Answer:
After the preoperative markings including the skin island are made, the flap is harvested with the patient in the lateral position. An incision is made around the skin island and exposure is achieved for the muscle to be transferred. After incising the muscle posterolaterally, the musculocutaneous flap is then elevated toward the axilla. After identification of the thoracodorsal pedicle, the flap is transposed via a subcutaneously-created tunnel from the axilla to the area of the mastectomy defect. After checking for adequate pedicle length and flap size, the back incision is closed, and a drain is placed. The patient is then placed in a supine position with her arms symmetrically abducted at about 60 degrees. A breast implant or expander is positioned under the latissimus dorsi flap and pectoralis muscle, and the skin island is positioned within the mastectomy wound. The flap is sutured in place, usually to the lower margin of the pectoralis major and along a line above the inframammary crease.
The complications include, like any flap procedure, partial or total necrosis of the flap including loss of the skin island. The most frequent complication is a seroma at the back donor site despite use of drains. Other complications include hypertrophic scarring and complications associated with implant use such as contractures, rupture, and displacement.
To avoid use of an implant, one could take more subcutaneous tissue or combine it with another flap such as a TRAM.