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Background: The impact of unilateral extended autologous latissimus dorsi (EALD) flap harvest and axillary surgery on shoulder function has been well described, but the impact of bilateral EALD flap harvest not clearly defined. Nor is it clear whether reconstructions should be synchronous, or staged. Methods: In this prospective observational study, patients undergoing bilateral EALD breast reconstruction (February 2003-December 2009) completed the disability, arm, shoulder and hand (DASH) questionnaire pre-operatively, and at five post-operative time-points. Intensive shoulder physiotherapy was offered to those whose DASH score was >30 at 6 weeks, or >20 at 12 weeks post-operatively. Results: Sixty patients underwent bilateral EALD flap breast reconstruction (51 synchronous, 9 metachronous). Patients with pre-existing shoulder pathology (n=1) and those who failed to return any post-operative DASH questionnaire (n=10) were excluded from initial DASH analysis. However, these eleven patients were included in a separate analysis as an intention to treat analysis. A statistical analysis was performed using non-parametric, Friedman test and multiple comparison model. Forty-nine patients' DASH scores were analysed. DASH score initially increased after surgery then returned to functionally normal within 3-6 months (median DASH: pre-operative=1 vs. 6 weeks post-operative=26, P=<0.001; vs. 3 months=19, P=<0.001; vs 6 months=13, P=<0.001; thereafter the scores remained less than 12 P=<0.001). Median DASH score after synchronous reconstruction was not higher than after metachronous reconstructions, although the metachronous sample size was small. Conclusion: With appropriate patient selection and intensive physiotherapy bilateral EALD breast reconstruction does not appear to cause significant longterm impairment of shoulder function, and patients can now be counselled about the likely timecourse of shoulder recovery. There seems no reason to stage bilateral reconstruction in order to reduce shoulder morbidity.

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