Early and late capsular "deformation" as a cause of unsatisfactory results in the latissimus dorsi breast reconstruction.

The latissimus myocutaneous flap breast reconstruction continues to be a popular method, and the mechanics of flap elevation and inset have become routine. Still, it is difficult to obtain a lasting aesthetic result. It may be that we are asking the latissimus reconstruction to do things that are beyond its capabilities. This should challenge us to correct these deficiencies, rather than to discard the procedure in disappointment. The fundamental issue is the implant deformation, both early and late, which is related to the forces of capsular contraction. Early implant firmness and elevation and the late loss of both ptosis and projection are problems that are caused by the capsule itself. These late contour deformities have not previously been reported, but they are disturbing because of the untoward effect on symmetry. If these late findings are confirmed, the standard latissimus reconstruction must be viewed as an operation that can be expected to deteriorate after 5 or more years. The immediate placement of a tissue expander, instead of a permanent implant, is suggested as a means of mechanically manipulating these capsular contraction forces in the latissimus reconstruction. Although this is a logical suggestion, it will require a long-term study to confirm its efficacy.