Sometimes, a combination of different techniques may be required for breast reconstruction. This is usually seen in women who previously received radiotherapy to their breasts (for example after lumpectomy). In such cases, surgeries performed with tissue expanders and prosthesis alone are not recommended because complications, such as scar formation, commonly occur around the prosthesis. Some women do not want an additional scar on their abdomens (or hip/thigh). The abdominal and hip tissues of some women are so weak that they cannot be used. Howsoever rare, some women avoid the risk of complications of microsurgery. In such cases, the latissimus dorsi muscle (the large, flat and triangular-shaped muscle at the back) can be used to surround the tissue expander/prosthesis and to bring the tissues that has not received radiation previously to the breasts.
Reconstruction with the latissimus dorsi (LD) can be used for immediate or delayed breast reconstruction. In addition, the LD can be used for both breasts simultaneously or at different times.
Reconstruction with the LD is performed as a flap with pedicle, in other words, the circulation remains intact. The muscle is tunnelled from the back up to the breast under the skin. Even if bilateral, loss of the LD muscle results in minimal functional deficiency in the vast majority of patients since other muscles provide the functions of this muscle (extension of the arm ) to a large extent.
The incision made to use the LD muscle is often a scar that can be hidden with the bra line, and sometimes, it is in the form of a cross incision.
Mostly, patients who have undergone reconstruction with the LD muscle require the implantation of a tissue expander or prosthesis to provide a sufficient volume in the breast. The expander allows the reconstruction to be adjustable. In some women with small breasts, the muscle, skin and soft tissue in the LD may be sufficient for breast reconstruction without the need for prosthesis.
The majority of patients, who have undergone breast reconstruction with the LD muscle, stay in the hospital for 3-5 days. The recovery period takes shorter after this procedure, but some patients may require a short-term physiotherapy for their shoulders to obtain their previous movements. Most patients feel a pain that can be taken under control with oral painkillers. In general, patients can return to their normal activities within 3-4 weeks and to their athletic activities within 6-8 weeks. Generally, healing after the reconstruction with the LD is faster and easier than in reconstruction with TRAM since no incision is made on the fascia (the structure covering abdominal muscles).
Breast reconstruction with the LD muscle usually takes 3-4 hours under general anaesthesia. The length of hospital stay after breast reconstruction with the LD muscle is usually 3-5 days and the majority of patients feel comfortable with mild narcotic analgesics. The drains in the breasts are pulled out in the next 1-2 weeks while the drains in the back are pulled out in the next 2-3 weeks. Rarely, the drains in the back may stay longer.
In patients with implanted tissue expander, the inflation begins within 10-14 days after the surgery and it is continued to be inflated once or twice a week until adequate expansion is achieved. Prosthesis is replaced (replacement of the tissue expander with permanent implant) 2-4 weeks after the completion of inflation. Usually, nipple reconstruction and surgeries for asymmetry are performed at the same time as well.