the others are considered for the women who had radiation and the skin on their chest is damaged and can't be expanded, so flaps of skin with the underneath tissue are used to form the necessary pocket for the implant. The more muscular tissue used, the harder the normal function of the body is impacted. It's simple logic. If you get a muscle that is 6" long and 1" wide, weighs 2 oz, and controls very little movement, is one thing - if you get a muscle that is almost a foot long, 8" wide at the base and controls basic functions of propping the torso up, turning around, getting up from a sitting or laying down position, what do you think, logically, will happen to the normal functioning of the body? How "normal" will you feel?
There are many women who have been tragically impacted by this surgery and left these forums because they got tired of being told that their disability is a fluke and it doesn't count. I guess I am the only one who still cares enough to come back and warn others, in spite of all the rebukes wielding rainbow-glittered flags of "oh you'll have nice boobs". Forgive me for being so abrupt, but it comes from the fact that I personally sometimes wonder if it was worth it to survive it for a life like the one I'm living now, because of this type of reconstruction that I chose without being told the entire truth.
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Seachain - Let me see if I understand this correctly. You created an account on BCO about a month ago and have actively posted over 100 posts during the weeks that have followed because you want to warn women about potential risks of a surgery that you had over 6 years ago. Help me to understand this because I do question your motives. Regardless of the circumstances surrounding your situation, your public service announcements serve to frighten women who are already scared to death. But then again you may enjoy this type of drama. I've seen much empathy expressed for those who have experienced adverse outcomes but your subjective experience and pseudo medical knowledge should not be substituted for medical consult. This reminds me of the people who tell new comers of the horrors of chemo or how ones life will be ruined by radiation or hormonal treatment. Your dissatisfaction with your own outcome is regrettable but should not be used to infuse terror into the minds of vulnerable people.
Ladies - In light of the conflicting accounts you may read on BCO of LD Flap surgery or anything else discussed on this forum, talk directly with your doctors about your specific circumstances. I found it helpful when I was contemplating my surgery options to private message women who impressed me as having sound judgement. As an athlete I was especially concerned about my post surgical quality of life as everyone is. The only thing I cannot do today are pull-ups. But then again I've never been able to do pull-ups. Not a darn thing has changed. I did show my PS some of the horror stories posted on this thread over a year ago. Not only did he state that he has never seen such outcomes but he questioned if the posters were women with breast cancer or sadists with too much time on their hands. If you're contemplating this surgery, get to a surgeon with expertise in LD Flaps and get physical therapy by a PT with expertise in LD reconstruction.
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seachain, my heart aches for those of you who have had bad complications from this surgery. I asked my PS some of the exact things you mentioned. This muscle has a job. What happens when it can't do that job? He said other muscles compensate. Two other PS's told me the same thing. They were apparently right in my case because I can do all the things I used to do including swimming and strength training. I asked my PS how many of his LD flap surgeries over the 30+ years he's been in practice resulted in long term complications. He said he only had one person who had lingering pain. I thought those were pretty good odds of success. Maybe he was lying, but I don't think so. I guess some surgeons probably do lie to patients, but I still have to believe that most of them don't. Maybe your surgeon lied. Maybe he's not a good surgeon, and that's why you've had such an awful result. I don't know. From what I've read here and elsewhere, issues like yours seem to be the exception, but that doesn't mean they "don't count" to use your words. Of course, they count. Jo was unlucky enough to get a secondary cancer from radiation therapy, which from what my RO says, is very rare. I have a very rare form of incurable lymphoma. These are things our docs tell us not to worry about because they're so rare. But they do happen to somebody, and those people definitely do count. I didn't want to have any flap surgeries and especially not one that sacrificed a muscle, but as I mentioned I had no other options for recon. I could have stayed flat, but I was having a horrible time dealing with that. I tried it for a year, but every time I saw myself in the mirror, I literally wanted to take a knife and stab my hideous chest. That's how bad I felt. God knows how long I'd have had to be in therapy to get past that. Believe me, I was completely blind sided by those feelings because I'm not a girly girl, didn't have big boobs, and thought I might be fine with being flat before the mastectomy. I guess my point is that we all have to weigh the risks and benefits of whatever choices we have then make a decision and go with it. In my case, I thought the risk of surgery was worth it. I'm really sorry you and others have had such an awful time. Can I ask if you know why you're having such issues? Did something go wrong during the surgery, or is it that for some reason your body can't compensate for the muscle loss? Hang in there. I hope the surgery you have coming up gives you some relief.
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Warrior woman, you are so many degrees of unbelievable that "I can't even". Your post has definitely earned a place on all those threads where we post the incredible rude and idiotic comments people tell us. You are nothing but a bully. And bullying on this type of forums is nothing but despicable.
IF you had a little bit of brain to search my "over 100" posts, you would have seen that 1. I had an account on BCO back in 2009, when I was diagnosed; 2. I took a break from the forum and when I came back I had forgotten the password and couldn't recover it because I had closed the email I opened it with - many here still remember me, especially the ladies in my "May 2010 chemo" group. So I had to make a new account. A simple look at my signature would have given you plenty of an idea about what I've been through.3. Not only that, but a look in my past "over 100 posts" would have brought you to the post I have initiated on the "Breast reconstruction" forum that actually has photos of the issues I am confronted with. Issues for which I have to go back in the OR, almost 6 1/2 years after the reconstruction surgery. 4. Don't assume that everybody who posts here has "pseudo medical knowledge". I happen to have a medical degree, true, a European one and never practiced in the US. That doesn't nul my knowledge in the medical field, and neither does your bullying post. Because it's very obvious that YOU are the one who has a serious lack of knowledge about this. Mind your own business. You go ahead and paint the whole LD in rainbow colors with glitter sprinkles and let me do my posts about warning others. That's your deal, this is mine. If you got a problem with it, it's YOUR problem, not mine. Deal with it and stop throwing childish tantrums and high school bullying crap. Seriously. Grow up. I would say "shame on you" but I know your kind: you are never ashamed because you aren't able to see what you're doing wrong.
2Tabbies, to answer your questions. My PS is a very good one, and the result of his work, from the aesthetic point of view is nearly perfect. You wouldn't believe that my breasts are not natural. But he also said that I was his first former athlete he did this procedure on and will be the last one as well. See, years ago, in the talks with another former member of this forum who had such issues following this type of reconstruction that she had to go through a surgery of completely removing the LD muscle, we came to the conclusion that it is the former athletes or anyway, women who had a fairly athletic life that seem to have the most issues with this surgery. Their LD muscle being very developed and actually taking a great role in holding their torso upright, when it is removed, the remaining muscles cannot compensate. You can get in touch with her, her name is Gina Maisano and she since has founded the No surrender breast cancer foundation to help others that are going through this horrible journey. She wrote a book too. Her blog can be found HERE. She didn't come on this forum much anymore because both of us - and a few others with the same issues - were permanently treated like this Warrior Woman is trying to treat me and she had enough of it.
Anyway, that is the main issue. My remaining muscles were never able to compensate. I lost about 60% of arm and hand strength. Due to the incorrect position of the torso I got slipped vertebrae in my neck. And now the abdominal obliques are herniating due to the effort of trying to compensate for the missing LD muscle. The recent post I made about this that has accompanying pictures can be found HERE.
As for how much the PSs tell you and how much they know of the long-term outcome? Ask your PS for how long he has followed up with his former patients after their final surgery. 6 months? A year? I bet you not even that. Simply because the health insurance doesn't pay anymore - follow-up with no immediate issues is not compensated. My PS, I saw him the last time before this a couple of months after my last surgery, back in 2011. Now, in 2015, he had no idea what was going on. Simply because the primary care doctor and the spine specialist and the pain management doctor don't call the PS to tell him "you know, you should be aware that X patient has issues because of that reconstruction". I was fortunate to have a pain management specialist who figured out on the spot what the problem was with those herniated muscles and called the PS office to schedule an appointment before I even left his office - the primary care doctor when I saw her two days before the pain management specialist said she thought it was just some stubborn fat.I know it's a very rare complication, until now only a handful of cases have been reported and I'm glad they caught it in time before I got colon entrapment or kidney displacement due to the hernia caused by the obliques ripping. And, by the way, those handful of cases reported? NOT former athletes. Yes, it's very rare. It doesn't mean it doesn't happen and it should be disregarded.
Does a PS care enough to do the follow up? No. The PS is interested in the esthetic outcome. Not interested in the quality of life. So is the oncologist. So is the radiologist. What they are interested in is that "you are NED". Period. That is the sad truth.
And I am sorry, but I think that women should be aware of the possibility of life-long effects of this surgery. And that if they can have a reconstruction using another method, they should choose it over this one, and this one should be chosen only when everything else is impossible.
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seachain, thanks for the explanation. Again, I'm sorry you're going through this. I do have to say that I think my PS does care about quality of life. We've discussed this. Do they follow patients for years? No. As you said, if insurance doesn't pay, it won't be done. And how many women are going to go back to a surgeon unless they are already experiencing a problem? I agree that it's too bad they don't mention rare, but possible, complications. That's a pet peeve of mine. For that matter, common side effects of treatment like the damage radiation does to tissue weren't even mentioned to me until it was a done deal. But I won't go there, or I'll get really angry. I also have an MO who only wants to deal with whether the cancer has come back not quality of life. He never uses the term NED. Which is a good thing because I'd call him on it. Nobody is looking for a recurrence in my case. No scans, no blood tests. Nothing. We just wait to see if symptoms show up. We won't find "evidence of disease" if we don't look, will we. But that topic is another place I shouldn't go, and a digression from the topic at hand. All the other accounts of complications from an LD flap that I've read were because of a mistake/accident during the surgery i.e. something was cut that shouldn't have been. That's a risk with any surgery. Bottom line is that there's no guarantee in any of this. You do your research, make a decision and hope for the best. Most of us, fortunately, get through this procedure ok. Good luck with your surgery.
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Heh. I hear you on the "nobody tells us". I, unfortunately, did draw the short straw on most of the treatment steps. Pulmonary apical fibrosis from Cytoxan (irreversible). Disappearing teeth from Taxotere (they just dissolved, practically). Peripheral neuropathy and fibromyalgia from any of the two above. Post mastectomy pain syndrome. Iron bra. Iron corset due to the bottom 2/3 of my back being scar tissue because the surgeon took the "we'll wait for them to reabsorb themselves" approach on my extensive back seromas. That is on him. The slipped vertebrae I mentioned in the previous post due to the lack of LD muscle to keep my torso up. Herniated muscles. Rapidly advancing osteoarthritis following AI treatment - no the MO won't tell you that, will vehemently deny - but my spine and pain management specialist said that he sees it all the time in women over 45 who have undergone AI treatment. Did anyone tell me beforehand? Nope. At least when it came to radiation I was well informed by then, and put my foot down stubbornly. BS wanted to do ALND followed by radiation. I said "what are you going to radiate if there's no more breast tissue and no more lymph nodes". He said "just to make sure". I said "I'm not going to make sure I get lymphedema, I had enough side effects". Finaly we got to a compromise - if my lymph nodes were going to be negative at pathology, no radiation. They were negative. So the only thing I had to deal with was the axillary web syndrome. At least that one went away in about 6 weeks. 6 weeks of getting around 12 underarm scar cords broken every 2-3 hours and hurting something fierce when broken otherwise my arm would be stuck at a 90 degrees angle at the elbow and hurt like hell.
Now you see why I am so adamant in telling others about the risks. There is that short straw and nobody deserves a poor quality of life after they went through what they had to go through in this journey.
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Seachain-one thing I am not clear on in your story--did you have a second surgery to cut the thoracodorsal nerve? In yesterday's posts you said you hated the breast animation and didn't have any size decrease after the nerve was cut.
I'm just curious.
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Yes, I had the thoracodorsal nerve cut at the first major "nip and tuck" that was done almost a year after the first surgery. Look in my signature, the dates of the surgeries are there. A month after the first surgery I had to go in for emergency surgery as I had infection on the "spared" areola of the left breast so the dr. had to go in, clean everything, remove the infected tissue and replace the compromised implant with a new one, then left me for almost a year to make sure the implants got to the final setting (had to wear an Ace bandage to make them descend for like 4 or 5 months) before he'd give them the final form.
So I had breast animation for a year. Then after the nerve was cut I didn't notice any decrease in volume. Just the "loaf" under the arm got a little smaller, and went almost completely away after I lost weight.
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To note that you will still have some animation even after the thoracodorsal nerve is cut, from the pectorals, as most surgeons will do the covering of the upper 1/3 of the implant with the pectoralis major. If you don't know what breast animation is, here is a good example:
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Seachain--thanks for the lesson on how to read your signature, but just in case you don't read it--it doesn't describe the surgery other than to say "Reconstruction" and it therefore could mean a variety of things, that is why I asked.
As a person still trying to make a decision about my reconstruction options I feel some of your posts are similar to the commercials for medications that list a gazillion side effects without the facts regarding likelihood of those side effects.
I am sorry you have had the complications you have during your re-construction.
After reading some of the studies you have posted I see that those studies say that your specific complication is caused by incorrect harvesting of the LD muscle. To quote one of the studies you cited: " An adequate harvesting of LDMF is important in order to avoid this complication.", another study you posted says basically the same thing, but also points out that at the time of the study only 3 cases of this complication from breast reconstruction have been reported. Again, I am sorry you find yourself with this problem.
One thing that would be really helpful to people considering reconstruction is a way to research the experience of surgeons and results from these surgeries(like how many cases done and % of complications, etc.) from outside sources, not just the drs. themselves. I wonder if there is such a place.
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oh Sam2U, I so agree! That is exactly what is needed.
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Hi - I had my lat flap surgery in 2011 and in the spring of 2015, accumulated fluid in the surgical site on my back, where the lat flap muscle was removed. No amount of lymphodema massage will budge it. Does anyone else have this problem? If so, any suggestions for improvement? I am considering contacting my surgeon to aspirate it, if he will.
Thanks!
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Sam2U and Ruth7733, I suggest that you contact Whippetmom. She has a list of a lot of plastic surgeons that are good. She might be able to give you some names in your area.
Camille, it can't hurt to contact your surgeon and ask. It seems awfully late for a seroma, but who knows.
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I had a direct to implant Nipple Sparing BMX two months ago. My surgeon used Alloderm to create a lower pocket, and I thought the Pec was on top the implant above. I had good function before my right lymph node removal a month later. Now I'm rehabbing my right arm.
I'm very pleased with the cosmetic results. I can move my breasts singly, but so what? They still feel like foreign objects, but so does my hip replacement. I've had a number of major surgeries and you always have leftover pain and numbness. To expect a complex surgery like a Breast Replacement to look and feel like your old breasts is unrealistic. There are many choices for reconstruction, and all require compromises. I had to stay close to my size for direct to implant, and taking 475 cc hurt like hell for 3 weeks. Most all major surgeries hurt like hell for at least 6 weeks. Cutting a nerve so my breast wouldn't move would cause major loss of functionality. No thanks. If I can't live with these, I'd go flat with pretty tattoos. But I'm pretty sure I can.0 -
I'm sorry, what is the functionality you're talking about? Of the muscle formerly on you back that now covers your reconstructed breast? That functionality was lost the moment the LD was prelevated. the only functionality the muscle still has is to... cover the breast. Not to MOVE the breast.
Sam2U, I'm sorry. I presumed you already knew that the nerve is never cut in the initial surgery, but in any of the follow-ups, to avoid complications. And if you read all my posts, the herniated muscle is not the only complication I have. I am just unfortunate that it seems I got most complications, while other women get only one at a time.
You are right. It would be wonderful if there were such a central database where all the patients of a doctor could go an follow-up with how they are faring.
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Searchin,
I didn't have any back muscles used. I had a pocket made with the Pecs and Alloderm. Full functionality to me means I can reach overhead, grab, hold, lift and have full range of movement. I had most of that before the lymph node surgery, but I swim almost every day. This is nothing compared to rehabbing my Rotator cuff surgery last year.
I've had multiple invasive surgeries and live with chronic pain from arthritis and side effects. My right hip hurts far more than my BMX.
If you haven't had surgery before, or experienced chronic pain I can see how this BMX would be hard to adjust to. Any woman who has a c-section; given live birth; had any abdominal or joint surgeries, and/or live with arthritis will not find this as painful.
I watched the animation video you posted. She was really pressing hard to exaggerate the deformity. Her "after" result looks like she went too large so the scaring around her nipple is very obvious. Not a natural look at all. Plastic Surgeons are in it for $. I can sorta cause the deformity if I really try, but why would I? This surgery wouldn't be possible without the Pec's support. I need some fat infill, but that's it
I see you had a reconstruction 1 month after your first surgery. That was far too soon. Why did your surgeon recommend it? 6 months minimum after the first surgery to allow things to heal. You were the victim of poor decisions, not the technique itself.
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