Aesthetic andReconstructive Breast Surgery Solving Complications and Avoiding Unfavorable Results Edited by Seth Thaller Zubin J Panthaki Aesthetic and Reconstructive Breast Surgery Aesthetic and Reconstructive Breast Surgery Solving Complications and Avoiding Unfavorable Results Edited by Seth Thaller, MD, DMD, FACS Chief and Professor, Division of Plastic, Reconstructive, and Aesthetic Surgery, The DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida, USA Zubin J Panthaki, MD Associate Professor of Surgery, Division of Plastic, Reconstructive, and Aesthetic Surgery, The DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida, USA Inc. Designs and Patents Act 1988 or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency Saffron House. or damage caused to any person or property arising in any way from the use of this book. stored in a retrieval system. All rights reserved. II. we would be glad to acknowledge in subsequent reprints or editions any omissions brought to our attention. UK. and the appropriate best practice guidelines. USA (www. New York NY 10017. This book does not indicate whether a particular treatment is appropriate or suitable for a particular individual. © 2012 Informa Healthcare. 5. Although every effort has been made to ensure that all owners of copyright material have been acknowledged in this publication. 2. 7th Floor. WP 910] 618. mechanical. Breast: surgery. in any form or by any means. Because of the rapid advances in medical science. . 52 Vanderbilt Avenue. A CIP record for this book is available from the British Library. 119 Farringdon Road. Informa Healthcare is a trading division of Informa UK Ltd.Published in 2012 by Informa Healthcare. or otherwise. unless with the prior written permission of the publisher or in accordance with the provisions of the Copyright. MA 01923.copyright. relevant manufacturer’s instructions. electronic. Reconstructive surgical procedures: methods. and although reasonable efforts have been made to publish accurate information. USA. Seth R. Reoperation. Panthaki. Library of Congress Cataloging-in-Publication Data: Aesthetic and reconstructive breast surgery: Solving complications and avoiding unfavorable results/edited by Seth Thaller and Zubin J Panthaki. 6-10 Kirby Street. The publisher wishes to make it clear that any views or opinions expressed in this book by individual authors or contributors are their personal views and opinions and do not necessarily reflect the views/ opinions of the publisher. or transmitted. 4. 222 Rosewood Drive. p. Reprinted material is quoted with permission. photocopying. London EC1R 3DA. London W1T 3JH.. Danvers. recording. London EC1N 8TS UK. ISBN 978-1-84184-847-1 (hb : alk. Save for death or personal injury caused by the publisher’s negligence and to the fullest extent otherwise permitted by law. injury. No claim to original U. any information or advice on dosages. Includes bibliographical references and index. except as otherwise indicated. paper) I. Product or corporate names may be trademarks or registered trademarks and are used only for identification and explanation without intent to infringe. knowledge of the patient’s medical history. the publisher makes no warranties (either express or implied) as to the accuracy or fitness for a particular purpose of the information or advice contained herein. UK.1’90592--dc23 2011038490 . neither the publisher nor any person engaged or employed by the publisher shall be responsible or liable for any loss. procedures. Any information or guidance contained in this book is intended for use solely by medical professionals strictly as a supplement to the medical professional’s own judgement. Thaller. 3. Simultaneously published in the USA by Informa Healthcare. This book contains information from reputable sources. Zubin J. so as appropriately to advise and treat patients.com or telephone +1 978-750-8400). Mammoplasty. [DNLM: 1. Registered in England and Wales number 1072954. No part of this publication may be reproduced. Postoperative complications: prevention and control. or the Copyright Clearance Center. Registered Office: 37–41 Mortimer Street. or diagnoses should be independently verified. Ultimately it is the sole responsibility of the medical professional to make his or her own professional judgements. Government works.S. cm. Colchester. Sheepen Place.informa.com Typeset by Exeter Premedia Services Private Ltd.com For corporate sales please contact:
[email protected] For foreign rights please contact: RightsIHC@informa. India Printed and bound in the United Kingdom . Essex CO3 3LP.informahealthcarebooks.com Informa website: www. UK Telephone: +44 (0)20 7017 6682 Email:
[email protected] Informa Healthcare Website: www.ISBN-10: 1-84184-847-6 ISBN-13: 978-1-84184-847-1 eISBN: 978-1-84184-848-8 Orders may be sent to: Informa Healthcare.com For reprint permissions please contact: PermissionsIHC@informa.. Chennai. Dedication I would like to thank my wife and family for supporting and allowing me the time and opportunity to pursue the best career in the world. Zubin . I also extend my deepest gratitude to my parents who provided me with the environment to successfully pursue a career in Plastic Surgery. and our sons. Their love and support is a continuous source of strength and inspiration to me. Nergish and Jal Panthaki. I would like to thank my mentors and colleagues whom I have had the good fortune to meet and work with throughout my career. Lastly. on the occasion of their fiftieth wedding anniversary. I would also like to thank my wife. Dimple. Karl and Kayaan. Seth I would like to dedicate this book to my parents. who make it all worthwhile. Volpe. Peter J.. Panthaki 10 Tissue expansion reconstruction 87 Sheri Slezak and Tripp Holton vii . Subhasis Misra. and patient selection 1 Bassan J. Kahn 3 Radiologic evaluation of the breast 16 Ada P. analysis. Allan. DiPasco. Möller 2 Congenital disorders of the breast 9 Eric Chang and David M. initial consultation. Angela T. Paul Yang. evaluation of the patient undergoing breast surgery. Romilly 4 Breast asymmetry 26 Thomas R. and Eli Avisar 8 Lumpectomy and radiation therapy 66 Onelio Garcia Jr. Stevenson 5 Mastopexy 37 Deniz Dayicioglu and Bulent Genc 6 Reduction mammoplasty 47 Rosiane Roeder and Seth Thaller 7 Oncoplastic surgery of the breast 56 Robert A. and Nuria Lawson 9 Preoperative evaluation in post-mastectomy reconstructive surgery 81 Charles R.Contents Contributors ix Acknowledgments xi Foreword xii Preface xiii 1 Breast and chest: Applied anatomy. Grossman. Prescott. and Zubin J. and Mecker G. Roberto Comperatore. Benjamin Liliav. Alexander Nguyen. Hassid. Antony. D. Volpe. and Mimis N. Mailey and Gregory R. Cohen 17 Gynecomastia 190 Gary Rose 18 Breast reconstruction CPT coding 197 Keith Brandt and Scott Oates Index 203 . Oeltjen and Haaris Mir 13 Other free flaps in breast reconstruction 124 Brian A.CONTENTS viii 11 The pedicled TRAM flap 102 M. and Zubin J. Victor J. Hiro and Deniz Dayicioglu 15 Managing the unfavorable result in breast surgery 155 Charles R. Smith 12 Transverse rectus abdominis myocutaneous (TRAM) flap and deep inferior epigastric artery perforator (DIEP) flap breast reconstruction 109 John C. Lance Tavana and Paul D. Panthaki 16 Optimizing long-term outcomes in breast surgery 166 Anuja K. Evans 14 Nipple–areola complex reconstruction 139 Matthew E. and Division of Plastic Surgery. Illinois. Illinois. Maryland. USA Robert A. USA Eli Avisar Division of Surgical Oncology. University of South Florida College of Medicine. Miami. The DeWitt Daughtry Family Department of Surgery. Division of Plastic Surgery. Florida. Washington University. USA Tripp Holton Breast Reconstruction.Contributors Bassan J. University of Illinois at Chicago Medical Center. D. Division of Plastic Surgery. Chicago. Grossman Division of Surgical Oncology. Miami. Maryland. Florida. Reconstructive and Cosmetic Surgery. USA Mimis N. Florida. Reconstructive. Lauderdale. and Aesthetic Surgery. USA Onelio Garcia Jr Division of Plastic. Florida. Miller School of Medicine. USA Roberto Comperatore Department of Surgery Nova-Southeastern University of Health Sciences Ft. Miller School of Medicine. Irvine. Hialeah. University of Miami Leonard M. The DeWitt Daughtry Family Department of Surgery. USA ix . Tampa. The DeWitt Daughtry Family Department of Surgery. University of Illinois at Chicago Medical Center. Hiro Department of Surgery. The DeWitt Daughtry Family Department of Surgery. Antony Division of Plastic. USA Victor J. Evans Aesthetic and Plastic Surgery Institute. University of Miami Leonard M. Missouri. Chicago. Miami. California. Florida Matthew E. University of California. Florida. University of Illinois at Chicago Medical Center. Palmetto General Hospital. USA Deniz Dayicioglu Department of Surgery. Miller School of Medicine. Reconstructive and Cosmetic Surgery. St Louis. DiPasco Division of Surgical Oncology. Baltimore. Florida and Department of Surgery Palmetto General Hospital Hialeah. USA Gregory R. University of Miami Leonard M. Illinois. University of Miami Leonard M. University of Miami Leonard M. Reconstructive and Cosmetic Surgery. Istanbul. University of South Florida College of Medicine. Florida. Chicago. USA Keith Brandt Division of Plastic and Reconstructive Surgery. Miami. Florida. Cohen Division of Plastic. Miller School of Medicine. Columbia. Hassid Division of Plastic. USA Bulent Genc Istanbul Aesthetic Surgery. Miller School of Medicine. Allan The DeWitt Daughtry Family Department of Surgery. USA Anuja K. Turkey Eric Chang Columbia Aesthetic Plastic Surgery. University of Maryland Medical Center. Tampa. USA Peter J. Tampa. USA . Smith Department of Surgery. USA John C. Illinois. Miami. Miami. The DeWitt Daughtry Family Department of Surgery. Oeltjen Division of Plastic. Miller School of Medicine. Volpe Division of Plastic Surgery. Chicago. Tampa. Miller School of Medicine. Miami. USA Gary Rose Charles E. University of Miami Leonard M. Miami. Florida Benjamin Liliav Division of Plastic. Miller School of Medicine. Miami. University of Miami Leonard M. Irvine. Florida. and Aesthetic Surgery. University of Miami Leonard M. The DeWitt Daughtry Family Department of Surgery. Florida. Palo Alto. USA Scott Oates Department of Plastic Surgery. University of Miami Leonard M. Florida. The DeWitt Daughtry Family Department of Surgery. MD Anderson Cancer Center. University of Miami Leonard M. University of Illinois at Chicago Medical Center. Reconstructive. University of Maryland Medical Center. Lauderdale. Florida. Houston. University of Miami Leonard M. Panthaki Division of Plastic. Miller School of Medicine. University of Texas. USA Rosiane Roeder The DeWitt Daughtry Family Department of Surgery. Florida. Maryland. Miami. and Breast Reconstruction. USA Alexander Nguyen Division of Plastic Surgery. Miller School of Medicine. California. USA Paul Yang Division of Plastic Surgery. Prescott The DeWitt Daughtry Family Department of Surgery. Lance Tavana Department of Surgery. and Aesthetic Surgery. Möller The DeWitt Daughtry Family Department of Surgery. Division of Plastic Surgery. USA Brian A. Miller School of Medicine. Miami. University of South Florida College of Medicine. USA Haaris Mir Division of Plastic. and Aesthetic Surgery. USA Nuria Lawson Department of Surgery Nova-Southeastern University of Health Sciences Ft. Stevenson Division of Plastic Surgery.CONTRIBUTORS David M. Boca Raton. USA Zubin J. Florida. Baltimore. University of Miami. Mailey Department of Surgery. Miami. Florida. Reconstructive. Jackson Memorial Hospital. University of California. Reconstructive. Kahn Division of Plastic and Reconstructive Surgery. Florida and Department of Surgery Palmetto General Hospital Hialeah. Jackson Memorial Hospital. USA Angela T. Florida. Miller School of Medicine. Davis. Reconstructive. Florida. The DeWitt Daughtry Family Department of Surgery. Florida. and Aesthetic Surgery. California. University of Miami. Division of Plastic Surgery. Jackson Health System. USA Seth Thaller Division of Plastic. Miami. USA Charles R. Florida. University of California Davis Medical Center. University of Miami. The DeWitt Daughtry Family Department of ix Surgery. University of Miami Leonard M. Schmidt College of Medicine. USA Paul D. Florida. Jackson Memorial Hospital. USA Thomas R. Florida. Florida. USA M. Texas. Miami. Miller School of Medicine. USA Mecker G. Florida. USA Sheri Slezak University of Maryland School of Medicine. Reconstructive and Cosmetic Surgery. Miami. California. Romilly Diagnostic Radiology. Miami. Florida Atlantic University. USA Subhasis Misra Division of Surgical Oncology. University of Miami Leonard M. University of South Florida College of Medicine. USA Ada P. Stanford University. The editors would also like to acknowledge Robert Peden for his outstanding editorial assistance. and Myra Ramos and the office staff at the DeWitt Daughtry Family Department of Surgery of the University Of Miami Health System consistently provided administrative support.Acknowledgments The editors would like to thank many people for their assistance and support in the editing and production of this text. Ken Fan was constantly willing to assist. Dr Alan Livingstone provided institutional support. Dr Deniz Dayicioglu helped organize and edit the chapters. xi . In Aesthetic and Reconstructive Breast Surgery Drs. such as oncoplastic surgery. They capture new Andrea L. Breast surgery brings together both the art and science of plastic surgery.Foreword and evolving issues. plastic surgeons require high quality research data along with insightful reflections of expert clinicians. In each chapter. As breast surgeons. Aesthetic and Reconstructive Breast Surgery should find a place on the bookshelves of both junior and senior surgeons. the invited authors provide concise summaries of the existing literature along with germane discussions of their own experience. This book is particularly timely in light of our specialty’s increasing focus on evidence-based practice. as well as core competencies such as the management of complications. we are continually seeking ever better ways to practice our craft and to improve the quality of our patients’ live. Pusic MD MHS FACS Memorial Sloan-Kettering Cancer Center xii . With this goal in mind. Thaller and Panthaki have succeeded in bringing together both of these important elements. To achieve optimal surgical results. and communicates how to avoid unfavorable results in a concise and detailed manner. with the goal of providing the plastic surgeon with clear and contemporary information detailing available aesthetic and reconstructive alternatives for surgery involving the breasts. Panthaki xiii . Throughout the book. The book also details the risks and benefits.Preface detailed step-by-step instruction of both the routine methodstas also the innovative approaches. Each author has made an effort to provide a Seth Thaller Zubin J. Each chapter analyzes specific clinical issues that are frequently encountered in the plastic surgeon’s practice. This book will assist the plastic surgeonoin navigating through this unique terrain. Management of both reconstructive and aesthetic surgery of the breast involves a myriad of options. Breast surgery demands a comprehensive approach and has tremendous influence on a patient’s self-esteem and quality of life. the authors emphasize the need for a comprehensive appreciation of the underlying anatomy and the need for preoperative evaluation and active patient participation. We hope this book will become a useful tool in the plastic surgeon’s practice by improving patient satisfaction and minimizing the risks associated with breast surgery. The authors have been chosen because of their extensive experience in the individual chapter subject. . initial consultation. and lower medial) with the nipple functioning as the axis of the quadrants. One pair of the mammary buds persists in the chest. and axillary anatomy is of high clinical and surgical importance in breast surgery. including the axilla (2). These mammary ducts converge into a retroareolar ampulla 1 . When the embryologic bands do not involute. Surface anatomy of the female breast varies widely in shape and size (Fig. invading mesenchymal components form supporting structures around the breast. Throughout gestation. pregnancy. and lactation. At around 4 months. For instance. Human breasts develop in the ventral surface of the embryo originating from epithelial bands derived from ectoderm (1). evaluation of the patient undergoing breast surgery. or breast tissue along the embryologic mammary line. this chapter outlines important considerations about the evaluation of a patient prior to undergoing aesthetic breast surgery. and patient selection Bassan J. The breast is divided into four anatomic quadrants (outer upper. Throughout development the female breast undergoes significant changes in its appearance and cellular composition. Angela T. Allan. Knowledge of breast.2). individuals present with variants of small accessory nipples. to the mid-clavicular line down to the groin. Careful preoperative considerations and surgical planning is essential and helps decrease surgical complications. This unique gland undergoes visible changes that are dependent upon hormonal variability. and Mecker G. After birth further development of the lobular components of the breast is regulated by sex steroids with the onset of puberty. nipple–areolar complexes. Additionally. Prescott. The placement of incisions for lumpectomy and biopsy is important for optimizing cosmetic results (1). chest wall. 1. while the others involute. GROSS ANATOMY BREAST DEVELOPMENT Knowledge of external anatomy of the breast is of utmost importance in breast surgery. A complex network of mammary lobules extends from invading squamous epithelium which by birth comprises a radial system of branching mammary ducts.1). upper medial. chest wall. Möller INTRODUCTION and open onto the nipple (Fig.1 Breast and chest: Applied anatomy. This chapter highlights relevant anatomy of the breast. Disease in one of these structures requires a thorough evaluation of the anatomy of the others as they are intimately related. analysis. These epithelial bands extend from the mid-axillary line. with aging the female breast decreases in volume. and axilla. keeping aesthetic considerations in mind. squamous epithelium invaginates and begins to form what will eventually become the nipple. 1. The accessory breast tissue remnants can also become hormonally active in females during pregnancy or during the menstrual cycle. outer lower. The surface of the areola contains small subcutaneous glands that help lubricate the nipple and render its rough appearance.2 Picture courtesy of Dr Zubin Panthaki. however. The inframammary fold (IMF) is another important anatomical and aesthetic landmark. C: Axilla. B: Sternal notch. A B C D E G F Figure 1. Variations in size and shape of the female breast. G: Deltopectoral groove. consideration and. F: Inframammary fold.1 Sagittal section of the female breast. The IMF is a natural boundary between the breast and the chest. it is generally round and of variable pigmentation. flattens. A: Clavicle. The nipple—areolar complex ranges from 1 to 6 centimeters in diameter.2 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY Fat lobules Mammary vessels Mammary glands Areola Nipple Pectoralis minor muscle Pectoralis major muscle Intercostal muscle Inframammary fold Figure 1. preservation of the IMF are important because manipulation is difficult and prone to complications and poor aesthetic results (5). if possible. During breast surgery. Important gross anatomical landmarks are depicted in this picture. E: Nipple–areolar complex. and becomes more pendulous and softer (2). . Depending on the shape of the breast this complex may appear distorted. Anatomical variants are rare and noted in 2–6% of the female population exhibiting polythelia (accessory nipples) or polymastia (extra-mammary breast tissue) (2). D: Sternum. The anatomic locations of the axillary lymph nodes are largely described with respect to their relationship with the pectoralis minor muscle. lymph flow parallels major venous tributaries to drain into regional lymph nodes. which extend from the deep fascia to the deep layer of the skin and help provide the rounded contour of the breast. As the alveoli gradually transition into the lactiferous ducts. Lymphatic routes arborize in multiple directions through the superficial components of the breast as they drain unidirectionally to the deep lymphatic plexus (Fig. and level III ALNs are medial to the superior border of the pectoralis minor. Major arteries include: the internal mammary artery. a small percentage (3–5%) of tumors located in the medial quadrants can drain to the internal mammary lymph node (IMLN) chain. The glandular tissue of the breast is composed of tubulo-alveolar structures embedded in loose connective tissue. BLOOD SUPPLY TO THE BREAST Extensive arterial collateralization exists around the breast. also known as Cooper’s ligaments. have been described as a site of recurrence for breast cancer (23). MICROSCOPIC ANATOMY Breasts are considered modified sweat glands. The arterial supply to the breast can be subdivided into major and minor vessels. Lymphatic drainage of the breast is largely to the axillary lymph nodes (ALN).3). The breasts are composed of compartments of fatty tissue bounded by fibrous bands and glandular tissue containing 15–20 lactiferous ducts (Fig. Rotter’s or interpectoral nodes located between the pectoralis minor and pectoralis major muscles.1). The fat lobules are compartmentalized by suspensory ligaments. 1. as such they lie in the superficial fascia. 1. Subsequently. However. Of clinical relevance. It is estimated that over 97% of the lymphatic drainage of the breast flows to the axillary lymph nodes (3). the composition of the cells changes to stratified squamous epithelium. The ducts open onto the nipple. The arrows demonstrate unidirectional flow of most lymphatic fluid toward the axillary lymph nodes. Level II ALNs are deep to the pectoralis minor. Minor arteries include: the thoracoacromial. the external mammary artery off the lateral thoracic artery and the branches of the intercostal arteries. and thoracodorsal arteries. Venous drainage of the breast is to the internal mammary vein and . upper thoracic. Level I ALNs are located lateral to lower border of the pectoralis minor. The alveolar system is lined by a single layer of columnar or cuboidal cells. LYMPHATIC DRAINAGE OF THE BREAST Knowledge of the lymphatic drainage of the breast is important when treating patients with a history of breast disease. Layers of circumferential and radially arranged fibers of smooth muscle are found deep to the nipple and lactiferous control erection after stimulation of sensory nerve endings located in the dermal papillae.BREAST AND CHEST 3 A Axillary lymph nodes Figure 1. subscapular.3 Lymphatic drainage of the female breast. 4 the axillary vein. The intercostal veins drain into the internal mammary veins, the external mammary veins and the lateral thoracic veins drain into the axillary veins. The three arterial sources to the breast are the internal mammary artery (IMA), axillary artery, and the costocervical trunk from the descending thoracic aorta. The course of the IMA runs beween the superficial parietal pleura of the lung and the intercostal muscles of the chest wall. The anterior branches of the IMA (anterior rami mammary) travel anteriorly to supply the second to fifth intercostal spaces of the chest wall and enter the breast approximately 1–2 cm lateral to the parasternal border. During a mastectomy, the perforating branches are encountered at this level, emerging from the pectoral muscle and into the breast tissue. Awareness of their location helps minimize operative bleeding by ligating or cauterizing this prior to accidentally dividing them. The lateral thoracic artery (also known as the external mammary artery/long thoracic artery) arises from the posterior segment of the axillary artery and travels between the subscapularis muscle anteriorly and the fibers of the brachial plexus posteriorly. It courses the lateral chest wall along the lower border of the pectoralis minor, also supplying the pectoralis muscles and serratus anterior. The lateral thoracic artery also supplies branches to the axilla and subscapularis muscle. The external mammary branch also supplies the free edge of the pectoralis major. A surgeon must have knowledge of breast anatomy, blood supply, and lymphatic drainage in order to minimize post-operative risks; including capsular contraction, hematoma, seroma, and skin necrosis (9). INNERVATION OF THE BREAST Breast innervation is best understood when subdivided by structural components: breast parenchyma, breast skin and nipple–areolar complex. The skin around the breast receives its nervous supply from somatic sensory nerve roots. The medial and lateral aspects of the breast are innervated by branches of the thoracic intercostal nerves. The superior aspect of the breast is innervated by the supraclavicular nerve off the brachial plexus. The breast parenchyma is under strict hormonal control and bears no nervous innervation. The nipple and areola are innervated by sympathetic autonomic fibers, which upon stimulation erect the nipple and contract the areola (4). ANATOMY OF THE CHEST WALL About 7% of women who present for aesthetic breast surgery will have thoracic wall deformities such as pectus excavatum (depressed sternum), Poland’s syndrome (pectoralis hypoplasia, deformed axillary fold, and asymmetric inframammary fold), pectus carinatum (pigeon’s chest), or AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY scoliosis. Careful consideration of the thoracic wall anatomy before and during breast surgery along with surgical technique and choice of implant in mind is essential in yielding optimal outcomes (6). The musculoskeletal thoracic wall is composed of 12 thoracic vertebrae along with 12 ribs, which join anteriorly to the sternum via 12 costal cartilages. The spaces between the 12 ribs are the 11 intercostal spaces, which carry the external, internal, and innermost intercostal muscles. Continuous with the innermost layer of intercostal muscles is the endothoracic fascia, a fibrous connective tissue plane, which is also continuous with the periosteum of the ribs. Just deep to the endothoracic fascia is the parietal pleura. The most superficial layer of muscles is formed by the external intercostal muscle fibers, which course inferomedially. Lateral to the sternum, between the costal cartilages, this layer exists as the external intercostal membrane. Deep to the external intercostal muscles are the internal intercostal muscles fibers, which course inferolaterally. Deep to the internal intercostal muscle layer is the innermost intercostal muscle layer (intima of the internal intercostal muscles), which run in the same direction as the internal intercostal muscle fibers. This innermost layer is the least developed layer of the three; however, it is separated from the internal intercostal layer by the presence of the intercostal arteries, veins, and nerves. The subcostalis and transversus thoracis muscles lie in the same plane as the innermost intercostal muscles on the internal surface of the thoracic wall. Anteriorly, the transversus thoracis muscle fibers originate from the medial border of the sternum and course superiorly and laterally to enter the costal cartilages of the second to sixth ribs. Parallel to the lateral sternal border exits the internal thoracic (mammary) arteries, veins, and lymphatic channels. The transversus thoracis muscle fibers run deep to the internal thoracic vessels and lymphatic channels. The subcostalis muscle lies on the posterior thoracic wall and is thought to be the posterior extension of the innermost internal costal muscles; however, these fibers span at least two intercostal spaces. PECTORALIS MAJOR AND MINOR Pectoralis major is a fan-shaped muscle with two divisions: the clavicular division and the larger sternocostal division (Fig. 1.3). The clavicular division originates from the clavicle while the sternocostal division originates at the sternum and costal cartilages of the second to the sixth rib. The pectoralis major muscle fibers then join each other traversing laterally to enter the greater tubercle of the humerus along the lateral bicipital groove. The pectoralis major is enclosed by pectoral fascia, and is innervated by the medial and lateral pectoral nerves, which arise from the medial and lateral cords of the brachial plexus, respectively. The clavicular division is innervated by C5–C6, whereas the sternocostal division is innervated by C7, C8, and T1. During surgical identification BREAST AND CHEST of pectoralis major, the cephalic vein serves as the upper lateral landmark in the deltopectoral groove, separating the pectoralis muscle from the deltoid muscle. Pectoralis major is largely responsible for adduction of the upper extremities and medial rotation of the humerus. The pectoralis minor muscle lies deep to the pectoralis major muscle, and is triangular in shape. It originates from the second to fifth ribs and enters the coracoid process of the scapula. Its innervation is from the medial pectoral nerve only (C8–T1) (Fig. 1.4). Care must be taken not to injure the medial pectoral nerve at time of mastectomy. When removing the breast from the lateral edge of the pectoral muscle or during high axillary dissection, injury to the medial pectoral nerve may result in atrophy of the pectoralis minor. Pectoralis minor aids in stabilizing the scapula and affords extra reach during extension of the outstretched arm (13). Superior to pectoralis minor, lies the subclavius muscle, which lies horizontally with the upper extremity at rest. This muscle originates from the first rib near the costochondral junction and enters laterally at the inferior and posterior surface of the clavicle. Its innervation is from the upper trunk of the brachial plexus (C5–C6), and is termed the nerve to the subclavius. Although the subclavius is not a particularly strong muscle, it can provide some protection of the underlying brachial plexus branches and subclavian vessels should the clavicle fracture. Clavipectoral fascia encloses pectoralis minor and the subclavius muscles. It is continuous with the deep cervical fascia superiorly and continuous with the suspensory ligament of the axilla inferiorly, before continuing on as axillary fascia. The segment of clavipectoral fascia between the subclavius and pectoralis minor muscles is termed the costocoracoid membrane. Once important fascia is divided, the axillary artery and vein may be exposed in axillary dissection. Halstead’s ligament is described as the dense portion of the clavipectoral fascia that lies between the first rib 5 and the clavicle, and is also an important landmark in axillary surgery, as it lies anterior to the subclavian vessels as they transition to axillary vessels. AXILLA The axilla is a pyramid-shaped compartment between the upper extremity and the thoracic wall, with a base, four walls, and an apex. With the upper extremity relaxed at the side of the chest wall, the base of the axilla is made of axillary fascia, subcutaneous tissue, and more superficially is the dome-shaped area that bears hair after puberty, commonly termed as the “armpit.” The apex is located in the posterior triangle of the neck in the cervicoaxillary canal. The boundaries of the cervicoaxillary canal are the middle third of the clavicle anteriorly, the superior border of the scapula posteriorly, and the lateral border of the first rib medially. The anterior wall of the axilla is made of the pectoralis major and minor muscles with their associated fasciae. The posterior wall of the axilla is made up largely of the subscapularis muscle anterior to the scapula, and also by the teres major, and latissimus dorsi muscles. The lateral wall of the axilla is defined by the bicipital groove of the upper extremity. The medial border of the axilla is the serratus anterior muscle (covering the thoracic wall spanning the first to the fifth ribs). The inferior border of the axilla is defined by the apical intersection of the latissimus dorsi and the serratus anterior muscles. During axillary dissection, however, the upper extremity is abducted, which slightly alters the borders of the axilla. During axillary surgery, the base of the axilla (superior skin flap overlying the armpit) is retracted laterally for exposure. The superiormost landmark is the axillary vein, the posterior border is largely the subscapularis muscle, and the latissimus dorsi becomes the lateral border of the axilla. The medial and inferior borders of the axilla remain the same (Fig. 1.5). Pectoralis major muscle (divided) Pectoralis minor muscle Serratus anterior muscle Long thoracic nerve Thoracodorsal nerve Figure 1.4 Pectoralis major muscle fibers (left) with two origins, the clavicular and costosternal heads, entering the crest of the greater tubercle of the humerus along the lateral lip of the bicipital groove. Courtesy of Dr. Mecker G. Möller. Figure 1.5 Pectoralis minor muscle (left), with pectoralis major muscle divided (cephalad = top of image). Courtesy of Dr. Mecker G. Möller 6 The contents of the axilla include the axillary artery, axillary vein, branches of the brachial plexus, axillary lymph nodes and lymphatic channels. The great vessels and nerves of the upper extremity pass through the axilla and are enclosed within a fascial layer termed the axillary sheath. These structures, along with other axillary contents, are surrounded by the loose connective tissue of the axilla. Within the axilla, the axillary artery may be divided into three segments: the medial, posterior, and lateral segments (so termed in relation to pectoralis minor muscle). The medial segment of axillary artery becomes the supreme thoracic artery, supplying the first and second intercostal spaces of the chest wall. The posterior segment of axillary artery has two branches: the thoracoacromial trunk and the lateral thoracic artery. The thoracoacromial trunk has acromial, clavicular, deltoid, and pectoral arterial branches. The lateral thoracic artery has branches to pectoralis minor muscle as well as serratus anterior muscle. These pectoral branches of the thoracoacromial and lateral thoracic arteries should be preserved, as these branches supply the pectoralis major and minor muscles. Special care of the lateral mammary branches from the lateral thoracic artery must also be taken, so as to not disrupt the lateral blood supply to the breast. The lateral segment of axillary artery gives off three branches: the anterior humeral circumflex artery, the posterior humeral circumflex artery, and the subscapular artery. The anterior and posterior humeral circumflex vessels supply the proximal upper extremity. During axillary dissection, consideration of the subscapular artery must be carefully made, because it is the largest branch within the axilla and after only a short distance gives off its terminal branches: the subscapular circumflex and the thoracodorsal artery. Special care must be taken by the surgeon when dissecting in the axilla along the serratus anterior, subscapularis, and latissimus dorsi muscles so as to not disrupt the supplying branches of the thoracodorsal artery. This vessel is also of utmost importance in rotational and free flap viability, due to its supply of the latissimus dorsi, a muscle of great versatility in aesthetic surgery. The venous drainage of the axilla is structured in such a way that the branches run parallel to the axillary arterial supply. Identification of the axillary vein is crucial during axillary surgery. With the pectoralis minor muscle retracted, by palpating and incising the costocoracoid membrane of the clavipectoral fascia, the axillary vein comes into view. The cephalic vein lies in the deltopectoral groove, demarcating the pectoralis major from the deltoid muscle. It passes through the clavipectoral fascia, posterior to pectoralis minor, joining the axillary vein. The thoracodorsal vein lies on the posterior aspect of the axilla, runs with the thoracodorsal artery and nerve, and drains into the axillary vein. AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY BRACHIAL PLEXUS The medial, lateral, and posterior cords of the brachial plexus are named according to their relationship to the axillary artery, and give many branches within the axilla. The medial cord of the brachial plexus usually gives five branches, the medial pectoral nerve (supplying the pectoralis major muscle and the majority of innervation to the pectoralis minor muscle), the median brachial cutaneous nerve, the medial antebrachial cutaneous nerve, the ulnar nerve (a terminal branch) and the lateral root of the median nerve (a terminal branch). The posterior cord of the brachial plexus has five branches: the upper subscapular nerve, the thoracodorsal nerve, the lower subscapular nerve, the axillary nerve (a terminal branch), and the radial nerve (a terminal branch). The lateral cord of the brachial plexus has three branches: the lateral pectoral nerve (innervating the pectoralis major muscle), the musculocutaneous nerve, and the lateral root of the median nerve. The thoracodorsal nerve originates from cervical branches of the spinal cord (C6–C8) as well as the posterior cord of the brachial plexus and enters the axilla deep to the axillary vein. The thoracodorsal nerve travels on the posterior aspect of the axilla, over the subscapularis muscle and courses anteromedially over the latissimus dorsi muscle, innervating this large muscle (Fig 1.6). Injury to the thoracodorsal nerve results in weakness of arm extension, adduction, and medial rotation of the humerus. During climbing or pull-ups, for example, a thoracodorsal nerve injury would result in weakness when attempting to bring the thoracic wall toward the arms. The long thoracic nerve arises from C5–C7 of the spinal cord and enters the axilla through the cervicoaxillary canal. It travels along the medial wall of the axilla, within the fascia of the serratus anterior muscle, innervating this powerful muscle of the thoracic wall (Fig. 1.6). The serratus anterior fascia may be resected during axillary dissection, inadvertently injuring the long thoracic nerve. Injury to this nerve results in inability to keep the scapula opposed to the thoracic wall, difficulty with scapular rotation, and extreme weakness when attempting to raise the arm above the level of the shoulder. The most prominent sensory nerve of the axilla is the intercostobrachial nerve, which is formed from the lateral cutaneous branch of the second intercostal nerve joining with the medial cutaneous nerve of the arm. This large nerve supplies the sensation to the skin over the floor of the axilla and the medial aspect of the upper arm. A second intercostobrachial nerve may be present during axillary surgery, which may form from the anterior branch of the third lateral cutaneous nerve. Disruption of these cutaneous nerves results in sensory deficits overlying the skin of the axilla, upper medial aspect of BREAST AND CHEST 7 Pectoral nerve bundle Pectoralis muscles Axillary vein Thoracodorsal bundle Intercostobrachial nerve Subscapularis muscle Latissimus dorsi muscle Long thoracic nerve Serratus anterior muscle Figure 1.6 Anatomy of the thoracic wall and axilla of a female after undergoing a mastectomy, with the upper extremity (left) abducted with 90º shoulder extension. Courtesy of Dr. Mecker G. Möller. the arm, and the lateral chest wall around the second and third ribs. FASCIAL PLANES INVOLVING THE BREAST AND CHEST WALL The breast tissue is located in the hypodermis or superficial fascia of the anterior chest wall. An avascular plane exists just deep to the dermis that a surgeon may dissect, which will leave the blood vessels and lymphatics of the deeper layer of the superficial fascia undisturbed. In thin individuals, this provides for a two- to three-millimeter-thick skin flap that may be thicker in obese individuals. Anterior to the breast, fibrous processes, called the suspensory ligaments of Cooper, are continuous with the septa that divide the lobules of the breast and enter the skin. The retro-mammary space or bursa exists between the posterior aspect of the breast and the deep layer of the pectoralis major fascia. During total mastectomy, this layer is usually included as part of the specimen. Posterior suspensory ligaments also extend from the posterior surface of the breast to the deep pectoral fascia, requiring removal of some adjacent pectoralis muscle during breast resection. Surgical consideration must also be taken with the suspensory ligaments of Cooper and the retro-mammary space due to its contribution to the mobility of the breast tissue against the thoracic wall. Two thirds of posterior breast tissue overlies fascia of the pectoralis major. The remaining posterior breast tissue extends over abdominal oblique muscles superiorly and the fourth to seventh parts of the serratus anterior muscle. Laterally, breast tissue also overlies the axillary fascia. Anatomical considerations of the submammary, subfascial and submuscular planes are also important in the setting of optimizing aesthetic outcomes. The submuscular plane beneath the pectoralis muscle results in less disruption of the sensory nerves of the retromammary space, has less adverse capsular contracture, and is more easily concealed (7,8,10). PRE-OPERATIVE CONSIDERATIONS, INITIAL EVALUATION, ANALYSIS, AND PATIENT SELECTION A surgeon must perform a thorough evaluation of a patient prior to undertaking any cosmetic procedure. As previously mentioned, an understanding of the anatomy is of great importance for avoiding complications. When planning and performing cosmetic breast surgery a complete pre-operative assessment and plan will help reduce unfavorable results, decrease reoperation rates, and simplify intraoperative misadventures (12). The initial evaluation of a patient starts with a complete history and physical exam. Of importance is to highlight previous breast surgeries, history of breast disease, anatomical variants, menstrual cycles and associated breast changes, and history of radiation therapy to the chest wall and/or breast. A surgeon must bear in mind the timing of an intervention based on the patient’s overall plan of care, for example, staged breast reconstruction on breast cancer patients requiring adjuvant therapy. Moreover, based on the intended procedure, a full evaluation of a patient’s overall general condition should be undertaken, and if necessary preoperative consultations should be obtained to optimize medical management prior to surgery. Plastic surgeons must perform a systematic physical exam of the breast, chest wall, axilla, and torso. Special attention should be given to the symmetry of the breasts, symmetry of the infra-mammary fold, nipple–areolar complex position, as well as the tactile characteristic of the patient’s breast parenchyma (i.e., fullness, elasticity, and thickness) (11). A quantifiable approach to tissue assessment, using measurements in lieu of subjective visual Lastly. 3. In: O’Leary JP. In: Cameron JL. 14. indications for surgery. Schnabel FR. Thoracic wall. Five critical decisions in breast augmentation using five measurements in five minutes: the high five decision support process. 59: 1017–24. Dalley AF. Philadelphia: Saunders. Adams WP. Breast augmentation: Part III – preoperative considerations and planning. In: Cameron JL. Bland KI. and areolar diameter. adequate preparation and instructions about standard post-operative management and recovery should be provided to the patient in the pre-operative setting. Shestak KC. 2002: 52–69. preparation and education of the preoperative breast patient. 2009: 1–14. ed. Plast Reconstr Surg 2006. 2008. Manahan M. Aesthetic Breast Surgery. 4. 12. et al. and related metastatic sites. 1991: 17–35. Tebbetts JB. Aesthetic breast augmentation and thoracic deformities. Philadelphia: Lippincott Williams & Wilkins. Bauer VP. 4th edn. Bland KI. inter-mammary and inter-nipple distance. Henriksen TF. Komenaka IK. Grinfeder C. 7th edn. Kern KA. chest wall. Aesthetic Plast Surg 2003. 9th edn. 139: 175–8. Louis: Mosby. McGreevy JM. Pinsolle V. Interpectoral nodes as the initial site of recurrence in breast cancer. ed. Clinically Oriented Anatomy. Louis: Mosby. 118: 35S–45S. a discussion with the patient should outline expectations. and alternative treatment options. techniques. Philadelphia: Lippincott Williams & Wilkins. axilla. Romrell LJ. 2002: 321–49.. eds. Patients should understand all risks associated with the intended procedure and its potential complications. 10. Anatomy of the breast. Lorenz S. Hölmich LR. Cucchiara V. Ann Plast Surg 2005. provides surgeons with quantifiable data on which to base decisions (12). 8. et al. Current Surgical Therapy. In: Bucky LP. 1999. Philadelphia: Lippincott Williams & Wilkins. 3rd edn. Berry M. 2. The Physiologic Basis of Surgery. Mathoulin-Pelisser S. Preoperative evaluation. 6. REFERENCES 11. Surgical intervention and capsular contracture after breast augmentation: a prospective study of risk factors. 2nd edn. such as: the position of the nipple–areolar complex relative to the infra-mammary fold. Góes JC. J Plast Reconstr Aesthet Surg 2011. The breast. After a thorough review of a patient’s history and physical exam. 27: 178–84. 13. Doing so may help reduce a patient’s anxiety level and help increase overall patient satisfaction. 1. Diagnostic options in symptomatic breast disease. AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY 5. Complications analysis of 266 immediate breast reconstructions. Moore KL. 9. Current Surgical Therapy. St. and results. 64: 1401–9. Optimizing outcomes in breast augmentation: seven years of experience with the subfascial plane. . 34: 612–16. In: The Breast: Comprehensive Management of Benign and Malignant Diseases. Neuhann-Lorenz C. Breast reconstruction following mastectomy: indications. the position of the breast/nipple relative to the mid-sternum and chest wall. Wolter TP. Davies DM. et al. Arch Surg 2004. Fryzek JP. Aesthetic Plast Surg 2010. Agur AM.G. Capote LR. Landecker A. PA: Saunders-Elsevier. 7.8 assessment. 2001: 678–745. J Plast Reconstr Aesthet Surg 2006. Philadelphia. Most surgeons utilize standard pre-operative checklists to carefully record anatomical landmarks. Singh N. Moore KL. 54: 343–51. In: Essential Clinical Anatomy. St. ed. on the other hand. This association is due to the parallel embryological development of the renal and mammary tissues. Supranumerary nipples are often misdiagnosed as nevi. 9 . as well as renal carcinoma. The surrounding mesenchymal tissue will become the superficial fascial system of the breast (2–4). and only becomes apparent at times of EMBRYOLOGY Breast growth begins at the fifth week of gestation when breast tissue develops from the mammary ridges of the ectoderm. These disorders can span from the simple presence of extra nipples.2 Congenital disorders of the breast Eric Chang and David M. such as supernumerary nipples. or even hidradenitis. Accessory breast tissue is often misdiagnosed as a lipoma. and eventually the mammary lobules of the breast. cyst. whereas other conditions are quite rare. The treatment of these varied conditions can be better understood by categorizing these deformities as either hyperplastic. This is a relatively common occurrence. in the axilla down to the level of the groin. The most common location for accessory breast tissue is the axilla. ultimately regressing. Some of these anomalies are quite common. is the presence of accessory breast parenchyma. Kahn INTRODUCTION HYPERPLASTIC BREAST DISORDERS Congenital breast disorders. This tissue is often quiescent at birth. hypoplastic. Fifty percent of cases have been noted to be bilateral (6). renal malformation. head. neck. noted in 1–2 percent of the population (5). lymphatic enlargement. branching of the gland produces secondary buds. These “milk lines” develop along the ventral surface of the embryo and extend from the axilla to the groin area. can cause an extreme amount of emotional distress. Supranumerary nipples have been found in anatomic areas as varied as the scapula. Most commonly these are found in the inframammary area. Polythelia can be associated with renal abnormalities. By week 10. to complex disorders such as Poland’s syndrome or tuberous breast deformity. Polymastia. The most common hyperplastic breast disorder is the supernumerary nipple. especially during late childhood and the early teenage years. with an overall incidence of 1–5 percent (8). or deformational (1). Some authors recommend ultrasound for evaluation of renal anomalies when supernumerary nipples are present (7). the ridge at the fourth intercostal space becomes the mammary gland. Normally. or polythelia. though rarely functional in nature. whereas the remaining areas undergo apoptosis. Incomplete regression of the embryonic mammary ridge tissues leads to the development of accessory nipples along the milk line. The treatment of choice for polythelia is simple excision. These can be found above the breast. and thigh. including supernumerary kidneys. The Kajava classification of persistent mammary ridge structures was developed in 1915 (9). The eight classifications are as follows: 1. such as puberty.10 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY hormonal stimulation. Supernumerary breast is without areola but with nipple and breast tissue. or lactation. pregnancy. Ectopic breast tissue.2 of anomalies from complete. Supranumerary nipple. 2. accessory breast with nipple and areola. and can be subject to the same problems as the normal breasts such as fibrocystic disease and malignancy. Polymastia – is that which includes completely formed accessory breast with glandular tissue. areola. to simple supernumerary nipples. It includes the range Figure 2. . Accessory breast tissue can wax and wane with the menstrual cycle.1 Figure 2. and nipple. 4. including the latissimus dorsi. In addition. external oblique. Poland syndrome is thought to be a sporadic mutation. or thermal injury. Amasia on the other hand. surgery. all secondary sexual characteristics mature normally but with the absence of the breast (10).. syndactyly. In some cases the muscles that are present. and serratus anterior. may become hypertrophied. thus further accentuating the contour deformity.000 live births (12). In severe cases. Polythelia pilosa – is supernumerary breast represented only by a patch of hair. such as the clavicular head of the pectoralis. Familial transmission.e. HYPOPLASTIC BREAST DISORDERS Amastia is a rare condition characterized by the complete absence of the breast parenchyma. with a 3:1 sex predeliction. At the onset of puberty. and was given its name by Alfred Poland in 1841 (11). Pseudomamma is with nipple and areola (fatty tissue rather than true breast tissue). where he worked as a demonstrator in the anatomy lab. This results in the loss of the normal-appearing anterior axillary fold and a noted step-off below the clavicular portion of the pectoralis due to the absent sternal portion of the muscle. is quite rare (13). without defined inheritance. breast. 6. The absence or deformity of the anterior portions of the second to fifth ribs is commonly found. Aberrant glandular tissue is that which is only without nipple or areola (i. upper extremity anomalies such as hypoplasia of the ipsilateral hand. nipple. The syndrome that bears his name refers to an absence of the pectoral muscle combined with anomalies of the chest wall. It has a female to male ratio of 5:1. Poland syndrome is more common in men. and synbrachydactyly are characteristic of Poland syndrome as well. Its frequency is estimated at one in 30. The entire muscle may be missing. ectopic axillary breast tissue). This is often the result of traumatic injury during childhood. Polythelia areolaris – is supernumerary areola only 8. Polythelia – is supernumerary nipple only. The ipsilateral nipple is usually hypoplastic and both the breast and the nipple may be superiorly malpositioned. though reported. Options for treatment of accessory breast tissue are elliptical excision or liposuction alone if the problem does not include skin excess. 7.3 11 a medical student at Guy’s Hospital. Athelia refers to the absence of the nipple–areola complex and is rarely found without amastia.CONGENITAL DISORDERS OF THE BREAST 3. whether radiation. . 5. and upper extremity. Poland was Figure 2. and the right side is affected more commonly than the left. as are deficiencies in surrounding muscles of the trunk. Poland syndrome was first described in 1826. It is due to the failure of development of the breast tissue with the lack of mammary line development at 5–6 weeks in utero. functional pulmonary problems may result. and areola. Poland syndrome. refers to absence of the breast tissue with presence of the nipple–areola complex. The pathognomonic finding in Poland syndrome is the absence of the sternocostal head of the pectoralis major muscle. as well as the pectoralis minor muscle. Supernumerary breast is without nipple but with areola and breast tissue. This device can be serially expanded to keep pace with the contralateral breast development. 2. Omental . usually with a silicone implant. Second degree (severe) – mammary and nipple–areola complex asymmetry with complete absence of the pectoralis major muscle. Management of Poland syndrome is related to the breadth and severity of hypoplastic elements. In thin patients. 3. Minor limb anomalies may be seen. Identification of the Poland patient early in puberty allows for the option of a tissue expander to be placed early in breast development. The secondary advantage of a tissue expander used in this fashion is that the technique allows for expansion of the hypoplastic nipple–areola complex as well.12 The etiology of Poland syndrome is thought to be an extrinsic disruption of the embryonic blood supply to the upper limb bud during the sixth week of gestation. In addition. whereas distal limb vascular disruption leads to synbrachydactyly (14). Pocket dissection should be limited to the exact size of the implant to limit migration. the diameter of the areola can be expanded to create a better match with the normal side. using the leading edge of the latissimus muscle to simulate the anterior fold while substituting the bulk of the pectoralis muscle with the latissimus. In addition to careful clinical examination of the latissimus muscle. Single stage implant reconstruction may also be performed. Implant reconstruction of the female Poland syndrome patient is usually performed with either a single stage implant. Autologous reconstruction involves transfer of the latissimus muscle anteriorly. Once the breasts have been fully developed. the implant may need to be covered by a latissimus flap to provide better camouflage of the implant. depending on the amount of asymmetry present and the ability of the skin envelope to accept an appropriately sized implant. Careful. such as absence of the pectoralis minor or serratus anterior muscles. 2. systematic examination of the following structures must be undertaken: 1. Ipsilateral muscle or chest wall hypoplasia. Possible lung hernia or widened opening of the mediasteinum. Implant reconstruction is typically performed with a custom-shaped silicone implant. Recreation of the anterior axillary fold can be accomplished by rotation of the latissimus dorsi muscle anteriorly. Major ipsilateral chest alterations. The Clinical and Radiographic Poland Syndrome (CRPS) classification separates patients into three degrees of severity (16). First degree (mild) – includes mammary and nipple– areola complex asymmetry with partial absence of the pectoralis major muscle. Chest wall defects may require further imaging with CT or MRI and ultimately split-rib grafting or mesh prostheses. the loss of the latissimus muscle mass in the back is not insignificant. Smoking and other intrauterine insults have also been implicated as risk factors for Poland syndrome (15). This leads to a regional vascular hypoplasia of the subclavian vessels and its branches. determining whether the latissimus muscle is of normal size and functioning. Ischemia to the pectoral vessels leads to aplasia of the muscle. Careful dissection must be performed on the chest wall to avoid a pneumothorax. post-operative adjustable implant or 2-stage tissue expander/implant reconstruction. The final silicone implant is placed through an axillary incision into a pocket developed immediately on the chest wall. Upper extremity – the ipsilateral upper extremity and hand must be carefully examined. 1. imaging with spiral CT and 3-D reconstruction should be considered to confirm intact vascular pedicle anatomy (17). care must be taken in evaluating the patient. 4. final implant exchange can be undertaken. Ipsilateral limb hypoplasia. Chest wall – contour depression from the absence of the anterior ribs should be examined for. whose shape is threedimensionally transferred to a wax model prior to final casting with silicone. as well as chest width discrepancies between the affected and non-affected sides. The size and location of the nipple– areola complex should also be noted. 3. Breast – the development as well as location of the breast should be noted in relation to the contralateral normal breast. ruling out limb anomalies. The implant is first sculpted with a plaster moulage. No other muscular or skeletal anomalies are present. as costal cartilage and rib may be missing. The downside to this procedure is the sacrifice of the latissimus muscle and its posterior axillary fold in reconstructing the anterior axillary fold. Hand and upper extremity anomalies may require radiographs to evaluate bony anatomy prior to release of syndactyly. The psychological sequella of marked breast asymmetry and amastia can be masked by this maneuver. AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY Chest reconstruction of the male Poland syndrome patient focuses on replacing anterior chest wall volume as well as recreation of the anterior axillary fold. Muscles – the pectoralis muscle as well as surrounding muscles must be isolated and tested. A recent classification for Poland syndrome in female patients has been proposed based on both clinical and imaging studies. Because of the wide range of clinical presentations of Poland syndrome. One can also fix the implant to the chest wall with sutures to prevent movement and migration. Though the vertical position and height of the nipple may only marginally be improved. Autologous options used in acquired amastia such as pedicled TRAM flap and microsurgical free flap transfer have also been applied to Poland syndrome (18). Third degree (very severe) – amastia with complete absence of the pectoralis major muscle. The recent interest in autologous fat grafting to the breast has given reconstructive surgeons another option for either primary breast reconstruction or secondary contouring after implant or autologous reconstruction. Type 1 – Lower medial quadrant deficiency 2. Rees and Aston advocated the radial scoring of the posterior capsule of the breast. The ultimate shape of the malformation depends on the severity of the constriction and can range from inferior medial quadrant hypoplasia to a global hypoplasia with marked areolar enlargement. Furthermore. increasing volume follows the path of least resistance and leads to parenchyma herniating through the subareolar defect. narrow base of the breast. A variety of classifications have been proposed in tuberous breast deformity. because of the inability of the breast to expand inferiorly. A round block Benelli-type suture was used to address the areolar enlargement (24). The pathognomonic feature of the tuberous breast is the herniation of the breast tissue (A) 13 through the constricted. In discussing fat grafting with patients one should emphasize that this will often require more than 1 session to achieve the desired end result. with the inferior flap folded onto itself to fill the inferior pole of the breast. in which the constricting ring of the breast was divided into two. Grolleau and colleagues offered a simple and logical classificiation system in 1999 (23). Careful counseling as to the hypoplastic nature of Poland syndrome and the probability of continued asymmetry of the chest wall.21). the breast has a constricted base. During breast development. Type 3 – Deficiencies in all four quadrants Along with the variety of classifications has been a variety of surgical techniques to correct the tuberous breast. leading to a markedly enlarged areola. or flap transposition. without accompanying circumferential fullness. This leads to a narrow outward projection of the breast. Type 2 – Lower lateral and medial quadrant deficiencies 3. Nipple transposition can be performed as a second stage for both the male and female Poland patients. Fat grafting to the infraclavicular hollow or anterior axillary fold can allow for soft tissue augmentation is areas which are traditionally difficult to address (20. (B) Type 2 tuberous breast postop. lacking in both the vertical and horizontal dimensions (22). This can include either free nipple grafting for repositioning of the nipple–areola complex. Mandrekas describes a similar approach in which the unfurled breast parenchyma is split vertically at the 6 o’clock position to divide the constriction band. The two pillars are then loosely approximated with suture. .” Riberio described an autologous periareolar approach to the breast. (B) Figure 2. feathering of implant edges and minor asymmetries can also be addressed. breast. and nipple–areola complex is an important part of treatment.CONGENITAL DISORDERS OF THE BREAST flap for reconstruction with or without silicone implants have been described as well (19). 1. TUBEROUS BREAST DEFORMITY The characteristic shape of the tuberous breast presents at the time of breast development. The development of the aberrant shape of the tuberous breast is thought to relate to the presence of a constricting fibrous ring at the base of the breast. as well as the lack of superficial fascia within the parenchyma beneath the areola. Given its name by Rees and Aston for its likeness to a tuberous plant root. to allow for its “unconing. particularly in the male Poland patient.4 (A) Type 2 tuberous breast preop. either to the reconstructed breast or the contralateral breast. The residual presence of a double-bubble deformity from a tightened constriction band has been addressed with autologous fat grafting as a second stage. Furthermore. can help to improve upon the suboptimal result (32). placement of the implant in a partial subpectoral space may be required. These disorders are relatively uncommon. Many surgeons prefer Gore-tex for this suture. and augmenting the upper medial pole of the breast at the same time as treatment of the double bubble (27). Serra-Renom and colleagues addressed the deformity at six months after the initial surgery. or the creation of a flap either of breast tissue or latissimus muscle. Many of these patients will require a skin reduction component to their procedure. Despite these advances. as well as visibility and palpability of the implant. The overwhelming majority of patients seem to be satisfied with the results even if optimal aesthetics is not achieved (31). As the majority of these procedures will require an implant for reconstruction. . wound healing problems. in plastic surgery where we are guided by principles to manage challenging problems we can draw from our experiences in breast augmentation. AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY We would propose the following principles to guide us in reconstructing the hypoplastic breast. after conventional parenchymal rearrangement with implant placement. Finally. One should also ensure that the nipple–areola complex is centered over the most projecting point of the implant. This will help the implant maintain its position and limit migration in the case of a solid silicone implant used for chest wall reconstruction or breast implant used for mound reconstruction. breast reshaping (mastopexy and reduction). small numbers of patients in the reports with varying degrees of expression of the problem. tend to be similar to the complications seen in other types of reconstructive and aesthetic procedures. As with any procedure. remains the gold standard (28). A blocking suture. Furthermore. The areolar deformity is addressed at a second stage during expander exchange (26).14 If necessary. An alternative approach to the correction of tuberous breast deformity involves the use of tissue expanders to both expand the circumference of the breast. an implant can be placed beneath the glandular pillars in either the subglandular. and breast reconstruction. the reconstruction of congenital breast problems can have tremendous benefit to the patient’s selfesteem. when they occur. etc. Many of the complications that develop after surgery either in the reconstruction itself (i. accurate diagnosis of the problem. There is not much in the plastic surgery literature about the management of the complications of congenital breast reconstruction. The authors have used mersilene with good results with no suture exposure in their cases. such as the use of acellular dermal matrices. adhering to principles of reconstruction and knowledge of the tools available. the treatment of tuberous breast deformity continues to be a challenge to the breast surgeon. and the literature discussing the management of these issues suffers from a small number of papers. as well as the constricted lower pole of the breast. and short term follow up with little presentation of longer term results. Recurrence of an enlarged areola can be problematic. To achieve this goal. Complications. will continue to lead us toward a more satisfying approach for addressing this difficult problem. Neo-pockets and fat grafting. The difficulty in treating the tuberous breast is illustrated by the range of options offered for treatment of the deformity. placed in a purse string or pinwheel fashion to help control areolar size as described by Hammond. However.e. we recommend precise dissection of the pocket that limits its size to that of the implant. which in this case is the ratio of skin envelope volume to breast mound (either natural or augmented with an implant) volume should guide one in choosing the proper technique of skin excision for the mastopexy (30). the selection of an implant of the appropriate size for the chest wall will also limit these issues as well as the complications that can develop over the long term from larger sized implants (29). This will also help to limit the appearance of rippling of the implants. Next is ensuring adequate thickness of coverage over the implant and providing for a gradual transition of thickness of overlying coverage. including autologous fillers which can augment the soft tissue deficiency. However. The development of new techniques. or dual plane (partial sub-glandular/partial subpectoral) to provide additional volume to the breast (25). marked areolar reduction with a blocking suture can lead to an unattractive flattening of the breast. implant malposition. wide scars. using a standard Coleman technique in harvesting the fat. scoring of the overlying breast tissue.) or related to the aesthetics of the result are likely related to either the surgeon selecting the wrong operation for the problem or compromising the choice of technique to meet the patient’s desires (for example by limiting the incision to a peri-areolar approach when a vertical component is indicated). CONCLUSIONS The management of congenital breast disorders and in particular the hypoplastic disorders such as Poland syndrome and the tuberous breast disorder present a challenging problem to the plastic surgeon.. yet even this solution is plagued by high rates of suture exposure and subsequent recurrence of the deformity. This will limit the appearance of a double bubble. Hum Hered 1973. 32. 166: 339–40. Aesthetic reconstruction of the tuberous breast deformity. Aesthetic Plast Surg 2011. 101: 42–50. Serra-Renom JM. Hammond DC. 20: 392–5. 26. Aston SJ. Grolleau JL. LoTempio MM. 137: 952–3. Osbourne M. Treatment of tuberous breasts utilizing tissue expansion. Clinical and radiographic Poland syndrome classification: a proposal. supernumerary breasts. Garty BZ. . 2. Delay E. In: Harris K. Velanovich V. 13. ed. Guys Hosp Rep 1841. Kim J. Am J Dis Child 1983. et al. Plast Reconstr Surg 2003. Chekaroua K. 104: 2040–8. 31. AJR Am J Roentgenol 1996. Plastic and Reconstructive Breast Surgery. 61: 784–91. Ann Thorac Surg 2002. 6: 191. Handel N. Opitz JM. The interlocking GoreTex suture for control of areolar diameter and shape. 10.CONGENITAL DISORDERS OF THE BREAST REFERENCES 1. 1991: 1–13. The Poland syndrome – clinical and genealogical data. Surgery of the Breast: Principles and Art. Latham K. 28: 463–7. 29: 494–504. 31: 143–70. Anatomy and physiology. et al. Koch H. Poland’s syndrome revisited. 115: 1039–50. Eur J Pediatr 2002. van Aalst JA. et al. et al. Ann Plast Surg 2007. Aesthet Surg J 2008. dermatoglyphic analysis. et al. March 17 Epub. Clin Plast Surg 1976. Robb GL. Prevel C. Merlob P. Plast Reconstr Surg 2002. Poland’s sundrome in one identical twin. Lipomodeling of Poland’s syndrome: a new treatment of the thoracic deformity. 119: 804–9. et al. 3: 339–47. 12. The tuberous breast. Anastasopoulos A. 59: 35–8. Fink BA. Rozzelle AA. Philadelphia: Lippincott. Sinna R. Zambacos GJ. et al. Bostwick J. Lanfrey E. Martinez-Frias ML. Bianca S. Treatment of grade 3 tuberous breasts with Puckett’s technique (modified) and fat grafting to correct the constricting ring. 74: 2218–25. Mariano MB. 2006: 1417–35. Breast Diseases. Propeck PA. 9. 23. Chichery A. et al. Pediatrics 1984. 161: 455–9. 14. 15 17. Varsano IB. 6. 73: 103–5. and incidence. Blotta RM. Munoz-Olmo J. Chavoin JP. Louis: QMP. Isolated congenital amastia: a subclavian artery supply disruption sequence? Am J Med Genet A 2010. Congenital breast deformity reconstruction using perforator flaps. 25. 30: 680–92. Scanlan KA. 109: 1396–409. 18. et al. 58: 353–8. 34: 218–25. Poland A. In: Bostwick J. 88: 903–6. Allen RJ. Breast base anomalies: treatment strategy for tuberous breast deformities and asymmetry. Aesthetic Plast Surg 1991. Managing complications of augmentation mammaplasty. Autologouc fat injection in Poland’s syndrome. 23: 97–104. 20. J Craniofac Surg 2006. Rodriguez-Pinilla E. Ectopic breast tissue. Pediatric breast deformity. 152A: 792–4. Nahabedian MY. Smoking during pregnancy and Poland sequence: results of a population-based registry and a case-control registry. Duodecim 1915. Barrano B. 16. 15. St. Urinary tract abnormalities in children with supernumerary nipples. Gabriel A. 30. Canzi W. Hammond D. Iteld L. Pinsolle V. Aesthetic Plast Surg 2010. Sanner D. Maxwell G. Tuberous breast: a new approach. Ribeiro RC. A system for breast implant selection based on patient tissue characteristics and implant-soft tissue dynamics. 3. 2nd edn. Willey SC. Teratology 1999. Fokin A. 29. 4. Philadelphia: Lippincott-Raven. 28. Sadove MA. 15: 307–12. 27. eds. J Pediatr Orthop 2000. and supernumerary nipples. Ribeiro L. Mentzel H. 112: 1099–108. Kajava Y. 17: 454–67. Freire-Maia N. Stevens DB. Rees TD. Lavigne B. Mandrekas A. 11. The proportions of supernumerary nipples in the finnish population. 7. Aesthet Surg J 2010. 5. 19. Plast Reconstr Surg 2007. Plast Reconstr Surg 1999. Versaci AD. Grolleau J. Jaber L. Gautam AK. Mimouni F. et al. Seidel J. Accessory breast tissue in an unusual location. 21. Khuthaila D. Breast development and anatomy. J Plast Reconstr Aesthet Surg 2008. Mangles GM. Radiological aspects of the Poland syndrome and implications for treatment: a case study and review. Plast Reconstr Surg 1998. 34: 634–9. Aesthet Surg J 2009. Dos Santos Costa S. et al. Aesthetic reconstruction of the tuberous breast deformity: a 10-year experience. Congenital and acquired pediatric breast anomalies: a review of 20 years experience. The neopectoral pocket in revisionary breast surgery. Reisner SH. Ettore G. 2000: 77–123. 22. Fernandez S. Serra-Mestre JM. Robiscek F. Mandrekas AD. Saltz R. Buss A. 24. Licciardello M. Zambacos G. Aesthetic Plast Surg 2010. Tebbetts JB. In: Spear SL. et al. ed. South Med J 1993. Occurrence of supernumerary nipples in newborns. 8. Czeizel AE. Chautard EA. Plast Reconstr Surg 2006. Aesthetic improvements in Poland’s syndrome treatment with omentum flap. Deficiency of the pectoral muscles. The American College of Radiology (ACR) and the American Cancer Society (ACS).6). These images are the result of a composite of all the structures in the breast. Romilly X-RAY MAMMOGRAPHY The techniques used to image the breast are based on morphological and/or physiologic differences between tumors and normal breast tissue. there are limitations of the technique. There has been a significant decrease in breast cancer mortality by approximately 30% since 1990 and this is due in large part to the use of X-ray mammography for breast screening. 16 . The resultant image is the result of how the breast tissue attenuates the X-ray beam and is displayed in either film or digital format. Although X-ray mammography is the only imaging modality that has been proven to decrease mortality from breast cancer.3 Radiologic evaluation of the breast Ada P. Evidence to support regular screening comes from the results of multiple randomized controlled trials (5. In some instances where the breast tissue is very dense. have recently published updated guidelines for breast cancer screening with imaging (1. Contrastenhanced magnetic resonance imaging (MRI) is unique in that both morphological features and functional lesion features are used for diagnosis. The American College of Radiology Imaging Network (ACRIN) digital mammographic imaging screening trial study showed a significantly higher accuracy rate for breast cancer detection on digital versus screen film mammography in patients with dense breasts (7). X rays are used to penetrate the compressed breast tissue in two projections for screening examinations. Digital images undergo image processing and lesion conspicuity can be increased by contrast manipulation.2). craniocaudal and mediolateral oblique. X-ray mammography and ultrasound imaging methods are based primarily on the morphology of breast masses whereas differences in the physiology of tumors versus normal breast tissue are used to produce positron emission mammography (PEM) and breast-specific gamma imaging (BSGI) images. Dense tissue attenuates the X-ray beam more than fatty tissue and appears white whereas fatty tissue causes less attenuation and is dark on the image. Additional imaging modalities have been developed and sometimes it is confusing for the referring physician to determine when the different imaging techniques should be utilized. The ACR appropriateness criteria for nonpalpable mammographic findings (3) and for the initial diagnostic workup for microcalcifications (4) are a good reference for determining the procedure which should be performed in a specific situation to provide the highest diagnostic yield. the difference in attenuation of the X-ray beam between a tumor and surrounding dense tissue is so little that there is lack of visualization of the tumor. This imaging method remains the gold standard for the detection of breast cancers in both symptomatic and asymptomatic patients. The recommendations are based on available evidence and consensus opinions of experts in breast imaging. it is very important that if prior X-ray mammograms are available these are used for comparison. Breast cancers are seen as discrete masses. 3. a diagnostic examination is performed which may include targeted views of the areas of interest. (B) Ultrasound images of the masses seen in Figure 3. (D) X-ray mammogram—Area of architectural distortion on screening mammogram. Both masses are solid.1 A–D). or microcalcifications (Fig. (C) X-ray mammogram—Dense breast with a cluster of new pleomorphic microcalcifications. Because a significant number of breast cancers present as subtle areas of increasing density on the X-ray mammograms.RADIOLOGIC EVALUATION OF THE BREAST 17 If a screening examination is abnormal or when mammograms are needed to evaluate specific symptoms. The smaller mass is lobulated with indistinct margins.1 A. architectural distortion. .1 (A) X-ray mammogram spot compression views of two adjacent non-palpable malignant masses in a fatty breast. Pathology—ductal carcinoma in situ. Breast density is an important risk (B) (D) Figure 3. areas of asymmetric density. The composition of the tissue in the breast can vary with age and hormonal status. Breast density has been shown to (A) (C) decrease by 10 percent in a significant number of women after a full-term pregnancy (8). Pathology—tubular carcinoma. Pathology—invasive ductal carcinoma. The larger mass has irregular margins and contains pleomorphic calcifications. Some patients with very dense breasts at a young age may develop predominantly fatty breast tissue after menopause. detection of masses was dependent on lesion size. ultrasound can further define the abnormality and increase the specificity of diagnosis (17) (Fig. The reflected information is translated into an image. and repeat mammograms performed. If no correlative abnormality is seen on ultrasound. the abnormality seen on the X-ray mammogram and for the screening of patients with extremely dense breasts.additional imaging is needed and or prior mammograms for comparison. 4 .highly suggestive of malignancy. A recent multi-institutional study of screening breast ultrasound sponsored by ACRIN. in which whole breast ultrasound was performed by qualified physicians. In a study reported by Berg et al. Ultrasound of the axilla is now increasing being used preoperatively in breast cancer patients. If a correlative abnormality is seen on ultrasound and is suspicious for malignancy. 3. Current challenges with the use of the procedure include operator dependence on lesion detection and characterization.2 B–E). 1 .2 cancers per 1000 women scanned (16). The composition of breast tissue on X-ray mammograms is described as follows: • • • • Predominantly fatty Scattered fibro-glandular tissue Heterogeneously dense Extremely dense The results of the examination are defined as follows and determine the final disposition of the patient. negative mammograms. Appropriate action should be taken. included not only women who had dense breasts but who were also at an increased risk for breast cancer. and the development of minimally invasive biopsy procedures. demonstrated that breast carcinomas showed significant enhancement following contrast injection (21).6 additional cancers per 1000 women in patients with dense breasts.8–4. ultrasound-guided core biopsy could be performed.12).18 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY factor for breast cancer because patients with dense breasts have been shown to have an increased risk for breast cancer and have a higher mortality from the disease partly as a result of the masking effect of the dense tissue on X-ray mammograms (9. . The current categories are: 0 . Many published reports state that ultrasound can detect between 2.negative 2 . Ultrasound is a useful adjunct to mammography in assessing breast tumors in all patients and is used as the primary modality in evaluating the palpable mass in the young patient (Fig. Specially focused high resolution transducers are used to produce sound waves which are transmitted through the breast tissue and are reflected back to the transducer. Masses 11 mm or greater were consistently detected and less than half of lesions 5 mm or smaller were detected (19). The American College of Radiology has standardized the interpretation of mammograms and the characterization of the breast tissue through the Breast Imaging Reporting and Data System (BIRADS) system (11.known biopsy proven malignancy. Correlation between subtle mammographic abnormalities and ultrasound is sometimes difficult because ultrasound is performed with the patient supine and mammogram with the patient upright. When an abnormality is seen on the X-ray mammogram.probably benign findings. Appropriate action should be taken. The technique is based on the fact that masses attenuate the ultrasound beam differently from normal breast parenchyma because of differences in the transmission of the sound waves through the tissue. In these situations BB correlation is performed in which a marker is placed in the area of the abnormality seen on ultrasound. 5 . 6 . This format for communicating results to referring physicians is now used in most modalities of breast imaging.10). and physical examination (13–15). If abnormal axillary nodes are detected.2 A). Biopsy should be considered. The recent ACR guidelines for screening with ultrasound states that the technique can be considered in high risk women for whom MRI screening may be appropriate but who cannot have MRI for any reason. The ACRIN study reported similar results to those of the single institution studies with an incremental detection rate of 4. ULTRASOUND Ultrasound has traditionally been used for evaluating the palpable abnormality. Substantial improvements have been made over the past decade on the definition of technical requirements for image quality. MRI BREAST IMAGING MRI technique was initially used to evaluate the integrity of breast implants (20). alleviating the need for a sentinel node biopsy if the biopsy of the node is positive (18). Interval short-term follow-up suggested.suspicious abnormality. then stereotactic core biopsy would be performed.benign findings 3 . and can be considered in women with dense breast tissue as an adjunct to mammography (1). ultrasound-guided core biopsy is performed. Contrast-enhanced MRI of the breast was first performed in the late 1980s when Heywang et al. 3. the definition of interpretive guidelines with a BIRADS lexicon. Abnormalities seen on X-ray mammogram may appear far distant from the anticipated location depending on the pendulous nature of the breast. Mass is not well defined.2 B.RADIOLOGIC EVALUATION OF THE BREAST 19 (A) (B) (C) (E) (D) Figure 3. (D) X-ray mammogram of a palpable left breast mass. Pathology—invasive ductal carcinoma. (C). (B) Mammograms of palpable mass in the left breast. Pathology—fibroadenoma. Ultrasound of mass in Figure 3. Benign appearing solid mass. Mass shows irregular borders.2 (A) Ultrasound of a palpable mass in a young patient.2 D shows a simple cyst. Irregular solid mass. . (E) Ultrasound of the mass in Figure 3. The diagnosis of benign versus malignant is determined by the morphology of the tumor and the contrast-enhancement pattern.3 A.20 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY During the MRI procedure. the tumor signal is enhanced. This technique uses high resolution small field (B) Figure 3. which rapidly absorbs the gadolinium and the contrast material just as rapidly washes out of the tumor because of increased permeability of the cell membrane. The technique takes advantage of the differences in metabolic activity between tumor and normal breast tissue. The inherent differences in the soft tissues of the breast are insufficient for accurate diagnosis. Benign masses such as fibroadenomas also demonstrate contrast enhancement but the initial absorption is slower and contrast enhancement persists for a longer period of time.3 (A) MRI shows a lobulated contrast-enhancing mass in the right breast. Several studies have documented that breast MRI has a high sensitivity for the detection of breast cancer (24. By using the contrast agent containing gadolinium.25). Left breast shows 5-mm contrast-enhancing mass. PEM had a greater specificity for lesion identification particularly DCIS (28).22–25) are • Evaluate implant integrity in patients with questionable rupture (A) • Evaluate patients with newly diagnosed breast cancer for multifocality and extent of disease.23) (Fig. PEM is not universally used but seems to have its greatest role in the pre-surgical planning for ipsilateral breast cancer. PEM has been shown to detect breast malignancies not seen on mammograms or ultrasound images in dense breasts and areas of scar tissue (27). Pathology of left breast mass—atypical ductal hyperplasia. • Evaluation for breast cancer in patients with an unknown primary. • Evaluation of abnormalities of the lumpectomy site in cancer patients and for indeterminate areas detected on X-ray mammograms and ultrasound. 3. The specificity rate was 88%. BSGI uses technetium 99m sestamibi for breast cancer detection. These findings are similar to other reported single institutional studies for breast cancer screening with MRI (26). A recent reported study has shown that PEM and MR have comparable breast sensitivity. and women with a greater than 20 percent lifetime risk for breast cancer. Specific techniques have been developed to capture the maximal temporal (dynamic) and spatial (morphologic) resolution for diagnosis (22. multiple images of thin slices of breast tissue are obtained and computer manipulation enables viewing in a three-dimensional manner. • Screening of high risk patients such as BRCA positive patients. Pathology of right breast mass—invasive ductal carcinoma. Malignant masses have neovascularity. Pathology—ductal carcinoma in situ. An 8-mm enhancing mass is seen in the left breast. The multi-institutional study ACRIN 6667 reported a sensitivity of 91% for the detection of breast cancer in the contralateral breast of patients with recently diagnosed breast cancer. POSITRON EMISSION MAMMOGRAPHY (PEM) AND BREAST-SPECIFIC GAMMA IMAGING (BSGI) PEM is a high-resolution PET scan that uses detectors specialized for the molecular imaging of the breast with fluorine 18-fluorodeoxyglucose (FDG). (B) MRI breast screening for a high-risk patient. women who have a family history suggesting a familial disposition for breast cancer. . B). The current recommendations for the use of MRI (1. 4 percent has been recorded. Most dense areas from scar tissue will decrease with time but initial imaging examinations of areas of (B) (C) Figure 3. Residual silicone decreases mammography sensitivity. Sensitivity as high as 96. (A) 21 THE SURGICALLY ALTERED BREAST It is important for the plastic surgeon to understand the limitations that may occur with imaging of a breast that has undergone surgical intervention. (B) X-ray mammogram (MLO view) with history of implant rupture and replacement with a silicone implant. Most areas of scarring are radiographically dense with a subsequent decrease in accuracy for diagnosis with the traditional methods of breast imaging such as X-ray mammography and ultrasound. . Both PEM and BSGI are helpful for evaluating ipsilateral cancers in newly diagnosed breast patients in whom MRI cannot be performed.RADIOLOGIC EVALUATION OF THE BREAST of view (fov) detectors which can detect uptake of the radiotracer in breast tissue.5 percent (29).4 (A) Calcifications in an implant capsule which appeared similar to calcifications within the breast. The uptake in the breast is classified as positive if there is focal increased radiotracer uptake and negative if there is no uptake or there is scattered heterogeneous physiologic uptake. but specificity is moderate at 59. (C) MRI shows an intact implant and no contrast-enhancing masses. post reduction mammoplasty. Calcifications of the implant capsule may also be mistaken for suspicious microcalcifications in the breast which may result in unnecessary surgery.4 A) Ultrasound is used to evaluate all palpable abnormalities. In a study by Silverstein et al. Silicone injections. the calcifications increase and become coarse. On X-ray imaging these masses may initially present as microcalcifications or low-density masses with rim-like calcifications (30). 3. The X-ray imaging characteristics are often classic that biopsy is not needed.4 B. Subpectoral implants are more easily displaced than (A) prepectoral implants and allow for more tissue to be evaluated.5 A. The commonest palpable mass that is found in the surgically altered breast is fat necrosis. Although MRI is a more expensive imaging modality. MRI imaging is usually negative in these areas of the mammographic abnormality. In some cases calcifications of the capsule of the implant occurs and makes displacement of the implant extremely difficult. We have found MRI to be very helpful in evaluating masses at the partial mastectomy site in breast cancer patients and in patients with reduction mammoplasty and dense breasts. The silicone granulomas are usually palpable and make it clinically difficult to differentiate from malignant masses. 3. THE AUGMENTED BREAST Silicone and saline implants are most commonly used for breast augmentation. (cc) view shows multiple silicone granulomas. (B) MRI shows multiple masses with no contrast enhancement and low signal intensity on the T1 images. Routine views and implant displacement views were performed and there was a decrease of 15–25 percent of visualized tissue depending on whether the implants were subglandular or submuscular with more breast tissue seen with submuscular implants.22 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY clinical concern should include X-ray mammography and adjunctive techniques such as MRI. it allows a more complete evaluation of the breast tissue and is recommended for high-risk patients and in patients with suspected rupture of silicone implants (Fig. are first obtained and then similar views are performed with the implants displaced. B). which are no longer performed in the United States. C). and augmentation with autologous fat injections. This is commonly seen at partial mastectomy sites. (Fig. Other materials also have been used for augmentation of the breast such as the injection of fat and the injection of silicone. result in the formation of silicone granulomas which create non-diagnostic images on X ray and ultrasound. MRI imaging is currently the most accurate method for detecting malignant masses in these patients (Fig.5 (A) X-ray mammogram craniocaudal. Two views of each breast—craniocaudal and mediolateral oblique views. 3. (32) measurements of the visualized breast tissue were compared between the preand post-augmentation mammograms. . As the masses age. Evaluating masses in areas of scar tissue is sometimes difficult as the imaging characteristics of surgical scars and malignant breast masses can be similar. Specific X-ray imaging techniques have been developed to maximize the amount of breast tissue visualized (31). (B) Figure 3. Multiple low-density masses are seen with rimlike calcification of fat necrosis. Potentially the areas of fat necrosis may form coarse calcifications which are diffuse and palpable making the diagnosis of new breast cancers difficult with X-ray mammography and ultrasound.6 A).7 B. Routine screening for breast cancer in these patients is not recommended because of the low yield (32). B) Recurrent CA in a reconstructed breast. (B) (B) (C) Figure 3. the underlying implants are visualized in a similar manner to the augmented breast.RADIOLOGIC EVALUATION OF THE BREAST 23 The injection of fat into the breast is becoming more common and we have seen a few of these patients who have diffuse nodules of fat necrosis within the breast (Fig.6 X-ray mammogram of a patient with autologous fat injections. The TRAM flap has a signal intensity equivalent to fat. CT scan shows a mass just posterior to an intact implant.7 (A. Long-term studies are needed to review the imaging characteristics of these masses with age. . The recent recommendations for the use of MRI for follow up of the breast cancer patient allows a three-dimensional evaluation of the reconstructed breast at the time the normal breast is being evaluated (33). With the latissimus dorsi flap. (C) Ultrasound of the mass seen in Figure 3. Recurrent tumors are easily detected as (A) (A) Figure 3. THE RECONSTRUCTED BREAST Breast reconstruction methods such as the transverse rectus abdominis myocutaneous (TRAM) flap and latissimus dorsi flap with implant are commonly used post mastectomy. 3. Current status of breast MR. Cokkinides V. Byng JW. American college of radiology appropriateness criteria. Liberman L. stage. Choice of technique. Looman CW. 25. High cancer yield and positive predictive value: outcomes at a center routinely using preoperative breast MRI for staging. A single institution review of new breast malignancies identified solely by sonography. McCavert M. . Radiology 2007. Cardenosa G. Breast MRI screening of women with a personal history of breast cancer. 22. Gutierrez RL. Acharyya S. 17: 95–103. Mendelson EB. et al. Corsetti V. 6. 15. Long-term effects of mammography screening: updated overview of Swedish radomised trials. Brennan S. Pisano E. Otto SJ. J Am Coll Radiol 2010. Ultrasound is a useful adjunct to mammography in the assessment of breast tumors in all patients. Heywang SH. et al. Effect of baseline breast density on breast cancer incidence. Aroori S. D’Orsi C. 18: 1587–98. A review of the current American cancer society guidelines and issues in cancer screening. et al. Kuhl C. 299: 2151–63. 11. The current status of MR imaging. 14.24 contrast-enhancing masses. The breast imaging reporting and data system: positive predictive value of mammographic features and final assessment categories. Kreymerman P. Abramson AF. Houssami N. Kaplan S. Lancet 2003. 18. Radiology 2001. AJR Am J Roentgenol 2011. et al. Deershaw DD. et al. et al. 7: 920–30. 10. Guidelines for the use of these imaging methods for both screening and diagnosis have been provided by the ACR and are a great tool for determining how patients should be evaluated with the currently available imaging methods. Fracheboud J. Guidelines for using breast magnetic resonance imaging to evaluate implant integrity. Cole E. Heusinger K. Radiology 1989. Berg WA. Ghiradi M. Radiology 2000. 19: 405–12. et al. Operator dependence of physician – performed whole breast US: lesion detection and characterization. 252: 348–57.12. 195: 510–16. 3. Bassett L. Masses can also be detected on CT scans of the chest which can then be confirmed with ultrasound or MRI (Fig. SUMMARY It is important to understand the multiple imaging methods that are used to evaluate the breast and the accuracy and limitations of each procedure. Nees AV. Pruss E. AJR Am J Roentgenol 1998. 62: 355–7. JAMA 2008. et al. Ann Plast Surg 2009. et al. The technique is useful in patients on whom MRI cannot be performed. 257: 335–41. 221: 541–649. 244: 672–91. Patrick RJ. Int J Clin Pract 2009. Bjurstam N. Assessment of mammographic density before and after first full-term pregnancy. Chiu SY. Greene T. Rim A. Kuhl C. doi:10. Squires FB. Duffy S. AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY 9. and BSGI complement X-ray mammography by providing additional diagnostic information. Nystrom L. Studies have shown that ultrasound is valuable in the assessment of both palpable and clinically occult recurrent breast cancers in patients with autogenous myocutaneous flaps (34). 36: 1411–17. Clinical utility of bilateral whole-breast US in the evaluation of women with dense breast tissue. 19: 1219–28. Birdwell R. et al. 19. O’Donnell ME. Eur J Cancer Prev 2010. et al. 3. ACR appropriateness criteria on nonpalpable mammographic findings (excluding calcifications). Blume JD. Can preoperative axillary US help exclude N2 and N3 metastatic breast cancer. Estabrook A. diagnostic accuracy and transfer to clinical practice. Mendelson E. Jud SM. J Am Coll Surg 2006. et al. 17. Morris E. Breast cancer screening with imaging: recommendations from the society of breast imaging and the ACR on the use of mammography. MR imaging of the breast with Gd-DTPA: use and limitations. Radiology 2006. REFERENCES 1. 16. As stated in this chapter. Brooks D. AJR Am J Roentgenol 2010.7 A–C). Blume JD. Smith R. Andersson I. J Am Coll Radiol 2009. Evidence of the effect of adjunct ultrasound screening in women with mammography-negative dense breasts: interval breast cancers at 1 year follow up. 23. Helvie MA. 7: 18–27. 13. mortality and screening parameters: 23-year follow up of a Swedish mammographic screening.2010. 203: 89408. 20. Eur J Cancer 2011. 12. Kopans D. Combined screening with ultrasound and mammography vs mammography alone in women at elevated risk of breast cancer. et al. Cormack JB. 7. 215(Suppl): 973–80. 241: 355–65. Daly CP. Wolf A. Radiology 2009. Sickles EA. Neal CH. Cancer screening in the United States. Part 1. Initiation of population-based mammography screening in Dutch municipalities and effect on breast-cancer mortality: a systematic review. breast density plays a significant role in determining breast cancer risk and diminishes the accuracy of X-ray mammography. Bassett LW. et al. Radiology 2010. 5. Lancet 2002. Burside ES.ejca. 24. Berg WA. 244: 356–78. 61: 8–30. Lee CH. DeMartini WB. Analysis of mammographic density and breast cancer risk from digitized mammograms. Dershaw D. 21. Cocilovo C.002. 2. Yen AM.1016/ j. et al. Clinical Applications. et al. Radiology 2007. Newell M. and other technologies for the detection of clinically occult breast cancer. Radiographics 1990. 6: 851–60. 4. et al. Part 2. MRI. Silbergeld JJ. Yaffe MJ. Appropriate imaging work up of breast microcalcifications. PEM. 359: 909–19. breast ultrasound. Cancer Epidemiol Biomarkers Prev 2010. Cancer cases form ACRIN digital mammographic imaging screening trial: radiologist analysis with use of a logistic regression model. et al. 64: 1589–94. image interpretation. Loehberg CR. Liberman L. 2011. 196: W93–9. Cormack JB. 8. The ACR BI-RADS experience: learning from history. CA Cancer J Clin 2011. et al. 17: 35–40. Adjunctive methods of imaging such as ultrasound. Jong RA. J Am Coll Radiol 2010. 28: 635–40. et al. Aesthet Surg J 2008.RADIOLOGIC EVALUATION OF THE BREAST 26. et al. Bedi DG. 151: 469–73. Job JS. 224: 211–16. et al. Fornage BD. Eur J Cancer 1992. Brem RF. 356: 1295–303. N Engl J Med 2007. Silverstein MJ. 35. 28:153–62. Eideiken BS. 30. Patino C. et al. 34. Park C. Berg WA. Berg WA. Breast cancer diagnosis and prognosis in women following augmentation with silicone gel-filled prostheses. Miller SH. Floerke AC. 28. 21: 784–91. Handel N. Improved imaging of the augmented breast. High-Resolution fluorodeoxyglucose positron emission tomography with compression (positron emission mammography) is highly accurate in depicting primary breast cancer. Shilling K. J magn Reson Imaging 2005. Breast J 2006. Lehman C. 29. Mammographic screening of TRAM flap breast reconstructions for detection of nonpalpable recurrent cancer. et al. et al. Busby RC. . 25 31. 32. Helvie MA. 12: 309–23. Radiology 2002. Eklund GW. Radiology 2011. Breast cancer: comparative effectiveness of positron emission mammography and MR imaging in the presurgical planning for the ipsilateral breast. Recurrence in autogenous myocutaneous flap reconstruction after mastectomy for primary breast cancer: US diagnosis. Narayanan D. Radiology 2008. MRI evaluation of the contralateral breast in women with recently diagnosed breast cancer. Jung JI. Rapelyea JA. 27. Breast-specific gamma imaging as an adjunct imaging modality for the diagnosis of breast cancer. Weinberg I. Kuhl C. et al. Madsen KS. et al. Radiology 2003. 33. Roubudoux MA. 247: 651–7. Mammographic findings after breast augmentation with autologous fat injection. Gamagami P. 227: 542–8. Gatsonis C. Kang BJ. AJR Am J Roentgenol 1988. 258: 59–72. Bailey JE. Breast MRI findings after modified radical mastectomy and transverse rectus abdominis myocutaneous flap in patients with breast cancer. and comparative volumes of the left and right breasts. interpret a certain amount of asymmetry as normal. when observing their own breasts. When a woman is considering a breast operation of any sort. Fourth. specifically juvenile CLINICAL PRESENTATIONS Bilateral Macromastia and Asymmetry We define macromastia as a state wherein the patient’s breasts are larger than would be ideal and cause the patient symptoms of back. either unilateral or bilateral. or lack thereof. grade and symmetry of any ptosis.4 Breast asymmetry Thomas R. No individual has perfectly matched breasts. We discuss level of inframammary folds. Although in nature symmetry is the ideal. It is our practice to point out the pre-existing symmetry. This principle holds true for virtually all paired human organs. The potential patient. the surgeon may not. the surgeon may feel that the breasts are remarkably asymmetric. Poland’s Syndrome) nor shall we describe the management of breast asymmetry associated with breast reconstruction. breast reduction. asymmetry is the norm (1–3). and relationship to the contralateral nipple. Second.. without macromastia. attention to preoperative symmetry is important (4. Most people. BASIC PRINCIPLES In the material that follows.5). While the patient may perceive a significant lack of symmetry. When considering any breast operation. Conversely. Large breasts 26 . For the purposes of this chapter. we shall cover the class of patients who have small breasts. the authors will address five general categories of patients who present with specific clinical problems of breast asymmetry (10. or a procedure to address perceived asymmetry. First will be those patients who have macromastia. neck. The relative magnitude of breast asymmetry is subjective. This can lead to patient dissatisfaction and pressure for unnecessary re-operation. be she desirous of breast augmentation. breasts included. nipple size. we believe it is incumbent upon the surgeon to discuss symmetry preoperatively. to all patients considering an operation on one or both breasts. We shall not consider asymmetry secondary to breast agenesis (e. or shoulder pain. either bilateral or unilateral. breast base diameters. Not infrequently. Third. the authors will confine themselves to consideration of female breast asymmetry. we shall examine the group of patients with unusual causes for asymmetry. but the patient does not. position. a patient who does not recognize the presence or extent of preoperative asymmetry will note lack of symmetry postoperatively.g.11). we shall discuss patients with bilateral breast ptosis and asymmetry. must have an accurate preoperative appreciation of the amount of pre-existing asymmetry and the possible outcome following any proposed operative procedure (6–9). Stevenson INTRODUCTION macromastia and benign tumors. could result in the right nipple being too high. . fat. usually.2 reduction to remove proportionately more skin. she has significantly more right breast tissue. skin elasticity will pull the right nipple differentially higher and. In the majority of patients. since the right breast is heavier. preop) or laterally (Fig. fat.1 (A) Figure 4. 11 months. skin. While her nipples are similar in size and position. (B) Postoperative. nipple size. 4.1 suffers from bilateral macromastia and asymmetry. the right breast skin is under more tension due to the force of gravity. 4. nipples displaced medially. if not anticipated. Asymmetry in the presence of bilateral macromastia may be manifest by asymmetric excess in any of these elements. Macromastia may be accompanied by displacement of the nipple medially (Fig. (A) Preoperative. preop).3. fat.. redundant breast skin with the skin of the breast lying against the chest or abdominal wall. breast tissue. i. In the process of planning. areolar enlargement with the areolar diameter exceeding 4 (four) centimeters. This is done with the understanding that.e. and/or nipple position. (B) Postoperative. the right nipple position was marked approximately 1 centimeter lower than the left. preoperative breast Bilateral macromastia and asymmetry.BREAST ASYMMETRY 27 are characterized by excess breast tissue and fat. When that force is reduced by breast reduction. and. we tailored her breast (A) (B) Figure 4. 4 months. (B) Bilateral macromastia and asymmetry. (A) Preoperative. and breast tissue from the right breast. The patient in Figure 4. and skin.2. Using an inferior pedicle technique and Wise (inverted T) skin pattern. This amounts to a unilateral breast reduction and contralateral mastopexy. the patient may present with unilateral macromastia and contralateral breast ptosis (Fig.1). although postoperative skin stretching on the reduced side can produce some recurrent asymmetry (Fig. That estimate is confirmed intraoperatively. including weight of breast tissue to be excised from each breast (12).7). In this circumstance. the patient has unilateral macromastia and a contralateral breast that is both small and ptotic. 4. Here. When performing a mastopexy. The patient presents with . the scar beneath the nipple is oriented vertically and intersects the inframammary fold perpendicularly. Over time. marking determines ultimate nipple position and dimensions of skin excision. In spite of our best efforts. delivery. nipple size does not appear to increase significantly on the reduced side. removing excess breast tissue from the enlarged breast.28 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY (A) Figure 4. usually commensurate with the preoperative disparity (Fig. respectively. Macromastia and Adequate Contralateral Volume A patient may develop unilateral macromastia in the face of an adequately proportioned contralateral breast (Fig. and cessation of nursing. nipples displaced laterally. we have preferred a central pedicle technique with a Wise pattern skin reduction.3 (B) Bilateral macromastia and asymmetry.4) (13). 4.5). the patient is best served by reducing both nipples to a similar size. we prefer breast reduction to treat the macromastia and breast augmentation with mastopexy for the opposite breast (Fig. Review of the postoperative results demonstrates that. while longer on the macromastia side. If the nipple is not displaced medially or laterally in the preoperative state. A preoperative estimate of necessary proportional skin and tissue excision is always made. nor does the nipple descend significantly on that side. 4 months. 4. the contour of the breasts may be different. Discrepancies are corrected by immediate additional excision. Correcting medial or lateral nipple position operatively results in the “vertical” reduction scar being tilted medially or laterally.4. The patient needs to know preoperatively that postoperatively. 4. however. center and right). 4.6). and tailoring the remaining skin bilaterally. For such a patient. is confined to an area concealed by the brassiere. (B) Postoperative. a patient will present with unilateral macromastia and a contralateral breast of satisfactory contour but inadequate volume (Fig. postoperative asymmetry may occur. breast feeding. We prefer the inferior pedicle technique and Wise (inverted T) skin pattern. Similar changes can occur with modest weight loss or adult breast involution. (A) Preoperative. The resulting inframmary scar. unilateral breast reduction decreases the size asymmetry. The tissue resected (fat and breast parenchyma) from each breast is weighed and compared. Volume symmetry may be achieved. If. Breast Ptosis and Asymmetry Changes in breast size and contour are often attendant upon pregnancy. 4. In some cases. Macromastia and Inadequate Contralateral Volume Occasionally. although the volumes of the individual patient’s breasts are similar. some asymmetry of shape likely will be apparent. we elect to perform a unilateral breast reduction and contralateral augmentation. It has been our practice to recommend implants of . bilateral breast ptosis and asymmetry confined primarily to disparity in skin excess. (A) Preoperative. Bilateral Hypomastia and Asymmetry Bilateral hypomastia is almost always accompanied by a degree of asymmetry. nipple size. may be accentuated.BREAST ASYMMETRY 29 (A) (B) (C) Figure 4. we shall consider only those patients who have undergone breast augmentation using round implants. Our patient (Fig. 1 year. and nipple size.) Patients who come with complaints of small breasts and breast asymmetry are evaluated and the extent of that asymmetry is assessed by the surgeon. 4. (For the purposes of this discussion. Preoperatively. Volume asymmetry must be significant enough to warrant placement of implants of different size and base diameter. 2 years. the patient should be made aware of differences in breast size. but a difference in skin envelope and nipple size was apparent. (C) Postoperative. and nipple location. right). shape. Each patient must decide for herself regarding the operative procedure indicated for improvement in symmetry.4 Macromastia and adequate contralateral volume. left) elected unilateral mastopexy. and nipple position (Fig. (B) Postoperative.8. left).8. 4. One year postoperatively (Fig.8. 4. Patients should be advised of these possibilities. asymmetries in inframammary fold and nipple location. volume asymmetry was improved. While breast augmentation may improve volume discrepancy. 6 Macromastia and inadequate contralateral volume. we emphasize to the patient preoperatively that the asymmetries will be addressed but not completely remediated by placement of implants. sizing. and a discussion of the procedure’s likely outcome. 4 months. (B) Postoperative. (B) Postoperative. 3 months. with risks and possible complications (15). In every circumstance. the same volume and base diameter to those patients whose volume asymmetry is less than 50 cc. Every patient scheduled for breast augmentation undergoes preoperative screening that includes a detailed history and physical examination. (A) Preoperative. (A) (B) Figure 4. Sizing is accomplished by fitting the patient with an appropriate brassiere and placing silicone gel sizers (of various volumes) in it.5 Macromastia and adequate contralateral volume. no matter what the dimensions of the implants (14). The patient selects the .30 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY (A) (B) Figure 4. (A) Preoperative. photographic documentation of the preoperative state. Careful preparation of the asymmetric patient is particularly important in preventing postoperative disappointment. inframammary fold position. Modest volume discrepancies (less than 50 cc) are addressed by placing implants of identical volume and profile. rather than a particular cup size. and small right nipple diameter. 9 months. (A) (B) Figure 4.BREAST ASYMMETRY 31 (A) (B) Figure 4. The patient in Figure 4. skin excess. Intraoperatively. periareolar approaches were used to develop subpectoral pockets for . patients are discouraged from selecting disproportionately large implants. Finally. and nipple size and position. “look” she desires. contour. bilateral insertion of 330 cc subpectoral saline implants resulted in satisfactory breast volume. indistinct right inframammary fold.10 suffers from asymmetry in breast volume. and these issues are discussed with the patient.8 Breast ptosis and asymmetry. Preoperative asymmetries in patients considering bilateral breast augmentation include variations in breast volume. 4. as such implants tend to become displaced or produce breast deformity as the patient ages. (B) Postoperative. (A) Preoperative. and symmetry. In this patient (Fig.9). Consideration is given to implant profile and base diameter. 11 months. (A) Preoperative.7 Macromastia and inadequate contralateral volume. (B) Postoperative. the breast volume discrepancy was decreased. Not infrequently. If the patient presents with physical findings demonstrating the center of the nipple to be at or above the level of the ipsilateral inframammary fold. Variation in inframammary fold position can be addressed by dissecting one side slightly lower than that on the opposite. 3 months. It is easier operatively to lower an inframammary fold. Sizers were removed and bilateral saline implants were placed. In Figure 4. placement of implants. (A) (B) Figure 4. Based on the sizer volumes. (B) Postoperative.11. thus matching the contralateral inframammary fold.32 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY (A) (B) Figure 4. Postoperatively. (A) Preoperative. (B) Postoperative. breast augmentation . (A) Preoperative. Inflatable sizers were inserted bilaterally and filled differentially with saline until the volume asymmetry was corrected to the extent possible. improving the preoperative asymmetry.9 Bilateral hypomastia and asymmetry. than to attempt to elevate a fold.10 Bilateral hypomastia and asymmetry. Patients with small breasts who desire breast augmentation also may evidence disparate skin excess. the surgeon placed the subpectoral implant slightly lower on the right. 8 months. attempts at elevating an inframammary fold fail to produce a durable result. a 360-cc implant was inserted on the right and 270 cc on the left. but asymmetry in nipple size and inframammary fold contour persist. . (B) Postoperative. without mastopexy is an acceptable alternative.12) to moderate (Fig. are often accompanied by asymmetry. 4. with improvement in breast contour and diminution of asymmetry. (A) (B) Figure 4. (A) Preoperative. (B) Postoperative. 6 months. characterized by a deflated breast appearance. many patients select mastopexy and breast augmentation. it is appropriate to augment the breasts simultaneous with mastopexy. The likelihood of subsequent revision is increased if augmentation and mastopexy are done at the same time.14) underwent mastopexy and bilateral subpectoral breast augmentation at a single setting. 4 months. Performance of breast augmentation alone may be used to treat individuals with mild (Fig. and Asymmetry Involutional breast changes occur after pregnancy and delivery. In selected patients. Performing a mastopexy. and are exacerbated by breast feeding. As a treatment alternative.12 Bilateral hypomastia and asymmetry. to reduce the amount of skin excess and nipple diameter.11 Bilateral hypomastia and asymmetry. nipple descent. 4.BREAST ASYMMETRY 33 (A) (B) Figure 4. Mastopexy may be performed several months prior to breast augmentation. Ptosis. may contribute to a decrease in breast asymmetry. (A) Preoperative. and nipple enlargement.13) skin excess in the face of hypomastia. This patient (Fig. 4. Bilateral Hypomastia. These changes. 16. 6 months. Juvenile Macromastia As they pass through puberty and adolescence. Surgical intervention is better undertaken when the period of rapid breast growth and inflammation have subsided. (B) Postoperative. Differential bilateral breast reduction relieved her of the symptomatic macromastia (Fig.16.14 Bilateral hypomastia. Six months later (Fig. but persistent contour differences. right). . the patient is advised that unilateral breast augmentation will improve the volume differences between the two breasts. center). (A) (B) Figure 4.16 (left) had been suffering very rapid and uncomfortable breast enlargement. The patient in Figure 4.13 Bilateral hypomastia and asymmetry. In most circumstances. the patient in Figure 4. but will not correct the contour discrepancies. This form of macromastia may be associated with significant asymmetry. (A) Preoperative. a few women experience juvenile macromastia (also termed juvenile gigantomastia or virginal breast hypertrophy). 4. Unilateral Hypomastia and Contralateral Adequate Volume A patient seeking surgical correction of unilateral hypomastia may have a contralateral breast of adequate volume and contour. patients with rapid breast growth should be treated medically or expectantly. Assuming the patient is aware and accepting of these realities.34 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY (A) (B) Figure 4. Her postoperative result displays better volume symmetry.15 underwent right subpectoral breast augmentation employing a saline implant. unilateral breast augmentation is a satisfactory treatment to improve asymmetry. When initially seen. Again. her rapid breast size increase had subsided. during the preoperative consultations. ptosis. 8 months. and asymmetry. (B) Postoperative. 4. (A) Preoperative. BREAST ASYMMETRY 35 (A) (B) Figure 4.15 Unilateral hypomastia and contralateral adequate volume. (A) Preoperative. (B) Postoperative, 7 months. (A) (B) (C) Figure 4.16 Juvenile macromastia. (A) Six months preoperative. (B) Immediately preoperative. (C) Postoperative, 7 months. 36 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY (A) (B) Figure 4.17 Benign tumor. (A) Preoperative. (B) Postoperative, 1 year. Benign tumor A benign breast tumor or fibroadenoma may develop in the juvenile or young adult breast, resulting in marked asymmetry (16). Smaller adenomas may be removed without an effect on symmetry. Larger benign tumors may produce such marked asymmetry, in terms of nipple size, position, and skin excess, that a staged correction is preferred. Our patient (Fig. 4.17) first underwent tumor resection, tailoring of skin excess, and nipple repositioning, followed in one year by unilateral left breast augmentation for symmetry. REFERENCES 1. Reilley A. Breast asymmetry: classification and management. Aesthet Surg J 2006; 26: 596–600. 2. Araco A, Gravante G, Araco F, et al. Breast asymmetry: a heterogeneous condition. Plast Reconstr Surg 2006; 118: 563. 3. Scutt D, Lancaster G, Manning J. Breast asymmetry and predisposition to breast cancer. Breast Cancer Res 2006; 8: 1–7. 4. Novakovic´ M, Lukacˇ M, Kozarski J, et al. Principles of surgical treatment of congenital, developmental, and acquired female breast asymmetries. Vojnosanit Pregl 2010; 67: 313–20. 5. Juri J. Mammary asymmetry: a brief classification. Aesthetic Plast Surg 1989; 13: 47–53. 6. Neto M, Lemos da Silva A, Garcia E, et al. Quality of life and self-esteem after breast asymmetry surgery. Aesthet Surg J 2007; 27: 616–21. 7. Pozzobon A, Neto M, Veiga D, et al. Magnetic resonance images and linear measurements in the surgical treatment of breast asymmetry. Aesthetic Plast Surg 2009; 33: 196–203. 8. Gliosci A, Presutti F. Asymmetry of the breast: some uncommon cases. Aesthetic Plast Surg 1994; 18: 399–403. 9. Oakes M, Quint E, Smith Y, et al. Early, staged reconstruction in young women with severe breast asymmetry. J Pediatr Adolesc Gynecol 2009; 22: 223–8. 10. Smith D, Palin W, Katch V, et al. Surgical treatment of congenital breast asymmetry. Ann Plast Surg 1986; 17: 92–101. 11. Gasperoni C, Salgarello M. Breast shape malformations. Aesthetic Plast Surg 1997; 21: 412–16. 12. Descamps M, Landau A, Lazarus D, et al. A formula determining resection weights for reduction mammaplasty. Plast Reconstr Surg 2008; 121: 397–400. 13. Shulman Y, Westreich M. Treatment of mild breast asymmetry. Plast Reconstr Surg 1981; 67: 31–3. 14. Hvilsom G, Hölmich L, Henricksen T, et al. Local complications after cosmetic breast augmentation: results from the danish registry for plastic surgery of the breast. Plast Reconstr Surg 2009; 124: 919–25. 15. Liu C, Luan J, Mu L, et al. The role of three-dimensional scanning technique in evaluation of breast asymmetry in breast augmentation: a 100-case study. Plast Reconstr Surg 2010; 126: 2125–32. 16. Park C, David L, Argenta L. Breast asymmetry: presentation of a giant fibroadenoma. Breast J 2006; 12: 451–61. 5 Mastopexy Deniz Dayicioglu and Bulent Genc MASTOPEXY of the discussion (Table 5.5). Mastopexy has well-known complications. In order to prevent these most common complications, each technique with its most common drawbacks and solutions will be discussed. Preoperative assessment is an important part of surgical planning (Table 5.2). The most common mastopexy complications are listed in Table 5.4. There are numerous techniques that have been described for mastopexy. Common techniques are described in Table 5.5. The overall goal in mastopexy is to create a more pleasant, aesthetic, young, and appealing breast. Lifting the nipple– areola complex, shaping the excess skin, and shaping breast parenchyma are necessary. Breast ptosis is decreased as the gland and nipple–areola complex (NAC) are lifted. The result is a well-projected and less-ptotic breast (1). Aging, breastfeeding, and weight loss can lead to ptosis. Various ptosis classifications have been based on several criteria: (i) location of the NAC in relation to inframammary fold, (ii) gland position in relation to inframammary fold, and (iii) nipple position in relation to gland (Table 5.1) (2–4). MASTOPEXY MARKINGS • The patient is marked preoperatively in the standing upright position. • Marking should be symmetrical and equal on both breasts (1). • The mid-axial line of the breast (breast meridian) is marked in reference to sternal notch and mid-clavicular point. This line can be adjusted depending on nipples placed centrally or divergent (5). • Existing inframammary fold is marked. • The proposed new nipple location is determined just above the inframammary fold (2 cm) (10). • Four-finger test is one of the most commonly used methods. Four finger tips are placed in the inframammary fold and the thumb tip is placed in opposition to the middle finger tip (11). MASTOPEXY TECHNIQUES AND TECHNIQUE SELECTION Since there are various types of ptosis, the plastic surgeon should be able to offer more than one technique. Learning curve and operation duration are important determinants. Mastopexy procedures have been detailed in the literature according to four basic determinants—NAC pedicle pattern, resulting scar orientation, skin shaping, and breast parenchyma shaping. Preoperative patient assessment is the first step in the mastopexy encounter (Table 5.3). Physical exam follows this (Table 5.4). The physician is able to discuss the surgical plan with the patient. Complications should always be a part 37 38 Table 5.1 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY Ptosis Classifications and Definitions Regnault Traditional Ptosis Classification: Grade 1—Minor ptosis Nipple at level of inframammary fold, above lower contour of gland Grade 2—Moderate ptosis Nipple below level of inframammary fold, above lower contour of gland Grade 3—Major ptosis Nipple below level of inframammary fold, at lower contour of gland NAC location shift below the point of maximal projection. Grade 1—Nipple at the most projecting point of the breast. Grade 2—Nipple between the most projecting and lower breast contour. Grade 3—Nipple at the lower breast contour. Bostwick Ptosis Classification: Table 5.3 Physical Examination Physical Examination (4): ✓ Evaluation of breast scars ✓ Inframammary fold location in relation to torso ✓ Suspicious masses ✓ Enough breast parenchyma ✓ Pictures ✓ Measurements: • Internipple distance • Sternal notch to nipple distance • Nipple diameter • Nipple to inframammary fold distance • Nipple projection • Measurements of previous scars • Breast base diameter ✓ Ptosis degrees ✓ Chest wall abnormalities ✓ Breast asymmetry ✓ Nipple areola complex sensation Grade 1—1 cm below inframammary crease Grade 2—1–3 cm below crease but anterior to gland Grade 3—3 cm below the crease and inferior to breast mass Positional ptosis: Hammond has described positional ptosis in which the inframammary fold is descended commonly due to massive weight loss. This creates an illusion of ptosis, yet is a malposition of the breast in relation to the torso. This is very difficult to correct with ptosis surgery. Pseudoptosis: Volume ptosis as a result of tissue stretching with descent of volume of the breast inferiorly creating a concavity on the upper pole. The nipple remains in the upper pole with the breast parenchyma concentrated in the lower pole, creating an elongated appearance. Breast Skin Ptosis: This is due to involution of breast gland and ptosis of the skin envelope (3) Table 5.2 Preoperative Assessment Preoperative Patient Assessment (3): ✓ Patient goals ✓ Previous breast surgeries ✓ Number of pregnancies ✓ Plans for future breast feeding ✓ Desire for breast size—Realistic expectations of breast size because breast will appear smaller after mastopexy ✓ Approach to breast implants ✓ History of breast cancer in the family ✓ Previous mammograms ✓ Previous ultrasound exams ✓ Screening mammography—35 yo Table 5.4 Complications Mastopexy Techniques Mastopexy Complications: (4–9) • Widened areolar diameter • Areolar herniation: This is due to the areolar skin having more elasticity compared to breast skin. Is overcome by reducing the diameter of the areola. • Hematoma • Infection • Nipple areolar necrosis: diversity of nipple–areolar circulation source mandates inclusion of as many arteries as possible. Some authors advise including dual blood supply for the nipple by use of at least two/three of the following: internal thoracic artery, lateral thoracic artery, and anterior intercostal artery (10). • Nipple and breast asymmetry (Fig. 5.1) • Asymmetrical areolar shape (Fig. 5.2) • Nipple too low—can be corrected easily by crescentric excision (11) (Fig. 5.3) • Nipple too high—necessitates complicated procedures including an expander (11). • Nipple too medial or too lateral—Up to 1 cm can be acceptable per the patient (11) • Overall absence of longstanding breast shape and contour • Flat non-projecting breast • Lack of upper fullness • Lack of medial fullness • Recurrent ptosis • Bottoming out: Gravity as well as skin elasticity is responsible. May be prevented by removing lower breast tissue or by suspending it with a sling (7) • Diminished or absent nipple sensation • Inability to breast feed (Continued) 5 Mastopexy Techniques (4) Periareolar scar (O) Vertical scar (lollipop) Inverted-T scar (anchor) L-shaped scar (A) 39 • This typically results in a suprasternal notch to nipple distance of 18–24 cm. the parenchyma is then folded using two hands to identify the most projecting portion of the breast in lateral view (11). This point is superimposed breast meridian in the horizontal plane and upper edge of the areola is located 2 cm below this point (11). • The inframammary fold is often loose and subsequently lower than desired. • Mid-humoral level for the new position of NAC should be checked (1. Note the asymetry and size mismatch. and a horizontal line is drawn between this line and the breast meridian (11). This gives the proposed NAC its highest projection.11). With the patient in sitting position. level of the inframammary fold. • Breast parenchyma imbrication offers a dynamic position of the nipple as opposed to fixed points for the NAC. This needs to be taken into consideration when determining nipple height (10).1 (A) Patient with right breast cancer was reconstructed with postop adjustable saline implant. • The position of the nipples should be symmetrical in the horizontal plane and of equal height in the breast meridian (11). (B) Complication: For symetry left vertical mastopexy was performed. depending on the height of the patient. • Using a stencil for areola markings has been accepted by many surgeons.4 • • • • • • • • • • • • • • • • • • • • • • • • • (Continued) Flat nipples Patient dissatisfaction Persistent periareolar wrinkling (12) Purse string suture rupture Suture exposure Need for suture removal Need for periareolar scar revision Boxy square-shaped appearance Asymmetry Wound dehiscence Fat necrosis Hematoma Scar-related complications Hypertrophic scar Widened areola Flap necrosis Hypertrophic scar formation (13) Cellulitis abscess Lipomatous cyst Suture complications Suture spitting (12) Foreign body reactions Too long T scars Need for reoperations Interference with breast cancer screening (10) Table 5. • A less commonly used method for identification of the new nipple–areola position is by the following Lateral endpoint of inframammary fold where it crosses the lateral axillary line is identified.11). (B) Figure 5.MASTOPEXY Table 5. . Breast meridian is determined below and above the nipple. and desired size after the mastopexy (depending on implant use and autoaugmentation) (1. • Lassus identified the midpoint between olecranon and acromion. 2 (A) Patient with left breast cancer who was reconstructed with tissue expander.4) (4). (A) (B) Figure 5. This technique is associated with the greatest need for revisions (12). Supra-areolar Mastopexy) In this technique. This technique focuses on location of the NAC rather than tightening of the skin. . If excessive skin is removed. this technique can deform the areola (4). This technique can result in an elongated. It is also widely utilized in unilateral reconstruction (3. (B) Tissue expander exchanged to silicone implant and right vertical mastopexy with augmentation was performed. Asymmetrical areola and crescentric skin excision only allows resection of 2 cm skin above the areola (Fig. or widened areola. adding a vertical segment to periareolar skin segment. 5.40 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY (A) (B) Figure 5. tension can cause lengthening of the periareolar diameter after surgery. and using periareolar purse string technique (3).6). Periareolar scar technique is used for mild ptosis. and in small and moderate size breasts with mild to moderate ptosis. 5. Note the low location of the right nipple and boxy appereance on the right.3 (A) Patient with left breast cancer who was reconstructed with left tissue expander. oval-shaped. Periareolar Mastopexy) This technique involves removal of circumferential skin around the NAC.5). Minimizing tension can be achieved by limiting skin excision. Donut. as well as irregular and prominent scars. Circumareolar Mastopexy. gynecomastia. PERIAREOLAR SCAR TECHNIQUE The ultimate goal in periareolar scar technique is to lift the NAC (4. Note the hypertrophic scarring of the right areolar scar. Due to the areola’s elasticity. Useful in mild ptosis where a subtle lift is necessary. Periareolar mastopexy’s most recognized complication is widening of the areola. It is that this technique is useful for tuberous breast deformity.14) (Fig. using smaller implants. limited excision of a crescent-shaped skin above the NAC is performed. Periareolar Scar Technique with Symmetrical Areola Shape (Concentric Mastopexy. (B) Tissue expander exchanged to silicone implant and right mastopexy was performed. Periareolar Scar Technique with Asymmetrical Areola Shape (Crescent Mastopexy. Undermining of the periareolar incision 1–2 cm in all directions releases the pressure and prevents the breast parenchyma from being pulled in around the areola once the purse string is tied. Lejour modified Lassus’s technique (Fig. Benelli’s technique describes shaping the breast parenchyma. Brink modified Benelli’s technique by creating a crescent-shaped skin excision and preventing undermining the inferior half of the breast to preserve Cooper’s ligaments. 5. For concentric mastopexy.6). . Markings are then completed in the standard Wise and vertical fashion (16). and gland. A concentric oval area surrounding the areola is de-epithelialized. Attention should be given to large periareolar openings. Figure 5. an oval is planned around the areola. This is performed in various ways. 5. no undermining. periareolar mastopexy techniques are only effective in certain cases (3). These rules can be applied to periareolar augmentation mastopexy techniques as well: D outside < D original + (D original – D inside) D outside < 2 × D inside D final = 1/2 (D outside + D inside) (14) VERTICAL SCAR TECHNIQUE This technique involves removal of excess skin from the inferior aspect of the breast to improve the shape of the breast parenchyma. This can flatten over time. Use of a straight needle aids in distributing the tension evenly. fat. the breast parenchyma undermined in the lower pole. and each wing is tacked to opposite side of the fourth and fifth ribs (15).7) is that in which a mushroom-shaped areolar pattern is planned instead of an oval. When the periareolar opening exceeds 10 cm. It entails en bloc resection of skin.4 Asymmetrical areola and crescentric skin excision only allows resection of at most 2 cm skin above the areola. but might become more wrinkled. Nylon).MASTOPEXY 41 Figure 5.5 Periareolar scar technique with symmetrical areola shape. The vertical lift of the NAC is 4–5 cm. Aggressive liposuction is performed prior to glandular resection. the amount of resection versus the nipple size has been described in three rules for identifying dimensions of the donut for more predictable final areola size results (14). In order to overcome the flattening of the breast in periareolar mastopexy. Purse string technique evenly distributes tension on the periareolar opening by using appropriate suture material. the suture material in the dermal plane is placed 5 mm away from the de-epithelialized skin edge to uniformly create a dermal shelf. In Lassus technique. A diameter of approximately 5 cm and a length of the periareolar scar of less than 16 cm are desirable. Interlocking purse string technique in which the dermis of the areola is directly sutured to the dermis of the outer periareolar incision is also used in preventing widening (3). Prolene. Therefore. vertically split. pleating can occur on the upper lateral corner. significant amount of skin reduction might be necessary. all mastopexy techniques should improve shape and breast contour to withstand the test of time (4). transposition of the areola on a superiorly based flap. all of which result in a periareolar scar with a vertical limb. In order to prevent extrusion complication. Permanent monofilament sutures rather than resorbable sutures reduce the chances of peri-areolar widening (GoreTex. and a vertical scar (Fig. When wide resections are necessary. Subglandular implant placement was also added. Circumareolar Scar Technique with Periareolar Purse String Closure Mastopexy Besides making the scar less visible. 6 Lassus’s technique.8). Asplound-Davies modified Lassus technique by minimizing tension around the areola. Instead of relying on sutures holding the breast tissue in the chest wall. Periareolar incision is closed using Gore-Tex sutures (17). Redundant vertical skin is stapled temporarily. Then the deep edge of the upper skin flap is advanced upward. Biggs and Graf described an inferior pectoralis major sling to support an inferiorly based parenchymal flap. this technique is more valuable to those where upper pole hollowness is predominant (17). the inferior pedicle also is re-suspended superiorly to pectoralis fascia. The difference is that a superior breast flap is undermined starting from thin (3 cm) progressing to thick (6 cm) flaps. This is overcorrected and is responsible for direct upper pole fullness. as opposed to indirect shaping of upper pole by inferior tissue gathering. In addition to shaping skin flaps. SPAIR short scar periareolar inferior pedicle reduction mammoplasty: Inferior pedicle breast reduction technique applied to mastopexy is a complex and invasive procedure (3) (Fig. . Hall-Findlay modified Lejour by medial pedicled NAC. no skin undermining. 5. is folded on itself to fill in the upper pole and is fixed to the pectoralis muscle.42 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY Figure 5. and hold it in place by a muscle sling. targeted liposuction. These techniques are designed for overcorrection and will achieve their final results months later. The medial skin flap is also plicated on itself to create a round medial contour. In Lejour and Lassus. Vertical Short Scar Technique. In patients with very elastic tissue. it is positioned on the upper part of the breast. Mastopexy with Short Scar Periareolar Inferior Pedicle Reduction Technique. Medial and lateral pillars are then brought together to add more support (7. and the inferior pedicle de-epithelialized. overcorrection should be more aggressive than those with tissue that is more firm. This technique offers direct control of the upper pole fullness. skin is resected in the lower portion of the breast where the nipple is receiving its blood supply superiorly. Therefore. Figure 5. resulting in a more cosmetic scar. pull it upward. SPAIR Figure 5.8 SPAIR (short scar periareolar inferior pedicle reduction) mammoplasty. they mobilize the lower pole. and no pectoralis fascia sutures. In this technique the NAC blood supply is inferiorly based.7 Lejour’s modification of Lassus’s technique.15). The breast parenchyma is shaped by central tissue sutured to the pectoralis fascia and medial and lateral parenchymal pillars sutured together. Instead of discarding the lower pole. This technique should be reserved for patients with previous scars (3). Upper pole parenchyma plication with permanent sutures has been tried where upper fullness is necessary without the need for an implant (18). 5.15) Peixoto: ellipse rectangle (4) (Fig. mastopexy relies on specific nipple–areola circulation patterns in order to prevent partial or total flap necrosis. and minimal scars are the major goals in mastopexy. This technique is associated with bottoming out and additional inframammary scar (12). so as to prevent future ptosis.11) Flowers and Smith: modified Wise (4) (Fig. potential postoperative changes caused by skin stretching. These are usually compensated for by overcorrection and by controlled bottoming out (3. 5. Different designs have been described: • • • • • • • Strombeck: inverted horseshoe (4) (Fig. this technique has been slow to gain popularity due to the need for extensive undermining and concerns about use of mesh associated with interference in mammographic imaging (17). and mesh placement have been developed.7). As in reduction mammoplasty. Mesh: Non-absorbable mesh provides permanent support as performed by Goes. inverted-T scar was found to be the most widely used technique. Modification of underlying tissues is the key rather than skin tension or excision of skin (7).3% (10). 5. 5. • Chiari-standardized geometric pattern (Fig.13) Wise: pre-patterned curvilinear (4) (Fig. internal pedicle flaps. 5. 5. and upper pole concavity can occur. Nipple necrosis in breast reduction and mastopexy has been reported at 7. Although effective.12) Pitanguy: inverted-T incision (4) (Fig.10 Regnault-B shaped pattern.MASTOPEXY Figure 5. parenchyma-suturing techniques. 5. In order to maintain upper pole fullness.10) INVERTED-T SCAR TECHNIQUE In a survey among plastic surgeons. 5. Final skin excisions are done after parenchymal adjustments. 5. Breast re-suspension: Releasing the breast parenchyma from the pectoralis major and re-suspending to a higher level (1). Dermal flaps: Redundant skin is de-epithelialized and used as a support by wrapping it around the inferior pedicle. L-SHAPED SCAR TECHNIQUE (VERTICAL SCAR WITH A SHORT HORIZONTAL INCISION) This technique is useful when the nipple to inframammary fold distance is longer than 8 cm. Reliable NAC transposition.9 43 Chiari-standardized geometric pattern. breast parenchyma ptosis. In these techniques however. Svedman technique utilizes a lower fasciocutaneous flap dissected and folded to form a sling for the inferior pole of the breast. It is an alternative to extending the vertical incision below the inframammary crease. In a majority of mastopexy techniques. dermal flaps.16) Nicolle: modified Wise (4) (Fig. the final breast shape is created by skin that gives support to the structure. and to have more predictable outcomes. Pectoralis muscle slings: Bi-pedicled pectoralis muscle flaps to support the breast parenchyma (1).17) Most breast reduction techniques are applicable to mastopexy. Pectoralis Fascia suspension: Mastopexy techniques that attach the inferior breast parenchyma to a bi-pedicled pectoralis fascia strip to achieve long-term medial fullness have been described (1). Figure 5. . maximal parenchymal support.9) • Regnault-B shaped (Fig.14) Marcah: arched gateway (4) (Fig. and lift.14 Wise pre-patterned curvilinear incision. Autologous dermal graft has been used in a similar manner as cadaveric grafts. Pitanguy inverted-T incision. recurrent ptosis and capsular contracture (21). These patients might also need capsular surgery. It is more common to encounter complications such as skin flap or nipple necrosis with these. . it is important to preserve the blood supply through the thicker superior pedicle for the NAC circulation in the augmented patient. Proper planning is necessary in this population in order to prevent complications. thinning. In secondary mastopexy (in the augmented patient) adverse effects of implants on breast tissue include atrophy. areola asymmetry. a thicker superior pedicle and a thinner inferior pedicle is present. These combined surgeries carry a significant risk. Cadaveric acellular dermal matrices: Use of these has been described in augmenting support in mastopexy. The most common complications encountered with combining these two procedures are implant deflation. Due to compression and atrophy of the implant.11 Figure 5. Therefore. and is also a useful adjunct (20). Combined mastopexy and breast augmentation procedure are widely used.13 Strombeck inverted horseshoe. stretching. as well as in strengthening attenuated skin.44 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY Figure 5. These have been used as support slings.12 Flowes-Smith modified Wise incision. and reduction of the blood supply to the nipple–areolar complex. Their use has grown in the last five years in mastopexy (19). implant exchange. poor scarring. Figure 5. Periareolar techniques are recommended including superior. Figure 5. Plast Reconstr Surg 1985.16 Peixoto ellipse-rectangle incision. 126: 786–93. 13. ed. Mastopexy involves a large number of procedures in order to accomplish the goal of a rejuvenated breast. In search of better shape in mastopexy and reduction mammoplasty. 75: 533–43.MASTOPEXY Figure 5. 7. 9. Graewe FR. 12. 2. retaining the medial vertical ligament of Wuringer. Although the procedure is commonly done. Ritz M. 1. Biggs TM. most surgeons would agree that excellent results that are long-lasting are difficult to achieve. . Marcel Dekker. Grunert JG. 118: 1631–8. The atlas of aesthetic breast surgery. Plast Reconstr Surg 2004.15 45 Marcah arched gateway incision. Improved standards in reduction mammaplasty and mastopexy. Crescent mastopexy and augmentation. Rohrich RJ. 117: 86–94. 113: 2085–90. 11. Enhancing pedicle safety in mastopexy and breast reduction procedures: the posteroinferomedial pedicle. The limited scar mastopexy: current concepts and approaches to correct breast ptosis. Fascial suspension mastopexy. Rohrich RJ. Bostwick J. Gulyas G. 2009. discussion 18–22. 8. Meyer VH. 10. 114: 1622–30. Plast Reconstr Surg 2004. Reinisch JF. 3. Saunders Elsevier. Vertical scar with the bipedicle technique: a modified procedure for breast reduction and mastopexy. Nicolle F. superomedial. Silfen R. Aesthetic Plastic Surgery. REFERENCES Figure 5.17 Nicolle modified Wise incision. 5. and that need for revision is probable. Jakubietz MG. 3rd. Thornton JF. Aston SJ. Hammond DC. Plast Reconstr Surg 2010. Gosman AA. 31: 337–42. Reisch J. The patient should be made aware that mastopexy results are temporary. Plast Reconstr Surg 1982. Graf R. ACKNOWLEDGMENT The authors would like to thank Ceren Dayicioglu for drawings. Plast Reconstr Surg 2002. Jakubietz RG. 69: 453–9. Plast Reconstr Surg 2006. Aesthetic Plast Surg 2007. The constellation of procedures is necessary to accommodate various patient needs. 4. Southwick G. Puckett CL. van Deventer PV. Mastopexy preferences: a survey of board-certified plastic surgeons. or superolateral. 110: 309–17. 2004. Brown SA. 6. Figure 5. Khan UD. Plast Reconstr Surg 2006. Mastopexy in patients with large implants should be avoided (22). Marking the position of the nipple-areola complex for mastopexy and breast reduction surgery. Handbook of plastic surgery. 120: 1674–9. AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY 19. 121: 1533–9. St Louis. Stevens WG. Missouri: Quality Medical Publishing. 118(7 Suppl): 152S–63S. Secondary mastopexy in the augmented patient: a recipe for disaster. et al. Jones GE. Mastopexy using the short scar periareolar inferior pedicle reduction technique. Handel N. ed. 21. Selected Readings in Plastic Surgery 2002. 61: 138–42. 3rd edn. Plast Reconstr Surg 1990.46 14. Bostwick’s Plastic and Reconstructive Breast Surgery. Little JW. Khuthaila DK. Adams S. Adams WP. 66S–67S. Kassan M. Reduction Mammaplasty and Mastopexy. 17. Adams KG. One-stage mastopexy with breast augmentation: a review of 321 patients. Stoker DA. 16. 2010: 641–729. Improving shape and symmetry in mastopexy with autologous or cadaveric dermal slings. discussion 64S–65S. Colwell AS. 85: 961–6. 20. Plast Reconstr Surg 2007. Alfonso D. . Grabb and Smith Plastic Surgery. Guidelines in concentric mastopexy. Autologous Dermal Graft in Breast Reconstruction. 9: 29. Plast Reconstr Surg 2006. Hudson DA. Ann Plast Surg 2011. Freeman ME. Spear SL. 18. Ann Plast Surg 2008. Hammond DC. Plast Reconstr Surg 2008. 15. 22. However. Reduction mammoplasty is a reconstructive procedure performed for the alleviation of pain and discomfort associated with excessive and pendulous breast tissue of any origin. Some techniques are more appropriate for patients with very large reductions or favor the less-experienced surgeon. • breast size. The sheer number of available breast reduction techniques shows that one approach does not necessarily fit all. symmetry. it is clear that there are important common concepts that should be observed in order to guide the surgeon’s choice of procedure: Breast hypertrophy (macromastia or gigantomastia) is defined as a condition of having excess bilateral breast tissue weighing over 600 grams (1). • Associated with obesity. however.6 Reduction mammoplasty Rosiane Roeder and Seth Thaller INTRODUCTION Plastic Surgeons.000 breast reductions were performed in the U. Throughout its evolution. • need of a vascularized pedicle for the nipple–areola complex (NAC). Breast reduction remains one of the top five most common reconstructive procedures performed in the United States. The exact etiology remains known. it was not until the late 1890s that the first reports of reduction mammoplasties appear in the literature. • Adult onset—This is the most commonly encountered type with progressive enlargement leading to physical discomfort and decreased functional capacity. The vast majority of operations are safely performed in an outpatient setting under general anesthesia (4). 53. • Iatrogenic—This is secondary to certain medications such as penicillinime. • knowledge and respect for breast anatomy and neurovascular supply. Hypertrophy can be classified as: • Virginal—This is seen prior to the onset of puberty. According to the American Society of 47 . There is also a familial component (2). • Gestational—This generally occurs in the second trimester. in 2009. The first breast reduction surgery may have been performed as far back as 625–690 AD (6). It can impact milk supply and lead to mastitis.7% of them in women 40 years or older (3). • and relationships of breast size to body mass index (BMI). many surgeons pioneered different procedures as the understanding of breast anatomy flourished and patient’s expectations for aesthetically pleasing results and minimal scaring increased. However. Breasts may undergo substantial growth during a very short period of time.S. it is most likely due to an abnormal response of breast tissue to the stimulatory effects of estrogen and progesterone. Satisfaction associated with breast reductions have been reported at greater than 90% (5). approximately 78. and degree of ptosis. It usually can be reversed by cessation of medication or anti-estrogen therapy. 3. lateral thoracic branches. Pectoralis fascia overlies the pectoralis major muscle and is covered by a layer of loose connective tissue that allows for movement of breast tissue. axillary. Embryologically. They reach the surface from each side anastomosing around the midline. They overlie three different muscles: the pectoralis major inferiorly. ANATOMY OF THE BREAST Overview AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY from 3 main arterial trunks that converge into an anastomotic network: 1. and pre-operative evaluation for surgery. There is engorgement of the fatty and glandular tissue. 21 cm. The axillary tail of Spence is the breast tissue that extends superiolaterally into the axilla. Adult breasts are located between the second and the sixth ribs just lateral to the sternum and medial to the midaxillary line. Blood supply to the breast is derived Breast shape can be described as a cone with a round base and the tip projecting horizontally from the thoracic wall and ending at the nipple (9). and fifth intercostal nerves. However. Nonetheless. Level I lymph nodes are located inferiorly to the pectoralis minor usually in the axilla. Nerves penetrate the deep fascia at the mid-axillary line and lateral to the sternum. This eventually regresses to form paired nipple and breasts. the fourth intercostal branches are the ones thought to always be involved (8). in particular.48 This chapter will highlight relevant anatomy. lateral branches. indications. a distance that can be significantly greater in women with macromastia and/or ptosis. There is also drainage to the inframammary nodes. Axillary artery. Intercostal artery. The NAC complex is supplied by a network of perforating branches derived from the dermis. They extend transversely from the dermis and the pectoralis fascia. Innervation . Interthoracic artery. post-operative care. The distance between the NAC and the sternal notch measures. and complications.7). The ratio between these two components changes in females in relation to stage of development and hormonal shift during pregnancy and senescence. Supply to the nipples may have contributions from the anterior and lateral branches of the third. mainly the subscapular nodes. is of great importance. and innervation of the breast is very important for successful breast surgery. Size of resection may also affect sensation. Sensory nerve supply to the breast and the NAC. which are involved in cancer metastasis in less than 15% of cases (7. it arises from a milk streak in the torso spanning from the axilla to the groin. The nipple lies at the level of the fourth intercostal space. Lymph nodes are generally divided into three levels according to relationship with the pectoralis minor muscle. the anterior cutaneous branch of the fourth intercostal is primarily involved. fourth. This is an important reference measurement for the future repositioning of the nipple during reconstructive surgery. and posterior intercostal veins. most commonly performed techniques. Veins drain toward the axilla into three main groups: internal thoracic. Vessels and Lymphatics Shapes and Landmark Measurements Understanding of the blood supply. They receive most of the lymphatics from the breast (7). Breast buds may be enlarged in the neonate due to maternal estrogens that remain in circulation immediately after birth. there are significant changes in breast tissue. several observations report the eventual recovery of loss sensation from the breast after a period of 6 months from the initial surgery (5). on average. Breast parenchyma is composed of fatty and glandular tissue. Level II nodes are behind the pectoralis minor. Specifically. Glandular tissue is replaced by fatty tissue and/or significant decrease in breast size occurs in addition to decreased amounts of collagen. there is further proliferation of glandular and secretory epithelium that allows for lactation. Cooper’s ligaments are collagen-rich structures that maintain breast shape. Level III nodes are superior to the pectoralis minor. During pregnancy. Conservation of the anterior branch of the fourth intercostal nerve should guarantee sensory supply to the NAC from its most reliable source. Breast tissue remains otherwise underdeveloped until puberty when the ducts proliferate in response to estrogen and progesterone. All contribute to ptosis associated with aging. About 15–20 lactiferous ducts are present that covalence at the nipple at birth. and the rectus sheath at its most caudal portion. However. With the onset of menopause. internal mammary perforating branches. despite the pedicle used. 2. Innervation to the female breast and overlying skin is derived from cutaneous branches of the first to the seventh intercostal nerves. There may be a certain degree of regeneration of these cutaneous nerves. The lymphatic system also runs alongside blood vessels. Intercostal nodes receive contribution from the most lateral aspect of the breast. lymphatic drainage. it is not a perfect Venous system runs in parallel with the arterial system. the serratus anterior inferiorlateral. In small reductions (<200 g).5 cm. Trusting self report is insufficient. Full breast examination should be performed by the surgeon. However. sleep disturbances. significant psychosocial sequalea associated with large breasts cannot be overlooked.1). Any suspicious cancerous findings require referral to a surgical oncologist. Breast reductions are considered a reconstructive procedure not a cosmetic one. Two measurements are necessary to determine brassiere cup. Nipple to inframammary fold distance is on average 6. it is Table 6.1): X = (chest wall girth) – (girth at nipple line) Regnault used chest wall girth and cup size to estimate the expected weight of tissue removed during a reduction Table 6.1 Brassiere Cup Size Reference X Cup Size 1 2 3 4 5 6 7 8 9 10 A B C D DD or E DDD or F G H I J (11). except for the rare virginal hypertrophy. and/or respiratory problems (Fig. In 1955. limitation of activities of daily living. breasts. and lowers the level of the NAC (9). 6. insurance coverage does apply to most cases.3. Best estimates are determined when the breasts are elevated to the level of ideal nipple position. measure the girth at the level of the nipple.9 cm. Second. documentation regarding pain symptoms and/or activity of daily living limitations. and that asymmetry between the two breasts may occur. measure the chest wall girth at the level of the inframammary fold.2 Reduction Size Estimate Based on Chest Wall Measurement and Cup Size. For a given chest wall size. INDICATIONS FOR BREAST REDUCTION Breast reduction are performed in women with excessive breast tissue who present with any of these associated symptom: head. Specific guidelines exist by most insurers. Chest wall measurement 1 Cup 2 Cups 3 Cups 4 Cups 32–34 inches 100 grams 200 grams 300 grams 400 grams 36–38 inches 200 grams 400 grams 600 grams 800 grams 40–42 inches 300 grams 600 grams 900 grams 1200 grams . An equilateral triangle can be drawn between the suprasternal notch and the nipples with limbs measuring 21 cm (10). Most women do not know their true brassiere size. Reductions should be performed primarily in adult. although most require a minimum of 500 gram resection per breast. brassiere strap groove caused by a tight-fitting brassiere. Macromastia increases flattening of the upper pole. consideration of the final aesthetic result is important to patients’ satisfaction. fully developed. Although it is known that smaller reductions do provide amelioration of symptoms. These pathologic features should be addressed during a breast reduction. Pre-operative evaluation should ascertain overall good health. First. 1 cup reduction results in a particular weight in grams as seen in Table 6. Also. Understanding Brassiere Cup Size and Reduction Volumes Knowing how to measure cup size during a pre-operative visit is essential to surgical planning and for individually determining the size of the reduction.2. Being thus a reconstructive procedure. temporary or permanent loss of sensation. because the desired outcome is functional and not aesthetic. A summary of indications is listed in Table 6. Preoperative mammogram for women over 35 years of age (or any with lumpy breasts or significant past or family history of breast cancer) should be requested to exclude any occult malignancy. This can be a challenge with severely ptotic breasts. Nonetheless. it may be possible to achieve this with only removing fat or glandular tissue. the size of the rounded base. intertrigimous dermatitis. difficulties or inability to breastfeed after procedure. Penn studied 150 women to describe landmark measurement and positioning of the nipple within the breast. shoulder and back pain. Patients undergoing reduction mammoplasty generally request the procedure due to physical debilitation secondary to large breast. including scars on the breast. Patients should understand potential surgical complications. neck. most resections will require removal of excess skin and repositioning of the NAC to restore shape and projection.8–4.REDUCTION MAMMOPLASTY 49 cone with the upper pole somewhat flattened. and that efforts to ameliorate symptoms without surgery have failed. Estimating reduction size is especially important due to insurance coverage arbitrarily requiring anywhere from 500 to 1000 grams to be removed from each side for the reduction to be considered medically necessary. The following formula is used to calculate the brassiere cup (inches) (Table 6. Patients for breast reduction must be optimal candidates for surgery and general anesthesia. Ideal areolar diameter is 3. Therefore.e. Even though some of the techniques given below can be used with modifications for small. Techniques are generally described based on the pedicle and/or skin incision pattern. This is the most commonly used procedure in the United States according to a survey of members of the American Society of Plastic Surgeons (4). It has since been modified by many (14). No clear classification for breast reduction techniques exists. (B) Should groove from bra strap. This chapter will describe two of the most common techniques and briefly refer to some that may be used on specific occasions. back Should grooves from brassiere strap Activity limitation Intertigimous dermatitis Sleep disturbances Respiratory illness extremely difficult to have these covered. the surgeon should choose a technique with which they are familiar and comfortable performing.. (C) Intertigimous dermatitis. neck. SURGICAL TECHNIQUES Wise Pattern. long discussion with patients toward their expectations and financial responsibility for the procedure is warranted.1 Indications for reduction mammoplasty. In order to avoid technically related complications. inverted-T inferior pedicle). Inverted-T. that the skin resection patterns are not unique to a particular parenchymal resection. certain techniques are better suited than others.50 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY (A) (B) (C) Figure 6. Table 6. medium. (A) Enlarged breasts (macromastia/gigantomastia). It was described by Ribeiro in 1975 (13). It is important to note. . Inferior Pedicle Numerous breast reduction techniques have been reported over the years resulting in over one hundred different procedures (12). shoulder. Consideration of patient’s individual needs is also important.3 • • • • • • Indications for Breast Reduction Pain – head. and large reductions. thus a technique may be named by its scar and pedicle (i. Next. 6. Xeroform dressing is used along the . Note scar around areola. It is reported as a predictable. Deep tissues are closed using 3-0 Vicryl sutures. Surgical site is irrigated and hemostasis is achieved. Pedicle is displaced superiorly so that the nipple can be repositioned anatomically.2). Inferior pedicle is then outlined. 6. Vertical limbs of the wise pattern should be between 5 and 7 cm. Deepithilialization of the inferior pedicle and tissue surrounding the areola is performed (Fig. NAC is then brought to the surface and sutured into place with 4-0 Vicryl. Breasts are prepped and draped in sterile fashion. Prophylactic antibiotics are given. relatively quick. pre-cut patterns are commercially available. Holding sutures are used to tack the skin envelope so that the new nipple can be estimated with the patient in a sitting position. yet still allows for a tailored surgery based on patient’s needs. Incision is made around the areola usually after a “cookie cutter” is used to mark the desired areolar area. Inverted-T is sutured with 4-0 Vicryl subdermal followed by running layer of 4-0 Monocryl.2 Inverted-T scar. NAC sensation is frequently preserved.3). Scars resulting from use of the Wise pattern are the typical inverted-T (Fig. Glandular and fatty tissue outside the inferior pedicle is then excised. This should exit at the distal end of the inframammary incision. It also gives the surgeon some artistic freedom. Technique The patient is placed supine in the operating room table with arms positioned at 90º. Laterally. Wise developed his keyhole technique in 1956 after patterns used for making brassieres (15). vertical scar from midline areola to the inframammary line. Base of the pedicle should be between 8 and 10 cm depending on reduction size (larger for larger reductions). superior flaps are elevated to the pectoralis fascia. Markings Pre-operative marking should be done with the patient sitting or standing and the arms relaxed at the sides prior to the patient receiving any sedation (Fig. It can be used for small or very large reductions. Inframammary fold (IMF) is marked.REDUCTION MAMMOPLASTY 51 Figure 6. A paramedian line is drawn from mid-clavicle to the nipple on each breast. New nipple position will be transposed to the paramedian line at or slightly below the level of the inframammary fold. Importantly. A nipple size of about 3–5 cm is appropriate for most reductions. It is then repositioned as necessary. This incision may be extended as far posteriorly as needed depending on the size of the reduction. and inframammary scar extending toward the axilla. The skin around the areola is sutured with 5-0 Monocryl. easy to learn and teach procedure. It employs the Wise pattern of skin incision to determine the area of skin to be resected and establish the new location of the NAC. Horizontal limbs are then drawn medially toward the IMF resting about 4 inches from the xyphoid in order to avoid symmastia. Although most surgeons free hand their Wise pattern markings. A vertical line is drawn at the midline from the suprasternal notch and the umbilicus.4). the horizontal limb should follow the natural breast contour. Distance between the new nipple position and the suprasternal notch should be approximately 21–25 cm allowing for the final position to lay at 19–21 cm. Area for the new NAC should be marked slightly larger than the desired nipple size. 6. One #10 Jackson-Pratt drain is placed in the dependent region of each breast. .3 Pre-operative marking for inferior pedicle inverted-T scar with Wise pattern. X indicates new nipple position based on transposition of IMF at breast median.52 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY (A) (B) (C) Figure 6. Figure 6.4 Intraoperative view of inferior pedicle after parenchymal resection. (C) Wise pattern. (A) Line establishing the midline. (B) Use of measuring tape around the neck to determine the breast midline (mid-clavicle to nipple). Skin pattern of incision is marked. and can be performed for any size reduction. A blunt-tip multi-hole cannula is introduced. . it is not a procedure for the novice surgeon. most patients return to normal activity within 72 hours. Also. This mixture is infused in the superficial plane until the skin looks raised. It requires training. Incision is made around the areola and de-epithilialization of the pedicle follows. This is attached to a pressurized 1 L normal saline bag containing a 2% lidocaine and 1–2 mg of epinephrine. vertical reduction mammoplasty has the advantage of fewer scars. the area of the superior pedicle is outlined. However. described the use of free nipple grafting after amputation (20). However. surgical skill. Another group that can potentially benefit comprises patients who have a tendency to form hypertrophic scars (19). good aesthetic result. It is indicated for patients whose breasts have predominately fatty tissue. This technique used a mosque dome pattern for skin incision. and lateral to the remaining superior pedicle. FREE NIPPLE GRAFTING Breast amputations were the first surgeries performed for macromastia. However. Glandular pattern used by Lejour is traditionally the superior pedicle. LIPOSUCTION Liposuction has been used as an adjunct to other reduction techniques for some time. Skin incision is closed using buried 4-0 Monocryl. bruising and pain in breast area are expected. When surgery is complete. The surgeon can then wait 10 minutes for local vasoconstriction to take place before proceeding with pretunneling. At first. Skin is closed with a resultant vertical 53 scar at the midline below the nipple. Next. but is unconcerned with breast shape. the surgeon may switch to a smaller cannula (2–3 mm) and tunnel superficially without vacuum. Although. it hallmarks the transition to a period in reduction mammoplasty where the conservation of function and sensitivity to the NAC became essential. Once the area to be liposuctioned is ready. some surgeons will use other patterns. results are not immediately seen post-operatively. medial. However. This is done by displacing the breast on its verticle axis medially and laterally. possibility of breastfeeding. in 1922. Thorek. and does not rely on a fixed pattern of resection. Patients with large reductions should be aware of this possibility. such as superiomedial and bipedicle techniques. Technique Patient is placed supine in the operating room table with arms at 90º. Future areolar circumference is marked around the nipple. if a patient is older. surgical tape is used to maintain breast shape and a surgical brasserie placed. where ptosis is not a significant problem and acceptable results are achieved without skin resection. Once the desired amount of fat is removed.REDUCTION MAMMOPLASTY incision lines and fluffed gauze is placed over the breast before a surgical brasserie is placed. Prophylactic antibiotics are given. as it cannot remove glandular tissue. Ideal patients are young without major hypertrophy or ptosis. Medial and lateral flaps are raised as breast tissue is excised inferior. Vertical Scar Described by Lassus in 1964 (16) and adapted by LeJour in 1994 (17). Pre-operative markings are not required. the remaining tissue is irrigated. Also. this technique can also be considered. Fat from the breast tissue can also be suctioned (17). has major hypertrophy. this procedure is not widely used today. When the position of the NAC is optimized. it is best for small reductions. the blunt cannula is attached to a vacuum and fat is removed from the deep to superficial layer in a fanning pattern. This will result in controlled scarring that can help prevent ptosis. Tacking sutures are placed to close the flaps and check the final position with the patient in a sitting position on the operating room table. Peripheral limbs join together at about 5 cm from the inframammary fold. good sensation. The inframammary fold is also marked. Recently. An incision is made 2 cm above the IMF slightly lateral to the midline. A vertical line marks the breast at the midline and beneath the inframmary fold. At times. a small horizontal scar may be necessary to accommodate excision of redundant skin in larger resections (18). Allow 10 cm of the pedicle width at the upper border of the future areolar area. Breasts are prepped and draped in sterile fashion. the site of the future areola is marked slightely below the inframammary fold as a semicircle of approximately 16 cm. Also. Markings Patient is marked while standing. Patient should be aware that the possibility of conversion to a traditional breast reduction may be needed intraoperatively if good results from liposuction only are not expected or if any complications occur. Advantages of the superior pedicle include upper pole fullness and less ptosis over time. liposuction alone has gained attention lately due to the perspective of a minimally scarring process. since at least 3 months will go by before the breasts reach their new desired shape. Placement of drains is up to the surgeon and if placed should be in a dependent position. The NAC is placed at its final position. We will report on Lejour’s superior pedicle technique. There should be minimal undermining in the superior flap so that the remaining breast will have adequate projection. and rarely seen now that the surgeons understand the origin of the blood and nerve supply to the NAC. Some controversy exists on the use of post-operative antibiotics. In order to detect early seroma or hematoma formation. Most common complications are seroma. Hypertrophic scarring is most often seen in the inframammary fold incision and occurred in about 3. High body mass index and large resection size were predictive of wound healing complications (23). however.4). However. necrosis of the NAC. and wound dehiscence.5 cm. Pre-operative marking should follow that of the chosen dermatoglandular pattern to be followed.54 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY Free nipple grafting today is reserved for specific indications. wound infection.5). high-risk patients with expected resection of more than 2 kg per breast (21). especially if drains are left in place. Table 6. These are left for about 24 hours post-operatively. has been significantly reduced in new techniques. NAC final positioning should again be estimated from a projection of the inframammary fold onto the midline of the breast superiorly at a distance of approximately 21 cm from the mid-clavicular line. The number of wound infections has decreased with the use of pre-operative antibiotics. leaving a centrally located position for placement of the nipple graft.4 Surgery Common Complications of Breast Reduction Seroma Hematoma Wound infection Wound dehiscence Fat necrosis Necrosis of NAC Loss of sensation of NAC Loss of erectile function of NAC Hypertrophic scarring Figure 6. . Non-healing wound at junction of inverted-T incision. wound dehiscence. the surgeon will close the breast mount. many surgeons use drains. hematoma. Harvest of the free-nipple graft should be accomplished first. Thereafter. Complication rates occur in about 5–20% of cases depending on the series and definition of complication (5.12. fat necrosis. immediate drainage is required to avoid suppurative infection. recent studies in patients undergoing oncological breast surgery show that the use of post-operative prophylaxis did not reduce the overall number of surgical site infections (25). These should be administered within 30 minutes of incision time. loss of sensation and erectile function of the nipple. the surgeon will proceed with parenchymal resection according to the desired breast reduction technique of choice. However. Non-healing wounds and wound dehiscence are most often seen at the junction site of the inverted-T scar (Fig. Many glandular pattern of glandular and skin resection can be used. it is sutured and held in position with a tie-over bolster. These include older.22–24). With free nipple grafting techniques. a de-epithelialized pedicle should be used to receive the nipple graft. if a seroma or hemaroma is detected. This. and hypertrophic scarring (Table 6. After the nipple graft is in place. not all patients appear to adversely affected by this (21). however. there is a greater likelihood of partial necrosis. However.5 Post-operative complication. Deaths have been rarely recorded. build up of pressure that can compromise blood supply to the NAC. Complications related to the NAC were initially a great problem in breast reductions.3% in a series of patients who underwent reduction with an inferior COMPLICATIONS Breast reduction surgery is generally a very safe procedure. 6. Usually. Diameter of the graft should be about 4. Shestak KC. Poell JG. Puckett CL. and aesthetic results. Postoperative prophylactic antibiotics and surgical site infection rates in breast surgery patients. 94: 100–14. Operat Tech Plast Reconstr Surg 2011. 35: 402–7. Andrades P. Neto MS. Jurkiewicz M. Jakubietz DF. Boughey JC. 18. Lymphatic drainage patterns from the breast. 55 11. Ferreira LM. Posma AN. 25. Garcia EB. Functional capacity and postural pain outcomes after reduction mammaplasty. Quaresma MR. Obesity in mammaplasty: a study of complications following breast reduction. Possibilities in the reconstruction of the human form. Anastasopoulos A. 2010 Report of the 2009 Statistics. 2010. Breast reduction techniques and outcomes: a meta-analysis. J Plast Reconstr Aesthet Surg 2011. This is a very rewarding procedure for both surgeon and patient.REDUCTION MAMMOPLASTY pedicle technique (26). Wieacker P. REFERENCES 1. 7: 357–71. but the inferior pedicle inverted-T scar is currently most popular. 12. Plast Reconstr Surg J 2009. 1984: 2101. 38: 335–9. 19: 293–303. 43: 201–6. Hapsas DA. Kang N. Nieweg OE. Storer E. patients should be well informed about the procedure. 4. Spencer D. Aesthetic Plast Surg 2004. 16. Zambacos GJ. Vertical mammaplasty and liposuction of the breast. et al. Plast Reconstr Surg 1994. Klok J. A preliminary report on a method of planning the mammaplasty. Okoro SA. Breast reduction by liposuction in females. Barone C. Understanding modern breast reduction techniques with a simplified approach. 3: 184–8. Thorek M. 49: 442–6. Lassus C.22. Shah R. Bohnenblust M. Boostrom SY. Int Surg 1970. 13. Rockwell WB. Plast Reconstr Surg (1946) 1956. A technique for breast reduction. Jakubiczka S. Several techniques exist. Estourgie SH. Ann Surg Oncol 2009. 116: 572–3. Plastic and reconstructive surgery. Jaspars JJ. as this is most important to avoid surgical complications. eds.28). and aesthetic outcomes. Familial translocation t(1. have higher rates of hypertrophic scarring (23). Mandrekas AD. 7. Breast reduction. . Clinical outcome. Prado A. 16: 2464–9. Apeshiotis N. van Immerseel AA. as expected. 17. 239: 232–7. WISE RJ. 124: 1040–6. 50: 249–59. 15. 2. 55: 330–4. et al. 14. Plast Reconstr Surg 1975. 8. 5. Lickstein LH. 1: 35–41. BMC Wom Health 2009. Gruenert JG. Plast Reconstr Surg 2008. after reduction mammaplasty. eds. 19. 21. Freire M. Shires G. The cutaneous innervation of the female breast and nipple-areola complex: implications for surgery. The common principles of effective breast reduction techniques. Principles of Surgery. Daniel RK. 6. 119: 1149–56. potential complications. Scand J Plast Reconstr Surg Hand Surg 2004. 20: 213–17. Gittenberger-de Groot AC. CONCLUSION Breast reduction is a common reconstructive procedure of the breast. 6: 88–96. Cano SJ. Eggert E. Al-Ajam Y. African Americans. Ferreira LM. Quality of life after reduction mammaplasty. Med J Rec 1922. Vertical reduction mammaplasty. PENN J. 1984. 26. Olmos RA. Br J Plast Surg 1955. The conceptual evolution of modern reduction mammaplasty.27. Singapore: McGraw-Hill. Importantly. 9: 11. patients’ satisfaction. Plast Reconstr Surg 2007. Throckmorton AD. 20. A new technique for reduction mammaplasty. J Plast Reconstr Aesthet Surg 2008. Amputation/free nipple graft reduction mammaplasty. Wang HT. Restifo R. Stott D. 28. Saltz R. Br J Plast Surg 1996. Wieland I. Boston: Little Brown. Scott A. Aesthetic Plast Surg 2011. de Souza A. Sex Dev 2007. Regnault P. 24. Pusic AL. High patient satisfaction is widely reported (5. Aesthetic Surg J 2000. Breast reduction trend among plastic surgeons: a national survey. In: Schwartz S. Schuss R. Lalikos J. Satisfaction and quality of life in women who undergo breast surgery: a qualitative study. 27. Reduction mammaplasty with the inferior pedicle technique: early and late complications in 371 patients. Neto MS. American Society of Plastic Surgeons. Stevenson T. Garcia EB. Daniel RK. Surgeons should choose a technique they are proficient performing. Risk factors and complications in reduction mammaplasty: novel associations and preoperative assessment. Ann Surg 2004. Henry SL. 17: 367–75. Rutgers EJ. Scand J Plast Reconstr Surg Hand Surg 2009. Lejour M. Ribeiro L. 10. quality of life. 22. 4th ed. 53: 69–72. Aesthetic Plastic Surgery: Principles and Techniques. Operat Tech Plast Reconstr Surg 1999. Breast reduction. Jakubietz RG. Edsander-Nord A. Kroon BB. 9. Freire M. 3. In: Regnault P. Klassen AF. Volleth M. 23. Br J Plast Surg 1997. Aesthetic Surg J 1999. Crawford JL.9) associated with macromastia: molecular cloning of the breakpoints. Quaresma MR. 28: 59–69. Daane SP. 61: 1284–93. 64: 508–14. 122: 1312–20. Grossman. and in some cases the skin attaches to the deep cavity surface resulting in even worse cosmetic results. The goal of this chapter is to explain the concepts of OPS as well as to familiarize the reader with the most common oncoplastic techniques in the approach to early-stage breast cancer. The techniques of oncoplastic Oncoplastic surgery (OPS) has emerged as the latest paradigm in the treatment of cancer of the breast. Peter J. Lastly. While the incision length itself is kept to the minimum in breast conserving surgery. BCS combined with radiation therapy to the breast has demonstrated low local recurrence rates and equivalent survival outcomes as mastectomy for early-stage breast cancer. Oncoplastic surgery allows the surgeon to perform larger resections of the breast with better cosmetic outcome while adhering to oncologic principles (1–5). Furthermore. OPS emerged as a means by which the appropriately trained surgeon utilizes plastic surgical techniques for immediate breast reconstruction and breast tissue re-approximation after wide excision for breast cancer in order to maintain oncologic and cosmetic goals (1. Unfortunately. To remedy this. OPS will require longer incisions in order to allow for appropriate breast tissue reconstruction.6). it is often difficult for the radiation oncologist to estimate the exact location of the breast tissue previously surrounding the tumor. Prior to the development of OPS. the depth of excision is mandated only by the location of the tumor in the breast parenchyma while a full thickness excision (from subcutaneous fat to fascia) is necessary for OPS. after this seroma gets reabsorbed. and Eli Avisar THE PURPOSE OF ONCOPLASTIC SURGERY attempt to re-approximate the breast tissue around the excision cavity for fear of causing further cosmetic deformities. in which the goal is complete excision of the tumor with adequate surgical margins while maintaining the natural structure and form of the breast (1). however. With integration of plastic surgical techniques into the repertoire of the breast surgeon. the concept of purposefully leaving a seroma in the breast is opposed to general surgical principles elsewhere in the body. and BCS does not always produce acceptable cosmetic results (1). the surgeon could provide either a modified radical mastectomy or a segmental excision with subsequent radiation to the breast cancer patient (1). Traditionally. OPS stems from breast conserving surgery (BCS). has limitations: it is often difficult to completely excise the tumor and maintain the natural shape of the breast. For that reason. Breast conserving surgery. OPS allows for significant movement of the breast tissue. A few very distinct differences in the surgical principles characterize OPS as a separate technique. Another significant difference is the length of the skin incision. a new way to treat women with early-stage cancer of the breast has emerged. The cavity is left to fill with serous fluid that will appear to have replaced the missing tissue in the first postoperative phase. DiPasco. a deformity forms. marking clips are usually left in the surrounding tissue prior to reconstruction of the breast. In standard breast conserving surgery.7 Oncoplastic surgery of the breast Robert A. BCS includes no 56 . Subhasis Misra. we find it rarely necessary.6). whereas horizontal incisions in the superior medial quadrant or radial incisions in the remainder of the breast are otherwise employed. level II and III procedures require the practitioner to have training in oncoplastic technique. OPS allows for a much larger volume of excision while reducing the risk of post-operative deformity. While BCS techniques allow for at most 80 g of tissue excision without deformity. Level I techniques are to be used for procedures in which less than 20% of the breast volume is to be excised. describe a succinct and beneficial way in which the breast surgeon may select patients appropriate to receive OPS (1). The area of undermining should be reduced if a history of smoking.ONCOPLASTIC SURGERY OF THE BREAST surgery range from primary remodeling and mobilization of breast tissue to advanced plastic surgical techniques that may allow up to 50% of the breast volume to be extirpated. OPS enables a 200 g average volume of tissue with ranges over 1000 g to be removed from a medium-to-large-sized breast without cosmetic loss (1. A very dense breast has a lower risk of undergoing post-operative fat necrosis when compared to a fatty breast.and/or contralateral breast will undergo reduction as well as extirpation of the tumor. While OPS is not new. while the upper outer pole is an area in which defects may be corrected much more easily (1. 7. and is based on advancement of a breast tissue flap in the subcutaneous as well as the prefascial planes in order to fill the lumpectomy defect (1). If the lesion is close to the NAC or significant undermining of the NAC will be necessary for recentralization. it is yet to be widely embraced within the United States (1. They identify three components that are key for an oncoplastic approach to breast conserving therapy: excision volume. these patients require the underlying breast tissue for blood flow to the nipple and areola and repositioning of the NAC will require de-epithelialization (Figs. and glandular density (1. The locations in the . which will be briefly summarized. The difficulty associated with certain regions of the breast is in part due to the abundance or lack thereof of surrounding structures from which the surgeon may mobilize tissue in order to replace a defect. The glandular density of the breast plays a key role in the surgeon’s ability to undermine and reshape tissue without complications (1). extirpation of “smaller” tumors may result in significant cosmetic deformity in women who have smaller breasts.8). The position of the skin incision is very important in level I OPS.11). Tumor location is an essential component in the surgical planning of OPS. nipple–areola complex (NAC) recentralization is performed if deformity is expected. scattered fibroglandular. there are four main factors to be considered when evaluating a patient for an oncoplastic approach: excision volume. During the flap development. TECHNIQUES OF ONCOPLASTIC SURGERY Clough et al. or extremely dense (2. A mnemonic to remember this by is “Vikings Love Slim Dancers. Preoperative mammographic evaluation of breast density may aid the surgeon in deciding whether to perform extensive undermining in the removal of a breast cancer. We have developed a slightly different working algorithm that takes into consideration the size of the breast. breast size.3 and 7.4). or fatty composition of the breast is present. tumor location. After the tissue has been reapproximated. Accordingly. Level I procedures do not require specific training in plastic surgery.7. we will often extend the radial incision along the areolar margin and on both sides of the radial incision.” We have found that taking the size of the breast into account allows the practitioner to better anticipate what form of surgical procedure will be required. as each is a risk factor for fat necrosis (1). See Figure 7. We propose to add a third level to this algorithm: Level III techniques are to be used for oncoreductive procedures in which the ipsi. In addition. Details of specific techniques to reshape the breast will be discussed later in the chapter.1 for a visual representation of when to perform the various techniques of OPS. heterogeneously dense. The Breast Imaging Reporting and 57 Data System (BI-RADS) classifies breasts into four groups based on mammographic density: fatty. and glandular density. Clough et al. tumor location. the NAC is allowed to fall back down to its central position. obesity. We typically utilize curvilinear incisions in the upper outer quadrant and in the superior central area. have provided an excellent atlas based on tumor location. have created a two-tiered system by which one may approach the oncoplastic breast surgery (1). Certain areas of the breast carry higher risks of deformity than others (1).9). Patients for whom this technique cannot be performed are those who have previously undergone circumferential incisions around the NAC. no skin excision is expected. the NAC is completely freed from the deeper parenchyma similar to a subcutaneous mastectomy. Clough et al. Although some authors have described de-epithelialization for NAC repositioning. For example.13). Excision volume and breast size are the most important factors in predicting the outcome of surgery and the probability of breast deformity (1). Level II OPS procedures depend on the position of the tumor and the extent of excision volume. Level II techniques are to be undertaken when 20–50% of the breast volume is to be extirpated in which skin will also be removed in order to reshape the breast (1). A study by Bulstrode and Shortri determined that greater than 20% breast volume excision is associated with almost certain risk of postoperative deformity (10). The lower pole of the breast and the upper inner quadrants are associated with a high risk of deformity. 58 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY Breast Cancer < 20% Volume >= 20% Volume Poor Location Good Location Level I Procedure Normal Breast Size Large or PtoticBreast Large or ptotic breast Fatty Breast Dense Breast Fatty Breast Dense Breast Level III Procedure Level I Procedure Level II Procedure Level I Procedure Level II Procedure Figure 7.2 Procedures for areas of the breast. . Verticle mammoplasty or modified round bloc Verticle mammoplasty Omegaplasty or “batwing” excision Racquet mammoplasty Lateral mammoplasty V-mammoplasty or medial mammoplasty J-mammoplasty V-mammoplasty Superior pedicle mammoplasty with inverted-T or vertical scar Figure 7.1 Level III Procedure Oncoplastic algorithm. the breast is reshaped by re-approximation of the medial and lateral glandular tissue to the midline. followed finally by NAC recentralization. The technique of choice for tumors in this location is a superior pedicle mammoplasty with inverted-T or vertical scar. Tumors of the lower inner quadrant (7–9 o’clock) are more difficult due to the paucity of excess breast tissue medially.ONCOPLASTIC SURGERY OF THE BREAST Figure 7. oriented for the left breast. Lesions in the lower pole (5 to 7 o’clock) have a high risk of “bird’s beak” deformity.3 Figure 7. this is similar to the technique used for breast reduction. 5 months after radiation of the breast and internal mammary chain (side view). An inframammary incision is then completed.4 59 Level I OPS in lower inner quadrant. A V-mammoplasty has been proposed. Level I OPS in lower inner quadrant. 5 months after radiation of the breast and internal mammary chain. involving pyramidal excision of the gland down to the pectoralis fascia followed by rotation of the lateral glandular flap to fill the defect. Once the resection is complete. The procedure begins with de-epithelialization of the peri-areolar region followed by dissection of the NAC from the underlying breast tissue on a superior dermoglandular pedicle. breast will be referred to as one would the face of a clock. followed by undermining of the breast tissue off the pectoralis fascia and finally en bloc removal of the tumor. Cancers of the upper inner quadrant (10–11 o’clock) may be some of the more challenging to extirpate due to . Figure 7. .6). Silverstein et al. Tumors of the upper pole (11–1 o’clock) rarely cause deformity.5 Level II OPS in superior central right breast with concomitant matching of the left side and 3 years after radiation of the right breast (note the slight drop of the left breast). The technique is performed by mobilizing the lateral and central gland into the cavity made by resection and suturing the two portions of glandular tissue together. We find it usually unnecessary to incise the NAC circumferentially. 7.14).60 the extremely low amount of nearby tissue free for flapping.7 and 7. 7.5 and 7.8). as one can perform a vertical based mammoplasty re-approximating the medial and lateral breast tissue with or without a partial breast lift. Tumors of the upper outer quadrant (1–3 o’clock) have the lowest associated risk of deformity unless more than 20% of the breast volume is resected (1). describe an omegaplasty for lesions in this area (6. Rather. while Berry et al. Clough has described a round block technique in which concentric periareolar incisions are made (1).6 Level II OPS in superior central right breast with concomitant matching of the left side and 3 years after radiation of the right breast (note the slight drop of the left breast) (side view). Figure 7. NAC undermining and repositioning are also undertaken during this procedure (Figs. described a “batwing” excision pattern. AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY a crescent shape incision from 3–9 o’clock of the areola is sufficient (Figs. A racquet mammoplasty can be used for resection of tumors in this location. 2 shows a visual representation of the procedures one may perform for each area of the breast. both slightly curving to the lateral side of the breast. usually through a classic inverted-T technique (Figs.8 61 the NAC with the tumor can often be performed and will maintain a better projection of the breast than a classic horizontal fish mouth incision around the NAC.7 Figure 7. A Lejour vertical mammoplasty excising Figure 7.9 and 7. This entails de-epithelializing the nipple-areola complex while allowing it to retain blood flow from a superior pedicle. retroareolar masses may also be removed via oncoplastic surgery. Finally. The medial and lateral glandular tissues may then be approximated with concurrent lift of the NAC into the superior pedicle of the breast. Level III oncoreductive techniques can be employed in patients who may have larger tumors in large-sized or pendulous breasts.10). Level II OPS of the upper outer quadrant of the right breast 2 years after surgery (side view).ONCOPLASTIC SURGERY OF THE BREAST Cancer of the lower outer quadrant (4–5 o’clock) may have a J-type mammoplasty performed in order to avoid lateral retraction or deviation of the breast. This procedure presents an advantage also from the standpoint Level II OPS of the upper outer quadrant of the right breast 2 years after surgery. In those cases the oncologic resection is combined with a bilateral breast reduction. Two incisions are then made from the NAC to the inframammary fold. The nipple and areola can be reconstructed at a later date. Figure 7. . 7. The alternative is to delay the creation of symmetry of the contralateral breast until the post-radiation changes have reached final form. A completely different approach to OPS is the performance of volume replacement surgery rather than volume displacement surgery (15–17). Regardless. both significant concerns in large and pendulous breasts. Panthaki). when the contralateral side is operated simultaneously.62 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY Figure 7. Panthaki). The exact timing of the contralateral breast reduction remains controversial because. long-term results are difficult to predict after radiation therapy to the affected breast which typically ends up more edematous and less pendulous.9 (courtesy of Zubin J. although a bilateral procedure will achieve the best immediate symmetry. There are four main approaches to volume replacement surgery: the use of . of radiation therapy by reducing the exposure of intrathoracic structures to the radiation fields and by optimizing the homogeneity of the radiation.9 Preoperative view of level III OPS for a tumor in the left breast which is more pendulous than the right breast (courtesy of Zubin J. Figure 7.10 Postoperative view of patient in Figure 7. compensation for future changes in the radiated breast should be taken into account. and radiotherapy. Skin necrosis was found to be the most common complication of OPS followed by seroma at the latissimus donor site in a study by Slavin et al (34). The disadvantage is that in case of a local recurrence the latissimus will not be available for whole breast reconstruction. This is especially true when the oncologic and the plastic components are not performed in a comprehensive team approach where each discipline is very familiar with the other’s principles. With appropriate oncoplastic technique. flap loss.8% (28).29. Proficiency at OPS technique will spare the patient from undergoing a repeat procedure. We employ volume replacement techniques only in patients with very small breasts who do not have enough breast tissue for volume displacement and who do not want a reduction on size of the breasts. after major breast tissue displacement it might often be difficult if not impossible to re-excise a positive margin forcing mastectomy as the only viable option. and can be made thicker through harvesting of surrounding adipose tissue. Partial thickness skin necrosis will typically revascularize in time with little to no detriment to cosmesis (28).or full-thickness. and hematoma (35). At the University of Miami. demonstrated 5-year recurrence-free and overall survival rates of 93. the placement of an implant requires special Eklund views to perform mammographic surveillance of the breast for recurrence and may also necessitate additional screening MRIs in this high-risk population (21.ONCOPLASTIC SURGERY OF THE BREAST silicone implants. either partial.31–35). however. Skin necrosis may be avoided by ensuring adequate vascular supply of all areas. COMPLICATIONS Complications arising in oncoplastic surgery can be divided into two broad categories: oncologic and surgical.6%. Risk factors for complications of OPS are smoking. seroma of the flap donor site. hematoma. particularly of the lateral side of the breast (7. However. We have since changed this approach and reexcised positive margins even after those major tissue displacements with excellent oncologic results. obesity. Fat necrosis is associated with extensive mobilization of fat-replaced breast tissue that has a poor blood supply. which is both boon and detriment—it adds to the replacement volume. A study by Staub et al. and poor cosmesis (5. leaving the patient with a cosmetic defect. demonstrated the most frequent complications to be. infection. myosubcutaneous latissimus dorsi flaps. Unfortunately. poorer cosmetic appearance with . The former carries an added skin paddle. In a study by Clough et al. but due to the difference in skin quality between the breast and the skin overlying the latissimus dorsi. Hence. and lateral adipose tissue flaps. The oncoplastic surgical team should always keep in mind a possible positive margin to enable a re-excision if necessary. Commonly. these flaps are not favored by us in our practice. A recent study by Olsha et al.22). and capsular contracture. a relatively low local recurrence rate may be achieved.29. depending on size of the study and the experience of the surgeons (5. The issue of positive margins is one that merits some additional discussion. Surgical complications of oncoplastic surgery include skin necrosis. the cosmetic result may be lacking. it will lead to a nodular breast parenchyma. Although this is not problematic in the immediate postoperative phase. for patients treated with 63 OPS (29). Silicone implants have fallen out of favor among oncoplastic surgeons due to high rates of capsule formation and local deformity (18–19). respectively (5. Myocutaneous latissimus dorsi flaps and myosubcutaneous latissimus dorsi flaps are useful for upper and lower pole defects. infection. These studies clearly show that oncologic compromise does not occur while using OPS techniques. This includes ensuring adequate surgical margins through intra-operative frozen pathologic sections.23–27). These changes can be attributed to the use of post-operative radiotherapy. A myosubcutaneous flap avoids the problems associated with cosmesis of a myocutaneous flap.29. a latissimus dorsi mini-flap is performed in those cases. seroma at a flap donor site. skin necrosis. which may speed formation of the scar tissue surrounding an implant as well as cause soft tissue atrophy in the tissues surrounding the implant (18–20).7% and 94. A study by Pinsolle et al. Furthermore. At the beginning of our experience we were recommending mastectomies for patients with positive margins after level II or III OPS procedures. myocutaneous latissimus dorsi flaps.7% and a 5-year disease-free survival rate of 82. the long-term survival and oncological safety of breast cancer patients treated with OPS is comparable with the survival and safety of conventional BCS.9% to 20%. particularly to the NAC. the rate of margins involvement has been lower than reported with routine BCS (30). Many flaps will undergo necrosis or involution after manipulation.. capsular contracture if a prosthesis was implanted. in order. which affect rates of skin necrosis. Further.16). Because OPS enables much wider lumpectomies.32–35). respectively. Studies have demonstrated reoperation rates for margin involvement ranging from 8. Adipose tissue flaps may be considered as an additional technique for volume replacement surgery of the breast (15. the low vascularity encountered in most adipose tissue causes these flaps to be difficult to work with. fat necrosis.31–35). has demonstrated that careful use of the ultrasound as an adjunct tool in the operating room can significantly decrease the positive margin rate (36). we routinely use intraoperative ultrasound to guide the lumpectomy and assess margins. 100 patients undergoing level II OPS demonstrated a 5-year overall survival of 95. if needed the necrotic skin may be resected and the healthy edges apposed. Perry C. 63: 1233–43. 12. Studies have shown that a significantly inferior cosmetic outcome has been associated with patients receiving pre-operative radiation therapy due to the atrophic tissue available for reconstruction. The purpose of this delay is to allow the atrophic effects of radiation on breast tissue to fully take effect before reshaping the contralateral breast. caution should be exercised in terms of OPS (28. . 11. 10. Garusi C. 52: 177–81. Salmon RJ. Oncoplastic breast surgery: a review and systematic approach. Generally. Clough KB. 149: 219–25. 2003. Outcome of oncoplastic breast surgery in 90 prospective patients. from frank deformity of the breast to mild breast asymmetry without any deformity. Breast 2001. Ann Surg Oncol 2005. Petit JY. 9. 152: 202–11. 200: 224–8. and in the event that breast surgery is contemplated after previous radiation extreme. Oncoplastic techniques allow extensive resections for breast-conserving therapy of breast carcinomas. Meretoja TJ. 5. Rietjens M. Kaufman GJ.35). Jahkola TA. benfits. Roger P. radiation therapy is delayed until after surgery (28. Wolfe AJ. Petit JY. Rainsbury RM. these complications require a mastectomy with immediate breast reconstruction. Comparative study of surgical margins in oncoplastic surgery and quadrantectomy in breast cancer. Giacalone PL. Ann Surg 2003. Hopefully more surgeons will adopt the practice of oncoplastic surgery within the coming decade in order to achieve a better overall result for women affected by breast cancer. Recent Results Cancer Res 1998. Salvadori B. et al. Greuze M. 111: 1102–9. Ann Surg Oncol 2010.64 local deformities. Cosmetic complications may take many forms. Buccimazza I. Bulstrode NW. 237: 26–34. 4. 17: 1375–91. J Plast Reconstr Aesthet Surg 2010. Eur J Cancer 1998. Lewis JS. Couturaud B. Wound infection unfortunately needs to be treated with re-operation. et al. Improving breast cancer surgery: a classification and quadrant per quadrant atlas for oncoplastic surgery. Donor site seromas may be treated by needle aspiration of the seroma fluid. 14: 605–14. 3. 7. Clough et al. a three. may be avoided by ensuring adequate vascular supply to the pedicle through meticulous operative technique. cosmetic reconstruction of the breast may be undertaken at a later date. REFERENCES 1. The primary indication for OPS is a large breast lesion relative to the size of the breast for which a standard excision with clean margins would be either unfeasible or lead to major deformity of the breast. 8. Tsangaris TN. Amichetti M. Oncology 1995. et al. Reston VA: American College of Radiology.37). Spear SL. Flap loss. While in some cases immediate surgical symmetry has been advocated. Pennanen MF. Surgery insight: oncoplastic breast-conserving reconstruction—indications. Svarvar C. the most important factor to consider is the symmetry of the breasts. Am J Surg 2010. Experience with reduction mammoplasty combined with breast conservation therapy in the treatment of breast cancer. In all of these cosmetic complications. and can occasionally become a diagnostic problem for the oncologic follow up on clinical exam and on imaging studies (28). Sarfati IM. The importance of such a procedure AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY cannot be stressed enough: the ability to fully resect a tumor of the breast coupled with an immediate or nearimmediate reconstruction or even in some cases an improvement in breast cosmesis creates an opportunity to provide patients with the satisfaction of preserving body despite the distressing emotional waypoints of their cancer treatment. For that reason breast density should be a major determinant of the OPS approach. Ten year results of a randomized trial comparing two conservative strategies for small size breast cancer. Long term cosmetic outcome and toxicity in patients treated with quadrantectomy and radiation for early-stage breast cancer.35. 4: 657–64. Nat Clin Pract Oncol 2007. Fitoussi AD. Pelletiere CV. classified three types of cosmetic complications: type I. Rietjens M. 6. Type I complications involved an asymmetry in the volume or shape between the breasts without any deformity—generally the unoperated breast was larger and more ptotic than the operated breast. and III (28). Caffo O. Breast imaging reporting and data systems (BI-RADS). even utilizing irradiated breast tissue in the reconstruction. Curnier A. Comparative study of the accuracy of breast reconstruction in oncoplastic surgery and quadrantectomy in breast cancer. Berry MG. 12: 539–45.to six-month delay is recommended after the completion of adjuvant radiation therapy prior to reoperation to create cosmetically symmetrical breasts (28. like skin necrosis. and the wound must be allowed to heal by secondary intention. Ann Surg Oncol 2006. II.35). choices and outcomes. Shortri S. Plast Reconstr Surg 2002. 10: 124–6. American College of Radiology. Couturaud B. Dubon O. Type II complications involve deformities of the operated breast that could be corrected by partial breast reconstruction. Nos C. 2. Type III complications involve major deformities or diffuse painful fibrosis of the treated breast. Integration of plastic surgery in the course of breast-conserving surgery for cancer to improve results and racality of tumor excision. Mariani L. SUMMARY Oncoplastic surgery is a burgeoning field in the United States that has already been established as a standard for care in Europe. Marubini E. et al. 13. The techniques of OPS allow the woman affected by breast cancer to undergo adequate surgery both oncologically and cosmetically. Busana L. Prediction of cosmetic outcome following conservative breast surgery using breast volume measurements. Kaur N. Clough KB. Ford HT. Use of silicome implants after wide local excision of the breast. Elton C. McCulley S. Fitoussi A. Nat Clin Pract Oncol 2007. Pearl RM. Extending the role of breast-conserving surgery by immediate volume replacement. 75: 166–70. Salmon RJ. 20: 89–92. Otto A. Plast Reconstr Surg 1998. 58: 902–7. Anderson BO. 18. Clough KB. Br J Plast Surg 2005. 19. Wechselberger G. Salmon RJ. 59: 1017–24. Rey PC. Durand JC. 25. Gazet JC. et al. 106: 755–62. Papp C. Eur J Surg Oncol 1999. Boice JD Jr. Long-term oncological results of breast conservative treatment with oncoplastic surgery. Therapeutic mammaplasty— analysis of 50 consecutive cases. Int J Surg Oncol 2011. Kiyohara H. Fitoussi A. et al. Satomi S. 96: 363–70. Moffat FL. Soussaline M. Jones PA. Schnitt SJ. 34. Ann Surg Oncol 2011. Carmon M. Rainsbury RM. Masetti R. 37. 36. Painter T. Int Surg 1990. 20: 102–3. 34: 1143–7. Breast 2007. Ishida T. Anterior transposition of the latissimus dorsi muscle through minimum incisions. 20. 25: 138–41. Harada Y. Caruso F. Breast-conserving surgery for primary breast cancer: 65 27. 16. Urban CA. DiPasco P. 76: 83–6. 32. Extending the role of breast-conserving surgery by immediate volume replacement. Immediate transposition of a latissimus dorsi muscle for correcting a quadrantectomy breast deformity in Japanese patients. Breast reconstruction following lumpectomy and irradiation. Breast cancer following breast reduction surgery in Sweden. Breast Cancer 1997. Ann Chir Plast Esthet 2007. Rainsbury RM. Breast cancer surgery: use of mammaplasty. choices and outcomes. Macmillar R. Complications analysis of 266 immediate breast reconstructions. Misra S. 16: 387–95. Staub G. Adv Surg 2010. Lancet Oncol 2005. immediate volume replacement using lateral tissue flap. Skin-sparing mastectomy and immediate reconstruction: oncologic risks and aesthetic results in patients with early-stage breast cancer. Shemesh D. Galli A. Screening criteria for breast cancer. 6: 145–57. Clough KB. Berrino P. Eur J Surg Oncol 2008. Mathoulin-Pelissier S. Persson I. Miyazaki I. 23. Catanuto G. Slavin SA. Breast Cancer 1998. Scand J Plast Reconstr Surg 1986. Faucher A. 18: 447–52. Paramanathan N. Brinton LA. Recent progress with breast-conserving volume replacement using latissimus dorsi miniflaps in UK patients. 33. 28. Silverstein MJ. Thomas PR. 31. 84: 1172–3. Avisar E. 15. Plast Reconstr Surg 1995. Straker VF. et al. Noguchi M. Eur J Surg Oncol 1994. 41: 471–81. 2011. Results. Cuminet J. 4: 657–64. Conservative treatment of breast cancers by mammoplasty and irradiation: a new approach to lower quadrant tumours. Br J Surg 1993. Outcomes of bilateral mammoplasty for early stage breast cancer. Initial experience of intramammary prosthesis in breast-conserving surgery. benefits. Series of 298 cases. Raja MA. Br J Surg 1997. Rainero ML. Wisnicki J. De Meo L. Resection margins in ultrasound-guided breast-conserving surgery. 21. Cosmetic sequelae after conservative treatment for breast cancer: classification and results of surgical correction. Br J Surg 1997. Misra S. Breast Conservation with latissimus dorsi miniflap: a new technique. Taniya T. 102: 49–62. Grinfeder C. Plast Reconstr Surg 2000. Oncoplastic approaches to partial mastectomy: an overview of volumedisplacement techniques. 30. Article ID 428653. Nos C. 22. 35. Rainsbury R. 17. Surgery Insight: oncoplastic breast-conserving reconstruction—indications. Koniaris LG. Olsha O. Rietjens M. Solomon NL. Pinsolle V. Plast Reconstr Surg 1985. Duda RB. Schoeller T. Saito Y. 53: 124–34. et al. 29. 24. Ann Plast Surg 1998. 80: 868–70. Falcou MC. 44: 87–100. et al. 4: 135–41. Ohuchi N. J Plast Reconstr Aesthet Surg 2006. 5: 139–47.ONCOPLASTIC SURGERY OF THE BREAST 14. 84: 101–5. 26. Santi P. Nos C. . Mosseri V. Effect of magnetic resonance imaging on breast conservation therapy versus mastectomy: a review of the literature. Rainsbury RM. Quondamcarlo C. Several authors have identified risk factors that help in identifying patients at high risk for positive margins following lumpectomy for breast cancer (6–9). and patients unable to undergo radiation therapy. Patient selection is of paramount importance when considering BCT as a treatment option for breast cancer.4). lymph node involvement. partial mastectomy defects. Their original conclusion that the less-invasive procedures provided equal survival rates to radical mastectomy has since been validated by randomized trials involving 20-year follow-up of these patients (3. there are studies that report that local recurrences are independently associated with an increased incidence of systemic recurrences (10).. tumors displaying extensive intraductal components.2% for lumpectomy alone versus 14. that the only means of achieving acceptable aesthetic results is to complete the mastectomy 66 . The local recurrence rate was also affected by radiation (39. Prevention is by far the best approach when it comes to local tumor recurrence following BCT. Roberto Comperatore.3% for quadrantectomy) (5). These long-term randomized studies involving a large number of patients have provided a wealth of important information regarding the behavior of breast cancer over time. On occasion. These risk factors include younger age. and family history. invasive lobular carcinoma. large tumors. Patients with small breasts and large tumors are not good candidates for BCT.8 Lumpectomy and radiation therapy Onelio Garcia Jr. and Nuria Lawson INTRODUCTION inability to obtain clear surgical margins. the local recurrence rate was found to be twice as high in the BCT patients as opposed to the mastectomy patients (1). lymphovascular invasion.3% for lumpectomy plus radiation). RECONSTRUCTION FOLLOWING BREAST CONSERVATION THERAPY Some of the most challenging reconstructive surgeries that plastic surgeons frequently encounter are the postradiation. Pre-menopausal women and those with tumors displaying an extensive intraductal component had the worst prognosis for local recurrences. the breast is so distorted by the lumpectomy or the radiation damage is so extensive. Avoiding the dreaded local recurrence of the cancer begins with obtaining clear resection margins during the lumpectomy. inflammatory cancers. It has been more than 30 years since several noted authors brought to our attention the concept of breast conservation therapy (BCT) as an alternative treatment for certain breast cancers (1. the higher the recurrence rate (13.2). Although the survival rates may be equal for these two treatment modalities. The less tissue margin removed around the tumor. Although most studies support the notion that local recurrences per se do not adversely influence long-term survival. First and most important is tumor size in relation to breast size.3% for lumpectomy versus 5. Other contraindications for BCT include multicentric tumors. for that reason a clear resection margin confirmed histologically by permanent section remains the gold standard of care. 1 B–F).LUMPECTOMY AND RADIATION THERAPY and perform a total breast reconstruction. 8. free-tissue transfer may not be available and the tissue replacement needs 67 can be significant. (D) Intra-operative flap inset. . The use of acellular dermal matrix is useful in these cases to (A) (B) (C) (D) (E) (F) Figure 8. (C) A contralateral. These reconstructions can be quite complex since these cases often exhibit radiation damage with significant soft tissue fibrosis (Fig. patients with limited autologous donor tissue volumes may require a combination of flap transfer plus prosthesis to complete the reconstruction (Fig.1 (A) Extensive radiation damage to right chest after mastectomy for failed lumpectomy. 8.1 A). (E) Acellular dermal matrix was used to line the subpectoral-sub-TRAM flap pocket for the prosthesis. muscle-sparing. When the radiation damage is extensive. adequate recipient vessels for autologous. (B) Pre-operative planning. pedicle TRAM flap was used due to extensive damage to recipient vessels. (F) 3-year postoperative result. While autologous tissue transfer remains the first reconstructive choice for the radiated mastectomy defect. Werner Audretsch introduced the concept of oncoplastic surgery in 1998 (11) and since then several authors have made significant contributions to the field. Although the delayed approach avoids the possibility that a surgical complication may delay the start of adjuvant therapy.18–20). including methods for classification of the partial breast defects as well as reconstructive algorithms (12–15).18–21). Several authors have reported poorer aesthetic outcomes in these cases (12. Many delayed reconstructions are still performed in the United States where surgeons have been slower in incorporating oncoplastic techniques than in Europe. Patients exhibiting those conditions which have been previously discussed in this chapter are not ideal candidates for immediate reconstruction. several studies have reported that immediate reconstruction as a general rule does not compromise the timing of chemotherapy or radiation (22–24). Slavin and collaborators (17) proposed a simpler classification that considered only the skin. Currently. Immediate-Delayed Reconstruction The main advantage of immediate-delayed reconstruction is the ability to confirm the BCT resection margins by permanent sections prior to embarking on the reconstructive procedure. The disadvantage of immediate reconstruction is the potential for AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY Table 8. in 2008 (12). most authors cite the benefits of immediate reconstruction prior to the radiation (12. The reconstruction in these cases is performed several days after the lumpectomy.1 Risk Factors for Positive Lumpectomy Margins Age < 40 Large tumor size Lymph node involvement Lobular carcinomas Extensive intraductal invasion Lymphatic or vascular extension Hereditary factors positive margins which have been reported to be as high as 10% following BCT. months or years after the radiation is completed (delayed reconstruction) or several days or weeks following the lumpectomy but prior to radiation (immediatedelayed reconstruction). The timing of delayed reconstruction should take into account when the post-surgical and post-radiation changes have stabilized. the size of the defect. the higher surgical complications associated with surgery on irradiated tissue remains a significant disadvantage of delayed reconstruction (18. Immediate Reconstruction Whenever possible. Delayed Reconstruction A significant number of partial mastectomy defects are reconstructed years after the completion of the radiation. Prior to the advent of breast oncoplastic surgery. These classifications are further subdivided based on breast shape (presence of ptosis) and associated skin deficiency. different classification systems for partial mastectomy defects have been proposed by Munhoz et al. performing the reconstruction immediately following the lumpectomy. Oncoplastic surgery. the great majority of the partial mastectomy defects underwent delayed reconstruction. Currently.19. most of the proposed classifications of partial mastectomy defects are based on three factors. Recently. TIMING OF THE RECONSTRUCTION Reconstruction following BCT can be performed immediately at the time of the lumpectomy (immediate reconstruction). and degree of breast retraction (16). A disadvantage of this staged approach is the need for a second operation within several days of the first one. and condition of the nipple–areola. loss of parenchyma. Subsequently.1). local tissue deficiency. avoids the difficulties of operating on a breast that exhibits fibrosis and cicatricial contracture from the previous surgery or radiation. These classifications have led to the development of logical algorithms for the reconstruction of partial mastectomy defects (12. allowing time for histological examination of the margins by permanent sections. usually years after the completion of the radiation (17).18). Several authors have reported certain conditions associated with an increased incidence of positive margins (6–9) (Table 8.13. the size of the breast.19). Some of the earlier classifications of partial mastectomy defects took into account the condition of the nipple–areola complex (NAC). and the location of the defect. is recently gaining popularity in the United States as a means of avoiding the difficult post-lumpectomy deformity while at the same time allowing for more aggressive tumor resections with greater margins. repeating the physical and mental discomfort associated with surgery as well as the additional . frequently used in Europe for BCT. degree of radiation deformity. The re-arrangement of the breast parenchyma that takes place as a result of the reconstruction would make it difficult to identify the original margins at the time of secondary resection. Although there is an advantage to operating on a patient who has been recurrence free for several years. as well as Losken and Hamdi in 2009 (15). Indeed several authors have reported decreased surgical complications and improved aesthetic results when performing immediate reconstructions (12.20).68 provide support for the expander/implant and to better delineate the inframammary and lateral mammary folds. RADIOTHERAPY TECHNIQUES Patient satisfaction with the cosmetic result of BCT and radiation is of course subjective. Its goal is to deliver a higher dosage of radiation up to one centimeter beyond the cavity walls within a shorter time frame. APBI may be given with interstitial catheter placement or by a balloon catheter placed within the cavity. In fact persistent. the technique of accelerated partial breast radiation (APBI) has been gaining popularity (25–27). Whole breast radiation diffusely affects the entire mammary gland whereas APBI generates a more intense. This treats up to 2 cm of breast tissue surrounding the lumpectomy cavity.LUMPECTOMY AND RADIATION THERAPY expense. Use of intraoperative sonography allows the surgeon to estimate the tumor margins more accurately avoiding excessive tissue removal. Soucy et al. Trying to minimize the breast deformity while respecting oncologic principles remains an ongoing endeavor. Bedford. 69 When post-surgical ABPI is planned. The author is of the opinion that patients with large tumors or with significant local invasive disease who prefer breast conservation should first undergo neoadjuvant chemotherapy. (31) compared the incidence of positive tumor resection margins in patients undergoing BCT following chemotherapy to those undergoing primary surgical treatment for invasive breast cancer and found both groups to be very similar in that respect. PARTIAL BREAST RECONSTRUCTION OPTIONS The decision to proceed with reconstruction of a partial mastectomy defect versus completing the mastectomy and performing a complete breast reconstruction is usually dictated by the quantity and quality of the remaining breast tissue. patients considering BCT with large ptotic breasts can tolerate a relatively large lumpectomy. but it is often influenced by the degree of radiation-induced breast retraction. and reconstruction within the same setting. followed later by fibrosis and soft tissue retraction. Based on a series of 173 patients with advanced breast cancer treated with pre-operative chemotherapy.2 A–C).3). there is enough remaining breast tissue that a reconstruction with breast tissue rearrangement through reduction . The author also believes that it is prudent to use this staged approach in cases where the reconstruction involves distant tissue transfer. 8. McIntosh et al. These changes tend to stabilize after several years. NEOADJUVANT CHEMOTHERAPY IN BREAST CONSERVATION THERAPY The administration of pre-operative chemotherapy has been shown to decrease tumor size. Because the new tumor margin following chemotherapy induced regression is sometimes difficult to detect. For non-palpable tumors. melding lumpectomy. local tissue reaction (Fig. If oncoplasty is performed during the lumpectomy. Patients with large tumors (greater than 5 cm) who prefer breast conservation may increase the possibility of BCT following a positive response to pre-operative chemotherapy (29). Recently. This approach should be reserved for those cases who present a high risk for positive resection margins following lumpectomy. Early in the post-radiation timeline we may see edema and hyperpigmentation. not visualized by ultrasound. It is important to understand that these modalities are associated with different tissue complications. The degree of radiationinduced breast distortion is often influenced by the radiation technique employed. It is also of paramount importance to maintain a spacing of 7–10 mm between the cavity wall and the overlying skin in order to decrease the amount of dermal damage and radiation-induced dermatitis. In these cases. This technique allows for oncoplastic tissue rearrangement to be performed. the margins cannot be rearranged by oncoplastic techniques. Another radiation alternative currently under development is intraoperative radiation therapy. then whole breast radiation becomes the obligatory modality. 8. The most common technique is whole breast radiation in which the entire breast is irradiated with a usual dose of 50 Gy delivered in 25 fractions and a 10-Gy boost to the lumpectomy cavity walls. accurate preoperative wire localization will also limit unnecessary tissue excision.. less invasive surgical and radiation modalities should improve the cosmetic outcomes of BCT. MA) has simplified the process of insertion and dosage planning (28) (Fig. The original cavity walls must be respected in order to ensure that that the tissue that surrounded the tumor is subjected to the planned radiation dose. long-term cavity seromas are more common with APBI. It is important to point out that in order for the patient to be appropriately treated with APBI. The decision to follow with BCT should be based on the response to the chemotherapy. the MammoSite applicator (Hologic Inc. the degree of the eventual distortion can be decreased by careful design of the lumpectomy. Newer. This process tends to be progressive and may worsen with the passage of time. (30) concluded that BCT could be safely offered to selected patients with positive response to the chemotherapy. the reconstructive procedure should be staged (immediate-delayed reconstruction) to allow assessment of the margins by permanent sections. similar to APBI. radiation. With this method a short interval of radiation is given intraoperatively during the lumpectomy with an electron beam source. Regarding the quantity of breast tissue. Recently. or in some cases completing the mastectomy and performing a total breast reconstruction. Inc. Bedford.2 (A) MammoSite breast brachytherapy applicator (Hologic.70 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY (A) (B) (C) Figure 8. (C) Balloon inflated within the lumpectomy cavity. On the other hand. a small breast can suffer significant deformity following a small to moderate lumpectomy. These patients may necessitate reconstruction with techniques that replace the missing volume such as distant flaps. 8. The limited amount of remaining tissue may not be sufficient to reconstruct an aesthetically pleasing breast. 8. Another consideration in these cases is the .5 A–D)..4) can provide an acceptable aesthetic result (Fig. MA) (B) Inflating MammoSite balloon. mammaplasty techniques (Fig. Occasionally. one must account for the radiation-induced tissue retraction that occurs over time and transfer enough volume to . For example.4 Pre-operative markings for breast conservation therapy on a patient with large. Figure 8. An integral part of BCT is radiation therapy.LUMPECTOMY AND RADIATION THERAPY 71 Figure 8. quality of the remaining tissue following the lumpectomy. when distant flap transfers become necessary for tissue replacement. Meticulous planning is imperative when volume replacement is under consideration. Patients who present for delayed reconstruction of partial mastectomy defects have undergone breast radiation therapy. ptotic breasts and lateral tumor location. right breast lumpectomy followed by accelerated partial breast irradiation (APBI) using a MammoSite device. that the only option for achieving acceptable results is to perform an extensive resection of the remaining tissue followed by tissue replacement by means of a distant flap transfer. the radiation damage can be so extensive and the quality of the remaining tissue so poor. Arrow points to irradiated area.3 Patient following upper pole. .6A.5 (A. the acute radiation changes significantly improve over the first year following completion of their treatment (Fig. 8. Algorithms for reconstruction of the partial mastectomy defect provide very useful guidelines for the surgical (A) (B) (C) (D) Figure 8. Fortunately for most patients. (C.6 (A) Acute radiation changes following BCT.72 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY overcorrect the defect. the reconstructive options in these cases are limited due to significant radiation damage to potential recipient vessels at the site (32). B) Pre-operative appearance. (B) (A) Figure 8. B). Frequently. (B) Appearance 1 year after completion of the radiation. D) Post-operative appearance following BCT by means of reduction mammoplasty. 8 A–D). Familiarity with the different approaches to reduction mammoplasty is of paramount importance when employing this approach in BCT. . superomedial pedicle or central mound techniques of reduction mammoplasty will allow the surgeon to reconstruct most defects while maintaining nipple– areola viability. irradiated. These techniques usually allow for large resections while resulting in aesthetic results resembling those expected from reduction mammoplasty or mastopexy procedures with similar complication rates (39).7 A. An oncoplastic approach using an inferior pedicle reduction mammoplasty technique.LUMPECTOMY AND RADIATION THERAPY approach to these difficult cases. such as shorter. Fat grafting or the use of an acellular dermal matrix can be useful adjuncts that help camouflage the contour deformity that often persists as a result of the scar contracture and radiation fibrosis (Fig. 8. Lateral defects created by large lumpectomies often cause significant breast deformities as well as asymmetry with the contralateral breast. and minimal breast flap undermining. This oncoplastic technique using different variations of a Wise pattern mammoplasty has been extensively described in the literature (13.9 A–D). Often. can be one of the most challenging situations that plastic surgeons may face following BCT. 8. modifications of the algorithms are necessary. Spear et al. in which case the surgeon may resort to a free nipple–areola graft technique. These defects can be reconstructed by adjacent breast advancement flaps (3). implantation of acellular dermal matrix. B). (40) noted that reduction mammoplasty could be safely performed in the previously irradiated breast if certain technical variations were employed. is devastating to the patient who had chosen BCT over a mastectomy in the first place to avoid a major surgical procedure. broader pedicles. in a patient exhibiting a superior-central tumor of the left breast is depicted in (Fig. keeping in mind that the partial mastectomy defect is a unique deformity that requires an individualized treatment plan. Isolated deformities located laterally can be usually reconstructed in an acceptable fashion with local tissue advancement. 33–38). Occasionally a small prosthesis can be useful for improving breast projection and shape. breast tissue wedge resection is performed to centralize the NAC and a contralateral reduction mammoplasty is performed to achieve symmetry of volume and shape (Fig. This technique is also useful for delayed BCT reconstruction. although sometimes necessary. superior pedicle. The use of mammoplasty (A) 73 techniques in BCT requires that the surgeon be familiar with the different options for pedicle design to maintain nipple–areola viability. It is important to elevate the breast advancement flaps in a full thickness fashion at the level of the pectoralis muscle fascia in order to properly obliterate any empty space created by the lumpectomy. Occasionally. As previously noted. the tumor resection interferes with the creation of a safe vascular pedicle option. This approach. Often. a medial. 8. (B) Correction of lateral breast deformity with adjacent tissue advancement. and prosthetic breast augmentation. Women with relatively large or ptotic breasts are good candidates for lumpectomy through breast reduction or mastopexy incisions. however. partial mastectomy defect with significant soft tissue loss.7 (A) Right breast deformity following lateral lumpectomy and radiation. Breast reconstruction of the complex. The surgeon should be familiar with the algorithms and employ them in the surgical planning. This is a very versatile approach to BCT in that it allows for large tumor resections in different locations within the breast. in some cases the best approach is to complete the mastectomy and perform a total breast reconstruction with autologous tissue transfer. The ability to base the NAC circulation on an inferior pedicle. The fact that she has now been subjected to breast irradiation makes the mastectomy and reconstruction (B) Figure 8. these complex defects have been reconstructed with distant. Appearance following right breast advancement flaps and left reduction mammoplasty for symmetry. 8.50). The latissimus dorsi musculocutaneous flap is frequently employed in these cases since it can provide adequate soft tissue coverage for most partial mastectomy defects anywhere on the breast (Fig.74 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY (A) (B) (C) (D) Figure 8. procedures far more complex and more prone to complications (20. although the human-derived matrixes are most frequently used in breast reconstruction. particularly outside the affected breast. These matrixes may be prepared from cadaver donor tissue allografts or porcine-derived xenografts. (C.42). The literature reports good outcomes in selected patients treated with radiation who undergo implant reconstruction (49. reconstruction of these complex. partial mastectomy defects is further complicated by the lack of suitable donor tissue for transfer or the patient's reluctance to undergo an autologous tissue transfer procedure. D). however. leaves the abundant abdominal tissue intact and available for a future reconstruction should the patient at some point require a total mastectomy.10 A–D). Typically. They are composed of dermal tissue which undergoes a process that removes all cellular components and maintains an intact tissue matrix that accepts tissue in-growth and revascularization. the mindset of many of these patients is that they wish to avoid major surgical procedures. which is why they chose BCT in the first place. Using the latissimus dorsi for these partial defects. The use of ADM has expanded the breast reconstruction options for patients who desire implant-based reconstruction. B).22. Right breast deformity and breast asymmetry following BCT. it is generally accepted that implant procedures in irradiated patients are associated with higher complication rates and poorer .8 (A. Occasionally. The use of acellular dermal matrix (ADM) in expander-implant based breast reconstruction has gained popularity in the United States over the past 7 years (44–48).41. Traditionally. autologous flap transfers to replace the tissue deficiency (43). cosmetic results (50–52). (C. Salzberg and Koch (55) reported on a series of implant-based reconstructions using ADM in irradiated breasts and found that none of their patients developed capsular contracture. B) Pre-operative appearance of patient with superior. Many of the problems associated with implant reconstruction of the irradiated breast are related to radiation-induced capsular contracture. (E.54).9 (A. D) Intra-operative resection margins and central lumpectomy defect. Recently. Our experience in breast . there has been experimental evidence reported in the literature regarding the lack of peri-prosthetic capsular contracture in ADM-assisted surgery using implants (53. central location of tumor on left breast.LUMPECTOMY AND RADIATION THERAPY 75 (A) (B) (C) (D) (E) (F) Figure 8. F) Post-operative appearance following left BCT with oncoplastic reconstruction. B) Appearance following right breast lumpectomy and MammoSite local irradiation. The expander or implant must allow proper surface contact between the ADM and the mastectomy flap in order for tissue integration and revascularization of the matrix to occur. In cases where all or most of the expander pocket is lined with ADM.11 C. 8. the use of ADM in these cases has made it a viable alternative for patients in whom autologous tissue reconstruction may not be a good option (Fig. B). reconstruction using ADM and implants in the radiated breast is similar in that we have not seen the radiationinduced capsular contracture expected in these cases.76 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY (A) (B) (C) (D) Figure 8. D) The successful use of ADM in these cases is very technique dependent.11 E. Avoidance of these complications requires the surgical judgment to strike that fine balance of initial expander volume fill that avoids the empty space while not jeopardizing the circulation to the mastectomy flap.10 (A. Although implant-based reconstruction is not my ideal choice for reconstructing the irradiated breast. it is imperative that the matrix be sutured to the chest wall in a manner that precisely delineates the inframammary fold and lateral mammary fold as well as the medial and superior boundaries of the breast. Occasionally. 8. (D) Latissimus dorsi musculocutaneous flap used for soft tissue replacement. Adhering to these technical principles will allow the surgeon to achieve acceptable breast reconstruction results in these difficult cases where the use of autologous donor tissue may not be an option (Fig. (C) Markings include the extent of radiation-affected tissue.11 A. This can sometimes be the result of an inadequate resection or poor patient selection such as in young patients . I will perform a complete lining of the pocket with ADM as a means of avoiding capsular contracture (Fig. creation of an empty space between the matrix and the mastectomy flap inevitably leads to seroma formation which in most cases prevents integration of the ADM. F). however. Too much internal pressure as a result of placing an implant that is too large or overzealous filling of an expander may lead to mastectomy flap necrosis. COMPLICATIONS OF BREAST CONSERVATION THERAPY One of the most dreaded complications of oncoplastic surgery for BCT is the subsequent finding of positive tumor margin. when reconstructing with an expander in an irradiated field. 8. 11 (A. D) Acellular dermal matrix was used to line the revised dual plane subpectoral pocket.LUMPECTOMY AND RADIATION THERAPY 77 (A) (B) (C) (D) (E) (F) Figure 8.5% incidence of positive margins on permanent sections following examination of lumpectomy specimens that had negative margins on frozen section submitted during surgery. (E. B) Left breast deformity following BCT with radiation induced periprosthetic capsular contracture in a patient reluctant to undergo autologous tissue transfer. (C. Several other authors have reported that the need for a second surgery following BCT in order to achieve negative margins ranges . with large tumors who are associated with a higher incidence of positive margins following BCT. Munhoz and collaborators (7) have reported a 5. F) Postoperative appearance following tissue expansion and insertion of gel breast prosthesis. Since all of the BCT patients will require radiation and in some cases also chemotherapy. Kaplan J. Munhoz AM. Montag E. et al. For all these reasons. Veronesi U. it is imperative that negative tumor margins be achieved during the primary lumpectomy procedure. Fisher B. Singletary SE.D. Bard (Davol) Inc. 347: 1227–32. 26: 671–3. Pre-operative imaging may be helpful in evaluating the extent of the tumor and currently magnetic resonance imaging (MRI) appears to provide the most accurate evaluation in this respect (60). (59). Sound Surgical Technologies (Louisville. The Disclosures only apply to the lead author Onelio Garcia Jr. Aesthetic outcomes in BCT are frequently influenced by the patient's response to the radiation therapy. (63) reported significantly worse aesthetic outcomes in BCT patients who received their radiation preoperatively versus postoperatively. 4. 2. Luini A. Most large series report that the majority of patients undergoing BCT are satisfied with their breast appearance.78 from 6. Anderson S. et al. Reconstructive surgeons need to take into account the radiation-induced tissue retraction that occurs over time when planning volume replacement techniques and overcorrect the defects. Bleiweiss I. Twenty year follow up of a randomized trial comparing total mastectomy. Several authors have reported that the surgical complications associated with properly planned oncoplastic techniques are relatively minor and usually are not associated with a delay in the initiation of the adjuvant therapy (12. 18: 47–54. 7.23. Meric F. Arruda E. Twenty year follow up of a randomized study comparing breast-conserving surgery with radical mastectomy for the early treatment of breast cancer. Mariani L.6% (56–58). 184: 383–90. Am J Surg 2002. axillary dissection and radiotherapy in patients with small cancers of the breast. Quadrantectomy versus lumpectomy for small size breast cancer.65). 347: 1233–41. do not delay the initiation of the adjuvant therapy. A correlation between positive margins and increased incidence of local tumor recurrence has been reported by Leong et al. Margolese R. Bauer M. Eur J Cancer 1990. Haffty BG. Not everyone is a candidate for BCT and patients at high risk for local tumor recurrences should undergo alternative total mastectomy and reconstruction.Participates in investigational studies funded by the company and participates in company’s speakers bureau. Tartter PI. Comparing radical mastectomy and quadrantectomy. lumpectomy and lumpectomy plus irradiation for the treatment of invasive breast cancer. et al. Clough et al. 305: 6–11. Unfortunately. Several authors have also correlated large volume resections with unsatisfactory cosmetic results. Performing re-excisional surgery in these cases can be difficult once the breast parenchyma has been re-arranged by the oncoplastic procedure since it may not be possible to determine the original location of the tumor margins within the reconstructed breast. Canc J Sci Am 2000. A retrospective analysis of over 100 BCT patients reported lower complication rates for BCT when compared to mastectomy (66). Cascinelli N. REFERENCES 1.24. Obedian E. Fisher B. M. Saccozzi R.61. 179: 81–90. Five year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. re-excision and local recurrence of breast cancer. Breast 2009. The aesthetic outcome failure rate for that series was 18% and correlated highly with radiation-induced breast retraction. et al. Negative margin status improves local control in conservatively managed breast cancer patients. et al. et al. N Engl J Med 2002. Immediate reconstruction following breast conserving surgery: management of the positive surgical margins and influence on secondary reconstruction. 3. N Engl J Med 1985. particularly in small or moderate size breasts (64. 10. 5. Surgical margins in patients with early-stage breast cancer treated with breast conservation therapy. et al. Excaliard Pharmaceuticals (Carlsbad. it is of paramount importance that surgical complications that may occur as a result of the reconstructive procedures.Participates in investigational studies funded by the company and participates in company's speakers bureau. Bryant J.R. Appropriate patient selection and determining the best surgical procedure for a given defect are of paramount importance to the success of BCT. 8. CO) . DISCLOSURES Mentor Corporation (Santa Barbara. (Warwick. Lumpectomy margins. Am J Surg 2000. Patients with small breasts often cannot tolerate moderate to large lumpectomies and will achieve better aesthetic results from skin sparing mastectomy and reconstruction.. RI) . N Engl J Med 2002. 6. radiation changes occur over time and are often unavoidable. 9. Positive surgical margins and ipsilateral breast tumor recurrence predict . C. and participates in company's speakers bureau. Vlastos G. 6: 28–37.62). Veronesi U. Volterrani F.2% to 19.Consulting agreement. Del Vecchio M. Mirza NQ. 312: 665. Advances in oncoplastic surgical AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY techniques and breast radiation technology are certainly going to improve the oncologic efficiency and aesthetic outcomes of BCT. CA) . Veronesi U. recipient of investigational grant. CA) Participates in investigational studies funded by the company. et al. N Engl J Med 1981. SUMMARY Breast-conservation therapy offers select breast cancer patients another viable treatment option. Spear SL. 180: 299–304. An approach to the repair of partial mastectomy defects. 104: 409–20. McIntosh SA. 22. Papp C. Plast Reconstr Surg 1992. Hammond DC. Wechselberger G. et al. Partial mastectomy reconstruction. Munhoz AM. Munhoz AM. Santi P. Patel KM. 30.1. Spear SL. Plast Reconstr Surg 2006. Plast Reconstr Surg 1987. 16. 2011: 213–17. Plast Reconstr Surg 2007. J Clin Oncol 2005. Plast Reconstr Surg 2005. Hamdi M. Nos C. Plast Reconstr Surg 2006. Tumor-specific immediate reconstruction in breast cancer patients. 124: 722–36. Arruda E. et al. Breast Cancer 2000. Plast Reconstr Surg 2003. Hunt KK. Plast Reconstr Surg 2008. Robb GL. Assessment of immediate conservative breast surgery reconstruction: A classification system of defects revisited and an algorithm for selecting the appropriate technique. Kroll S. Masetti R. Conservative treatment of breast cancer by mammaplasty and irradiation: a new approach to lower quadrant tumors. Int J Radiat Oncol Biol Phys 2003. Rezai M. Robb GL. 117: 12–14. 24. 35. 29. Vicini FA. Mango S. Experience with reduction mammaplasty combined with breast conservation therapy in breast cancer. 7: 276–80. et al. A management algorithm and practical oncoplastic surgical techniques for repairing partial mastectomy defects. Philadelphia: Lippincott Williams & Wilkins. Clough KB. Kolotas C. 13. Rey PC. Belanger J. Nahabedian MY. Hammond DC. Slavin SA. Campora E. Polgar C. Oncoplastic approaches to partial mastectomy: an overview of volume replacement techniques. Plast Reconstr Surg 2005. 6: 145–57. Initial clinical experience with the MammoSite breast brachytherapy applicator in women with early-stage breast cancer treated with breast conserving therapy. Choice of recipient vessels in delayed TRAM flap breast reconstruction after radiotherapy. Montag E. Clin Plast Surg 2007. Anderson BO. 102: 1932. Vicini F. disease-specific survival after breast conserving therapy. 23: 1726–35. Wolmark N. 79: 567. Arruda E. Silverstein MJ. Sadowsky NL. Philadelphia. Willey SC. Fittoussi AD. 15. Nahabedian M. 31. Hamdi M. Oncoplastic techniques in the conservative treatment of breast cancer. Schoeller T. PA: Lippincott Williams and Wilkens. 2011: 140–64. Reconstruction of partial mastectomy defects: classifications and methods. 120: 1. 17. 121: 716–27. 12. 206: 1116–21. Leblanc G. Breast-conserving treatment with partial or whole breast irradiation for low-risk invasive breast carcinoma-5year results of randomized trial. Reconstruction of the irradiated partial mastectomy defect with autogenous tissue. Plast Reconstr Surg 2008. Plast Reconstr Surg 1995. Outcome analysis of breast-conservation surgery and immediate latissimus dorsi flap reconstruction in patients with T1 to T2 breast cancer. Strom FA. Partial breast reconstruction: current perspectives. Berrino P. Kuske RR. Arthur DW. 122: 1631–47. Clough K. 21. 40. 116: 741–50. et al. Losken A. Kronowitz SJ. Pirullo PG. 33. Am J Surg 2003. Love SM. 20. 23. 69: 694–702.2) breast cancer. Surgical margins in breast-conservation operations for invasive carcinoma: does chemotherapy have an impact? J Am Coll Surg 2008. Kuske RR. Plast Reconstr Surg 2006. King TA. et al. et al. eds. et al. Burke JB. et al. Mamounas E. et al. Determining the optimal approach to breast reconstruction after partial mastectomy. Feledy JA. 11: 71–9. Plast Reconstr Surg 1998. Critical analysis of reduction mammaplasty techniques in combination with conservative breast surgery for early breast cancer treatment. 117: 1091–107. Cancer 2003. Clough KB. eds. Major T Fodor J. Payne S. 97: 926–33. Wolfli J. Buchholz TA. 19. Masetti R. . 37. Plast Reconstr Surg 1998. 114: 1743–50. Management algorithm and outcome evaluation of partial mastectomy defects using reduction or mastopexy techniques. 79 27. 30: 96–102. Montag E. Postquadrantectomy breast deformities: Classification and techniques of surgical correction. 115: 105–13. Ann Plast Surg 2007. 39. Losken A. Kuerer HM. Youssef A. et al. Audretsch W. Montag E. Willey SC. J Natl Cancer Inst Monogr 2001. 38. Long term oncological results of breast conservative treatment with oncoplastic surgery. et al. Parikh PM. Lancet Oncol 2005. Pelletiere CV. Styblo TM. 18. Experience with reduction mammaplasty following breast conservation surgery and radiation therapy. 25. 3rd edn. Arruda EG. Rietjens M. Thomas SS. 96: 363–70. et al. Kuerer HM. Surgery of the Breast: Principles and Art. Forman D. Urban CA. et al. 55: 289–93. In: Spear SL. et al. et al. Wang J. et al. Bolton JS. Spear SL. 14. Pre-operative chemotherapy in patients with operable breast cancer: nine year results from the national surgical adjuvant breast and bowel project B18.LUMPECTOMY AND RADIATION THERAPY 11. 111: 1102–10. Accelerated partial breast irradiation as part of breast conservation therapy. Long term results of wide-field brachytherapy as the sole method of radiation therapy after segmental mastectomy for T(is. Surgery of the Breast: Principles and Art. 59: 235–42. Autologous breast reconstruction after breast-conserving cancer surgery. 185: 525–31. Carlson GW. 28. Breast 2007. Soucy G. Reconstruction after conservative treatment for breast cancer: cosmetic sequelae classification revisited. 41. 16: 387–95. Local recurrence in patients with large or locally advanced breast cancer treated with primary chemotherapy. Keisch M. et al. Plast Reconstr Surg 2004. Perspect Plast Surg 1998. Munhoz AM. 117: 1–11. Hunt KK. Plast Reconstr Surg 1999. Losken A. Temple CF. et al. Kronowitz SJ. 90: 854. Ogston KN. Plast Reconstr Surg 2009. et al. Reduction mammaplasty as part of breast conservation therapy of the large-breasted patient. Determining the optimal approach to breast reconstruction after partial mastectomy. Am J Surg 2000. Kronowitz SJ. et al. 26. et al. Salmon RJ. Nahabedian MY. 34. In: Spear SL. Practical guidelines for repair of partial mastectomy defects using the breast reduction technique in patients undergoing breast conservation therapy. Int J Radiat Oncol Biol Phys 2007. 34: 51–62. 32. 42. 36. Audretsch W. Van Landuyt K. Wolfe AJ. 102: 1913–16. Harter J. Surgery of the Breast: Principles and Art. Mus RD. 53. Breuing KH. et al. Leong C. et al. Oncoplastic surgery: managing common and challenging problems. Accuracy of intraoperative frozen-section analysis of breast cancer lumpectomy margins. Gendy RK. Breast tumors: comparative accuracy of MR imaging relative to mammography and US for demonstrating extent. 90: 433–9. 44. 188: 349–57. Couturaud B. 105: 930. Geribela A. Menon NG. Reisin E. Schultz DJ. Int J Radiat Oncol Biol Phys 1989. Ann Plast Surg 2006. J Am Coll Surg 2005. Am J Surg 2004. Salzberg CA. Philadelphia: Lippincott Williams & Wilkins. Munoz A. 54. Disa JJ. Clough KB.negative breast carcinoma. Coco D. Staged breast reconstruction with saline-filled implants in the irradiated breast: recent trends and therapeutic implications. 197: 743–7. Rainsbury RM. et al. Implant based reconstruction with allograft. Nonexpansive immediate breast reconstruction using human acellular dermal matrix graft (AlloDerm). 34: 29–37. Willey SC. A-Timek A. 55: 232–9. Schusterman MA. 58. Lewis JS. Munhoz AM. Holland R. Int J Radiat Oncol Biol Phys 1997. Mills JM. AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY 56. Ann Plast Surg 2006. 16: 13–16. 124: 82. Pussic AL. The use of acellular dermal matrix to prevent capsule formation around implants in a primate model. Salzberg CA. Robb GL. 32: 418–25. Holton LH. Technical tricks to improve the cosmetic results of breast-conserving treatment. Hammond DC. 123: 807–16. Olson TP. 45. 63. Ricci MD. Boyages J. Plast Reconstr Surg 2000. Nahabedian MY. 62. Onyewu C. Plast Reconstr Surg 2007. 3rd edn. Spear SL. 61. 50. Copeland EM. 56: 22–5. Immediate breast reconstruction with implants and inferolateral AlloDerm slings. et al. Effect on margins on ipsilateral breast tumor recurrence after breast conservation therapy for lymph node. The effect of AlloDerm envelopes on periprosthetic capsular formation with and without radiation. 59. Kroll SS. Surgery of the Breast: Principles and Art. 39: 637–41. 200: 1823–32. Evans GR. Dupont E. 60. Munhoz AM. In: Spear SL. In: Spear SL. Spear SL. Direct to implant breast reconstruction with acellular dermal matrix. Connor J. 52. 96: 1111. Ann Plast Surg 2005. eds.80 43. Robb GL. Impact of skin-sparing mastectomy with immediate reconstruction and breastsparing reconstruction with miniflaps on the outcome of oncoplastic breast surgery. The influence of reduction mammaplasty techniques in synchronous breast cancer diagnosis and metachronous breast cancer prevention. 49. 57: 1–5. Preservation of cosmesis with low complication risk after conservative surgery and radiotherapy for ductal carcinoma in situ of the breast. 120: 373–81. Impact of radiotherapy on breast reconstruction. Parikh PM. Frozen section analysis for intraoperative margin assessment during breast conserving surgery results in low rates of re-excision and local recurrence. Philadelphia: Lippincott Williams & Wilkins. . Spear SL. Warren SH. Clin Plast Surg 2007. Jugenberg M. et al. Osteen RT. Willey SC. et al. Reconstruction and the radiated breast: is there a role for implants? Plast Reconstr Surg 1995. In: Spear SL. 2011: 412–19. et al. 57. Olivotto IA. Jayasingue UW. 55. Cedan JC. 64. Acellular dermis-assisted breast reconstruction. Kerby CO. Stump A. 237: 26–34. Cancer 2004. Philadelphia: Lippincott Williams & Wilkins. Breast 2007. Robb GL. Weinberg E. De Lorenzi F. Gamboa-Bobadilla GM. 65. 57: 125–36. Petit JY. 2011: 460–75. et al. 2011: 123–39. 3rd edn. 47. Nahabedian MY. Karacaoglu E. Ann Plast Surg 2006. et al. 66. Radiology 1995. Aesthetic Plast Surg 2008. 48. et al. eds. Ann Surg Oncol 2007. et al. 201: 194–203. Solin LJ. Hammond DC. Plast Reconstr Surg 2009. 17: 747–53. Surgery of the Breast: Principles and Art. Br J Surg 2003. eds. Cox C. Koch RM. 51. Willey SC. Implant based reconstruction using acellular dermal matrix. Boetes C. Ann Surg 2003. Nahabedian MY. Prosthetic reconstruction in the irradiated breast. Hammond DC. Rietjens M. Jespersen MR. Komorowska-Timek E. Able JA. et al. Plast Reconstr Surg 2009. 46. Rose MA. Local recurrence in lumpectomy patients after imprint cytology margin evaluation. 14: 2953–60. Oncoplastic techniques allow extensive resection for breast-conserving therapy for breast carcinomas. Late cosmetic outcome after conservative surgery and radiotherapy: analysis of causes of cosmetic failures. 3rd edn. Zienowics RJ. With the advent of genetic counseling and a greater understanding of tumor biology. an increasing number of women are deciding to undergo prophylactic mastectomies (2). Rather.9 Preoperative evaluation for post-mastectomy reconstructive surgery Charles R. alcohol or tobacco use). At present. and radiation treatment protocols need to be known for each patient. and free myocutaneous or fasciocutaneous flap transfer. and any relevant allergies. no single procedure has become the gold standard of post-mastectomy reconstruction. the patient’s concerns and expectations must be addressed. past surgical procedures. With these improvements. Initial attempts involved several disfiguring operations that produced largely unsatisfactory results. Paul Yang. As a result. Breast reconstruction has come a long way since the first procedure performed by Czerny in 1895 (3). Despite the ever-increasing therapeutic options. mastectomy continues as the mainstay of breast cancer treatment much as it has for over a century. The medical history should include a detailed account of past and coexisting medical problems.g.5 million women in the United States can be considered breast cancer survivors. Most importantly. more than 2. post-operative chemotherapy. social history (e. To achieve the highest satisfaction. Panthaki INTRODUCTION reconstructive procedure chosen should be specifically tailored to the individual patient’s needs and the surgeon’s clinical experience. pedicle flap reconstruction with or without implant placement. As of 2010. Volpe.. Additional time must be spent educating the patient about the various surgical options including the safety and limitations of each procedure. 81 . detailed understanding of the patient’s oncologic treatment plan is needed. In addition. and that number is predicted to increase by 30% by 2015 (1). and Zubin J.g. the surgeon must properly evaluate the patient and select the appropriate reconstructive procedure in an effort to minimize postoperative complications and improve patient outcomes. family history.. current medication and vitamin use. a wide variety of post-mastectomy reconstructive procedures have emerged over the years. the MEDICAL HISTORY A thorough medical history is of utmost importance during the preoperative evaluation and should be performed for all patients. Information gleaned from this interrogation may influence the decision to proceed with reconstruction and/or the type of procedure offered to the patient. refinements in surgical technique and oncologic principles occurred (e. pectoralis muscle preservation and skin-sparing mastectomy) allowing improved functional outcomes. Neoadjuvant chemotherapy. a greater demand for breast reconstruction can be expected. As the understanding of breast cancer’s natural history increased. Access to and involvement with an institutional tumor board is an invaluable asset to the preoperative planning. These include tissue expander and/or implant reconstruction. Cigarette smoking increases platelet aggregation and the risk of flap thrombosis (10. However. especially related to the mastectomy. Spear et al. active smoking has long been considered a relative contraindication to performing pedicled TRAM flap reconstruction (17. Known complications of smoking include skin flap necrosis (14).11). chronic obstructive lung disease. as well as gather a complete family history of cancer. Any patient found to have an abnormal test should have an HbA1c drawn in the hospital and should receive follow-up testing as an outpatient (9). Clearance from the patient’s pulmonary specialist should be considered especially if free-flap breast reconstruction is entertained.18). Long-time smokers may also present with chronic obstructive pulmonary disease (COPD) and lack the capacity to tolerate a lengthy operation. Recognition of a poorly controlled diabetic state may warrant performing a delayed reconstruction when the patient’s medical condition improves. Aspirin should be routinely discontinued 5–7 days prior to surgery (21). reviewed their AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY experience with pedicled TRAM flap procedures and found that active smokers had a statistically significant increased risk of multiple flap complications. However. and echinacea should be stopped at least 2 weeks prior to the operative date as they have been shown to increase the risk of bleeding in the perioperative setting (24). and carbon monoxide binds hemoglobin resulting in tissue hypoxia (13). The actual incidence of complications attributed to be active during breast reconstruction varies considerably between studies and between the methods of reconstruction offered. as well as fat necrosis. Mastectomies involving pectoralis major muscle resection pose a greater reconstructive challenge due to the lack of remaining tissue. Current recommendations from the American Diabetes Association include preoperative fasting blood glucose or HbA1c (a marker of glycemic control for the previous 3 months) for all surgical patients who have not been previously screened or have risk factors for diabetes. preoperatively (22). and free flap loss have been found when comparing well-controlled diabetic (Type 1 or 2) to non-diabetic cohorts (4). flap loss. Higher rates of local complications including wound healing problems and implant extrusion have been found in diabetic patients undergoing concomitant implant and TRAM flap reconstructions (5). and congestive heart failure should be identified early in the medical history taking process. Status of the pectoralis major muscle should be determined. in and of itself. be considered a contraindication to autologous free flap reconstruction. Medications Medications that affect hemostasis should be discontinued before surgery. fat necrosis. St. wound infection (15). Active smokers were found to be three times more likely to experience a complication following surgery and had a three-fold increase in the risk of mastectomy flap necrosis when compared to non-smokers (15). Patients presenting to the office for delayed reconstruction should provide detailed operative reports from prior surgical procedures. Clopidogrel (Plavix) use within 7 days of elective surgery has been shown to increase the risk of postoperative bleeding but no significant risk of intensive care unit admissions or mortality has been demonstrated. In addition. Comparable rates of anastomotic patency. higher rate of flap infection. ginseng. Breast-related History Special attention should be given to the patient’s breastrelated history during the initial evaluation for reconstructive breast surgery. cerebral vascular disease. and wound dehiscence (16). cessation of Clopidogrel 7 days prior to breast reconstruction is recommended (23). Smoking Smoking is universally accepted to be a risk factor for postoperative complications. poorly controlled or undiagnosed diabetes can present significant problems. The clinician should obtain a detailed history of previous breast disease. A history of diabetes and coronary artery disease may suggest widespread vascular involvement that may preclude a patient from a lengthy procedure such as autologous breast reconstruction. . especially delayed wound healing caused by smoking (20). and a higher rate of delayed wound healing as compared to non-smokers (19). nephropathy. well-controlled diabetes should not. Implant reconstruction may be difficult if not impossible given this situation. Due to the increased incidence of flap and abdominal donor site complications. arrythmia. John’s wort. Patients who currently smoke tobacco should be advised to quit for at least one month prior to scheduled surgery. Non-steroidal anti-inflammatory drugs (NSAIDs). Studies have shown that poorly controlled diabetes can result in wound healing problems following cardiac and non-cardiac surgery (6–8). Examination of data from deep inferior epigastric perforator (DIEP) flap and muscle-sparing TRAM free-flap breast reconstruction found a higher rate of donor site complications. The incidence of complications following tissue expander/implant breast reconstruction is also significantly higher with active smokers. However. should be discontinued between 2 and 7 days. such as ibuprofen or naproxen. blood vessel thrombosis.82 Systemic Illnesses Comorbid medical conditions such as retinopathy. peripheral vascular disease. coronary artery disease. if warranted. Homeopathic medications such as garlic. nicotine causes cutaneous vasoconstriction thus reducing capillary blood flow (12). hypertension. 36). The minimum risk of developing invasive breast cancer after the diagnosis of LCIS is 7. shape. Radiation and Chemotherapy Discussions concerning the reconstructive options for patients with breast cancer must address the potential need for neoadjuvant chemotherapy and/or post-operative chemotherapy and radiation. alteration in flap contour. the decision to perform autologous free tissue transfer in obese patients should be individualized based upon the patient’s and the surgeon’s perspective. Obese patients have a significantly increased risk for flap failure (3.g. Patients proceeding with breast reconstruction after neoadjuvant chemotherapy should be aware that there is increased risk of skin changes including tissue envelope retraction and hypertrophic scarring. Significant family history of breast or ovarian cancer may suggest a genetic predisposition to breast cancer through the BRCA gene. Photographic documentation of the patient should be made with standardized AP. Armed with this information. Patients with biopsyproven LCIS are at increased risk of developing an invasive breast cancer in either breast. The patient’s satisfaction with their current breast size should be determined and clearly documented. has a more favorable anatomy and may be an alternative method of reconstruction in morbidly obese patients (42). Breast volume can be estimated using bra size. Obese patients considered candidates for pedicle TRAM reconstruction might benefit from flap delay approximately 14 days prior to the scheduled reconstruction (41). Currently.1% at 10 years (26).8% (37). The diagnosis of lobular carcinoma in situ (LCIS) presents a second scenario in which bilateral mastectomy and breast reconstruction can be offered in select cases. or nipple–areola configuration should be noted (43). Tamoxifen) (27. Similarly.31). Any asymmetries in volume. A BMI greater than 30 has been shown to increase rates of complications in pedicled TRAM flap operations as well.5% (32.. Studies have shown that radiation exposure following implant-based reconstruction is associated with delayed wound healing. Clinical staging affords the reconstructive surgeon an understanding of the patient’s chemotherapy and/or radiation therapy requirements along with a timeline for the administration of these treatments.33). Unrealistic expectations of the reconstructive process must be addressed during the consultation. however.28). Bilateral prophylactic mastectomy has been shown to reduce the risk of breast cancer in this patient population by 90% (25). Paclitaxel for anthracyclic failures) has been shown to adversely affect breast reconstruction efforts.PREOPERATIVE EVALUATION FOR POST-MASTECTOMY RECONSTRUCTIVE SURGERY Two topics deserve careful consideration when discussing the patient’s breast-related history. and lateral views. it may be wise to delay autologous breast reconstruction until after the therapy is completed (30. 83 Neoadjuvant chemotherapy administration (Adriamycin + Cyclophosphamide. the most common clinical recommendation for women with LCIS is close follow-up combined with chemoprevention (e. In 2000. and infection (29). the reconstructive plan can be appropriately determined. Testing for BRCA1 and BRCA2 genotypes should be made available to these patients. Free tissue transfer for breast reconstruction in obese patients may be considered an acceptable choice for those willing to accept the higher risk of complications. Complication rates for immediate autologous breast reconstruction followed with post-operative radiation therapy range from 60 to 87. In general. but can be determined more objectively by direct breast volume assessment. Confirmed carriers of the BRCA 1/2 genes should be offered bilateral prophylactic mastectomy along with bilateral breast reconstruction. capsular contractures. and loss of symmetry (34). Breast Exam Breast size. The midabdominal TRAM flap. which uses a simple formula based on anthropomorphic measurements (44). PHYSICAL EXAMINATION Obesity Obesity remains a considerable problem in the United States. if postoperative radiotherapy is warranted. and wound healing problems at the donor site (35. the prevalence of obesity (BMI ≥30 kg/m2) was 19. fat necrosis. radiotherapy planned in the immediate post-operative period for a patient with a large tumor and positive axillary nodes might sway the decision to provide delayed reconstruction rather than immediate reconstruction with an expander/ implant. Because of a high incidence of postoperative complications. high rate of implant extrusion or malposition. These patients may benefit from delayed reconstruction when post-mastectomy radiation therapy is indicated. base diameter. Known complications related to radiation therapy include acute changes such as mild to brisk erythema and flap skin desquamation. Patients must be aware that surgical procedures on . Long-term changes include volume loss secondary to fat necrosis or parenchymal fibrosis. and degree of ptosis should be assessed preoperatively. proper clinical staging of the patient’s breast cancer should be made prior to the evaluation for reconstructive surgery. morbidly obese individuals are generally not candidates for autologous reconstruction.2%) and donor-site complications and thus should avoid TRAM flap reconstructions (38–40). oblique. Therefore. For example. Lastly. It should be noted that Pfannenstiel incisions and transverse suprapubic cesarean section scars are not considered contraindications to tram or diep flap procedures as they rarely damage the deep inferior epigastric artery and veins (47). back. 6.84 the opposite breast may be required to achieve symmetry with the reconstructed breast. and lower extremities should be conducted. Grunkemeier GL. 63: 256. 4. Attempts should be made to provide muscle-sparing breast reconstruction in these patients. management recommendations are best made on an individualized basis noting the patient’s desires. Perka MF. Donor Sites Any discussion concerning post-mastectomy reconstructive surgery must cover a comprehensive list of possible methods to recreate the breast mound. Paramedian abdominal incisions. 7. Bleznak A. The Rubens (deep circumflex iliac artery perforator) flap.46). Chest Wall A focused exam of the chest and axillae should be performed on all patients during the initial examination. an augmentation and/or mastopexy may be required. Kroll SS. In general. Reece G. The reconstructive efforts should address this proactively so that the aesthetic results are not compromised. it is important to determine the patient’s level of daily physical activity and involvement in sports. Careful documentation of previous surgical procedures and co-existing surgical scars should be performed as their existence may preclude certain reconstructive options. in detail. studies have shown that return to preoperative levels of physical activity is possible whether muscle-based reconstruction is performed or not (49. 2005–2015. 2. With that in mind. Full examination of the chest. Previous mastectomy sites should be examined along with previous biopsy sites. Plastic surgeons should be able to explain. 115: 1954–66. Oc M. Ultimately. Full disclosure will allow the patient to make an educated decision regarding the reconstructive process. Tavilla A. Ann Plast Surg 1991. Fortunately. Surgical and financial implications of genetic counseling and requests for concurrent prophylactic mastectomy. Breast reconstruction: systemic factors influencing local complications. Furnay AP. 49: 531. Clear communication with the patient will improve the likelihood of a satisfactory outcome. However. noting the condition of the skin and thickness of the subcutaneous tissue. In addition. Namey T. superior or inferior gluteal artery perforator flaps (S-GAP and I-GAP). Drei Plastiche Operationen Verhand Deutsch Gesellsch Chir 1895. Microvascular breast reconstruction in the diabetic patient. Ann Surg 2011. if the unaffected breast is large and pendulous. respectively. however. and transverse proximal gracilis flaps are potential options for complex breast reconstruction. The buttock. Glycemic control and infections in patients with diabetes undergoing noncardiac surgery. Breast cancer is an indiscriminate disease process that affects active women both young and old. et al. evidence suggests that a contralateral breast reduction may decrease the risk of subsequent breast cancer (45. The surgeon should be prepared to discuss techniques that he/she does not perform. or a tram/diep flap for breast reconstruction. 8. and abdominal scarring can. careful consideration to potential donor sites should be made. Miller RB. Passoglu I. Cancer 2009. Prior radiation treatment to the chest wall should be noted along with the quality of the skin and soft tissue within the radiated field. history of an ipsilateral AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY thoracotomy or an abdominoplasty would prohibit the use of a pedicled latissimus dorsi flap. The likelihood of skin flap compromise with the excision of previous biopsy scars must be anticipated. and thigh region should always be evaluated as sources for flap reconstruction in difficult cases. Glucose control lowers risk of wound infection in diabetics after open heart operations. flank. subcostal or Kocher incisions. 119: 38. Murphy RX Jr. Plast Reconstr Surg 2007. flank. 64: 684–7. Guvener M. buttocks. or rashes should be addressed prior to the planned breast reconstruction. the patient’s body habitus. in comparison.50). the anterolateral thigh flap. Falcone RE. the thought of operating on the remaining “normal” breast may be a sensitive topic to the patient. problematic skin lesions. King JT. compromise blood supply to the abdominal wall skin potentially compromising flap outcomes (48). . Ann Plast Surg 2010. Zerr KJ. especially if they hope to return to their physically active lifestyle. If the unaffected breast is small. 24: 216–17. Demircin M. Miller AP. Perioperative hyperglycemia is a strong correlate of postoperative infection in type II diabetic patients after coronary artery bypass grafting. Czerny V. Oncologic surgeons often request that previous biopsy incisions be excised at the time of reconstruction. contralateral reduction mammaplasty will improve symmetry and facilitate reconstruction. Rosenthal RA. The chest wall should be examined. 5. Endocr J 2002. abdomen. Verdecchia A. and the need for treatment beyond the reconstructive period. De Angelis R. Breast cancer survivors in the United States: geographic variability and time trends. Eid S. 3. 253: 158. The presence of any masses. This may have a psychological impact on the patient. et al. 27: 115. Goulet JL. et al. For example. Plastischer Ersatz der Brustdrusse durch ein Lipom. Ann Thorac Surg 1997. REFERENCES 1. each of the reconstructive options afforded to the patient. Locations of all scars and biopsy incisions should be documented. Adkinson JM. Munder B. Plast Reconstr Surg 118: 1100–9. Brown S. An overview of preoperative glucose evaluation. Prospective evaluation of immediate reconstruction after mastectomy. Chu E. Watterson PA. Plast Reconstr Surg 2006. 118: 313. 22: 1055–62. Necrosis of abdominoplasty and other secondary flaps after TRAM flap reconstruction. Complications in smokers after postmastectomy tissue expander/implant breast reconstruction. Plast Reconstr Surg 2000. Vilhunen R. The midabdominal TRAM flap for breast reconstruction in morbidly obese patients. Hartzell T. McGreal GT. 30. The effect of radiaton on pedicled TRAM flap breast reconstruction: outcomes and implications. Morbidity of microsurgical breast reconstruction in patients with comorbid conditions. 126: 12–16. ex-smokers and nonsmokers. Kroll SS. Lineaweaver WC. Chuba PJ. Browne E. Bilateral risk of subsequent breast cancer after lobular carcinoma-in-situ: analysis of surveillance. Evans GR. et al. carbon monoxide and atherosclerotic disease. Complications after microvascular breast reconstruction: experience with 1195 flaps. 115: 84–95. Eby JB. Mehrara BJ. 1: 268–70. et al. 14. Kroll SS. 55: 16. 106: 313–17. 10. Complications of postmastectomy breast reconstructions in smokers. Rebbeck TR. Eberlein TJ. Mahajan AL. An acute effect of cigarette smoking on platelet function: a possible link between smoking and arterial thrombosis. Wang HT. 43. Tran NV. Chang DW. 37. Barber WH. et al. et al. 42. 11. Plast Reconstr Surg 2000. Smoking. 38. Cuoco F. Pusic AL. 105: 2374. Gupta A. 19. Carlson GW. Jones G. Punsar S. 25. Kirkland SA. Albino FP. management and perioperative impact. Chang D. Ann Intern Med 2005. Kroll SS. Plast Reconstr Surg 2001. Fisher B. Wang B. Heliovaara M. Tamoxifen for prevention of breast cancer: report of the national surgical adjuvant breast and bowel project P-1 study. and end results data. Bowman BA. Mokdad AH. P. Arch Surg 2011. Plast Reconstr Surg 2006. Ann Plast Surg 2008. Cessation of clopidogrel before major abdominal procedures. Gabbay RA. et al. 236: 450–2. J Diabetes Sci Technol 2009. Circulation 1973. Clinical pharmacology of nicotine. Comparison of immediate and delayed free TRAM flap breast reconstruction in patients receiving postmastectomy radiation therapy. Forman DL. Spear SL. 26. Plast Reconstr Surg 2000. Effect of smoking on complications in patients undergoing free TRAM flap breast reconstruction. Santoro TD. Wang B. Chiu J. Page AL. McCarthy CM. Study for determination of the optimal cessation period of therapy with anti-platelet agents. 40: 360. Olbrich KC. et al. Ford ES. 116: 1873. 60: 568–72. Goldenberg NA. 16. 107: 342–9. Nature 1972. 39. Plast Reconstr Surg 1989. 124: 395–408. platelets. The effect of smoking on flap and donor site complications in pedicled TRAM breast reconstruction. et al. et al. Plast Reconstr Surg 2009. Annu Rev Med 1986. Gabbay JS. 3: 1261–9. Brief communication: duration of platelet dysfunction after a 7-day course of Ibuprofen. 23: 5524–41. 17. 94: 637. Benowitz NL. Haagensen CD. Hartley W. 41. Ducic I. Rohrich RJ. 218: 29. Arcilla E. Complications of TRAM flap breast reconstuction in obese patients. The continuing epidemics of obesity and diabetes in the United States. 20. 15. 2006. Ducic I. Plast Reconstr Surg 2011. The peri-operative implications of herbal medications. 146: 334–9. Hamre MR. 24. Plast Reconstr Surg 2005. Kronowitz SJ. 142: 506–9. epidemiology. Plast Reconstr Surg 2001. quiz A59–61. Yap J. Muskett A. et al. Padubidri AN. Postoperative adjuvant irradiation: effects on transverse rectus abdominus muscle flap breast reconstruction. 200: 564–73. Ann Surg 1993. Plast Reconstr Surg 1994. 18. 34. Tran NV. 90: 1371–88. Low M. Jacobson L. Cahill RA. Bostwick J. Breast volume determination in breast hypertrophy: an accurate method using two anthropomorphic measurements. et al. 33. 127: 1086. et al. 32. BMJ 1978. Crespo LD. Lane N. Wickerman DL. Kulber DA. J Clin Oncol 2005. et al. 21. 31. 29. Karvonen MJ. J Clin Oncol 2004. Robb GL. Lattes R. Chang DW. Sigurdson LJ. Cancer 1878. Manco-Johnson MJ. 35. 85 28. Effects of radiation therapy on pedicled transverse rectus abdominis myocutaneous flap breast reconstruction. Bried JT. 12. et al. Crowe BH. 48: 619–23. 105: 1640–8. Smoking. unipedicled TRAM flap breast reconstruction. Hawkins RI. 23. Goodwin SJ. Lynch HT. 36. Radiation therapy and breast reconstruction: a critical review of the literature.. Hannan C. Yetman R. Plast Reconstr Surg 1995. Peters K. Seidenstuecker K. Ann Plast Surg 2005. JAMA 2001. Ann Plast Surg 1998. Restifo RJ. Lobular neoplasia (so-called lobular carcinoma in situ) of the breast.PREOPERATIVE EVALUATION FOR POST-MASTECTOMY RECONSTRUCTIVE SURGERY 9. 95: 1185. 27. et al. A comparison of morbidity from bilateral unipedicled and unilateral. 13. and thrombosis. Kroll SS. 116: 613. Netscher DT. 44. Plast Reconstr Surg 2010. Ann Plast Surg 2005. 286: 1195–200. 37: 21–32. Robb GL. 115: 764–70. Irradiated autologous breast reconstructions: effects of patient factors and treatment variables. Langstein HN. Constantino JP. Delay of transverse rectus abdominis myocutaneous flap reconstruction improves flap reliability in the obese patient. Breast reconstruction in previously irradiated patients using tissue expanders and implants: a potentially unfavorable result. 118(7 Suppl): 7S. Smith BL. 22. Robb GL. Telem DA. 42: 737–69. et al. et al. Chernoguz A. Levine PH. W. 84: 886. Koltz PF. J Natl Cancer Inst 1998. . et al. Reece G. 54: 570. Effect of obesity on flap and donor-site complications in free transverse rectus abdominis myocutaneous flap breast reconstruction. Plast Reconstr Surg 2005. 40. Spear SL. Sheehy AM. Bilateral prophylactic mastectomy reduces breast cancer risk in BRCA1 and BRCA2 mutation carriers: the PROSE study group. Plast Reconstr Surg 2005. Ling MN. Cuoco F. 108: 78–82. Plast Reconstr Surg 2005. Friebel T. Incidence of breast and chest wall asymmetry in breast augmentation: a retrospective analysis of 100 patients. J Am Coll Surg 2005. The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction. Losken A.86 45. The impact of pfannenstiel scars on TRAM flap complications. 99: 713. Monstrey SJ. Brown MH. Weinberg M. 53: 432. Ann Plast Surg 2004. . et al. AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY 48. McLaughlin JK. discussion 2111–2. 103: 1674. Dayhim F. et al. Blondeel PN. Lipworth L. 50: 322–30. TRAM flaps in patients with abdominal scars. 65: 17–22. Chong N. Takeishi M. Ahn CY. 49. A cohort study of breast cancer risk in breast reduction patients. Plast Reconstr Surg 1997. Outcomes evaluation following bilateral breast reconstruction using latissimus dorsi myocutaneous flaps. Breast reduction surgery and breast cancer risk: does reduction mammaplasty have a role in primary prevention strategies for women at high risk of breast cancer? Plast Reconstr Surg 2004. Tarone RE. Nicholas CS. Shaw WW. 113: 2104–10. Br J Plast Surg 1997. 50. Young VL. Carlson GW. Pinell XA. 46. Plast Reconstr Surg 1999. Ann Plast Surg 2010. et al. 47. Vanderstraeten GG. Wilkins EG. In a survey of female. migration. patients should be well apprised of the potential drawbacks of implant-based breast reconstruction. 86. worked with Dow Corning Corporation to develop the first silicone breast implants. Current guidelines entail a baseline MRI after three years followed by MRIs every two years thereafter. Cronin and Gerow. Patients need to be informed about standard complications inherent to implants. Therefore.424 women underwent breast reconstruction in 2009 (1). have expanders. boardcertified plastic surgeons in the United States. Since then. an implant may fail to produce a comparatively “normal” shape. infection. Women can be self-sufficient within a short period of time allowing them to return to work quickly with good levels of function. Many patients worry that reconstruction will hide a recurrence so this information is comforting. When matching an unoperated contralateral breast. half would still choose expanders for their own surgery. the deep margin of the resected breast is above the device and is thus palpable. Two thirds of these women (56. themselves. Further. and there is no risk of hernia or abdominal weakness.10 Tissue expansion reconstruction Sheri Slezak and Tripp Holton According to statistics reported by the American Society of Plastic Surgeons. Patients are typically hospitalized for 24 hours or less and the recovery time is generally 1–2 weeks. Of the female plastic surgeons who primarily perform implant-based surgery. Of the women who do primarily autologous tissue for their patients. it confers no new scars in other areas of the body. Conversely. and it is minimally invasive. soon thereafter. and exposure and that these are more likely to happen after radiation therapy. contracture. including rupture. Cancer surveillance is not adversely affected by the presence of an expander or an implant since these are placed beneath the pectoralis major muscle. These patients should also recognize that tissue expansion can be time-consuming and will require future surgery. palpability. TISSUE EXPANDERS AND BREAST IMPLANTS In 1957 Neumann was the first to use tissue expansion for reconstructive surgery. Implant surveillance should also be discussed. wrinkling. This approach has a short procedure length. His use of a rubber balloon to expand the temporo-occipital skin provided soft tissue coverage for an ear reconstruction (3). there has been a steady improvement in both technology and technique for tissue expansion and implant-based reconstruction for breast deformities. There are many reasons that surgeons recommend and women choose implant-based reconstruction.5).978) opted to have tissue expansion and subsequent placement of an implant. rippling. 66% reported that they would choose implant-based reconstruction for themselves if they had mastectomies (2). 87% would. But it was not until the mid-to-late 1970s that Radovan and Austad independently reported their respective experiences using tissue expansion for breast reconstruction (4. 87 . and this is filled in the office (Fig. and the probable volume of the breast to be reconstructed. Expanders can be filled well beyond their intended volumes so that an exact size match is not necessary when choosing a size in the operating room. A second anterior chamber is located only in the lower pole. At this time in the United States breast implants are saline or silicone-filled and have either textured or smooth surfaces. and as far medially as possible to maximize medial cleavage and ptosis. Current silicone implants are made with a cohesive gel filler that has more crosslinking between silicone molecules than the silicone filler of previous generations. Some surgeons prefer to use expandable implants. These salinebased.2 A–C). the shape of her breasts. profiled and dual chamber expanders were developed. The simplist device is a round expander with a single chamber. Choosing the size of the tissue expander will depend on the diameter of the patient’s chest. Profiled expanders allow the lower pole skin to stretch more than the skin of the upper pole. Ports can be integrated or remote. profiled. and (C) a Mentor CPX3 profiled expander. Choices include round.88 Tissue expanders are now manufactured in a wide variety of sizes. and expanders that become permanent implants. The FDA is currently studying profiled form-stable cohesive “gummy bear” silicone implants and these may soon be available. . The anterior chamber is round and has a port located superiorly—this is filled intra-operatively. (B) a Sientra dual chamber expander. This provides a reasonably accurate estimate of the volume to be replaced unless the reconstruction is done to match a large concurrent reduction to the contralateral breast. limit silicone leakage and migration Figure 10. This technology seeks to increase the life span of the device. shapes and designs. An advantage of this round expander is that they tend to provide a uniform and reproducible result and if they rotate it does not distort the shape of the skin envelope. it is important to place the bottom of the expander right at the inframammary fold.1). which enables the expansion to create an envelope that can house a natural. ptotic-appearing breast. or silicone/saline hybrid devices are sequentially inflated via a remote and removable port.1 (A–C) Various breast tissue expanders are available. This novel design allows for the AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY tissue expansion and permanent implants to be delivered through only one major surgery and a separate minor procedure. Intra-operatively. a separate incision is made over the port and it is removed by pulling the tubing through a double sealing system. dual chamber. Many models have tabs that can be sewn to the muscle to prevent displacement. 10. Some surgeons use a one-shape-fits-all approach whereas others utilize different types for various patient morphologies (Fig. Silicone implants are round and are offered in various projections. Pictured here are: (A) A Natrelle expander by Allergan. Once appropriately expanded. 10. Saline implants come in round or profiled shapes. In order to expand the skin envelope into the shape of a natural breast. The mastectomy specimen can be weighed intra-operatively to check the size. Dual chamber models have separate anterior and posterior chambers. (A) Pre-operative view. While many surgeons have lauded the qualities of new anatomically shaped expandable implants. Gahm et al. and offer a more natural. her physical requirements for work. anatomic shape. recently published a study comparing profiled with round expandable implants and found no difference in cosmetic outcome or patient satisfaction (6). which serves to minimize silicone gel bleed. While the shells’ outer layer is still composed of a mix of dimethyl siloxane and amorphous silica they now have an inner barrier coat of diphenyl (A) 89 siloxane.2 (A–C) A patient undergoing reconstruction with dual chamber expanders. Modern implants are vastly superior to those of previous generations. (C) On profile view. (B) Expanded to volume. and (B) (C) Figure 10. The strength of these new shells far exceeds the minimum acceptable level set by the American Society for Testing and Materials. the shape of her body. Note the differential expansion of the lower pole compared to the upper pole.TISSUE EXPANSION RECONSTRUCTION should rupture occur. . PATIENT SELECTION The patient will ultimately select the type of reconstruction that she wishes to have based on her health. sports. In the Michigan Breast Reconstruction Outcome Study. It may take several visits to have all of their questions answered. it may not be worthwhile. There is no time limit in which expansion must be completed. Occasionally. Often. then the expander can be left empty to place less stress on the flaps. and the size of the breast. If too much is placed at once. the expander is partially filled in the operating room. 10. 82% underwent immediate reconstruction whereas only 18% selected a delayed reconstruction (10). The Michigan Breast Reconstruction Outcome Study reviewed psychosocial outcomes at one and two years. or at the patient’s preference or convenience. Patients must absorb a lot of information in a short period of time. the patient who asks for the “simplest reconstruction possible” is not a good candidate for a potentially time-consuming and complex microvascular reconstruction with secondary surgical sites. of the women who elected to undergo implant-based reconstruction. the quality of the muscle coverage. it is incumbent upon the reconstructive surgeon to differentiate the reconstructive process from the implantbased cosmetic augmentation with which most patients are peripherally familiar. We have the mastectomy specimen weighed. and axillary infections. Thirty-six percent of the women who underwent delayed reconstruction in the Michigan study developed complications. A striking 52% of patients in the immediate group developed complications. with no scars or recovery period. and often information that she discovers on the Internet.3 A–D). family. but this is time well spent. That study found that both immediate and delayed reconstruction with implant and TRAM methods provided substantial psychosocial benefits to patients as measured by the Short Form—36 and the Functional Assessment of Cancer Therapy—Breast (9). friends. but the shape of the breast should not be altered during radiation therapy because the computer-generated dosing plan would be compromised. Patients must be adequately informed of the possible methods and complications of breast reconstruction. fresh mastectomy flaps which may have unapparent ischemia.90 hobbies. It is in everyone’s best interests to have a full discussion of reconstruction methods and complications and to let the patient decide what reconstruction she will have. for example. Some studies show less mourning and a faster return to daily activities if women have some form of reconstruction started at the time of the mastectomy. patients should not be promised absolute symmetry or perfection. Expansion can be continued during chemotherapy. They must know that no reconstruction at all is a reasonable and safe option. In the study by Alderman. The tissue expanders are then filled in the office by the physician or by an appropriate physician extender (Fig. This may be partially explained by the fact that immediate reconstruction will include the complications of the mastectomy as well such as seromas. the best way to manage complications is to have helped the patient develop a reasonable set of expectations. to persuade a patient into implant-based reconstruction if they start with a clear fear of implants or a desire for autologous reconstruction. chemotherapy or radiation therapy may be needed in the postoperative period. and the length of the recovery period that she is willing to accept. and this helps us choose the expander and predict the target volume for expansion. and they can feel pressured while doing so because of their cancer. the patient has considerable pain from stretching of the muscle. There is little data to tell us if the formation of a capsule or the “stretch-ability” of the skin is affected by the time course of expansion. so that reconstruction is begun with a single operation. And while implant-based reconstruction may seem like the easiest method of reconstruction. Reconstruction is not a surgery without risks. Ninety percent of normal non-operated women do not have symmetrical breasts (7). and the need to heal quickly if chemotherapy is recommended. We aim for a 50% fill in the operating room—enough for the patient to see some shape but not enough to give them severe pain or to compromise the flaps and incision. IMMEDIATE VERSUS DELAYED RECONSTRUCTION Tissue expansion reconstruction may be started at the time of mastectomy. major complications occurred in 46% of patients in the immediate group and in 21% of the patients in the delayed group. FILLING THE EXPANDER Generally. mastectomy flap necrosis. uncertainty about the need for post-operative radiation. Similarly. . biweekly. She will be guided by advice from doctors. Often. AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY The disadvantages of immediate breast reconstruction include a longer operative time. anesthesia. Specifically. and recovery period. The valve is found with a magnet or by palpation and 30–120 cc of fluid is placed per session. and expanders have been left in place for extended periods without difficulty. The amount of fill in the operating room can be varied given the thickness of the flaps. Fills are continued weekly. If the mastectomy flaps are thin or of questionable blood supply. First. Many women wish to do this at the time of the mastectomy. Patients also need to realize that this surgery has risks. her tolerance for complications. a tissue expander must be deflated so that a radiation beam can be effectively aimed at the internal mammary nodes. or it may be commenced at a later date. While it is nearly impossible to counsel patients without injecting one’s own bias. both implant-based and autologous breast reconstruction had complication rates of 52% (8). Anderson Cancer Center. at M. the initially placed saline-filled expander can be deflated to accommodate appropriate radiation therapy which is improved when a filled expander is not obstructing the standard three-beam delivery of radiation. (D) The completed reconstruction with areolar tattooing. first described the concept of delayed-immediate breast reconstruction. Should post-mastectomy radiation be recommended.D. In short. if needed. By fast-tracking reconstruction it can prevent unnecessary delay of adjuvant chemotherapy. this pre-placed expander is utilized and the breast skin is recruited in an effort to house an autologous tissue flap or implant (11). (A) Pre-operative view of a patient with left breast cancer. Since the need for radiation cannot always be predicted at the time of mastectomy. this expander is replaced with an implant within two weeks. Should radiation not be warranted. (C) After exchange of the left tissue expander for a permanent implant. (B) Filling of the left tissue expander (the right breast has been augmented with a permanent implant).TISSUE EXPANSION RECONSTRUCTION 91 (A) (B) (C) (D) Figure 10. he proposed the empiric placement of a saline-filled tissue expander at the time of skin-sparing mastectomy. Kronowitz. Once radiation is completed. This approach preserves the skin envelope and the natural ptosis of the breast while allowing a fully reconstructed breast to heal promptly. this protocol affords non-radiated breasts the full aesthetic benefit of a skin-sparing mastectomy while protecting .3 (A–D): The process of tissue expansion. not twins. Feldman et al. and repeat expanders attempts were each significant predictors of expander infection risk (14). and are more comfortable. using multivariable analysis. it is harder to eradicate.4).7% in reconstruction patients (13). but if the infection involves the pericapsular space and implant. When the expansion is complete. Some surgeons prefer to over-expand patients by 10% or so to increase skin redundancy and obtain more ptosis. We find that a vast majority of mastectomy patients prefer silicone implants because these are softer. 10. Similarly. move with the patient. These findings should be considered when choosing an empiric course of antibiotics for patients with implant-/expanders-related infections. Spear and Seruya studied the treatment of infected implants and found that 64.4% whereas McCarthy (12) found that in 1170 patients who underwent implant-based reconstruction 3. the Mentor Core Study reported an infection rate of 5.4% of patients developed an infection not requiring prosthesis removal and 1.4 Outcome Study (10) the infection rate was 35. studied post-operative tissue expander infections and found. different amounts of fill are needed on different sides. feel more like normal tissue. that breast size larger than “C. In the Michigan Breast Reconstruction Figure 10. The goal of expansion is symmetry with the opposite breast. At this second operation. The authors concluded that relative contraindications to salvage include atypical pathogens on wound culture such as MRSA. the target is symmetry to the size of their choice. Often. In the series reported by Throckmorton 60% of breast infections were caused by staphylococci and the remaining infections involved Gramnegative rods/anaerobes (40%) (15). capsules may be altered. They also note that a heightened concern for recurrence should exist for Infection of a recently placed left tissue expander demonstrating redness and swelling. This is generally an outpatient procedure and is very well tolerated by patients.5% of patients developed an infection necessitating explantation. . Francis et al.4% could be salvaged with a combination of operative treatment and/or antibiotics (17). Superficial cellulitis can be treated with antibiotics. also found that two-thirds of breast infection cultures grew Staphylococcus aureus and that two-thirds of these were methicillin-resistant (16). For the bilateral patient. and excess skin can be revised to complete the reconstruction. secondary surgery is scheduled to remove the expander and place a permanent silicone or saline implant. as the muscle and/or flap is thicker on one side than the other. nipples made. Candida parapsilosis. COMMON COMPLICATIONS AND HOW TO AVOID THEM Infection Infection remains the most feared complication of implantbased reconstruction because it can cause the loss of the entire effort (Fig. patients must understand that breasts are “sisters. Despite revisions.92 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY radiated reconstructions from the problems caused by radiation delivery to an immediate reconstruction.” previous irradiation. Importantly. half of the staphylococcal isolates were drug-resistant.” and that perfect symmetry is not present in 90% of normal un-operated women. and Gram-negative rods. or 5 days (20). In the Inamed Silicone Breast Implant Core Study. A systematic review of the literature from 2007 demonstrated that povidoneiodine irrigation compared to saline. Further. Compared to those patients who received a topical antibiotic wash. The Michigan Breast Reconstruction Outcome Study found a rate of 15. surgery and continuous peri-prosthetic irrigation with saline and intermittent antibiotic infusion.2% (10). it is wise to abandon the reconstruction and restart after the cancer treatment is complete. and the use of infection prevention measures at drain sites. A drain is placed and the infection typically improves rapidly.” These recommendations stem from early data thought to link betadine exposure to implant rupture. The findings from Khan’s study parallel the data from general surgery demonstrating that appropriately timed and dosed peri-operative antibiotics decrease surgical site infections when compared to either no antibiotics or prolonged post-operative dosing.9% at 6 years (31). the cohort denied this treatment experienced a statistically significant increase in the rate of infections and seromas.26). Strategies to prevent infection include appropriate use of antibiotics. fluid drainage. They found that Staphylococcus aureus infection was associated with poorer salvage rates but that previous radiation to the chest wall did not affect the salvage outcome (18). and should the time for chemotherapy to start be reached. Chun and Schulman similarly reported the salvage of nine expanders using intravenous antibiotics. Pfeiffer et al.30). This is of dual interest as bacterial infection or colonization of implants has been associated with the development of capsular contracture. We often do this in the office. that the antibiotic is re-dosed throughout the case if needed and that any peri-operative antibiotics are stopped on schedule.” change of gloves and re-prepping. In the Mentor Core Study it was 8. a history of radiation or a wound culture demonstrating resistant Staphylococcus aureus.3% in primary reconstructions and 16. manual debridement. . Historically. water. Khan studied implant patients given antibiotics as a pre-operative dose alone or followed by intermittent post-operative dosing for 24 hours. this solution has been shown to reduce rates of capsular contracture when used to wash implant pockets (25. Several groups have investigated the role of chlorhexidinegluconate impregnated sponge (Biopatch) dressings in prevention of infection or colonization at access sites for percutaneous indwelling foreign bodies such as pin sites for external fixators as well as epidural and central venous catheters. use of irrigation solutions. used cephalothin irrigation for infection prevention in cosmetic breast augmentation surgeries (28). Topical installation of antibiotic fluid or washing of implants has been cited as beneficial for infection prevention. Weekly Biopatch changes for pin-site care of wrist external fixators was no more efficacious than either weekly dry dressing changes or daily pin-site care with a normal saline and peroxide mixture and was accordingly not recommended by Egol et al. it is 1 or 2 cm from the incision. Capsular Contracture: Baker Grades III and IV Capsular contracture has been a vexing complication since breast implants were introduced in 1960. Newer data clearly demonstrates that appropriately utilized topical betadine fails to mediate a deleterious effect on the integrity of implants (29.3% in reconstruction revision patients at 10 years (13). Mann et al. or no irrigation was beneficial in lowering surgical site infections in general (24). Should infection be severe. device exchange. it is best to remove the expander. and curettage of the infected pocket. Yii and Khoo reported salvage for 9/14 infected implants using a rather austere combination of intravenous antibiotics. It is important to note that salvage of a breast reconstruction must be deemed less important than the treatment of the breast cancer. Removal of the expander is quite easy as the area is numb. the Baker III/IV capsular contracture rate was 15. Used together. It is essential for the surgeon to ensure that the right antibiotic is given at the appropriate time interval before skin incision. However. found a 93 profound decrease in bacterial colonization for epidural catheter sites covered with the Biopatch (22). Allergan’s product insert states: “do not allow the implant to come into contact with povidone iodine.TISSUE EXPANSION RECONSTRUCTION patients with prior devise infection/exposure. Current manufacturer recommendations (see Mentor MemoryGel silicone gel-filled breast implants product insert) warn against immersing the implants in betadine (povidone iodine) and notes that if betadine is used in the pocket it should be rinsed thoroughly so that no residual solution remains in contact with the implant. He found that a single dose of preoperative antibiotics resulted in the lowest incidence of infection. a “no-touch technique. but evidence is lacking at this time. a regimen of povidone-iodine wash of the breast pocket and topical irrigation with antibiotic solution reduces infection rates in breast implant surgeries compared to povidone-iodine alone (27). and try again if the patient desires. and post-operative antibiotics (19). and it can be deflated and removed from a small incision. wait a minimum of two months. Use of these patches on mastectomy drains may confer a benefit. Levy’s randomized controlled study evaluating central venous catheter entrance sites demonstrated a decreased incidence of catheter site colonization but no difference in the incidence of bloodstream infections between Biopatched patients and patients with a polyurethane insertion site dressing (23). the rate has been reported as high as 40%. (21). saline instead of silicone filler. or Terramycin® all were able to resist biofilm formation at seven days (35). Hwang found numerous myofibroblasts within contracted capsules and correlated contractures with the tensile strength of the studied specimen (37). saline versus silicone. Fucidin®. Tumor necrosis factor-α has been associated with capsular contracture in seven patients studied on a biochemical level by Tan et al. implants were thought to no longer leech significant amounts of silicone into the peri-prosthetic space. Van Heerden’s group investigated numerous antimicrobial agents directed against the formation of implant-associated biofilms excreted by Staphylococcus epidermidis. those with capsular contracture had a positive culture rate of 33% whereas those removed for other reasons had a 5% positive culture rate (32). Staphylcoccus epidermidis and Corynebacterium. There was a significant decrease in firmness at six month in the Accolate group when measured with a mammary compliance device. Weintraub et al. 10. subclinical infection. capsular contracture remains a source of patient and surgeon dissatisfaction (Fig.5 A–B).6% of positive pockets developed capsular contracture (34). Schreml found a 66. cultures were positive for Propionbacterium. (36). or interval of time between expander and implant placement. It was noted by Huang et al. Tamboto induced a Staphylococcus epidermidis biofilm layer in a pig model and 80. was able to demonstrate that (A) implants pretreated with topical Chloramex®. using an in vitro model. studied patient factors in capsular contracture and found no effect from smoking. a leukotriene antagonist was studied in a prospective study of 120 women (39). Operative technique adopted to address capsular contracture revolved around placing the implants in a submuscular or dual-plane location. Forceful mechanical disruption of the capsule has been attempted but ultimately not embraced because of fears of also rupturing the underlying implant.5 (A–B) (A) Left capsular contracture 10 years after reconstruction with a left sided silicone implant. The study group was given Accolade for 6 months and a control group was given Vitamin E. Fifty years later. Treatment with Accolade (zafirlukast). Physicians have tried various treatments: submuscular or dual-plane implant placement. find that complications which required the disruption of a capsule around a permanent implant greatly increased the risk of developing pathologic contracture (38). leukotriene antagonists administration. allergy. and capsulectomy all with various degrees of success. acellular dermal matrix coverage. This data is incomplete and the studies are of insufficient power to prove efficacy. (B) Status post left capsulectomy and replacement of a new silicone implant and contralateral peri-areolar scar revision. textured shells. Textured implants were also designed during this period and thought to form a less organized scar. In Del Pozo’s study of explanted breast prostheses. and patient factors have all been hypothesized. however. Use of these drugs for capsular contracture remains an off-label (B) Figure 10. Various causes for the formation of a contracted capsule have been proposed: silicone bleed. prior radiation. Singulair (montelukast) is also a leukotriene antagonist. foreign body reaction. This group. They did. In that study. vitamin E therapy. to improve and prevent capsular contracture in 83% of 19 patients treated (40). bacterial biofilm formation. .94 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY With the advent of increasingly sophisticated outer shells. It was thought that this would help decrease the incidence of capsular contracture.7% colonization rate for Baker III and IV capsules whereas no colonization was detected for Baker I or II capsules (33). The SPY® Elite Intraoperative Perfusion Assessment System is becoming increasingly popular in breast reconstruction. but we do not yet have a good solution for patients affected by this vexing complication of implants. We vary the amount of expander fill placed in the operating room based on the condition of the flaps.5% for revisions (13). and allows a stretchable area in the lower pole. It is . whichever is needed. This may be done in several ways. A mastectomy. Plication involves scoring or damaging the capsule to be closed and then placing 2-0 Vicryl or Gortex sutures. The expander is placed and the ADM is sewn to the upper edge of the muscle. The precision of the dissection and subsequent viability of the flaps hinges on the skill and experience of the ablative surgeon.3% in primary reconstruction and 3. Mastectomy Flap Ischemia An expander and subsequent implant can only succeed if there is an adequate skin envelope to surround it. As one expands the device. Before placement of any expander. the flap and muscle coverage must be assessed. Spear had 16 patients with capsular contracture that were treated with ADM placement after capsulectomy: no recurrent contractures were seen after an average of eight months’ follow-up (41). presence of a layer of fatty subcutaneous tissue on the underside of the flap. Questionable areas may be excised as long as there is adequate skin to close the wound. Submuscular placement of the expander keeps the upper portion of the expander in place. If inadequate. Hematoma or Seroma The risk of hematoma in the Mentor Core Study was 1. not the actual pocket. and foreign body giant cell inflammation were seen in the ADM group (42). yields thin flaps since the primary objective is to eliminate breast tissue. We pie-crust the ADM and use only one drain since there is free communication above and below the sling. Clearly. Acellular dermal matrix (ADM) has been shown by several authors to decrease the rate of contracture. and we need to evaluate the biochemical modulators within wounds that might create conditions for this excess scarring. bleeding from the edge of the flap. from 0 fill to 450 cc. It is of fundamental importance to develop a close working relationship with the surgeon performing the mastectomies so that they can find the appropriate balance between removing breast tissue and preserving skin flaps.9%)—especially when the prosthesis is placed into a fresh mastectomy bed.44). dissecting lateral to the anterior axillary line and sometimes below the inframammary fold. The perfusion of the flaps determines the success of the expander. Drains are generally needed and some surgeons use two. and refill with pressure. capsule fibrosis. Some surgeons leave extremely thin flaps whereas others dissect on the superficial fascia of the breast. the deep fascia and the dermis of the fold to secure it to the chest wall at the desired place. The location of the tumor can also affect the design and integrity of the mastectomy flaps as well. The suture catches the ADM. by necessity. or plicated. This keeps the caudal edge of the pectoralis major muscle pulled down over the implant. a 6 × 12 cm piece of medium thickness ADM is pie-crusted and sewn to the inframammary fold. tightens and fixes the inframammary fold. Implant Displacement With immediate placement of a tissue expander one must recognize that the ablative surgeon typically opens a wide pocket. chronic inflammatory changes. Expander displacement may also be addressed if needed at the second operation during which one exchanges the expander for the permanent implant. The other option is to secure the expander to the chest wall by sewing down the tabs that several of the expander models have. it is better to delay the reconstruction or plan to bring in new tissue with the use of autogenous flaps. the lower pole is more easily expanded and this gives a better shape. 95 We place little value on information garnered by fluorescein injection although we have tried this technique in the past. more research into the effects of leukotriene inhibitors for the treatment of capsular contracture is warranted. Flaps may also vary in their thickness in different areas. but if the muscle is not secured it can contract superiorly and the expander is easily displaced into the supramuscular plane. The formed capsule can then be lowered. Decreased levels of granulation tissue. Our understanding of capsular contracture has progressed but is still underdeveloped. Clearly. The use of ADM has substantially helped the problem of displacement. widened. Seromas are much more common (4. fibroblast cellularity. The tissue expander must be fixed in place in order to expand the desired pocket. The mastectomy flaps should be examined for thickness. Basu also used ADM as a peri-implant sling and studied the capsule implant at the time of exchange. more information is needed to determine the cause of capsular contracture.TISSUE EXPANSION RECONSTRUCTION but promising indication for these agents. In this technique. This technology provides an accurate and real-time assessment of skin flap viability during immediate implant-based breast reconstruction and can also be utilized during microvascular breast reconstructions (43. Rates of contracture seem to be lower. The expander may then sit more laterally than desired and expand the subaxillary space. Baker III or IV capsular contracture can substantially undermine a patient’s satisfaction with reconstruction. If close to the goal volume one may simply proceed to implant exchange. If this is not acceptable to the patient then an autologous flap may be a better choice for them. The surgeon can also disguise ripples by placing ADM beneath the flap to increase the thickness or tighten the muscle and capsule. Many mastectomy flaps are very thin and the folds in the implant are visible—a reconstruction is. after all. Failure. Most patients realize that an implant is not real.7). Expander Deflation. not real. Visible rippling or wrinkling was seen in 10% of patients in the Inamed Core Study and in 3–7% of reconstructions in the Mentor Core Study (Fig. If not. The wound will dehisce if the flaps are ischemic or if the expander/implant is too large and puts pressure on the incision. The product inserts from Mentor and Inamed are replete with helpful suggestions designed to protect the implants. Silicone implants should be used. CA). There are good aspiration kits for office placement of drains if the collection is large or persistent. whichever comes first. There is no conclusive data to guide the decision to aspirate secondary seromas or to let them resolve passively. 10. the expander must be replaced. Clearly. A technique that distributes force broadly onto the implant will protect the integrity of the shell compared to a technique in which a single digit is used to force the implant through the access site. We use the 14 gauge Blunt Seroma Cath® and attach it to a Sapphire Suction Reservoir™ (both products: Greer Medical. If the flaps are thin and questionable.. Fat injections into the flaps can also disguise ripples. Santa Barbara. With the double chamber model. Persistent and high drainage may be a sign of a subclinical infection or a lymphatic leak. 10. There are several strategies to correct this. Late dehiscence is usually a sign of infection (Fig. care must be taken to avoid puncturing a device with instruments and needles—the swedged end of a needle can be as injurious as the tip. but this fluid is also a good media for infection. .6).6 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY Thinned scar and wound dehiscence with exposure of underlying implant during chemotherapy. removed when the drainage is down to 30 cc a day or at three weeks. The increased pressure of the seroma can make the process self-limiting. the device may be weakened or injured if placed through an access incision that is too small— this is especially true for implants rather than expanders. Wound Dehiscence Rippling and Contour Deformities The success of the reconstruction depends on the success of the mastectomy flaps. or it can be accidentally injured at the time of surgery or during injections in the office. When implanted. one can merely expand the remaining intact chamber. Inc.96 Figure 10. It is generally only ripples in the cleavage area that are bothersome to the patient. and Rupture The expander can have a mechanical fault. A latissimus dorsi flap can also be rotated under the skin to provide more muscle coverage. it is better to abort the reconstruction or place no fluid at all in the expander. as they show less ripples than do saline models. The pathological examination of the contralateral side is also comforting to the patient if it is normal.TISSUE EXPANSION RECONSTRUCTION Figure 10. The latissimus dorsi myocutaneous flap or the thoracodorsal artery perforator flap can both add reliable soft tissue to the implant-based breast reconstruction. despite a normal mammogram (45). 10. or unable to stretch. This can be done initially to her desired cup size. rather than the upper. the choices are further expansion or the addition of skin in the lower pole with a latissimus dorsi flap. Whereas an autologous reconstruction can be placed temporarily with all of its skin behind marginal mastectomy flaps and tailored back in the operating room after the flaps declare themselves. Generally. 10. this is a patient who should leave the operating room with either no expander or an expander that is completely deflated. the surgeon needs to add skin and/or muscle to cover the expander. 10. This defect can be caused by an inadequate skin envelope and/or capsular contracture. It is important to recognize this patient preoperatively. she needs to consider reduction of the contralateral side (Figs.78% of reductions in the contralateral breast of women with cancer have a pathological finding of cancer. Profiled expanders and implants are useful to selectively stretch the lower. PITFALLS AND HOW TO SOLVE THEM Insufficient Skin and Subcutaneous Tissue to Support an Implant In this case.7 97 Wrinkling of the right-sided upper inner pole. The use of ADM slings has substantially decreased this problem (Fig. or the reduction can be done secondarily at the expander to implant change. and are very pleased with the new look. and then aim the reconstructed side to this volume. This can replace skin that is too thin. The Contralateral Large and/or Ptotic Breast An implant will not match a heavy ptotic breast and the top size of implants is only 800 cc. technology like the SPY® can help to better determine that tissue which should be excised immediately. the surgeon can locate the area in question for further resection. If the volume of skin is insufficient due to loss of portions of the mastectomy flaps. so that a failure is prevented.10). We have found that 1. It is less heavy.11 A–C). We use a medium thickness matrix (approximately 1 mm) because we want this to stretch easily. If available.8 A–B. too radiated. Inadequate Ptosis Inadequate ptosis is historically the most common problem after implant-based reconstruction. If a patient has more volume than this. patients with larger breasts are delighted to have a reduction.9 A–B and 10. particularly when compared to a contralateral mature ptotic breast. skin. mastectomy flaps over tissue expanders or implants must be closed immediately. It is important to orient and identify these contralateral specimens so that if something is found. Patients may also consider removal . If the viability of the flaps is in question. The implant sits too high on the chest and has too much upper pole fullness. We label tissue from reductions based on the quadrant of resection. and they look like they have lost weight. If the patient’s skin is radiated and shows severe telangectasis. Non-stretchable Skin Envelope Figure 10. of the expander and the placement of an autologous tissue flap. B) (A) Pre-operative patient with previous right lumpectomy and radiation.10 Post-operative result after unilateral implant reconstruction by mastopexy of the contralateral breast. (B) Post-operative view with immediate right-sided 800-cc implant and contralateral reduction with free-nipple graft. then it is doubtful that this skin will successfully expand. current evidence is divided with regard to radiation and the development of complications . However. hyperpigmentation. and/or skin thickening.8 (A. The breasts were too large to match without contralateral reduction.98 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY (A) (B) Figure 10. radiation is not a contraindication for expansion in all cases. as this bridge has not been burned by expander reconstruction. Radiated. (A) (B) Figure 10. parenchymal asymmetry. (B) Post-operative result after bilateral expander/implant reconstruction and completion of nipple tattooing. Despite what we are taught about radiation.9 (A–B) (A) Pre-operative patient with previous lumpectomy and positive margins. Alternate methods of reconstruction should be chosen. performed a retrospective comparative study of 1170 expander/implant patients over 2 years (Level II). This usually gives a good. We have seen great changes in radiation techniques over the last 20 years. It is then secured through the ADM and fascia and tied. (Level IV) studied 103 women with BRCA gene mutations undergoing prophylactic mastectomy with immediate expander/implant reconstruction. We use an eight-point system to grade radiation. this trend did not reach statistical significance (10). (C) Final post-operative appearance.TISSUE EXPANSION RECONSTRUCTION (A) 99 (B) (C) Figure 10. Contant et al. Patients with lower numbers do well with expander reconstruction. the . which is not tightly adherent like a normal fold. patients are not typically distressed by it. telangectasia. however. Intraoperatively. We use 2-0 absorbable sutures. Radiation was found to be a significant risk factor. giving better long-term results. Radiation oncologists believe that the tangential beaming targets the breast parenchyma more so than the skin. and determined that preoperative or postoperative chest wall irradiation was not significant predictor of complications (12). They must. This can lead to a displaced and/or detached fold. radiotherapy. then it can be revised at the implant exchange operation. however.11 (A–C) (A) Pre-operative patient with significant ptosis. and the suture is brought from beneath to the deep dermis where it can be seen dimpling the skin. crisp fold. We can. Lack of a Crisp Inframammary Fold The inframammary fold is often obliterated during mastectomy by the general surgeon. If the contracture is Baker grade II. often see no residual changes in a radiated patient’s skin as compared to her other breast. In the Michigan Breast Reconstruction Outcome Study (level II evidence). For severe problems. now. giving 0–2 points for each of skin thickness. but if it is Baker grade III. (B) Acellular dermal matrix sling allows the tissue expanders to sit low in order to expand the lower poles thus creating an age-appropriate ptotic appearance. hyperpigmentation. both for complications and for implant removal (46). they will usually pursue capsulotomy to address the tightness. the fold should be sutured to the ADM and fascia in the desired place. during breast reconstruction. It seems that some radiated patients do well and others do not. McCarthy et al. and parenchymal shrinkage. If the fold is incorrect after expansion. be warned that some late capsular contracture is seen in approximately 40% of these reconstructions. both before and after surgery was associated with at least one complication. pdf] 2. The expansion of an area of skin by progressive distension of a subcutaneous balloon. Amalfi AN. Breast augmentation. 7. Kronowitz SJ. 124: 1790–6. The efficacy and risks of using povidone-iodine irrigation to prevent surgical site . Preferences in choosing between breast reconstruction options: a survey of female plastic surgeons. 29: 600–3. such as ADM slings and profiled expansion. 23. Stevenson KB. Sharabi SE. Lowery JC. Independent risk factors for infection in tissue expander breast reconstruction. It is imperative that you discuss the importance of the fold with your ablative surgeons. 24. Inamed silicone breast implant core study results at 6 years. Wright JG. and more research is needed to identify and prevent this problem. Khoo CTK. 11: 355–9. Implant-based reconstruction is efficient and cost effective and will continue to be popular in the evolving health care environment. Cunningham B. Kuhn LE. New memory gel implants have cohesive silicone and do not leak as much if ruptured. Radovan C. a chlorhexidine impregnated dressing. Baddour LM. Puopolo S. and infection: comparative analysis of 1. Breast reconstruction after mastectomy using the temporary expander. The short operating and recovery period are the primary reason that women choose implant-based surgery. Slicton A. Plast Reconstr Surg 1982. Walker PS.628 primary augmentation mammoplasties assessing the role and efficacy of antibiotics prophylaxis duration. Alderman AK. 12. Levy I. Chlorhexidine-impregnated dressing for prevention of colonization of central venous catheters in infants and children: a randomized controlled study. 34: 42–7. 4. et al. Anaesth Intensive Care 2001. 125: 463–74. Ann Surg 2008. Edsander-Nord A. Plast Reconstr Surg 2008. More durable models of implants are being produced with longer life spans. Incidence of breast and chest wall asymmetry in breast augmentation: a retrospective analysis of 100 patients. Aesthetic Plast Surg 2010. Hoskin TL. Plast Reconstr Surg 1982. 6. Chun JK. Solter E. 120(7 Suppl 1): 19S–29S. so that they are cognizant of its importance in reconstruction. Microbiology of surgical site infections complicating breast surgery. Mann TJ. Plast Reconstr Surg 2007. 124: 1781–9. Patients are often happy to alter the opposite breast by reduction or mastopexy if they do not like its appearance. et al. 16. Langstein HN. Plast Reconstr Surg 2006. 204: 7–12. The Mentor Core Study on silicone memorygel breast implants. 120: 581–9. Sbitany H. antibiotic prophylaxis.plasticsurgery. Neumann CG. Plast Reconstr Surg 2002. Jurell G. 121: 1886–92. 3. 88: 349–54. 70: 588–94. Bilateral expanders and implants for bilateral mastectomies match. Plast Reconstr Surg 2007. American Society of Plastic Surgeons (2010).org/Documents/Media/statistics/2009-UScosmeticreconstructiveplasticsurgeryminimally-invasivestatistics. McCarthy CM. 5. Complications in postmastectomy breast reconstruction: two-year results of the Michigan Breast Reconstruction Outcome Study. et al. Austad ED. Mehrara BJ. Orlikowski CE. 22. Kim HM. 118(7 Suppl): 7S–13S. Gahm J. Prospective analysis of long-term psychosocial outcomes in breast reconstruction: two-year postoperative results from the Michigan Breast Reconstruction Outcomes Study. 126: 1419–27. 111: 1087–92. The infected breast prosthesis after mastectomy reconstruction: successful salvage of nine implants in eight consecutive patients. Atisha D. Spear SL. J Am Coll Surg 2007. on bacterial colonization of epidural catheter exit sites. Alderman AK. With the use of techniques to give ptosis and a natural shape. No differences in aesthetic outcome or patient satisfaction between anatomically shaped and round expandable implants in bilateral breast reconstructions: a randomized study. Riedel E. Breast implant infections: is cefazolin enough? Plast Reconstr Surg 2010. Hartley W. Khan UD. Brown S. CONCLUSIONS There are many advantages of tissue expansion for breast reconstruction as compared to autologous reconstruction. The effect of the biopatch. Plast Reconstr Surg 2010. 69: 195–206. 126: 779–85. 120(7 Suppl 1): 8S–16S. Plast Reconstr Surg 2009. Chundamala J. Wilkins EG. Wickman M. 21. Murphy DK. Kontoyiannis DP. Egol KA. Lowery JC. Alderman AK. Feldman EM. Rohrich RJ. Wilkins EG. Katz J.100 Ryan open technique attaches a de-epithelialized section of dermis to the underlying rib fascia for a secure fold (47). Cosmetic and Reconstructive Procedure Trends. Pediatr Infect Dis J 2005. randomized trial. et al. Lowery JC. Does patient satisfaction with breast reconstruction change over time? Two-year results of the Michigan Breast Reconstruction Outcomes Study. [Available from: http://www . Plast Reconstr Surg 2009. 13. Francis SH. Delayed-immediate breast reconstruction: technical and timing considerations. 18. Predicting complications following expander/implant breast reconstruction: an outcomes analysis based on preoperative clinical risk. REFERENCES 1. 20. 10. 17. 24: 676–9. Plast Reconstr Surg 1957. Gurrin LC. et al. 15. AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY 8. A self-inflating tissue expander. an excellent outcome can be obtained. Keil AD. 2000/2008/ 2009 National Plastic Surgery Statistics. 247: 1019–28. Plast Reconstr Surg 2010. and the surgeon and the patient should take full advantage of them. Ruberg RL. Surg Infect 2010. 14. Plast Reconstr Surg 2003. 19. 19: 124. Throckmorton AD. J Bone Joint Surg Am 2006. and remain high and youthful for life without the discomfort of bras. Rose GL. Salvage of infected expander prostheses in breast reconstruction. Yii NW. et al. et al. 11. 9. The treatment of external fixation pins about the wrist: a prospective. 109: 2265–74. Plast Reconstr Surg 2007. Infection remains the major complication of implant-based reconstruction. Paksima N. Schulman MR. Int J Immunopathol Pharmacol 2007. 30. Leong M. Seynaeve C. 45. 126: 835–42. 50: 473–81. Erdmann D. . Acellular dermal matrix for the treatment and prevention of implant-associated breast deformities. Plast Reconstr Surg 2007. Occult carcinoma in 866 reduction mammaplasties: preserving the choice of lumpectomy. Aesthetic Surg J 2002. Kim DJ. 22: 438–45. 77: 919–32. Pfeiffer P. Burkhardt BR. Teitelbaum S. Infections of breast implants in aesthetic breast augmentations: a single-center review of 3. Araco A. et al. Gurtner GC. Plast Reconstr Surg 2010. Plast Reconstr Surg 2009. Spear SL. Kristiansen TB. Shis B. Sim HB. Hwang K. The timing of implant exchange in the development of capsular contracture after breast reconstruction. Spear SL. 43. Rubino C. Plast Reconstr Surg 1982. 127: 525–30. Schreml S. 47. van Heerden J. 34. Effects of zafirlukast on capsular contracture: controlled study measuring the mammary compliance. 28. Slezak S. Plast Reconstr Surg 2011. Tumour necrosis factorexpression is associated with increased severity of periprosthetic breast capsular contracture. 125: 1065–73. 124: 629–34. Aesthetic Surg J 2010. 96: 1317–25. Intraoperative perfusion mapping with laser-assisted indocyanine green imaging can predict and prevent complications in immediate breast reconstruction. Schnur PL. Subclinical (biofilm) infection causes capsular contracture in a porcine model following augmentation mammaplasty. Nahabedian MY. Acellular cadaveric dermis decreases the inflammatory response in capsule formation in reconstructive breast surgery. Plast Reconstr Surg 2011. Pestana IA. Araco F. Turner M. 28: 627–32. 34: 716–21. 41. Jerina KL. 39. Plast Reconstr Surg 2010. Bacterial colonization is of major relevance for high-grade capsular contracture after augmentation mammaplasty. J Clin Microbiol 2009. The effect of biocell texturing and povidone-iodine irrigation on capsular contracture around saline-inflatable breast implants. Coan B. Plast Reconstr Surg 2010. Eur J Surg Oncol 2002. 32. 47: 1333–7. Pilot study of association of bacteria on breast implants with capsular contracture.TISSUE EXPANSION RECONSTRUCTION 25. Moolman J. 101 37. Can J Surg 2007. et al. 44. 40. Dempsey PD. 20: 577–84. Wiener TC. Ann Plast Surg 2007. Management of the infected or exposed breast prosthesis: a single surgeon’s 15-year experience with 69 patients. Weintraub JL. 119: 12–15. Basu CB.002 patients. 125: 1074–84. et al. Tan KT. 62: 610–17. et al. Huan F. 45: 327–32. Myofibroblasts and capsular tissue tension in breast capsular contracture. Brandon HJ. 33. 127: 1047–58. Wijeratne D. Plast Reconstr Surg 2010. Jorgensen S. Mechanical analysis of explanted saline-filled breast implants exposed to betadine pocket irrigation. Tran NV. Antimicrobial coating agents: can biofilm formation on a breast implant be prevented? J Plast Reconstr Aesthet Surg 2009. Plast Reconstr Surg 1986. Petty PM. 27. Seruya M. 46. Clinical experience of prophylactic mastectomy followed by immediate breast reconstruction in women at hereditary risk of breast cancer (HB(O)C) or a proven BRCA1 and BRCA2 germ-line mutation. Handel N. 70: 153–60. Aesthetic Plast Surg 2010. 42. Kahn DM. Young VL. 59: 126–30. Huang CK. Scuderi N. 30: 404–8. Seruya M. et al. Contant CM. Tamboto H. Early experience with fluorescent angiography in free-tissue transfer reconstruction. 8: 303–11. et al. Aesthetic Plast Surg 2007. Mazzocchi M. Eur Surg Res 2010. Clemens MW. 31: 325–9. Tofield JJ. 35. 36. 38. Hicks MJ. Komorowska-Timek E. Hoffmann D. Eades E. Bluebond-Langner R. Del Pozo JL. Burkhardt BR. Capsular contracture: a prospective study of the effect of local antibacterial agents. 126: 1842–7. et al. Menke-Pluijmers MB. Ryan JJ. 29. 26. Prantl L. Plast Reconstr Surg 2009. Plast Reconstr Surg 1995. Vickery K. infections: an evidence-based review. Protective effect of topical antibiotics in breast augmentation. The role of Betadine irrigation in breast augmentation. Deva AK. Gravante G. Eisenmann-Klein M. 31. Effects of singulair (montelukast) treatment for capsular contracture. A lower thoracic advancement flap in breast reconstruction after mastectomy. 123: 1239–44. Eplasty 2008. Heine N. is a major factor in a successful outcome. The patient. no need for microsurgical equipment. Its ability to provide a large volume of tissue for reconstruction without the need for a prosthetic device has made it a popular option since its inception. in regard to both body habitus as well as medical and surgical history. 102 . Lance Tavana and Paul D. are the need for intact superior epigastric vessels. which are encountered and ligated as the muscle is raised during harvest. The superior pedicle is a termination of the internal mammary vessels. The complication of total flap loss when using a pedicled TRAM flap should be reduced almost to zero. The rectus abdominis muscle is a Mathes and Nahai Type 3 muscle with its main blood supply from the superior and inferior epigastric arteries. or smoking within the last 6 months ANATOMIC CONSIDERATIONS Several key anatomic facts guide surgical planning. it is our belief that pedicled reconstruction allows for greater movement of the flap without anastomotic risk and that the reduced operative time for flap transfer allows greater inset time for an superior aesthetic result. again in contrast to free technique.11 The pedicled TRAM flap M. while aesthetic design has developed in a less formal approach. sacrifice of the entire rectus muscle. We have found the ideal candidate for TRAM reconstruction to have the following attributes: • BMI between 25 and 35 with adequate abdominal tissue • No previous incisions on the abdomen interrupting the superior pedicle • No previous cardiac surgery with IMA harvest • No history of uncontrolled diabetes mellitus. barring unforeseen iatrogenic injury to the pedicle or poor patient selection. While some would argue that free transverse rectus abdominis myocutaneous (TRAM) reconstruction allows for easier inset of the transferred flap. Innervation of the rectus muscle is from the lower six or seven intercostal nerves. COPD. Smith OVERVIEW PATIENT SELECTION The pedicled transverse rectus abdominis muscle flap. The weaknesses of the pedicled technique. The benefits of the pedicled flap in contrast to free technique consist of shorter operative time. and less need for monitoring of the flaps in the postoperative period. and potential for greater fat necrosis. first described by Hartrampf in 1982. the proper decision may be made regarding reconstruction technique. Several variations on technique have been developed to improve the viability of the flap as well as to decrease donor site morbidity. consistent anatomy. while the inferior epigastric arises from the external iliac vessels. remains a reliable and reproducible autologous flap reconstruction of the breast. By adequately assessing the risk factors associated with the patient. the central incision is based in the midline. This marking is continued medially to 1–2 cm of the midline. By maximally utilizing the periumbilical perforators. The nipple–areola complex can then be replaced with flap skin. The inferior marking is then brought from a parallel horizontal marking centrally to a superiorly curving mark. The delay procedure reduces the risk of fat necrosis within the flap upon transfer. Once close. Flap width is determined by breast base width and translated to a caudal vertical distance from the upper abdominal marking. Care should be taken to bevel the dissection cephalad so that the superior perforators in the flap are conserved. the umbilicus is marked with an orientation stitch at the inferior portion so that that the stalk is not twisted on later inset. should that need to be performed. the surgeon is able to increase the size of viable flap. This axillary tail marking is carried for 5–6 cm superolaterally. the availability of the native breast skin allows the surgeon to use a reduction pattern for breast skin shape and to use the TRAM flap to fill that shape. The dual blood supply of the rectus muscle leads to a region of choke vessels in the middle of the muscle. is of secondary concern if delayed wound healing or partial flap loss is present. depending on whether the contralateral breast is a natural breast or to be reconstructed as well. In the face of post-radiation reconstruction. as the need to replace loss of the skin envelope becomes the major goal of reconstruction. Should the surgical oncologist require a larger incision. Should the natural breast be larger than the expected transposed flap. In a unilateral reconstruction. A delayed reconstruction presents a greater 103 challenge to the surgeon. which are found along the length of the rectus muscle. The umbilicus is . this marking may extend to the contralateral side—Hartrampf Zone 2—in order to increase flap size. This allows an inferiorly based scar that the patient prefers while providing a means to reduce the skin envelope. as most surgical oncologists use a transverse incision. What would be considered a rather obtuse angle for closure in reality allows for an even contour of closure as the upper abdominal skin is brought inferiorly. depending on contour. In a bilateral reconstruction. The abdomen is first marked with a straight horizontal line two to three centimeters above the umbilicus extending 22 cm laterally in each direction. the flap volume may be more than adequate the fill the breast space. sharp dissection using a #10 blade scalpel is performed to skeletonize the perforators. thereby increasing reliable blood flow to the flap. the mastectomy is typically performed through a skin-sparing technique. The highest concentration of these perforators is surrounding the umbilicus. If an immediate reconstruction is being planned. however.THE PEDICLED TRAM FLAP The skin island is based on medial and lateral rows of perforator vessels. At this point. This anatomy may be used to the surgeon’s advantage to augment the perfusion of the flap prior to transfer by a delay procedure. the abdominal flap and breast inset markings are essential for planning a successful operation. This allows for ease in preoperative marking as it only consists of a periareolar marking. For small breasted women. we have found a vertical reduction pattern incision to be the most reliable. A small split in the fascia can be noted prior to exposing each perforator. a vertical skin reduction is performed intraoperatively to conform to the flap size. leading to a greater perfusion of the tissue in the periumbilical area. The aesthetic concern of scar location. leading to a softer and more natural flap. This should allow enough exposure for sentinel node biopsy. Once the lateral row is exposed. as the vascular supply may not be ideal when compared to Zones 1 and 3. while important. Two weeks prior to the TRAM procedure. the previous mastectomy scar is used as the superior inset marking. In concert with the surgical oncologist. the inferior epigastric vessels may be ligated in order to make the muscle rely on the superior vessels as the sole blood supply. this goal is even more difficult to achieve. intersecting the upper marking at a 90º angle. the marking is curved superiorly and meets the upper marking to taper into the axillary tail at its most prominent point. The flap inset markings are variable depending on the type of reconstruction being performed. thereby reducing the chance of injury to the vessel. For immediate reconstruction. the cautery power is reduced in half and dissection carried close to the lateral row of perforators. This marking is then brought inferiorly at a 90º angle and gradually curved to stay 1 cm above the inframammary fold. About 1–2 cm lateral to the midclavicular line. The abdominal flap should be designed in a way that both reduces donor site morbidity and increases the viability of the maximum amount of transferred flap. We have found less partial flap loss in cases that needed less of Zone 2 for reconstruction. PREOPERATIVE MARKING Taken as separate but related. The inferior incision is then made and the lateral aspect of the flap is raised using electrocautery to the lateral border of the rectus muscle. For delayed reconstruction. though the amount of this marking used as a releasing incision is determined at the time of inset. SURGICAL TECHNIQUE The abdominal incision is first made at the superior marking. Care must be taken to only extend into Zone 2 a few centimeters. Dissection is carried suprafascially to the xiphoid process medially and the costal margin laterally. a vertical incision to the inframammary fold may be used. transferred completely and the fascia closed before the other flap is dissected. the flap is oriented in the breast pocket for the best volume filling of the space. In smaller breasts. This is performed one of two ways. By doing this. Once the flap is completely dissected. but can be generalized to be for immediate or delayed reconstruction. The inferior aspect of the rectus muscle is divided below the pedicle by electrocautery and the muscle raised inferior to superior. For a unilateral case. 11. A scalpel is used to incise the anterior rectus fascia along the strip then medially and laterally. This allows for a free-flap reconstruction using the inferior pedicle to still be an option. thereby leaving the medial inframammary fold intact and aesthetically pleasing. 11. The umbilicus is delivered through the abdominal flap while the central abdominal incision is temporarily closed with staples in order to provide proper position. We have found that a lateral tunnel for flap transfer advantageous over a traditional medial tunnel. thereby reducing the likelihood of kinking of the pedicle. The inferior and medial inset margins are created without undermining the mastectomy flaps. This superior strip also provides a tight closure of the upper abdomen after the rectus is transferred. 11. The flap is de-epithelialized except for the areola replacement. a drain is placed. the flap bulk is reduced for an easier flap transfer while also immediately reducing the metabolic demands of a larger flap. A single 20 × 30 cm piece of marlex mesh is used to cover the abdominal wall from external oblique fascia bilaterally to the superior and inferior extent of dissection. leaving as much of a pedicle length as possible as a lifeboat should the superior pedicle be accidentally injured during harvest. zone 4 and a majority of zone 2 is immediately removed for the same reason. onlay mesh is used to augment the strength of the abdominal wall. The mesh is sutured with either a running nonabsorbable monofilament or running barbed suture. By careful exposure of the perforators. with dissection starting between the muscle inscriptions for ease then taken to the inscriptions in the same plane. In delayed reconstruction. as this may shorten the stalk and provide for more difficult inset. taking care to sufficiently release the muscle medially for mobility. and laterally. the muscle is sutured to the adipose tissue of the flap using a running absorbable stitch medially. A 1-cm strip of fascia is outlined from the superior aspect of the adipocutaneous flap in between the lateral and medial perforators. This allows for an easier fascial closure. while a 90º rotation allows for greater upper pole fullness. Once the muscle is raised to the level of the superior aspect of the cutaneous flap. the flap is inset to replace the loss of skin from contraction and/or radiation (Fig. thereby creating a greater amount of skin on the newly . In immediate reconstruction using a skin sparing technique. This strip is continued up to the costal margin. We have also found that a 180º-flap rotation produces the best position for the muscular pedicle to be loose without strain on the pedicle. The dissection is carried from the abdominal space to the breast pocket completely lateral to the midline of the breast. the lateral tip (Zone 3) of the adipocutaneous portion of the flap is sharply excised. the closure of the fascia is made easier later in the case. sparing the perforators but leaving behind as much fascia as possible. The flap is then rotate laterally and up into the breast pocket. thereby decreasing abdominal wall bulge superiorly. Metzenbaum scissors can be used to dissect the umbilical stalk down to fascia. Blunt dissection is used under the muscle to protect the pedicle from injury. then the midline incision is performed and carried down to fascia. By excising an appropriate amount of zone 3. but left intact superiorly to provide a tether so that the muscle and pedicle are not stretched. Closed suction drains are placed through the dependent portion of the abdominal space. Second. This decision is made interoperatively.3). The mastectomy flaps are tailor tacked to reshape the skin envelope to the volume of the TRAM flap and the areola location marked on the flap. which should be easily visualized as the muscle is raised. Once fascial closure is complete. The flap is de-epithelialized except for the areola replacement. or in breasts in which the flap volume is greater than the mastectomy volume. inferiorly. First. the vertical reduction is performed on the breast skin (Fig. a lateral AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY tunnel allows the early bulk of the muscle to remain lateral to the midline of the breast. The superior muscle dissection is carried on its anterior surface to the costal margin. the muscle is rotated through a broader arc. the flaps may be inset without reducing the breast skin volume (Fig. Flap inset is variable case to case. The muscle is dissected medially and laterally from the fascia. This allows flap perfusion to be assessed by the rate of bleeding and the color of the blood. each flap is dissected. the areola is inset and the mastectomy flap incision closed. The inferior inset is performed with a 2:1 ratio of TRAM skin to fold skin.104 incised in a circular fashion without pulling too much tension on the stalk.1). a drain is placed.2). creating a greater fold inferiorly and appropriate central cleavage. The inferior pedicle is identified and ligated with clips. The medial perforators are exposed in a fashion similar to the lateral row. with several interrupted figure of eight sutures or a running barbed suture. This allows the myocutanous flap to be moved en block without increased risk of avulsing the perforators. When the flap volume is less than the mastectomy volume. The patient is flexed at the hips to bring the abdominal wound closed with the least amount of tension and the incision closed in multiple layers. the areola is inset and the mastectomy flap incision closed. On a bilateral case. the extent of fascia needed to be included with the flap is minimized. THE PEDICLED TRAM FLAP (A) 105 (B) Figure 11.1 (A) Preoperative right immediate skin-sparing mastectomy reconstruction. (B) Twelve-month follow-up after right nipple-areolar reconstruction. (A) (B) Figure 11.2 (A) Preoperative right delayed reconstruction with left immediate skin sparing reconstruction. (B) Sixteen-month follow-up after bilateral nipple-areolar reconstruction with tattooing. 106 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY (A) (B) Figure 11.3 (A) Bilateral delayed reconstruction. (B) Nine-month follow-up after nipple-areolar reconstruction. formed inferior breast. This provides for a greater fold as TRAM flap creates ptosis over the fold. A direct 1:1 ratio of inset tends to blunt the fold. The lateral and superior inset margins are performed with variable flap overlap to create an aesthetically pleasing shape, which can be adjusted with the patient sitting upright while on the operating table. In order to do this, the superior mastectomy flap skin is elevated on top of the pectoralis muscle to the clavicle as well as along the tail of the pectoralis toward its insertion. The lateral skin is elevated in a subcutaneous plane 2 cm laterally. Once these pockets are opened, the TRAM flap is placed under the skin flaps. The patient is put in an upright position and the amount of overlap of skin flap over TRAM flap is adjusted for aesthetics. The lateral pocket may be expanded for contour at this time. The axillary tail incision is opened to release the constriction of the flap in the superolateral quadrant, thereby allowing a pleasing contour of the breast. Temporarily stapled in position, the TRAM flap is marked, de-epithelialized and sutured on each border individually, so as to not lose the positioning of the skin to flap relationship. A drain is placed laterally prior to complete closure. POSTOPERATIVE CARE Starting immediately postoperatively, the patient is kept flexed at the hips. Bed transfers are made with a flexible transfer board while pillows are kept under the legs. The patient’s foley catheter is removed the morning after surgery and ambulation is started shortly thereafter. Physical therapy assists the patient with ambulation with a walker in order to keep the hips flexed. This position is kept for a period of 10–14 days and then slowly increased as the patient becomes more comfortable with the tension of the abdomen and as wound strength increases. All drains are kept until they are draining less than 30 cc over a 24-hour period for two straight days, or until a period of three weeks, whichever is sooner. COMPLICATIONS With proper surgical planning and postoperative management, most complications can be avoided. Total or partial flap loss, fat necrosis, contour deformity, wound healing delay, and abdominal wall laxity can all be attributed to several factors within and beyond the surgeon’s control. Vascular supply, both arterial and venous, can be affected by numerous technical mistakes. First, an error in judgment in patient selection can doom the outcome of the surgery from the outset. Prior mammary artery harvest or a subcostal incision across the epigastric artery should be ruled out prior to planning for a pedicled TRAM flap. In these patients, a free TRAM or deep inferior epigastric artery perforator using the inferior vessels should be considered, if THE PEDICLED TRAM FLAP not other forms of breast reconstruction such as a latissimus dorsi, superior gluteal artery, or transverse gracilis flap. Once a patient is considered to be a pedicled TRAM candidate, a direct injury to the pedicle in the most obvious iatrogenic error and must be noted at the time of surgery. The pedicle should be visualized and protected at the time of surgery, with only blunt dissection used to expose the pedicle. Tension or kinking of the pedicle can also be assessed at this time. If it is felt that the pedicle is not lax in its course, the superior dissection on top of the rectus may be carried above the costal margin and the anterior fascia released to the margin. This creates more length at the pedicle origin and allows for greater movement. Slight rotation of the flap on inset may also decrease the amount of tension on the pedicle. The perforators from the rectus muscle to the skin flap are also a frequent site of injury. Shearing of the vascular perforators must be avoided by careful attention in moving the flap as a unit on transfer to the chest. By tacking the muscle to the adipocutaneous flap prior to transfer, the likelihood of perforator shear can be decreased. The subcutaneous tunnel must also be assessed for adequate dissection space for flap transfer. If the flap is too large for the subcutaneous tunnel, two surgical moves can assist in transfer. The first is to simply enlarge the tunnel, however, this may further interrupt the inframammary fold and blunt the contour of the reconstructed breast. The alternative requires knowledge of the required flap size for appropriate reconstruction, as it easy to trim the flap to a smaller size in order to pass it through the tunnel. The lateral margin of the flap is logically the most anatomic site for resection as this tissue has the least amount of perfusion and the highest rate of fate necrosis and flap loss. Overall thinning of the bulk of the flap should be performed by removing subscarpal fat peripherally, leaving the suprascarpal fat which is more reliably perfused by the subdermal plexus. Should the reconstruction not require a significant amount of flap skin, a full thickness resection of the flap may be performed. Postoperatively, vascular complications of the pedicled tram flap should be addressed immediately upon suspicion of flap trouble. In early postoperative flap compromise, release of the sutures and return to the operating room for exploration of the pedicle should be considered. Unrecognized injury to the pedicle, twisting of the pedicle, or kinking of the pedicle may be the simple reason for flap failure. Often this can be assessed directly through the flap inset incisions with a lighted retractor, so that the abdominal approach does not need to be used. Should the pedicle be compromised, then full exploration of pedicle is warranted. If the pedicle is patent and muscle is viable, but the adipocutaneous portion of the flap is not, then the perforators may not be adequate or may be 107 injured. This is often an irreversible complication as the ability to augment or repair the perforators in limited. Reduction in the vascular and metabolic requirements of the flap by reducing its size may salvage the remaining flap, however this is at the expense of the aesthetic outcome. Both the abdominal wall and the lower abdominal incision may have their own complications. Wound dehiscence and delayed wound healing may be predicated by the patient’s medical history, such as smoking or diabetes. Proper patient selection will decrease a surgeon’s incidence of this complication. Tension and seroma formation contribute to delayed wound healing, so proper patient positioning and drain management are paramount to successful healing. Abdominal wall laxity, which is often a concern of the pedicled TRAM in contrast to the DIEP or free TRAM, can be avoided by providing entire wall support. By suturing the mesh across the abdomen from external oblique to external oblique fascias, the entire wall is supported. CONCLUSION With proper technique, the pedicled transverse rectus abdominis muscle flap for breast reconstruction is a safe, relatively quick, and reproducible method. The surgery can be performed with little morbidity and surgical resources, allowing it to be performed in centers that do not have the capabilities for consistent free flap performance. Complications are predictable and avoidable with proper patient selection and technique. Aesthetically, the pedicled TRAM flap can provide a pleasing breast shape that patients readily accept and integrate into their body image. FURTHER READING Arnez ZM, Khan U, Pogurelec D, et al. Rational selection of flaps from the abdomen in breast reconstruction to reduce donor site morbidity. Br J Plast Surg 1999; 52: 351–4. Baldwin BJ, Schusterman MA, Miller MJ, et al. Bilateral breast reconstruction: conventional versus free TRAM. Plast Reconstr Surg 1994; 93: 1410–16. Chang BW, Wang B, Robb GL, et al. Effect of obesity on flap and donor site complications in the transverse rectus abdominis myocutaneous flap breast reconstruction. Plast Reconstr Surg 2000; 105: 1640–8. Gherardini G, Arnander C, Gylbert L, et al. Pedicled compared with free transverse rectus abdominis myocutaneous flaps in breast reconstruction. Scand J Plast Reconstr Surg 1994; 28: 69–73. Grotting JC, Urist MM, Maddox WA, et al. Conventional TRAM flap versus free microsurgical TRAM flap for immediate breast reconstruction. Plast Reconstr Surg 1989; 83: 828–41. 108 Hartrampf CR, Bennett GK. Autogenous tissue reconstruction in the mastectomy patient: a critical review of 300 patients. Ann Surg 1987; 205: 508–12. Hartrampf CR, Soneflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg 1982; 69: 216–25. Moon HK, Taylor GI. The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep superior epigastric system. Plast Reconstr Surg 1988; 82: 815–32. AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY Scheflan M, Dinner MI. The transverse abdominal island flap: I. Indications, contraindications, results, and complications. Ann Plast Surg 1983; 10: 24–35. Seljavaara S, Svartline NE. Cutaneous blood flow in the TRAM flap. Br J Plast Surg 1992; 45: 261–9. Flap coverage was required prior to implant placement (5.16). Oeltjen and Haaris Mir HISTORY based on the superior epigastric vessels to cover an upper abdomen traumatic injury (7). Millard described a tubed abdominal flap incorporating the umbilicus and then waltzing it to the chest via the forearm (3. Cronin and Gerow described a delayed single-staged breast reconstruction using a silicone-gel-filled prosthesis. In 1982. Mathes. the free TRAM flap with different degrees of muscle sparing were developed. Tansini felt bringing distant tissue would be less likely to contain cancer (1).) and Sakai and colleagues all published their refinements on the VRAM flap for breast reconstruction (12. Prior to this in 1942 Gilles performed two breast reconstruction cases using a unilateral flap from the abdomen based on the flank.12 Transverse rectus abdominis myocutaneous (TRAM) flap and deep inferior epigastric artery perforator (DIEP) flap breast reconstruction John C. The transverse rectus abdominis muscle (TRAM) flap has remained the gold standard for pedicled breast reconstruction.6). Placement of the implant alone resulted in an aesthetically poor breast with an unnatural breast mound. Grotting coined the term “free abdominoplasty flap” when he used the SIEA flap for breast reconstruction (17).13). In 1896 Tansini published a paper describing an “autoplastic flap” which was a random. In 1963. Driver (9). Dinner (10)(11. With refinements in microsurgical techniques. The concept of breast reconstruction with autologous tissue is a concept that has been present for over a century. in 1977. During clinical dissections they were able to demonstrate that the skin and subcutaneous tissues remained viable even after placing a clamp on the deep inferior epigastric vessels (4). Anatomic dissections and studies performed by Sheflan and Dinner demonstrated dominant inferior epigastric arterial supply to the lower abdominal skin and fat previously described by Hartrampf (14). As early as 1959 it was recognized by Gilles that breast reconstruction was an important for the psychological well being of a female (2). In 1957. Robbins described using a vertical rectus abdominis muscle (VRAM) flap for breast reconstruction (8). Patients frequently required skin grafts for coverage for the pectoralis major muscle as well as wound defects. In 1979. In 1991. In describing complete rectus muscle preservation in 1989. Hartrampf and colleagues described an elliptical shaped flap based on a single rectus abdominis muscle. advances in imaging technology and the goal of reducing morbidity and mortality. radical mastectomy was a popular technique for breast cancer surgery. At that time. published a case report on a myocutaneous rectus abdominis muscle flap 109 . narrow based skin flap from the back transferred to the anterior chest wall defect. Koshima and Soeda developed the deep inferior epigastric artery perforator (DIEP) flap and superficial inferior epigastric artery (SIEA) flaps (15. This allowed chest wall coverage as well as the axillary wound after cancer extirpation.4). however. in some patients a superficial venous drainage system maybe dominant. Milloy was able to demonstrate that as the deep inferior epigastric artery traveled from the external iliac vessel to the umbilicus it pierced the rectus abdominis muscle at various levels: Lower third 17%. . • Vessels are accompanied by large sensory segmental nerves. During dissection and elevation of a DIEP flap. The vascular supply to the SIEA flap arises superficial to the rectus sheath. Lateral perforators: • Direct perpendicular course through rectus abdominis muscle. Within the rectus abdominis muscle.4 mm (0. however a large compensatory circumflex iliac artery was found with a mean diameter of 1. In 1975 Taylor and Daniel performed cadaveric dissections and were able to define the anatomy of the “superficial system” to the lower abdomen.8–3. The landmark for the SIEA at the inguinal ligament is the midpoint between the pubic bone and the anterior superior iliac spine. • Motor branches originating from the intercostals cross superficial to the main branches of the deep inferior epigastric vessels (15).4 mm (0. The vessel was noted to have a mean diameter of 1. 12.1 mm (0.27). Across the midline of the abdomen. This was based on the original description of Scheflan and Dinner. The venous drainage of the DIEP flap is dependent on the small perforating veins. Allen noted no hernias or abdominal wall weakness in elevating an SIEA flap (20). MS1: Lateral segment of rectus abdominis preserved. Contributions from intercostal segmental vessels and superior epigastric vessels are also made. The artery originates from the anterior surface of the femoral artery 4–5 cm below the inguinal ligament (19). The artery has also been found to have a dominant medial branch (18%) or a central course with multiple small branches (28%) (22). Blondeel and colleagues noted venous drainage was unreliable.5 mm in diameter. there is no violation of the abdominal wall musculature or fascia. In 35% of cadavers the SIEA was absent. When dissecting out the flap. The classification is as follows: MS-0: Sacrifice of the entire width of the rectus abdominis with preservation of partial length. it became better known after Hartrampf described his work on the TRAM flap (Fig. Nahabedian and colleagues developed a classification system to demonstrate the degree of muscle sparing in a free TRAM flap elevation. oblique and complicated. intramuscular route with numerous subsidiary muscular branches. Using color duplex ultrasonography. Three patterns of arterial perfusion based on the SIEA were identified: 1. 2.0 mm).8 mm).0 mm) (18). Bajaj subdivided MS 1 into MS 1-M or MS 2-L depending if the medial or the lateral segment of the rectus abdominis was spared. 3. however. MS3: Preservation of the entire muscle (equivalent to a DIEP flap) (25). the SIEA shared a common trunk with the superficial circumflex iliac artery.8–1. or even slightly lateral to this point.110 ANATOMY The lower abdominal wall receives its perfusion through two different arterial systems. In 17% of cadavers the SIEA was found to arise from the common femoral artery. The vascular supply can be divided into a superficial system as well as a deep system. The mean diameter was noted to be 1. Perfusion Zones Scheflan and Dinner studied the perfusion of the TRAM flap (14. it should be preserved and potentially be used as an alternate source for venous drainage or potentially convert to a free TRAM to reduce the risk of flap failure (24). Medial perforators: • Long. middle third 78%.” The origin of the deep inferior epigastric artery is from the external iliac artery deep to the inguinal ligament along with the venae comitantes (15). AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY • Greater likelihood of providing perfusion to the contralateral abdomen. the deep inferior epigastric artery usually divides into a non-dominant medial branch and a dominant lateral branch. if a large medial or superficial epigastric vein is noted. MS2: Preservation of both the medial and lateral segments of the rectus abdominis. The initial description of the perfusion zones divided the abdominal ellipse into four equal parts with perfusion decreasing as the zone number increased. With relevance to the “MS-1” group. The approximate site of the perforators was noted to be 2–6 cm caudal and 1–6 cm lateral to the umbilicus (23). and 5% in the upper third (21). A TRAM flap maybe raised with the entire rectus abdominis muscle or with a small amount of muscle fibers around perforating vessels in an effort to conserve as much muscle as possible. respectively (26). The TRAM and the DIEP flaps both rely on their perfusion via the “deep system.8–3. TRAM Flap Nomenclature and Classification Successful TRAM flaps may be raised with differing amounts of muscle with them. Blondeel was able to demonstrate that on each side of the anterior rectus fascia there are between two and eight paraumbilical perforators each greater than 0. In 48%.1) (4). Perfusion was better in Zone III than in Zone II. The amount of muscle removed in the process of the tissue transfer is variable and dependent on a combination of factors including the patient’s anatomy. and have a general understanding of the different treatment options for breast cancer so as to assure that the reconstruction does not interfere with or delay treatment.29). and finally. proposed treatment course for the patient. There are multiple decisions made to arrive at a free autologous tissue reconstruction of the breast after which the decision has to be made about which donor site to be used.1 Hartrampf perfusion zones. When a patient presents for consultation for breast reconstruction. the decision has to be made between a free-TRAM.TRAM FLAP AND DIEP FLAP BREAST RECONSTRUCTION 111 Rectus abdominis muscle 3 1 2 4 Figure 12. if the abdomen is appropriate. INDICATIONS The abdominal free flap breast reconstruction utilizes the deep inferior epigastric artery vascular supply to transfer and skin and fat from the abdomen to the chest region in order to replace the tissue removed in a mastectomy. Perfusion in Zones I and II was thought to be the best. and surgeon experience and skill level. 12. Anatomic dissections of DIEP flaps with special attentions to angiosomes by Taylor and colleagues demonstrated that the zones of perfusion for free-tissue transfer from the lower abdomen are in fact different from their original descriptions (28. thus he advocated changing the initial classification (Fig. In 1983 Dinner suggested that the ipsilateral hemiabdomen does indeed have better perfusion than the segment across the abdominal midline. For this reason it is the reconstructing surgeon’s responsibility to understand the pathology of the patient’s cancer. less in Zone III. patient preference. versus DIEP breast reconstruction. and the poorest in Zone IV with the most likelihood of flap necrosis. muscle-sparing TRAM. three goals for that reconstruction help shape the treatment course. The first goal of breast reconstruction is to no interfere with the patient’s cancer treatment. The second goal for reconstruction is to recreate a breast . unilateral versus bilateral reconstruction.2) (11). Inherent in this is communication between the reconstructive surgeon and the patient’s medical and surgical oncologist. 2 1 3 4 True perfusion of lower abdominal wall. One early consideration in the evaluation process is radiation treatment of the patient for the breast cancer. and scars may fade with time but never disappear. however. Once the goals are elucidated. in a patient’s wish to return to a feeling of normalcy. the physician should recommend delaying an autologous tissue reconstruction until after the radiation is completed. If the patient is being seen in evaluation for an immediate reconstruction following mastectomy and there is a strong likelihood for postoperative radiation. the patient’s goals are equally as important in .112 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY Rectus abdominis muscle 2 Figure 12. the scars are on the anterior most aspect of the breast and thus impossible to hide in any folds. Although the consulting physician can have an understanding of a treatment course prior to interviewing the patient. mound that appears normal in clothing and will allow the patient to continue wearing the clothing that she has previously. and contracture of the reconstruction in comparison to a delayed reconstruction (30). the reality needs to be stressed to the patient that surgery involves scars. It is often difficult. Often in a mastectomy. In contrast. Traditionally. Additionally. to ask them to wait an additional year before proceeding with reconstruction. volume loss. the process of evaluating the patient for the reconstructive course proceeds. Although this sensation may return with time. it is not regularly reconstructed during the breast reconstruction process. a reconstruction that replaces the breast well enough that the observer cannot tell that the patient has had surgery. The third goal for reconstruction is to reconstruct a breast mound that appears normal out of clothing. Although the immediate inflammation from the radiation subsides in the several months following radiation. the physician needs to consider the amount of time to wait after the radiation before proceeding. it is important for the patient to understand that a mastectomy includes removal of the sensation to the skin of the breast. Radiation to the free flap breast reconstruction has been shown to result in higher rates of fat necrosis. Although this is the ideal. a minimum of six months have been allowed for optimum recovery of the patient’s tissues before proceeding with reconstruction however a lower complication rate has been shown by waiting at least a year (31). the fibrosis and other associated changes never recover. if the patient is being seen in evaluation for a delayed reconstruction after completion of radiation. In patients of relevant concern. namely a DEIP flap. It is important for the requesting physician to explore the myths and realities behind the patient’s request. Other relative contraindications include previous abdominal suction-assisted lipectomy. Additionally comorbidities such as hypercoagulability. the patient’s comorbidities need to be evaluated and optimized in preparation for a long surgical course and postoperative recovery. and cardiac performance when cardiotoxic chemotherapy has been administered. patients will often present to the physician requesting a specific type of flap reconstruction. especially when compared with bilateral pedicled TRAM breast reconstruction (32). Patients that are candidates for free autologous tissue transfer breast reconstruction must have sufficient tissue available to reconstruct a breast mound that will result in a breast mound of the desired size. though. and 3 to provide a reconstruction of adequate size. chronic obstructive pulmonary disorder. Additionally. In the case of the abdomen. leukocytopenia. the patient must have sufficient mass or thickness to the infraumbilical fat pad to reconstruct a 113 breast mound and sufficiently laxity in the abdominal wall skin to close the donor site after harvest. hysterectomy. With today’s availability of information on the Internet. In contrast. the desire to perform the “sexy” muscle and fascia-sparing approach to abdominal free-flap breast reconstruction cannot overreach the technical skills of the reconstructive surgeon or outweigh the importance of patient safety in drastically increasing the anesthetic time in pursuit of a DIEP flap. the consideration of the muscle and fascial sparing approaches to the abdominal free flap breast reconstruction is dependent on multiple variables. Since the advent of the muscle. hormonal chemotherapy is associated with hypercoagulability. consideration should be given in patients with known coronary artery disease as the utilization of the internal mammary vessels as recipients for the free flap sacrifices a dependable source for cardiac revascularization. PERFORMANCE The preoperative preparation for an autologous abdominal free-flap breast reconstruction is for the most part similar to that of preparing for any other large surgery. Autologous tissue-based breast reconstructions are longer operations relative to implant-based reconstruction. Successful free flap reconstruction is dependent upon a stable patient who will not require ionotropic pressors or medications to keep the blood pressure elevated intra. laparotomy. More importantly. open cholecystectomy. patient’s willingness to accept placement of an implant. damage to these vessels during the procedure is possible. The patient must be stable enough to undergo a lengthy period of general anesthetic followed by prolonged recovery with abdominal wall morbidity. Relative contraindications to undergoing a single perforator DIEP reconstruction include the absence of any dominant perforator as found by imaging (see below) or direct exploration. A recent completion of chemotherapy warrants an analysis of the patient for anemia. An autologous reconstruction is appropriate for a patient not wanting to undergo implant placement but not for someone needing to return to work two weeks after the mastectomy. DIEP flap reconstruction is generally indicated in patients undergoing bilateral reconstruction. If the abdomen is void of scars or the scars present do not prelude the use of the abdominal tissue.TRAM FLAP AND DIEP FLAP BREAST RECONSTRUCTION determining the reconstructive course. and the patient’s willingness to accept scars on sites other than the breasts all are important in determining the course. A standard recovery course for an abdominal autologous free-flap breast reconstruction includes up to six weeks of no heavy lifting or strenuous activity Additional consideration must be given to the patient’s health. Additionally. where no muscle or fascia is spared is the fastest free-tissue transfer operation with the least amount of postoperative flap fat necrosis while the DIEP flap and MS-2 approach appear to have the least abdominal wall morbidity and decreased recovery time. the patient’s constraints on recovery that can include the need to return to work or physically demanding activity such as childcare. there is no data comparing the DIEP flaps where one versus two or more perforators is harvested. and colostomies. and back instability can likely contribute to a complicated postoperative course with possible flap failure. The free TRAM. Although the obstetric/gynecologic Pfannensteil incision routinely does not include ligation of the deep inferior epigastric artery. the advantages and disadvantages of the different approaches have been examined and reexamined. Finally. morbid obesity with the transfer of a large flap. or the need for zones 1. As mentioned earlier. thrombocytopenia. as mentioned previously. There is a limited number of donor sites on the patient that will have an appropriate vascular supply to allow for dependably transferring the tissue to the chest region. The medications should be . previous abdominal incisions including cesarean sections.and post-operatively. Any abnormalities should either be corrected or the patient’s surgery be postponed until the values normalize.and fascia-sparing approaches. the subcostal open cholecystectomy scar interrupts the blood supply that is important for donor site closure. the nutritional status should be investigated and optimized to ensure that the patient is in an anabolic state. The patient’s desired breast mound size after reconstruction. a previous abdominoplasty is a definite contraindication for a free TRAM or DIEP flap. Finally. liver function. In contrast. coagulation cascade function. These sites cannot have previously undergone surgery that will have interrupted the blood supply. 2. If not. In the preoperative staging area. a proposed inframammary fold is either designed utilizing the existing contralateral breast as a template in unilateral reconstruction or at the mid-humeral level in a bilateral reconstruction. In a delayed reconstruction. The general consensus is that preoperative imaging decreases the intraoperative time that was previously spent searching for the dominant perforators through dissection and direct visualization (34).114 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY discontinued 2 weeks prior to the operation and extra attention given to the administration of perioperative anticoagulation therapy in order to minimize the risks (33). the amount of operative time saved with the availability of CTA or MRA data. decreases.3 [P] C50 W380 CTA of the abdomen demonstrating a right-sided dominant periumbilical perforator. 12. The increasing popularity of abdominal wall fascia and rectus abdominis muscle preservation techniques along with technological advances in imaging have led to the use of either computed tomography angiograms (CTA) or magnetic resonance angiography (MRA) to map the abdominal wall vasculature in preparation for the operation. The disadvantages of the imaging include the cost of the studies. . A midline marking from sternal notch to pubic symphysis helps localization of the umbilicus along the midline during donor site closure. Additionally. the inferior incision can be raised and the superior incision lowered however it is preferably kept above the umbilicus. the patient is marked in preparation for the surgery. With a properly adjusted protocol. As to the chest. an excision line for the inferior mastectomy flap is designed above the planned inframammary fold approximately [R] [L] Applied Figure 12. Prior to being transported to the operating room. one just above the umbilicus and one approximately 7 cm above the superior limit of the vaginal cleft. The “standard” flap design entails two 12-cm horizontal incisions.3). (3) the ability to choose from the larger perforators that appear to vascularize a majority of the proposed flap tissue. however. The advantages of the imaging include: (1) the ability to determine if the deep inferior epigastric artery blood supply was interrupted by any previous surgeries. the individual perforators to the abdominal wall skin and subcutaneous tissue can be visualized as they branch off the rectus abdominis muscle vasculature and arborize throughout the subcutaneous tissue (Fig. The flap design for either a free TRAM or DIEP is similar except in the consideration that the DIEP flap may be designed a little higher on the abdomen in order to include the dominant perforators visualized in a CTA or MRA. The inferior incision should be placed just above the hirsute limit of the mons pubis and incorporate any previous Pfannensteil incisions. (2) preoperative localization of any dominant perforators to the abdominal wall. the markings for an immediate reconstruction include marking the inframammary folds bilaterally and working with the surgical oncologist to design the skin sparing or preferred incision. and the increased radiation exposure as associated with the CTA. the patient is placed in “beach chair” position (flexed at the hip with knees bent) on the stretcher and the abdomen is pinched to ensure that the donor site can be closed after removal of the proposed flap. the toxicities associated with the dyes. With increased experience by the surgeon. Laterally the horizontal incisions are joined by oblique incisions to approximately 3 cm lateral to the anterior superior iliac spine. TRAM FLAP AND DIEP FLAP BREAST RECONSTRUCTION 1. isolating the umbilicus on its stalk with a healthy cuff of tissue to ensure its survival. Additionally.4). the patient should have bilateral sequential compression devices and warming device placed prior to receiving any anesthesia.5 cm above the proposed inframammary fold. the patient can be taking to the operating room. In an immediate reconstruction. the fascia is incised and the muscle along with the deep inferior epigastric artery is isolated. prophylactic fractionated or unfractionated heparin and prophylactic antibiotics are administered prior to induction. If muscle and fascial sparing is the decided approach. In a bilateral flap procedure. Once dissected down to the fascia. harvesting of the abdominal flap can proceed concomitantly with the mastectomy if the reconstructive surgeon is sure that reconstruction will proceed regardless of findings of the surgical oncologist including positive sentinel lymph nodes.5 cm above the inframammary fold at the breast meridian tapering medially and laterally to meet the inframammary fold (Fig. Finally. the manubrium is marked along the midline as a landmark for the second rib. The flap is incised as marked with continued dissection through the subcutaneous tissues down to the fascia. the vein can be preserved for possible venous rescue of the flap. the perforators are meticulously and Proposed removal of interior mastectomy flap (dashed) Proposed new inframammary fold (solid) Rectus abdominis muscle Proposed abdominal flap (A) (B) Figure12. As should be standard protocol. 12. Dissection can proceed with ease up to the lateral edge of the rectus muscle. dissection 115 above Scarpa’s fascia at the midpoint of the inguinal ligament between the anterior superior iliac spine and the pubic symphysis needs to be done carefully in order to preserve a large superficial deep inferior epigastric artery or venae comitantes. the midline can be incised. Inferiorly in patients who have not had a Pfannensteil incision. Even in the absence of a sufficient artery. . a 2–3-cm length of vein can provide a flap lifeboat. With completion of the markings. Once the medial and lateral edges of the rectus muscle are encountered. If a freeTRAM flap is the decided approach.4 Graphic (A) and pictorial (B) demonstration of preoperative markings for a free flap breast reconstruction. Dissection from the midline in a lateral direction can proceed with care understanding that the medial row perforators are often within the first 1–2 cm of the midline. Note the right (A) and left (B) planned lower mastectomy flap excision is marked approximately 1. the decision for a free TRAM versus muscle sparing versus DIEP must be made. Placement of the patient on the operative room table should allow for intraoperative flexion while also accommodating a possible lymph node dissection by the surgical oncologist. dissection continues in a lateral to medial direction. preservation of the thoracodorsal pedicle allows for use of the latissimus dorsi myocutaneous flap in instances of failed free flap breast reconstruction. The microsurgical anastamosis is performed in standard fashion and is highly operator dependent upon the approach. Exposure includes rotating and anchoring the mastectomy skin flaps medially to provide access to the medial 3 cm of the third rib and second and third interspaces. abandonment of the flap should be considered.5 Internal mammary vessel exposure. The superior mastectomy flap (star) has been retracted superomedially with skin hooks and sutures and a laterally based pectoralis flap has been rotated laterally (solid arrow) to expose the internal mammary artery and vein (hollow arrow). the medial third rib can be removed along with the intercostal muscle exposing the internal mammary and venae comitantes between the second and fourth ribs (38). and its position allows for less restriction of flap position inset (36). After isolation. As alluded to previously. The vessels are carefully isolated from each other and prepared under the microscope for anastomosis (see Fig. The internal mammary artery as opposed to the thoracodorsal artery is predictably larger with a larger venae comitantes and better size match to the deep inferior epigastric vessels. No difference.5). harvesting of the medial row perforator is thought to preserve more innervation and functionally intact muscle. The pectoralis muscle is incised medially and rotated laterally or split longitudinally to expose the rib and interspaces. Additionally. Once the flap is isolated on its blood supply. not damaged by lymph node dissection. however. The medial third rib has been removed. the internal mammary AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY artery and venae comitantes have become the preferred recipient vessels for free autologous flap reconstruction of the breast. the dissection can be less meticulous however there is always a risk of discrepancy between the imaging data and reality. it can be observed while preparing the recipient vessels for any signs of compromised blood supply. An end-to-end anastamosis of the deep inferior epigastric artery to the internal mammary artery is preferred due to the ease and adequate back flow through the Figure 12. The goal of isolating the perforators from the muscle is to preserve the integrity of the blood vessels while causing minimal collateral damage including minimal muscle and fascial incision and sparing the intercostal nerves as they traverse the muscle. The vessels are generally harvested at the level of the third rib where the balance between branching and vessel size is optimum (37).116 carefully dissected free of the surrounding tissue at the interface between the fascia and overlying fat and skin utilizing loupe magnification. identification of the dominant perforator(s) allows for ligation of the remaining perforators followed by isolation of the chosen perforators from the surrounding fascia and underlying muscle. Dependent upon surgeon preference. Any evidence of compromise should be addressed and if not repairable. The vessel can be found beneath the intercostal muscle and the cartilaginous medial ribs. has been seen in abdominal wall morbidity in follow-up when comparing patients who have undergone medial or lateral row perforator harvest (35). In instances where preoperative imaging has identified the dominant perforators. 12. In instances where both medial and lateral row perforators appear sufficient. . Preparation of the recipient vessels is equally as important as the flap harvest in both providing a reliable source of inflow and outflow for the free flap while providing sufficient exposure for a straightforward microsurgical anastamosis. the skin paddle can be designed to include Dopplerable signal to provide a means to monitor the flap. a first-generation cephalosporin or clindamycin for penicillin allergies.and fascia-sparing approaches and often primarily with free TRAM approaches. or DIEP flap can be divided into two broad categories: technical complications and aesthetic complications. The flap skin from the abdomen is then tailored to comprise the entire inferior aspect of the reconstructed breast while de-epithelializing the superior aspect of the flap and placing it underneath the superior mastectomy flap. and pulmonary embolus. Each of these can often be prevented with proper planning. The presence of a skin paddle in all but nipple sparing approaches allows for direct visualization of the flap 117 for color. As alluded to above. the abdomen can be reinforced with insertion of either a biologic or synthetic mesh. the presence of Dopplerable signals allows for evaluation of continued presence of inflow. Hematoma and seromas can occur at either the breast or abdominal surgical sites. however. Careful design of the skin paddle that includes Dopplerable signals provides a method by which the flap can be monitored. Aesthetic complications include poor cosmetic results in the breast and abdomen. Deep shaping of the mound can be achieved with absorbable sutures tacking the flap to the surrounding fascia. noted the benefit using AlloDerm (Lifecell. For larger defects and in thinner fascia with risk of dehiscence and possible hernia. hematoma. Larger and/or expanding accumulations. Again. Technical complications include difficulties encountered with any surgery. Any changes in these parameters require immediate investigation and possible exploration. care must be taken to not translocate the umbilical stalk too far off from the midline resulting in an asymmetrically placed umbilicus. and turgor. In the immediate reconstruction. THEIR PREVENTION. Monitoring of the flap can be accomplished in multiple ways. seroma. once the flap’s vascular supply is verified. In primarily closing larger unilateral fascial defects. During inset. and poor nutrition. muscle-sparing TRAM. the inferior mastectomy flap is excised and sent for pathology. Multiple less elastic biologic products for repair of abdominal hernias are available but published comparisons of the products are not yet available. Poor wound healing can be a result of multiple different factors including poor perfusion. this is purely at the discretion of the surgeon and no specific recommendations exist. and difficulties with the abdominal donor site. Prevention is the . The venous anastamosis can be hand sewn however a high success rate has been noted with the use of the venous coupler (Synovis. There are several different biologic meshes available for repair of the abdominal wall however few published reports of their use in abdominal wall repair in the context of free TRAM flaps exist. warmth. smoking. COMPLICATIONS. small hematomas and seromas can be observed. In regards to infection. The donor site incisions are closed primarily in the muscle. warrant operative drainage and achievement of hemostasis. the surgery is considered a clean surgery and warrants perioperative antibiotics. The abdominal donor site is closed similar to an abdominoplasty. their use will help to prevent the occurrence (42). AND MANAGEMENT Complications of breast reconstruction via a TRAM. Consideration may be given to continuing the antibiotics for 48 hours postoperatively in irradiated breast reconstruction. Once such published report. Venous outflow monitoring is accomplished with implantable Dopplers.. thin mastectomy flaps. and radiation. Inc. General Surgical Complications General surgical complications encountered include infection. difficulties with the microsurgery. these antibiotics should not be continued in the post-operative period. Although drains and quilting sutures in the abdominal closure are not guaranteed prevention of seromas and hematomas. microsurgical technical difficulties. When they occur. Per accepted surgical recommendations for clean surgery. The DIEP flap can tolerate longer ischemia due to the absence of muscle (40). A synthetic mesh will provide the most strength but has a higher morbidity compared to biologics when it becomes infected. poor wound healing. NJ) in reinforcement of an abdominal repair but a high rate of bulge recurrence if used to try to primarily repair the fascia (41). Birmingham. Poor perfusion can be the result of previous scars on the abdomen. AL) with experienced microsurgeons (39). attention is paid to creating medial fullness and ptosis equivalent to that of the contralateral breast in a unilateral reconstruction. The internal mammary perforators and mastectomy flaps in the breast and the perforators of the abdominal wall are common sites of hematoma formation. difficulties with the breast recipient site. The ischemic time of the flap ideally should be under 1 hour however the muscle can tolerate up to 2 hours safely without any untoward effects. the skin from the abdomen replaces the areola removed during the mastectomy while de-epithelializing the remainder of the flap. Branchburg. deep vein thrombosis. especially in the breast where they can cause enough pressure on the free tissue transfer to cause constriction and loss of perfusion. The inset of the breast is performed after assuring an appropriate vascular supply. In the delayed reconstruction.TRAM FLAP AND DIEP FLAP BREAST RECONSTRUCTION distal internal mammary artery to provide perfusion to distant structures. and hemostasis. the distal internal mammary artery has sufficient reverse flow to perfuse an abdominal free flap (48). as mentioned previously. Although the more recent use of CT angiograms and MRA to identify the location of the prominent perforator(s) has taken some the guesswork out of the harvest. Additionally. however. If the mastectomy flaps appear too thin. These include the retrograde anastamosis to the internal mammary vena comitante referred to above. and the documented higher risk of deep vein thrombosis with an abdominoplasty procedure (47) all contribute to an increased risk of deep vein thromboses with breast reconstruction utilizing abdominal tissue. the internal mammary artery vena comitantes anatomy allows for both anterograde and retrograde venous anastamoses (49). the surgeon must have a number of “venous rescues” in his/ her armamentarium. a short summary in regards to breast reconstruction with abdominal free flaps can highlight some of the more common intricacies and difficulties. thoracoacromial. Deep vein thrombosis prophylaxis for a moderate risk patient includes perioperative heparin (unfractionated or low molecular weight) prophylaxis. dressing changes. 12. negative pressure wound therapy and in the case of irradiated tissue.51). an expanding hematoma within the breast pocket can eventually compress the pedicle resulting in vascular compromise necessitating early diagnosis. This would and commit the patient to a delayed reconstruction. Exposure for the anastamosis is critical.5). An additional available tool for evaluating the viability of the mastectomy flaps is the use of intraoperative fluoroscopy of the mastectomy flaps to map viability (44). The long pedicle associated with the DIEP flap dissection raises the risk of inadvertent twisting or kinking of the vessels and care must be taken during inset of the flap to ensure a proper alignment of the vessels. and skin in preparation for the anastamosis will make the procedure more straightforward (Fig. Additionally. Additionally. local wound care including debridement. the pedicle can become kinked as it passes over the edge of any excised rib or split pectoralis major muscle. In an immediate reconstruction. Probably more demanding than the actual anastamosis in a DIEP flap reconstruction.46). the perforators still must be dissected out of the muscle unharmed to provide perfusion to the free flap. the patient history of cancer. Utilization of the internal mammary artery and vein provides a good arterial size match for the deep inferior epigastric artery. and dissection of one of the two vena comitantes of the deep inferior epigastric artery off of the pedicle to provide venous grafts and or bypasses to the other venous systems listed above (see Fig. . hyperbaric oxygen therapy. Additionally when utilizing the internal mammary system. extra time spent preparing the vessels properly for the anastamosis will decrease the potential for occlusion of the vessels from inadvertent exposure of the intima and blood flow to clot initiating factors present in the externa and adventitia. the surgeon may require the patient to stop smoking and confirm this with urine or serum tests prior to performing the surgery.118 best approach to poor wound healing management but once the healing issues arise. as poor exposure makes a technically demanding procedure more difficult. As with smoking. Finally.6) (50. is the dissection of the perforators. or cephalic veins. nutrition should be optimized in all patients. utilization of the thoracodorsal. dependable patency of the venous and AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY arterial supply is crucial to success and venous failure is more common than arterial. should the proximal internal mammary artery become damaged or for some other reason not be adequate for anastamosis. As with all microsurgery. evacuation. Smoking has been shown to be more deleterious on the healing of the donor site than on the microsurgical transfer (45. 12. In a delayed elective reconstruction. liberal use of temporary sutures and urologic fish hooks or skin hooks to retract muscle. delaying cancer extirpation for smoking cessation is not appropriate and the reconstructive surgeon needs to balance the risks of smoking on success of the operation against the poorer cosmetic outcome in refusing to perform the immediate reconstruction because of patient smoking. preservation of a segment of the superficial inferior epigastric artery vena comitant to utilize for anastamosis. they can be debrided back to viable tissue or the skin paddle of the TRAM or DIEP flap can be preserved underneath the mastectomy flaps with plans to return to the OR to complete the inset of the flap once the mastectomy flaps have show Jerry day they can survive or have demarcated (43). sequential compression devices along with early ambulation. the learning curve is steep (52). The length of the surgery. decreased activity associated with the postoperative recovery due to abdominal discomfort. A long intramuscular course or serpentine course within the inscription of the perforators adds technical difficulty. Microsurgical Complications Although entire texts are devoted to microsurgery and its complications. As has been documented. As venous insufficiency of the free flap is more common. The patient should be encouraged to undergo smoking and nicotine cessation at least 3 weeks prior to the surgery. delayed reconstruction can be further delayed until the patient is nutritionally optimized. in immediate reconstruction the need to proceed with the extirpation takes priority. Whether using the internal mammary or thoracodorsal vessels as recipients. Finally. The index of suspicion for a pulmonary embolus should be high in patients who postoperatively desaturate or exhibit sudden hypotension and tachycardia. make up the armamentarium of the treating surgeon. soft tissue. pneumothorax. mastectomy flap necrosis.27) will increase the likelihood of fat necrosis.23. The dissection must be performed meticulously and gently and should an injury to the vessels occur. Postoperative chest radiographs should . dark coloration of peripheral flap. However. Breast and Abdominal Technical Complications The technical complications that fall outside of the realm of microsurgery include both the donor and recipient sites. attempts to utilize more of lateral Zone II and any of Zone IV of the Hartrampf zone perfusion description (14. the potential for partial flap loss due to inadequate perfusion increases (53) however the use of a non muscle-sparing TRAM will not necessarily avoid all difficulties with fat necrosis. As to the chest/breast recipient sites and reconstruction.54). localized areas of presumed fat necrosis within the flap parenchyma can be observed in the hopes that they will completely reabsorb. difficulties include partial free flap necrosis and/or fat necrosis.TRAM FLAP AND DIEP FLAP BREAST RECONSTRUCTION 119 Figure 12. attempts can be made to repair the injured vessels primarily or with interposition grafts if necessary. it can be treated conservatively with serial office debridements and wound care followed eventually by scar and breast reconstruction revision. The patient was returned emergently to the operating room and the flap was salvaged with venous anastomosis to the thoracodorsal pedicle. this should be followed closely with imaging and biopsy performed if any changes are noted or the mass does not disappear within six months time due to the remote possibility of cancer recurrence. Alternatively. As the number of perforators harvested for the DIEP flap decreases. Finally. Pneumothorax is a possible complication in any breast reconstruction especially when utilizing the internal mammary artery and vena comitantes as recipient vessels however this has only been reported twice in the literature (37. Larger areas of necrosis may require operative debridement of the necrotic tissue and flap shape revision. Despite what appears to be adequate perfusion of the TRAM or DIEP flap at the time of harvest. Additionally. the entire flap may not be perfused well enough to prevent partial flap loss or necrosis. and darkened serosanguinous drainage at the pin prick (arrow). A simple tear in the pleural lining can often be repaired primarily under Valsalva maneuver however any concern of injury to the lung parenchyma may warrant a chest tube. Routinely when fat necrosis or partial flap necrosis occurs. and cancer recurrence. Mastectomy flap necrosis as mentioned previously in the poor wound healing section can arise in both the immediate and delayed reconstruction settings and is particularly problematic with thin flaps or irradiated flaps. Intraoperative evaluation for proper perfusion beyond the standard observation for active bleeding at the skin edges has been reported utilizing fluorescent dye (44) but this specialized equipment is not widely available in hospitals. The preservation of several perforators or preservation of the contralateral flap until dissection of the chosen perforators is completed may rescue a doomed reconstruction. Note increased edema. the reconstructive surgeon is often at the mercy of the surgical oncologist and can only work with the materials that he or she is provided with.6 Post-operative day one congestion of a left breast free flap after bilateral deep inferior epigastric artery free-flap delayed breast reconstruction. the small caliber of the vessels makes repair difficult. Unfortunately. 12.8 percent in DIEP flap breast reconstruction (55). Any intraoperative concern of recurrence is better treated with a further delay in the reconstruction as opposed to having to remove portions of a free flap reconstruction if a recurrence is diagnosed. Similar to difficulties encountered in the mastectomy flap healing due to poor perfusion. Some tension is inherent this procedure and the preoperative pinch test is only a rough estimate of the ability to close the donor site intraoperatively. laxity. and weakness was 5. The literature reported incidence of abdominal wall bulge. laxity. and hernia is dependent on the harvest of unilateral and bilateral flaps and the degree of muscle sparing approach utilized. undermining. seroma formation. partial abdominal flap necrosis resulting in abdominal incision healing difficulties.1 percent in DIEP flap breast reconstruction. and loss of the umbilicus.120 be routine in free flap breast reconstruction cases to evaluate for pneumothorax and the index of suspicion should be high in patients who experience postoperative difficulties in adequate ventilation. In an immediate reconstruction. weakness. implants. Finally symmetry is dependent upon the amount of tissue provided by the free flap and the survival of that tissue. Perfusion can be compromised by smoking. Finally. Improvement of results comes with experience along with continued critical assessment of one’s own results coupled with intraoperative adjustments. Undermining of the superior abdominal flap in preparation for closure should be performed primarily centrally releasing the strong adhesions along the linea alba up to the level of the xiphoid while attempting to preserve the perforators from the rectus abdominis muscle to the abdominal flap. bulging.9 percent in free TRAM versus 3. tissue expanders. superior pole hollowing. a skin graft can be utilized where excessive and damaging tension would be required to close the donor site followed by excision and re-advancement of the abdominal flap in a subsequent surgery. Addi- AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY tionally. Additionally. Aesthetic complications of the breast reconstruction include poor shape. the repair of hernias resulting from free-flap harvest also varies but a majority will require insertion of mesh. as postoperative flap debulking in a revision procedure is fairly straightforward. serial debridement and wound care including negative pressure wound therapy will often heal the site without the need for a skin graft. Despite adequate closure. Caveats for improvement upon the breast inset include attention to the placement and re-establishment of the inframammary fold. As mentioned previously. a hernia/ bulge/or weakness may occur. the incidence of abdominal bulge. umbilical loss is related to poor perfusion from excessive dissection during the abdominal flap harvest or excessive tension from the inset. insistence on smoking cessation by the surgeon should be strongly considered in the delayed reconstruction setting and may be considered dependent upon timing in the immediate reconstruction setting. In instances where the incision breaks down due to partial necrosis.7). Alternatively. The author prefers to utilize a biologic mesh to reinforce only those fascial repairs that demonstrate a poor integrity either as thin fascia or easy tearing during the insertion of sutures. and utilization of the deepithelialized superior portion of the flap and the superficial fascial system to suspend the flap superiorly on the chest wall to create the breast mound. and failure. In a meta-analysis of the published literature. absorbable sutures are used along the inferior mastectomy flap and inferior free flap to anchor and reinforce the inframammary fold of the reconstruction to the chest wall. “over-shooting” the amount of tissue needed is preferable to having less than needed. recreation of the tail of Spence fullness of the breast reconstruction. the incidence of abdominal hernia was 3. the inset of the flap and closure of the donor site require as much surgical focus to achieve the optimum result. Usually serial debridement with wound care and time will result in a healed umbilicus. and fat grafting in a flap revision setting . Aesthetic complications of the abdominal donor site include “dog ear” deformities at the lateral aspects of the abdominal incision and umbilical asymmetry or poor appearance (see Fig. Breast and Abdominal Aesthetic Complications Although the microsurgical portion of the case including the harvest of the flap and the anastamosis is technically demanding. Excised mastectomy flaps and internal mammary lymph nodes removed in harvesting the internal mammary artery can be sent for permanent pathology. diagnosis of a cancer recurrence at the time of a delayed reconstruction is always a possibility. Although not optimal aesthetically. In unilateral reconstruction. Any tissue abnormalities encountered in the chest wall dissection can be investigated with intraoperative frozen sections. difficulties with healing of the abdominal donor site are also related to perfusion. and asymmetry. Technical complications associated with the abdominal donor site include hernia. The inframammary fold placement is dependent upon the contralateral breast if present and at the mid-humeral level. The triangular tip of the free flap when anchored to the pectoralis fascia superolaterally will reestablish the fullness previously filled by the breast tail of Spence. Despite a thorough preoperative work up by the patient’s medical oncologist as is recommended for a delayed reconstruction. Many reconstructive surgeons will routinely utilize either a biologic or synthetic mesh to prevent hernias however all meshes have inherent risks of infection. and excessive tension on the abdominal flap. improper location. Finally. undermining should only be performed to the extent that it is required to close the defect.9 percent in free TRAM versus 0. or weakness of the abdominal wall. SUMMARY The use of the abdominal free flap and its evolution to a muscle and fascial sparing approach has been an important contribution to the reconstruction of the breast. Smith P. Gillies H. In careful planning and a thorough knowledge of approaches to man- agement of complications associated with the abdominal free flap. Plast Reconstr Surg 1980. Breast reconstruction after a radical mastectomy. careful attention to umbilical location along with use of fascial anchoring sutures to invaginate the umbilicus will improve upon the appearance of the abdominal donor site in the abdominal free flap breast reconstruction procedure. central plication. can provide additional breast mound size for improved symmetry. Plast Reconstr Surg 1982. Plast Reconstr Surg 1976. REFERENCES 1. 2. Surgical replacement of the breast. Malafa M. Maxwell GP. Finally. Proc R Soc Med 1959. 3. 69: 216–25. Limited adjunctive liposuction. the closure of the abdominal donor site provides an opportunity for the reconstructive surgeon to utilize the experiences and techniques of the aesthetic surgeon. the reconstructive surgeon can provide a return of normalcy to the breast cancer patient.7 Preoperative (A. B) and 6-month postoperative (C. 65: 686–92. Note the larger reconstructed breast size in comparison to the native left breast. D) photographs of a right immediate DIEP free flap breast reconstruction. abdominal incision “dog ear” deformities and umbilicus inset to the left of the midline. IginioTansini and the origin of the latissimus dorsi musculocutaneous flap. Black PW. The patient elected to not undergo any nipple reconstruction or revisions. Hartrampf CR. 58: 283–91. 52: 597–602.TRAM FLAP AND DIEP FLAP BREAST RECONSTRUCTION 121 (A) (B) (C) (D) Figure 12. Millard DR Jr. Scheflan M. 5. Breast reconstruction with a transverse abdominal island flap. Suber J. Laronga C. 4. Prosthetic breast reconstruction after implant-sparing mastectomy in patients . Amsterdam: Excerpta Medica. et al. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Lipa J. and muscle-sparing free TRAM flaps on the abdominal wall: part I. Dinner MI. Augmentation Mammoplasty: A new “Natural Feel” Prosthesis. Salavati S. 126: 1142–53. Nelson J. 29. Arnstein M. Gupta A. Rectus abdominis myocutaneous flap for breast reconstruction. 98: 685–9. 106: 1295–9. Cronin TD. The extended vertical rectus abdominis myocutaneous flap for breast reconstruction. Reconstructive Surgery: Principles. Nahabedian MY. 31. and Technique. et al. The internal mammary artery and vein as a recipient site for free-flap breast reconstruction: a report of 110 consecutive cases. Rib-sparing internal mammary vessel harvest for microvascular breast reconstruction in 100 consecutive cases. 19. Milloy FJ. Daniel RK. Kashiwa H. 15. 123: 1403–7. The anatomy of several free flap donor sites. Scheflan M. Kikuchi N. Fosnot J. 1997 p. 32. Glass CA. and SIEA flaps. 18. J Plast Reconstr Aesthet Surg 2010. DIEP. 36. Dinner MI. vol II. Robbins TH. 119: 1993–2000. 23. Henton J. Blondeel PN. 108: 78–82. results and complications. Ann Plast Surg 1983. Jones G. Plast Reconstr Surg 2010. PA: Churchill Livingstone Inc. 16. Plast Reconstr Surg 1989. Bostwick J 3rd. 83: 1061–7. et al. Chevray PM. 23: 375–81. A rectus abdominis myocutaneous flap to reconstruct abdominal wall defects. 10: 120–9. Plast Reconstr Surg 1977. Bajaj AK. Murakami G. 8. Palmer JH. 51: 202–9. The rectus abdominis muscle and the epigastric arteries. Dowden RV. Clin Plast Surg 2007. 1000 consecutive venous anastomoses using the microvascular anastomotic coupler in breast reconstruction. discussion: 747–50. . The transverse abdominal island flap: part II. Bae HW. Soeda S. Kroll SS. Mathes SJ. Br J Plast Surg 1987. 110: 466–75. Tran NV. Jandali S. Clin Plast Surg 2007. 40: 113–41. Wu LC. 56: 243–53. Refinements in the use of the transverse abdominal island flap for postmastectomy reconstruction. et al. A prospective study comparing the functional impact of SIEA. 26. 22. 27: 351–4. Chevary PM. Anson BJ. Venous congestion and blood flow in free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps. Butler CE. 38. The transverse abdominal flap: part I. Abdominal donor-site outcomes for medial versus lateral deep inferior epigastric artery branch perforator harvest. Chang DW. One hundred cases of abdominal-based free flaps in breast reconstruction. Taylor GI. Comparison of the donor-site complications and functional out comes in free muscle-sparing TRAM flam and free DIEP flap breast reconstruction. Allen RJ. Morphometrical study of the arterial perforators of the deep inferior epigastric perforator flap. Plast Reconstr Surg 2006. 28. discussion: 1068–9. Dowden RV. 10: 24–35. 12. Ann Plast Surg 1983. Br J Plast Surg 1977. 59: 185–90. 63: 1597–601. 1095–105. Ann Plast Surg 1983. 10. Philadelphia. Takahashi H. Feng L. Bunch R. 30: 282–3. 21. Chang DW. Total breast reconstruction with either of two abdominal flaps. 7. 11: 362–72. 127: 1399–406. discussion: 476–7. Aust N Z J Surg 1979. Plast Reconstr Surg 2011. Drever JM. 114: 1077–83. and outcome. Robb GL. Lemaine V. Scheflan M. McAfee DK.122 6. Momen B. Labandter HP. Verhaeghe R. 1964. 17. Breast reconstruction with free flaps from the abdominal donor site-TRAM. Kaplan K. Dinner MI. DIEP. Baumann DP. 11. 34: 105–21. 49: 527–30. Tanabe H. Doppler flowmetry in the planning of perforator flaps. Chang DW. 27. The impact of preoperative computed tomographic angiography. Breast reconstruction with the free TRAM or DIEP flap: patient selection. Plast Reconstr Surg 2011. Anatomy. AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY with submuscular implants. Plast Reconstr Surg 1988. Changing trends in recipient vessel selection for microvascular autologous breast reconstruction: an analysis of 1483 consecutive cases. Selber JC. Beyens G. Br J Plast Surg 1989. Galdino G. et al. 14. 30. Nahai F. 35. et al. et al. Jallali N. Saint-Cyr M. 24. Dinner MI. The Vascular anatomy of rectus abdominismusculocutaneous flaps based on deep superior epigastric system. Youssef A. Ghattaura A. et al. Garvey PB. Verstraete K. discussion 1084–5. 20. unilateral reconstruction. Indications. Plast Reconstr Surg 2001. 42: 645–8. Scheflan M. 117: 737–46. 9. Taylor GI. Blondeel PN. 34: 83–104. Sakai S. Plast Reconstr Surg 2002. Plast Reconstr Surg 2009. et al. Dupin CL. choice of flap. The pedicled TRAM flap in breast reconstruction. Plast Reconstr Surg 2011. Sacks JM. 66: 546–50. 110: 293–302. Vega SJ. 39. Plast Reconstr Surg 1982. The free abdominoplasty flap for immediate breast reconstruction. surgical technique. Taylor GI. 125: 792–8. Surg Gynecol Obstet 1960. Plast Reconstr Surg 1996. Crosby MA. Plast Reconstr Surg 2000. Plast Reconstr Surg 2010. Plast Reconstr Surg 2004. Grotting JC. Robb GL. McCarthy C. Koshima I. Optimal timing of delayed free lower abdominal flap breast reconstruction after postmastectomy radiation therapy. Surg Radiol Anat 2001. 127: 2198–205. The role of the rectus abdominis myocutaneous flap in breast reconstruction. 13. Transactions of the Third International Congress of Plastic and Reconstructive Surgeons. 82: 815–32. Mathes SJ. Comparison of immediate and delayed free TRAM flap breast reconstruction in patients receiving postmastectomy radiation therapy. Inferior epigastric artery flaps without rectus abdominis muscle. Plast Reconstr Surg 2007. Breast reconstruction with the superficial inferior epigastric artery flaps: a prospective comparision with TRAM and DIEP flaps. Plast Reconstr Surg 1975. Chang DW. Ann Plast Surg 1991. contraindications. Moon HK. 34. Br J Plast Surg 1998. 25. 69: 209–15. 33. Selber JC. et al. 127: 1100–6. Venous thromboembolism following microsurgical breast reconstruction: an objective analysis in 225 consecutive patients using low-molecular-weight heparin prophylaxis. 37. Ann Plast Surg 2011. Arcilla E. et al. Begic A. Intercostal drain insertion for pneumothorax following free flap breast reconstruction—a near miss! J Plast Reconstr Aesthet Surg 2010. Mesic H. J Reconstr Microsurg 2010. Das-Gupta R. Converse JM. mammary vessels in the third intercostal space. Nahas FX. Mehrara BJ. Transplantation of skin. The application of laser-assisted indocyanine green fluorescent dye angiography in microsurgical breast reconstruction. 25: 21–6. 52. 124: 717–21. Munder B. Finocchi V. 65: 524–7. Philadelphia: WB Saunders. 48. Patel AJ. Does AlloDerm stretch? Plast Reconstr Surg 2007. Chevray PM. Plast Reconstr Surg 2009. et al. Perforator number predicts fat necrosis in a prospective analysis of breast reconstruction with free TRAM. Smith A. 62: 468–72. 65: 398–406. Seagle BM. Ferreira LM. J Plast Reconstr Aesthet Surg 2006. Seidenstuecker K. et al. Selber JC. 50. 124: 752–64. . and flaps. ed. Santoro T. Malata CM. 26: 637–8. 55. Ali R.TRAM FLAP AND DIEP FLAP BREAST RECONSTRUCTION 40. 46. Mahajan AL. Bernier C. Brauer RO. the learning curve explored. 119: 1060–4. Complications after microvascular breast reconstruction: experience with 1195 flaps. Newman MI. DIEP. Agarwal JP. Busic V. Gottlieb LJ. Lin YT. Anterograde and retrograde flow anastomoses to the internal 123 49. Ann Plast Surg 2010. Ballantyne DL. Morbidity of microsurgical breast reconstruction in patients with comorbid conditions. Lin HY. 1977. Baumann DP. 54. McCathy JG. In: Convers JM. Interval inset of TRAM flaps in immediate breast reconstruction: a technical refinement. Ghelfond C. Plast Reconstr Surg 2011. Reconstruction Plastic Surgery. Alternative venous outflow vessels in microvascular breast reconstruction. Santoro TD. 112: 448–55. Telischak KM. Clayman MA. grafts. 59: 580–4. et al. Barone-Adesi L. 45. et al. Plast Reconstr Surg 2006. and SIEA flaps. 41. 42. Ann Plast Surg 2009. Nahabedian MY. 43. Ann Plast Surg 2010. 44. The retrograde limb of the internal mammary vein: an additional outflow option in DIEP flap breast reconstruction. 63: 1929–31. Surgical strategies to salvage the venous compromised deep inferior epigastric perforator flap. J Reconstr Microsurg 2009. 118: 1100–9. The pathophysiology of venous thromboembolism: implications with compression garments. The deep inferior epigastric perforator flap for breast reconstruction. Salgarello M. Kerr-Valentic MA. 120: 1276–80. Cervelli D. Does quilting suture prevent seroma in abdominoplasty? Plast Reconstr Surg 2007. 53. Atisha DM. Plast Reconstr Surg 2010. Mehrara BJ. Abdominal wall following free TRAM or DIEP flap reconstruction: a metaanalysis and critical review. 51. Serletti JM. Samson MC. Clayman ES. Comizio RC. 127: 1086–92. Plast Reconstr Surg 2003. 47. Sadove R. Plast Reconstr Surg 2009. Man LX. 125: 1335–41. 13 Other free flaps in breast reconstruction Brian A. Mailey and Gregory R. D. Evans INTRODUCTION also be obtained by either computed tomography (CT) or magnetic resonance (MR) to assist in preoperative decision-making. Additionally, intraoperative use of laser angiography (e.g. indocyanine green) can define zones of perfusion in real-time and potentially further reduce postoperative complications. Formal protocols or management algorithms addressing choice of breast reconstruction do not exist. Therefore, cooperation of a multidisciplinary team is required for optimum outcomes and for patient satisfaction to be achieved. The collaboration of plastic surgeons and surgical oncologists works to develop an individualized treatment roadmap outlining expectations, potential complications and address how adjuvant therapies may alter the reconstruction prior to entering the operating room. Ultimately, the breast reconstruction method and timing depend on this coordination for each patient’s particular situation. Currently, the TRAM and DIEP flaps constitute the majority of free flaps used for breast reconstruction. Their consistent anatomy and convenient abdominal location contribute to their popularity as reliable options. They will likely maintain their place as the preferred option in breast reconstruction. However, recent advancements in preoperative angiographic assessment and increased operative experience have broadened the scope of free microvasular tissue transfer to include new perforator flap techniques. These represent the “other free flaps in breast reconstruction” and include the superficial inferior epigastric artery (SIEA) flap (4), when the lower abdominal basin is available to Breast reconstruction using autologous free flaps is widely practiced in the United States. The lower abdominal tissue provides the most common donor site for this type of reconstruction with the prototype being the free transverse rectus abdominus muscle (TRAM) flap (1,2). Advantages to the well-established TRAM include reliable anatomy, ample tissue for re-creating the breast mound and versatility of reconstruction options (e.g., pedicled vs. free). However, the TRAM compromises abdominal wall structure and has been associated with abdominal bulging and hernias (3). In an effort to reduce this donor-site morbidity, a movement from free TRAM to muscle-sparing TRAM and deep inferior epigastric perforator (DIEP) flaps has occurred (3). Additional investigations of free microvascular tissue transfer revealed techniques to avoid compromising abdominal structure (4), as well as alternative donor sites when lower abdominal tissue is unavailable. These autologous options include transfer of back tissue (5,6), buttock tissue (7,8) and thigh tissue (9–11). The factors directing choice in donor-site tissue include the size and shape of the native breast, the quantity of tissue at potential donor sites, the donor-site vascular anatomy, and patient comorbidities. Additional considerations include the length of the operative procedure and intraoperative positioning. Preoperative assessment is aimed at addressing these issues and defining patient expectations. An angiographic assessement of vascular anatomy can 124 OTHER FREE FLAPS IN BREAST RECONSTRUCTION provide donor tissue; or the SGAP (7), the IGAP (8), or the gracilis myocutaneous flap (9,11) when it is not. The Rubens, anterolateral thigh (ALT) and thoracodorsal artery perforator (TAP) flap are also alternate flaps described in breast reconstruction. This chapter will review these lesser common flaps with an emphasis on proper patient selection. SUPERFICIAL INFERIOR EPIGASTRIC ARTERY FLAP Grotting et al. described the SIEA flap for breast reconstruction in a 1991 case report (4). Promoted as the next level of abdominal wall preservation, it avoids excising the rectus abdominis fascia or muscle. The donor tissue is the same site for breast reconstruction as the DIEP flap. The vascular pedicle is the superficial inferior epigastric artery, 125 which originates from the femoral vessels in the groin and does not travel through any muscle (4,12) (Fig. 13.1). Aesthetic outcomes are reported to be indistinguishable between SIEAs, DIEPs, and free TRAMs (13). However, SIEA flaps have lower reported pain scores and hospital stays, with similar rates of common complications such as fat necrosis, hematomas, and seromas (3,13). The rates of abdominal hernia or bulge are lower with SIEA flaps, because the fascia is not removed (3,13). Despite these advantages, the SIEA flap has not gained widespread use in breast reconstruction. Any variability in vascular anatomy and skin territory limits popularity, as the SIEA and vein are inconsistently present in sufficient caliber to reliably support sufficient tissue for breast reconstruction (13). Assessment with CT/MR angiography has been advocated to determine operative feasibility (14,15). Figure 13.1 Depiction of the superficial inferior epigastric artery (SIEA) flap markings. The design is similar to an abdominoplasty. The SIEA comes off the femoral artery and anastomoses with branches of the superficial circumflex iliac artery. Pedicle lengths are 4–7 cm with a variable vessel diameter of <1.0–3.1 mm. Flap dimensions can be as large as 15 × 30 cm, however, perfusion is only to ipsilateral hemiabdominal tissues. 126 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY This preoperative evaluation of vascular anatomy can also decrease operative times and lower postoperative complications (14). Others authors describe an intraoperative assessment of SIEA caliber and if inadequate conversion to the deeper system as caliber size of the superficial system in inversely proportional to the deep system (16). The SIEA flap is generally considered useful when the artery is greater than 1 mm with palpable and visible arterial pulsations at the level of the lower abdominal incision and 1.5 mm at its origin from the femoral artery (13,17). This smaller average vessel size contributes to a higher rate of venous congestion seen with SIEA flaps. Additionally, only ipsilateral hemiabdominal tissues are perfused, with flow crossing the midline in only 5% of cases (13,17). This limits the ability to use the entire flap and any tissue taken more than 1–2 cm past the midline will often demarcate and necrose. Location of the pedicle can also be highly variable. The mean position of the artery is 2-cm lateral to the linea semilunaris (range 0–8 cm lateral) with a relationship to the SIEV also variable; the distance between them ranging from 0.3 to 8.5 cm apart (16). Inset of the SIEA flap may be easier if collected contralateral to the mastectomy site although some surgeons prefer ispilateral. This is due to the shape of the flap and eccentricity of the vascular pedicle (13), as it extends from one side of the flap. For this reason, insetting into the chest is considered more challenging than the TRAM or DIEP flaps (18). The SIEA is also associated with a smaller pedicle diameter and shorter pedicle length than the TRAM or DIEP (13,19). Nevertheless, with proper patient selection, the SIEA flap offers distinct advantages with excellent aesthetic results for breast reconstruction. pedicle is confirmed to be of sufficient size and quality, they are followed to their origin from the common femoral vessels and all other incised margins of the flap are deepened to the abdominal wall. Dissection from lateral-to-medial is generally safer and allows tubing of the flap on the occasion when donor vessels are unsuitable. A medial approach may risk damage to the superficial veins. Additionally, the anatomy may be confusing when a parent artery providing SIEA origin is different than the femoral (17% of cases) (21). The abdominal skin island is elevated in the plane superficial to the aponeurosis of the abdominal muscles from the contralateral side towards the vascular pedicle. Loupe magnification or microsurgical technique is used during the dissection. Care is taken around the inguinal ligament where the pedicle lies in the subcutaneous fat. The SIEA pierces the deep fascia below the inguinal ligament and passes cranially just superficial to the deep fascia. It lies deep to, and closely parallels, the superficial inferior epigastric vein. If available, a second team is simultaneously preparing the recipient vessels with the inferior mesenteric artery (IMA) and inferior mesenteric vein (IMV) as the preferred site and the thoracodorsal vessels as an alternate. When preparation of the recipient site is completed, the artery and vein of the pedicle are ligated at their base. The flap is transferred to the anterior chest wall. Depending on breast shape, the lateral portion of the flap is usually placed towards the axilla with the thicker medial aspect placed inferiorly and medially. Unneeded skin is de-epithelialized leaving a visible skin paddle for postoperative monitoring of venous congestion and for nipple construction at a later time. Finally, the abdominal wall is closed in a standard layered fashion over two closed suction drains. SIEA SURGICAL TECHNIQUE SUPERIOR GLUTEAL ARTERY PERFORATOR FLAP Surgical marking is made preoperatively with the patient in the standing position (Fig. 13.1). The contralateral abdomen to the mastectomy site is the preferred donor site because it provides easier insetting. The anterior superior iliac spine, pubic tubercle, inguinal ligament and femoral vessels are marked. Flaps are marked in an elliptical fashion (similar to an abdominoplasty) with the superior aspect drawn above the umbilicus and the inferior aspect measured to be approximately 12 cm lower at the midline (20). The lower border should be at least 5 cm below the inguinal ligament, and the dissection should include the fascia over the sartorius muscle (21). The superior and inferior incision sites are extended approximately 22–24 cm laterally from the midline and the SIEA and vein are found with Doppler probe and marked (22). The vessels lie superficially in the subcutaneous tissue and are approached midway between the ASIS and the pubic tubercle under Scarpa’s fascia and lateral to the linea semilunaris. The flap is designed in the same way as the free TRAM flap (1,2). Once the vascular The one-stage superior gluteal myocutaneous free flap described for breast reconstruction was reported in 1975 by Fujino et al. (23) With refinements in perforator flap surgery and flap harvest, the superior gluteal artery perforator (SGAP) flap developed, which minimized donor site morbidity and did not sacrifice the gluteal muscle (24). Initially described for coverage of sacral pressure ulcers (25), the SGAP eventually gained use in breast reconstruction and was published by Allen and Tucker in 1995 (7). The SGAP myocutaneous perforator flap carries fat and skin from the upper buttocks and provides good aesthetic shape low donor-site morbidity (Figs. 13.2 and 13.3). It is generally however less ptotic than abdominal wall free flaps. This reconstructive option is primarily considered in patients without appropriate abdominal donor tissues who have more skin and fat available in the buttock area. Superior and inferior gluteal artery perforators supply the gluteal region, therefore the gluteal perforator flap can be based on OTHER FREE FLAPS IN BREAST RECONSTRUCTION 127 (B) (A) Figure 13.2 (A) Photograph of a patient with previous right mastectomy interested in delayed autologous breast reconstruction. (B) Three-month postoperative picture from delayed reconstruction using a superior gluteal artery perforator flap. (A) (B) Figure 13.3 (A) Pre-operative photograph of patient to undergo superior gluteal artery perforator flap. (B) Three-month postoperative picture of donor site. The scar is well-concealed by undergarments or bathing suits. either nutrient vessel for its blood supply. These are known as the superior and inferior gluteal artery perforator flaps, respectively. A number of variations on skin island orientations, and dimensions have been described, each with advantages and disadvantages. An oblique or horizontal ellipse totally over the muscle oriented in the direction of the muscle fibers was first described (7). This provided an adequate perforator directly under the flap. Reported skin island sizes vary from 10 × 25 to 12 × 32 with flap weights between 210 and 820 g (7). With greater confidence in perforator harvesting and preoperative angiographic assessment of vascular anatomy, a more individualized skin island design emerged (24). These variations helped allow the limited pedicle length to be maximized and design the scar to be better concealed. CT or MR angiograms allow visualization of key musculocutaneous or septocutaneous perforators along with caliber, location, and course. Generally, septocutaneous branches pass between the gluteus maximus and medius muscles. Basing the SGAP flap on these perforators is possible, which frequently originate from the The superficial branch continues to give off contributions to the upper portion of the gluteus muscle and overlying fat and skin. For bilateral SGAP planning the patient is marked in the prone position.4). If possible. especially when the patient cannot shift weight to a non-operated side. a nicely shaped flap with less contour deformity can be obtained. These laterally located perforators produce longer pedicles. B-sized breasts and in whom abdominal donor tissue cannot be used. The deep branch travels between the iliac bone and gluteus medius muscle. In a review of 170 gluteal artery perforator flaps. Bilateral simultaneous SGAP flaps can be performed with two microsurgery teams (30. The sciatic nerve is not usually a problem. resultant buttock asymmetry. the SGAP can provide a significant amount of harvested tissue with average weights greater than mastectomy specimens (24). the overall take-back rate was approximately 8%. however small sensory nerves are divided with flap harvest. Septocutaneous perforators are the most lateral and course between the gluteal maximus and medius muscles. Additional perforators may be found slightly more lateral from above. where it divides into both superficial and deep branches. Contraindications to the flap include patients with unsuitable vascular anatomy or inability to tolerate frequent repositioning. The skin incisions are made and electrocautery used to dissect to the gluteus maximus muscle. The artery is short and runs dorsally between the lumbosacral trunk and the first sacral nerve emanating from the pelvis. candidates for SGAP flaps are those with large. This may increase wound complications. which increases ease of microvascular anastomosis (27). The superior gluteal artery is a continuation of the posterior division of the internal iliac artery and exits the pelvis superior to the piriformis muscle. In the right candidate. including dehiscence in the early postoperative period (24).24). 13. Donor site seroma occurred in 2% of patients and approximately 4% of patients required revision of the donor site (8). The point of entrance of the superior gluteal artery from the upper part of the greater sciatic foramen corresponds to the junction of the upper and middle thirds of this line. Perforating vessels are found off the superior branch of the superior gluteal artery (8. donorrecipient vessel size discrepancy potentially requiring additional vein grafting. The muscle is spread in the direction of the muscle fibers and the perforating artery and vein are dissected until both are of sufficient size to be anastomosed to the recipient vessels in the chest. although several perforators in the same plane can be taken together as well. A relatively short vascular pedicle is also frequently encountered and thus further limiting this flap’s popularity (24. while the SGAP flap is harvested. A line is drawn from the posterior superior iliac spine to the posterior superior angle of the greater trochanter (24). The flap is elevated from the muscle in the subfascial plane and the perforators approached lateral to medial. However sitting on the healing incision sites is painful.31). pear-shaped buttocks. The arterial . These difficulties have caused many surgeons to abandon the SGAP as a breast reconstructive option (28). Anatomic locations are planned with the femur in a slightly flexed and inward rotated position. Complications at the recipient-site include a fat necrosis rate of 8%. and intraoperative positioning inconveniences (7.29). Identification and use of the lateral septocutaneous pedicle result in a longer pedicle. The SGAP is based on perforators from the superior gluteal artery and vein. however liposuction of the upper buttock is uncommon and does not often affect harvesting of the SGAP flap (24). Beveling is used superiorly and inferiorly to harvest adequate tissue for good breast reconstruction. An oblique-ellipse orientation superiorly from the medial upper buttock to lateral has also been described with the advantage of concealing the scar in swimwear and undergarments (24). In general. The most common reason for donorsite revisions of the SGAP flap is contour deformity of the upper buttock. Breast flap contour causing asymmetry and requiring revision or fat grafting occurred in approximately 10% of cases (24). Previous liposuction is also a concern. The pedicle is found with the Doppler probe usually one third the distance from the posterior superior iliac spine to the greater trochanter. a two-team approach simultaneously prepares the recipient vessels. The internal mammary vessels are generally required for anastomosis due to the shorter SGAP pedicle length. SGAP flaps remain second choice procedures because of increased complexity in surgical dissection. A single larger perforator is preferred. Subfascial elevation is performed from medial to lateral to ensure the largest perforator is found until the flap is islanded out. AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY SGAP SURGICAL TECHNIQUE The patient is placed in the lateral decubitus position and the skin paddle is marked in an oblique or horizontal pattern from a slight inferior medial to superior lateral direction to include the perforators (or superiomedial to inferiolateral depending on surgeon preference) (Fig. These recipient vessels also allow for medialization of the flap when it is inset.128 anterior branch of the superficial branch of the superior gluteal artery (26). with a 6% rate of vascular complications (8).18). By beveling superiorly. The SGAP flap is also appropriate for women who require mostly fat with little skin as the buttock has a high fat-to-skin ratio (in comparison to the abdomen which has a high skin-to-fat ratio). The total flap failure rate was approximately 2%. This may be because of previous abdominoplasty or liposuction or those who only have excess tissue in the buttock area. The incidence of complications is low. 5 mm for the artery and vein. exits the pelvis through the greater sciatic foramen and travels with the superior gluteal nerve. Skin and subcutancous fat and soft tissue over the gluteus maximus muscle are elevated both superiorly and inferiorly to allow solid approximation of the fascia of the donor site. The design can be oriented in a variety of fashions. the definitive closure of the donor site is performed.5 mm and 3.0–2. with a pedicle 5–8 cm in length (24).5 mm. The recipient site is either definitively closed or temporarily stapled closed with a sterile occlusive dressing used to cover the wound. On average. The vessel diameters are 2. The flap is inset and the anastomosis performed to the internal mammary vessels under the operating microscope. perforator is preserved as it enters the main superior gluteal artery. Flap dimensions can be up to 12 × 32 cm. respectively.0–4. if not already completed. respectively.0–2. When the recipient chest vessels are ready. The SGA originates from the internal iliac artery. Pedicle lengths are usually 3–5 cm.0–4. but can be as long as 8 cm. Lastly. The donor site is closed in layers over a suction drain.5 mm and 3. The flap is inset over a suction drain into the defect with attention taken to place the flap as far inferiorly and medially as possible while not twisting the pedicle. approximating the fascia and skin separately.4 Illustration of the superior gluteal artery perforator flap (SGAP) skin island markings. The patient is then repositioned supine on the operating table and the recipient site is again prepped and draped. the gluteal artery and vein are divided and the flap harvested. The artery and vein diameters for anastomoses are 2.OTHER FREE FLAPS IN BREAST RECONSTRUCTION 129 Figure 13. . the flap height is 7–10 cm and the flap length is 18–22 cm. The IGA branches from the internal iliac artery and exits the pelvis through the greater sciatic foramen. gluteal tissue offers a viable alternative.5 Illustration of the inferior gluteal artery perforator flap (IGAP) design. INFERIOR GLUTEAL ARTERY PERFORATOR FLAP In 1978 Le-Quang performed the first reported breast reconstruction with an inferior gluteal myocutaneous free flap (32). By harvesting tissue from the lower buttock and beveling inferiorly. it was not until 2004 that the flap’s popularity rose as a preferred option when the abdominal wall is not a suitable donor site (8. The gluteal drain is left in place for several days longer than an abdominal donor site and removed in clinic. Patients are discharged when pain is controlled with PO medications and able to ambulate.5). This original French description outlined a multistep technique for delayed reconstruction creating a natural curvature and softness with a scar dissimulated in the gluteal fold (32). Pedicle lengths are generally longer than its superior counterpart. however. it uses tissue from the lower part of the buttock (36) with the donorsite scar concealed in the natural inferior crease (Fig. Abdominal tissue is generally preferred for breast reconstruction.130 In the postoperative period. revived the IGAP option in response to a short SGAP pedicle (34). IGA travels with the greater sciatic nerve inferior to the piriformis muscle.35). The inferior gluteal artery perforator flap relies on the inferior gluteal artery for its blood supply and resembles the SGAP. Few additional reports (33) included the AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY IGAP as a reconstructive option until 1989 when Paletta et al. The pain is generally less than with a TRAM flap reconstruction (24).35). the rounded shape of the upper buttock can be preserved. This approach conceals the donor-site contour and hides the scar in the inferior Figure 13. However. This typically occurs on the fourth to fifth postoperative day. but the pedicle lengths are 7–10 cm with flap dimensions of 8 × 18 cm. . 13. Vessel diameters are similar to the SGAP. although when unavailable. Good candidates for the IGAP flap are patients with excess buttock tissue and a “saddle bag deformity” (7. Oral pain meds are given on postoperative day one. ambulation is encouraged once the patient is transferred out of the ICU. The IGAP flap has a longer pedicle than the SGAP that will reach the thoracodorsal vessels if needed. 0 mm vein are required for anastomosis (24). One single large perforator or several smaller perforators. Its preservation will prevent donorsite discomfort when sitting. In the operating room.0–4. In contrast. In a review of almost 500 gluteal artery perforator flaps. This fat pad is often lighter colored. The gluteal fold is noted and the inferior limit of the flap is approximately 1 cm inferior and parallel to it. this is done both superiorly and inferiorly over the lateral aspect of the muscle. The vessels emerge from the lower part of the greater sciatic foramen and are usually located two thirds the distance from the posterior superior iliac spine along the line to the ischial tuberosity. Preoperative CT or MR angiography can also be used to locate the gluteal perforating vessels. which prevents the scooped-out appearance seen when the upper buttock donor site is used. intraoperative patient repositioning. Lateral thicker fat from the trochanteric area can increase flap volume and decrease a saddlebag deformity (24). to be more important factors. A line is drawn between the posterior superior iliac spine and the outer part of the ischial tuberosity.34. Once the mastectomy is completed and recipient vessels prepared. The perforator or perforators are followed until entering the main descending inferior gluteal artery. Skin incisions are made and electrocautery used to divide the flap to the gluteus maximus muscle. Donor-site seromas requiring aspiration occurred in 15% of patients and 20% required donor-site revisions at the time of second-stage breast reconstruction (8. the patient is placed in a lateral decubitus position for unilateral reconstruction and prone for bilateral. The inferior gluteal vasculature exits the pelvis caudal to the piriformis muscle and continues toward the skin by perforating the sacral fascia. Microsurgical expertise. Laterally positioned vessels perforate the gluteus maximus more obliquely and are generally longer than the medial ones. Therefore.5 mm artery and 3. IGAP SURGICAL TECHNIQUE Anatomic landmarks are drawn with the patient in the standing position. which may affect the IGAP flap viability. with 4% and 2% being venous and arterial. The inferior gluteal artery branches from the internal iliac artery and exits the pelvis through the greater sciatic foramen inferior to the piriformis muscle. including consistent vascular anatomy and adequate perforator length. Skin markings can be customized to correct a saddlebag deformity by 131 shifting the pattern laterally (24). medial to the gluteus maximus muscle. which lie in the same plane and the direction of the gluteus maximus muscle fibers. respectively (24). Donor-site morbidity is generally low and no sacrifice of muscle is required. Beveling is used to affect the amount of tissue harvested. Skin and fat overlying the gluteus maximus muscle and posterior thigh are elevated both superior and inferior to permit a layered approximation and prevent a contour deformity. can be used.35). Overall complications are low. The flap is harvested and the donor site is closed in layers with absorbable suture. The remainder of the skin paddle is drawn in an elliptical fashion to include the perforators. champions of the inferior gluteal myocutaneous flap (34) consider its favorable attributes. A suction drain is placed and skin closure is performed with nonabsorbable sutures. and the posterior femoral cutaneous nerve. and lengthy procedures have also limited its popularity. have a longer pedicle length than their superior gluteal counterparts. In appropriate candidates. The dimensions are approximately 8 × 18 cm (24). Total flap failure rate was 2%. Contour asymmetry of the breast flap requiring fat grafting or revision occurred in 10% of cases. the gluteal artery and vein are divided. which can generally be accomplished by liposuction. the in-the-crease IGAP flap provides excellent breast reconstruction with well-concealed scars. The length of the inferior gluteal artery perforator and resultant pedicle length is 7–10 cm for the IGAP flap. Contraindications to the IGAP include previous liposuction of the saddlebag area. . in particular. The muscle is spread in the direction of its fibers and perforators followed until both the artery and the vein are of sufficient size for anastomosis in the chest. The inferior gluteal vessels course obliquely through the gluteus maximus and therefore. ischial fat pad preventing the discomfort when sitting (20.24). A 2. pedicles based on lateral perforators are longer and chosen over the ones more medial. The perforators are approached both lateral to medial and medial to lateral as the flap is elevated off the muscle in the subfascial plane. the overall takeback rate for vascular complications was 6 percent. The artery travels with the greater sciatic nerve. the associated morbidity can be decreased by preservation of the lighter-colored medial. Complications at the recipient-site include a fat necrosis rate requiring revision of 8%. Care must be taken to avoid harvesting the fat pad over the ischial tuberosity. This technique provides width and volume for a natural breast shape. A number of inferior gluteal artery perforators will supply both the medial and lateral aspects of the buttocks.OTHER FREE FLAPS IN BREAST RECONSTRUCTION gluteal crease. Difficulties and problems associated with the IGAP include potential exposure of the sciatic nerve. the internal pudendal vessels. The inferior gluteal perforators are located and marked using the Doppler probe. The in-the-crease IGAP flap can allow for more beveling superior and inferior because a soft-tissue deficiency in the crease is normal. The limiting factor in this dissection is frequently the artery.0–2. Additionally. The most common revision for the IGAP donor site is contouring of the lateral trochanter. if similar in caliber. which has been associated with postoperative pain when sitting (34). which can be managed in the outpatient setting (43). the recipient vessels can be prepared by a second team while the flap is harvested. combination of both) and if the gracilis muscle is utilized in the reconstruction. The IMA is the preferred recipient vessel. an ellipse is designed over the course of the gracilis muscle. When using the internal mammary perforators as recipient vessels. The median hospital stay is 5 days. Overall. GRACILIS MYOCUTANEOUS FLAP SURGICAL TECHNIQUE Surgical technique varies slightly depending on skin island design (e. they deduced that complete muscle survival would result in complete survival of all the overlying skin (11). despite occasional intraoperative AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY arterial thrombosis (43). A suction drain is placed into the breast pocket. fat necrosis. Complete or partial flap loss is a rare event (41). but when occur most commonly include hematoma. For bilateral simultaneous procedures using gluteal artery perforator flaps. (11) Using the concept that the blood supply to the muscle and its overlying skin is synonymous. The skin island can be harvested to a width up to 30 cm and a height of 10 cm (41).41). hyperesthesia or a “tight feeling” at the thigh which usually resolves in 2–3 weeks (41). Harvest times are reported to be as low as forty-five minutes with flap weights ranging from 220–420 g (9. These factors have led this inner thigh and lower gluteal tissue flap to be an excellent option for providing the necessary amount of tissue required for thin. The ventral limit of the transverse flap is the greater saphenous vein and the posterior margin the midline of the inferior gluteal fold. The patient is then positioned for flap harvest and repositioned supine for anastomosis and insetting. Ideal candidates are thin patients with small to medium-sized breast. Adjuvant chemo. Other notable attributes. At a mean follow-up of 6 months. The limits of the transverse portion can be estimated by palpating the thigh laxity as it courses posterior into the infragluteal fold area. which may be done horizontally. For the transversely oriented design.41). the gracilis myocutaneous free flap allows for a moderate breast volume harvested in a reasonable amount of time in the supine setting.39. This configuration provides a reliable vascular anatomy with the needed tissue bulk for creating the breast mound.40). Intraoperative repositioning is also not necessary. or obliquely. The vascular anastomosis is performed with loupe magnification or preferably under the operating microscope. Other minor complications include delayed healing on the donor site or mastectomy skin. athletic patients with smaller breasts and minimal excess abdominal tissue desiring autologous tissue reconstruction. The internal mammary vessels or their perforators allow easier medialization of the flap when it is inset. longitudinal vs. Preoperative marking of the skin paddle and gracilis muscle are performed with the patient in the standing position. Donor-site complications are uncommon. if necessary. one of which was for breast reconstruction (11). These factors have contributed to this flap’s increasing popularity in Europe (42).38). In unilateral procedures. as this flap does not yield an excessive amount of tissue. Their anatomic study also included two cases. GRACILIS MYOCUTANEOUS FLAP The gracilis myocutaneous muscle flap was first described using a longitudinal skin island in 1976 (37. with most patients willing to undergo it again (41). the inferior gluteal pedical is often long enough to reach to the thoracodorsal vessels. as long as the vascular pedicle is not twisted or kinked. Donor–site infections are infrequent. However. vertically. the patient starts supine for mastectomy and recipient vessel preparation. Functional deficits are minimal and asymmetry of the thigh in unilateral cases is not usually apparent. The gracilis flap is suited for patients desiring autologous breast reconstruction without available abdominal donor tissue. Several subsequent series have described the musculocutaneous graciliis flap with high success rates in both transverse and longitudinal based skin islands (9. acceptable donor-site morbidity and a pleasing breast contour. In the late 1990s the gracilis myocutaneous flap’s popularity increased using a smaller transverse component and a larger longitudinal one (42). Overall flap success rates are high with many series reporting 100%. Further investigations demonstrated the presence of perforators running in both transverse and longitudinal directions.or radiotherapy does not interfere with the reconstructed breast flap (41).. which led to the use of a transversely based gracilis flap in 1992 by Yousif et al. and small wound dehiscence. The resultant reconstruction has been promoted as soft and supple with a well-concealed scar. A minimum of 6 cm is needed to include perforators supplying the skin (41). the flap is harvested contralateral to the mastectomy site for a better pedicle orientation and contour match when anastomosing with the internal mammory vessels.g. transverse vs. Postoperative surveys demonstrate high satisfaction rates with the gracilis free flap. Concerns over skin paddle necrosis due to uncertain cutaneous perfusion resulted in limited use (11. but the thoracodorsal vessels are also used with good success. a shorter pedicle and smaller artery may suffice and thereby simplifying flap harvest. include consistent anatomy. For the longitudinal design. This is located by drawing a line from the pubic tubercle to the medial tibial .132 The flap is then inset onto the chest. almost all surveyed patients were regularly exercising and sexually active (41). The length can be extended distally to 27 cm by including a constant intramuscular anastomosis (44). but can extend up to 27 cm. respectively. This is correlated with the skin requirement at the recipient site. the patient is placed in the lithotomy position (or supine with the thighs abducted at the hip and knees in flexion) and flap elevation started during the mastectomy. Flap dissection proceeds from anterior to posterior in a subfascial plane until the intermuscular septum between the adductor longus and the gracilis muscle is encountered.0–2. Usual flap dimensions are 5–9 cm in width and 10–18 cm in length. descending and transverse branches (44). The pedicle enters the gracilis muscle 9–12 cm distal to the public tubercle dividing in a consistent pattern into ascending. Flap harvesting is commenced near the groin. The proximal end of the skin island is planned at least 2–3 cm distal to the pubic bone. The vascular pedicle length and vessel diameter are 6–8 cm and 1. regardless of skin paddle design. The skin is incised and the deeper subcutaneous tissues elevated in a beveled fashion (A) 133 away from the flap to provide bulk and shape.6 A). Flap dimensions are generally reported from 5 × 10 to 9 × 18 (9). The flap is centered on the pedicle with the skin paddle boundaries varying by surgeon choice of transverse versus longitudinal.6 (A) Demonstration of the skin island design for the transverse upper gracilis flap along with the gracilis muscle and vascular supply via the ascending branch of the medial circumflex femoral artery.OTHER FREE FLAPS IN BREAST RECONSTRUCTION prominence. it is usually from a common profunda takeoff. when separate the proximal pedicle is dominant in size and number of perforators (44). In the operating room. where the adductor longus tendon can be palpated. The length of the skin paddle can be 10–18 cm and is determined by the amount deemed necessary to close the resultant defect without creating skin excess. however. The anterior portion of the skin island is lifted off the adductor longus muscle and (B) Figure 13. Flap width is determined by approximating the amount of skin laxity and underlying fat. Flap dimensions are as large as 10 × 30 cm. (B) The skin island can be designed in a longitudinal fashion or a combination of both.5 cm posterior to this line. When this occurs. The vascular pedicle is followed to its takeoff from the profunda femoral vessels or occasionally the medial circumflex femoral vessels (44). The gracilis muscle lies approximately 2. . anatomic studies define a vascular territory of 18 × 15 cm. with usual dimensions varying between 5 and 9 cm. A doubled main vascular pedicle can be encountered. The skin markings can be thought of as nearly identical to the properative markings of a classic medial thigh lift.5 mm. 13. The transverse myocutaneous gracilis crescent shaped skin paddle is oriented in an anteroposterior direction (Fig. but dissection is described as difficult with small diameter vessels. This length allows recipient anastomisis to either the internal mammary or thoracodorsal vessels (49). including a large flap dimension (25 × 15 cm).5 mm (43). in 1983 and 1984. The TAP flap offers distinct advantages. A vein coupler is utilized and the artery sewn with 9-0 nylon suture. respectively (56. the distal aspect of the incision is made first to locate the gracilis muscle. Promoted for pliable skin quality and underlying fat. The TAP was first described in 1995 as the latissimus dorsi musculocutaneous flap without sacrificing the latissimus muscle (52).134 the muscle retracted anteriorly. It is based on the 4th lumbar perforator located posterior to the posterior axillary line. have achieved a good volume match for this flap in Asian women (10). a close relationship to the thoracodorsal nerve branches and inconsistent venous drainage contribute to the complexity (46. After completion of the mastectomy. The TAP flap has not gained wide popularity compared to other perforator flaps. The Rubens flap is based on the deep circumflex iliac artery and uses the flank skin and fat for reconstructing the breast (45. The buried skin is de-epithelialized under the mastectomy flaps over one to two suction drains. Dissection of these flaps is often more difficult and time consuming than dissection of the other flaps described in this chapter. Centering the dissection over the vascular pedicle improves the perforator capture and holds the intact origin and insertion of the gracilis muscle and its pedicle. including the Fu-chan Wei group in Taipei. from the outer hip area. the ALT (10) free flap from the anterior thigh and the TAP (5. making identification difficult even with an intraoperative Doppler assessment (45). OTHER FLAPS Additional flaps attempted in breast reconstruction have included the Ruben’s flap (45). A modification of the flap developed to make closure of the donor site easier with less chance of morbidity is the Rubens II flap (50. The paddle design can then be adjusted over the gracilis muscle (9). A perforator signal on the skin paddle is marked with a prolene suture for postoperative Doppler monitoring.6) flap from the back.51). 13. increasing exposure of the flap pedicle. less conventional sources of autogenous tissue may be preferred in select circumstances.57). Advocates for the ALT flap. quality and location.6 B).55). and the tissue volumes are also often less abundant and more difficult to shape into a breast (39. The donor flap pedicle is then ligated (and gracilis muscle divided at the distal muculotendinous junction if taken) and the flap inset with loupe magnification or an operating microscope. Additionally. but can be challenging and lead to postoperative morbidity. Muscle harvesting is not required.7). a customizable flap thickness. which often times results in donor site asymmetry and leads to additional contralateral flank contouring procedures to achieve a symmetric appearance (48). The flap is elevated over the fascia and the main vascular pedicle exposed as it enters underneath the gracilis muscle. Nonetheless. Alternatively.48) (Fig.48). Closure at the level of the internal oblique and transversus abdominis muscles is important for abdominal wall integrity. Patients considered for this flap are generally thin or those with previous abdominal surgery (48). Harvesting can be done in the supine position producing average pedicle lengths around 6–10 cm (45.47). the ALT flap is described as similar to tissue of the lower abdominal flaps and superior to that in gluteal flaps (10). The flap is rolled into the upper pole of the breast to allow for a natural breast shape. which gives this flap a reputation for being difficult to dissect (46. When available the TAP produces minimal donor site morbidity with good flap shaping and aesthetic results. The main pedicle is encounted in the adiopofascial space at the dorsal border of this muscle. Dissection is continued to the profunda femoral vessels resulting in an average pedicle length of 6 to 8 cm. perforators may be small or in spasm. Conversely.46. A drawback to the Rubens flap is considered the tedious process required for flap harvest. the ALT flap based on the descending branch of the lateral circumflex femoral artery has found some utility as an alternate in autogenous breast reconstruction (10). The nomenclature was changed to more accurately represent the actual tissue harvested and its vascular supply (53). the IM vessels (or thoracodorsal) are prepared. In those situations this . The posterior aspect is incised and subcutaneous tissue beveled obliquely until muscle encountered. 13.53). and a variable pedicle length that is readily tailored to the recipient status (54). The donor leg is wrapped in an ace bandage and the patient is permitted to ambulate on POD#1.5–2. the perforator is inconsistent in size. The vascular pedicle is followed to its takeoff from the profunda femoral vessels or occasionally the medial circumflex femoral vessels (44). The operative technique and anatomical basis were initially described by Baek and Song et al. as the caliber of the gracilis vessels are 1. For the longitudinally based flap (Fig. Advantages include a reliable AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY amount of soft tissue volume that is usually present in this region of most female patients. Additionally. It has been described as the most exacting portion of the operation and the key to its ultimate success (48). The volume of the ALT flap may not be adequate without an additional prosthetic in Western and African populations.52. The donor site is closed in two layers with 2-0 monocryl and 3-0 monocryl over two bulb suction drains. The pedicle is left in its investing fascia during dissection to the profunda vessels. The IM vessels at the third to fourth interspace allow for the best size match between the donor and recipient vessels. Opponents to the ALT flap also describe the vascular dissection as tedious. Other disadvantages of the flap are scar and contour defects at the donor site. then spaced out to every 2 and 4 hours for postoperative days 2 and 3. if the transverse component is more than 9 cm. This typically occurs on the 4th or 5th postoperative day. monitoring of drain output and continued flap checks every 4 hours. The soft tissue dissection provides large flaps from this region with weights of 600–1. Additionally.OTHER FREE FLAPS IN BREAST RECONSTRUCTION 135 Figure 13. The breast and donor-site drains are taken out at the first . flap can still be augmented with a prosthesis or require the use of tissue from both legs (58). The following day. respectively. The patient is discharged once ambulating and pain is controlled on PO medications.7 A depiction of makings for the Rubens flap over the iliac crest. However. tensor fasciae latae. POSTOPERATIVE MANAGEMENT In the postoperative period.5–3 mm. Hourly flap circulation monitoring is performed for the first 24 hours. patients are observed in a monitored bed (ICU or flap monitoring unit) for two to three nights. the ALT can be a practical solution in select circumstances. allowing a pedicle length of 6 to 10 cm with vessel diameters of 1. The vascular supply is from the deep circumflex iliac artery.59).200 g. Nonetheless. patients are transferred to the floor for pain control.. a primary closure is difficult (10. The ALT flap is usually based on the descending branch of the lateral circumflex femoral artery but can come directly from the profunda femoris (60). including bilateral simultaneous reconstruction. anteromedial thigh. Pedicle dissection can be taken off the origin of the iliofemoral vessels. anatomic variations are frequently encountered and occasionally may require conversion to an alternate flap (e. yielding limited tissue volumes with unpredictable outcomes (46).g. as repositioning of the patient between the harvesting and insetting of the flap is not required. This vascular pedicle is usually long with a moderate thickness and a large cutaneous distribution. or contralateral ALT flap) (60). As breast reconstruction strategies and preoperative vascular imaging advances. The autogenous latissimus breast reconstruction. Wu LC. Clin Plast Surg 1994. 30: 386–91. Plast Reconstr Surg 1982. Granzow JW. The free abdominoplasty flap and its use in breast reconstruction. et al. The abdominal flap continues to be the standard autogenous tissue for breast reconstruction. Imaging of the superficial inferior epigastric vascular anatomy and preoperative planning for the SIEA flap using MDCTA. Breast reconstruction using perforator flaps. Plast Reconstr Surg 2002. 56: 243–53. and muscle-sparing TRAM flaps for breast reconstruction. 27: 351–4. Holm C. discussion 84–5. 2. Chiu ES. 94: 441–54. abdominoplasty. Guerra AB. 110: 82–8. Cheng MH. 11. Granzow JW. Allen RJ. however. Plast Reconstr Surg 2007. Scheflan M. 95: 1207–12. 17: 1890–900. DIEP. 122: 702–9. Allen RJ. Kind GM. et al. LoTempio MM. 60: 946–51. 13: 423–7. Taylor GI. Comparison of donor-site morbidity of SIEA. 7. Breast reconstruction with superficial inferior epigastric artery flaps: a prospective comparison with TRAM and DIEP flaps. AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY 4. 17.62). Ann Surg Oncol 2010. Metzinger SE. Rosson GD. 72: 810–18. McCraw JB. The free abdominoplasty flap for immediate breast reconstruction. 69: 216–25. 63: 1597–601. Allen RJ. 18. Yousif NJ. Superior gluteal artery perforator free flap for breast reconstruction. Lai YL. Iimura H. 21: 279–88. 16. Chiu ES. Grotting JC. Mayr M. . Levine JL. The individual’s body fat distribution influences the ultimate decision. Sakurai H. or back can vary largely between individuals. 20. Samra F. Ann Plast Surg 2004. Others have limited published data and require more investigation to establish their place as a practical solution. Breast reconstruction with a transverse abdominal island flap. 5. Kolachalam R. Jallali N. The transverse gracilis musculocutaneous flap. This reconstructive equality has increased the availability of autogenous reconstruction to a greater number of women. Ihara K. Celik N. et al. 120: 1–12. or back tissue) for autogenous soft tissue transfer requires an individualized approach. Grinsell D. The anatomy of several free flap donor sites. Grunert BK. J Plast Reconstr Aesthet Surg 2007. Kuwatsuru R. Microsurgery 2010.g. Chang DW. McMellin A. The impact of preoperative computed tomographic angiography. buttocks. Sanger JR. previous liposuction. Rozen WM. etc. buttock. J Plast Reconstr Aesthet Surg 2011. An experimental study and clinical case report. 61: 513–20. These include thin patients or patients with contraindications to a lower abdominal flap (e. 19. Nipple creation and additional contouring procedures are performed at a later date. 14. Ann Plast Surg 1992. The longitudinal gracilis myocutaneous flap: broadening options in breast reconstruction. 64: 63–8. Shridharani SM. Holmstrom H. Anterolateral thigh flap for postmastectomy breast reconstruction. The quality of the skin and fat pad also need to be considered. usually in 2–3 months. Hartrampf CR. 122: 348–55. then back. thigh. Wei FC. Plast Reconstr Surg 2008. Hofter E. Many of these strategies are extensively studied and offer excellent. Mastectomy reconstruction without a prosthetic implant. as do the donor-site morbidity and resultant scars and tissue defects. Breast reconstruction with gluteal artery perforator (GAP) flaps: a critical analysis of 142 cases. Plast Reconstr Surg 1975. One hundred cases of abdominal-based free flaps in breast reconstruction. Fukaya E.. 52: 118–25. A majority of patients will qualify for this approach. 15. Plast Reconstr Surg 1983. Bristol M. The variability of the Superficial Inferior Epigastric Artery (SIEA) and its angiosome: A clinical anatomical study. 114: 1077–83. Edwards A. et al. Henton J. as the lipodystrophy of the thigh. Tucker C Jr. CONCLUSION The Women’s Health & Cancer Rights Act of 1998 requires medical insurance providers covering mastectomy to authorize coverage for all stages of ipsilateral reconstruction and contralateral procedures for creating a symmetrical appearance (61. It has also contributed to an increase in surgeon experiences with soft tissue transfer and created new challenges.. Matloub HS. Chevray PM. Ashton MW. Decision between one of the secondary options (e. approximately 15% of patients are not good abdominal donor-site candidates (63). J Surg Oncol 2006. Bajaj A. Chevray PM. 8. thigh. which in turn allowed novel strategies to be developed for re-creating the breast. Magarakis M. The versatility of the SIEA flap: a clinical assessment of the vascular territory of the superficial epigastric inferior artery. Chubb D. Plast Reconstr Surg 2004. Ninkovic M.). 6. Suominen S. Ghattaura A. 13. Scand J Plast Reconstr Surg 1979. Plast Reconstr Surg 1995.g. but generally list the abdomen as the preferred site followed by the buttock. Rank orders published by highly experienced centers will vary slightly. 10. Black PW. surgeons will continue to have additional options for creating a near-normal-appearing breast. Ann Plast Surg 1991. 9.136 or second clinic visit. Ann Plast Surg 2008. A head-to-head comparison between the muscle-sparing free TRAM and the SIEA flaps: is the rate of flap loss worth the gain in abdominal wall function? Plast Reconstr Surg 2008. 12. A review of the surgical management of breast cancer: plastic reconstructive techniques and timing implications. Selber JC. Foster RD. Bidros RS. 21. J Plast Reconstr Aesthet Surg 2010. 3. Levine JL. Daniel RK. 29: 482–90. Breast reconstruction with perforator flaps. REFERENCES 1. Papp C. reliable options for creating a natural appearing breast. Hokin JA. A preliminary report. 63: 2123–7. et al. Koshima I. Anderl H. Jeng SF. Ninkovic M. Ohmori K. The Doppler probe for planning flaps: anatomical study and clinical applications. Frerichs O. 57: 133–43. Aoyagi F. 35. The free musculocutaneous flap. Plast Reconstr Surg 2004. McCarten G. Allen RJ. Siebert J. The in-the-crease inferior gluteal artery perforator flap for breast reconstruction. Spyropoulou GA. 91: 678–83. Van Landuyt K. 108: 352–8. Erk Y. 55. 124: 1400–9. Van Landuyt K. Am J Surg 2008. Plast Reconstr Surg 2008. Serletti JM. Microsurgery 2010. Internal mammary vessels as a recipient site. Juricic M. Weiler-Mithoff E. Inferior gluteal artery perforator flap breast reconstruction. 34. 51. Stal S. 93: 402–7. 58. Lykoudis EG. Paige KT. 24: 281–4. 107: 1766–71. Hartrampf CR Jr. Ackermann G. A clinical experience with perforator flaps in the coverage of extensive defects of the upper extremity. Peek A. 122: 146e–8e. 33. Doyle M. Microsurgery 2004. The anatomic basis of the gracilis perforator flap. 53: 305–10. 57: 294–303. et al. 23. Prucz RB. Clin Breast Cancer 2009. Bailey S. Reconstructive management of contralateral breast cancer in patients who previously underwent unilateral breast reconstruction. DellaCroce FJ. Sullivan SK. 40. Spira M. 25. Angrigiani C. Metzinger SE. Plast Reconstr Surg 1976. Plast Reconstr Surg 1989. Exner K. Hodgson EL. 44. and reliable method for breast reconstruction. Clinical experience with the lateral septocutaneous superior gluteal artery perforator flap for autologous breast reconstruction. Harii K. Plast Reconstr Surg 2006. Surg Radiol Anat 1993. et al. Secondary microsurgical reconstruction of the breast and free inferior gluteal flap. Plast Reconstr Surg 1995. Warnecke IC. Rozen WM. Plast Reconstr Surg 2005. Vlastou CC. 36. Shaw WW. A modified gluteus maximus musculocutaneous free flap based on the inferior gluteal vessels. Anatomic basis for use of a gracilis muscle flap. 59. 25: 213–21. et al. Moriguchi T. Paletta CE. discussion 9–60. Hamdi M. 55: 390–5. 46. Latissimus dorsi musculocutaneous flap without muscle. Plast Reconstr Surg 1994. Superior gluteal artery perforator flap based on septal perforators: preliminary study. 28. Kuo YR. 47. Ann Chir Plast Esthet 1992. Bilateral anterolateral thigh flaps for large-volume breast reconstruction. 56. 52. Taylor GI. Kim JT. Beshlian KM. Ross MI. Microvascular reconstruction of the breast. 58: 1090–4. Simultaneous bilateral breast reconstruction with superior gluteal artery perforator (SGAP) flaps. Breast reconstruction by superior gluteal microvascular free flaps without silicone implants. Ann Plast Surg 1983. Dackiw A. Two new cutaneous free flaps: the medial and lateral thigh flaps. 54. Plast Reconstr Surg 2001. Levine JL. Schwabegger AH. Perforator flap breast reconstruction. . Harasina T. The free gracilis perforator flap: anatomical study and clinical refinements of a new perforator flap. Baek SM. Nahai F. 29. 48. 118: 333–9. Rosson GD. Grilli D. Elliott LF. 45. et al. Vaysse P. Song YG. 96: 1608–14. Rajkomar AK. Anavekar NS. Soeda S. 43. Stapleton SM. 57: 531–9. Gracilis myocutaneous free flap in autologous breast reconstruction. Reconstruction for aplasia of the breast and pectoral region by microvascular transfer of a free flap from the buttock. Ashton MW. Guerra AB. 30. Br J Plast Surg 2002. Breast Dis 2002. Bossert RP. 116: 97–103. Vega SJ. Chandawarkar R. 50. 27. Ann Plast Surg 2004. 37: 149–59. 25: 283–91. 16: 93–106. 84: 875–83. 30: 339–47. Chang DW. Plast Reconstr Surg 2009. Sandeen SN. Drazan L. Harii K. 71: 354–65. Plast Reconstr Surg 1993. Song YL. Boeckx W. 49. J Plast Reconstr Aesthet Surg 2010. The deep circumflex iliac artery flap. Plast Reconstr Surg 1983. The gluteal perforatorbased flap for repair of sacral pressure sores. 56: 178–81. 43: 1–16. Ohmori K. Guitard J. 38. Hartrampf CR Jr. 24. discussion 84–5. Semin Surg Oncol 2000. Blondeel P. Application and refinement of the superior gluteal artery perforator free flap for bilateral simultaneous breast reconstruction. Schaverien M. Singletary SE. Saint-Cyr M. 122: 1326–33. 123: 578–88. The transverse myocutaneous gracilis muscle flap: a fast 137 42. Lataster A. Robb GL. Blondeel P. Thoracodorsal artery perforator (TAP) flap: report of our experience and review of the literature. Plast Reconstr Surg 2001. The inferior gluteal free flap in breast reconstruction. Free anterolateral thigh flap for extremity reconstruction: clinical experience and functional assessment of donor site. Kroll SS. Soueid N. with microneurovascular anastomoses for the treatment of facial paralysis. Kuo MH. Thoracodorsal artery perforator flap and Latissimus dorsi myocutaneous flap—anatomical study of the constant skin paddle perforator locations. Malata CM. Chevray PM. Cervelli A. Granzow JW. Plast Reconstr Surg 2009. Monstrey S. discussion 4–5. Plast Reconstr Surg 2008. Van Der Hulst R. 195: 651–3. Plast Reconstr Surg 2005. 57. Clin Plast Surg 1998. Plast Reconstr Surg 1983. Baumeister S. Br J Plast Surg 2004. Ninkovic MM. 9: 145–54. Flores JI. 11: 344–6. Bostwick J 3rd. 53. Allen RJ. Noel RT. 39. The free thigh flap: a new free flap concept based on the septocutaneous artery. Schirmer S. Fansa H. Pedicled perforator flaps in breast reconstruction: a new concept. Clin Plast Surg 1998. Br J Plast Surg 1984. Rad AN. 32. Muller M. 37. Post-mastectomy breast reconstruction: a history in evolution. Rosenberg JJ.OTHER FREE FLAPS IN BREAST RECONSTRUCTION 22. Chen GZ. Hamdi M. 37: 723–41. 41. Plast Reconstr Surg 1975. 19: 264–71. Breast reconstruction with SGAP and IGAP flaps. Br J Plast Surg 1990. Monstrey S. Tuinder S. 115: 755–63. 15: 163–8. 113: 1175–83. Ruben’s fat pad for breast reconstruction: a peri-iliac soft-tissue free flap. Two options for perforator flaps in the flank donor site: latissimus dorsi and thoracodorsal perforator flaps. 72: 490–501. 31. Br J Plast Surg 2005. 26. Torii S. Fujino T. LoTempio MM. Moran SL. Le-Quang C. Free gracilis muscle transplantation. Bodner G. Schwabegger AH. Plast Reconstr Surg 2010. 126: 393–401. Sekiguchi J. et al. The Rubens flap. Piza-Katzer H. Plast Reconstr Surg 1976. Parsa FD. Wong C. J Reconstr Microsurg 2003. 62. Department of Labor Web site. Sullivan SK. 2011. 61. Bernard S. U. Fukuda H. Women’s Health & Cancer Rights Act of 1998.dol.138 60. Accessed January 30. Allen RJ. The anterolateral thigh flap.html].S. Soeda S. 63. Guerra A. Djohan R. Br J Plast Surg 1989. Your rights after a mastectomy. 75(Suppl 1): S17–23. Breast reconstruction options following mastectomy. Gage E. . Cleve Clin J Med 2008.gov/ebsa/publications/whcra . 19: 63–8. variations in its vascular pedicle. Anterolateral thigh flap for breast reconstruction: review of the literature and case reports. Koshima I. AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY [Available from: http://www. Kaplan JL. Utunomiya R. 42: 260–2. General anesthesia may be required for certain patients. As summarized by Wellisch (5). Enhancement of body image 5. expander/ implant techniques. When done correctly with appropriate preoperative planning and design. After creation of a breast mound using autologous tissue flap techniques. The following chapter will help guide the plastic surgeon in the principles of successful nipple and areola complex reconstruction including: 1. adding a surgically created nipple and areola completes the reconstruction. Several studies have demonstrated this benefit (5–7). the procedure can be completed in the office setting under local anesthesia with or without sedation. Improvement in sexual responsivity • • • • • QUALITATIVE BENEFITS OF NIPPLE AREOLA RECONSTRUCTION • • • • • • • • The benefits of breast reconstruction have been well documented in the literature (1–4). Elevation of dysphoric mood and diminished anxiety 4. the benefits of replacing the lost breast have been shown to include: In most patients. transforming the mound into an actual breast. or a combination of both. Reduction in women’s preoccupation with life-threatening disease 2. However. The goals of nipple and areola reconstruction include optimal surgical design and technique to create a construct with appropriate Patient selection and timing of reconstruction Design of reconstruction Surgical technique Postoperative care Secondary techniques after complications 139 Position Symmetry Shape Projection Texture Color Size Sensitivity . Facilitation of wardrobe flexibility formerly restricted to wearing a prosthesis 3. Hiro and Deniz Dayicioglu Surgical creation of a nipple and areola represents the final step in breast reconstruction. reconstructing a pleasing nipple–areola complex (NAC) leads to improved quality of life (QOL) outcomes. Overall. the procedures described have relatively low morbidity. Similarly.14 Nipple–areola complex reconstruction Matthew E. nipple and areola complex reconstruction can lead to higher patient satisfaction rates and improved outcomes. complications do exist and can lead to difficult surgical dilemmas and unhappy patients. Nipple flap necrosis in a smoker patient. an average nipple diameter of 1. How to Avoid Errors in Timing of Surgery Ideally.99 cm on left and 7.83 ± 1. placement of an anatomically accurate surgically created nipple and areola are paramount for proper aesthetics.y.00:1 and for the breast mound to the areola as 3. or avoiding completely.34:1 (15). Hauben measured the breast proportions in 37 women and showed a proportional ratio for the areola to the nipple as 3.18). Before proceeding with nipple and areola complex reconstruction. Often.1).45 ± 1. . The soft tissue envelope of the reconstructed breast should have adequate thickness.3 ± 0. Ideally.140 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY ANATOMY The nipple and areola. These potential complications may be limited. most recommend a period of 3–6 months before proceeding (17. How to Select Patients to Avoid Complications Nipple and areola reconstruction is an elective procedure that should be only offered in patients who are healthy enough for surgery and have tissue characteristics suitable Figure 14. mobility and vascularit. The overall health of the patient should be addressed and all medical comorbidities should be optimized before surgery (Fig.14 ± 1. 14. The impact of these therapies cannot be overlooked as they may change the tissue characteristics of the breast reconstruction or contribute to the health status of the patient. However. with appropriate delay before proceeding with nipple and areola reconstruction (18). along the breast meridian. the patient should be reevaluated and an appropriate physical should be completed with particular attention to the reconstructed breast mound.1 for reconstruction.44 ± 1.0cm. the nipple and areola reconstruction is attempted when the breast mound is complete and all revision procedures are finalized.44 cm on the right. Therefore.3 cm and an average nipple projection of 0. Numerous studies have looked at the relationship of the nipple and areola in relation to the surrounding breast mound (9–15).3 cm (16). additional therapies. scar contracture and resolution of edema. most projecting portion of the breast mound. the aesthetically pleasing nipple is located on the central.0 ± 1. The chest wall should be without infection or open wounds. tissue healing.46 cm on the left and 11. and nipple to midline distance was 11. represent the most important aesthetic unit of the breast (8). The final shape of the breast mound may change in the post-operative period due to gravity.9 ± 0. Results showed the nipple to inframammary fold distance was 7. Although some surgeons advocate immediate nipple reconstruction at the time of breast mound reconstruction. Adjuvant therapy may also lead to implant capsular contracture leading to nipple asymmetry and malposition. Smith included all patients measuring 55 consecutive female volunteers (13). these studies generally included patients with aesthetically perfect breasts or patients being evaluated for breast reduction surgery. should have been completed since the original cancer surgery. with its central location and hyperpigmentation.86 cm on the right. Sanuki measured 600 breasts and showed an average areola diameter 4. including chemotherapy and radiation. and residual asymmetries between the breast mounds. the nipple should be placed without regard for the position of the skin paddle even though this design may include only a portion (or none) of the skin paddle (Fig. How to Avoid Errors with Proper Technique There are numerous ways to construct a nipple and the ideal has yet to be discovered as evidenced by the myriad of described techniques (20). These areas can be marked the night before surgery (Fig. . Although this often leads to superior aesthetic results (8). Here. and projection must be made in designing the new nipple. the nipple and areola reconstruction could then be designed using only the skin paddle of the flap resulting in a “scar-less” reconstruction. location of scars and skin paddles. the nipple position should not be jeopardized by strict adherence to the skin paddle position. Careful attention to the position. cartilage. transverse rectus abdominis myocutaneous (TRAM) flap and latissimus dorsi flap reconstructions often result in circular or oval skin paddles inset into the previous areolar defect. electrocardiogram leads. shape. Then. How to Avoid Malposition in Autologous Reconstructions with Existing Skin Paddles Skin paddles on the breast mound deserve special mention. the native nipple serves as a template for the reconstruction (17). it is often helpful to mark each breast individually and then make adjustments for symmetry. or prosthetic nipple/areolas can be sent home with the patient. bone). anatomic landmarks of the chest wall. Patient input is very helpful in determining location of the new nipple.2 141 using a mirror. With the increase in use of skin-sparing mastectomy (19). How to Avoid Malposition in Unilateral Reconstructions In unilateral reconstructions. size. free tissue grafts (including fat. 14. local flaps for nipple reconstruction have evolved to include numerous designs with various long-term results. the nipple position is placed using a combination of aesthetic preferences of the patient. in the privacy of the home in various positions until the patient is satisfied.NIPPLE–AREOLA COMPLEX RECONSTRUCTION How to Avoid Malposition of the NAC Additionally. The goal in the Nipple can be marked with a bandaid or an ECG lead. These can then be placed by the patient Figure 14.3).4). the native breast can be exposed and slight adjustments can be made for symmetry that most resembles the contralateral nipple (Fig. and soft tissue fillers and substitutes. It is often helpful to cover the native breast and mark the center point for the reconstructed nipple without bias. All can be categorized into different types: local skin flaps. 14.2). With settling of the breast mound. As in unilateral reconstructions. Placement of the nipple and areola should include a discussion between the surgeon and the patient to optimize results. How to Avoid Malposition in Bilateral Reconstructions In bilateral reconstructions. Circular adhesive bandages. the skin paddle may no longer be in the ideal position. 14. Ideally. strict adherence to measurements and anatomic landmarks may be misleading and lead to nipple malposition. First described by Diperro (21). this patient had bilateral latissmus dorsi reconstruction. the skin edges of the flaps should be judged for appropriate viability. Skate Flap First described by Little (22). All areas of poor vascularity should be excised before final closure. Also. Regardless of the flap type selected. gentle tissue handling. proper dissection technique and accurate placement of sutures are necessary to decrease scar formation and prevent retraction. Figure 14. the skate flap has become the most popular technique for nipple reconstruction. design of local flaps is the creation of a three-dimensional construct using a two-dimensional segment of skin and soft tissue (18).20). The .142 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY Figure 14. before final closure. The focus will be on the more common flaps that have been adequately reviewed in long-term studies (17.3 Patient should assess the position of the nipples and participate in the discussion.4 If skin paddles have acceptable positions. they should be used for reconstruction template. Mark the center of the new position of the nipple 2. Mark center position of new position of nipple 2. This preserves the subdermal blood supply to the flap. However. The vertical excess of the flap is trimmed to the final desired height. This can be oriented in any direction but should avoid the mastectomy scar to preserve blood supply. Possible donor sites include the upper medial thigh. Mark the base of the flap. Mark the base of the flap and three laterally designed arms at 90º to each other. skate flap includes a vertical skin and fat flap with subdermal “wings” which wrap around the central core. Once the flaps are adequately elevated. The width of the core flap determines the diameter of the resulting nipple. In order to adequately raise the flaps. it is important to remember the final height should be 2–3 times longer than expected to account for tissue retratction. be careful to avoid crossing scars with the base of the flap. Here. Authors Preferred Steps for Star Flap Technique 1. As the flaps are elevated centrally. A full thickness skin graft is used to close the donor site and de-epithelialized area. The vertical extent of the flap below this horizontal determines the projection Author’s Preferred Steps for Skate Flap Technique 1. Use appropriately sized cookie cutter to mark the new areolar border. 3. 6. designed by Anton and Hartrampf (23). Again. Deepethilialize the portion skin that will not be included in the flap. The length and width of the lateral skin arms contributes to flap projection. Star Flap The star flap. which should be expected with this flap.5).NIPPLE–AREOLA COMPLEX RECONSTRUCTION 143 Figure 14. the three flap design allowed for primary closure of the donor site. In unilateral reconstructions.5 Skate flap and full thickness skin graft technique. standing cutaneous deformities associated with previous flap donor sites and excess breast skin along the axilla (Fig. the incision must extend along the lateral aspects of the base protecting the central portion. they are rotated centrally and sutured together. Like the skate flap. lower abdominal area. contralateral nipple. 3. dissect slightly deeper including more subdermal fat with the flap. a few millimeters of subcutaneous . Raise the lateral wings preserving a few millimeters of subdermal fat to protect the blood supply. 5. Closure of the arms in primary fashion can lead to some flattening of the central aspect of the breast mound. In bilateral reconstructions. Incise the skin along the periphery of the flap. The width of the horizontal line determines the diameter of the created nipple. utilized a similar design as the skate flap. 7. The vascular core must be preserved. a 35–45 mm cookie cutter should be used based on the breast mound size. The base should be marked slightly off the central diameter of the flap to ensure a central position once the flap is raised. 4. 14. The lateral arms are incised and raised toward the base. this should be roughly equal to the normal. 8. The surgical technique of the modified star flaps is similar to the description above. Once the flap is raised the two lateral arms are wrapped around the central core and sutured into position to create the projecting portion of the nipple. Here.10). In these designs. The flaps are raised in the subdermal plane. The differences lie in the design and closure of the lateral arms and the shape of the central cap (Figs. 14. transposed across the mastectomy scar and sutured together to create a projecting nipple. The width and length of the flap design determines the ultimate projection of the nipple. DIFFERENT TECHNIQUES OF NAC RECONSTRUCTION (FIG. To create areola projection. 4. the cylindrical flap by Thomas (25). several modifications were made to the star flap. and mobilized from the surrounding breast skin beveling away from the areola. The vascular core is protected beneath the central part of the flap. This leads to slight areola projection. . the areolar border is marked. Other modifications to the typical star flap include the purse-string modification by Hammond and Weinfeld (28. Once the cylindrical flap is raised. In these cases. the diameter of the cap determines the diameter of the nipple and the projection is determined by the width of the lateral arms.29). as in a periareolar mastopexy. This periareolar skin is then closed using a purse string technique using a Gore-tex suture. The areola is similarly marked in an oval fashion with the long axis perpendicular to the lateral arms of the cylindrical flap. The final nipple shape may appear more oval (Fig. This creates a circular neoareola. which are oppositely based. a cylindrical flap is designed in the standard fashion. Avoid all undermining in this area. The double pedicled flaps include two flaps of skin. which closely resembles that of a real areola (Fig. the blood supply for the single pedicled flaps. 5.6 Star flap technique with CV flap modification markings.144 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY Figure 14.6 and 14. incised. superior and inferior dermal areolar flaps are advanced to close the donor site. Although some differences do exist.7). They include the S flap by Cronin (30) and the double opposing tab flap by Kroll (31). Star Flap Modifications In subsequent years. as described above. 14. the three-flap design with central cap and lateral arms is the same. Primary closure of the donor site may lead to flattening of the central portion of the breast mound. The middle arm becomes the cap of the nipple. These modified star flaps include the CV flap by Bostwick (24). like the star flap.8). fat should be left on the wings to protect the blood supply. Care should be taken to avoid closing the donor site too tightly along the vascular core of the flap. 14. would compromise the blood supply and lead to tissue necrosis. 14. The donor sites are closed primarily with absorbable or permanent suture. the top-hat flap by Hamori and LaRosa (26) and the arrow flap by Guerra (27).9) Double Pedicled Flaps Double pedicled flaps were designed for situations in which the mastectomy scar traversed the central position of the nipple reconstruction. This was corrected later by debridement and secondary suturing. The use of two flaps increases the bulk to the flap and increases the blood supply.33). Most recommend a width of . transposing the two flaps can lead to tension during closure.8 Periareolar goretex suture technique. The lateral limbs of the flap are designed in an “S” shape and should have a wide enough base to preserve the blood supply but still allow for primary closure. Note the ischemic appereance immediately after CV flap reconstruction on the left. Originally these flaps were designed as deepithelialized dermal flaps that were covered with a full thickness skin graft.NIPPLE–AREOLA COMPLEX RECONSTRUCTION (A) 145 (B) Figure 14.7 (A) Star flap technique with CV flap modification. (B) Note the partial flap necrosis on the left. Figure 14. However. Later modifications changed the design with transposition of skin flaps that allowed primary closure of the donor site (32. increasing the restrictive forces on the flaps and leading to loss of projection (17). Draw the central common limb of the two flaps through the center of the new nipple. Authors Preferred Steps for Double Pedicled Flap Technique 1. Mark the center of the new position of the nipple 2. Contrary to the star and skate flaps. loose fitting clothes and chamisoles to avoid pressure on the nipple. The donor sites are closed primarily taking care to avoid tension (Fig. the undersurface of the graft should be irrigated with saline to evacuate any (B) (A) Double S flap technique immediate postoperative period. The dressing should be taped down and left in place for 5–7 days.10 After nipple reconstruction using local flaps with primary closure of the donor site. Once the dressing is removed. a bra may be worn during the immediate post-operative period (Fig. Incise the skin around both flaps and the central common limb. Others recommend using the base of a 12-cc syringe to place around the new nipple. 3. 6. 5. Sometimes it is advisable to avoid wearing a bra for 2 months or wearing a protective hard splint to cover the nipple. the incisions are dressed with antibiotic ointment and a non-adherent dressing. A “Z” modification may be made at the distal aspect of each flap to allow the two tabs to “key-in” and form a more stable construct. If a skin graft is used for the areola.12). The flaps are rotated centrally to form a cylindrical. antibiotic ointment and a light dressing is used along the incisions for an additional 7 days. (A) Figure 14. Again. The dressing should be bulky enough to protect the entire projecting portion of the nipple. Postoperative Care Figure 14.9 Most common nipple–areola reconstruction techniques are depicted. The flaps are raised in the subdermal plane preserving some fat on the flaps to protect the blood supply. The distal portions of each flap become the most projecting portion of the nipple. 14. projecting nipple and sutured together. The patient is instructed to wear light. 14. 4. .11). In these patients. the core in this flap is lateral. care is taken to avoid undermining past the central vascular core of each flap.146 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY 18–22 mm. beneath the base of each flap. (B) Double S flap technique late postoperative period. This can be secured to the breast skin with tape forming a rigid protective dressing around the entire nipple. recent evidence has shown that tissue grafts may lead to aesthetically pleasing results and be a reasonable option in certain patients. Results with Local Flaps Successful nipple and areola reconstruction requires attention to size. (B) Protection of the nipples with donut-shaped cushions. most outcomes articles in nipple and areola reconstruction tend to focus on long-term projection as the primary result of interest (34). . most of which have been abandoned with the use of local flaps. However.11 (A) 147 symmetry. Moist cotton gauze is then placed over the xeroform and a suture tie-over bolster is tightened over the graft. However. Figure 14. (B) Figure 14. sensitivity.12 (A) Protection of the nipples with syringes. The bolster is removed in 5–7 days. labia minora. and projection. position. Afterwards.NIPPLE–AREOLA COMPLEX RECONSTRUCTION hematoma. shape. texture. color. All patients may shower once the postoperative dressing is removed. Attention should be given not to pressure the nipple itself but the areola by the bolster dressings. toe pulp. The graft is then covered with xeroform with a small hole for the base of the nipple. Free Tissue Grafts The use of free tissue grafts were some of the earliest described techniques for nipple reconstruction. including mucous membrane. antibiotic ointment and a light dressing are used for an additional 7 days. and banked nipple areola. Skate flap technique. Many different types of tissues were used. respectively. the amount of subcutaneous fat may be inadequate to support a local flap. Soft tissue fillers have been used to augment nipples reconstructed with local flaps or tissue grafts and in secondary reconstructions with loss of projection (50–52). In theory. without the sacrifice of donor sites. injectable polymethylmethacrylate in 3. Placing the tissue in the subcutaneous space did not guarantee long-term projection. in design. Twelve-month maintenance of projection was 56% in TRAM patients and 47% in tissue expanderimplant patients (48). There was no total graft loss and no cases of hypopigmentation. this technique was originally described in the 1970s. Projection was maintained in 100% of patients. Pulmon Medical. Again. Scottborgh South Africa) was used to increase . or placing the graft on the dermis and wrapping the graft in centrally based flaps with full thickness skin grafts (45). This technique may also be useful in patients who have previously failed one local flap in whom another flap is planned (43). The cost of the acellular dermal matrix may be prohibitive however (47). color and shape. Artificial bone (hydroxyapatite–tricalciumphosphate) has been used in a similar fashion as rolled auricular cartilage (46). patient satisfaction was high and most would undergo the procedure again. the subareolar tissue was positive for tumor and the graft was discarded. Most importantly. Acellular dermal matrix has been used in both primary and secondary reconstructions (47–49). in 2009. Similarly. Only one case of local recurrence was observed. as it offers a potential exact match in regards to size. sensation and erectile function was retained in 35% and 42% of patients. grafts were harvested using approximately 50% of the donor nipple. texture.0 cc) with 100% patient satisfaction and minimal loss of projection. a small piece of thick acellular dermal matrix was cut to a 1. AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY Cartilage Grafts Cartilage grafts have been used as soft tissue fillers with local flaps since the 1970s (44). Small (2 × 6 mm) pieces of acellular dermal matrix were also used in secondary reconstructions after failed primary local flap (projection 0–2 mm) with C-V flaps. Zenn reexamined the use of nipple sharing in 2008 (42). In eight cases. analyzed the use of nipple and areola (NAC) replantation and nipple only replantation 7 days after reconstruction (41). offers the same benefits of free tissue grafts.5 × 4. Corrective surgery was necessary in 11 of 52 patients. one of the original techniques described for nipple and areola complex reconstruction. The construct is then covered with a full thickness skin graft. Results were analyzed with patient questionnaires. The construct was placed into the central core of a modified star flap and sutured into position. The risk of total or partial graft necrosis was higher in the NAC group (69%) compared to the nipple only group (26%). In this study. Histology of the specimen showed a mild inflammatory response with typical capsule formation around the artificial bone. Reports have described placing the auricular cartilage grafts within a flap in the subcutaneous space (44). autologous fat placed beneath the area of proposed flap design may augment the amount of tissue recruited into the flap leading to improved results. Here. There was no total flap loss or graft loss. but few were willing to use the contralateral normal nipple as a donor site. This is a useful technique in unilateral reconstructions where the native nipple is large or has excessive projection. nipple banking represents an attractive option in unilateral reconstructions. San Mateo California) was used in six patients (volume 0.4–1. The authors conclude that nipple–areola banking is oncologically safe if the subareolar tissue is negative for tumor. When used for primary reconstructions.5%). Depigmentation was also seen in 52% of grafts. although the aesthetic results may not be appropriate for most patients. The amount of fat that is included within the local flap is paramount in achieving long-term projection. Merz Inc.5% bovine collagen (Artecoll. The use of soft tissue filler and substitutes. particularly where the soft tissue envelope is deficient in subcutaneous fat. In these cases. In tissue expander-implant reconstruction. the substance is shaped into a column and placed on deepithelialized dermis and wrapped in centrally based flaps.148 Nipple banking. Complications were minimal with 5% graft exposure and 5% partial flap loss. but supporting the graft on the dermis showed excellent results with no necrosis or skin graft loss and maintenance of projection. fell out of favor in the late 1970s due to potential risk of transplanting a nidus of carcinoma cells back to the reconstructed breast mound. Four of five patients demonstrated maintenance of adequate projection (4–5 mm) at 6–12 months (49). Wirth.5 cm piece and rolled into a barrel shape. Nipple Sharing Nipple sharing is another technique that offers very similar graft characteristics. utilizing either a coronal or inferior tissue harvest. Injectable calcium hydroxyapatite (Radiesse. but may cause donor site morbidity. Autologous Fat Grafting Autologous fat grafting can also be useful in nipple reconstruction. Soft Tissue Fillers/Substitutes Free tissue grafts offer adequate results when appropriate. Donor site complications including total loss of sensation were seen in only a few patients (3. Here. Patients may also be encouraged to participate in choosing the pigment with the surgeon. Attention must be placed to adequate depth of pigment introduction. Tattooing can either be used as primary areola reconstruction directly on the skin of the new breast mound. this patient healed by secondary intention with good color match. a 35–45 mm cookie cutter is used according to patient and breast mound characteristics. Dermatech. Both will lead to early fading of the areola. . the areola must then be reconstructed to create the final form. ethylmetacrylate in a hyaluronic acid suspension (Dermalive. 14. The two most common are intradermal tattooing and tissue grafting. a mixture of hydroxyethylmetacrylate. Although some recommend tattooing before or during flap reconstruction (60. an autologous chondrocytes were suspended in a copolymer gel and injected into a previously isolated area of dermis on the ventral abdominal wall. note the superficial skin loss on the right side. Some authors recommend slightly darker pigments in this area (58) (Fig.13). Bella Vista.13 (A) Tattooing-related complication: On a double S flap technique. areola tattooing is best reserved until approximately 6–12 weeks after nipple reconstruction to allow for appropriate healing and maturation of the flap or graft (58). the injected implant grossly resembled a human female nipple and histologically demonstrated elastic cartilage (53). (B) Figure 14. 4%). as fading of the tattoo will inevitably occur (54).NIPPLE–AREOLA COMPLEX RECONSTRUCTION 149 projection after local flaps. Lastly. Nipple tattooing follows the areola. Pigments placed too superficial are subject to loss after desquamation of the epidermis. Three weeks after 10–12 injections. Results at 12 months showed improved increase in projection in the labia minora graft group compared to the nipple-sharing group (80% vs. (B) Tatooing set for the plastic surgeon. In bilateral reconstructions. As with nipple reconstruction. Rees then described the use of intradermal tattoo to achieve color symmetry in areola reconstruction using a skin graft (55). Deeper pigment is taken up in lymphatics (17). Two injections were used 3 ± 1 months apart with statistically significant increase in projection (1. In a porcine model. or to achieve improved color match after graft reconstruction. Mark the areolar border using an appropriately sized cookie cutter to match the native contralateral nipple. Becker and Spear then further popularized (A) Authors Preferred Steps for Tatooing 1. several different techniques have been described. Color choice is important. Bunchman first described the use of intradermal tattooing to recreate the areola after nipple reconstruction (54).24 mm). 2. Australia) was injected at three separate time points (0.60 ± 1. local anesthesia should be used to help with patient discomfort during the procedure. the technique with refinement in technique and presentation of larger case series (56–59). Tissue engineering and creation of surgically implantable tissue may represent the future of plastic surgery. Slightly darker pigments are encouraged. Although not always necessitated. and 5 months) after labia minora graft or nipple sharing. Slight adjustments may be required to closely match the natural appearance and shape. This technique has yet to be attempted in a human model.61). Areolar Reconstruction After nipple reconstruction. not the skin graft border. Eightyfour percent of tattoos were rated as satisfactory. Any residual color mismatch after grafting can be corrected with appropriate tattooing. Spear (59) showed excessive fading in 10% of patients. skate flap).14–14. 4. 5. simplicity. However. rash (<1%). O’Donoughue (62) recommends tattooing the native nipple with the same pigment with excellent results. secondary attempt with local flaps. Antibiotic ointment is used for an additional 7 days to keep the raw area moist while it epithelializes. Also. Other complications included infections (3%). Postoperative Care After tattooing. fat or cartilage).e. 6. the final outcome may not be evident until a year (or longer) after surgery (see Table 14. patients should be followed at regular intervals to evaluate for the presence of expected outcomes and patient satisfaction. The surrounding scar of the graft recreates the natural transition expected between the areola and the surrounding breast skin (8). and skin slough (<1%). it serves as an excellent option to recreate the shape and texture of a native nipple. secondary reconstruction offers a reasonable option for salvage. After primary nipple areola reconstruction. perineum/upper thigh.. However. A Permark (PMT/Permark. to create a more natural appearing areola. along previous scars and along the projecting nipple. we follow the circular shape of the cookie cutter. To achieve improved color match. partial flap/graft loss and loss of areola pigmentation after tattooing. irregular healing of the graft creates AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY slightly raised and irregular surface similar to native areola. retroauricular area. tissue grafts require additional surgical donor sites and further scarring. Each of these complications can lead to poor patient satisfaction and need for revision surgery. suprapubic area and others (17). Numerous techniques are available for secondary reconstruction including: 1. This is left in place for 3–5 days. some risks do exist. As demonstrated in long-term studies. MN) micropigmentation system is used with a #6 flat needle pack. The patient is reevaluated in 6 weeks for any skin slough or pigment loss. Use of tissue grafts can also decreases the flattening of the apex of the breast that may occur with primary closure of star flaps and star flap derivates.. use of autograft (i. We feel this gives superior control and consistent pigment delivery. Some nipple reconstruction techniques require skin graft from closure (i. We generally use one pigment for all areas along the nipple and areola for simplicity. However. The decision to proceed with secondary reconstruction after failed nipple areola reconstruction should be made on an individual basis based on patient preference. use of alloplastic materials/soft tissue fillers. Additional thought should be directed towards possible causes of the failed primary surgery to avoid repeat occurrences. as these areas are more difficult to get adequate pigment take. If complications arise. creating an oval shape. Others may have issues with autologous tissue harvest and additional donor sites. However. The area is then dressed with a non-adherent dressing and tape. Long-term outcomes with areola tattooing have been excellent. repeat tattoo (Figs.. With careful surgical planning. Endpoints are consistent with the appearance of pigment in the deep dermis or punctate bleeding. Secondary Procedures After Nipple Areola Reconstruction The most common complications after nipple–areola reconstruction are loss of projection. These patients required retattooing for improved color match. 5.2 months. Color match again is paramount. Then the dressing is removed and the patient is allowed to clean the area with soap and water. Benefits over other techniques include short procedure time.e. though 57% of women reported similarity in color with the native nipple. the development of intradermal tattooing allows any skin to serve as potential donor site. 3. Historically.150 2.17). The upper thigh skin is a popular donor site due to its hidden location and close color match. If a skin graft has been used (ie with a skate flap). reduction of the existing nipple projection. Therefore. Expectations with secondary reconstruction should be realistic. the residual pigment is painted on to the raw surface to increase the amount of pigment that might be taken up by the tissues. 14. In other flaps. Chanhassen. 4. donor grafts were taken from the labia majora. wound healing complications at donor site. 2. or a patient is unhappy with final result. In these instances. secondary . In a large review of 151 patients with mean follow-up of 25. Some patients may not wish to proceed with further surgery. Little data exists comparing complications with grafting in areola reconstruction. Care is taken along the areolar border. Use of tissue grafts is another common way to reconstruct the areola after nipple reconstruction. additional scar tissue is formed creating additional retractive forces making secondary reconstruction more challenging and subsequent results less predictable.1). the complication rate should be similar to other tissue grafts in other areas. Hypopigmentation was seen in 60% of reconstructed NAC. the borders of the skin graft often contract asymmetrically. Inc. upper eyelid. and lack of distant donor site. Anesthetize the area with 1% lidocaine with epinephrine 3. The areola is tattooed starting at the periphery and moving centrally with deliberate strokes. star flaps Arrow flap Mean 2.4%* Skate 59.05.3 years 3.1% Star 56.7% at 3 yrs 2. * = p < 0. RCT = randomized controlled trial.7 years Arrow: 49. Star flap Skate flaps Star flaps Bell flaps 1 year 153 nipples Retrospective review 40 nipples Prospective study 76 nipples Retrospective review Double opposing tab flap vs. Complications were not listed for all studies.1% partial skin graft nontake – Star flap Mean 2.05 comparing bell flaps to skate and star flaps.5 mm 14 nipples Retrospective review 93 nipples Prospective study CV flap Mean 5.2%.4%* Skate: 57% Star 35. (C) Recreation of the nipple using the CV flap technique to regain projection.87 mm 7.97 mm* 46.NIPPLE–AREOLA COMPLEX RECONSTRUCTION 151 Table 14. 3. .1 years 59% at 1 yr – 1 year 1 year NR – 12% open wound at suture line – – (A) (B) (C) Figure 14.1 Summary of studies demonstrating quantitative results with different flap techniques for nipple reconstruction.1% skin graft donor site dehiscence. Author Details of study Rubino (35) 32 pts RCT Alfano (36) 30pts RCT Shestak (37) 74 nipples Retrospective review Kroll (33) Farace (34) Zhong (38) Losken (39) Few (40) Flap types Follow-up Average Residual Projection (% of initial size or mm) Complications Arrow Flap vs. 2. **p < 0.55% at 2 yrs 45. (B) Loss of projection of nipple.6% Bell 26.1%** Tab: 2.1% Star: 35. Star Flap Skate flap vs. No significant difference between skate and star flaps.14 (A) Loss of projection of nipple.43 mm Star: 1.27 years 3 years Skate flap Mean 3. 17 Dehiscence of the CV flap due to improper suture selection. Figure 14.16 Areolar irregularity after tattooing necessitating “re-do” tattooing.152 Figure 14.15 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY Tattooing-related complication: Incisional scars not taking tattoo pigment well. . Figure 14. this patient needed “re-do” tattooing. Aesthet Surg J 2010. Spear SL. Plast Reconstr Surg 1986. Khoobehi K.. Taskinalp O. Plastic Surgery. 121: 186e–94e. Ruiz-Razura A. Lowery JC. Ann Plast Surg 2003. 12. Noone RB. Ann Plast Surg 2003. 52: 355–9. Plast Reconstr Surg 1997. Guyomard V. It is important for all plastic surgeons to be comfortable with several techniques to adequately address the individual needs of each patient. 13. Plast Reconstr Surg 1970. Purse-string nipple areolar reconstruction. Wilkins EG. Maksvytyte GK. Nipple-areola reconstruction. 247: 1019–28. Nipple areola reconstruction. Prospective analysis of psychosocial outcomes in breast reconstruction: one-year postoperative results from the Michigan Breast Reconstruction Outcome Study. Reconstruction of the nipple-areola complex: an update. 30: 44–50. et al. Hamori CA. 15. 16. Ringrose C. 64: 360–3. Disa JJ. 112: 440–7. Determinants of patient satisfaction in postmastectomy breast reconstruction. 20. Pool R. New technique for nipple areola reconstruction: arrow flap and rib cartilage graft for long-lasting nipple projection. 7: 357–71. REFERENCES 1. 120: 399–406. Br J Plast Surg 1999. The top hat flap: for one stage reconstruction of a prominent nipple. Karas T. discussion 26–7. 19. Guerra AB. . 81: 783–7. 10. Leinster S. 97: 1053–6. Mathes SJHVR. Vendemia N. Philadelphia. Schaefer DJ. Weinfeld AB. 7. Breast 2007. Breast reduction. Sbalchiero JC. 1: 35. Anthropometric breast measurement: a study of 385 Turkish female students. Metzinger SE. 14. J Plast Reconstr Aesthet Surg 2006. Regev D. 27. 18. 5: 67. Collins DR Jr. Herman O. Nipple reconstruction with the doubleopposing-tab flap. Rosenberg L. Cederna PS. Breast volume and anthropomorphic measurements: normal values. Wilkins EG. Breast Cancer Res Treat 2008. 29. Avsar DK. Cancer J 2008. Jabor MA. Aesthetic subunits of the breast. It should be kept in mind that general anesthesia is hardly ever necessary and patients are more willing to progress with minor corrections when done under local anesthesia. Breast-areola-nipple proportion. Anton M. Wellisch DK. Kim MS. Nipple reconstruction with a new local tissue flap. 153 11. Benlier E. McCarthy CM. The psychological contribution of nipple addition in breast reconstruction. 78: 331–5. Kim J. Reconstruction of the nipple and areola after a burn. Uchida Y. Gellis MB. 25. 32. Lowery JC. Plast Reconstr Surg 2000. 61: 364–7. Aygit AC. 22. Little JW 3rd. 22: 142–4. Br J Plast Surg 1955. PA: Saunders Elsevier. DiPirro ME. Aesthetic Plast Surg 1998. Farhadi J. Anthropomorphic breast measurement: protocol and results in 50 women with aesthetically perfect breasts and clinical application. 5. As shown above. Aesthetic Plast Surg 2009. A method of assessing female breast morphometry and its clinical application. 83: 904–6. patient satisfaction after NAC reconstruction remains high and should be encouraged. 3. 46: 299–300. 21. 16: 547–67. 14: 253–7. Silfen R. 84: 520–5. Thomas SV. Nipple-areola reconstruction: satisfaction and clinical determinants. Alderman AK. et al. Plast Reconstr Surg 2008. Penn J. Martin NA. 50: 510–13. Brown TP. Scheufler O. Eskenazi L. Wilkinson M. 8. Hyland RE. 17. 110: 457–63. 2. Katch VL. Schain WS. 23. 31. Plast Reconstr Surg 2003. The skate flap pursestring technique for nipple-areola complex reconstruction. Hartrampf CJ. Kroll SS. 111: 391–403. and the ideal technique has yet to be discovered. Little JW 3rd. preoperative planning and surgical technique are paramount in optimizing results. Plast Reconstr Surg 2000. Nipple reconstruction with local flaps: star and wrap flaps. Hammond DC. Cronin ED. Adler N. Lowery JC. 11: 351–64. Clin Plast Surg 1984. 2nd ed. Assessment of breast aesthetics. Alderman AK. The S nippleareola reconstruction. numerous techniques are available to reconstruct the nipple and areola. 100: 468–79. Humphreys DH. Kim M. 59: 40–53. et al. 28. Oncological and aesthetic considerations of skin-sparing mastectomy. 4. Pierer G. Khuthaila D. Patani N. Plast Reconstr Surg 1988. Hamilton S. Goh SC. Sanuki J. Palin WE Jr. 30. 106: 1014–25. Plast Reconstr Surg 2007. Smith DJ Jr. Top H. Cole AA. Ann Surg 2008. 33: 295–7. Davis JA. 9. Perspect Plast Surg 1991. Jones G. 50: 31–7. SUMMARY NAC reconstruction represents an important final stage of breast reconstruction. Fukuma E. Atisha D. Reece GP. Patient satisfaction following nipple-areolar complex reconstruction and tattooing. Pandya AN. Cutress RI. Davison SP. Weiss J.NIPPLE–AREOLA COMPLEX RECONSTRUCTION reconstruction offers a reasonable option for patients to achieve their reconstructive goals. Plast Reconstr Surg 1987. Proper patient counseling. Westreich M. Shafir R. Mokbel K. Nipple reconstruction: the S flap. Case report. J Plast Reconstr Aesthet Surg 2011. Although minor complications may occur. 80: 699–704. Brotherston TM. Codner MA. 6. 24. 26. Mesbahi AN. Allen RJ. Plast Reconstr Surg 1989. Shayani P. Bostwick J 3rd. Plast Reconstr Surg 1996. Cohen BE. Plast Reconstr Surg 2002. LaRossa D. Systematic review of studies of patients’ satisfaction with breast reconstruction after mastectomy. Nipple-areola reconstruction. Operat Tech Plast Reconstr Surg 1994. Bennett JE. Prospective analysis of long-term psychosocial outcomes in breast reconstruction: two-year postoperative results from the Michigan Breast Reconstruction Outcomes Study. discussion 64–5. Somia N. Ann Plast Surg 2008. Hauben DJ. 106: 769–76. 2006. Plast Reconstr Surg 1989. Morphologic study of nippleareola complex in 600 breasts. J Plast Reconstr Aesthet Surg 2010. Feldman S. Becker H. Plast Reconstr Surg 1975. Plast Reconstr Surg 1999. 119: 1663–8. Kalimuthu R. Aesthetic outcome and oncological safety of nipple-areola complex replantation after mastectomy and immediate breast reconstruction. Plast Reconstr Surg 1998. Panettiere P. Nipple and areola reconstruction in the burned breast. Nahabedian MY. Plast Reconstr Surg 1993. Unilateral nipple reconstruction with nipple sharing: time for a second look. Lewis SR. 63: 1490–4. 63: e756–7. O’Donoghue JM. Kim TH. Eplasty 2010. Case report. AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY 48. Spear SL. 46. Cao YL. 40. Long-term experience with nipple-areola tattooing. McCarthy CM. The arrow flap for nipple reconstruction: long term results. Kiyokawa K. 104: 1936. Miller MJ. et al. 44. Plast Reconstr Surg 2002. 53. Tenna S. Secondary nipple reconstruction using local flaps and AlloDerm. Filler injection enhances the projection of the reconstructed nipple: an original easy technique. Posadinu A. Nipple-areola reconstruction with a dermal-fat flap and rolled auricular cartilage. 46: 127–31. Plast Reconstr Surg 2007. Few JW. 99: 1602–5. Sarfati I. 57. Long-term predictable nipple projection following reconstruction. . Acta Chir Plast 2004. Campanella A. Lach E. 41. Tissue-engineered nipple reconstruction. 61. The use of intradermal tattoo to enhance the final result of nipple-areola reconstruction. Antony A. Rubino C. Pre-reconstruction tattooing eliminates the need for skin grafting in nipple areolar reconstruction. et al. 102: 2293–8. Bunchman HH 2nd. Pusic AL. 54. 110: 780–6. 55. Accorsi D. 123: 1648–53. Plast Reconstr Surg 2003. Lennox P. Garofalo JA. 34. Plast Reconstr Surg 2001. Spear SL. Yamauchi T. Kahler SH. Evans KK. Lam B. Aitken ME. Eskenazi L. Bostwick J 3rd. Plast Reconstr Surg 1999. Wirth R. Nipple-areola reconstruction with a dermal-fat flap: technical improvement from rolled auricular cartilage to artificial bone. Reconstruction of the breast areola by intradermal tattooing and transfer. 104: 1321–4. Caggiati A. 62: 591–5. Convit R. Garramone CE. Banic A. Nipple reconstruction by local flaps: a long-term comparative study between star and skate techniques. 108: 361–9. 51. 36. Br J Plast Surg 2003. Barounis D. Comparison of nipple projection with the modified double-opposing tab and star flaps. 47. Ann Plast Surg 2009. Gabriel A. Lenert J. Scott AM. VanLaeken N. 60. Zenn MR. 92: 547–9. Aesthetic Plast Surg 2005. Brent B. Erni D. 49. Manders EK. 45. A one-stage nipple reconstruction with the “modified star” flap and immediate tattoo: a review of 100 cases. Bulla A. Puddu A.154 33. Redding J. Nipple-areola reconstruction using intradermal tattoo. Intradermal tattoo as an adjunct to nipple-areola reconstruction. Bernard RW. Kroll SS. 55: 620–1. 60: 353–61. Ann Plast Surg 2005. Plast Reconstr Surg 2009. Tai Y. 92: 671–80. 50. Marchetti L. Plast Reconstr Surg 1977. Mackay GJ. Surgical outcomes and nipple projection using the modified skate flap for nippleareolar reconstruction in a series of 422 implant reconstructions. Plast Reconstr Surg 1997. Bostwick J. Zhong T. Rees TD. Arias J. 62. Plast Reconstr Surg 1993. Chen WF. 54: 531–6. 59. Reece GP. Nipple-areola reconstruction with auricular tissues. 112: 1863–9. 10: e7. et al. A novel cost-saving approach to the use of acellular dermal matrix (AlloDerm) in postmastectomy breast and nipple reconstructions. 112: 964–8. Wong RK. Alfano C. 55: 25–9. A modified technique for nipple reconstruction: the ‘arrow flap’. 56. 100: 431–8. Cordeiro P. Ann Plast Surg 1995. The “double bubble” technique. 77: 673–6. Plast Reconstr Surg 1988. Beran SJ. Plast Reconstr Surg 2003. The use of calcium hydroxylapatite for nipple projection after failed nippleareolar reconstruction: early results. 43. discussion 9. Casas LA. Nipple reconstruction using the C-V flap technique: a long-term evaluation. Solving the problem of color mismatch in nipple-areola reconstruction. Autologous fat graft in nipple reconstruction. 35: 232–6. 81: 450–3. 38. Plast Reconstr Surg 2005. Tanabe HY. 37. Plast Reconstr Surg 1986. Plast Reconstr Surg 1989. Banducci DR. 35. 56: 247–51. Rasko Y. 83: 907–11. 115: 2056–61. Dessy LA. Plast Reconstr Surg 1997. Marcus JR. Plast Reconstr Surg 1974. 39. Clough KB. Becker H. Landecker A. Farace F. 42. 52. Plast Reconstr Surg 2010. Olding M. 29: 287–94. Shestak KC. 125: 479–81. The efficacy of Artecoll injections for the augmentation of nipple projection in breast reconstruction. Losken A. Little JW 3rd. Assessment of long-term nipple projection: a comparison of three techniques. Huang TT. Use of AlloDerm in primary nipple reconstruction to improve long-term nipple projection. 58. Yanaga H. Larson DL. J Plast Reconstr Aesthet Surg 2010. Rubino C. and Zubin J.15 Managing the unfavorable result in breast surgery Charles R.2). Therefore. and anger that could result in medico-legal action. Patients who are informed postoperatively that their unfavorable 155 . However. resentment. Proper handling of the patient’s poor outcome becomes of utmost importance to the operative surgeon to prevent feelings of distrust. Ideally. These complications can and will happen amongst even the most talented and skilled of surgeons. the patient’s feelings of stress and anxiety may become feelings of distress. BREAST CONSERVATION THERAPY Modern trends in the treatment of breast cancer include early cancer detection through increased mammographic screening and the targeted use of neoadjuvant chemotherapy and whole breast radiation to allow some breast cancer patients to be treated with breast-preserving procedures (1. Though preservation of the breast provides many women with a psychological sense of being “whole. Breast surgery can impart considerable anxiety upon patients regardless of whether the surgery is performed for oncologic purposes or for aesthetic reasons. The intent of this chapter is to provide a concise understanding of the potentially avoidable complications encountered during aesthetic and reconstructive breast surgery along with management strategies designed to treat these failures when they occur. Volpe. Many breast cancer patients are treated with partial mastectomy (lumpectomy) followed by radiation therapy and have similar disease-free survival as those undergoing total mastectomy (3). When an unfavorable result does occur. will typically respond with hostility and anger. dissatisfaction. the patient will view the physician’s explanation as dishonest and accusatory. this should be presented in both a written and verbal manner to maximize patient comprehension. By achieving this goal. In addition. Alexander Nguyen. Though never intended nor expected. The potential for unfavorable aesthetic outcomes has increased as a growing number of breast cancers GENERAL CONSIDERATIONS Untoward results in surgery occur in an unpredictable manner. Patients who are properly advised of the potential risks and complications of a given procedure preoperatively will typically handle an unfortunate situation with objectivity and reason. and despair. full disclosure of the potential risks and complications of the planned procedure should be presented to the patient prior to entering the operating theater.” the resulting cosmetic appearance can be quite disfiguring. the patient’s response to an unfavorable result follows very predictable lines. any untoward or adverse events that occur postoperatively may be dealt with in a satisfactory manner for both patient and physician. Panthaki INTRODUCTION result was a risk or complication of the given procedure. Direct lines of communication must be established between the patient and the physician prior to the surgical date. poor outcomes or unfavorable results from these procedures do occur. 21). These techniques should be avoided in patients who have already received whole breast radiation as irradiation increases the risk of further complications and may prevent a favorable cosmetic outcome (11). the reconstructed breast tissue remains at oncologic risk. Delayed reconstruction by definition refers to all reconstructions that occur after BCT and whole-breast radiation has been completed.8 to 35. AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY the previously radiated skin envelope must be incorporated in the repair. Interestingly. if possible. but prior to the delivery of radiation therapy. It is the opinion of the authors that defects requiring the use of abdominal flaps should be treated with completion mastectomy and full breast reconstruction as outlined in previous chapters. Autologous fat grafting provides an additional means of correcting small contour deformities. The majority of patients presenting with poor outcomes following BCT do so after the delivery of radiation therapy (delayed group). and avoidance of severe bleeding or hematoma formation. McCarthy et al. The breast reduction technique is usually limited to patients with large breasts (D-cup bra size or larger) and tissue rearrangement directed to patients with moderate size breasts (C-cup bra size) who have minimal or no nipple ptosis (10). General principles in managing capsular contracture should focus on capsulectomy NOT capsulotomy. Minor infections can occasionally be treated conservatively without removal of the implant. reduction mammoplasty of the unaffected breast may be the best option to achieve a symmetrical. the delayed-immediate. Infection of an implant typically occurs around the time of placement and is commonly related to mastectomy skin flap necrosis. infection. In complex cases. These flaps prove advantageous in the reconstruction of lateral breast defects and in cases where a deficient breast envelope exists.17). on the method of primary reconstruction. Consideration should be given to the placement of closed suction drains to minimize the accumulation of blood following capsulectomy. Silicone gel bleed from the implant may have facilitated capsular contracture in this circumstance. The treatment options for previously radiated BCT defects include pedicle reconstructions with the latissimus dorsi myocutaneous flap or thoracodorsal artery perforator (TAP) flaps. Finally. and malposition of the implant. The cosmetic appearance will be superior and oncologic control will be maximized. favorable outcome. Controversy exists as to whether smooth versus textured implants alter the occurrence of capsular contracture and there are no studies to date that resolve this debate (18.4% incidence of infections managed .19). Immediate reconstructions occur at the time of BCT. may be unaware that reconstructive techniques are available to treat their deformity. and breast reduction techniques based upon the standard inferiorly based dermoglandular pedicle (9). First. Delayed-immediate reconstruction occurs once final margin status has been confirmed. BREAST RECONSTRUCTION WITH EXPANDERS AND IMPLANTS Unfavorable results following expander or implant-based reconstructions can be difficult to deal with and often require multiple procedures to adequately correct. and pain. Common complications seen after expander/implant reconstruction include capsular contracture. found a 3. Every attempt should be made to remove the offending capsule particularly when a contracture formed around an older style silicone implant.5). keloid scarring. or superficial inferior epigastric artery (SIEA)] and recommend the creation of “mini” flaps to reconstruct the BCT defects (13). Treatment of the most severe or recurrent forms of capsular contracture should focus on implant removal. Repeat fat injection to correct contour deformities can be performed and is likely in patients with a history of radiation therapy (15). irradiated skin can be replaced with healthy skin and subcutaneous tissue (12). Second. Some authors advocate the use of lower abdominal flaps [transverse rectus abdominus myocutaneous (TRAM). These patients possibly fear additional surgical procedures. fat necrosis. deep inferior epigastric perforator (DIEP). Reconstructive techniques to correct a BCT defect can be applied in three settings: the immediate. preservation of thick NOT thin soft tissue flaps. Treatment options for capsular contracture depend. The contracted.4% (20. Autologous breast reconstruction should be evaluated as an alternative means of reconstruction. in part. Baker class III and IV capsular contracture (severe) following breast reconstruction has been reported to occur in 0–56% of patients following breast reconstruction (16. or simply may be too embarrassed to seek improvement (7). only five to forty percent of patients receiving BCT report a poor aesthetic outcome caused by a significant breast deformity (6). These complications included erythema.156 are now being treated with breast conserving therapy (BCT) including larger tumors and tumors in unfavorable locations (4. Reported rates of infection following expander/implant reconstruction range from 1. These flaps should be avoided on several accounts. and the delayed time frame. implant exposure. especially when pain is the primary complaint. The treatment options for patients who have yet to radiation include local tissue rearrangements that remodel the breast tissue (8). The true percentage of patients suffering poor cosmetic outcomes following BCT is likely to be greater given the fact that those with poor outcomes are less likely to seek additional treatment. Minor complication rates following fat grafting of 8.5–11% have been reported (14). a significant portion of the raised abdominal flap tissue will be discarded to reconstruct a small defect. the TRAM flap was originally described by Holmstrom as a free flap. treatment requires prompt removal of the implant. Pseudomonas.1). Common bacterial isolates include Staphylococcal species. AUTOLOGOUS BREAST RECONSTRUCTION Autologous reconstruction of the breast is dominated by use of abdominal myocutaneous TRAM and fasciocutaneous DIEP and SIEA flaps. Proper management is to identify the correct location for the implant. and proximal thigh.26).1 implant. Klebsiella. Poor outcomes related to TRAM and DIEP flap breast reconstruction can be broken down into donor site and recipient site complications. 157 to non-operative maneuvers such as taping or manual displacement of the implant. expander/implant reconstructions can be salvaged in a delayed manner with latissimus-based flap reconstruction with an implant in most cases. Malposition of the implant or expander is usually due to improper placement (typically placed too high) at the time of the primary reconstruction (Fig. as well as. an increasing use of fasciocutaneous flaps derived from the flank. mastectomy skin flap necrosis. Management of the exposed implant in the most conservative fashion is explantation. However. Exposure of the implant can be linked to infection as previously discussed. the focus of this chapter will be with unfavorable outcomes related to the abdominally based pedicle and free flap reconstructions of the breast. Interestingly. The authors found that only 42% of patients managed with implant removal returned for secondary reconstruction. Common donor site complications include contour abnormalities of the abdominal wall and hernia formation. Exposure of expander/implants in reconstructed breasts usually occurs secondary to mastectomy skin flap necrosis. Therefore. divide the capsule. overdissection of the pocket. If a conservative approach is followed. buttock.MANAGING THE UNFAVORABLE RESULT IN BREAST SURGERY without removal of the implant (22). Capsule formation prevents the implant/expander from responding Figure 15. and Enterococci species (23). 15. The modern evolution of breast reconstruction has moved toward the greater use of the free abdominally based fasciocutaneous flaps. but was later popularized as a pedicled flap by Hartrampf in the 1980s (25. as well as abdominoplasty flap necrosis. along with targeted antibiotic treatment based upon intra-operative cultures from the implant pocket. and reposition the implant after creating the proper soft tissue pocket. and fat necrosis. they argue that aggressive measures should be taken to salvage the exposed implant (24). or migration of the . Common recipient site complications include partial and complete flap necrosis. For more significant infections. Any attempt to replace the implant should be delayed for 3 to 6 months after implant removal. a recent European study suggests that nearly half of exposed implant reconstructions can be salvaged by replacing the exposed implant with a smaller volume implant followed by either direct closure of the defect or coverage with a thoraco-abdominal tissue advancement. For the sake of brevity. Asymmetry—implant malposition can result from capsular contracture. skin grafts will prevent wound contracture making cosmetic improvements through secondary procedures more difficult. The addition of mesh reinforcement to the abdominal wall should be considered when risk of hernia is evident. Pedicled TRAM flap dissections are at greatest risk for this complication as the abdominal flap elevation is the most extensive. This is a rare condition where antibodies (lupus anticoagulants. Attempts to elucidate the causative factors for the flap failure. contour abnormalities (bulging) with the use of DIEP flaps do occur and are directly related to denervation of the recutus abdominis muscle during flap elevation (28). or anti-β2-glycoprotein I) predispose to thrombosis (37).42). DIEP flap reconstructions have evolved as the “gold standard” by which all other flap reconstructions are compared. In addition. anticardiolipin. prevention is the key to avoiding unfavorable contour deformities.33). If cause for failure of the primary flap cannot be determined. Fat necrosis is a rather common complication following autologous breast reconstruction.4% (41. These defects when appreciated postoperatively are exceedingly difficult to correct.31). Key anatomical points to the elevation of the DIEP flaps deserve mention. re-evaluation of the necessity for free flap reconstruction. the nerves to the rectus muscle encroach from its lateral border and run with the most lateral branch of the deep inferior epigastric artery and its lateral row perforators (29). surgeons should recognize that a large motor nerve to the rectus. Minimally invasive techniques such as ultrasound assisted liposuction (43) (UAL) and the “needle aeration” method (44) have been described .158 Contour abnormalities and hernias associated with TRAM flap reconstruction are typically related to the sacrifice of the rectus abdominis muscle and improper restoration of the abdominal (internal and external oblique) fascial layers.0% have been reported in the literature (21. 15. Abdominal flap necrosis is a devastating problem that can be prevented by limited abdominal flap elevation. Reported rates of fat necrosis following DIEP flap reconstruction range from 6 to 17. consideration should be given for second free flap reconstruction. This is partially due to the decreased abdominal wall morbidity associated with the procedure. Revisions needed for mastectomy flap necrosis should be focused on removal of the scar tissue that results from delayed closure. Management of acute flap failure is beyond the scope of this chapter and will be discussed in greater detail elsewhere. Therefore.3% and 6. provided the patient is a good candidate for a second procedure and that the surgeon is confident that success flap creation can be achieved. Baumeister et al. Any bulge or hernia that is recognized postoperatively should be approached with attempts to reestablish the proper internal and external oblique anatomy along with wide application of prosthetic mesh reinforcement (in the absence of infection). A vascular workup for an antiphospholipid syndrome should be considered (36). one must consider rare hemolytic disorders as the source. is typically present and should be preserved. Patients should be informed that increased donor site complications can occur given the history of previous abdominal surgery. For severe deformities. Studies have implicated division of this nerve branch a major cause of lower abdominal weakness and bulge formation following DIEP harvest (30. activated protein C resis (factor V Leiden) (39). The decision to proceed with a second free flap should be made only after critical evaluation of the primary surgical procedure occurs. Second. Patients presenting with unfavorable cosmetic appearance to the breast reconstruction secondary to partial flap necrosis should be evaluated for possible revision with transposition flaps as discussed previously in this chapter (Figs. fat necrosis can lead to considerable patient anxiety because it can be confused with recurrent breast cancer. Despite this. Direct excision of the larger areas of fat necrosis may require extensive dissection and result in a significant contour deformity. AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY Primary free flap failure rates between 0. Other conditions such as protein S deficiency (38). critical appraisal of one’s surgical skill should be performed with consideration given to referral to another surgeon for treatment. particularly presence of a subcostal incision. First. Small areas of fat necrosis can be managed conservatively as they will resolve with time and massage.3). History of previous abdominal surgery. at the level of the arcuate line. Limiting dissection to the lateral border of the rectus sheath can minimize the risk of flap necrosis. has been shown to increase the risk of abdominal wall flap necrosis in both TRAM and DIEP flap reconstruction (32.35). and careful consideration of the patient’s psychosocial needs should be achieved prior to proceeding with secondary reconstruction. Though it is a common occurrence following autologous tissue transfer. and anti-thrombin III deficiency (38) should also be excluded. Attempts to correct acute wounds with split thickness skin grafting should be avoided as the graft will provide a poor color match. successful DIEP flap surgery can still be performed as long as the abdominal flap dissection is done in respect to the pre-existing abdominal scar (34). present an excellent self-critical checklist that should be reviewed prior to secondary free flap reconstruction (40). In addition. Preservation of these nerve branches should be made whenever possible.2 and 15. Muscle sparing techniques of flap harvest and meticulous attention to detail during the abdominal wall closure have been advocated to minimize the contour abnormalities (27). Complete recipient site flap loss is a catastrophic event that can happen to surgeons at all skill levels and among all types of pedicle and free autologous tissue reconstructions. However. the greater the risk of complications and the greater the chances of implant removal. implant rupture.MANAGING THE UNFAVORABLE RESULT IN BREAST SURGERY Figure 15. wrinkling. Based on these findings. and infection can occur. BREAST AUGMENTATION The 2011 FDA Update on the Safety of Silicone GelFilled Breast Implants—Executive Summary suggest that 20–40% of breast augmentation patients will require reoperation within 8–10 years based upon recent data collected from the core studies of the major implant manufacturers in the United States (46). silicone bleed from gel implants is thought to contribute significantly to the .2 Figure 15. Patients should also be informed that implants are not lifetime devices. to treat larger lesions after recurrent breast cancer has been clinically ruled out by surgeon/oncologist or ultrasound examination (45). The longer implants remain. Historically. Though the etiology of capsular contracture is poorly understood. It should be noted that the risk and complication profile of saline implants is similar to gel-filled implants and thus will be the focus of this discussion. asymmetry. rates of capsular contracture are higher among silicone gel implants as compared to saline implants (48). as graded by the Baker classification system (47). Capsular contracture.3 159 TRAM contour deformity resulting from fat necrosis. remains a leading reason for revision augmentation. TRAM contour deformity can be corrected with placement of a small implant or fat grafting. scarring. the FDA recommends that patients be informed that complications including capsular contracture. should be treated with a change in implant position. Folding is directly related to the viscosity of the fluid AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY within the implant shell. In addition to viscosity. etc. or textured implants can be exchanged for smooth-walled implants. as well. Newer cohesive gel implants may demonstrate decreased risk of capsular contracture as the cohesive gel does not migrate or bleed (49). and the general body habitus of the patient (how much breast tissue the patient has). skin wrinkling and implant palpability result from folding of the implant shell. the conservative recommendation for implant removal without revision cannot be discounted (58). In addition. if technically possible. The likelihood of increased palpability and wrinkling is considerable in this patient population. One example worthy of discussion is the development of symmastia after primary augmentation. explains how silicone implants allow shell folding to occur. when it occurs. whereas high viscosity fluids (silicone) do not. including evaluation for signs of silicone migration (54). Thin patients. From an engineering standpoint. Treatment options for patients with severe skin wrinkling and/or palpable implants should address all of the risk factors mentioned previously. poor surgical decision-making and technical erros can occasionally be associated. Implant rupture can present in a readily apparent manner with saline implants or in an insidious. Partial capsulectomy should be considered when removal of a subglandular capsule will result in thin. Symmastia can occur in either a subcutaneous or submuscular plane. To date.59). partial capsulectomy can be performed.160 increased contracture rates. in part. Complete capsulectomy should be considered when it can be performed safely. with submuscular implants. Silicone implant rupture with extracapsular spread requires removal of the implant and complete capsulectomy. altering the plane of implant placement should be considered (e. Some of the more innovative techniques involve the use of the implant capsule to reattach the pectoralis muscle to . risk of pneumothorax.g. The causes of skin wrinkling include the implant position (whether subglandular or submuscular). who complain of severe implant palpability and/or wrinkling may not benefit from placement of implants in a subglandular position. Symmastia is considered a relatively rare unfavorable outcome from augmentation mammaplasty but deserves mention as it is one of the most difficult iatrogenic disorders to treat. There are situations where consideration for non-operative management or even explantation should be considered. Otherwise. whether the implant is smooth-walled or textured.. Current trends are for placement of the implant in a dual plane position with partial submuscular coverage (50). Symmastia is an aberrant communication of the breasts across the midline caused by medial migration of one or both breast implants following augmentation.53). subcutaneous coverage or when excessive blood loss is encountered. Low viscosity fluids (saline) allow the shell wall to deform easily. Common situations that lead to the occurrence of symmastia include multiple or successive augmentations to increase breast volume (56) or primary implant placement associated with over-aggressive medial dissection and excessively large implants for the patient’s body habitus (Volume >400 cc or implant diameter ≥14 cm (57) (Fig. Saline implants can be exchanged for silicone implants. However.4). Risk of injury to the chest wall. Efforts should be directed toward implant removal in this difficult patient subset. Skin wrinkling is considered one of the more significant disadvantages to the use of saline implants for aesthetic augmentation. Suture repair of the midline defect can be accomplished in any number of ways. Most surgeons performing breast augmentation through the era of the silicone implant moratorium know that saline implants are intimately associated with skin wrinkling. silent manner with silicone gel implants. treatment options become multifactorial. If revision is offered. there is little evidence to support the mandatory removal of these implants. Implant removal and replacement is recommended for any compromised saline implant. There is no roll for closed or open capsulotomy in the treatment of capsular contracture (52. Textured implants have been shown to have an increased risk of implant palpability and should be used with caution especially in thin patients (55). Treatment options for symmastia vary by author. implants placed in the subglandular position should be repositioned in a retro-pectoral fashion. This. However. submuscular to subglandular location and vice-versa) (56. but it seems prudent to offer explantation to concerned patients. if possible. the total volume of fluid within the shell will determine how much shell folding can be achieved. and creation of an acellular dermal matrix sling for implant coverage of the subglandular component (51). intracapsular silicone implant ruptures. Implant asymmetry or malposition can be related to capsular contracture as previously discussed. More controversial is the need for implant removal and capsulectomy for asymptomatic. Current recommendations from the FDA encourage women to have MRI studies of their silicone implants 3 years after placement and every two years thereafter. the fill volume of the implant. 15. Capsular contracture. but in general. Therefore. patients should be aware that skin wrinkling can occur with the use of silicone implants. those electing to keep the implants should be followed with regular clinical examinations. Skin wrinkling and implant palpability have become significant reasons for unfavorable aesthetic outcomes following augmentation. or risk of excessive blood loss is indicative of partial capsulectomy in the submuscular position. For instance. though the mechanism of action is poorly understood. irrigation of the implant pocket. and placement of closed suction drains. Careful questioning and physical examination of the can often determine which patients are prone to hypertrophic or keloid scar formation. Superficial infections. Treatment of the abnormal scarring should occur as soon as it is recognized. the sternal periosteum (56). subcutaneous tissue atrophy. Patient satisfaction is generally high with up to 93% of patients reporting that they would undergo the procedure again (62). Scarring can be a significant source of anxiety for patients undergoing an aesthetic procedure such as augmentation mammoplasty.4 161 Symmastia—improper pocket dissection can lead to webbing across the midline of the chest. but it does occur. Treatments include intralesional injection of corticosteroid alone or in combination with 5-fluorouracil (64). 11% of plastic surgeons polled stated that a dissatisfied patient had sued them at least once following breast reduction surgery (63). Deep infections involving the implant necessitate expeditious removal of the implant. Patients should be warned that hypo-pigmentation. Patients at risk of adverse wound healing (e. fat necrosis. limited to mild cellulitis and erythema may be treated with antibiotics. REDUCTION MAMMOPLASTY Reduction mammoplasty is one of the most common procedures performed in plastic surgery. and contour depressions might occur following intralesional corticosteroid administration.. Capsulectomy should routinely be avoided given the risk of significant bleeding in the setting of severe infection. over-reduction. under-reduction. Despite the high level of satisfaction. Bear in mind that. Silicone sheeting has been advocated. and epidermal cysts. Intralesional treatments can be repeated at 6-week intervals for 2–3 cycles. cautious incision and debridement. Staphylococcal species are the most common isolates associated with implant related infections (61). Scar formation following reduction mammoplasty can be a significant problem especially when hypertrophic scarring or keloid scarring results. Careful evaluation of the patient preoperatively is necessary to assess the risk of poor wound healing.g. Patients presenting with hypertrophic or keloid scarring should treated as directed in the reduction mammaplasty section (see below). These include scars. Infection following breast augmentation is a rare reason for revision augmentation. the surgeon needs to get a clear understanding of the patient’s complaints as well as their expectations from revision surgery. and creating an acellular dermal matrix sling to prevent the medial migration of the replaced implants (60). Intravenous antibiotics should be tailored to the wound cultures collected during implant removal. hypertrophic scarring. Most surgeons would consider waiting 3–6 months before replacing the implant in the setting of previous infection. Primary management of the patient with an active implant related infection involves determining the extent of infection. as needed. and wound culture. Replacement of the implant should occur in conservative fashion and correspond with absolute resolution of the infection. keloid scarring) should be approached with caution. breast and scar asymmetry. Prior to treating any of the aforementioned complications. . nipple–areola problems.MANAGING THE UNFAVORABLE RESULT IN BREAST SURGERY Figure 15. unfavorable results and complications do occur following reduction mammoplasty. malposition of the NAC. corrective adjustments can be made on both breasts. Reconstructive efforts should be delayed until full wound maturation has been achieved. The patient should be followed in the office for 6 to 12 months to allow for wound maturation and stabilization of the breast contour/size. Patients referred or presenting in a delayed fashion with nipple malposition can be difficult to treat.66). residual areola. All of these unfavorable positions should be recognized and corrected at the time of the primary reduction when possible.5 NAC malposition in reconstruction can be a technical error or can result from further settling of the implant leading to late asymmetry. The scar left from the donor Figure 15. . especially in situations where the nipple has been placed too high. Informed consent should include the possibility of pedicle transection with the attendant need for free nipple grafting (68). Irrespective. and (3) attempts to create pre-determined breast size set by the patient. Patients should be informed that the later might provide a superior cosmetic result. Breast asymmetry often goes unrecognized by patients preoperatively. Excision of the lesions that persist after several months should be considered.5). The only treatments for over-reduction are breast augmentation or augmentation/mastopexy. Needle aspiration of focal areas of fat necrosis should be performed to rule out the possibility of malignancy. Repeat reduction procedures similar to the primary operation can be performed.162 Fat necrosis presents as a focal area of firm or hard tissue and is seen most commonly in obese patients. Recreation of the NAC as offered in breast cancer reconstruction should be discussed with the patient who has lost a significant amount of the NAC. Liposuction can be used as a useful adjunct for treating minor contour irregularities or volume discrepancies (65. Nipple necrosis seen acutely should be managed with conservative wound care and debridement limited to truly non-viable tissue. or with convergence or divergence. Serial debridements may be necessary and these patients should be followed closely. Under-reduction typically represents discordant perceptions of the aesthetic ideal between surgeon and patient. Malposition of the NAC is considered an error in preoperative planning in which the resultant NAC can be placed too high or low. Preoperative breast asymmetry should be identified and addressed with the patient. Common scenarios that lead to over-reduction are: (1) older patients with marked ptosis where significant breast volume is below the inframammary crease. (2) attempts to meet the weight requirements imposed by insurance companies. as needed to achieve symmetry. Any persistent dissatisfaction with the resultant scarring and contour deformities should be managed expectantly for 18–24 months. Over-reduction is an extremely compromising problem to correct. The patient should be informed that scar length discrepancies and breast asymmetry might occur given the baseline asymmetries noted before surgery. Once scar remodeling has stabilized. These pre-existing asymmetries may have a significant impact on the postoperative results. Nipple–areola complex (NAC) problems can range from nipple necrosis. revision should be deferred for 6–12 months AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY to provide time to educate the patient about the risks and complications associated with breast implants (67). as discussed previously in this chapter. and irregular pigmentation. Return to the operating theater should be deferred for at least 12–18 months. 15. Superficially located areas of fat necrosis are easy to diagnose whereas deeper areas may require confirmation with ultrasonography (45). (Fig. Treatment options for high placement of the nipple include surgical repositioning of the nipple with its pedicle in a lower position. Early and late capsular “deformation” as a cause of unsatisfactory results in latissimus dorsi breast reconstruction. 126: 12. Plast Reconstr Surg 2005. Management algorithm and practical oncoplastic surgical techniques for repairing partial mastectomy defects. 14. et al. Foresman PA. infected implant-based breast reconstruction and strategies for salvage. Small corrections of nipple placed too low. 121: 1886–92. Nos C. Partial breast reconstruction with mini superficial inferior epigastric artery and mini deep inferior epigastric perforator flaps. Schwartz GF. Brohim RM. 112: 467. 65: 147–54. Prada C. 10. Feledy JA. Fisher B. Disa JJ. Kronowitz SJ. Albino FP. Ling MN. widened scarring and an overall poor outcome. Boehmler JH. 15. An unfavorable outcome will result from the temptation to excise all of the residual areolar tissue at the time of primary reduction. Grant G. Plast Reconstr Surg 2008. 347: 1233–41. Cohen SM. Eldor L. Therapeutic mammaplasty for centrally located breast tumors. 13. Sadowsky NL. Plast Reconstr Surg 2006. N Engl J Med 2002. Larger movements may require more formal mastopexy type procedures to correct. 119: 1–9. REFERENCES 1. Ann Surg 2002. Anderson Cancer Center experience. Durani P. Carey LA. Aesthetic outcomes in patients undergoing breast conservation therapy for the treatment of localized breast cancer. Calvo BF. Buchholz TA. 24. Meric-Bernstam F. McCulley SJ. Twenty-year follow-up of a randomized trial comparing total mastectomy.D. Fitoussi A. Maxwell GP. et al. J Clin Oncol 2004. Management of exposed. 163 8. Epidermal cysts following breast reduction occur due to incomplete de-epithelialization of the dermoglandular pedicle. . Ann Plast Surg 2010. Wilkins EG. Plast Reconstr Surg 2003. Induction chemotherapy followed by breast conservation for locally advanced carcinoma of the breast. 5. et al. Koltz PF. Alderman AK. Breast conservation after neoadjuvant chemotherapy: the M. Chen AM. Fat injection to correct contour deformities in the reconstructed breast. Hidalgo DA. Kon PS. Hunt KK. Bennett SP. 19. Quantitative monitoring of capsular contraction around smooth and textured implants. Plast Reconstr Surg 2010. Nahabedian M. 2. 41: 471. 23. et al. Practical guidelines for repair of partial mastectomy defects using the breast reduction technique in patients undergoing breast conservation therapy. et al. J Plast Reconstr Aesthet Surg 2011 64: 1270–7. Lockwood MD. 12. 4. 7. Sikoro K. 18. 5: 1300–5. Bahram M. 22: 2303.MANAGING THE UNFAVORABLE RESULT IN BREAST SURGERY position should be closed in an oblique manner toward the axilla so that the resultant scar can be hidden under clothing. Plast Reconstr Surg 2007. Cordeiro PG. et al. 104: 1662–5. Plast Reconstr Surg 1997. Fituossi AD. 100: 1566–9. Manson P. Bryant J. Birchansky CA. Oberg KC. 16. 3. 117: 1. 236: 295. Determining the optimal approach to breast reconstruction after partial mastectomy. et al. Losken A. Definitive treatment for problematic cysts is direct excision. Riedel E. 66: 518–22. The role of the latissimus dorsi flap in reconstruction of the irradiated breast. 109: 2265–74. Irregular pigmentation or hypo-pigmentation can result in dark skinned individuals and is seen most frequently when nipple grafting is required. lumpectomy. Kuerer HM. Spear SL. 73: 362–9. Mehrara BJ. 15: 717–26. Kronowitz S. 117: 366–73. Tsangaris T. et al. 6. Pinell XA. Wilson HB. Love SM. Predicting complications following expander/implant breast reconstruction: an outcomes analysis based on preoperative clinical risk. Macmillan RD. Ohlsén L. Cance WG. Miles DA. Irradiated autologous breast reconstructions: effects of patient factors and treatment variables. Komaricky LT. Cuminet J. Anderson S. and lumpectomy plus irradiation for the treatment of invasive breast cancer. McCarthy CM. Plast Reconstr Surg 2002. Hunt KK. Cosmetic sequelae after conservative treatment for breast cancer: classification and results of surgical correction. Taylor NS. Ann Plast Surg 1993. Hunt KK. Plast Reconstr Surg 2006. 17. Long-term outcome of neoadjuvant therapy for locally advanced breast cancer. Ad-El DD. These patients should be warned that this is unavoidable but correctable with time. Kronowitz SJ. Women with excessively large areolar tissue are at risk of residual areola incorporated in the vertical limb of their reduction. Complications in postmastectomy breast reconstruction: two-year results of the Michigan breast reconstruction outcome study. Berry MG. Plast Reconstr Surg 2004. 20. Autologous fat grafting in secondary breast reconstruction. Needle aspiration of these cysts can be attempted in the office with the caveat that recurrence is possible. 21. Plast Reconstr Surg 1999. Kuerer HM. Epub 2011 Jun 25. Infectious complications following breast reconstruction with expanders and implants. Hakelius L. free nipple grafting may be required to achieve an aesthetically pleasing correction. Occasionally. High tension will be placed along the vertical limb risking dehiscence. 114: 1442. Langstein HN. 90: 854. Plast Reconstr Surg 1992. et al. Pigmentation problems following reduction mammoplasty are not uncommon. Lowery JC. 11. Ann Plast Surg 2011. Clin Plast Surg 1988. Kim HM. Slavin SA. The premature removal of tissue expanders in breast reconstruction. 122: 1631. Clough KB. 120: 1755. medial or lateral can be corrected with elliptical skin excisions in the direction the nipple needs to be transferred. 30: 424–34. Ann Plast Surg 1998. Tattooing can be offered for small areas of depigmentation whereas larger areas respond more favorably to excision and primary closure. Plast Reconstr Surg 2007. et al. Mosseri V. Spear SL. Reconstruction of the radiated partial mastectomy defect with autogenous tissues. Speigel AJ. Bajaj AK. Patients should be clearly informed of this possibility. 9. Plast Reconstr Surg 2008. Cancer 1994. McCraw JB. Tendency to capsular contracture around smooth and textured gel-filled silicone mammary implants: a five-year follow-up. et al. 22. and where we need to go. Hunt JP. Ashton MW. 99: 713. Mouffarrege R. Khan UD. The free abdominoplasty flap and its use in breast reconstruction: an experimental study and clinical case report. Thomassen JM. Pathobiology of infection in prosthetic devices. Spear SL. 52. Lee BT. Esclamado RM. Plast Reconstr Surg 2006. 34. Mofid MM. Hartrampf CR. Eisenberg HV. Galdino G. et al. et al. (June 2011). [Available from: http://www. Early results using ultrasound-assisted liposuction as a treatment for AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY 44.164 25. Plast Reconstr Surg 1997. Transcript of the FDA Panel Executive Summary: Update on the safety of silicone gel-filled breast implants. Plast Reconstr Surg 2010. Rev Infect Dis 1988. Plast Reconstr Surg 2006. Ashton MW. 117: 757. 46. Holmstrom H. DIEP flaps in women with abdominal scars: are complication rates affected? Plast Reconstr Surg 2008. A long-term study of outcomes. 51. Importance of right subcostal incisions in patients undergoing TRAM flap breast reconstruction. Comparison of strategies for preventing abdominal wall weakness after TRAM flap breast reconstruction. 42. Vandevoort M. Aesthetic Plast Surg 2009. Jensyn AJ. Arnout J. A simplified technique for the management of fat necrosis in autologous breast reconstruction. Svensson H.fda. Plast Reconstr Surg 1982. 110: 466–75. Plast Reconstr Surg 2009. 28: 531–52. Conrad C. 47. Antiphospholipid syndrome and thrombosis. 101: 1850. 122: 962. 50. Jandali S. Eller AG. Murray AC. Plast Reconstr Surg 2006. Parrett BM. Ashton MW. Plast Reconstr Surg 2004. Gutierrez J. et al. Bartels RJ. et al. Correction of acquired synmastia with musclesplitting biplane implant replacement. Clin Obstet Gynecol 2006. Dickinson BP. where we are. Ongeval CV. choice of flap. Fat necrosis in deep inferior epigastric perforator flaps: an ultrasound-based review of 202 cases. 28. Hober M. Beauregard G. 33: 327–35. 114: 1258–62. 10: 1102–17. et al. Aesthetic Plast Surg 2009. Plast Reconstr Surg 1998. Carroll WR. 49. 19: 62–4. Ganz JC. Plast Reconstr Surg 2002. 117: 1711–19. Fabre G. et al. Holmich LR. 54. Bogue DP. 122: 710–16. No correlation between activated protein C resistance and free flap failures in 100 consecutive patients. DIEP and pedicled TRAM flaps: a comparison of outcomes. Rozen WM. Bosse JP. Plast Reconstr Surg 1977. Carter ME. fat necrosis in breast reconstruction. Breast reconstruction with the free TRAM or DIEP flap: patient selection. The correction of capsular contracture by conversion to “dual-plane” positioning: techniques and outcomes. and patient satisfaction with breast implants. Plast Reconstr Surg 2008. 61. Tobias AM. 55. Untreated silicone breast implant rupture. Plast Reconstr Surg 2008. 122: 1321–5. Kroll SS. J Thromb Haemost 2007. complications. Arizona. 26. Jernbeck J. Plast Reconstr Surg 2001. Taylor GI. 114: 204–14. Attempts to make sense of the antiphospholipid syndrome. Peeters WJ. Plast Reconstr Surg 2010.htm] Baker JL Jr. Head Neck 1999. et al. 21: 355. Carreras LO. Trussler AP. Vermylen J. Rozen WM. 29. Follmar KE. Watson ME. 13: 423. 29: 12–18. J Plast Reconstr Aesthet Surg 2011. et al. Nahabedian MY. Outcome of mammary capsulotomies. Takeishi M. Fat necrosis in free rectus abdominis and deep inferiour epigastric perforator flaps. Momen B. Cordray T. discussion 476–7. Pocket conversion made easy: a simple technique using AlloDerm to convert subglandular breast implants to the dual-plane position. . Lee BT. Curtis MS. Bucky LP. et al. Plast Reconstr Surg 2010. Soderstrom T. 107: 1611–12. The pathogenesis of vascular thrombosis and its impact in microvascular surgery. 112: 456. 124: 1754. Jones GE. Avoiding denervation of rectus abdominis during DIEP flap harvest II: an intraoperative assessment of nerves to rectus. 31. Marchi M. 58. Lesavoy MA. 33. Scheflan M. Plast Reconstr Surg 2003. Spear SL. 60. 43. Garvey PB. Kiil BJ. Presented at the Aesthetic Breast Symposium. Clin Plast Surg 2001. Improving outcomes in autologous breast reconstruction. 41. 37. Hassa A. 96: 216. Dougherty SH. Plast Reconstr Surg 2004. 49: 115. “Out point” criteria for breast implant removal without replacement and criteria to minimize reoperations following breast augmentation. Classification of spherical contractures. Singh NK. 64: 831–3. 89: 1045–51. 53. Carlson GW. Buchel EW. 32. 56. 5: 1. Breast implant research: where we have been. Gill PS. Plast Reconstr Surg 1992. 36. Ann Plast Surg 2002. 59. TRAM flaps in patients with abdominal scars. 33: 605–10. 48. Heden P. Use of AlloDerm for correction of symmastia. Clin Plast Surg 2001. Nanhekhan L. Ware Branch D. Scottsdale. Black P. 59: 849–50. 121: 1527. Synmastia after breast augmentation. 49: 861. Breast augmentation with anatomical cohesive gel implants: the world’s largest clinical experience. Baumeister S. 35. Arnljots B. Losken A. Rozen WM. 113: 1153. Caterson SA. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg 2004. Young VL. 126: 762. 57. 38. Keller A. Tebbetts JB. Pockaj BA. Vejborg IM. 30. Nguyen MD. 1975. Plast Reconstr Surg 2008. Rupture of a silicone bag-gel breast implant by closed compression capsulotomy. and outcome. 126(Suppl): 192e–193e. Aesthet Surg J 2009. 28: 451–83. 39. 27. Scand J Plast Reconstr Surg 1979. Avoiding denervation of rectus abdominis during DIEP flap harvest: the importance of the medial row perforators.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/ucm259866. Zenn MR. Handel N. Strategy for reoperative free flaps after failure of a first flap. Ann Plast Surg 1987. Colakoglu S. Ahn CY. A 10-year retrospective review of 758 DIEP flaps for breast reconstruction. 45. Difficulties with subpectoral augmentation mammaplasty and its correction: the role of subglandular site change in revision aesthetic breast surgery. Manson PN. 118(Suppl): 168S. Shaw WW. 40. 125: 363. Guerra AB. Slavin SA. 68. Plast Reconstr Surg 1995. 64. Ringler SL. Aesthetic Plast Surg 2005. Plast Reconstr Surg 1999. Hayek SN. Davis GM. Darougheh A. morbidity. and pulsed-dye laser for treatment of keloid and hypertrophic scars. 65. Hudson DA. Reduction mammaplasty: a medicolegal hazard? Aesthetic Plast Surg 1987. 104: 401–8. Short K. Plast Reconstr Surg 2005. 60: 372–4. Shariati F. Colwell AS. New combination of triamcinolone. Rubiez MT. May JW. et al. 11: 113. 116: 1558. 67. 165 66. and patient satisfaction. Liposuction breast reduction. Ann Plast Surg 2008. 32: 907. Skoll PJ. Refinements of vertical scar mammaplasty: circumvertical skin excision with limited inferior pole subdermal undermining and liposculpture of the inframammary crease. 96: 1106.MANAGING THE UNFAVORABLE RESULT IN BREAST SURGERY 62. Breast augmentation after reduction mammaplasty: getting the size right. 29: 519–31. Atiyeh BS. . Asilian A. 63. Reduction mammaplasty: long-term efficacy. Dermatol Surg 2006. Repeat reduction mammaplasty. Brauman D. Hoffman S. 5-fluorouracil. Victor J. and patient selection criteria (1. Unfavorable results typically occur when patient expectations do not match the patient’s anatomy. rupture.2). high quality breast surgery whether for reconstructive or cosmetic reasons can improve a woman’s self-confidence and interpersonal relationships. Implant displacement. The patient should be informed that tissue quality. the patient should be educated Introduction Breast augmentation is one of the most commonly performed cosmetic procedures in the United States. outcomes of breast surgery are still not always perfect (6). Patients who desire replication of results seen in popular media should be made aware of achievable. Patient selection criteria have evolved with tissue-based planning focused on the optimal approach within a framework of realistic expectations (1). In addition. deflation. Cohen INTRODUCTION dissection (1. Furthermore. Many of the imperfections are related to symmetry. Since the introduction of silicone implants in the early 1960s. and overall anatomy vary between different individuals and affect end results. as they are often accentuated after augmentation. body type.4). realistic outcomes and potential limitations. and available sizes and shapes (3). Antony. each situation presents with unique challenges. This chapter will address current thoughts on minimizing complications and avoiding unfavorable results in the reconstructive and aesthetic breast surgery patient to achieve optimal long-term results. Patient Education AESTHETIC BREAST SURGERY: BREAST AUGMENTATION Patient education is a key component when dealing with a breast augmentation patient. However. Actively involving the patient in the planning process permits shared responsibility for the final outcome (7). wrinkling. and volume discrepancies. our ability to deliver reproducible and predictable outcomes has improved. Surgical techniques emphasize the importance of absolute sterility. However. contour irregularities.16 Optimizing long-term outcomes in breast surgery Anuja K. and Mimis N. capsular contractures. Optimizing long-term outcomes is a goal for both the reconstructive and aesthetic surgeon. Benjamin Liliav. meticulous hemostasis. Along with a positive body image. existing asymmetries should be pointed out. rippling. Thus. Breast implants have improved with modifications in the implant shell. and double-bubble deformity are among the reported complications that affect patient satisfaction and long-term outcomes (6). Successful breast surgery can significantly impact a woman’s psychological well-being. filler materials. Hassid. and demand for primary breast augmentation continues to rise (5). surgical techniques. our understanding of breast augmentation has continued to expand with greater appreciation for implant technology. and careful 166 . inadequacy of inframammary fold. However. The subpectoral (SP) implant plane.gov. Previous concerns regarding the deleterious effects of silicone on patients’ health have been unsubstantiated. there is higher risk for implant visibility as well as capsular contracture. 16.22). the position of the inframammary fold.plasticsurgery. and lower pole definition. newer generation cohesive gel silicone implants do not deflate when cut or ruptured. and the type of incision that will be used (12. Potential disadvantages of this approach are the possibility of a high riding implant. As of this writing. 167 especially when silicone implants are being used (15. Our institutional preference is to use smooth. . In terms of implant texture. has the advantages of less capsular contracture than subglandular placement. site accessioned on April 19. Tissue-based preoperative planning has been proposed to avoid long-term unfavorable results (11). smooth versus textured. However. they can be associated with malrotation (23.21). The subglandular plane (SG) is a good option in patients who have adequate breast tissue and subcutaneous fat. the rate of long-term complications has been reported to be as high as 14–18% (10).13). 34 unique cases of ALCL have been identified in the 5–10 million women with breast implants worldwide. and the skin thickness is <1. and implants are felt to be safe and effective (19). and tend to have softer consistency (16. additional information is need to fully understand this possible relationship. She should also be educated regarding the recommendations for long-term care of silicone breast implants. in which the implant is placed partially under the muscle. the surgeon and the patient must consider silicone versus saline implant. soft tissue quality. However. Implant Selection When choosing a breast implant for breast augmentation. Lastly. the surgeon must be familiar with preoperative tissue assessment.22). 2011) Patients should be informed that although older generation silicone implants have been historically associated with a high rate of capsular contracture. The submuscular approach (SM). as well as breast animation with contraction of the pectoralis major muscle (athletes should be informed of such a possibility during the operative planning process). the breast cone. in which total muscle coverage of the implant is provided.fda. This approach allows for soft tissue redraping. In order to obtain reliable and reproducible results in breast augmentation. the recommendations for long-term care after silicone implants are still evolving and long-term studies are ongoing by the manufacturing companies. As of this writing.1) (4. Another inherent difference is that with implant rupture. and therefore a different implant pocket should be used (12–14). in general. silicone-filled implants feel more natural. (www. and improved upper pole breast contour (17). patients should be alerted that the FDA has identified a potential association between silicone breast implants and the rare disease entity of anaplastic large cell lymphoma (ALCL).24).16). results in less visibility and palpability as well as decreased rate of capsular contracture. Prerequisites for creation of an attractive breast include accurate assessment of the footprint of the breast. and round versus anatomic types (Fig. round implants to avoid malrotation potential. Some surgeons feel that anatomic implants provide better lower pole fullness. the quality and quantity of the breast envelope (skin and subcutaneous tissue). which in turn creates a more aesthetically pleasing lower pole contour (18). if the patient does not have enough soft tissue for coverage. as with any surgical procedure. Optimal Planning Based on Tissue Assessment Although breast augmentation is a very common procedure. both the FDA and the American Society of Plastic Surgeons (ASPS) are confident that breast implants remain safe and effective (www. Currently the United States Food and Drug Administration (FDA) recommends an initial MRI screen three years after implantation followed by an MRI test every two years thereafter. and personal expectations and preferences (8). the FDA has recently identified a potential association between silicone breast implants and anaplastic large cell lymphoma (ALCL) (20. which can provide soft tissue coverage of the implant (14). a patient should be made aware of all possible complications and adverse sequellae associated with breast augmentation. as well as the implant type and size. Additionally. Effects of Implant Pocket Plane Various techniques exist for implant placement in breast augmentation. However. while saline implants decompress and older generation implants leak.gov. are less palpable. the recently described dual plane (DP) technique creates a desirable breast shape using the subpectoral in conjunction with the subglandular planes.fda. www . Textured anatomic implants are a viable option for patients.org).OPTIMIZING LONG-TERM OUTCOMES IN BREAST SURGERY with regards to implant selection based on her specific anatomical dimensions. However. provided that a meticulous pocket dissection is performed (23).5–2 cm.8). the patient must be informed of several studies which link subglandular positioning of smooth salinefilled implants to a high capsular contracture rate as compared to textured saline-filled implants (16. in order for a silicone leak to be identified in a timely fashion (9). Each type confers its own advantages and disadvantages. Also. surgeons should be skilled in several approaches in order to provide an optimal outcome. smooth saline implant. The patient’s anatomic variables and wishes in terms of scarring should determine which type of incision will be undertaken. textured silicone implant. This is a good approach for a patient with tuberous breast deformity who will require breast parenchyma alterations. if one chooses to have the scar on the inferior (B) (A) (C) Figure 16.168 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY Incision Type in Breast Augmentation Patients in general are concerned about and conscious of their scars following any surgery. Placing the incision 1–2 cm below the inframammary crease. (C) Round. In order to avoid this error. . 16. while using this incision.2 and 16. which must be considered with the patient preoperatively. one should consider the desired final location of the scar. Currently there are four different incision sites that can be utilized to augment the breast. The inframammary approach is the most commonly used and has the advantage of excellent visualization of the breast pocket as well as creation of a relatively inconspicuous scar at or above the inframammary fold. (B) Round. Periareolar incisions give central access to the breast and may be used with various implant types and planes of dissection.1 Implant selection: (A) round. resulting in misplaced and more visible scar after implant insertion. realizing that the scar will migrate several centimeters after implant insertion (Figs. is placing the inframammary incision too low or too high. some reports in the literature suggest nipple sensation alterations with this approach (25). Hence. smooth silicone implant. which will make the scar more conspicuous. Areolar diameter may be a limiting factor in patients who have light-colored areolas with indistinct margins. However. A common pitfall. will allow for final scar position in the crease.3). Additionally.OPTIMIZING LONG-TERM OUTCOMES IN BREAST SURGERY Figure 16. Any bleeding encountered cannot be controlled well. The transumbilical approach (TU) is associated with high rate of implant malposition as it confers less control and accuracy in placing the implant.2 Inframammary incision placed 1–2 cm below IMF. most plastic surgeons and our institution do not favor this approach.28). It is less suitable for silicone gel implants. 169 pole of the breast. placing the incision at the IMF will have the final scar at the inferior pole. However. (B) Inframammary insicion with contralateral circumareolar mastopexy.3 (A) Preoperative appearance in patient with Poland’s syndrome (note small areolar diameter on right). . (B) (A) (C) Figure 16. silicone implants cannot be placed via this approach. provide better hemostasis. there are some limitations associated with this approach. as a small incision may fracture the implant during placement. the use of an endoscope has been shown to enhance visualization and prevent implant malrotation by careful and accurate dissection of the pocket. and facilitate complete transection of the muscle fibers (26). Due to its many limitations. which will be relatively inconspicuous as well. The transaxillary approach has the advantage of not leaving any scar on the breast and not violating the breast parenchyma. (C) Postoperative result. Moreover. and it may be associated with more asymmetry postoperatively (27. It causes parenchymal and soft tissue atrophy. and exerts a greater force on the breast tissue. weight fluctuation. both wrinkling and rippling occur more often with saline-filled implants than with silicone-filled implants. In most cases. and the unfavorable results and complications that may arise. or pregnancy. and estimated to be 1–1. If gross asymmetry is encountered preoperatively. as the asymmetry may be exacerbated by augmentation. consultation with an infectious disease specialist should be sought. However. Any implant greater than 350–400 ml is considered large. In patients with penicillin allergies. A key to optimizing the results of breast augmentation is to take into account any natural preoperative asymmetry. includes the administration of preoperative prophylactic dose of antibiotics to cover Gram positive organisms of the skin. The culprit is usually a perforating vessel coming off the internal thoracic artery. especially if a deep-seated infection is suspected which will lead to loss of the implant. In case of no response. The most common causative organisms identified in the literature are staphylococcal species.30). our institutional preference is to place a drain and administer a short course of antibiotics.34). Role of Implant Size in Long-Term Outcomes Recent literature suggests that implant size correlates directly to unfavorable long-term results and complications (37). Repeat breast augmentation may be considered. or select different sizes of silicone implants based on preoperative samples and/or intraoperative sizers. the current recommendation in regards to breast augmentation with implants. prior to proceeding with explantation of the implant. Besides adhering to meticulous sterile operative techniques. the true incidence is unknown (38). The timing of such an approach is surgeon-dependent. it is vital to inform the patient preoperatively of the existing asymmetry and of the possibility that her breast shape may change with time. Asymmetry Most female patients are unaware that their breasts or nipple areola complexes may be asymmetric (35). clindamycin is the recommended prophylactic antibiotic. If signs and symptoms do not improve despite aggressive treatment and the infection worsens. while the patient is receiving broad-spectrum antibiotics. In addition. This is likely secondary to more tissue adhesions leading to a dimple on the skin envelope. usually within the first week postoperatively. one may choose saline implants of different volumes to compensate. If a definitive hematoma is confirmed in the postoperative setting.5% in the short term. Although a large implant may initially look appealing to the patient and the surgeon. such as administration of broad-spectrum antibiotics and close monitoring of the patient’s progress (32). If infection ensues. aging and gravity. the recommendation is to reoperate and evacuate it.5% (29. a prophylactic dose is sufficient to almost entirely eliminate risk of surgical site infection. the bleeding vessel cannot be located. typically several months later. The use of lighted retractors has been recommended for adequate visualization of encountered vessels. the pocket should be thoroughly irrigated and the same device may be reinserted. however. it eventually accelerates the aging process of the breast by accentuating the gravitational effects. Soft Tissue Envelope Wrinkling and Rippling Although some studies cite a wrinkling and rippling incidence of 20–30%. and necessitates early identification and treatment. Typically. intercostal and lateral vessels can also be injured during pocket dissection. while long-term hematomas are exceedingly rare (33. swelling.170 Minimizing Complications and Avoiding Unfavorable Results Infection The incidence of infection following breast augmentation is usually very low. and is associated with higher rates of revisional surgeries (13). which in turn will stretch and thin the surrounding soft tissue envelope over time. It is important to confirm absence of any bleeding history and cessation of anticoagulation medications prior to operative intervention. and drainage. it is imperative that any patient who inquires about breast augmentation of a very large size be fully aware of the long-term implications of aging and of tissue thinning. Moreover. such as first generation cephalosporin given 1 hour prior to surgical incision (31). we prefer to wait for 48–72 hours in case of cellulitis. revisional breast surgery via mastopexy may be needed in order to achieve better symmetry. pain. Once hematoma AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY control is achieved and the pocket is deemed to be dry with excellent hemostasis. the current recommendation is to remove the implant and tailor the antibiotic regimen based on the results of intra-operative wound cultures (32). . The role of three-dimensional technology in the preoperative assessment of breast augmentation candidates is promising but not yet fully determined (36). Also. the patient may require hospitalization for intravenous antibiotic therapy. Thus. The literature suggests. it manifests with redness. once there is complete resolution of the infectious process. that there is a higher incidence when using textured implants as compared to smooth implants (39). Hematoma The incidence of hematoma after breast augmentation is 2–5. Once asymmetry is encountered postoperatively. recontouring the involved breast with the use of fat grafting has been described and has led to satisfactory outcomes (40). Once a patient has developed significant capsular contracture. Soaking implants and washing the pocket with antibiotic solution has been shown to reduce the capsular contracture rate in breast augmentation (46. However. the long-term implications of this technique are unclear.55). capsular contracture. Sound surgical technique is important in the prevention of capsular contracture (15). Implant replacement. . likely contributing to a higher incidence of infection and contracture. and minimizing manipulation of the implant once inside the pocket have also been shown to reduce the rate of capsular contracture. the previously described prophylactic measures are surgeon dependent. folds and pleats causing rippling will appear. There have been various attempts with other treatment modalities such as mechanical implant displacement.45). Careful planning and adequate communication with the patient are key factors to successful treatment.44.59). The incidence of capsular contracture in general is 15% following breast augmentation (15. one may elect to replace it with a silicone-based implant and consider changing the position from subglandular to submuscular. The underlying etiology of rippling depends on soft tissue implant dynamics. if the deformity is severe. for example. In case of mild irregularities. However. In summary. or excisions. if a superficial saline implant is the reason. However. one must be familiar with various available correction modalities to contour these deformities (10). vitamin E. and infection theories (15). not amenable to revision with some of the previously described corrective maneuvers. and especially when the implant is not filled to full capacity (38). Textured surface implants have been found to minimize capsular contracture when inserted subglandularly (15. location.41). Additionally. most theories lack sound data and the underlying etiology for capsular contracture is still unclear (45.OPTIMIZING LONG-TERM OUTCOMES IN BREAST SURGERY This complication is more obvious when the implant is placed in the subglandular region.43). and implant volume must all be taken into consideration. soft tissue infections. Many studies confirm that implant position affects capsular contracture and that submuscular as opposed to subglandular positioning minimizes contractures (51). type of implant. Secondary Deformities Patients who present with breast deformities and contour irregularities as a result of previous biopsies. The literature offers multiple explanations for encapsulation.31. and that the inframammary incision is associated with a decreased risk of capsular contracture compared with other incisions (56. replacement of the implant. capsular contracture is multifactorial and adherence to basic surgical techniques with meticulous dissection and minimization of any inflammatory potentiators are important for its prevention. Finally. In particular.50) (allergen and mentor studies). such as the hematoma. one may consider replacing it with a smooth nontextured implant. avoiding contact between the implant and surrounding skin. When the implant is overfilled or underfilled.47). Two recent studies revealed that the ideal incision should minimize implant exposure to bacteria. the choice of incision may influence the incidence of contracture. In cases of contour deformity. steroids. as a result of infection. augmentation with autologous tissue may be considered. It is also the most common reason for 171 reoperation following insertion of implants (46. some authors are proponents of fat injection into the subcutaneous layer overlying the capsule (40. Tissue quality. or previous breast surgery with subsequent contour distortion. the underlying etiology must be considered. but believe that the etiology is multifactorial (15). and are interested in breast augmentation.52–54). Lastly.57). The use of acellular dermal matrix has been proposed for correction of secondary deformities and demonstrated successful results in revision after breast augmentation as well (42. Timely identification and appropriate management are necessary for an optimal outcome. To treat rippling and wrinkling. myofibroblast. It is necessary that during pocket dissection the extent of unnecessary tissue trauma and bleeding be minimized in order to decrease any inflammatory stimuli that can lead to capsular contracture. the complexity of the problem and its treatment increases. deserve special consideration. Most experts support the infection theory. but is noticed most commonly in the superior aspect. glove changing prior to implant handling has been shown to minimize capsular contracture. and leukotriene inhibitors (58. Cleansing the skin surrounding surgical incisions. the periareolar incision disrupts ducts that contain bacteria. Typically. further studies are necessary in order to define the efficacy of such approaches. However. If a textured breast implant has resulted in rippling. In order to achieve symmetrical results post augmentation. if the patient’s skin is overlying the implant is thinner. Capsulotomy and/or capsulectomy should be added during implant exchange if a tight capsule is contributing to implant deformity. along with capsulotomy or capsulectomy may alleviate the problem in cases of capsular contracture.49. with or without a change in implant position from the subglandular plane to submuscular or dual planes. Rippling may occur anywhere along the breast.48). it should be addressed with open capsulotomy and capsulectomy. Capsular Contracture Capsular contracture is the most common long-term complication in both aesthetic and reconstructive breast surgery (44. However. In order to minimize unfavorable results. and should not violate the anterior axillary line. whereas a superiorly displaced implant will lead to aesthetically unpleasing asymmetry.61). Use of acellular dermal matrix in order to provide additional support to the underlying revision is well-documented in the current literature (42. implant volume. the sternal midline. To avoid double bubble in patients with tuberous breasts. and dimensions must be carefully selected. Numerous mastopexy procedures are available for different grades of ptosis and the surgeon must be cognizant of which procedure fits the underlying problem of his/her particular patient who presents with ptosis (67). Double Bubble Deformity Double bubble deformity is seen in patients in whom the implant falls below the inframammary crease with glandular breast tissue superior and anterior to the implant (62). should extend down to the predetermined IMF level. However. nipple asymmetry. AESTHETIC BREAST SURGERY: SKIN ENVELOPE Mastopexy Goals The goals of mastopexy are elevation of the nipple areolar complex. and contour irregularities. along with optimal scar quality (64). Procedure Selection After all contributing factors have been considered.43. may lead to different complications. Basic principles to follow are accurate assessment of the degree and nature of ptosis. the gland must be modified with radial incisions to optimize the transition between implant and gland and to expand the base of the breast. Patient Selection and Informed Consent Accurate patient selection requires careful assessment of nipple position. degree of ptosis. A medially displaced implant may cause symmastia. which may be considered an unfavorable result by the patient (66). respectively. appropriate procedure selection.172 Implant Malposition Implant malposition as a result of capsular contracture is the most common reason for revision following breast augmentation (60). scarring is the tradeoff for achieving a long-lasting improvement in the shape and aesthetic appearance of the breast. the appropriate procedure must be undertaken in order to achieve an aesthetically pleasing outcome. Correct identification of the above factors will in turn assist the surgeon in choosing the appropriate procedure in order to achieve a long-term favorable result. Dissection past the midline should be avoided. In a subpectoral type augmentation. patients should be informed that mastopexy results may be temporary and with weight fluctuations. aging. or the medial origin of the pectoralis major muscle. the patient and surgeon should be aware of the fact that even with meticulous surgical technique and adherence to sound principles. One factor is severe ptosis with loose attachments at the muscle parenchyma interface. adequate preoperative planning and meticulous execution (65). It is important to note that this operation will result in scarring either in the periareolar region or on the breast itself. and patients should be well-informed prior to proceeding with surgery. Implant malposition is variable and. aesthetic enhancement of the breast shape. and pregnancy. the breast parenchyma slides in a cephalad direction over the implant. breast skin elasticity. with one breast mound sitting higher than the contralateral one. ptosis may recur. Revisional surgery. Accurate AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY planning in regard to implant selection and pocket dissection can help prevent the development of double bubble deformity. projection. with possible recreation of the IMF. Another risk factor is use of an implant of insufficient volume and projection in a patient with contracted or tuberous glandular tissue. and the anterior axillary line. along with a short nipple to inframammary fold distance. and to pay close attention to important landmarks. depending on the location. implant malpositioning can still occur. in case of inferior or medial displacement. improvement of projection. The best time to prevent implant malpositioning is during the initial operation. One of the underlying etiologies of double bubble breast deformity is failure to recognize the risk factors for it preoperatively. leading to this deformity. An inferiorly displaced implant causes obliteration and change in the position of the inframammary fold compared with the contralateral breast. and is amenable to multiple treatment modalities. The pocket plane should be of adequate dimensions in order to be filled by the selected implant. First-degree . could lead to satisfactory results. therefore. such as the existing or new inframammary fold (IMF). the surgeon must be familiar with different techniques of mastopexy that will adequately address the skin envelope and minimize the need for revisions. Moreover. The incidence of double bubble deformity is reported in the literature to be between 2 and 7% (63). in order to prevent the development of symmastia. Patients must be aware of scar burden and location as well as the possibility of hypertrophic scar formation. The key is to avoid over-dissection of the pocket during the initial augmentation procedure. a laterally displaced one will result in axillary fold bulging. (A) 173 Scar Widening and Hypertrophy When selecting a patient for mastopexy. In a patient with third degree ptosis and volume loss. scar revision may be undertaken one year after the initial surgery (69). choosing a larger implant may produce the desired outcome. Patients who have inelastic skin or are prone to keloid formation should be informed that they might be prone to scar widening and hypertrophic scars. . (B) Vertical mastopexy markings with planned plication.4 (A) Patient with Grade III ptosis and volume loss. This can be achieved by periareolar mastopexy if the distance is less than a few centimeters.OPTIMIZING LONG-TERM OUTCOMES IN BREAST SURGERY ptosis can be corrected with breast augmentation alone and if the patient has modest amount of excess skin. If scars persist despite conservative nonoperative measures. In a patient with second-degree ptosis. In the case of hypertrophic scar formation. a significant amount of skin excision with a short vertical scar or inverted-T procedure in conjunction with a subsequent augmentation. Closure using a periareolar mastopexy should be done with a non-absorbable blocking suture that will evenly distribute tension across the tissues and help prevent scar widening (68).71). Although performing both procedures in (B) (C) Figure 16. for patients with a greater degree of ptosis. along with scar massage. breast implant alone will be insufficient and will lead to an unfavorable aesthetic outcome. it is important to pay utmost attention to the patient’s skin quality. the nipple may need to be transposed to a greater degree and a more extensive resection of the skin envelope using a short vertical scar or inverted T method will be required. respectively. 16. Augmentation Mastopexy Many surgeons advocate placement of subglandular or subpectoral breast implants in conjunction with mastopexy (70. In order to correct the problem in a patient with more pronounced ptosis. However. and/or plication may be necessary for correction and optimal outcome (Fig. (C) Early 3-week postoperative result after vertical mastopexy and parenchymal redistribution with plication. the nipple should be elevated to the desired ideal position at or slightly above the IMF level.4). local corticosteroid injections can be used. to minimize and prevent bulky scars. To avoid unfavorable results many surgeons recommend performing the mastopexy first followed by a second stage of breast augmentation (72. both surgeries act in opposition to each other. Careful patient selection and appropriate use of available reconstructive options with meticulous surgical technique are prerequisites for a successful outcome. timing. as well as history of hypertension contributes to an increased risk for complications (77). and capsular contracture. Patient co-morbidities and poor social habits should be carefully considered when planning a reconstruction. Fundamental Principles in Breast Reconstruction The goal in breast reconstruction is to restore absent breast tissue in a long-lasting and aesthetically pleasing manner and establish overall symmetry.80). Tissue Expanders and Implants The advantages of a two-stage tissue expander/implant breast reconstruction are the relative ease of use. BREAST RECONSTRUCTION Introduction The beginnings of breast reconstruction date back to more than 100 years ago with a case by Dr Vincenz Czerny in 1893. weight management and tobacco cessation should be included in the preoperative management of a breast reconstruction patient. the surgeon must be aware of the potential for complications and unfavorable results. body mass index (BMI) greater than 30. Patients in poor general health who cannot tolerate reconstructive procedures may be better served with an oncological resection without reconstruction. This may lead to wound healing problems and is technically very challenging. This will be discussed in other chapters and is beyond the scope of this chapter. tactile sensation should not be used to localize the port. Augmentation of the ptotic breast is more complex and many plastic surgeons advise against or recommend caution when performing this procedure (72). A two-staged approach is much safer and simpler. whereas augmentation expands the skin envelope. Diabetes and poor glycemic control contribute to wound healing problems and increased infection rates (79. A positive smoking history is associated with a 2–3 fold increase in the incidence of both major and minor complications in implant-based breast reconstruction (77. Breast Reduction Various techniques for breast reduction have been described in the literature from suction assisted lipectomy to different resection patterns of breast parenchyma and skin. Medical optimization. 16. 16. many surgeons have moved toward utilizing integrated ports (Fig.76). and increased patient involvement in final volume selection (Fig. Assessment of a patient’s candidacy for breast AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY reconstruction is a critical first step in minimizing complications and optimizing outcomes (75. or can be fitted with an external prosthetic device. When an integrated port is used. who transplanted a lipoma from the buttock to reconstruct a patient’s breast (74). This section will address current thoughts on how to optimize long-term outcomes by minimizing complications and preventing unfavorable results in the breast reconstruction patient. in cases of adjuvant or neo-adjuvant chemoradiation. Tissue Expander Ports There are two types of injection ports for a tissue expander: remote and integrated. patients should also be aware of possible complications associated with use of a device including exposure.78).174 one setting lowers the overall cost for the patient. it is generally recommended that final skin resection follow implant placement to avoid closure under tension. but distant enough from the implant to minimize the risk of implant perforation. and difficulty with localization.73). Single-stage implant reconstruction may offer the advantages of eliminating multiple expansions but require careful patient selection. With the evolution of breast reconstruction techniques and their increasing sophistication and technical complexity. Innovation and technical improvements have subsequently brought significant advancement in breast reconstruction. extrusion. as well as type of breast reconstruction should be taken into consideration in regard to the patient’s preoperative planning. A remote port must be placed in the subcutaneous tissue in a position easy to localize.5) (82). Finally. However. Consequently. Similarly. from a physiologic standpoint.84). and increases the breast volume. If one chooses to undertake a simultaneous augmentation-mastopexy. Mastopexy repositions the nipple. healthy mastectomy flaps and technical comfort and experience on the part of the reconstructive surgeon (85–87). infection. Remote ports can be associated with port malposition and leakage. reshapes the breast and removes excess skin while limiting tension and scarring. lack of donor site morbidity. Furthermore. reconstruction with tissue expanders requires significant patient commitment to multiple office-based visits in order for the expansion process to be completed. the .6). The reverse can be performed but is much less common. which may require additional operations (83. Patients should be evaluated in regard to realistic expectations and be informed about the expected results and limitations of reconstructive techniques. The role of advanced age as a risk factor in breast reconstruction has not been clearly defined (81). which have a larger port.OPTIMIZING LONG-TERM OUTCOMES IN BREAST SURGERY 175 (B) (A) Figure 16. Careful expander inflation intraoperatively and in the outpatient setting with accurate identification of the port is important to prevent puncture of the device. Meticulous operative technique and careful handling of the device are required in order to avoid puncturing the expander during Implant Exposure Implant exposure has a reported incidence of approximately 3% and most commonly occurs at the mastectomy incision scar (32). Tissue Expander Rupture Device defects and technical errors are among the most important causes of tissue expander rupture.89). the different segments of the reconstructive procedure. Localization of the port with a magnetic finder is recommended to accurately identify the port site.5% (65).6 Tissue expander with integrated port (note large port size). Figure 16. It is usually associated with insufficient . Integrated ports may be associated with difficulty during radiation therapy and various modifications have been described to improve the radiation field (88. has decreased the incidence of puncturing during expansion to approximately 1.5 (A) Preoperative appearance in patient who desired larger breasts. (B) Postoperative result after bilateral immediate twostage tissue expander and implant breast reconstruction. overlying tissue may be misleading and needle insertion may lead to puncture of the expander. The introduction of newer generation of expanders. Newer technology incorporating ICG perfusion (SPY technology.100.) (65) may facilitate identification of the compromised mastectomy flaps intraoperatively (93–97). or closure of the incision under significant tension (Fig. Implant Malpositioning Implant malpositioning can result from either suboptimal initial placement of the implant or as a consequence of Mastectomy flap necrosis in patient who underwent immediate breast reconstruction using TE with latissimus flap. and in the case of inadequate response. Additionally. However. poorly controlled diabetes. debridement and revision of wounds with impending implant exposure. pectoralis muscle superiorly with serratus fascia and/or acellular dermal matrix inferolaterally).7). improper device handling and failure to comply with sterile principles during tissue expansion may lead to periprosthetic infection. local wound care with possible debridement of the necrotic skin and future scar revision should be considered. and careful expansion in order not to compromise mastectomy flap vascular supply reduce the risk of implant exposure (90). Obesity (BMI > 30). . Technologic advances have made the harvesting and delivery of injectable autologous fat a great tool in the armamentarium of the plastic surgeon while minimizing complications such as decreased fat graft take and cyst formation. management usually entails removal of the implant. Close cooperation between the breast and reconstructive surgeons is necessary for optimization of the final result. the patient should be treated promptly with antibiotics.176 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY soft tissue coverage and/or inadequately perfused mastectomy flaps. Mastectomy Flap Necrosis Mastectomy flap necrosis is usually related to either inadequate perfusion of the mastectomy flaps. Timed excision of the mastectomy flap necrosis with continued expansion may be considered if full musculofascial coverage of the implant is present (92).41. Key principles in avoiding exposure include the creation of mastectomy flaps of adequate thickness and a subpectoral pocket with full implant coverage (typically.101). the long-term implications of this technique are unclear (40. appropriate wound care and future reconstruction (91). Failure to adhere to sterile principles in the intraoperative and postoperative phase and/or presence of multiple comorbidities affecting the patient’s immune status can contribute to a higher infection risk.98. Moreover. early recognition and appropriate treatment of surgical site infections. In case of such complication.50. Contour Deformities Fat injection into the subcutaneous layer overlying the capsule has been recommended in order to address this finding. implant removal and delayed reconstruction is advised.99). 16. When this complication is encountered. immunocompromised state and active smoking have been linked to higher infection rates (77. Figure 16. Lifecell Corp.77–80).7 Infection Periprosthetic infection in reconstructive breast surgery has been reported to be 7–25% of all cases (44.49. Once clinical evidence of an infection appears. Use of saline. Strattice™. and careful pocket design. Placement of ADM as a lower lateral sling limits the need for dissection of the serratus anterior and rectus abdominis muscles for breast pocket creation. Early development of capsular contracture around the tissue expander may serve as a predictor for significantly increased contracture rates around the subsequently placed implant (15).121).8 177 (A. early recognition and treatment of capsular contracture may include revision with capsulotomy. leading to an aesthetically displeasing result (84). and exposure of the breast device (65. shape and type). accurate preoperative markings. but is not necessarily associated with higher failure rates (119). although they have been associated with increased seroma rates and higher complication rates in patients with increased age.106–108).9). Key principles to minimizing the incidence of malposition are precise breast implant selection (appropriate size. Role of Biologic Implants in Breast Reconstruction Acellular dermal matrices (ADM). Newer technologies. when compared with nonradiated breasts (78). seroma and infection as well as sterile antibiotic irrigation of the (A) implant has been suggested to reduce contracture rates (46.OPTIMIZING LONG-TERM OUTCOMES IN BREAST SURGERY capsular contracture. Capsular Contracture The development of capsular contracture can negatively affect an otherwise pleasing reconstruction. (B) Figure 16.8 and 16. ADMs also contribute to aesthetically pleasing inferior pole expansion and lower the incidence of capsular contracture (112–114). higher BMI. once a seroma is identified. Additionally. with subsequent non-integration of the biologic implant used. serial aspirations with careful drainage of the fluid collection may be required. An implant that is initially placed too high above the inframammary fold may be subject to future capsular contracture and further implant distortion. and Allomax™ and have become very popular in immediate breast reconstruction. and axillary dissection (109.93–97). Avoidance of hematoma. such as mastectomy flap necrosis. Biological mechanisms such as the wingless signaling pathway have been implicated in the pathogenesis of radiation-induced fibroproliferation associated with capsular contracture in expander/implant reconstruction (105). Additionally.115–119). thereby reducing patient morbidity (Figs. Capsular contracture rates in the radiated breast are estimated to between 20 and 50%. B) Placement of ADM as lower lateral sling.120. such as Alloderm™. The major risk factor identified in the development of capsular contracture is radiation (102–104). 16. capsulectomy and/or implant replacement. Flex HD™. textured and subpectoral implants has been reported to decrease contracture rates (15). Intraoperative drain placement into the sub-mastectomy and sub-ADM planes may reduce seroma rates (115. . Newer studies suggest that implantation with acellular dermal matrices (ADM) can deter the development of capsular contracture (109–111). may prevent complications. such as SPY. morbid obesity. necrosis of skin flaps. In cases of inadequate perforator anatomy. which may preclude ipsilateral pedicled TRAM flap reconstruction (135.178 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY (B) (A) Figure 16. Breast Reconstruction with Autologous Tissue The use of autologous tissue for breast reconstruction has been shown to provide excellent results with high longterm patient satisfaction. DIEP reconstruction can be considered more ideal in patients with small. alternatives flaps such as the superior gluteal artery perforator (SGAP). improper insetting of the flap. wound dehiscence. Careful planning of incisions and optimal planning can prevent many of these complications and affect the overall outcome. and patient preference (126). patient body habitus and vascular anatomy. The transverse rectus abdominus myocutanous (TRAM) flap has been considered the autologous tissue of choice by many surgeons for breast reconstruction (127.130). Technical errors. The DIEP flap offers less sacrifice of rectus muscle and fascia. expectations and potential complications is critical to achieving successful long-term outcomes in breast reconstruction. the muscle-sparing TRAM or free TRAM flap is a reasonable alternative. B) Preoperative and postoperative result after ADM-assisted left TE/I breast reconstruction (and right mastopexy). such as the deep inferior epigastric perforator (DIEP) flap. There is ongoing debate with regards to the superiority of the DIEP vs. TRAM flap (131–133). and infections. Donor site complications include abdominal bulging. Additionally. Total versus Partial Flap Loss Technical errors. Complications related to this type of reconstruction can be categorized into donor site-related complications and flap-related complications. and scarring. Flap-related complications include flap loss and fat necrosis. improper insetting of the flap may lead to venous congestion due to outflow obstruction and resultant flap compromise. and patient-related factors can lead to flap necrosis and/or loss.to moderatesized breasts and presence of optimal perforator anatomy (134).136). and the transverse upper gracilis (TUG) free flaps may be used based on optimal location of adiposity and acceptability of the donor site defect. development of hernia defects. Ideal Flap Selection Multiple factors need to be considered when selecting a flap type for breast reconstruction including prior history of abdominal or thoracic surgery. poor planning. . including kinking or twisting of the pedicle. venous congestion. tissue volume availability. if autologous tissue is required. will lead to vascular compromise of the flap. Morbid obesity is a relative contraindication to abdominal-based reconstruction and an alternative flap such a latissimus flap with or without implants may be a reasonable choice. In addition.128). Concerns over abdominal wall morbidity have led to the evolution of fascial-sparing techniques and perforator flaps. Careful flap selection with a thorough assessment of the patient’s anatomy. Smoking history. Patient-related factors include a history of prior abdominal operations such as open cholecystectomy and coronary artery bypass. but may be associated with an increased rate of fat necrosis (129. and previous abdominal surgery should be taken into consideration prior to autologous breast reconstruction (125).9 (A. largely due to the “like for like” advantage of native tissue and a more natural-feeling reconstruction for the patient (122–124). the inferior gluteal artery perforator (IGAP). donor site morbidity. may be required in order to accomplish symmetry (152). Lastly. One important caveat in deciding on perforator flap surgery is that the surgeon must be able to demonstrate a complication rate comparable to his/her own rates with TRAM flaps.154).10) (153). 16. which can have a negative effect on overall patient satisfaction. twisting or tension.147. Supercharging of the flap may be required if flap perfusion after insetting does not seem optimal (139). Partial flap loss may require debridement and re-inset. however. although the feasibility of this approach may be institution specific (149–151). Mastectomy Flap Necrosis Mastectomy flap necrosis is usually related to either aggressive thinning of the mastectomy flap or closure of the incision under significant tension. Technical aspects that may reduce the incidence of abdominal wall morbidity include perforator or fascialsparing methods with clear identification of the perforators. report only slight increase in morbidity with the TRAM versus DIEP flap (134. and prior surgery. If the flap is unable to be salvaged. Repair involves imbricating the attenuated fascia and reinforcing it with the application of an onlay mesh and/or acellular dermal matrix (156). Banking of TRAM flap skin and early return to the operating room have been proposed in cases of patients with skin flaps of questionable viability. Perforator flaps have become increasingly popular as our understanding of anatomy improves. may influence the success of the type of flap chosen for reconstruction (137). early return to the operating room and debridement of the necrotic flap should be performed and may prevent infection and future tissue compromise. contralateral breast surgery is staged at 3–6 months after the original autologous reconstruction. Long-term studies comparing free TRAM to perforator flaps are still ongoing. including a recent meta-analysis. Key principles to avoid this type of complication include appropriate lay of the pedicle in order to prevent kinking. and revisional procedures on the autologous reconstructed breast can be carried out at the same time (Fig.146). Inclusion of more perforators when harvesting DIEP or SIEA flaps reduces the rate of fat necrosis (142. and a tension-free closure. Mastopexy. Drains should be used to prevent seroma formation. 16. Secondary procedures such as fat grafting have been used to treat late deformities with success. ICG perfusion imaging allows identification of areas with compromised blood supply that may need to be excised (145). Moreover.up should be performed and evaluation of alternative recipient vessels may be considered prior to a second free flap (140). Preoperative mapping of the abdominal vessels using different imaging techniques. In cases of increased tension and inability to fully approximate the fascia. and MR angiography has been associated with lower rate of complications and improved outcomes (129. modification of the flap orientation may facilitate better venous drainage. it will not improve over time and it must be repaired.148). Typically. morbid obesity. Although most cases of fat necrosis resolve spontaneously with gradual softening of the affected areas. Typically.OPTIMIZING LONG-TERM OUTCOMES IN BREAST SURGERY In addition. and reduction mammoplasty. while other studies. a mesh should be used to bridge the gap (155. chemotherapy. If venous congestion is evident after insetting. color duplex ultrasound. suction-assisted lipectomy as well as excision of the necrotic tissue are among the suggested treatment options. which may need to be resected at the time of operation (142–144).156). local wound care with possible debridement 179 of the necrotic skin and future scar revision should be considered. Methylene blue dye can be used to maintain the orientation of the pedicle (138). Some authors suggest that TRAM flap reconstructions lead to weaker abdominal wall. careful insetting. Once a hernia occurs. such as hand-held Doppler. careful tissue re-approximation during abdominal closure.130. Breast Asymmetry Key principles to optimize obtaining symmetrical results are choice of appropriate flap. a thorough anticoagulation work. the abdominal bulge occurs at or below the arcuate line where there is absence of the posterior rectus sheath (Fig. CT angiography. The most susceptible areas to fat necrosis are Hartrampf’s zones III and IV (areas most distant from donor blood supply). once a complete flap loss occurs.11). and proper selection and timing of future procedures on the ipsilateral as well as contralateral breast. augmentation. In cases of this complication. it is important to educate the patient regarding future asymmetry and need for revisions if partial or full-thickness flap loss occurs. the most common adverse sequellae associated with an abdominal-based flap is a bulge or hernia. Abdominal wall morbidity Traditionally. as they do not require the degree of sacrifice of the underlying muscle and fascia that a TRAM flap does. As previously described. fat necrosis still remains a possible unfavorable result in any autologous breast reconstruction as a result of compromised blood supply to the subcutaneous tissue (141). Fascial-sparing techniques and reinforcement of the abdominal wall are the key methods to avoiding this complication. . Fat Necrosis Although a more minor complication. once it occurs. Abdominal Flap Necrosis Umbilical Deformities and Necrosis The main blood supply to the abdominal flap comes from the intercostal.180 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY (A) (B) (C) (D) Figure 16. however. This complication is rare. Defatting the umbilical tunnel may be undertaken to allow easy passage of the stalk. (C) Postoperative result after contralateral breast reduction. (D) Postoperative result after right NAC reconstruction. and a tension-free closure can help prevent abdominal wound healing complications.10 (A) Preoperative appearance of patient with right breast cancer and breast asymmetry. careful incision planning. Limiting unnecessary undermining of the abdominal flap. avoid excessive skeletonization of the umbilical stalk and dissect carefully around it. and lumbar vessels. the eschar should be debrided to allow the wound to contract and heal by secondary intention with local wound care. in order to preserve the blood supply necessary to prevent necrosis. local wound care with dressing changes should be . (B) Postoperative result after right immediate breast reconstruction using deep inferior epigastric artery perforator (DIEAP) flap. subcostal. Key principles are to place the umbilicus in the correct position at the intersection of the anterior superior iliac spine with the line connecting the xiphoid to the pubic bone. In case of umbilical necrosis and or loss. Careful design of the umbilical stalk is necessary in order to obtain an aesthetically pleasing. and viable umbilicus after reconstruction. Excessive undermining of the flap or closure under tension can cause vascular compromise and lead to ischemic changes of the abdominal flap. OPTIMIZING LONG-TERM OUTCOMES IN BREAST SURGERY (A) (B) (C) (D) 181 Figure 16.11 (A. . and either as pedicled or free flap (162). B) Preoperative and postoperative result after bilateral immediate breast reconstruction using DIEP and musclesparing TRAM flaps. It can be used either in an immediate or in a delayed reconstruction. This type of reconstruction often requires incorporation of an implant to match the opposite breast in size and volume. In patients who present with a complication from prior surgery such as winging of the scapula after axillary dissection. the latissimus dorsi myocutaneous flap is a reliable and reproducible method to reconstruct a post-mastectomy defect. An ipsilateral thoracotomy incision is considered an absolute contraindication for latissimus dorsi breast reconstruction. Additionally. D) CT angiography demonstrating abdominal vasculature. athletes who use the latissimus muscle routinely are less ideal candidates. (Continued) done and future reconstruction of the neoumbilicus has been described using various techniques (157–161). Breast Reconstruction with Latissimus Dorsi and Implant Because of its versatility and vascularity. (C. an imaging study such as an angiogram can be performed to assess the viability of the thoracodorsal and serratus branches of the subscapular artery prior to contemplating reconstruction with the latissimus dorsi flap. The skin paddle over the latissimus dorsi muscle bears little hair and is an excellent color match to the anterior chest skin. the scar can be placed vertically or horizontally along the bra line. They allow the transfer of the patient’s own skin and fat in a reliable manner with minimal donor-site morbidity. and TUG are viable options in breast reconstruction and are capable of achieving good results but are often chosen if the aforementioned flaps are less suitable. Reconstruction with the latissimus dorsi flap has a lower complication rate than implant-based reconstruction alone. Alternate Free Flaps in Breast Reconstruction Perforator flaps represent the latest in the evolution of softtissue flaps. The advantages of the IGAP flap include donor site defect that can be concealed in the infragluteal crease. and other modalities such as using quilting stitches or fibrin glue to decrease dead space and to reduce seroma rates are important considerations. IGAP. as well as potential for buttock effacement and the development of a painful scar (166). The SGAP flap can be used in patients in whom the lower abdomen is not suitable for reconstruction secondary to scarring or insufficient soft tissue volume. to conceal the scar. achievement of adequate hemostasis. as well as excellent tissue volume. Breast reconstruction with the latissimus dorsi flap has proved to provide patients with a high level of satisfaction and predictable and favorable outcomes (123).11 (Continued) (E–G) Intraoperative views of DIEP and muscle sparing TRAM flaps. patient repositioning.182 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY (F) (E) (G) Figure 16. In order to optimize long-term outcomes. shorter pedicle length and small vessel diameter (164. Additionally. Advantages of the SGAP flap include minimal donor site morbidity. drain placement. . Disadvantages mirror those of the SGAP flap. more globular fat consistency. Disadvantages include difficult dissection. and minimal donor site morbidity.165). particularly for the radiated patient (163). when possible. SGAP. meticulous surgical technique. OPTIMIZING LONG-TERM OUTCOMES IN BREAST SURGERY (A) 183 (B) Figure 16. Addition of radiation to the breast cancer treatment protocol and timing of radiation affect the reconstructive plan and options available (169–171). Radiotherapy and Breast Reconstruction Radiation therapy. If the soft tissue envelope is inadequate. 16. With regard to free flap breast reconstruction. One advantage of this flap is that it can be raised simultaneously during mastectomy and recipient vessel exposure. Recognizing and understanding how to minimize complications and avoid unfavorable results are critical aspects to achieving optimal long-term success after breast surgery. If radiation is required after an immediate expander reconstruction. import of autologous tissue with or without a prosthetic device is recommended. is an integral part of breast reconstruction in the multidisciplinary management of breast cancer.88. Some authors are proponents of this type of reconstruction in a delayed setting provided that tissue of adequate quality exists with minimal changes due to radiation (172). CONCLUSION Optimizing long-term outcomes is a goal for both the reconstructive and aesthetic surgeon. B) Preoperative and postoperative appearance of patient who underwent bilateral TE/I breast reconstruction with radiation (note changes secondary to radiation). scar migration. radiation therapy has a deleterious effect on the longterm aesthetic outcome in patients who have undergone TRAM flap breast reconstruction (176). Disadvantages include variable soft tissue volume availability. It is particularly useful for patients less amenable to scarring on the abdomen.173.or implant-based reconstructive methods. The TUG flap is indicated for women with small breasts and regional adiposity in the medial thigh region. pre-reconstruction radiation therapy increases the rate of vascular complications in free flap breast reconstruction. Although radiation does not hinder the overall success of reconstruction or contribute to postoperative complications. wound dehiscence requiring healing by secondary intention. back. surgeons should be aware that working in a previously irradiated field carries additional technical risk (175). In the post-reconstruction patient. protocols have been developed with close cooperation with the radiation oncology specialist with high success rates (89. who seek primary autologous reconstruction after a skinsparing mastectomy.168). the majority of which appear intraoperatively. In general. At the soft tissue level radiation resembles a burn injury and at the vasculature level radiation induces transient microvascular occlusion (Fig. either in a neoadjuvant or adjuvant setting. and appropriate choice of available options are prerequisites for successful breast surgery.12). Careful patient selection. Radiotherapy has many deleterious effects on skin and soft tissue as well as on the vasculature of tissue. A patient who requires radiation should be counseled on the risks and benefits of an immediate versus delayed reconstruction in the settings of either autologous. The role of the plastic surgeon with these patients is twofold: treatment of patients who have already been radiated and treatment of patients who will undergo radiation after reconstruction. . and labial distortion (167.174). tissue expansion in the radiated patient can be difficult. meticulous technique.12 (A. or gluteal region. Ann Chir Plast Esthet 2003. Plast Reconstr Surg 2010. 118(7 Suppl): 53S–80S. 3. Van Landuyt K. 23. .628 primary augmentation mammoplasties assessing the role and efficacy of antibiotics prophylaxis duration. Patel K. Cordray T. . Plast Reconstr Surg 2006. operative planning. Clin Plast Surg 2009. 33: 752–9. 300: 2030–5. Schwartz J. discussion 204–5. Barnard JJ. Prospective analysis of the outcome of subpectoral augmentation. 2. Aesthetic Plast Surg 2007. 36: 49–61. Todd EL. and infection: comparative analysis of 1. 5. Plast Reconstr Surg 2006. 8. Management of common and uncommon problems after primary breast augmentation. Codner MA. Vasmel WL. de Weerd L. A long-term study of outcomes. Hartley W. Gravante G. 20.002 patients. Shaping the breast in aesthetic and reconstructive breast surgery: an easy three-step principle. 118(7 Suppl): 35S–45S. 63: 1761–8. Adams WP. 33: 44–8. Bronz G. Howard MA. et al. Rheingold LM. Lee AK. et al. Silicone breast implants and magnetic resonance imaging screening for rupture: do U. 113: 1634–44. Rohrich RJ. A system for breast implant selection based on patient tissue characteristics and implant-soft tissue dynamics. Tassin X. Reynaud JP. Plast Reconstr Surg 2004. Boehmler JH. Gutierrez J. Plast Reconstr Surg 2006. complications. Schaub TA. Sterodimas A. The high five process: tissue-based planning for breast augmentation. 25. Singh NK. Davies DM. Aesthetic Plast Surg 1993. 13. 10. discussion 14S. and surgical techniques to increase control and reduce morbidity and reoperations in breast augmentation. Mofid MM.S. Breast augmentation. Complications in breast augmentation: prevention and correction. 34. 16. 27. Clin Plast Surg 2001. JAMA 2008. The transaxillary approach to breast augmentation. discussion 768–72. Araco A. Plast Reconstr Surg 2002. Dual plane breast augmentation: optimizing implant-soft-tissue relationships in a wide range of breast types. 31: 325–9. 127:409–13. Weum S. Food and Drug Administration recommendations reflect an evidencebased practice approach to patient care? Plast Reconstr Surg 2008. Breast augmentation: part I—a review of the silicone prosthesis. 33. 122: 1287–8. Blondeel PN. and revisions in breast augmentation. Hijjawi J. Outcome assessment of breast distortion following submuscular breast augmentation. Tebbetts JB. 36: 127–38. 11. Andrades P. Complications. Li S. Bengtson BP. Plast Reconstr Surg 1994. Part IV—aesthetic breast surgery. 4. Form stability of the style 410 anatomically shaped cohesive silicone gel-filled breast implant in subglandular breast augmentation evaluated with magnetic resonance imaging. Aesthetic Plast Surg 2010. 29. 31. Chester DL. vii. Cohen AT. et al. Teitelbaum S. Araco F. Handel N. Jensen JA. 118(7 Suppl): 81S–98S. 32. Plast Reconstr Surg 2005. Past. Adams WP Jr. Clemens MW. Ahmad J. Aesthetic Plast Surg 2009. Distribution of organosilicon polymers in augmentation mammaplasties at autopsy. de Boer JP. Long-term safety and effectiveness of style 410 highly cohesive silicone breast implants. Breast augmentation roundtable. Pereira LH. Tebbetts JB. Brown S. Bengtson BP. Breast augmentation today: saline versus silicone—what are the facts? Plast Reconstr Surg 2008. 28. 124: 372–82. Capsular contracture with breast implants in the cosmetic patient: Saline vs. Clin Plast Surg 2009. Clin Plast Surg 2001. Kristiansen B. antibiotic prophylaxis. Plast Reconstr Surg 2006. subfascial. Hodgson E. 26. 30. Khan UD. Tebbetts JB. 126: 2140–9. 115: 1781 author reply 1781. discussion 1410–15. et al. Plast Reconstr Surg 2006. Aesthetic Plast Surg 2009. 28: 501–21. reoperations. Dayan JH. Courtiss EH. de Jong D. Adams WP Jr. vii. Plast Reconstr Surg 2010. 117: 1694–8. Roche N. The infected or exposed breast implant: management and treatment strategies. Hidalgo DA. Yoo RP. 118(7 Suppl): 175S–87S. 21. 24. Transaxillary breast augmentation: a prospective comparison of subglandular. 22. Adams WP. 28: 587–95. author reply 1592. 36: 119–26. 15. “No-touch” submuscular saline breast augmentation technique. 118(7 Suppl): 7S–13S. Spector JA. Heden P. et al. Spear SL. Nahabedian MY. 33: 430–6. Nippleareola complex sensitivity after primary breast augmentation: a comparison of periareolar and inframammary incision approaches. 14. 48: 389–98. 93: 118–22. 6.184 REFERENCES 1. and submuscular implant insertion. viii. J Plast Reconstr Aesthet Surg 2010. 9. Spear SL. Depypere H. and patient satisfaction with breast implants. Pacella SJ. 3: 117–27. 15S–17S. Clin Plast Surg 2009. 122: 1591–2. A Systematic Review of the Literature. Gray L. Elberg JJ. 34: 42–7. 17. Rohrich RJ. Silicone. Plast Reconstr Surg 2006. Berry MG. 18. Plast Reconstr Surg 2009. Nahabedian MY. Preoperative sizing in breast augmentation. 36: 139–56. 117: 757–67. Patient evaluation. Tebbetts JB. Five critical decisions in breast augmentation using five measurements in 5 minutes: the high five decision support process. Mladick RA. Rohrich RJ. Mielcarek R. Hester TR. Anaplastic largecell lymphoma in women with breast implants. Plast Reconstr Surg 2011. future of breast implants. Plast Surg Nurs 2007. 27: 197–201. discussion 437–8. Plast Reconstr Surg 1997. Capsular contracture: what is it? What causes it? How can it be prevented and managed? Clin Plast Surg 2009. Klatsky SA. Wilson WG. discussion 99S–102S. discussion 596. 12. Tebbetts JB. 100:197–203. 7. fact or fiction? Int J Clin Exp Pathol 2009. 35. Axillary endoscopic breast augmentation: processes derived from a 28-year experience to optimize outcomes. Khanna A. present and . Plast Reconstr Surg 2006. 125: 1781–7. Incidence of breast and chest wall asymmetry in breast augmentation: a retrospective analysis of 100 patients. Silicone implant and primary breast ALK1negative anaplastic large cell lymphoma. 17: 183–92. Aesthetic Plast Surg 2009. 109: 1396–409. Prado A. Experience with 326 inflatable breast implants. . Infections of breast implants in aesthetic breast augmentations: a single-center review of 3. vi. Codner MA. AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY 19. Doucet J. discussion 17S–18S. 67. Rohrich RJ. Aesthet Surg J 2005. 114: 1622–30. 101: 827–37. Casas LA. Garson S. Aesthetic Plast Surg 2009. 104:529–38. 62. 111: 2182–9. et al. Plast Reconstr Surg 2009. 3D evaluation and mammary augmentation surgery.OPTIMIZING LONG-TERM OUTCOMES IN BREAST SURGERY 36. Plast Reconstr Surg 2007. results. Missouri: Quality medical publishing. Ann Plast Surg 2010. Henriksen TF. The use of human acellular dermal matrix for the correction of secondary deformities after breast augmentation: results and costs. Safety and effectiveness of Mentor’s MemoryGel implants at 6 years. 3rd edn. A new periareolar mammaplasty: the “round block” technique. 69: 641–5. Aesthetic Plast Surg 1990. Taghinia AH. 61. Detection of subclinical infection in significant breast implant capsules. 43. Holmich LR. The limited scar mastopexy: current concepts and approaches to correct breast ptosis. Capsular contracture and ripple deformity of breast implants. and investigation of breast surgery. Tousson G. Rohrich RJ. 117: 2182–90. Plast Reconstr Surg 2006. 64: 390–6. Inamed Silicone Breast Implant U. The Danish Registry for Plastic Surgery of the Breast: establishment of a nationwide registry for prospective follow-up. The effect of zafirlukast (Accolate) on early capsular contracture in the primary augmentation patient: a pilot study. 117: 30–6. Breast ptosis. Delay E. 29: 360–76. Spear SL. 58. Argenta LC. Henriksen TF. 47. Aesthet Surg J 2009. Regnault P. Low M. 42. Bostwick’s Plastic and Reconstructive Breast Surgery. Jakubietz MG. Ann Plast Surg 2003. 124: 629–34. Ten-year review of a prospective randomized controlled trial of textured versus smooth subglandular silicone gel breast implants. 38. Late side effects related to inflatable breast prostheses containing soluble steroids. Vargas AF. 33: 440–4. Plast Reconstr Surg 2011. Autologous fat transplantation to the breast: a personal technique with 25 years of experience. Relative implant volume and sensibility alterations after breast augmentation. Camirand A. Sinna R. Araco F. Rios JL. Fat injection to the breast: technique. Breast augmentation: compression—a very important factor in preventing capsular contracture. 50. 64. Pajkos A. 57. Ann Plast Surg 2005. et al. Barnsley GP. 106: 786–91. Local complications after cosmetic breast augmentation: results from the Danish Registry for Plastic Surgery of the breast. 48. 59. Aesthetic Plast Surg 1996. Ann Plast Surg 2000. 118: 1224–36. Protective effect of topical antibiotics in breast augmentation. Wong CH. 50: 643–51. 118:215–22. Overton J. Harris J. Eder H. Henriksen TF. Capsular contracture in subglandular breast augmentation with textured versus smooth breast implants: a systematic review. 14: 93–100. 68. 41. treatment. Massiha H. Spear SL. Revision augmentation mastopexy: indications. Lebreton E. operations. 52. Plast Reconstr Surg 2010. Foo IT. discussion 2190–1. Augmentation in ptotic and densely glandular breasts: prevention. Grunert JG. Surgical intervention and capsular contracture after breast augmentation: a prospective study of risk factors. Plast Reconstr Surg 2004. 49. quality assessment. prevention and treatment. 124: 1808–19. 54: 343–51. 20: 311–14. Plast Reconstr Surg 2009.S. Clin Plast Surg 1976. Aesthetic management of the breast following explantation: evaluation and mastopexy options. 54. discussion 223. Jorgensen S. Balaguer T. Aesthetic Plast Surg 2007. Holmich LR. Murphy DK. Medard de Chardon V. Greve SD. St. and outcomes. Enhancing patient outcomes in aesthetic and reconstructive breast surgery using triple antibiotic breast irrigation: six-year prospective clinical study. Plast Reconstr Surg 1998. 56. Smith SJ. Pfeiffer P. Benelli L. Clemens MW. Nahabedian MY. 44: 143–6. Illouz YG. The Mentor Core Study on Silicone MemoryGel Breast Implants. Nunes D. Jakubietz RG. 185 53. Samuel M. Seruya M. Deva AK. Radwanski HN. Lin SJ. et al. Definition and treatment. 33: 706–15. Kristiansen TB. 65. Plast Reconstr Surg 2006. Oneal RM. The use of human acellular dermal matrix for the correction of secondary deformities after breast augmentation: results and costs. Plast Reconstr Surg 2007. 25: 26–30. Louis. Chignon-Sicard B. Gravante G. 111: 1605–11. 55. Pitanguy I. Barnsley SE. Walker PS. Nahabedian MY. et al. discussion 539–41. Coleman D. Restifo RJ. 2010. Plast Reconstr Surg 2006. . Cunningham B. 60. Plast Reconstr Surg 2010. 37. Sinna R. Sterodimas A. Study Group. Friis S. Slavin SA. Al-Sabounchi S. Beran SJ. Collis N. 31: 238–43. 127: 1047–58. Chang J. 40. 3: 193–203. Holmich LR. Plast Reconstr Surg 1999. 126: 1711–20. Reid RR. 51: 540–6. Nicolle FV. Acellular dermal matrix for the treatment and prevention of implant-associated breast deformities. et al. Garson S. Cunningham B. Plast Reconstr Surg 2009. 120(7 Suppl 1): 8S–16S. Slicton A. Textured salinefilled breast implants for augmentation mammaplasty: does overfilling prevent deflation? A long-term follow-up. Copit SE. Double breast contour in primary aesthetic breast augmentation: incidence. Aesthetic Plast Surg 2009. 44. Thornton JF. Textured surface breast implants in the prevention of capsular contracture among breast augmentation patients: a meta-analysis of randomized controlled trials. 126: 1721–2. and classification of double-bubble deformity. Song C. Delay E. 45. Plast Reconstr Surg 1982. 66. De Mey AM. Capsular contractures: a systematic review. Vaena M. Hartzell TL. Plast Reconstr Surg 2000. Spear SL. Jorgensen A. Discussion. Teitelbaum S. and indications based on 880 procedures over 10 years. 46. Sharpe DT. Inamed silicone breast implant core study results at 6 years. Hvilsom GB. McCue J. Holmich LR. 63. 120(7 Suppl 1): 19S–29S. 39. Tan BK. Plast Reconstr Surg 2003. Jones GE. Ann Chir Plast Esthet 2005. 124: 919–25. Fryzek JP. Adams WP Jr. Araco A. discussion 30S–32S. Ducic I. Plast Reconstr Surg 2006. 51. Sigurdson LJ. Plast Reconstr Surg 2003. Caruso R. Vickery K. 99. Breast reconstruction: a review and rationale for patient selection. et al. Plast Reconstr Surg 2005. Nonexpansive immediate breast reconstruction using human acellular tissue matrix graft (AlloDerm). 75. Spittler CJ. beware. Stevenson KB. Frey M. Seruya M. Immediate bilateral breast reconstruction with implants and inferolateral AlloDerm slings. Holm C. Plast Reconstr Surg 2001. 78. A classification and algorithm for treatment of breast ptosis. discussion 135S. Discussion. 72. Clough KB. Petit JY. 71. 124: 356–63. 118: 832–9. Francis SH. Walden JL. Falcou MC. 105: 2143–9. Freeman ME. Evaluation of perfusion in skin flaps by laser-induced indocyanine green fluorescence. 107: 177–87. Warren SM. the lower pole of the breast to reduce unwanted lift. et al. McCarthy CM. Cunningham BL. Dalton EF. 124: 55–62. Clin Hemorheol Microcirc 2008. 28: 259–67. Plast Reconstr Surg 2001. Kronowitz SJ. 103. 118(7 Suppl): 133S–4S. Complications after autologous fat injection to the breast. Bedford MS. Gais S. 57: 1–5. Clin Plast Surg 2005. 34: 39–50. Menon N. Henke J. Kamolz LP. 86. Plast Reconstr Surg 2006. 26: 674–81. Plast Reconstr Surg 2009. 80. 94. Brown SA. quiz 188. Ganchi P. 85. Nos C. Topol BM. Leong M. Optimizing the patient for surgical treatment of the wound. 124:1790–6. Fate of exposed breast implants in augmentation mammoplasty. 24: 347–54. Spear SL. 96. 73. Disa JJ. 97. Izadi K. 74. Conant EF. Ponn T. Skin-sparing mastectomy and immediate autologous tissue reconstruction after whole-breast irradiation. Lamby P. 121: 1886–92. Intraoperative evaluation of skin-flap viability using laser-induced fluorescence of indocyanine green. Handchir Mikrochir Plast Chir 2005. Fodor L. Nahabedian MY. Glass GE. 84. 61: 635–41. Plast Reconstr Surg 2010. Gosman AA. Aesthetic Plast Surg 2004. 93. 81. Evaluation of skin perfusion by use of indocyanine green video angiography: rational design and planning of trauma surgery. Autologous fat grafting to the reconstructed breast: the management of acquired contour deformities. Kanchwala SK. Plast Reconstr Surg 2009. Pusic AL. Spear SL. 107: 1702–9. et al. Age as an exclusion criterion for breast reconstruction. J Trauma 2006. Plast Reconstr Surg 2009. et al. 124: 326–7. 92. Spear SL. Ullmann Y. Plast Reconstr Surg 2009. McCarthy CM. Vincenz Czerny and the beginnings of breast reconstruction. Newman MK. et al. 22: 355–63. Ann Plast Surg 2006. Implant reconstruction. 100. Kirwan L. Spear SL. Lokeh A. Is one-stage breast augmentation with mastopexy safe and effective? A review of 186 primary cases. Prospective evaluation of late cosmetic results following breast reconstruction: I. Gutowski KA. Auer T. Holzbach T. et al. 82. 98. 79. 61: 673–81. et al. Plast Reconstr Surg 2010. Riedel E. et al. Disa JJ.” Plast Reconstr Surg 2006. Heerdt AH. Preliminary results. Delayed-immediate breast reconstruction: technical and timing considerations. et al. 50: 447–9. discussion 2150–1. O’Donoghue JM. 39: 253–63. Ann Plast Surg 2003. Fitoussi AD. McCarthy CM. 76. 90.186 69. 125: 463–74. Evaluation of skin perfusion after nipple-sparing mastectomy by indocyanine green dye. 32: 209–22. An analysis of long-term complications. Br J Plast Surg 2002. Disa JJ. Clin Plast Surg 2007. Hofter E. Unilateral postoperative chest wall radiotherapy in bilateral tissue expander/ implant reconstruction patients: a prospective outcomes analysis. et al. 61: 494–9. J Exp Clin Cancer Res 2005. Ruberg RL. 89. 77. Plast Reconstr Surg 2003. Plast Reconstr Surg 2008. Plast Reconstr Surg 2006. Peled IJ. Clin Plast Surg 2007. Taskov C. Mehrara BJ. 122: 340–7. Antony AK. Stevens WG. Mastopexy preferences: a survey of board-certified plastic surgeons. Goldwyn RM. 125: 1074–84. 119: 1954–5. Phillips LG. 91. Mayr M. Salzberg CA. Ramon Y. 34: 607–20. Plast Reconstr Surg 2007. Spear SL. Immediate versus delayed reconstruction. Andel H. 102. Pelletiere CV. 124: 409–18. Prantl L. Breast reconstruction with implants and expanders. et al. Chronic wounds. Myers WT. Augmentation/mastopexy: “surgeon. Management of the infected or exposed breast prosthesis: a single surgeon’s 15-year experience with 69 patients. 101. Bucky LP. Immediate single-stage breast reconstruction using implants and human acellular dermal tissue matrix with adjustment of AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY 88. Breuing KH. A single surgeon’s 12-year experience with tissue expander/implant breast reconstruction: part II. A retrospective analysis of outcomes using three common methods for immediate breast reconstruction. McCarthy CM. 118: 1631–8. 111:118–24. Plast Reconstr Surg 1978. De Lorenzi F. 95. Meissl G. and patient satisfaction. Plast Reconstr Surg 2009. Stoker DA. Cordeiro PG. 87. 55: 635–44. abstract vi. Yamaguchi S. aesthetic outcomes. One-stage augmentation combined with mastopexy: aesthetic results and patient satisfaction. 124: 63–4. Evaluation of the vascular integrity of free flaps based on microcirculation imaging techniques. Breast reconstruction: a review and rationale for patient selection. Salvage of tissue expander in the setting of mastectomy flap necrosis: a 13-year experience using timed excision with continued expansion. Eldor L. Aesthet Surg J 2002. 70. Ann Plast Surg 2005. 83. Plast Reconstr Surg 2000. 116: 1642–7. Plast Reconstr Surg 2008. Glatt BS. Rohrich RJ. Mehrara BM. Saline-filled breast implant safety and efficacy: a multicenter retrospective review. Independent risk factors for infection in tissue expander breast reconstruction. Kronowitz SJ. Predicting complications following expander/implant breast reconstruction: an outcomes analysis based on preoperative clinical risk. Ann Plast Surg 2008. Plast Reconstr Surg 2009. 37: 396–402. Aesthet Surg J 2006. . Cordeiro PG. Reisch J. Campbell CJ. 55: 232–9. Lee DJ. DIEP. 126: 492–8. Komorowska-Timek E. 126: 1121–2. The role of betadine irrigation in breast augmentation. The effect of AlloDerm envelopes on periprosthetic capsule formation with and without radiation. 128. 108. Nahabedian MY. Slavin SA. Lutz JC. The reconstructive matrix: a new paradigm in reconstructive plastic surgery. Walton RL. Boehmler JH. Becker S. The effect of Siltex texturing and povidone-iodine irrigation on capsular contracture around saline inflatable breast implants. TRAM. 107. Vyas R. 129. 123: 205e–6e. Patient satisfaction with mastectomy breast reconstruction: a comparative evaluation of DIEP. Mafi AA. Plast Reconstr Surg 2009. Beahm EK. Newman MI. Plast Reconstr Surg 2010. Kulber DA. et al. 105. Bilateral reconstruction. 134. Fabre G. Uppal RS. Spear SL. Kramer S. AlloDerm in breast reconstruction: 2 years later. and irradiation. 118. Plast Reconstr Surg 2009. Guerra AB. 124: 1741–2. Connor J. Wong C. Disa JJ. Burkhardt BR. Ashton MW. Van Landuyt K. Plast Reconstr Surg 2010. Plast Reconstr Surg 2010. 48:68–75. Plast Reconstr Surg 2010. Gill PS. Plast Reconstr Surg 2009. Expander/implant reconstruction with AlloDerm: recent experience. Ann Plast Surg 2005. Kummel S. 124: 1754–8. Blondeel P. 130. Sinha I. Improving outcomes in autologous breast reconstruction. 116. et al. . 33: 327–35. Erba P. Peeters WJ. Acellular human dermis implantation in 153 immediate two-stage tissue expander breast reconstructions: determining the 120. 131. AlloDerm versus DermaMatrix in immediate expander-based breast reconstruction: a preliminary comparison of complication profiles and material compliance. Eades E. Chun YS. Wiener TC. Plast Reconstr Surg 2010. discussion 129–30. Saint-Cyr M. indications and results. 120: 1477–82. Comparison of morbidity. Nelson J. Zink S. author reply 1122. Plast Reconstr Surg 2009. Plast Reconstr Surg 2010. Plast Reconstr Surg 1994. Acellular dermis-assisted prosthetic breast reconstruction versus complete submuscular coverage: a head-to-head comparison of outcomes. The use of acellular dermal matrix to prevent capsule formation around implants in a primate model. Selber JC. and implant techniques. Rosen H. Van Ongeval C. 96: 1317–25. et al. 119. et al. J Plast Reconstr Aesthet Surg 2009. et al. Hannan C. Orgill DP. Bindingnavele V. Plast Reconstr Surg 2009. Rozen WM. Fosnot J. 122: 379–88. Koch RM. Halvorson EG. 62: 859–64. 119: 12–15. Which breast reconstruction procedure provides the best long-term satisfaction? Ann Chir Plast Esthet 2010. et al. Plast Reconstr Surg 2007. 55: 547–52. AlloDerm performance in the setting of prosthetic breast surgery. 125: 429–36. 60: 1214–18. Options in reconstructing the irradiated breast. et al. Use of acellular cadaveric dermis and tissue expansion in postmastectomy breast reconstruction. and implant techniques. Casaer B. 124: 1743–53. Ashikari AY. 126. Cordeiro PG. 125: 1585–95. Yueh JH. 123: 807–16. Bogue DP. 106. Techniques to reduce seroma and infection in acellular dermis-assisted prosthetic breast reconstruction. Plast Reconstr Surg 2009. Adesiyun T. Namnoum JD. Cuoco F. Sbitany H. Leong M. Spear SL. Miles DA. 114. 127: 514–24. Nanhekhan L. Fat necrosis in deep inferior epigastric perforator flaps: an ultrasound-based review of 202 cases. 117. 110. et al. Alman BA. Demas CP. Pathogenesis of radiation-induced capsular contracture in tissue expander and implant breast reconstruction. A prospective study comparing the functional impact of SIEA. 126: 1842–7. An 8-year experience of direct-to-implant immediate breast reconstruction using human acellular dermal matrix (AlloDerm). 93:123–8. and satisfaction following bilateral TRAM versus bilateral DIEP flap breast reconstruction. Bodin F. Plast Reconstr Surg 1995. 109. 113. A 10-year retrospective review of 758 DIEP flaps for breast reconstruction. Patient satisfaction in postmastectomy breast reconstruction: a comparative evaluation of DIEP. Acellular cadaveric dermis decreases the inflammatory response in capsule formation in reconstructive breast surgery. 111. Plast Reconstr Surg 2010. et al. Samson MC. 126: 1438–53. 133. 126: 1133–41. Oberg KC. functional outcome. infection. Salzberg CA. Safety and risk factors for breast reconstruction with pedicled transverse rectus abdominis musculocutaneous flaps: a 10-year analysis. Turko A. Gaon M. Aesthetic Plast Surg 2009. Plast Reconstr Surg 2004. Plast Reconstr Surg 2011. 55: 559–64. 113: 1153–60. et al. and musclesparing free TRAM flaps on the abdominal wall: part II. 125: 1596–8. Chun YS. discussion 16–17. Antony AK. 127. Immediate postoperative complications in DIEP versus free/musclesparing TRAM flaps. Pang CY. Spear SL. 124. Vandevoort M. TRAM. 115. 112. Qiu W. Ota KS. 123. Timek TA. Holton LH 3rd. Rezai M. 121. Lipa JE. Berho M. 125. The effect of Biocell texturing and povidone-iodine irrigation on capsular contracture around saline-inflatable breast implants. Huang N. Hicks MJ. 125: 437–45. The efficacy of preoperative mapping of perforators in reducing operative times and complications in perforator flap breast reconstruction. Plast Reconstr Surg 2009. 124: 82–91. J Plast Reconstr Aesthet Surg 2007. 123: 1–6. Darsow M. Ducic I. Gridley DS. Chen CM. 125: 1606–14. latissimus flap. Hunt JP. Verma K. Discussion. Plast Reconstr Surg 2010. 132. Stump A. Burkhardt BR. latissimus flap. Plast Reconstr Surg 2010. McCarthy CM. Discussion. Plast Reconstr Surg 2009. 122. Basu CB. Plast Reconstr Surg 2007. Gynakol Geburtshilfliche Rundsch 2008. Autologous and alloplastic breast reconstruction—overview of techniques. Chabner-Thompson E. discussion 107–8. Plast Reconstr Surg 2010. Ogawa R. 187 incidence and significant predictors of complications. Plast Reconstr Surg 2008. Implant-based breast reconstruction using acellular dermal matrix and the risk of postoperative complications. 124: 387–94.OPTIMIZING LONG-TERM OUTCOMES IN BREAST SURGERY 104. 158. unilateral reconstruction. Plast Reconstr Surg 2006. author reply 2288–9. 59: 614–21. Rozenblit AM. Taylor GI. Ann Plast Surg 1984. Atisha DM. Spear SL. 119: 1–9. 146. Taylor NS. 17: e20–3. Ashton MW.188 135. Kroll SS. Walter S. et al. Supercharging the transverse rectus abdominis musculocutaneous flap: breast reconstruction for the overweight and obese population. 142. 155. Outcomes of various techniques of abdominal fascia closure after TRAM flap breast reconstruction. 160. Al-Shaham A. 64: 722–5. 147. Liao EC. Bozikov K. Umbilicoplasty in abdominoplasty: a new approach. Strategies and options for free TRAM flap breast reconstruction in patients with midline abdominal scars. Allen RJ. Neoumbilicoplasty is a useful adjuvant procedure in abdominoplasty. Hartrampf CR Jr. Feingold RS. Hsieh F. Higgins JH. Plast Reconstr Surg 2010. Complications after microvascular breast reconstruction: experience with 1195 flaps. Abdominal wall competence in transverse abdominal island flap operations. Prada C. et al. Labow BI. Chernyak V. Cordeiro P. Israeli R. et al. Breast reconstruction with SGAP and IGAP flaps. 163. AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY 150. 126: 375–84. 151. Ashton MW. The single dominant medial row perforator DIEP flap in breast reconstruction: three-dimensional perforasome and clinical results. risk. 141. Peek A. Radiology 2009. 55: 531–8. Perforator number predicts fat necrosis in a prospective analysis of breast reconstruction with free TRAM. Comizio RC. O’Brien BM. Tram flap reconstruction. Mehrara B. 165. Hazani R. Mistry D. Aust N Z J Surg 1982. 145. Morrison WA. Interval inset of TRAM flaps in immediate breast reconstruction: a technical refinement. DIEP. Whitaker IS. Tanaka S. Chang DW. et al. 139. Mosahebi A. Is a second free flap still an option in a failed free flap breast reconstruction? Plast Reconstr Surg 2010. 138. Plast Reconstr Surg 2009. Reconstructing a natural looking umbilicus: a new technique. 144. et al. 118: 1100–9. Wong C. 116: 753–9. 27: 207–8. Ueda K. Bando M. discussion 760–1. 164. 159. Ensor J. Vlastos G. Allen RJ. 52: 174–82. Ann Plast Surg 2008. Arnez T. 60: 609–13. Aesthetic Plast Surg 2010. Markowicz MP. Ann Plast Surg 2010. Malata CM. Ann Plast Surg 2009. Boehmler JH. MacLeod A. J Plast Reconstr Aesthet Surg 2006. Lawler DL. 28: 417–23. Momiyama M. 250: 417–24. 157. Plast Reconstr Surg 2010. Schusterman MA. Martin NC. The internal oblique repair of abdominal bulges secondary to TRAM flap breast reconstruction. 162. The versatile latissimus dorsi myocutaneous flap in breast and other reconstruction. and SIEA flaps. Stella DL. Santoro TD. Bailey SH.0-T gadolinium-enhanced MR imaging for preoperative localization of abdominal wall perforators. discussion 10–1. Ann Chir Plast Esthet 2010. Fat necrosis in free DIEAP flaps: incidence. Phillips TJ. Kovach SJ. May JW Jr. Saint-Cyr M. 126: 739–51. Rozen WM. Sakaba T. Werdin F. 136. LoTempio MM. O’Donoghue JM. 34: 306–12. Prospective evaluation of late cosmetic results following breast reconstruction: II. Ann Plast Surg 2010. Granzow JW. 156. Butler CE. Selber JC. Fosnot J. Plast Reconstr Surg 2007. 166. 64:718–21. Microsurgery 2008. 126: 1142–53. Nelson J. 143. Thiessen F. Wu LC. 126: 2286–8. Breast reconstruction—some refinements of TRAM flap procedure. Chubb D. Chiu ES. 63:358–60. Kumiponjera D. and musclesparing free TRAM flaps on the abdominal wall: part I. Guihard T. Plast Reconstr Surg 2007. Dogan T. Falcou MC. 126: 393–401. Aesthetically pleasant umbilicoplasty. Plast Reconstr Surg 2005. 161. Greenspun DT. Umbilicoplasty for types of umbilical deformities. . Breast reconstruction with deep inferior epigastric artery perforator flap: 3. Katsuragi Y. Heller L. 153. J Reconstr Microsurg 2011. Arnez ZM. The role of the latissimus dorsi flap in reconstruction of the irradiated breast. Can J Plast Surg 2009. DIEP. Plast Reconstr Surg 2001. Hamdi M. Grosse F. Telischak KM. 65: 524–7. Ann Plast Surg 2006. Boehmler JH 4th. Ann Plast Surg 2010. Increasing the reliability of SIEA flap using peroperative fluorescent angiography with indocyanine green in breast reconstruction. Clough KB. Fitoussi AD. Skin banking closure technique in immediate autologous breast reconstruction. Newing RK. 64: 17–21. Iteld L. Rozen WM. Ardehali B. J Plast Reconstr Aesthet Surg 2009. et al. 125: 263e–4e. Pallua N. Arcilla E. Smit JM. Andrades P. Hertl K. Song DH. Aesthetic refinements and reoperative procedures following 370 consecutive DIEP and SIEA flap breast reconstructions: important considerations for patient consent. 21(Suppl 2): 249–54. Feledy JA. 152. Baumeister S. 107: 1710–16. An algorithmic approach to abdominal flap breast reconstruction in patients with pre-existing scars—results from a single surgeon’s experience. 120: 1133–6. Enajat M. Collins ED. Le Masurier P. 123: 773–81. Rozen WM. Kajikawa A. Painting the pedicle: a twist-proof marking method. 137. Breast reconstruction with gluteal artery perforator flaps. 148. Quilichini J. Stereotactic image-guided navigation in the preoperative imaging of perforators for DIEP flap breast reconstruction. and predictor factors. Georgiade GS. 62: 1650–60. 63: 138–42. 96: 100–4. A prospective study comparing the functional impact of SIEA. 140. Gan To Kagaku Ryoho 1994. Plast Reconstr Surg 1995. discussion 1110–11. 57: 366–9. The “banked” TRAM: a method to insure mastectomy skin-flap survival. Plast Reconstr Surg 2010. 154. Mehrara BJ. Kronowitz SJ. Superior gluteal artery perforator flap in bilateral breast reconstruction. Ann Plast Surg 2010. 149. Plast Reconstr Surg 2010. 12: 139–46. Levine JL. Plast Reconstr Surg 2010. Ann Plast Surg 2009. Breast reconstruction by the free transverse gracilis (TUG) flap. Selection criteria for expander/implant breast reconstruction following radiation therapy. Leinster S. 169. Planinsek F. Disa JJ. Successful prosthetic breast reconstruction after radiation therapy. Page AL. 189 172. Jugenburg M. Dickson MG. Radiation effects on the cosmetic outcomes of immediate and delayed autologous breast reconstruction: an argument about timing. Johnson EW. Cordeiro PG. Fosnot J. 168. Pusic AL. Cordeiro PG. An accelerated approach to tissue expansion for breast reconstruction: experience with intraoperative and rapid postoperative expansion in 370 reconstructions. Fischer JP. abstract v–vi. 111: 1871–5. Hawaii Med J 2009. et al. 170. 57: 481–2. Ahcan U. 60: 568–72. 171. Br J Plast Surg 2004. 68: 66–8. 60: 527–31. Arnez ZM. Radiation therapy and breast reconstruction: a critical review of the literature. Clin Plast Surg 2007. Bucky LP. et al. Percec I. 176. Schoeller T. Jackowe DJ. Wechselberger G. Pusic AL. James NK. Br J Plast Surg 2004. 173. Pogorelec D. 174. 59: 16–26. Robb GL. Song F. Plast Reconstr Surg 2003. Ann Plast Surg 2008. 124: 395–408. 127: 496–504. Javaid M. J Plast Reconstr Aesthet Surg 2006.OPTIMIZING LONG-TERM OUTCOMES IN BREAST SURGERY 167. . 175. Breast reconstruction by the free transverse gracilis (TUG) flap. 57: 20–6. Peters K. Parsa AA. Ann Plast Surg 2008. Does previous chest wall irradiation increase vascular complications in free autologous breast reconstruction? Plast Reconstr Surg 2011. 34: 29–37. Kronowitz SJ. et al. Carlson GW. Smartt JM Jr. Effects of radiation therapy on pedicled transverse rectus abdominis myocutaneous flap breast reconstruction. Impact of radiotherapy on breast reconstruction. Plast Reconstr Surg 2009. 1) or bilateral (Fig.17 Gynecomastia Gary Rose Gynecomastia is hypertrophy of the male breast and can be either unilateral (Fig. Of course this also assumes normal skin elasticity. there should be no problem with the skin envelope shrinking down and conforming to the shape of the tissue left beneath it. within a year or two. the surgery becomes much more extensive. varying from a segment type of excision. then it is essentially the same procedure as a lumpectomy. and if there is no major excess of skin. 17. The earliest record is attributed to Paulus Aeginata (3). If it is a small gynecomastia. who was a seventh century Byzantine physician. Pseudogynecomastia is seen with obesity and in the aging male. Most often it is quite benign and resolves uneventfully. Persistence of gynecomastia of 3 years or more occurs in up to 8% of pubertal males. not to be confused with pseudogynecomastia which is hypertrophy of fat contained within the skin envelope of the male breast. This hypertrophy is of the glandular tissue. or may progress to a complete subcutaneous mastectomy. If it is a large gynecomastia. The normal male breast contains a small amount of parenchymal tissue and fat. there is a parallel aromatic conversion of the free testosterone to estrogen from circulating aromatase. of 306 men. In the last few decades there has been a sharp rise in the number of cases of steroid-induced gynecomastia in body builders and athletes. or intraareolar incision. often extending from the clavicle to the 7–8 rib. There have been various techniques that have been described for the surgical correction of gynecomastia. Basically. or very fit older male. This was affirmed in a post-mortem study by Williams (2) of 447 men. With increasing levels of free testosterone. 17. and a resultant increase in the parenchymal tissue and ducts of the male breast. there was a 57% incidence of gynecomastia in males over the age of 44 years. Most utilize a periareolar. and sternum to anterior axillary line. This form of gynecomastia is much more fibrous than the nonsteroid-induced variety of gynecomastia. Over the centuries the technique has been reinvented and refined. Surgical excision has been described since antiquity. all of the surgical excision techniques have similar characteristics. However. no 190 . The causative agent is the ingestion. or injection of high doses of testosterone for the very effective anabolic effects. application.2). there is a parallel rise in the amount of free testosterone. a proliferation of the male breast tissue occurs in 50–65% of males during the pubertal years. It is also important to note that there is an extensive centrifugal growth of the parencymal tissue. In a study by Nuttall (1). With high levels of total testosterone. Then a local surgical excision of the gynecomastia tissue is completed. with an incidence of gynecomastia in 44%. In a young male. Most notable among these was the technique described by Webster (4) in the 1940s. (B) (A) (C) Figure 17.1 Unilateral gynecomasty.2 (A–C) Bilateral gynecomasty. .GYNECOMASTIA 191 Figure 17. In 1987. gynecomastia has its origin in the immediate subareolar glandular tissue. or exogenous causative agents. has been identified. post-operative bleeding and hematoma are AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY common occurrences after surgical excision. Correction of failed previous attempts of gynecomastia surgery is not an easy road to travel. Otherwise.) In addition to leaving 1 cm of tissue after the surgical excision. Occasionally the surgeon becomes a little too enthusiastic when excising excess skin. and will. and all. or has been unsuccessful. 17. Later refinements of instrumentation made this possible for others to utilize this technique with consistent results (8). then surgery is a realistic option. or with surgical tattooing. especially with exceedingly large gynecomastia. Infection with Gram negative organisms is not as common. Poor planning of the skin incision can lead to distortion of the areola. He terminated the case after completing a subcutaneous mastectomy of the left breast (Fig. except for a very limited skin incision of 2–3 mm. Alternatively. they must be dealt with. It appears that prevention is much more successful than reversal.3 exemplifies many of the problems discussed. Today.3 B). Bilateral . The use of aromatase inhibitors is gaining popularity in preventing the development of gynecomastia in aging males taking bioidentical hormone replacement therapy (bHRT) for andropause. To leave less of it will often lead to slough and resultant deformity of the areola. or deeper wound infection. lead to irregularities and deformities of the remaining skin and breast. Temourian and Pearlman (5). The skin was totally contracted and the areola had sloughed (Fig. This will often result in hypertrophic scarring. 17. the incidence of hematoma does not correlate with size. described limited liposuction of the male breast for gynecomastia. Tissue will be distorted. The addition of ultrasound enhanced skin shrinkage in patients with very large gynecomastia (9). But note. Most likely cellulitis will be secondary to Gram positive organisms that are susceptible to penicillin or vancomycin. As in preparation for all surgical procedures. If serious endogenous disease. which will result in saucer deformity. or improper understanding and actuation of perioperative instructions by the patient. I described the use of liposuction alone (7). This was combined with surgical excision of the gynecomastia tissue. Most will resolve spontaneously with time. scar tissue plentiful. the surgeon must be vigilant and compulsive in technique. Hypertrophic scarring is always a concern whenever skin is excised. a thorough workup is in order. Figure 17. The initial surgical excision was attempted by a general surgeon. The size of the hematoma correlates with the amount of parenchyma excised. Blood supply is not an issue. parenchymal excisions leave a potential space. surgical excision techniques do have a greater potential for recurrence than does liposuction techniques. for the correction of gynecomastia in all ages. blocking the conversion or testosterone to estrogen. This can be corrected by local excisions with advancement of the areola.and medium-sized gynecomastia. but can occur when unbalanced forces produced by asymmetric healing pulling the areola in unnatural directions. As you can easily see. poor closing technique can also result in excessive scarring. Any. Cellulitis can be successfully treated by warm compresses and utilization of the correct antibiotics. and the skin/areola will present in unusual ways. the organization of the clot and resultant fibrosis can. even with pressure dressings and drainage in place. If there is abscess formation. has had limited success in the correction of gynecomastia. as I previously published (10). As soon as hematoma is suspected. aromatase inhibitors. UNFAVORABLE RESULTS AND COMPLICATIONS As with all surgery. (One of the most important steps in the suction lipectomy for gynecomastia procedure is to use a spatulated cannula to scrape the underside of the areola to remove this glandular tissue. It is imperative to understand that the vast majority of pubescent males only require reassurance and understanding. Although very rarely seen after suction lipectomy for gynecomastia. The patient presented 6 months later with a huge deformity. In the 1980s. Wound infection can lead to irregularities of the skin. or previous surgery to the area. suction lipectomy is utilized more commonly for small. Slough of the areola can also occur. If the surgeon chooses to use surgical excision techniques. to determine the underlying cause. the surgeon must also very assiduously bevel the edges of the resection to prevent the areola from adhering unnaturally to the underlying pectoralis major muscle. and Courtiss (6). additional treatment with drainage is required. Hormone levels must be obtained as a baseline. it must be drained completely. If medical treatment is not an option. or surface contour of the breast. For older men. without any surgical cutting.192 history of trauma or radiation. he/she must leave behind 1 cm of subareolar tissue to maintain blood supply to the areola.3 A). and then is forced to close the skin with excess tension. However. Infection is the result of poor sterile technique. The reason that I first thought of utilizing suction lipectomy for gynecomastia was the unacceptable incidence of hematoma. This is not very common. Skin excision is limited to those cases where there is a large amount of skin redundancy. 3 Poor technique has resulted in excessive scarring. (A) Failed initial attempt by general surgeon to correct massive gynecomastia with subcutaneous mastectomy. (C) One year after correction with bilateral simple mastectomies and excision of excess skin.GYNECOMASTIA 193 (B) (A) (C) Figure 17. Areolae were created with tattooing. (B) Six months later. . There was no consideration of the excess skin. it is one of the most commonly performed male plastic surgery procedures today. (B) One year post-operation: the surgical correction was made with suction lipectomy without surgical resection (see also D for side view).194 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY (A) (C) (B) (D) Figure 17.3 C). seroma. Areolae were created with tattooing (Fig. and scar contractures were released in the left breast. there is a potential for hemorrhage.5). The other great advantage is that patients are able to return to full activities the day after surgery (Figs.4 and 17. In fact. fat necrosis. I strongly recommend the utilization of suction lipectomy.4 (A) A 42-year-old male: pre-postoperative view (see also C for side view). infection. mastectomies were then performed. 17. changes in sensation. 17. The public’s awareness of the availability of gynecomastia surgery has made tremendous strides forward. Although I have not seen these complications with suction lipectomy for gynecomastia. . and gross asymmetry. hematoma. Excess skin was excised from the right breast. It is easier and inherently carries with it much less risk of complication. GYNECOMASTIA 195 (A) (B) (C) (D) Figure 17. (B) One year post-operation: The correction was made with suction lipectomy.5 (A) A 19-year-old male with large tuberous gynecomastia. . No surgical excision was carried out (see also D for side view). Pre-operative view (see also C for side view). Rosenberg GJ. Philadelphia: Lippincott-Raven Publishers. 94: 548. ed. 9. 1848. External ultrasonic lipoplasty: an effective method of fat removal and skin shrinkage. 80: 379. Gynecomastia as a physical finding in norrmal men. Surgeryfor gynecomastia. Gynecomastia. 48: 338. recognition and host characterization in 447 autopsy cases. 105: 785.196 REFERENCES 1. Translated from Greek by Francis Adams. Courtiss EH. 79: 740. AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY 6. Pearlman R. 7. Cabrera RC. J Clin Endocrinol Metab 1979. Gynecomastia: its incidence. Rosenberg GJ. Mastectomy for gynecomastia through a semicircular intra-areolar incision. Gynecomastia: analysis of 159 patients and current recommendations for treatment. Plast Reconstr Surg 1994. 1998: 831. section 46 London: London Syndenham Society. Surgery of the breast: principles and art. Aeginata P. Rosenberg GJ. 8. 10. 3. Ann Surg 1946. 34: 103. Plast Reconstr Surg 2000. Webster JP. . 5. 2. Gynecomastia: suction lipectomy as a contemporary solution. Nuttall FQ. 4. vol 2. Aesthetic Plast Surg 1983. book 6. Teimourian B. Plast Reconstr Surg 1987. Plast Reconstr Surg 1987. The Seven Books of Paulus Aeginata. Williams MJ. 124: 557. Rosenberg GJ. Am J Med 1963. A new cannula for suction removal of parenchymal tissue of gynecomastia. 7: 155. In: Spear SL. 197 . (2) practice expense. In the mid 1980s Medicare contracted with Drs Hsaio and Braun at Harvard to create a cross-specialty resourcebased relative value scale. preoperative visits the day of or day before surgery. organized medicine. Because of the wide diversity of physicians’ fees for the same service. eliminating fee based payments. In three different phases the Harvard study valued services for 33 different specialties. These groups were charged with determining the services performed within their specialty and then develop surveys used to value and rank the various services.18 Breast reconstruction CPT coding Keith Brandt and Scott Oates No discussion of CPT coding is complete without at least a basic understanding of the Resource Based Relative Value Scale (RBRVS) system. The AMA was subcontracted to act as a liaison between the Harvard researchers. physician payments were based on usual and customary charges from physicians. services provided by the surgeon within 90 days of the surgery that do not require a return trip to the operating room and follow-up visits provided during the 90 days that are provided by the surgeon and are related to the surgery. The Omnibus Budget Reconciliation Act of 1989. established a resource-based relative value scale for physicians. For the first 25 years of Medicare. and (3) medical liability expense. other than Medicare. Medicare paid markedly different amounts for the same service. In 1991 Center for Medicare and Medicaid (CMS) defined the specific services included in the global surgical package.” All medical specialties are represented at the RUC and the process still involves surveys completed by physicians who perform that service (1). Even though insurance carriers. attempting to relate the magnitude and intensity of services across specialties. the operation itself. It is not a payment schedule. The Harvard-produced RBRVS was used as the initial scale but has been modified extensively since then. the conversion factor used is negotiable. uncomplicated follow-up). To maintain the RBRVS system the AMA set up the RBRVS Update Committee affectionately know as the “RUC. Readers should understand that the RBRVS is only a scale. The AMA worked with national societies to create Technical Consulting Groups within each specialty. may use the RBRVS. These services include. GLOBAL PERIOD The value assigned to any CPT code includes three parts: (1) the physician work (including the immediate preoperative care. and normal. Medicare determines the amount it will pay for procedures by multiplying the relative value from the RBRVS times a conversion factor which is adjusted each year to maintain budget neutrality as mandated by congress. intra-operative services that are normally a necessary part of the procedure. and practicing physicians. Initial Evaluation by the Surgeon The surgeon’s initial evaluation or consultation is considered a separate service from the surgery and is paid as a distinct evaluation and management (E&M) service. these services are paid separately from the global surgical amount. These services include: • • • • dressing changes local incisional care removal of operative packs removal of cutaneous sutures. Strattice® and Surgimend®) use codes 15430 and 15431. then add 15331 (acellular dermal allograft. elevation of the pectoralis major and serratus anterior muscles. If some type of additional acellular dermal allograft (such as AlloDerm®) is placed at the time of the tissue expander. Modifier 78 is used to identify a related procedure that requires an unplanned return to the operating room. When the decision is made prospectively or at the time of the first surgery to perform a second procedure. includes creation of the expander pocket. Implant-based Breast Reconstruction Preoperative Visits with the Surgeon Postoperative Services by the Surgeon The global surgery package typically includes a postoperative period of 90 days during which no separate payment is made for the surgeon’s visits or services. allografts and xenografts. does not require a return trip to the operating room. use the E&M code and bill for the supplies separately. is being revised and new codes should be available in 2012. When the patient undergoes the second stage procedure to exchange the tissue expander for a permanent implant. If the decision to perform a major surgery (surgical procedures with a 90-day global period) is made on the day of or the day prior to the surgery. Complications Following Surgery BREAST RECONSTRUCTION If a patient develops a complication following surgery that requires additional medical or surgical services but.g. trunk. Modifier 57 (Decision for Surgery) is used to indicate an evaluation and management (E/M) service that resulted in a decision to perform surgery. placement of the tissue expander. . the complication requires a patient’s return to the operating room for a medically necessary service. however. comply with hospital rules for an H&P.198 Previously. some carriers bundled the initial evaluation into the global package if it occurred within the week prior to the surgery. utilizing the appropriate E&M code. and removal of urinary catheters • routine peripheral intravenous lines and nasogastric and rectal tubes • change and removal of tracheostomy tubes All E&M services performed during the postoperative global period are not billable unless the E&M services are Immediate placement of a tissue expander at the time of mastectomy remains the most common procedure performed for breast reconstruction. tubes. . then they can be billed for separately. staples. Full payment for all procedures is allowed for situations when distinctly separate but related procedures are performed during the global period of another surgery. cm of AlloDerm® is utilized. and to answer any remaining questions for the patients are included with the global surgical package. if performed. It also includes all of the postoperative expansions during the 90-day global period. and splints • insertion. acellular dermal replacement grafts. In contrast. Currently the code for placement of AlloDerm® is 15330 (acellular dermal allograft. If the expansions extend beyond the 90-day global period. cast. these services are considered part of the global surgical package. These services are paid separately by appending modifier 24 (unrelated evaluation and management service by the same physician during a postoperative period) to the appropriate level of E&M service and submitting the appropriate documentation. filling of the expander at the time of the procedure. the surgeon should identify the need for additional staged procedures and the approximate time those procedures can be expected. lines. first 100 sq. the reason the value of this code approaches some of the flap procedures is because of the large number of postoperative visits included with this code. cm). irrigation. If xenografts are utilized (e. the section on. Instead. cm or less). separate payment is allowed for the visit at which “the decision to perform surgery” is made if adequate documentation is submitted with the claim. trunk . this is coded separately. modifier 58 (staged or related procedure by the same physician during the postoperative period) should be reported. each additional 100 sq. assuming that the evaluation and decision to perform surgery had been made at a previous visit. wires. If. There is no separate CPT code for in-office filling of a tissue expander. AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY performed for a diagnosis which is unrelated to the surgery that was performed. In the initial operative report. drains. . and closure of the mastectomy incision. The CPT code for this procedure 19357. Be alert. modifier 79 is used to identify a procedure that requires a return to the operating room during the global period that is unrelated to the procedure performed that initiated the 90-day global period. Staged Procedures Preoperative visits with the surgeon the day before or the day of surgery to obtain consent. In fact. If more than 100 sq. You can only use the code once no matter how many vessels you repair using the microscope. 19342. however. All of the components of the procedure. then use codes 11970 and 19371 (periprosthetic capsulectomy). If additional arteries or veins are anastomosed then this extra work can be coded using the vessel repair code 35206 (repair blood vessel. Code 19367 describes the procedure for breast reconstruction utilizing a single pedicled TRAM flap. in reconstruction) (2). in reconstruction) to the latissimus flap code. Check with your carriers as to how they would like this additional procedure to be coded. transfer to the breast defect. 19361. upper extremity). If a permanent implant is being placed at the time of mastectomy or in a delayed fashion. (Table 18. are coded with 19364. microvascular anastomoses of one artery and up to two veins. The work of elevating the muscle is included in the codes 19340. trunk. which is not done routinely. TUG. Sup/Inf gluteal artery flaps etc. Some payers may not allow the coding of 11970 together with 19370 and instead prefer that the procedure be coded with 19342 (delayed insertion of breast prosthesis . This code includes elevation of a muscle or myocutaneous flap. 19367-58. a more substantial procedure is performed to reset the inframammary crease by advancing the upper abdominal tissues. DIEP. 19364 is appropriately valued relative to procedures in other specialties. 14001. direct. Because of the more 199 extensive defect to the abdominal wall fascia with the double pedicle procedure. insetting and closure of the donor site is included in the code (3). and also the breast tissue expander code 19357. then this is considered a Ryan flap and is coded with 14001 (adjacent tissue transfer. exists for breast reconstruction utilizing a latissimus myocutaneous flap. . Again. Previously this code included placement of an implant. Closure of the donor site with mesh is not included and can be coded separately. If a significant number of capsulotomies are performed to reposition the permanent implant. Poll your most utilized providers preoperatively to determine their desired coding preference. would also be appropriate for an internal Ryan procedure if this included elevation and advancement of abdominal tissues and insetting at the new inframammary fold (2). intrathoracic) involves a thoracotomy. code 11970. add the -59 modifier to indicate separately billable work. Autologous Tissue Breast Reconstruction A separate code.BREAST RECONSTRUCTION CPT CODING the appropriate code is 11970 (replacement of tissue expander for a permanent prosthesis).1) (4). While everyone would certainly like to receive more payment for the work they do. All of the vessel repair codes are macrovascular. the use of mesh to help close the abdomen is included with code 19369. . If. If both inferior epigastic arteries are ligated then use 15600 twice (3). . If a new inframammary crease is created at the time of the tissue expander exchange for a permanent implant and this is done with capsular plication. upper extremity). Harvesting of the flap. 10. If a double pedicle flap is used then the code is 19369. elevation of the pectoralis or serratus muscle does not constitute a “muscle flap” as described in 15734. The mesh code is an add-on code specifically linked to the hernia codes so a letter of explanation may be required. not microvascular procedures and therefore the surgeon must indicate that the procedure was performed using microsurgical techniques by appending the 69990 code. . immediate . direct. cm to 30. closure of the donor site and insetting of the flap. If a TRAM flap is delayed the correct code to use is 15600 (Delay of flap or sectioning of flap (division and inset). insetting of the flap and closure of the donor defect. whether used for breast reconstruction or otherwise are inherently microsurgical and one should not add the 69990 code to microvascular flap codes.0 sq. together with 19370 (periprosthetic capsulotomy). cm). Also add code 69990 (use of the operating room microscope). If a tissue expander is placed. Code 35206 should be used for both internal mammary and thoracodorsal vessels. The local advancement flap. are included in the code. The work to expose and perform anastomoses with the internal mammaries is much closer to work depicted by 35206. harvest of the flap. If vein grafts are needed these can be coded separately with code: 35236 (Repair blood vessel with vein graft. but this separate service was separated from the code in 2009. Do not use 19367-59 as this grossly overestimates the work performed. Another concern heard frequently is that the value of 19364 does not take into account the extra work involved . All microvascular flaps.1 sq. Since the subsequent TRAM flap breast reconstruction will occur within the global period of 15600 (90 days) modifier -58 (staged or related procedure by the same physician) should be added to the TRAM code. code 19357 together with the -59 (separately reportable procedure) modifier to indicate that both the latissimus flap and the tissue expander were used to reconstruct the same breast. Now if a permanent implant is placed at the time of the latissimus flap then add code 19340 (placement of an implant. Many people continue to express their discontent regarding the value of 19364. if the expansions continue beyond the 90-day global period they may be billed for separately using the appropriate E&M code. transfer to the breast defect. Code 35316 (repair blood vessel. All microvascular flap breast reconstructions: TRAM. Muscle Sparing TRAM. transfer of the flap to the breast defect. at trunk). The use of mesh is not included with a single pedicle TRAM and therefore can be coded separately with code 49568 (3). 0 10. If dog ears require resection at the ends of a TRAM scar and are closed in layers. CMS makes the final decisions regarding the values for codes recommended by the RUC. use the code 19380 (revision of reconstructed breast).58 42.88 40.424 6. Nipple Reconstruction The nipple/areola reconstruction code 19350. Symmetry Procedures If breast reduction is performed on the contralateral side for symmetry it should be coded with 19318 (reduction mammoplasty).6 100. especially in the area cephalad to the reconstructed breast where the mastectomy continued beyond the reconstruction. Poll your insurance carriers about which method they prefer. cm. and nipple/areola preservation whether it is done by pedicle technique or amputation and grafting. was created back at the time when it was common to reconstruct the nipple with a skate flap and at the same time construct the areola with a skin graft usually harvested from the thigh.8 5. This code includes parenchymal reduction.1–20 sq. cm). CPT 33534 20955 15842 33405 32851 19364 20802 33512 Descriptor Work RVU CABG arterial x 2 Microvascular fibular transfer Functioning neurovascular muscle tx Aortic valve replacement Lung transplant Microvascular TRAM Arm replant CABG arterial x3 39. capsulectomies (use 19371). it consistently insists that changes in values of codes within families of codes remain neutral. supplemental liposuction. intra-dermal . breast lift.14. instead of using two separate codes. The leadership of the payment policy committee of the American Society of Plastic Surgeons has concluded that until DIEP flaps constitute a greater percentage of breast reconstructions the risk of reductions for the majority of breast procedures is too great. each additional 20 sq. Do not use 19380 to code for scar revisions of the mastectomy or reconstruction scar (use 1310X. Fat grafting is coded with code 20926 which includes: harvest of the fat graft. Many surgeons now reconstruct the nipple alone and then latter color the nipple and create an areola with tattooing techniques. The standard 5 cm areola is 19. Append the -59 (separately identifiable procedure) modifier.327 4. processing of the fat.1 Listing of work RVU’s from Current Procedural Coding 2011.2 Statistics. that instead of reducing 19350. Thus any shifting of value to a new DIEP flap code would result in a reduction of the values of all the other codes in the breast reconstruction family. If liposuction is used to modify a reconstructed breast.98 Table 18.097 56. Most insurance companies consider this a cosmetic code and do not recognize its use in reconstructive procedures. The code is not site or volume specific. Do not use the liposuction code 15877.5 cm) and π is 3. replacement of an implant for a different size (use code 19340) when these procedures are performed alone. If separate anatomic areas are treated then code 20926 for each area. use code 19350 with the -52 (reduced services modifier).978 9. .26 41. two thirds of all breast reconstructions are performed with a tissue expander. To determine the square centimeters.62 sq. Some insurance carriers may prefer. 6.2) (5). it may be appropriate to use code 19380. Reconstruction with a DIEP flap constitutes only 5% of all reconstructions. The relative value of 19350 includes the work of reconstructing both the nipple and areola. use the formula A = π r2. the value of the code will stand for both nipple creation and tattooing.598 86. It is true that 19364 does not distinguish between a standard microvascular TRAM flap and a DIEP flap. . complex closure).61 42. When performed together on the same reconstructed breast.1 7.200 AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY Table 18.0 in a deep inferior epigastric artery perforator (DIEP) flap.62 43. Fat grafting is sometimes recommended to help correct contour defects.) 11922 (tattooing. Later when the tattooing is performed use the tattoo codes 11921 (tattooing. ASPS 2009 Procedural Procedure Implant alone Tissue expander TRAM DIEP Latissimus flap Total Total % 9. .01 41. use the resection codes (1140X) together with the intermediate closure codes (1203X) (6). cm. If liposuction is used alone. where r is the radius (usually 2. If large areas of the same breast are injected it may be better to use the code 19380 (breast revision) to adequately describe the work involved (7). nipple/areola repositioning.5 66. intradermal . trunk). injection of the fat. use code 15877 (suction-assisted lipectomy.32 41. .424 10. To code for nipple reconstruction alone. Because CMS must by law remain budget neutral. closure of the harvest and injection sites and 90 days of postoperative care. . The reason that a separate code for the DIEP flap has not been pursued is because of the negative impact this would have on all the other codes in the breast reconstruction family. According to American Society of Plastic Surgeons 2009 statistics (Table 18. code changes and the proper use of current codes. Plastic Surgery News 2009. IL: American Medical Association. Coding fat grafting procedures is straightforward. Holden K.BREAST RECONSTRUCTION CPT CODING Partial Mastectomy Defect Reconstruction Breast cancer surgery. Working with CPT code 19380 need not be confusing. Despite this. Breast Reconstruction Coding: Everything (almost) you need to know. 4. If an implant is required to restore significant volume loss then this is coded with 19340 (immediate placement of an implant in reconstruction (8). REFERENCES 1. results in defects that can be closed with straightforward layered closures all the way up to complete mastectomy defects. Chicago. Plastic Surgery News 2009. eds. Understand that all extirpative procedures include a straightforward closure. skin rearrangement. Medicare RBRVS – The Physician’s Guide 2007. Numerous societies including ASPS give coding workshops throughout the year. pg 10. Partial Mastectomy defect reconstruction requires coding accuracy. pg 12. Janevicius R. the vast majority of this information comes from CPT coding articles written by Dr Raymond Janevicius and printed in Plastic Surgery News. If the patient wants a plastic surgeon to close the wound after a procedure then that is cosmetic and should be handled accordingly. . Clarifying Breast Surgery Coding Confusion. 5. The interested reader is encouraged to review this valuable resource for additional information. it is prudent to obtain in writing pre-authorization from the insurance carrier prior to 201 performing surgery. If the defect is more than a quadrant but less than a total mastectomy and significant work to reshape the breast then code 19366 (breast reconstruction with other technique) may be appropriate. Janevicius R. Smith SL. The American Society of Plastic Surgeons produces a monthly newsletter that contains valuable information on. Arlington Heights. 2010. IL. 2010 Report of the 2009 Statistics. 8. 7. The coding of partial mastectomy defects is particularly challenging. then it is coded with the complex closure codes 1310X. Gabbert W. The world of CPT coding is constantly changing and the reader is encouraged to stay informed and up to date. If the breast defect is closed with standard breast reduction techniques (preservation of the nipple on a pedicle.” The Women’s Health and Cancer Rights Act of 1998. Plastic Surgery News 2011. Insurance carriers will review this code routinely and clear documentation of the extra work involved should be included in the op note. new codes. National Clearinghouse of Plastic Surgery Statistics. 2007. Canter KV. cm 14300. ACKNOWLEDGMENT Although supplemented with over 15 years of experience on the ASPS Payment Policy committee. Janevicius R. These courses include numerous tips on ethical coding and they just might produce enough extra reimbursement to pay for the trip. parenchymal reduction. If new incisions must be made in the breast skin. Kachur KH. then again use the code 19366. If the breast resection is less than a full mastectomy but the breast is reconstructed with standard mastectomy reconstruction techniques (tissue expansion. flaps) then code for that reconstructive procedure without code 19366. If a large lumpectomy or quadrantectomy defect requires significant “undermining” of tissues to achieve closure. 3. ed. tissue or both then this constitutes an adjacent tissue transfer and is coded with 1400X or if greater than 30 sq. American Society of Plastic Surgeons. Janevicius R. Janevicius R. 2011: Ingenix. mandates coverage for reconstruction of the breast after mastectomy and procedures on the contralateral breast for symmetry. Current Procedural Coding Expert. if the procedure is denied. Plastic Surgery News 2009. The ICD-9 code should include “breast neoplasm. Plastic Surgery News 2007. This will help avoid the frustration of multiple appeal letters. 6. 2. . 167 implant selection. 148. 167 patient education. 83 Biologic implants. 94 Acellular dermal matrix (ADM). 21–22 tissue expanders. 180 Abdominal wall morbidity. 3 BCS. 6–7 Breast anatomy brassiere cup size and reduction volumes. 179 Aberrant glandular tissue. 38 Brachial plexus. 82 Athelia. 47 innervation. 172–174 Allergan. 88 AlloDerm®. 48 and Poland syndrome. 3 microscopic anatomy. 63 ADM. 148–149 Artificial bone. 22–23 blood supply to. 11 Accelerated partial breast radiation (APBI). 3 parenchyma. 174 radiation therapy. 82 American Society of Plastic Surgeons. 167 incision type. 4 lymphatic drainage. 182–183 Amasia. 158. 166–167 breast reconstruction alternate free flaps. 18 American Diabetes Association. 8 pre-operative considerations. 156 Autologous tissue breast reconstruction. 1–2 hypertrophy. 26–28 Bilateral prophylactic mastectomy. 177. 74–76. See Acellular dermal matrix Adult onset hypertrophy. 200–201 Anterolateral thigh (ALT) flap. 128. 177 ALNs. 117. 11 American Cancer Society (ACS). 97. 190–191 203 Bilateral hypomastia. 177 latissimus dorsi and implant. 50. 49 innervation. 11 Amastia. 199–200 Autoplastic flap. 29–34 Bilateral macromastia. 9–10 Accolade. 198 Allomax™. 95. 47. 5–6 Axillary lymph nodes (ALNs). 170–172 implant pocket plane effects. See Axillary lymph nodes Alternate free flaps. 48–49 vessels and lymphatics. 182–183 autologous tissue. See Breast Imaging Reporting and Data System Blunt Seroma Cath®. 131 Bilateral gynecomastia. 36 Beveling. 16 American College of Radiology (ACR). 157–159 Autologous fat grafting. See American College of Radiology ACRIN. See Breast conservation therapy Benign breast tumor. 177 ACR. 7 patient selection. 48 augmented.Index Abdominal flap necrosis. 13. 12 reconstructed. 69 Accessory breast tissue. 178–181 biologic implants. 7 external anatomy. 3–4 and chest wall. 168–169 optimal planning on tissue assessment. 109 Axilla. 16. 174–177 skin envelope. See Accelerated partial breast radiation Areolar reconstruction technique. 148 Aspirin. 11 Augmented breast. 18 American College of Radiology Imaging Network (ACRIN). 22–23 Autologous breast reconstruction. 48 shapes and landmark measurements. See Breast conserving surgery BCT. 7 surgically altered. 16. 47 Aesthetic breast surgery breast augmentation complications. 38 surgery initial evaluation. 134–135 APBI. 177 BIRADS. 149–150 Artecoll. 87. 183 tissue expanders and implants. 96 Bostwick ptosis classification. 23–24 reduction (see Reduction mammoplasty) skin ptosis. See American Cancer Society Adipose tissue flaps. See American College of Radiology Imaging Network ACS. 181–182 principles. 87–89 . 198 preoperative visits. 171 double bubble deformity. See Clinical and Radiographic Poland Syndrome Deep inferior epigastric artery perforator (DIEP) flap anatomic dissections. 119–120 CPT coding. 33–34 and breast ptosis. 135–136 Rubens flap. 82 Hyperplastic breast disorders. 34 Breast augmentation complications asymmetry. 69 partial reconstruction techniques. 149 Double bubble deformity. 28–29 juvenile macromastia. 117–118 indications. 13–14 Contour deformities. 200 general surgical complications. 170 secondary deformities. 157–158 breast and abdominal aesthetic complications. 197 Chest wall anatomy of. 170 capsular contracture. 47 Gigantomastia. See Internal mammary artery IMF. ptosis. 198 implant-based breast reconstruction. 53–54 Free tissue grafts. See Center for Medicare and Medicaid Color duplex ultrasonography. 110 Delayed reconstruction. 158. 94 Circumareolar scar technique. 110 Comorbid medical conditions. See Superficial inferior epigastric artery Free flaps anterolateral thigh flap. 68 Dermal flap. 5 Clinical and Radiographic Poland Syndrome (CRPS). 12 Clopidogrel. 168–169 management strategies. 110–111 Hematoma. 162 principles. 125–126 superior gluteal artery perforator flap. 110. 118–119 performance. 68–69 immediate reconstruction. 155–156 neoadjuvant chemotherapy. 73 timing of reconstruction delayed reconstruction. 4 tuberous breast deformity. 28 bilateral. 132–134 inferior gluteal artery perforator flap. 43 Chloramex®. 170 infection. 11–13 Iatrogenic hypertrophy. 172 Double pedicled flaps. 43 Dermalive. 54–55. 93–95. 28 preoperative. 167 patient education. 94 Gestational hypertrophy. 73. 132–134 Gynecomastia bilateral. 177 INDEX Capsulectomy. 12 Chiari-standardized geometric pattern. 21–22 Calcium hydroxyapatite. 198 staged procedures. 144–147 Dual chamber tissue expander. See Inframammary fold . 26 unilateral hypomastia and contralateral adequate volume. 66 radiotherapy techniques. 179 benign tumor. 18. 198 symmetry procedures. 88 Fat grafting. 44 Calcifications. 4 and breast. 87 Capsular contracture. 130–132 postoperative management. 29–34 unilateral. 171. 44 Free abdominoplasty flap. 192–193 suction lipectomy. 82 Congenital breast disorders embryology. 96. 170 Homeopathic medications. 190–191 Halstead’s ligament. 194–195 unilateral. 134–135 DIEP flap (see Deep inferior epigastric artery perforator flap) gracilis myocutaneous flap. 20–21 BSGI. 148 Cancer surveillance. 66–68 reduction mammoplasty. 176 Cooper’s ligaments. 68 immediate-delayed reconstruction. See Benign breast tumor Flex HD™. 47 Hypomastia bilateral. 9 hyperplastic disorders. 159–160.204 Breast asymmetry aesthetic breast surgery. 111–113 microsurgical complications. See Breast hypertrophy Gracilis myocutaneous flap. 26–28 inadequate contralateral volume. 9–11 hypoplastic disorders. 159–161 optimal planning on tissue assessment. 5 Hartrampf perfusion zones. 166–167 Breast conservation therapy (BCT) complications of. 120–121 breast and abdominal technical complications. 110–111 venous drainage. 69–76 patient selection. 201 postoperative services. 76–78 management strategies. 179 Fibroadenoma. 36 and bilateral hypomastia. 170 implant malposition. 68 Breast conserving surgery (BCS). 82 CMS. 167 incision type. 47 IMA. 172 hematoma. 161 Cartilage grafts. 29–33 and bilateral hypomastia. 95–96. injectable. 9–11 Hypertrophic scarring. 57 Breast-specific gamma imaging (BSGI). 197–198 nipple reconstruction. 192–193 Hypertrophy. 134–135 superficial inferior epigastric artery flap. See Breast-specific gamma imaging Cadaveric acellular dermal matrices. 200 partial mastectomy defect reconstruction. 41 Clavipectoral fascia. 172 implant size. 11–13 management of complications. 177 Flowes-Smith modified Wise incision. 200 CRPS. 134–135 TRAM flap (see Transverse rectus abdominis myocutaneous flap) Free nipple grafting. 198–199 initial evaluation. 69 reconstruction following. 111 autologous reconstruction. 126–130 thoracodorsal artery perforator flap. 48 CPT coding autologous tissue breast reconstruction. 63. 199–200 complications following surgery. 190–191 hypertrophic scarring. 170–171 implant pocket plane effects. 34 Hypoplastic breast disorders. 113–117 perfusion zones. 56 Breast Imaging Reporting and Data System (BIRADS). 162. 147–148 Fucidin®. 171 wrinkling and rippling. 34–35 and macromastia adequate contralateral volume. 200 Fat necrosis. 7 and Poland syndrome. 167 implant selection. 148 Center for Medicare and Medicaid (CMS). 95 Implant malposition. 88 Methylene blue dye. 83 Omnibus Budget Reconciliation Act. 173–174 breast reduction. 142–143 star flap techniques. 160 Infection. 48 Macromastia and adequate contralateral volume. 41 Periareolar scar technique with asymmetrical areola shape. 148 soft tissue fillers. 68–69 Immediate reconstruction. 161–163 Marcah arched gateway incision. 11 Juvenile gigantomastia. 83 Nicolle modified Wise incision. 63 purpose of. 43 Lumpectomy. 147 nipple sharing. 176 Inferior gluteal artery perforator (IGAP) flap. 28 juvenile. 172–173 scar widening. 157–159 breast augmentation. 159–161 breast conservation therapy. See Oncoplastic surgery Over-reduction. 41–42 Lateral perforators. 69–76 Pectoralis fascia suspension. 69 post-mastectomy reconstructive surgery. 172 procedure selection. 162 Partial mastectomy defect reconstruction. 40–41 circumareolar scar technique. 150–153 techniques areolar reconstruction. See Clopidogrel Pneumothorax. 64 oncologic complications. 4 Latissimus dorsi flap. 4–5 Pectoralis muscle slings. 74. 34–35 Lassus technique. 149–150 autologous fat grafting. 53 Lobular carcinoma in situ (LCIS). 58 Oncoplastic surgery (OPS) cosmetic complications. 119 Poland syndrome. 147–148 local flaps. 18–20 Musculoskeletal thoracic wall. 40–41 circumareolar scar technique. 43 Non-steroidal anti-inflammatory drugs (NSAIDs). 38 vertical scar technique. 147 L-shaped scar technique. 11 Polythelia areolaris. 9. 162 Nipple sharing. 198–199 Implant displacement. 176 Permark micropigmentation system. 37. 97. 9–10 Polymethylmethacrylate. 148–149 Polythelia. See Lobular carcinoma in situ Lejour modified Lassus’s technique. 173 patient selection and informed consent. 45 Nipple–areola complex (NAC) reconstruction anatomy errors in timing of surgery. 28 bilateral. 179 Michigan Breast Reconstruction Outcome Study. 95 necrosis. 43–45 Ipsilateral nipple. 179 Mastopexy aesthetic breast surgery augmentation mastopexy. 93. 102–103 complications. 57–63 OPS. 144–147 free tissue grafts. 38–39 inverted-T scar technique. 130–132 Inframammary fold (IMF). 139 secondary procedures. 4 Myocutaneous latissimus dorsi flaps. 103 surgical technique. 43 markings. 43–45 L-shaped scar technique. 162–163 MammoSite applicator. 39 periareolar scar technique with asymmetrical areola shape. 119. 201 Partial mastectomy defects. 106–107 patient selection. 155 reduction mammoplasty. 161. 110–111 Periareolar purse string closure mastopexy. 2 Internal mammary artery (IMA). 106 preoperative marking. 68 Implant-based breast reconstruction. 172 205 hypertrophy. 34–35 Malposition. 174 goals. 102 postoperative care. 156–157 general considerations. See Juvenile macromastia Juvenile macromastia. 11–13 Polymastia. 96. 38 preoperative assessment. 40–41 physical examination. 141 patient selection.INDEX Immediate-delayed reconstruction. 110 Lateral thoracic artery. 4 Inverted-T scar technique. 44 Plastic surgeons. 200 principles of. 148 double pedicled flaps. 82 NSAIDs. 68–69 Lymph nodes. 43 pedicled Transverse rectus abdominis muscle (TRAM) flap anatomic considerations. 141. 170. 7 Plavix. See Positron emission mammography Perfusion zones. injectable. 43 Pectoralis major. 110 Mentor CPX3 profi led expander. 197 Oncoplastic algorithm. 155–156 expanders and implants with BCT. 63 Natrelle expander. 140 malposition. 41–42 Medial perforators. 26–28 and inadequate contralateral volume. 41 with symmetrical areola shape. 148 Nipple necrosis. 148–149 Nipple banking. 92–93. 11 . 140 skate flap techniques. 172 Implant rupture. 45 Mastectomy flaps ischemia. 41–42 Liposuction. 63–64 techniques of. 40–41 Periprosthetic infection. 41 with symmetrical areola shape. 45 PEM. 139 qualitative benefits. 83 Local flaps. 69–70 Management strategies autologous reconstruction. 181 LCIS. 176. See Non-steroidal antiinflammatory drugs Obesity. 88 Neoadjuvant chemotherapy breast conservation therapy. 103–106 Peixoto ellipse-rectangle incision. 63 Myosubcutaneous latissimus dorsi flaps. 38 ptosis classification. 173 complications. 148 cartilage grafts. 150 Pitanguy inverted-T incision. 4–5 Pectoralis minor. 199 MRI breast imaging technique. 148 Non-absorbable mesh. 56–57 surgical complications. 143–144 CPT coding. 182 Latissimus dorsi musculocutaneous flap. 99 Microvascular flap breast reconstructions. 88 Sapphire Suction Reservoir™. failure. 96 hematoma. 96 X-ray mammography. 90 patient selection. 174–177 Tissue expansion reconstruction complications capsular contracture. 50–52 Regnault-B shaped pattern. 73 complications. 161–163 INDEX surgical techniques vertical scar. 83 smoking. 90–92 immediate vs. 41–42. 136. 142–143 Skin necrosis. 88. 82 Soft tissue fillers. 16–18 RBRVS. delayed reconstruction. 88. 96 Volume ptosis. 97–99 insufficient skin and subcutaneous tissue. 13–14 Ultrasound. 53 Wise pattern. 83 Profiled tissue expander. 23. 54–55 free nipple grafting. See Resource Based Relative Value Scale Reconstructed breast. 20–21 MRI technique. 38 inadequate in tissue expansion reconstruction. 48 shapes and landmark measurements. 99 Radiesse. 99 Transverse rectus abdominis myocutaneous (TRAM) flap. 96 Singulair. 148 Radiologic evaluation augmented breast. 110. 33–34 classification. 120–121 breast and abdominal technical complications. 18–19 X-ray mammography. 82 Tatooing. 117–118 indications. 38 Positron emission mammography (PEM). 38 Volume replacement surgery. 43 Regnault traditional ptosis classification. 143–144 Strattice®. 94 Star flap techniques. 88 Rubens flap. 201 Wound dehiscence. 9 Surgically altered breast. 125–126 Superior gluteal artery perforator (SGAP) flap. 44 Women’s Health and Cancer Rights Act. 82 physical examination breast exam. 49–50 liposuction. 82–83 medications. 113–117 perfusion zones. 63. 18–20 positron emission mammography (PEM). rupture. 83 radiation. non-stretchable skin envelope. inverted-T. 180–181 Unilateral gynecomastia. 49 innervation. 63 Skin paddles. 44 Suction lipectomy. 21–22 Surgimend®. 161 Superficial inferior epigastric artery (SIEA) flap. 28–29. 94 Thoracodorsal artery perforator (TAP) flap. 97 radiated. 92–93 Superficial infections. 95–96 implant displacement. 171 Seroma. 97 ptotic breast. 111–113 microsurgical complications. 109 Vertical scar technique. 18–19 Umbilical deformities and necrosis. See Juvenile macromastia Virginal hypertrophy. 92–93 Staphylococcus epidermidis. 119–120 general surgical complications. 48 in breast conservation therapy. 10–11 Supranumerary nipples. 141 Smoking. 97 Pseudogynecomastia. 23–24 surgically altered breast. 97. 94 Skate flap techniques. 16–18 . 95. 53 Virginal breast hypertrophy. 194–195 Superficial cellulitis. 118–119 nomenclature and classification. 148–149 SPAIR (short scar periareolar inferior pedicle reduction) mammoplasty. 53 management strategies. 92–93 mastectomy flap ischemia. 96 Scarring. 47 Visible rippling. 53–54 indications. 60 Radiation oncologists. See Hematoma SIEA. 22–23 breast-specific gamma imaging (BSGI). 100 inadequate ptosis. 84 donor sites. See Superficial inferior epigastric artery Sientra dual chamber expander. 48–49 vessels and lymphatics. 23–24 Reduction mammoplasty breast anatomy brassiere cup size and reduction volumes. 93–95 expander deflation. 95 infection. 87–89. 38 Resource Based Relative Value Scale (RBRVS). 83–84 chest wall. 97–99 Racquet mammoplasty. 20–21 Post-mastectomy reconstructive surgery medical history breast-related history. 84 obesity. 96 wound dehiscence. 62–63 Wise pre-patterned curvilinear incision. 160–161 Systemic illnesses. 97. 38 Ptosis. 198 Symmastia. 198 Strombeck inverted horseshoe. 42 SPY® Elite Intraoperative Perfusion Assessment System. 190 Pseudomamma. 161 Secondary deformities. 95 rippling and contour deformities. 134–135 Saline implants. 88 Silicone implants. 89–90 pitfalls crisp inframammary fold. 157–158 breast and abdominal aesthetic complications.206 Polythelia pilosa. 110–111 Tuberous breast deformity. 190–191 Vertical rectus abdominis muscle (VRAM) flap. 82 systemic illnesses. inferior pedicle. 11 Pseudoptosis. 126–130 Supernumerary breast. 149–150 Terramycin®. 134–135 Thoracodorsal nerve. 199 autologous reconstruction. 82 neoadjuvant chemotherapy. 6 Tissue expanders. 177. 20–21 reconstructed breast. 21–22 ultrasound. 11 Positional ptosis. 110 performance. 177 Staphylococcus aureus. 197 Round tissue expander. 96 filling expander. . and Aesthetic Surgery The DeWitt Daughtry Family Department of Surgery University of Miami Leonard M Miller School of Medicine Miami. FACS Chief and Professor Division of Plastic. Florida Back cover illustrations by permission of Dr Sheri Slezak and Dr Tripp Holton. Florida Zubin J Panthaki.Aesthetic and Reconstructive Breast Surgery Solving Complications and Avoiding Unfavorable Results About the book Breast surgery has important implications for a patient’s self image and self esteem. About the editors Seth Thaller. and Dr Mecker G Möller. this will be an invaluable succinct guide that all surgical practitioners will want to have as a ready reference before any consultation or procedure. MD. and Aesthetic Surgery The DeWitt Daughtry Family Department of Surgery University of Miami Leonard M Miller School of Medicine Miami. DMD. Reconstructive. As such. Dr Ada P Romilly. Aesthetic procedures – whether augmentation or reduction – remain among the most popular reasons for seeking elective surgery. MD Associate Professor of Surgery Division of Plastic. This new book provides an expert approach to treating the patient and handling the operation with maximum attention to areas where mismatched expectations or technical difficulties may cause later problems or the need for further revision surgery. and reconstruction after surgery for cancer is an integral part of the patient’s treatment and recovery process. Reconstructive.