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Aesthetic and

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

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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.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-84184-847-1 (hb : alk. paper)
I. Thaller, Seth R. II. Panthaki, Zubin J.
[DNLM: 1. Mammoplasty. 2. Breast: surgery. 3. Postoperative complications: prevention and control. 4. Reconstructive
surgical procedures: methods. 5. Reoperation. WP 910]

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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. I also extend my deepest gratitude to my parents who provided me with the environment
to successfully pursue a career in Plastic Surgery. Lastly, I would like to thank my mentors and colleagues whom
I have had the good fortune to meet and work with throughout my career.
I would like to dedicate this book to my parents, Nergish and Jal Panthaki, on the occasion of their fiftieth
wedding anniversary. Their love and support is a continuous source of strength and inspiration to me. I would
also like to thank my wife, Dimple, and our sons, Karl and Kayaan, who make it all worthwhile.










1 Breast and chest: Applied anatomy, evaluation of the patient undergoing breast surgery,
initial consultation, analysis, and patient selection

Bassan J. Allan, Angela T. Prescott, and Mecker G. Mller

2 Congenital disorders of the breast

Eric Chang and David M. Kahn

3 Radiologic evaluation of the breast


Ada P. Romilly

4 Breast asymmetry


Thomas R. Stevenson

5 Mastopexy


Deniz Dayicioglu and Bulent Genc

6 Reduction mammoplasty


Rosiane Roeder and Seth Thaller

7 Oncoplastic surgery of the breast


Robert A. Grossman, Peter J. DiPasco, Subhasis Misra, and Eli Avisar

8 Lumpectomy and radiation therapy


Onelio Garcia Jr., Roberto Comperatore, and Nuria Lawson

9 Preoperative evaluation in post-mastectomy reconstructive surgery


Charles R. Volpe, Paul Yang, and Zubin J. Panthaki

10 Tissue expansion reconstruction


Sheri Slezak and Tripp Holton




11 The pedicled TRAM flap


M. Lance Tavana and Paul D. Smith

12 Transverse rectus abdominis myocutaneous (TRAM) flap and deep inferior

epigastric artery perforator (DIEP) flap breast reconstruction


John C. Oeltjen and Haaris Mir

13 Other free flaps in breast reconstruction


Brian A. Mailey and Gregory R. D. Evans

14 Nippleareola complex reconstruction


Matthew E. Hiro and Deniz Dayicioglu

15 Managing the unfavorable result in breast surgery


Charles R. Volpe, Alexander Nguyen, and Zubin J. Panthaki

16 Optimizing long-term outcomes in breast surgery


Anuja K. Antony, Benjamin Liliav, Victor J. Hassid, and Mimis N. Cohen

17 Gynecomastia


Gary Rose

18 Breast reconstruction CPT coding


Keith Brandt and Scott Oates




Bassan J. Allan
The DeWitt Daughtry Family Department of Surgery,
University of Miami Leonard M. Miller School of
Medicine, Miami, Florida, USA

Peter J. DiPasco
Division of Surgical Oncology, The DeWitt Daughtry
Family Department of Surgery, University of Miami
Leonard M. Miller School of Medicine, Miami,
Florida, USA

Anuja K. Antony
Division of Plastic, Reconstructive and Cosmetic Surgery,
University of Illinois at Chicago Medical Center,
Chicago, Illinois, USA

Gregory R. D. Evans
Aesthetic and Plastic Surgery Institute, University of
California, Irvine, California, USA

Eli Avisar
Division of Surgical Oncology, The DeWitt Daughtry
Family Department of Surgery, University of Miami
Leonard M. Miller School of Medicine, Miami,
Florida, USA

Onelio Garcia Jr
Division of Plastic, Reconstructive, and Aesthetic
Surgery, The DeWitt Daughtry Family Department of
Surgery, University of Miami Leonard M. Miller
School of Medicine, and Division of Plastic Surgery,
Palmetto General Hospital, Hialeah, Florida, USA

Keith Brandt
Division of Plastic and Reconstructive Surgery,
Washington University, St Louis, Missouri, USA

Bulent Genc
Istanbul Aesthetic Surgery, Istanbul, Turkey

Eric Chang
Columbia Aesthetic Plastic Surgery, Columbia,
Maryland, USA

Robert A. Grossman
Division of Surgical Oncology, The DeWitt Daughtry
Family Department of Surgery, University of Miami
Leonard M. Miller School of Medicine, Miami,
Florida, USA

Mimis N. Cohen
Division of Plastic, Reconstructive and Cosmetic Surgery,
University of Illinois at Chicago Medical Center,
Chicago, Illinois, USA

Victor J. Hassid
Division of Plastic, Reconstructive and Cosmetic Surgery,
University of Illinois at Chicago Medical Center,
Chicago, Illinois, USA

Roberto Comperatore
Department of Surgery Nova-Southeastern University of
Health Sciences Ft. Lauderdale, Florida and Department
of Surgery Palmetto General Hospital
Hialeah, Florida

Matthew E. Hiro
Department of Surgery, Division of Plastic Surgery,
University of South Florida College of Medicine, Tampa,
Florida, USA

Deniz Dayicioglu
Department of Surgery, Division of Plastic Surgery,
University of South Florida College of Medicine, Tampa,
Florida, USA

Tripp Holton
Breast Reconstruction, University of Maryland Medical
Center, Baltimore, Maryland, USA



David M. Kahn
Division of Plastic and Reconstructive Surgery, Stanford
University, Palo Alto, California, USA
Nuria Lawson
Department of Surgery Nova-Southeastern
University of Health Sciences Ft. Lauderdale,
Florida and Department of Surgery
Palmetto General Hospital
Hialeah, Florida
Benjamin Liliav
Division of Plastic, Reconstructive and Cosmetic Surgery,
University of Illinois at Chicago Medical Center,
Chicago, Illinois, USA
Brian A. Mailey
Department of Surgery, University of California, Irvine,
California, USA
Haaris Mir
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
Subhasis Misra
Division of Surgical Oncology, The DeWitt Daughtry
Family Department of Surgery, University of Miami
Leonard M. Miller School of Medicine, Miami,
Florida, USA
Mecker G. Mller
The DeWitt Daughtry Family Department of Surgery,
University of Miami Leonard M. Miller School of
Medicine, Miami, Florida, USA
Alexander Nguyen
Division of Plastic Surgery, Jackson Memorial Hospital,
University of Miami, Miami, Florida, USA
Scott Oates
Department of Plastic Surgery, MD Anderson Cancer
Center, University of Texas, Houston, Texas, USA
John C. Oeltjen
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
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
Angela T. Prescott
The DeWitt Daughtry Family Department of Surgery,
University of Miami Leonard M. Miller School of
Medicine, Miami, Florida, USA
Rosiane Roeder
The DeWitt Daughtry Family Department of Surgery,
University of Miami Leonard M. Miller School of
Medicine, Miami, Florida, USA
Ada P. Romilly
Diagnostic Radiology, Jackson Health System, Miami,
Florida, USA
Gary Rose
Charles E. Schmidt College of Medicine, Florida Atlantic
University, Boca Raton, Florida, USA
Sheri Slezak
University of Maryland School of Medicine, and Breast
Reconstruction, University of Maryland Medical Center,
Baltimore, Maryland, USA
Paul D. Smith
Department of Surgery, Division of Plastic Surgery,
University of South Florida College of Medicine, Tampa,
Florida, USA
Thomas R. Stevenson
Division of Plastic Surgery, University of California
Davis Medical Center, Davis, California, USA
M. Lance Tavana
Department of Surgery, Division of Plastic Surgery,
University of South Florida College of Medicine, Tampa,
Florida, USA
Seth Thaller
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
Charles R. Volpe
Division of Plastic Surgery, Jackson Memorial Hospital,
University of Miami, Miami, Florida, USA
Paul Yang
Division of Plastic Surgery, Jackson Memorial Hospital,
University of Miami, Miami, Florida, USA


The editors would like to thank many people for their

assistance and support in the editing and production of
this text. Dr Deniz Dayicioglu helped organize and edit
the chapters; Ken Fan was constantly willing to assist;
Dr Alan Livingstone provided institutional support; 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.
The editors would also like to acknowledge Robert Peden
for his outstanding editorial assistance.



and evolving issues, such as oncoplastic surgery, as well

as core competencies such as the management of complications. As breast surgeons, we are continually seeking
ever better ways to practice our craft and to improve the
quality of our patients live. With this goal in mind, Aesthetic and Reconstructive Breast Surgery should find a
place on the bookshelves of both junior and senior surgeons.

Breast surgery brings together both the art and science of

plastic surgery. To achieve optimal surgical results, plastic
surgeons require high quality research data along with
insightful reflections of expert clinicians. In Aesthetic and
Reconstructive Breast Surgery Drs. Thaller and Panthaki
have succeeded in bringing together both of these important elements. This book is particularly timely in light of
our specialtys increasing focus on evidence-based practice. In each chapter, the invited authors provide concise
summaries of the existing literature along with germane
discussions of their own experience. They capture new

Andrea L. Pusic MD MHS FACS

Memorial Sloan-Kettering Cancer Center



detailed step-by-step instruction of both the routine

methodstas also the innovative approaches. Throughout
the book, the authors emphasize the need for a comprehensive appreciation of the underlying anatomy and the
need for preoperative evaluation and active patient participation. The book also details the risks and benefits,
and communicates how to avoid unfavorable results in a
concise and detailed manner.
We hope this book will become a useful tool in the plastic surgeons practice by improving patient satisfaction and
minimizing the risks associated with breast surgery.

Management of both reconstructive and aesthetic surgery

of the breast involves a myriad of options. This book will
assist the plastic surgeonoin navigating through this unique
terrain. Each chapter analyzes specific clinical issues
that are frequently encountered in the plastic surgeons
practice, with the goal of providing the plastic surgeon
with clear and contemporary information detailing available aesthetic and reconstructive alternatives for surgery
involving the breasts.
Breast surgery demands a comprehensive approach
and has tremendous influence on a patients self-esteem
and quality of life. The authors have been chosen because
of their extensive experience in the individual chapter
subject. Each author has made an effort to provide a

Seth Thaller
Zubin J. Panthaki


Breast and chest: Applied anatomy, evaluation of the patient undergoing
breast surgery, initial consultation, analysis, and patient selection
Bassan J. Allan, Angela T. Prescott, and Mecker G. Mller


and open onto the nipple (Fig. 1.1). One pair of the mammary
buds persists in the chest, while the others involute. When the
embryologic bands do not involute, individuals present with
variants of small accessory nipples, nippleareolar complexes,
or breast tissue along the embryologic mammary line, including the axilla (2).
After birth further development of the lobular components of the breast is regulated by sex steroids with the
onset of puberty. The accessory breast tissue remnants can
also become hormonally active in females during pregnancy or during the menstrual cycle.

Knowledge of breast, chest wall, and axillary anatomy is

of high clinical and surgical importance in breast surgery.
Disease in one of these structures requires a thorough evaluation of the anatomy of the others as they are intimately
related. Careful preoperative considerations and surgical
planning is essential and helps decrease surgical complications. This chapter highlights relevant anatomy of the
breast, chest wall, and axilla, keeping aesthetic considerations in mind. Additionally, this chapter outlines important considerations about the evaluation of a patient prior
to undergoing aesthetic breast surgery.



Knowledge of external anatomy of the breast is of utmost

importance in breast surgery. The breast is divided into
four anatomic quadrants (outer upper, outer lower, upper
medial, and lower medial) with the nipple functioning as
the axis of the quadrants. The placement of incisions for
lumpectomy and biopsy is important for optimizing cosmetic results (1). Surface anatomy of the female breast
varies widely in shape and size (Fig. 1.2). Throughout
development the female breast undergoes significant
changes in its appearance and cellular composition. This
unique gland undergoes visible changes that are dependent
upon hormonal variability, pregnancy, and lactation. For
instance, with aging the female breast decreases in volume,

Human breasts develop in the ventral surface of the embryo

originating from epithelial bands derived from ectoderm (1).
These epithelial bands extend from the mid-axillary line, to
the mid-clavicular line down to the groin. Throughout gestation, invading mesenchymal components form supporting
structures around the breast. At around 4 months, squamous
epithelium invaginates and begins to form what will eventually become the nipple. A complex network of mammary lobules extends from invading squamous epithelium which by
birth comprises a radial system of branching mammary ducts.
These mammary ducts converge into a retroareolar ampulla


Fat lobules
Mammary vessels
Mammary glands

Pectoralis minor muscle
Pectoralis major muscle
Intercostal muscle

Inframammary fold

Figure 1.1

Sagittal section of the female breast.


Figure 1.2 Picture courtesy of Dr Zubin Panthaki. Variations in size and shape of the female breast. Important gross anatomical
landmarks are depicted in this picture. A: Clavicle, B: Sternal notch, C: Axilla, D: Sternum, E: Nippleareolar complex, F: Inframammary fold, G: Deltopectoral groove.

flattens, and becomes more pendulous and softer (2).

Anatomical variants are rare and noted in 26% of the
female population exhibiting polythelia (accessory
nipples) or polymastia (extra-mammary breast tissue) (2).
The nippleareolar complex ranges from 1 to 6 centimeters in diameter. The surface of the areola contains small
subcutaneous glands that help lubricate the nipple and render its rough appearance. Depending on the shape of the

breast this complex may appear distorted; however, it is

generally round and of variable pigmentation. The inframammary fold (IMF) is another important anatomical and
aesthetic landmark. The IMF is a natural boundary between
the breast and the chest. During breast surgery, consideration and, if possible, preservation of the IMF are important because manipulation is difficult and prone to
complications and poor aesthetic results (5).


Axillary lymph nodes

Figure 1.3 Lymphatic drainage of the female breast. The arrows demonstrate unidirectional flow of most lymphatic fluid toward the
axillary lymph nodes.

Breasts are considered modified sweat glands; as such
they lie in the superficial fascia. The breasts are composed
of compartments of fatty tissue bounded by fibrous bands
and glandular tissue containing 1520 lactiferous ducts
(Fig. 1.1). The fat lobules are compartmentalized by suspensory ligaments, also known as Coopers ligaments,
which extend from the deep fascia to the deep layer of the
skin and help provide the rounded contour of the breast.
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. The ducts open onto the
nipple. The glandular tissue of the breast is composed of
tubulo-alveolar structures embedded in loose connective
tissue. The alveolar system is lined by a single layer of
columnar or cuboidal cells. As the alveoli gradually transition into the lactiferous ducts, the composition of the cells
changes to stratified squamous epithelium.
Knowledge of the lymphatic drainage of the breast is
important when treating patients with a history of breast
disease. Lymphatic drainage of the breast is largely to the
axillary lymph nodes (ALN). However, a small percentage
(35%) of tumors located in the medial quadrants can drain

to the internal mammary lymph node (IMLN) chain. It is

estimated that over 97% of the lymphatic drainage of the
breast flows to the axillary lymph nodes (3). Lymphatic
routes arborize in multiple directions through the superficial components of the breast as they drain unidirectionally
to the deep lymphatic plexus (Fig. 1.3). Subsequently,
lymph flow parallels major venous tributaries to drain into
regional lymph nodes. The anatomic locations of the axillary lymph nodes are largely described with respect to their
relationship with the pectoralis minor muscle. Level I
ALNs are located lateral to lower border of the pectoralis
minor. Level II ALNs are deep to the pectoralis minor, and
level III ALNs are medial to the superior border of the pectoralis minor. Of clinical relevance, Rotters or interpectoral
nodes located between the pectoralis minor and pectoralis
major muscles, have been described as a site of recurrence
for breast cancer (23).
Extensive arterial collateralization exists around the breast.
The arterial supply to the breast can be subdivided into
major and minor vessels. Major arteries include: the internal
mammary artery, the external mammary artery off the lateral thoracic artery and the branches of the intercostal
arteries. Minor arteries include: the thoracoacromial, subscapular, upper thoracic, and thoracodorsal arteries. Venous
drainage of the breast is to the internal mammary vein and

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 12 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).
Breast innervation is best understood when subdivided by
structural components: breast parenchyma, breast skin and
nippleareolar 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).
About 7% of women who present for aesthetic breast surgery will have thoracic wall deformities such as pectus
excavatum (depressed sternum), Polands syndrome (pectoralis hypoplasia, deformed axillary fold, and asymmetric
inframammary fold), pectus carinatum (pigeons chest), or


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 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 C5C6, whereas the sternocostal division is
innervated by C7, C8, and T1. During surgical identification


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 (C8T1) (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 (C5C6), 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. Halsteads ligament is described as the dense portion of the clavipectoral fascia that lies between the first rib

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.
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

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. Mller.

Figure 1.5 Pectoralis minor muscle (left), with pectoralis

major muscle divided (cephalad = top of image). Courtesy of
Dr. Mecker G. Mller

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.


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 (C6C8) 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 C5C7 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


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 90 shoulder extension. Courtesy of Dr. Mecker G. Mller.

the arm, and the lateral chest wall around the second and
third ribs.
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).
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 patients 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 patients
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, nippleareolar complex position, as well as the tactile characteristic of the
patients breast parenchyma (i.e., fullness, elasticity, and
thickness) (11). A quantifiable approach to tissue assessment, using measurements in lieu of subjective visual

assessment, provides surgeons with quantifiable data on

which to base decisions (12). Most surgeons utilize standard pre-operative checklists to carefully record anatomical landmarks, such as: the position of the nippleareolar
complex relative to the infra-mammary fold, the position
of the breast/nipple relative to the mid-sternum and chest
wall, inter-mammary and inter-nipple distance, and areolar diameter.
After a thorough review of a patients history and
physical exam, a discussion with the patient should outline
expectations, indications for surgery, and alternative treatment options. Patients should understand all risks associated with the intended procedure and its potential
complications. Lastly, adequate preparation and instructions about standard post-operative management and recovery should be provided to the patient in the pre-operative
setting. Doing so may help reduce a patients anxiety level
and help increase overall patient satisfaction.








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Congenital disorders of the breast
Eric Chang and David M. Kahn



Congenital breast disorders, though rarely functional in

nature, can cause an extreme amount of emotional distress, especially during late childhood and the early teenage years. These disorders can span from the simple
presence of extra nipples, to complex disorders such as
Polands syndrome or tuberous breast deformity.
The treatment of these varied conditions can be better
understood by categorizing these deformities as either
hyperplastic, hypoplastic, or deformational (1). Some of
these anomalies are quite common, such as supernumerary
nipples, whereas other conditions are quite rare.

The most common hyperplastic breast disorder is the

supernumerary nipple, or polythelia. This is a relatively
common occurrence, noted in 12 percent of the population (5). Incomplete regression of the embryonic mammary ridge tissues leads to the development of accessory
nipples along the milk line. These can be found above the
breast, in the axilla down to the level of the groin. Most
commonly these are found in the inframammary area.
Supranumerary nipples have been found in anatomic areas
as varied as the scapula, head, neck, and thigh. Fifty
percent of cases have been noted to be bilateral (6).
Supranumerary nipples are often misdiagnosed as nevi.
Polythelia can be associated with renal abnormalities,
including supernumerary kidneys, renal malformation, as
well as renal carcinoma. This association is due to the parallel embryological development of the renal and mammary tissues. Some authors recommend ultrasound for
evaluation of renal anomalies when supernumerary nipples are present (7). The treatment of choice for polythelia
is simple excision. Polymastia, on the other hand, is the
presence of accessory breast parenchyma. The most common location for accessory breast tissue is the axilla, with
an overall incidence of 15 percent (8). Accessory breast
tissue is often misdiagnosed as a lipoma, cyst, lymphatic
enlargement, or even hidradenitis. This tissue is often
quiescent at birth, and only becomes apparent at times of

Breast growth begins at the fifth week of gestation
when breast tissue develops from the mammary ridges
of the ectoderm. These milk lines develop along the
ventral surface of the embryo and extend from the
axilla to the groin area. Normally, the ridge at the fourth
intercostal space becomes the mammary gland, whereas
the remaining areas undergo apoptosis, ultimately
regressing. By week 10, branching of the gland produces secondary buds, and eventually the mammary
lobules of the breast. The surrounding mesenchymal
tissue will become the superficial fascial system of the
breast (24).



hormonal stimulation, such as puberty, pregnancy, or

lactation. Accessory breast tissue can wax and wane with
the menstrual cycle, and can be subject to the same problems as the normal breasts such as fibrocystic disease and
The Kajava classification of persistent mammary ridge
structures was developed in 1915 (9). It includes the range

Figure 2.1

Figure 2.2

of anomalies from complete, accessory breast with nipple

and areola, to simple supernumerary nipples. The eight
classifications are as follows:
1. Polymastia is that which includes completely formed
accessory breast with glandular tissue, areola, and nipple.
2. Supernumerary breast is without areola but with nipple
and breast tissue.

Supranumerary nipple.

Ectopic breast tissue.


3. Supernumerary breast is without nipple but with areola

and breast tissue.
4. Aberrant glandular tissue is that which is only without
nipple or areola (i.e., ectopic axillary breast tissue).
5. Pseudomamma is with nipple and areola (fatty tissue
rather than true breast tissue).
6. Polythelia is supernumerary nipple only.
7. Polythelia areolaris is supernumerary areola only
8. Polythelia pilosa is supernumerary breast represented
only by a patch of hair.
Options for treatment of accessory breast tissue are
elliptical excision or liposuction alone if the problem does
not include skin excess.
Amastia is a rare condition characterized by the complete
absence of the breast parenchyma, nipple, and areola. It
has a female to male ratio of 5:1. It is due to the failure of
development of the breast tissue with the lack of mammary line development at 56 weeks in utero. At the onset
of puberty, all secondary sexual characteristics mature
normally but with the absence of the breast (10).
Amasia on the other hand, refers to absence of the
breast tissue with presence of the nippleareola complex.
This is often the result of traumatic injury during childhood, whether radiation, surgery, or thermal injury. Athelia refers to the absence of the nippleareola complex and
is rarely found without amastia.
Poland syndrome was first described in 1826, and was
given its name by Alfred Poland in 1841 (11). Poland was

Figure 2.3


a medical student at Guys Hospital, where he worked as

a demonstrator in the anatomy lab. The syndrome that
bears his name refers to an absence of the pectoral muscle
combined with anomalies of the chest wall, breast, and
upper extremity. Poland syndrome is more common in
men, with a 3:1 sex predeliction, and the right side is
affected more commonly than the left. Its frequency is
estimated at one in 30,000 live births (12).
The pathognomonic finding in Poland syndrome is the
absence of the sternocostal head of the pectoralis major
muscle. 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. The entire muscle may be missing,
as well as the pectoralis minor muscle. In some cases the
muscles that are present, such as the clavicular head of the
pectoralis, may become hypertrophied, thus further accentuating the contour deformity. In addition, upper extremity
anomalies such as hypoplasia of the ipsilateral hand, syndactyly, and synbrachydactyly are characteristic of Poland
syndrome as well.
The absence or deformity of the anterior portions of the
second to fifth ribs is commonly found, as are deficiencies
in surrounding muscles of the trunk, including the latissimus dorsi, external oblique, and serratus anterior. In severe
cases, functional pulmonary problems may result. The
ipsilateral nipple is usually hypoplastic and both the breast
and the nipple may be superiorly malpositioned.
Poland syndrome is thought to be a sporadic mutation,
without defined inheritance. Familial transmission, though
reported, is quite rare (13).

Poland syndrome.


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. This
leads to a regional vascular hypoplasia of the subclavian
vessels and its branches. Ischemia to the pectoral vessels
leads to aplasia of the muscle, whereas distal limb vascular
disruption leads to synbrachydactyly (14). Smoking and
other intrauterine insults have also been implicated as risk
factors for Poland syndrome (15).
Because of the wide range of clinical presentations of
Poland syndrome, care must be taken in evaluating the
patient. Careful, systematic examination of the following
structures must be undertaken:
1. Muscles the pectoralis muscle as well as surrounding
muscles must be isolated and tested, determining
whether the latissimus muscle is of normal size and
2. Breast the development as well as location of the
breast should be noted in relation to the contralateral
normal breast. The size and location of the nipple
areola complex should also be noted.
3. Chest wall contour depression from the absence of
the anterior ribs should be examined for, as well as
chest width discrepancies between the affected and
non-affected sides.
4. Upper extremity the ipsilateral upper extremity and
hand must be carefully examined, ruling out limb
A recent classification for Poland syndrome in female
patients has been proposed based on both clinical and
imaging studies. The Clinical and Radiographic Poland
Syndrome (CRPS) classification separates patients into
three degrees of severity (16).
1. First degree (mild) includes mammary and nipple
areola complex asymmetry with partial absence of the
pectoralis major muscle. No other muscular or skeletal
anomalies are present.
2. Second degree (severe) mammary and nippleareola
complex asymmetry with complete absence of the pectoralis major muscle. Ipsilateral muscle or chest wall
hypoplasia. Minor limb anomalies may be seen.
3. Third degree (very severe) amastia with complete
absence of the pectoralis major muscle. Major ipsilateral chest alterations, such as absence of the pectoralis
minor or serratus anterior muscles. Possible lung hernia
or widened opening of the mediasteinum. Ipsilateral
limb hypoplasia.
Management of Poland syndrome is related to the
breadth and severity of hypoplastic elements. Chest wall
defects may require further imaging with CT or MRI and
ultimately split-rib grafting or mesh prostheses. Hand and
upper extremity anomalies may require radiographs to
evaluate bony anatomy prior to release of syndactyly.


Chest reconstruction of the male Poland syndrome patient

focuses on replacing anterior chest wall volume as well as
recreation of the anterior axillary fold. Autologous reconstruction involves transfer of the latissimus muscle anteriorly, 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, imaging with
spiral CT and 3-D reconstruction should be considered to
confirm intact vascular pedicle anatomy (17). The downside
to this procedure is the sacrifice of the latissimus muscle and
its posterior axillary fold in reconstructing the anterior axillary fold. In addition, the loss of the latissimus muscle mass
in the back is not insignificant.
Implant reconstruction is typically performed with a
custom-shaped silicone implant. The implant is first
sculpted with a plaster moulage, whose shape is threedimensionally transferred to a wax model prior to final
casting with silicone. The final silicone implant is placed
through an axillary incision into a pocket developed immediately on the chest wall. Pocket dissection should be limited to the exact size of the implant to limit migration. One
can also fix the implant to the chest wall with sutures to
prevent movement and migration. Careful dissection must
be performed on the chest wall to avoid a pneumothorax,
as costal cartilage and rib may be missing. In thin patients,
the implant may need to be covered by a latissimus flap to
provide better camouflage of the implant.
Implant reconstruction of the female Poland syndrome
patient is usually performed with either a single stage
implant, post-operative adjustable implant or 2-stage tissue expander/implant reconstruction. Identification of the
Poland patient early in puberty allows for the option of a
tissue expander to be placed early in breast development.
This device can be serially expanded to keep pace with the
contralateral breast development. The psychological
sequella of marked breast asymmetry and amastia can be
masked by this maneuver. Once the breasts have been
fully developed, final implant exchange can be undertaken, usually with a silicone implant.
The secondary advantage of a tissue expander used in
this fashion is that the technique allows for expansion of the
hypoplastic nippleareola complex as well. Though the vertical position and height of the nipple may only marginally
be improved, the diameter of the areola can be expanded to
create a better match with the normal side.
Single stage implant reconstruction may also be performed, depending on the amount of asymmetry present
and the ability of the skin envelope to accept an appropriately sized implant. Recreation of the anterior axillary fold
can be accomplished by rotation of the latissimus dorsi
muscle anteriorly.
Autologous options used in acquired amastia such as
pedicled TRAM flap and microsurgical free flap transfer
have also been applied to Poland syndrome (18). Omental


flap for reconstruction with or without silicone implants

have been described as well (19).
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. Fat
grafting to the infraclavicular hollow or anterior axillary
fold can allow for soft tissue augmentation is areas which
are traditionally difficult to address (20,21). Furthermore,
feathering of implant edges and minor asymmetries can
also be addressed, particularly in the male Poland patient.
In discussing fat grafting with patients one should emphasize that this will often require more than 1 session to
achieve the desired end result.
Nipple transposition can be performed as a second
stage for both the male and female Poland patients. This
can include either free nipple grafting for repositioning of
the nippleareola complex, or flap transposition.
Careful counseling as to the hypoplastic nature of
Poland syndrome and the probability of continued asymmetry of the chest wall, breast, and nippleareola complex
is an important part of treatment.
The characteristic shape of the tuberous breast presents at
the time of breast development. Given its name by Rees
and Aston for its likeness to a tuberous plant root, the
breast has a constricted base, lacking in both the vertical
and horizontal dimensions (22). This leads to a narrow
outward projection of the breast, without accompanying
circumferential fullness. The pathognomonic feature of
the tuberous breast is the herniation of the breast tissue



through the constricted, narrow base of the breast, leading

to a markedly enlarged areola.
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. During breast development, because of the inability of
the breast to expand inferiorly, increasing volume follows
the path of least resistance and leads to parenchyma herniating through the subareolar defect. 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.
A variety of classifications have been proposed in
tuberous breast deformity. Grolleau and colleagues offered
a simple and logical classificiation system in 1999 (23).
1. Type 1 Lower medial quadrant deficiency
2. Type 2 Lower lateral and medial quadrant deficiencies
3. 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. Rees and Aston advocated the radial scoring of the
posterior capsule of the breast, to allow for its unconing.
Riberio described an autologous periareolar approach to
the breast, in which the constricting ring of the breast was
divided into two, with the inferior flap folded onto itself
to fill the inferior pole of the breast. A round block
Benelli-type suture was used to address the areolar
enlargement (24). Mandrekas describes a similar approach
in which the unfurled breast parenchyma is split vertically
at the 6 oclock position to divide the constriction band.
The two pillars are then loosely approximated with suture.


Figure 2.4

(A) Type 2 tuberous breast preop. (B) Type 2 tuberous breast postop.


If necessary, an implant can be placed beneath the

glandular pillars in either the subglandular, or dual plane
(partial sub-glandular/partial subpectoral) to provide
additional volume to the breast (25).
An alternative approach to the correction of tuberous
breast deformity involves the use of tissue expanders to
both expand the circumference of the breast, as well as
the constricted lower pole of the breast. The areolar deformity is addressed at a second stage during expander
exchange (26).
The residual presence of a double-bubble deformity
from a tightened constriction band has been addressed
with autologous fat grafting as a second stage, after conventional parenchymal rearrangement with implant placement. Serra-Renom and colleagues addressed the deformity
at six months after the initial surgery, using a standard
Coleman technique in harvesting the fat, and augmenting
the upper medial pole of the breast at the same time as
treatment of the double bubble (27).
Despite these advances, the treatment of tuberous breast
deformity continues to be a challenge to the breast surgeon. Recurrence of an enlarged areola can be problematic.
A blocking suture, placed in a purse string or pinwheel
fashion to help control areolar size as described by Hammond, remains the gold standard (28). Many surgeons prefer Gore-tex for this suture, yet even this solution is plagued
by high rates of suture exposure and subsequent recurrence
of the deformity. The authors have used mersilene with
good results with no suture exposure in their cases. Furthermore, marked areolar reduction with a blocking suture
can lead to an unattractive flattening of the breast.
The difficulty in treating the tuberous breast is illustrated by the range of options offered for treatment of the
deformity. The development of new techniques, including
autologous fillers which can augment the soft tissue deficiency, will continue to lead us toward a more satisfying
approach for addressing this difficult problem.
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. These disorders are relatively uncommon, and the literature discussing the management of these issues suffers from a small number of
papers; small numbers of patients in the reports with varying degrees of expression of the problem, and short term
follow up with little presentation of longer term results.
However, in plastic surgery where we are guided by principles to manage challenging problems we can draw from
our experiences in breast augmentation, breast reshaping
(mastopexy and reduction), and breast reconstruction.


We would propose the following principles to guide us

in reconstructing the hypoplastic breast. As the majority of
these procedures will require an implant for reconstruction, we recommend precise dissection of the pocket that
limits its size to that 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.
This will also help to limit the appearance of rippling of
the implants. One should also ensure that the nippleareola complex is centered over the most projecting point of
the implant.
Next is ensuring adequate thickness of coverage over
the implant and providing for a gradual transition of thickness of overlying coverage. To achieve this goal, placement of the implant in a partial subpectoral space may be
required, scoring of the overlying breast tissue, or the creation of a flap either of breast tissue or latissimus muscle.
This will limit the appearance of a double bubble, as well
as visibility and palpability of the implant. Furthermore,
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).
Many of these patients will require a skin reduction
component to their procedure, either to the reconstructed
breast or the contralateral breast. As with any procedure,
accurate diagnosis of the problem, 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). Many of the complications
that develop after surgery either in the reconstruction itself
(i.e., wide scars, wound healing problems, implant malposition, etc.) 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 patients desires (for example by
limiting the incision to a peri-areolar approach when a vertical component is indicated).
Finally, the reconstruction of congenital breast problems can have tremendous benefit to the patients selfesteem. The overwhelming majority of patients seem to be
satisfied with the results even if optimal aesthetics is not
achieved (31). Complications, when they occur, tend to be
similar to the complications seen in other types of reconstructive and aesthetic procedures. There is not much in
the plastic surgery literature about the management of the
complications of congenital breast reconstruction. However, adhering to principles of reconstruction and knowledge of the tools available, such as the use of acellular
dermal matrices, Neo-pockets and fat grafting, can help to
improve upon the suboptimal result (32).


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Radiologic evaluation of the breast
Ada P. Romilly


The techniques used to image the breast are based on

morphological and/or physiologic differences between
tumors and normal breast tissue. 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. 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 (ACR) and the
American Cancer Society (ACS), have recently published
updated guidelines for breast cancer screening with imaging (1,2). The recommendations are based on available
evidence and consensus opinions of experts in breast
imaging. Although X-ray mammography is the only
imaging modality that has been proven to decrease mortality from breast cancer, there are limitations of the technique. 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.

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. Evidence to support regular screening comes
from the results of multiple randomized controlled trials
(5,6). This imaging method remains the gold standard for the
detection of breast cancers in both symptomatic and asymptomatic patients. X rays are used to penetrate the compressed
breast tissue in two projections for screening examinations;
craniocaudal and mediolateral oblique. 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. 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. These images are the result of a
composite of all the structures in the breast. In some instances
where the breast tissue is very dense, 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. 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). Digital
images undergo image processing and lesion conspicuity
can be increased by contrast manipulation.




If a screening examination is abnormal or when mammograms are needed to evaluate specific symptoms, a diagnostic examination is performed which may include
targeted views of the areas of interest. Breast cancers are
seen as discrete masses, areas of asymmetric density, architectural distortion, or microcalcifications (Fig. 3.1 AD).
The composition of the tissue in the breast can vary with
age and hormonal status. Breast density has been shown to



decrease by 10 percent in a significant number of women

after a full-term pregnancy (8). Some patients with very
dense breasts at a young age may develop predominantly
fatty breast tissue after menopause. Because a significant
number of breast cancers present as subtle areas of increasing density on the X-ray mammograms, it is very important
that if prior X-ray mammograms are available these are
used for comparison. Breast density is an important risk



Figure 3.1 (A) X-ray mammogram spot compression views of two adjacent non-palpable malignant masses in a fatty breast. The
larger mass has irregular margins and contains pleomorphic calcifications. The smaller mass is lobulated with indistinct margins.
Pathologyinvasive ductal carcinoma. (B) Ultrasound images of the masses seen in Figure 3.1 A. Both masses are solid. (C) X-ray
mammogramDense breast with a cluster of new pleomorphic microcalcifications. Pathologyductal carcinoma in situ. (D) X-ray
mammogramArea of architectural distortion on screening mammogram. Pathologytubular carcinoma.



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 (9,10).
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 (11,12). 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. The current
categories are:
0 - additional imaging is needed and or prior mammograms for comparison.
1 - negative
2 - benign findings
3 - probably benign findings. Interval short-term follow-up
4 - suspicious abnormality. Biopsy should be considered.
5 - highly suggestive of malignancy. Appropriate action
should be taken.
6 - known biopsy proven malignancy. Appropriate action
should be taken.
This format for communicating results to referring physicians is now used in most modalities of breast imaging.
Ultrasound has traditionally been used for evaluating the
palpable abnormality, the abnormality seen on the X-ray
mammogram and for the screening of patients with
extremely dense breasts. 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.
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. The
reflected information is translated into an image.
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, and can be considered in women with dense breast tissue as an adjunct
to mammography (1). Many published reports state that
ultrasound can detect between 2.84.6 additional cancers

per 1000 women in patients with dense breasts, negative

mammograms, and physical examination (1315). A recent
multi-institutional study of screening breast ultrasound
sponsored by ACRIN, included not only women who had
dense breasts but who were also at an increased risk for
breast cancer. The ACRIN study reported similar results to
those of the single institution studies with an incremental
detection rate of 4.2 cancers per 1000 women scanned (16).
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. 3.2 A). When an abnormality is seen on
the X-ray mammogram, ultrasound can further define the
abnormality and increase the specificity of diagnosis (17)
(Fig. 3.2 BE). If a correlative abnormality is seen on ultrasound and is suspicious for malignancy, ultrasound-guided
core biopsy could be performed. If no correlative abnormality is seen on ultrasound, then stereotactic core biopsy
would be performed. Ultrasound of the axilla is now
increasing being used preoperatively in breast cancer
patients. If abnormal axillary nodes are detected, ultrasound-guided core biopsy is performed, alleviating the
need for a sentinel node biopsy if the biopsy of the node is
positive (18).
Current challenges with the use of the procedure
include operator dependence on lesion detection and
characterization. In a study reported by Berg et al. in
which whole breast ultrasound was performed by qualified physicians, detection of masses was dependent on
lesion size. Masses 11 mm or greater were consistently
detected and less than half of lesions 5 mm or smaller
were detected (19). Correlation between subtle mammographic abnormalities and ultrasound is sometimes difficult because ultrasound is performed with the patient
supine and mammogram with the patient upright. Abnormalities seen on X-ray mammogram may appear far distant from the anticipated location depending on the
pendulous nature of the breast. In these situations BB
correlation is performed in which a marker is placed in
the area of the abnormality seen on ultrasound, and repeat
mammograms performed.
MRI technique was initially used to evaluate the integrity
of breast implants (20). Contrast-enhanced MRI of the
breast was first performed in the late 1980s when Heywang
et al. demonstrated that breast carcinomas showed significant enhancement following contrast injection (21). Substantial improvements have been made over the past
decade on the definition of technical requirements for
image quality, the definition of interpretive guidelines
with a BIRADS lexicon, and the development of minimally
invasive biopsy procedures.








Figure 3.2 (A) Ultrasound of a palpable mass in a young patient. Benign appearing solid mass. Pathologyfibroadenoma.
(B) Mammograms of palpable mass in the left breast. Mass shows irregular borders. (C). Ultrasound of mass in Figure 3.2 B. Irregular
solid mass. Pathologyinvasive ductal carcinoma. (D) X-ray mammogram of a palpable left breast mass. Mass is not well defined.
(E) Ultrasound of the mass in Figure 3.2 D shows a simple cyst.



During the MRI procedure, multiple images of thin

slices of breast tissue are obtained and computer manipulation enables viewing in a three-dimensional manner. The
inherent differences in the soft tissues of the breast are
insufficient for accurate diagnosis. By using the contrast
agent containing gadolinium, the tumor signal is enhanced.
The diagnosis of benign versus malignant is determined by
the morphology of the tumor and the contrast-enhancement
pattern. Malignant masses have neovascularity, 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. 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. Specific techniques
have been developed to capture the maximal temporal
(dynamic) and spatial (morphologic) resolution for diagnosis (22,23) (Fig. 3.3 A, B).
Several studies have documented that breast MRI has a
high sensitivity for the detection of breast cancer (24,25).
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. The specificity rate was 88%. These findings are similar to other reported single institutional studies for breast cancer screening with MRI (26).
The current recommendations for the use of MRI
(1,2225) are
Evaluate implant integrity in patients with questionable


Evaluate patients with newly diagnosed breast cancer

for multifocality and extent of disease.
Screening of high risk patients such as BRCA positive
patients, women who have a family history suggesting a
familial disposition for breast cancer, and women with a
greater than 20 percent lifetime risk for breast cancer.
Evaluation of abnormalities of the lumpectomy site in
cancer patients and for indeterminate areas detected on
X-ray mammograms and ultrasound.
Evaluation for breast cancer in patients with an
unknown primary.
PEM is a high-resolution PET scan that uses detectors specialized for the molecular imaging of the breast with fluorine
18-fluorodeoxyglucose (FDG). The technique takes advantage of the differences in metabolic activity between tumor
and normal breast tissue. PEM has been shown to detect
breast malignancies not seen on mammograms or ultrasound
images in dense breasts and areas of scar tissue (27). A
recent reported study has shown that PEM and MR have
comparable breast sensitivity, PEM had a greater specificity
for lesion identification particularly DCIS (28). PEM is not
universally used but seems to have its greatest role in the
pre-surgical planning for ipsilateral breast cancer.
BSGI uses technetium 99m sestamibi for breast cancer
detection. This technique uses high resolution small field


Figure 3.3 (A) MRI shows a lobulated contrast-enhancing mass in the right breast. An 8-mm enhancing mass is seen in the left breast.
Pathology of right breast massinvasive ductal carcinoma. Pathology of left breast massatypical ductal hyperplasia. (B) MRI breast
screening for a high-risk patient. Left breast shows 5-mm contrast-enhancing mass. Pathologyductal carcinoma in situ.


of view (fov) detectors which can detect uptake of the

radiotracer in breast tissue. 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. Sensitivity as
high as 96.4 percent has been recorded, but specificity is
moderate at 59.5 percent (29).
Both PEM and BSGI are helpful for evaluating ipsilateral cancers in newly diagnosed breast patients in whom
MRI cannot be performed.




It is important for the plastic surgeon to understand the
limitations that may occur with imaging of a breast that
has undergone surgical intervention. 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. Most dense areas from scar tissue will decrease
with time but initial imaging examinations of areas of



Figure 3.4 (A) Calcifications in an implant capsule which appeared similar to calcifications within the breast. (B) X-ray mammogram
(MLO view) with history of implant rupture and replacement with a silicone implant. Residual silicone decreases mammography
sensitivity. (C) MRI shows an intact implant and no contrast-enhancing masses.



clinical concern should include X-ray mammography and

adjunctive techniques such as MRI.
The commonest palpable mass that is found in the surgically altered breast is fat necrosis. This is commonly seen at
partial mastectomy sites, post reduction mammoplasty, and
augmentation with autologous fat injections. On X-ray imaging these masses may initially present as microcalcifications
or low-density masses with rim-like calcifications (30). As
the masses age, the calcifications increase and become
coarse. The X-ray imaging characteristics are often classic
that biopsy is not needed. MRI imaging is usually negative
in these areas of the mammographic abnormality.
Evaluating masses in areas of scar tissue is sometimes
difficult as the imaging characteristics of surgical scars
and malignant breast masses can be similar. 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.
Silicone and saline implants are most commonly used for
breast augmentation. Specific X-ray imaging techniques
have been developed to maximize the amount of breast tissue visualized (31). Two views of each breastcraniocaudal
and mediolateral oblique views, are first obtained and then
similar views are performed with the implants displaced.
Subpectoral implants are more easily displaced than


prepectoral implants and allow for more tissue to be evaluated. In a study by Silverstein et al. (32) measurements of
the visualized breast tissue were compared between the preand post-augmentation mammograms. Routine views and
implant displacement views were performed and there was
a decrease of 1525 percent of visualized tissue depending
on whether the implants were subglandular or submuscular
with more breast tissue seen with submuscular implants.
In some cases calcifications of the capsule of the implant
occurs and makes displacement of the implant extremely
difficult. Calcifications of the implant capsule may also be
mistaken for suspicious microcalcifications in the breast
which may result in unnecessary surgery. (Fig. 3.4 A)
Ultrasound is used to evaluate all palpable abnormalities. Although MRI is a more expensive imaging modality,
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. 3.4 B, C).
Other materials also have been used for augmentation
of the breast such as the injection of fat and the injection
of silicone. Silicone injections, which are no longer performed in the United States, result in the formation of silicone granulomas which create non-diagnostic images on
X ray and ultrasound. The silicone granulomas are usually
palpable and make it clinically difficult to differentiate
from malignant masses. MRI imaging is currently the
most accurate method for detecting malignant masses in
these patients (Fig. 3.5 A, B).


Figure 3.5 (A) X-ray mammogram craniocaudal, (cc) view shows multiple silicone granulomas. (B) MRI shows multiple masses with
no contrast enhancement and low signal intensity on the T1 images.



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. 3.6 A).
Long-term studies are needed to review the imaging characteristics of these masses with age. 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.
Breast reconstruction methods such as the transverse rectus
abdominis myocutaneous (TRAM) flap and latissimus dorsi
flap with implant are commonly used post mastectomy. Routine screening for breast cancer in these patients is not recommended because of the low yield (32). 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). The TRAM flap has a signal intensity
equivalent to fat. With the latissimus dorsi flap, the underlying implants are visualized in a similar manner to the augmented breast. Recurrent tumors are easily detected as



Figure 3.6 X-ray mammogram of a patient with autologous

fat injections. Multiple low-density masses are seen with rimlike calcification of fat necrosis.



Figure 3.7 (A, B) Recurrent CA in a reconstructed breast. CT scan shows a mass just posterior to an intact implant. (C) Ultrasound
of the mass seen in Figure 3.7 B.


contrast-enhancing masses. 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). The technique is useful in patients on whom MRI cannot be performed. Masses
can also be detected on CT scans of the chest which can then
be confirmed with ultrasound or MRI (Fig. 3.7 AC).
It is important to understand the multiple imaging methods
that are used to evaluate the breast and the accuracy and
limitations of each procedure. As stated in this chapter,
breast density plays a significant role in determining breast
cancer risk and diminishes the accuracy of X-ray mammography. Adjunctive methods of imaging such as ultrasound,
MRI, PEM, and BSGI complement X-ray mammography
by providing additional diagnostic information. 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.
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Breast asymmetry
Thomas R. Stevenson


macromastia and benign tumors. We shall not consider

asymmetry secondary to breast agenesis (e.g., Polands Syndrome) nor shall we describe the management of breast
asymmetry associated with breast reconstruction.
The relative magnitude of breast asymmetry is subjective. When considering any breast operation, we believe it
is incumbent upon the surgeon to discuss symmetry preoperatively. While the patient may perceive a significant lack
of symmetry, the surgeon may not. Conversely, the surgeon may feel that the breasts are remarkably asymmetric,
but the patient does not. Not infrequently, a patient who
does not recognize the presence or extent of preoperative
asymmetry will note lack of symmetry postoperatively.
This can lead to patient dissatisfaction and pressure for
unnecessary re-operation.
It is our practice to point out the pre-existing symmetry,
or lack thereof, to all patients considering an operation on
one or both breasts. We discuss level of inframammary
folds; nipple size, position, and relationship to the contralateral nipple; grade and symmetry of any ptosis; breast
base diameters; and comparative volumes of the left and
right breasts.

Although in nature symmetry is the ideal, asymmetry is

the norm (13). This principle holds true for virtually all
paired human organs, breasts included. No individual has
perfectly matched breasts. Most people, when observing
their own breasts, interpret a certain amount of asymmetry
as normal. For the purposes of this chapter, the authors
will confine themselves to consideration of female breast
asymmetry. When a woman is considering a breast operation of any sort, attention to preoperative symmetry is
important (4,5). The potential patient, be she desirous of
breast augmentation, breast reduction, or a procedure to
address perceived asymmetry, must have an accurate preoperative appreciation of the amount of pre-existing asymmetry and the possible outcome following any proposed
operative procedure (69).
In the material that follows, the authors will address five general categories of patients who present with specific clinical
problems of breast asymmetry (10,11). First will be those
patients who have macromastia, either bilateral or unilateral.
Second, we shall discuss patients with bilateral breast ptosis
and asymmetry, without macromastia. Third, we shall cover
the class of patients who have small breasts, either unilateral
or bilateral. Fourth, we shall examine the group of patients
with unusual causes for asymmetry, specifically juvenile

Bilateral Macromastia and Asymmetry
We define macromastia as a state wherein the patients
breasts are larger than would be ideal and cause the patient
symptoms of back, neck, or shoulder pain. Large breasts



are characterized by excess breast tissue and fat, redundant

breast skin with the skin of the breast lying against the
chest or abdominal wall, and, usually, areolar enlargement
with the areolar diameter exceeding 4 (four) centimeters.
Asymmetry in the presence of bilateral macromastia may
be manifest by asymmetric excess in any of these elements, i.e., skin, breast tissue, fat, nipple size, and/or nipple position.
The patient in Figure 4.1 suffers from bilateral macromastia and asymmetry. While her nipples are similar in
size and position, she has significantly more right breast
tissue, fat, and skin. Using an inferior pedicle technique
and Wise (inverted T) skin pattern, we tailored her breast



Figure 4.1


Figure 4.2

reduction to remove proportionately more skin, fat, and

breast tissue from the right breast. In the process of planning, the right nipple position was marked approximately
1 centimeter lower than the left. This is done with the
understanding that, since the right breast is heavier, the
right breast skin is under more tension due to the force of
gravity. When that force is reduced by breast reduction,
skin elasticity will pull the right nipple differentially
higher and, if not anticipated, could result in the right nipple being too high.
Macromastia may be accompanied by displacement of
the nipple medially (Fig. 4.2, preop) or laterally (Fig. 4.3,
preop). In the majority of patients, preoperative breast

Bilateral macromastia and asymmetry. (A) Preoperative. (B) Postoperative, 4 months.


Bilateral macromastia and asymmetry. (A) Preoperative, nipples displaced medially. (B) Postoperative, 11 months.




Figure 4.3


Bilateral macromastia and asymmetry. (A) Preoperative, nipples displaced laterally. (B) Postoperative, 4 months.

marking determines ultimate nipple position and dimensions of skin excision. If the nipple is not displaced
medially or laterally in the preoperative state, the scar
beneath the nipple is oriented vertically and intersects the
inframammary fold perpendicularly. Correcting medial
or lateral nipple position operatively results in the vertical reduction scar being tilted medially or laterally,
A preoperative estimate of necessary proportional skin
and tissue excision is always made, including weight of
breast tissue to be excised from each breast (12). That estimate is confirmed intraoperatively. The tissue resected (fat
and breast parenchyma) from each breast is weighed and
compared. Discrepancies are corrected by immediate additional excision. In spite of our best efforts, postoperative
asymmetry may occur, usually commensurate with the
preoperative disparity (Fig. 4.1).
Macromastia and Adequate Contralateral
A patient may develop unilateral macromastia in the
face of an adequately proportioned contralateral breast
(Fig. 4.4) (13). In this circumstance, unilateral breast
reduction decreases the size asymmetry. We prefer the
inferior pedicle technique and Wise (inverted T) skin
pattern. Over time, nipple size does not appear to
increase significantly on the reduced side, nor does the
nipple descend significantly on that side. Volume symmetry may be achieved, although postoperative skin
stretching on the reduced side can produce some recurrent asymmetry (Fig. 4.4, center and right).
In some cases, the patient may present with unilateral
macromastia and contralateral breast ptosis (Fig. 4.5).

Here, the patient is best served by reducing both nipples to

a similar size, removing excess breast tissue from the
enlarged breast, and tailoring the remaining skin bilaterally. This amounts to a unilateral breast reduction and
contralateral mastopexy. When performing a mastopexy,
we have preferred a central pedicle technique with a Wise
pattern skin reduction. The resulting inframmary scar,
while longer on the macromastia side, is confined to an
area concealed by the brassiere.
Macromastia and Inadequate Contralateral
Occasionally, a patient will present with unilateral macromastia and a contralateral breast of satisfactory contour
but inadequate volume (Fig. 4.6). For such a patient, we
elect to perform a unilateral breast reduction and contralateral augmentation. If, however, the patient has unilateral
macromastia and a contralateral breast that is both small
and ptotic, we prefer breast reduction to treat the macromastia and breast augmentation with mastopexy for the
opposite breast (Fig. 4.7). Review of the postoperative
results demonstrates that, although the volumes of the
individual patients breasts are similar, the contour of the
breasts may be different. The patient needs to know preoperatively that postoperatively, some asymmetry of shape
likely will be apparent.
Breast Ptosis and Asymmetry
Changes in breast size and contour are often attendant
upon pregnancy, delivery, breast feeding, and cessation of
nursing. Similar changes can occur with modest weight
loss or adult breast involution. The patient presents with






Figure 4.4

Macromastia and adequate contralateral volume. (A) Preoperative. (B) Postoperative, 1 year. (C) Postoperative, 2 years.

bilateral breast ptosis and asymmetry confined primarily

to disparity in skin excess, nipple size, and nipple position
(Fig. 4.8, left). Each patient must decide for herself regarding the operative procedure indicated for improvement in
symmetry. Our patient (Fig. 4.8, left) elected unilateral
mastopexy. One year postoperatively (Fig. 4.8, right), volume asymmetry was improved, but a difference in skin
envelope and nipple size was apparent.
Bilateral Hypomastia and Asymmetry
Bilateral hypomastia is almost always accompanied by a
degree of asymmetry. Preoperatively, the patient should

be made aware of differences in breast size, shape, and

nipple location. While breast augmentation may improve
volume discrepancy, asymmetries in inframammary fold
and nipple location, and nipple size, may be accentuated.
Patients should be advised of these possibilities.
Volume asymmetry must be significant enough to warrant placement of implants of different size and base diameter. (For the purposes of this discussion, we shall consider
only those patients who have undergone breast augmentation using round implants.) Patients who come with complaints of small breasts and breast asymmetry are evaluated
and the extent of that asymmetry is assessed by the surgeon. It has been our practice to recommend implants of





Figure 4.5

Macromastia and adequate contralateral volume. (A) Preoperative. (B) Postoperative, 4 months.



Figure 4.6

Macromastia and inadequate contralateral volume. (A) Preoperative. (B) Postoperative, 3 months.

the same volume and base diameter to those patients

whose volume asymmetry is less than 50 cc. In every circumstance, we emphasize to the patient preoperatively
that the asymmetries will be addressed but not completely
remediated by placement of implants, no matter what the
dimensions of the implants (14).
Every patient scheduled for breast augmentation undergoes preoperative screening that includes a detailed history

and physical examination, photographic documentation

of the preoperative state, sizing, and a discussion of the
procedures likely outcome, with risks and possible complications (15). Careful preparation of the asymmetric
patient is particularly important in preventing postoperative disappointment. Sizing is accomplished by fitting the
patient with an appropriate brassiere and placing silicone
gel sizers (of various volumes) in it. The patient selects the





Figure 4.7

Macromastia and inadequate contralateral volume. (A) Preoperative. (B) Postoperative, 9 months.



Figure 4.8

Breast ptosis and asymmetry. (A) Preoperative. (B) Postoperative, 11 months.

look she desires, rather than a particular cup size.

Consideration is given to implant profile and base diameter, and these issues are discussed with the patient. Finally,
patients are discouraged from selecting disproportionately
large implants, as such implants tend to become displaced
or produce breast deformity as the patient ages.
Preoperative asymmetries in patients considering bilateral breast augmentation include variations in breast volume, inframammary fold position, skin excess, and nipple

size and position. Modest volume discrepancies (less than

50 cc) are addressed by placing implants of identical volume and profile. In this patient (Fig. 4.9), bilateral insertion of 330 cc subpectoral saline implants resulted in
satisfactory breast volume, contour, and symmetry.
The patient in Figure 4.10 suffers from asymmetry in
breast volume, indistinct right inframammary fold, and
small right nipple diameter. Intraoperatively, periareolar
approaches were used to develop subpectoral pockets for





Figure 4.9

Bilateral hypomastia and asymmetry. (A) Preoperative. (B) Postoperative, 8 months.



Figure 4.10

Bilateral hypomastia and asymmetry. (A) Preoperative. (B) Postoperative, 3 months.

placement of implants. Inflatable sizers were inserted bilaterally and filled differentially with saline until the volume
asymmetry was corrected to the extent possible. Sizers
were removed and bilateral saline implants were placed.
Based on the sizer volumes, a 360-cc implant was inserted
on the right and 270 cc on the left. Postoperatively, the
breast volume discrepancy was decreased, but asymmetry
in nipple size and inframammary fold contour persist.
Variation in inframammary fold position can be
addressed by dissecting one side slightly lower than that
on the opposite. It is easier operatively to lower an

inframammary fold, thus matching the contralateral inframammary fold, than to attempt to elevate a fold. Not infrequently, attempts at elevating an inframammary fold fail
to produce a durable result. In Figure 4.11, the surgeon
placed the subpectoral implant slightly lower on the right,
improving the preoperative asymmetry.
Patients with small breasts who desire breast augmentation also may evidence disparate skin excess. 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, breast augmentation





Figure 4.11

Bilateral hypomastia and asymmetry. (A) Preoperative. (B) Postoperative, 4 months.



Figure 4.12

Bilateral hypomastia and asymmetry. (A) Preoperative. (B) Postoperative, 6 months.

without mastopexy is an acceptable alternative. Performance of breast augmentation alone may be used to treat
individuals with mild (Fig. 4.12) to moderate (Fig. 4.13)
skin excess in the face of hypomastia.
Bilateral Hypomastia, Ptosis, and Asymmetry
Involutional breast changes occur after pregnancy and
delivery, and are exacerbated by breast feeding. These
changes, characterized by a deflated breast appearance,
nipple descent, and nipple enlargement, are often accompanied by asymmetry. Performing a mastopexy, to reduce

the amount of skin excess and nipple diameter, may contribute to a decrease in breast asymmetry. As a treatment
alternative, many patients select mastopexy and breast
augmentation. Mastopexy may be performed several
months prior to breast augmentation. In selected patients,
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. This patient (Fig. 4.14) underwent mastopexy
and bilateral subpectoral breast augmentation at a single
setting, with improvement in breast contour and diminution of asymmetry.





Figure 4.13

Bilateral hypomastia and asymmetry. (A) Preoperative. (B) Postoperative, 6 months.



Figure 4.14

Bilateral hypomastia, ptosis, and asymmetry. (A) Preoperative. (B) Postoperative, 8 months.

Unilateral Hypomastia and Contralateral

Adequate Volume
A patient seeking surgical correction of unilateral hypomastia may have a contralateral breast of adequate volume
and contour. Again, during the preoperative consultations,
the patient is advised that unilateral breast augmentation
will improve the volume differences between the two
breasts, but will not correct the contour discrepancies.
Assuming the patient is aware and accepting of these realities, unilateral breast augmentation is a satisfactory treatment to improve asymmetry. The patient in Figure 4.15
underwent right subpectoral breast augmentation employing a saline implant. Her postoperative result displays better volume symmetry, but persistent contour differences.

Juvenile Macromastia
As they pass through puberty and adolescence, a few women
experience juvenile macromastia (also termed juvenile
gigantomastia or virginal breast hypertrophy). This form of
macromastia may be associated with significant asymmetry.
In most circumstances, patients with rapid breast growth
should be treated medically or expectantly. Surgical intervention is better undertaken when the period of rapid breast
growth and inflammation have subsided. When initially
seen, the patient in Figure 4.16 (left) had been suffering
very rapid and uncomfortable breast enlargement. Six
months later (Fig. 4.16, center), her rapid breast size increase
had subsided. Differential bilateral breast reduction relieved
her of the symptomatic macromastia (Fig. 4.16, right).





Figure 4.15

Unilateral hypomastia and contralateral adequate volume. (A) Preoperative. (B) Postoperative, 7 months.




Figure 4.16

Juvenile macromastia. (A) Six months preoperative. (B) Immediately preoperative. (C) Postoperative, 7 months.





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.
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2. Araco A, Gravante G, Araco F, et al. Breast asymmetry:
a heterogeneous condition. Plast Reconstr Surg 2006;
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3. Scutt D, Lancaster G, Manning J. Breast asymmetry and
predisposition to breast cancer. Breast Cancer Res 2006; 8:
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treatment of congenital, developmental, and acquired female
breast asymmetries. Vojnosanit Pregl 2010; 67: 31320.
5. Juri J. Mammary asymmetry: a brief classification. Aesthetic Plast Surg 1989; 13: 4753.

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: 61621.
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: 196203.
8. Gliosci A, Presutti F. Asymmetry of the breast: some
uncommon cases. Aesthetic Plast Surg 1994; 18: 399403.
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11. Gasperoni C, Salgarello M. Breast shape malformations.
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14. Hvilsom G, Hlmich L, Henricksen T, et al. Local complications after cosmetic breast augmentation: results from the
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scanning technique in evaluation of breast asymmetry in
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Deniz Dayicioglu and Bulent Genc


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 nippleareola 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) (24).

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).


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 determinantsNAC 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

Table 5.1


Ptosis Classifications and Definitions

Regnault Traditional Ptosis Classification:

Grade 1Minor ptosis
Nipple at level of inframammary fold, above lower contour of
Grade 2Moderate ptosis
Nipple below level of inframammary fold, above lower
contour of gland
Grade 3Major ptosis
Nipple below level of inframammary fold, at lower contour of
NAC location shift below the point of maximal projection.
Grade 1Nipple at the most projecting point of the breast.
Grade 2Nipple between the most projecting and lower
breast contour.
Grade 3Nipple 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
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 11 cm below inframammary crease

Grade 213 cm below crease but anterior to gland
Grade 33 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.
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 sizeRealistic 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 mammography35 yo

Table 5.4


Mastopexy Techniques
Mastopexy Complications: (49)
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.
Nipple areolar necrosis: diversity of nippleareolar
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 lowcan be corrected easily by crescentric
excision (11) (Fig. 5.3)
Nipple too highnecessitates complicated procedures
including an expander (11).
Nipple too medial or too lateralUp 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

Table 5.4


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
Wound dehiscence
Fat necrosis
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 5.5

Mastopexy Techniques (4)

Periareolar scar (O)

Vertical scar (lollipop)
Inverted-T scar (anchor)
L-shaped scar



This typically results in a suprasternal notch to nipple

distance of 1824 cm, depending on the height of the
patient, level of the inframammary fold, and desired
size after the mastopexy (depending on implant use and
autoaugmentation) (1,11).
Mid-humoral level for the new position of NAC should
be checked (1,11).
Lassus identified the midpoint between olecranon and
acromion. This point is superimposed breast meridian
in the horizontal plane and upper edge of the areola is
located 2 cm below this point (11).
A less commonly used method for identification of
the new nippleareola position is by the following
Lateral endpoint of inframammary fold where it
crosses the lateral axillary line is identified, and a
horizontal line is drawn between this line and the
breast meridian (11).
Using a stencil for areola markings has been accepted
by many surgeons.
The inframammary fold is often loose and subsequently
lower than desired. This needs to be taken into consideration when determining nipple height (10).
The position of the nipples should be symmetrical in
the horizontal plane and of equal height in the breast
meridian (11).
Breast parenchyma imbrication offers a dynamic position of the nipple as opposed to fixed points for the
NAC. This gives the proposed NAC its highest projection. Breast meridian is determined below and
above the nipple. With the patient in sitting position,
the parenchyma is then folded using two hands to
identify the most projecting portion of the breast in
lateral view (11).


Figure 5.1 (A) Patient with right breast cancer was reconstructed with postop adjustable saline implant. (B) Complication: For
symetry left vertical mastopexy was performed. Note the asymetry and size mismatch.





Figure 5.2 (A) Patient with left breast cancer who was reconstructed with tissue expander. (B) Tissue expander exchanged to silicone
implant and right mastopexy was performed. Note the hypertrophic scarring of the right areolar scar.



Figure 5.3 (A) Patient with left breast cancer who was reconstructed with left tissue expander. (B) Tissue expander exchanged to
silicone implant and right vertical mastopexy with augmentation was performed. Note the low location of the right nipple and boxy
appereance on the right.


The ultimate goal in periareolar scar technique is to lift the
NAC (4,6). Periareolar scar technique is used for mild ptosis. If excessive skin is removed, this technique can deform
the areola (4). This technique is associated with the greatest need for revisions (12).
Periareolar Scar Technique with Asymmetrical
Areola Shape (Crescent Mastopexy,
Supra-areolar Mastopexy)
In this technique, limited excision of a crescent-shaped
skin above the NAC is performed. This technique focuses
on location of the NAC rather than tightening of the skin.
Asymmetrical areola and crescentric skin excision only
allows resection of 2 cm skin above the areola (Fig. 5.4)
(4). This technique can result in an elongated, oval-shaped,
or widened areola.

Periareolar Scar Technique with Symmetrical

Areola Shape (Concentric Mastopexy,
Circumareolar Mastopexy, Donut, Periareolar
This technique involves removal of circumferential skin
around the NAC. Useful in mild ptosis where a subtle lift
is necessary. It is also widely utilized in unilateral reconstruction (3,14) (Fig. 5.5). It is that this technique is useful
for tuberous breast deformity, gynecomastia, and in small
and moderate size breasts with mild to moderate ptosis.
Periareolar mastopexys most recognized complication
is widening of the areola, as well as irregular and prominent scars. Due to the areolas elasticity, tension can cause
lengthening of the periareolar diameter after surgery. Minimizing tension can be achieved by limiting skin excision,
adding a vertical segment to periareolar skin segment,
using smaller implants, and using periareolar purse string
technique (3).



Figure 5.4 Asymmetrical areola and crescentric skin excision

only allows resection of at most 2 cm skin above the areola.

Figure 5.5 Periareolar scar technique with symmetrical areola


Circumareolar Scar Technique with Periareolar

Purse String Closure Mastopexy

Besides making the scar less visible, all mastopexy

techniques should improve shape and breast contour to
withstand the test of time (4). In order to overcome the flattening of the breast in periareolar mastopexy, Benellis
technique describes shaping the breast parenchyma. A concentric oval area surrounding the areola is de-epithelialized,
the breast parenchyma undermined in the lower pole, vertically split, and each wing is tacked to opposite side of the
fourth and fifth ribs (15).
Brink modified Benellis technique by creating a crescent-shaped skin excision and preventing undermining the
inferior half of the breast to preserve Coopers ligaments.
Subglandular implant placement was also added.

Purse string technique evenly distributes tension on the

periareolar opening by using appropriate suture material.
Permanent monofilament sutures rather than resorbable
sutures reduce the chances of peri-areolar widening (GoreTex, Prolene, Nylon). In order to prevent extrusion complication, the suture material in the dermal plane is placed
5 mm away from the de-epithelialized skin edge to uniformly create a dermal shelf. Use of a straight needle aids
in distributing the tension evenly. Undermining of the periareolar incision 12 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. 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).
Attention should be given to large periareolar openings.
When the periareolar opening exceeds 10 cm, pleating can
occur on the upper lateral corner. This can flatten over time,
but might become more wrinkled. Therefore, periareolar
mastopexy techniques are only effective in certain cases (3).
For concentric mastopexy, significant amount of skin
reduction might be necessary. When wide resections are
necessary, 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). 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)


This technique involves removal of excess skin from the
inferior aspect of the breast to improve the shape of the
breast parenchyma. This is performed in various ways,
all of which result in a periareolar scar with a vertical
In Lassus technique, an oval is planned around the areola. The vertical lift of the NAC is 45 cm. It entails en
bloc resection of skin, fat, and gland; transposition of the
areola on a superiorly based flap; no undermining; and a
vertical scar (Fig. 5.6).
Lejour modified Lassuss technique (Fig. 5.7) is that in
which a mushroom-shaped areolar pattern is planned
instead of an oval. A diameter of approximately 5 cm and
a length of the periareolar scar of less than 16 cm are desirable. Markings are then completed in the standard Wise
and vertical fashion (16). Aggressive liposuction is performed prior to glandular resection.



Figure 5.6

Lassuss technique.

Figure 5.8 SPAIR (short scar periareolar inferior pedicle

reduction) mammoplasty.

Instead of discarding the lower pole, it is positioned on the

upper part of the breast. Instead of relying on sutures holding the breast tissue in the chest wall, they mobilize the
lower pole, pull it upward, and hold it in place by a muscle
sling. Medial and lateral pillars are then brought together to
add more support (7,15).
Vertical Short Scar Technique, Mastopexy with
Short Scar Periareolar Inferior Pedicle
Reduction Technique, SPAIR

Figure 5.7

Lejours modification of Lassuss technique.

In Lejour and Lassus, skin is resected in the lower portion of the breast where the nipple is receiving its blood
supply superiorly. The breast parenchyma is shaped by
central tissue sutured to the pectoralis fascia and medial
and lateral parenchymal pillars sutured together. These
techniques are designed for overcorrection and will achieve
their final results months later.
Hall-Findlay modified Lejour by medial pedicled NAC,
no skin undermining, targeted liposuction, and no pectoralis fascia sutures.
Asplound-Davies modified Lassus technique by minimizing tension around the areola, resulting in a more cosmetic scar.
Biggs and Graf described an inferior pectoralis major
sling to support an inferiorly based parenchymal flap.

SPAIR short scar periareolar inferior pedicle reduction

mammoplasty: Inferior pedicle breast reduction technique
applied to mastopexy is a complex and invasive procedure (3)
(Fig. 5.8). In this technique the NAC blood supply is inferiorly based. The difference is that a superior breast flap is
undermined starting from thin (3 cm) progressing to thick
(6 cm) flaps. Then the deep edge of the upper skin flap is
advanced upward, is folded on itself to fill in the upper pole
and is fixed to the pectoralis muscle. This is overcorrected
and is responsible for direct upper pole fullness. The medial
skin flap is also plicated on itself to create a round medial
contour. In addition to shaping skin flaps, the inferior pedicle also is re-suspended superiorly to pectoralis fascia.
Redundant vertical skin is stapled temporarily, and the
inferior pedicle de-epithelialized. Periareolar incision is
closed using Gore-Tex sutures (17). In patients with very
elastic tissue, overcorrection should be more aggressive
than those with tissue that is more firm. This technique
offers direct control of the upper pole fullness, as opposed
to indirect shaping of upper pole by inferior tissue gathering. Therefore, this technique is more valuable to those
where upper pole hollowness is predominant (17).


Figure 5.9


Chiari-standardized geometric pattern.


This technique is useful when the nipple to inframammary
fold distance is longer than 8 cm. It is an alternative to extending the vertical incision below the inframammary crease.
Final skin excisions are done after parenchymal adjustments.
Chiari-standardized geometric pattern (Fig. 5.9)
Regnault-B shaped (Fig. 5.10)
In a survey among plastic surgeons, inverted-T scar was
found to be the most widely used technique. This technique is associated with bottoming out and additional
inframammary scar (12). This technique should be
reserved for patients with previous scars (3). Different
designs have been described:

Strombeck: inverted horseshoe (4) (Fig. 5.11)

Flowers and Smith: modified Wise (4) (Fig. 5.12)
Pitanguy: inverted-T incision (4) (Fig. 5.13)
Wise: pre-patterned curvilinear (4) (Fig. 5.14)
Marcah: arched gateway (4) (Fig. 5.15)
Peixoto: ellipse rectangle (4) (Fig. 5.16)
Nicolle: modified Wise (4) (Fig. 5.17)

Most breast reduction techniques are applicable to mastopexy. As in reduction mammoplasty, mastopexy relies on
specific nippleareola circulation patterns in order to prevent partial or total flap necrosis. Nipple necrosis in breast
reduction and mastopexy has been reported at 7.3% (10).
Reliable NAC transposition, maximal parenchymal support,
and minimal scars are the major goals in mastopexy.

Figure 5.10

Regnault-B shaped pattern.

In a majority of mastopexy techniques, the final breast

shape is created by skin that gives support to the structure. In these techniques however, potential postoperative changes caused by skin stretching, breast parenchyma
ptosis, and upper pole concavity can occur. These are
usually compensated for by overcorrection and by controlled bottoming out (3,7). Modification of underlying
tissues is the key rather than skin tension or excision of
skin (7). In order to maintain upper pole fullness, so as
to prevent future ptosis, and to have more predictable
outcomes, parenchyma-suturing techniques, internal
pedicle flaps, dermal flaps, and mesh placement have
been developed.
Upper pole parenchyma plication with permanent
sutures has been tried where upper fullness is necessary
without the need for an implant (18).
Breast re-suspension: Releasing the breast parenchyma
from the pectoralis major and re-suspending to a higher
level (1).
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). Svedman technique utilizes a
lower fasciocutaneous flap dissected and folded to form a
sling for the inferior pole of the breast.
Dermal flaps: Redundant skin is de-epithelialized and
used as a support by wrapping it around the inferior pedicle.
Pectoralis muscle slings: Bi-pedicled pectoralis muscle
flaps to support the breast parenchyma (1).
Mesh: Non-absorbable mesh provides permanent support
as performed by Goes. Although effective, 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).



Figure 5.11

Figure 5.13

Strombeck inverted horseshoe.

Figure 5.12

Flowes-Smith modified Wise incision.

Pitanguy inverted-T incision.

Figure 5.14

Wise pre-patterned curvilinear incision.

Cadaveric acellular dermal matrices: Use of these has

been described in augmenting support in mastopexy.
These have been used as support slings, as well as in
strengthening attenuated skin. Their use has grown in the
last five years in mastopexy (19). Autologous dermal graft
has been used in a similar manner as cadaveric grafts, and
is also a useful adjunct (20).
Combined mastopexy and breast augmentation procedure
are widely used. It is more common to encounter complications such as skin flap or nipple necrosis with these. The most
common complications encountered with combining these
two procedures are implant deflation, poor scarring, areola
asymmetry, recurrent ptosis and capsular contracture (21).

In secondary mastopexy (in the augmented patient)

adverse effects of implants on breast tissue include
atrophy, thinning, stretching, and reduction of the blood
supply to the nippleareolar complex. Proper planning is
necessary in this population in order to prevent complications. These patients might also need capsular surgery,
implant exchange, and lift. These combined surgeries
carry a significant risk. Due to compression and atrophy of
the implant, a thicker superior pedicle and a thinner
inferior pedicle is present. Therefore, it is important to preserve the blood supply through the thicker superior pedicle
for the NAC circulation in the augmented patient. Periareolar techniques are recommended including superior,


Figure 5.15


Marcah arched gateway incision.

Figure 5.17

Nicolle modified Wise incision.


Figure 5.16

Peixoto ellipse-rectangle incision.

superomedial, or superolateral. Mastopexy in patients with

large implants should be avoided (22).
Mastopexy involves a large number of procedures in
order to accomplish the goal of a rejuvenated breast. The
constellation of procedures is necessary to accommodate
various patient needs. Although the procedure is commonly done, most surgeons would agree that excellent
results that are long-lasting are difficult to achieve. The
patient should be made aware that mastopexy results are
temporary, and that need for revision is probable.
The authors would like to thank Ceren Dayicioglu for

1. Ritz M, Silfen R, Southwick G. Fascial suspension mastopexy. Plast Reconstr Surg 2006; 117: 8694.
2. Aston SJ. ed. Aesthetic Plastic Surgery. Saunders Elsevier,
3. Hammond DC. The atlas of aesthetic breast surgery.
4. Rohrich RJ, Thornton JF, Jakubietz RG, Jakubietz MG,
Grunert JG. The limited scar mastopexy: current concepts
and approaches to correct breast ptosis. Plast Reconstr Surg
2004; 114: 162230.
5. Nicolle F. Improved standards in reduction mammaplasty
and mastopexy. Plast Reconstr Surg 1982; 69: 4539.
6. Bostwick J, 3rd.
7. Graf R, Biggs TM. In search of better shape in mastopexy
and reduction mammoplasty. Plast Reconstr Surg 2002;
110: 30917; discussion 1822.
8. Khan UD. Vertical scar with the bipedicle technique: a
modified procedure for breast reduction and mastopexy.
Aesthetic Plast Surg 2007; 31: 33742.
9. Puckett CL, Meyer VH, Reinisch JF. Crescent mastopexy and augmentation. Plast Reconstr Surg 1985; 75:
10. van Deventer PV, Graewe FR. Enhancing pedicle safety
in mastopexy and breast reduction procedures: the posteroinferomedial pedicle, retaining the medial vertical
ligament of Wuringer. Plast Reconstr Surg 2010; 126:
11. Gulyas G. Marking the position of the nipple-areola complex for mastopexy and breast reduction surgery. Plast
Reconstr Surg 2004; 113: 208590.
12. Rohrich RJ, Gosman AA, Brown SA, Reisch J. Mastopexy
preferences: a survey of board-certified plastic surgeons.
Plast Reconstr Surg 2006; 118: 16318.
13. Handbook of plastic surgery. Marcel Dekker, 2004.

14. Spear SL, Kassan M, Little JW. Guidelines in concentric
mastopexy. Plast Reconstr Surg 1990; 85: 9616.
15. Grabb and Smith Plastic Surgery.
16. Adams WP. Reduction Mammaplasty and Mastopexy.
Selected Readings in Plastic Surgery 2002; 9: 29.
17. Hammond DC, Alfonso D, Khuthaila DK. Mastopexy using
the short scar periareolar inferior pedicle reduction technique.
Plast Reconstr Surg 2008; 121: 15339.
18. Jones GE. ed. Bostwicks Plastic and Reconstructive Breast
Surgery. 3rd edn. St Louis, Missouri: Quality Medical Publishing, 2010: 641729.


19. Colwell AS. Improving shape and symmetry in mastopexy
with autologous or cadaveric dermal slings. Ann Plast Surg
2008; 61: 13842.
20. Hudson DA, Adams KG, Adams S. Autologous Dermal
Graft in Breast Reconstruction. Ann Plast Surg 2011.
21. Stevens WG, Freeman ME, Stoker DA, et al. One-stage
mastopexy with breast augmentation: a review of 321
patients. Plast Reconstr Surg 2007; 120: 16749.
22. Handel N. Secondary mastopexy in the augmented patient:
a recipe for disaster. Plast Reconstr Surg 2006; 118(7
Suppl): 152S63S; discussion 64S65S, 66S67S.

Reduction mammoplasty
Rosiane Roeder and Seth Thaller


Plastic Surgeons, approximately 78,000 breast reductions

were performed in the U.S. in 2009, 53.7% of them in
women 40 years or older (3). The vast majority of operations are safely performed in an outpatient setting under
general anesthesia (4). Satisfaction associated with breast
reductions have been reported at greater than 90% (5).
The first breast reduction surgery may have been performed as far back as 625690 AD (6). However, it was
not until the late 1890s that the first reports of reduction
mammoplasties appear in the literature. Throughout its
evolution, many surgeons pioneered different procedures
as the understanding of breast anatomy flourished and
patients expectations for aesthetically pleasing results and
minimal scaring increased.
The sheer number of available breast reduction techniques shows that one approach does not necessarily fit all.
Some techniques are more appropriate for patients with
very large reductions or favor the less-experienced surgeon. However, it is clear that there are important common
concepts that should be observed in order to guide the
surgeons choice of procedure:

Breast hypertrophy (macromastia or gigantomastia) is

defined as a condition of having excess bilateral breast tissue weighing over 600 grams (1). The exact etiology
remains known, however, it is most likely due to an abnormal response of breast tissue to the stimulatory effects of
estrogen and progesterone. There is also a familial component (2). Hypertrophy can be classified as:
VirginalThis is seen prior to the onset of puberty.
Breasts may undergo substantial growth during a very
short period of time;
GestationalThis generally occurs in the second trimester. It can impact milk supply and lead to mastitis;
Adult onsetThis is the most commonly encountered
type with progressive enlargement leading to physical
discomfort and decreased functional capacity;
IatrogenicThis is secondary to certain medications
such as penicillinime. It usually can be reversed by
cessation of medication or anti-estrogen therapy;
Associated with obesity.

knowledge and respect for breast anatomy and neurovascular supply;

need of a vascularized pedicle for the nippleareola
complex (NAC);
breast size, symmetry, and degree of ptosis;
and relationships of breast size to body mass index

Reduction mammoplasty is a reconstructive procedure

performed for the alleviation of pain and discomfort associated with excessive and pendulous breast tissue of any
origin. Breast reduction remains one of the top five most
common reconstructive procedures performed in the
United States. According to the American Society of



This chapter will highlight relevant anatomy, indications, and pre-operative evaluation for surgery, most commonly performed techniques, post-operative care, and


from 3 main arterial trunks that converge into an anastomotic network:

1. Interthoracic artery, internal mammary perforating
2. Axillary artery, lateral thoracic branches;
3. Intercostal artery, lateral branches. The NAC complex
is supplied by a network of perforating branches derived
from the dermis.

Adult breasts are located between the second and the sixth
ribs just lateral to the sternum and medial to the midaxillary line. They overlie three different muscles: the pectoralis major inferiorly, the serratus anterior inferiorlateral,
and the rectus sheath at its most caudal portion. The
axillary tail of Spence is the breast tissue that extends
superiolaterally into the axilla. Coopers ligaments are
collagen-rich structures that maintain breast shape. They
extend transversely from the dermis and the pectoralis fascia. Pectoralis fascia overlies the pectoralis major muscle
and is covered by a layer of loose connective tissue that
allows for movement of breast tissue. The nipple lies at the
level of the fourth intercostal space. The distance between
the NAC and the sternal notch measures, on average,
21 cm, a distance that can be significantly greater in
women with macromastia and/or ptosis. This is an important reference measurement for the future repositioning of
the nipple during reconstructive surgery.
Breast parenchyma is composed of fatty and glandular tissue. The ratio between these two components
changes in females in relation to stage of development
and hormonal shift during pregnancy and senescence.
Embryologically, it arises from a milk streak in the torso
spanning from the axilla to the groin. This eventually
regresses to form paired nipple and breasts. About 1520
lactiferous ducts are present that covalence at the nipple
at birth. Breast buds may be enlarged in the neonate due
to maternal estrogens that remain in circulation immediately after birth. Breast tissue remains otherwise
underdeveloped until puberty when the ducts proliferate
in response to estrogen and progesterone. There is
engorgement of the fatty and glandular tissue. During
pregnancy, there is further proliferation of glandular and
secretory epithelium that allows for lactation. With the
onset of menopause, there are significant changes in
breast tissue. Glandular tissue is replaced by fatty tissue
and/or significant decrease in breast size occurs in
addition to decreased amounts of collagen. All contribute
to ptosis associated with aging.

Sensory nerve supply to the breast and the NAC, in particular, is of great importance. Innervation to the female
breast and overlying skin is derived from cutaneous
branches of the first to the seventh intercostal nerves.
Nerves penetrate the deep fascia at the mid-axillary line
and lateral to the sternum. They reach the surface from
each side anastomosing around the midline. Supply to
the nipples may have contributions from the anterior and
lateral branches of the third, fourth, and fifth intercostal
nerves. However, the fourth intercostal branches are the
ones thought to always be involved (8). Specifically, the
anterior cutaneous branch of the fourth intercostal is
primarily involved. Nonetheless, several observations
report the eventual recovery of loss sensation from the
breast after a period of 6 months from the initial surgery
(5). There may be a certain degree of regeneration of
these cutaneous nerves. Size of resection may also affect
sensation, despite the pedicle used. Conservation of the
anterior branch of the fourth intercostal nerve should
guarantee sensory supply to the NAC from its most
reliable source.

Vessels and Lymphatics

Shapes and Landmark Measurements

Understanding of the blood supply, lymphatic drainage,

and innervation of the breast is very important for successful breast surgery. 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). However, it is not a perfect

Venous system runs in parallel with the arterial system.

Veins drain toward the axilla into three main groups: internal thoracic; axillary; and posterior intercostal veins.
The lymphatic system also runs alongside blood vessels. Lymph nodes are generally divided into three levels
according to relationship with the pectoralis minor muscle.
Level I lymph nodes are located inferiorly to the pectoralis
minor usually in the axilla. They receive most of the lymphatics from the breast (7). Level II nodes are behind the
pectoralis minor. Level III nodes are superior to the pectoralis minor, mainly the subscapular nodes. There is also
drainage to the inframammary nodes, which are involved
in cancer metastasis in less than 15% of cases (7,7). Intercostal nodes receive contribution from the most lateral
aspect of the breast.



cone with the upper pole somewhat flattened. Macromastia

increases flattening of the upper pole, the size of the
rounded base, and lowers the level of the NAC (9). These
pathologic features should be addressed during a breast
reduction. In small reductions (<200 g), it may be possible
to achieve this with only removing fat or glandular tissue.
However, most resections will require removal of excess
skin and repositioning of the NAC to restore shape and
In 1955, Penn studied 150 women to describe landmark
measurement and positioning of the nipple within the
breast. An equilateral triangle can be drawn between the
suprasternal notch and the nipples with limbs measuring
21 cm (10). Nipple to inframammary fold distance is on
average 6.9 cm. Ideal areolar diameter is 3.84.5 cm.
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. 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.
Most women do not know their true brassiere size.
Trusting self report is insufficient. Two measurements are
necessary to determine brassiere cup. First, measure the
chest wall girth at the level of the inframammary fold.
Second, measure the girth at the level of the nipple. This
can be a challenge with severely ptotic breasts. Best estimates are determined when the breasts are elevated to the
level of ideal nipple position. The following formula is
used to calculate the brassiere cup (inches) (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

Cup Size


DD or E
DDD or F

(11). For a given chest wall size, 1 cup reduction results in

a particular weight in grams as seen in Table 6.2.
Breast reduction are performed in women with excessive
breast tissue who present with any of these associated
symptom: head, neck, shoulder and back pain; brassiere
strap groove caused by a tight-fitting brassiere; limitation
of activities of daily living; intertrigimous dermatitis;
sleep disturbances; and/or respiratory problems (Fig. 6.1).
Also, significant psychosocial sequalea associated with
large breasts cannot be overlooked. A summary of indications is listed in Table 6.3.
Patients for breast reduction must be optimal candidates for surgery and general anesthesia. Pre-operative
evaluation should ascertain overall good health. Full breast
examination should be performed by the surgeon. 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. Any suspicious cancerous findings
require referral to a surgical oncologist.
Reductions should be performed primarily in adult,
fully developed, breasts, except for the rare virginal hypertrophy. Patients should understand potential surgical complications, including scars on the breast, temporary or
permanent loss of sensation, difficulties or inability to
breastfeed after procedure, and that asymmetry between
the two breasts may occur.
Patients undergoing reduction mammoplasty generally
request the procedure due to physical debilitation secondary to large breast. Breast reductions are considered a
reconstructive procedure not a cosmetic one, because the
desired outcome is functional and not aesthetic. Nonetheless, consideration of the final aesthetic result is important
to patients satisfaction. Being thus a reconstructive procedure, insurance coverage does apply to most cases. Specific
guidelines exist by most insurers, although most require a
minimum of 500 gram resection per breast, documentation
regarding pain symptoms and/or activity of daily living
limitations, and that efforts to ameliorate symptoms without surgery have failed. Although it is known that smaller
reductions do provide amelioration of symptoms, it is
Table 6.2 Reduction Size Estimate Based on Chest Wall
Measurement and Cup Size.
Chest wall

1 Cup

2 Cups

3 Cups

4 Cups

3234 inches 100 grams 200 grams 300 grams 400 grams
3638 inches 200 grams 400 grams 600 grams 800 grams
4042 inches 300 grams 600 grams 900 grams 1200 grams






Figure 6.1 Indications for reduction mammoplasty. (A) Enlarged breasts (macromastia/gigantomastia). (B) Should groove from bra
strap. (C) Intertigimous dermatitis.
Table 6.3

Indications for Breast Reduction

Pain head, neck, shoulder, back

Should grooves from brassiere strap
Activity limitation
Intertigimous dermatitis
Sleep disturbances
Respiratory illness

extremely difficult to have these covered. Therefore, long

discussion with patients toward their expectations and
financial responsibility for the procedure is warranted.

No clear classification for breast reduction techniques

exists. Techniques are generally described based on the
pedicle and/or skin incision pattern. It is important to note,
that the skin resection patterns are not unique to a particular parenchymal resection; thus a technique may be named
by its scar and pedicle (i.e., inverted-T inferior pedicle).
In order to avoid technically related complications, the
surgeon should choose a technique with which they are
familiar and comfortable performing. Consideration of
patients individual needs is also important. Even though
some of the techniques given below can be used with modifications for small, medium, and large reductions, certain
techniques are better suited than others.

Wise Pattern, Inverted-T, Inferior Pedicle
Numerous breast reduction techniques have been reported
over the years resulting in over one hundred different procedures (12). This chapter will describe two of the most
common techniques and briefly refer to some that may be
used on specific occasions.

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 was described by Ribeiro
in 1975 (13). It has since been modified by many (14).



Figure 6.2 Inverted-T scar. Note scar around areola, vertical scar from midline areola to the inframammary line, and inframammary
scar extending toward the axilla.

It is reported as a predictable, relatively quick, easy to

learn and teach procedure, yet still allows for a tailored
surgery based on patients needs. It also gives the surgeon
some artistic freedom. It can be used for small or very
large reductions. Importantly, NAC sensation is frequently
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. Wise developed his keyhole
technique in 1956 after patterns used for making brassieres (15). Although most surgeons free hand their Wise
pattern markings, pre-cut patterns are commercially
available. Scars resulting from use of the Wise pattern are
the typical inverted-T (Fig. 6.2).
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. 6.3). A vertical
line is drawn at the midline from the suprasternal notch
and the umbilicus. A paramedian line is drawn from
mid-clavicle to the nipple on each breast. Inframammary
fold (IMF) is marked. New nipple position will be
transposed to the paramedian line at or slightly below the
level of the inframammary fold. Distance between the new
nipple position and the suprasternal notch should be
approximately 2125 cm allowing for the final position to
lay at 1921 cm. Area for the new NAC should be marked
slightly larger than the desired nipple size. A nipple size of
about 35 cm is appropriate for most reductions. Vertical
limbs of the wise pattern should be between 5 and 7 cm.
Horizontal limbs are then drawn medially toward the IMF

resting about 4 inches from the xyphoid in order to avoid

symmastia. Laterally, the horizontal limb should follow
the natural breast contour. This incision may be extended
as far posteriorly as needed depending on the size of the
The patient is placed supine in the operating room table
with arms positioned at 90. Breasts are prepped and
draped in sterile fashion. Prophylactic antibiotics are
given. Incision is made around the areola usually after a
cookie cutter is used to mark the desired areolar area.
Inferior pedicle is then outlined. Base of the pedicle should
be between 8 and 10 cm depending on reduction size
(larger for larger reductions). Deepithilialization of the
inferior pedicle and tissue surrounding the areola is performed (Fig. 6.4). Next, superior flaps are elevated to the
pectoralis fascia. Glandular and fatty tissue outside the
inferior pedicle is then excised. Surgical site is irrigated
and hemostasis is achieved. Pedicle is displaced superiorly
so that the nipple can be repositioned anatomically. Holding sutures are used to tack the skin envelope so that the
new nipple can be estimated with the patient in a sitting
position. It is then repositioned as necessary. One #10
Jackson-Pratt drain is placed in the dependent region of
each breast. This should exit at the distal end of the inframammary incision. Deep tissues are closed using 3-0
Vicryl sutures. NAC is then brought to the surface and
sutured into place with 4-0 Vicryl. The skin around the
areola is sutured with 5-0 Monocryl. Inverted-T is sutured
with 4-0 Vicryl subdermal followed by running layer of
4-0 Monocryl. Xeroform dressing is used along the






Figure 6.3 Pre-operative marking for inferior pedicle inverted-T scar with Wise pattern. (A) Line establishing the midline. X indicates
new nipple position based on transposition of IMF at breast median. (B) Use of measuring tape around the neck to determine the breast
midline (mid-clavicle to nipple). (C) Wise pattern.

Figure 6.4

Intraoperative view of inferior pedicle after parenchymal resection.


incision lines and fluffed gauze is placed over the breast

before a surgical brasserie is placed.
Vertical Scar
Described by Lassus in 1964 (16) and adapted by LeJour
in 1994 (17), vertical reduction mammoplasty has the
advantage of fewer scars, good aesthetic result, possibility
of breastfeeding, good sensation, and can be performed for
any size reduction. However, it is not a procedure for the
novice surgeon. It requires training, surgical skill, and
does not rely on a fixed pattern of resection. Also, results
are not immediately seen post-operatively, since at least
3 months will go by before the breasts reach their new
desired shape.
Glandular pattern used by Lejour is traditionally the
superior pedicle. However, some surgeons will use other
patterns, such as superiomedial and bipedicle techniques.
We will report on Lejours superior pedicle technique.
Advantages of the superior pedicle include upper pole fullness and less ptosis over time.
Patient is marked while standing. At first, the area of the
superior pedicle is outlined. Skin pattern of incision is
marked. This technique used a mosque dome pattern for
skin incision. A vertical line marks the breast at the midline and beneath the inframmary fold. The inframammary
fold is also marked. Next, the site of the future areola is
marked slightely below the inframammary fold as a semicircle of approximately 16 cm. Allow 10 cm of the pedicle
width at the upper border of the future areolar area. Peripheral limbs join together at about 5 cm from the inframammary fold. This is done by displacing the breast on its
verticle axis medially and laterally. Future areolar circumference is marked around the nipple.
Patient is placed supine in the operating room table with
arms at 90. Breasts are prepped and draped in sterile fashion. Prophylactic antibiotics are given. Incision is made
around the areola and de-epithilialization of the pedicle
follows. Medial and lateral flaps are raised as breast tissue
is excised inferior, medial, and lateral to the remaining
superior pedicle. Fat from the breast tissue can also be suctioned (17). The NAC is placed at its final position. 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. When the position of the NAC is optimized, the remaining tissue is irrigated. Placement of
drains is up to the surgeon and if placed should be in a
dependent position. Skin is closed with a resultant vertical


scar at the midline below the nipple. At times, a small

horizontal scar may be necessary to accommodate excision of redundant skin in larger resections (18). Patients
with large reductions should be aware of this possibility.
Liposuction has been used as an adjunct to other reduction
techniques for some time. Recently, liposuction alone has
gained attention lately due to the perspective of a minimally scarring process. It is indicated for patients whose
breasts have predominately fatty tissue, as it cannot
remove glandular tissue. Also, it is best for small reductions, where ptosis is not a significant problem and acceptable results are achieved without skin resection. Ideal
patients are young without major hypertrophy or ptosis.
However, if a patient is older, has major hypertrophy, but
is unconcerned with breast shape, this technique can also
be considered. Another group that can potentially benefit
comprises patients who have a tendency to form hypertrophic scars (19).
Pre-operative markings are not required. An incision is
made 2 cm above the IMF slightly lateral to the midline. A
blunt-tip multi-hole cannula is introduced. This is attached
to a pressurized 1 L normal saline bag containing a 2%
lidocaine and 12 mg of epinephrine. This mixture is
infused in the superficial plane until the skin looks raised.
The surgeon can then wait 10 minutes for local vasoconstriction to take place before proceeding with pretunneling. Once the area to be liposuctioned is ready, the
blunt cannula is attached to a vacuum and fat is removed
from the deep to superficial layer in a fanning pattern.
Once the desired amount of fat is removed, the surgeon
may switch to a smaller cannula (23 mm) and tunnel
superficially without vacuum. This will result in controlled
scarring that can help prevent ptosis. Skin incision is
closed using buried 4-0 Monocryl. When surgery is complete, surgical tape is used to maintain breast shape and a
surgical brasserie placed.
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. Also, bruising and
pain in breast area are expected. However, most patients
return to normal activity within 72 hours.
Breast amputations were the first surgeries performed for
macromastia. Thorek, in 1922, described the use of free
nipple grafting after amputation (20). Although, this procedure is not widely used today, it hallmarks the transition to
a period in reduction mammoplasty where the conservation
of function and sensitivity to the NAC became essential.



Free nipple grafting today is reserved for specific indications. These include older, high-risk patients with
expected resection of more than 2 kg per breast (21). Many
glandular pattern of glandular and skin resection can be
used. Pre-operative marking should follow that of the chosen dermatoglandular pattern to be followed. 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.
Harvest of the free-nipple graft should be accomplished
first. Diameter of the graft should be about 4.5 cm. Thereafter, the surgeon will proceed with parenchymal resection
according to the desired breast reduction technique of
choice. However, a de-epithelialized pedicle should be
used to receive the nipple graft. There should be minimal
undermining in the superior flap so that the remaining
breast will have adequate projection.
Usually, the surgeon will close the breast mount, leaving a centrally located position for placement of the nipple
graft. After the nipple graft is in place, it is sutured and
held in position with a tie-over bolster.

The number of wound infections has decreased with the

use of pre-operative antibiotics. These should be administered within 30 minutes of incision time. Some controversy exists on the use of post-operative antibiotics,
especially if drains are left in place. However, 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).
Non-healing wounds and wound dehiscence are most
often seen at the junction site of the inverted-T scar
(Fig. 6.5). High body mass index and large resection size
were predictive of wound healing complications (23).
Complications related to the NAC were initially a great
problem in breast reductions. This, however, has been significantly reduced in new techniques, and rarely seen now
that the surgeons understand the origin of the blood and
nerve supply to the NAC. With free nipple grafting techniques, there is a greater likelihood of partial necrosis,
however, not all patients appear to adversely affected by
this (21).
Hypertrophic scarring is most often seen in the inframammary fold incision and occurred in about 3.3% in a
series of patients who underwent reduction with an inferior

Breast reduction surgery is generally a very safe procedure. Complication rates occur in about 520% of cases
depending on the series and definition of complication
(5,12,2224). Deaths have been rarely recorded. Most
common complications are seroma, hematoma, wound
infection, wound dehiscence, fat necrosis, necrosis of the
NAC, loss of sensation and erectile function of the nipple,
and hypertrophic scarring (Table 6.4).
In order to detect early seroma or hematoma formation,
many surgeons use drains. These are left for about 24
hours post-operatively. However, if a seroma or hemaroma is detected, immediate drainage is required to avoid
suppurative infection, build up of pressure that can compromise blood supply to the NAC, and wound dehiscence.

Table 6.4

Common Complications of Breast Reduction

Wound infection
Wound dehiscence
Fat necrosis
Necrosis of NAC
Loss of sensation of NAC
Loss of erectile function of NAC
Hypertrophic scarring

Figure 6.5 Post-operative complication. Non-healing wound

at junction of inverted-T incision.


pedicle technique (26). African Americans, as expected,

have higher rates of hypertrophic scarring (23).
Breast reduction is a common reconstructive procedure of
the breast. This is a very rewarding procedure for both
surgeon and patient. High patient satisfaction is widely
reported (5,22,27,28). Several techniques exist, but the
inferior pedicle inverted-T scar is currently most popular.
Surgeons should choose a technique they are proficient
performing, as this is most important to avoid surgical complications. Importantly, patients should be well informed
about the procedure, potential complications, and aesthetic
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Familial translocation t(1;9) associated with macromastia:
molecular cloning of the breakpoints. Sex Dev 2007; 1:
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2009 Statistics. 2010.
4. Okoro SA, Barone C, Bohnenblust M, Wang HT. Breast
reduction trend among plastic surgeons: a national survey.
Plast Reconstr Surg 2008; 122: 131220.
5. Eggert E, Schuss R, Edsander-Nord A. Clinical outcome,
quality of life, patients satisfaction, and aesthetic results,
after reduction mammaplasty. Scand J Plast Reconstr Surg
Hand Surg 2009; 43: 2016.
6. de Souza A, Saltz R. The common principles of effective
breast reduction techniques. Aesthetic Surg J 2000; 20:
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BB. Lymphatic drainage patterns from the breast. Ann Surg
2004; 239: 2327.
8. Jaspars JJ, Posma AN, van Immerseel AA, Gittenberger-de
Groot AC. The cutaneous innervation of the female breast
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Plast Surg 1997; 50: 24959.
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Aesthet Surg 2008; 61: 128493.
10. PENN J. Breast reduction. Br J Plast Surg 1955; 7: 35771.

11. Regnault P, Daniel RK. Breast reduction. In: Regnault P,
Daniel RK, eds. Aesthetic Plastic Surgery: Principles and
Techniques. Boston: Little Brown, 1984.
12. Daane SP, Rockwell WB. Breast reduction techniques and outcomes: a meta-analysis. Aesthetic Surg J 1999; 19: 293303.
13. Ribeiro L. A new technique for reduction mammaplasty.
Plast Reconstr Surg 1975; 55: 3304.
14. Lickstein LH, Shestak KC. The conceptual evolution of
modern reduction mammaplasty. Operat Tech Plast Reconstr Surg 1999; 6: 8896.
15. WISE RJ. A preliminary report on a method of planning the
mammaplasty. Plast Reconstr Surg (1946) 1956; 17: 36775.
16. Lassus C. A technique for breast reduction. Int Surg 1970;
53: 6972.
17. Lejour M. Vertical mammaplasty and liposuction of the
breast. Plast Reconstr Surg 1994; 94: 10014.
18. Poell JG. Vertical reduction mammaplasty. Aesthetic Plast
Surg 2004; 28: 5969.
19. Jakubietz RG, Jakubietz DF, Gruenert JG, et al. Breast
reduction by liposuction in females. Aesthetic Plast Surg
2011; 35: 4027.
20. Thorek M. Possibilities in the reconstruction of the human
form. Med J Rec 1922; 116: 5723.
21. Restifo R, Lalikos J. Amputation/free nipple graft reduction
mammaplasty. Operat Tech Plast Reconstr Surg 2011; 3:
22. Freire M, Neto MS, Garcia EB, Quaresma MR, Ferreira LM.
Functional capacity and postural pain outcomes after
reduction mammaplasty. Plast Reconstr Surg 2007; 119:
23. Henry SL, Crawford JL, Puckett CL. Risk factors and complications in reduction mammaplasty: novel associations
and preoperative assessment. Plast Reconstr Surg J 2009;
124: 10406.
24. Shah R, Al-Ajam Y, Stott D, Kang N. Obesity in mammaplasty: a study of complications following breast reduction.
J Plast Reconstr Aesthet Surg 2011; 64: 50814.
25. Throckmorton AD, Boughey JC, Boostrom SY, et al. Postoperative prophylactic antibiotics and surgical site infection
rates in breast surgery patients. Ann Surg Oncol 2009; 16:
26. Mandrekas AD, Zambacos GJ, Anastasopoulos A, Hapsas
DA. Reduction mammaplasty with the inferior pedicle
technique: early and late complications in 371 patients. Br
J Plast Surg 1996; 49: 4426.
27. Freire M, Neto MS, Garcia EB, Quaresma MR, Ferreira
LM. Quality of life after reduction mammaplasty. Scand
J Plast Reconstr Surg Hand Surg 2004; 38: 3359.
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Oncoplastic surgery of the breast
Robert A. Grossman, Peter J. DiPasco, Subhasis Misra, and Eli Avisar


attempt to re-approximate the breast tissue around the

excision cavity for fear of causing further cosmetic deformities. The cavity is left to fill with serous fluid that will
appear to have replaced the missing tissue in the first postoperative phase. Unfortunately, after this seroma gets
reabsorbed, a deformity forms, and in some cases the skin
attaches to the deep cavity surface resulting in even worse
cosmetic results. Furthermore, the concept of purposefully leaving a seroma in the breast is opposed to general
surgical principles elsewhere in the body. In standard
breast conserving surgery, 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. Another significant difference is the length of the skin incision. While
the incision length itself is kept to the minimum in breast
conserving surgery, OPS will require longer incisions in
order to allow for appropriate breast tissue reconstruction.
Lastly, OPS allows for significant movement of the breast
tissue. For that reason, it is often difficult for the radiation
oncologist to estimate the exact location of the breast tissue previously surrounding the tumor. To remedy this,
marking clips are usually left in the surrounding tissue
prior to reconstruction of the breast. 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 (1,6). The techniques of oncoplastic

Oncoplastic surgery (OPS) has emerged as the latest paradigm in the treatment of cancer of the breast. Prior to the
development of OPS, the surgeon could provide either a
modified radical mastectomy or a segmental excision with
subsequent radiation to the breast cancer patient (1). With
integration of plastic surgical techniques into the repertoire of the breast surgeon, a new way to treat women with
early-stage cancer of the breast has emerged. Oncoplastic
surgery allows the surgeon to perform larger resections of
the breast with better cosmetic outcome while adhering to
oncologic principles (15). 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.
OPS stems from breast conserving surgery (BCS), 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). 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. Breast conserving
surgery, however, has limitations: it is often difficult
to completely excise the tumor and maintain the natural
shape of the breast, and BCS does not always produce acceptable cosmetic results (1). A few very distinct
differences in the surgical principles characterize OPS
as a separate technique. Traditionally, BCS includes no


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. While OPS is not new, it is yet to be widely
embraced within the United States (1,7,8).
Clough et al. describe a succinct and beneficial way in
which the breast surgeon may select patients appropriate
to receive OPS (1). They identify three components that
are key for an oncoplastic approach to breast conserving
therapy: excision volume, tumor location, and glandular
density (1,9).
We have developed a slightly different working algorithm that takes into consideration the size of the breast.
Accordingly, there are four main factors to be considered
when evaluating a patient for an oncoplastic approach:
excision volume, tumor location, breast size, and glandular density. A mnemonic to remember this by is Vikings
Love Slim Dancers. 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.
For example, extirpation of smaller tumors may result in
significant cosmetic deformity in women who have smaller
Excision volume and breast size are the most important factors in predicting the outcome of surgery and the
probability of breast deformity (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). 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, 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 (1,11). Details of specific techniques to reshape
the breast will be discussed later in the chapter.
Tumor location is an essential component in the surgical planning of OPS. Certain areas of the breast carry
higher risks of deformity than others (1). The lower pole
of the breast and the upper inner quadrants are associated
with a high risk of deformity, while the upper outer pole is
an area in which defects may be corrected much more
easily (1,6). 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 surgeons ability to undermine and reshape tissue without complications (1). A very dense breast has a lower risk
of undergoing post-operative fat necrosis when compared
to a fatty breast. The Breast Imaging Reporting and


Data System (BI-RADS) classifies breasts into four groups

based on mammographic density: fatty, scattered fibroglandular, heterogeneously dense, or extremely dense (2,13).
Preoperative mammographic evaluation of breast density
may aid the surgeon in deciding whether to perform extensive undermining in the removal of a breast cancer.
Clough et al. have created a two-tiered system by which
one may approach the oncoplastic breast surgery (1).
Level I techniques are to be used for procedures in which
less than 20% of the breast volume is to be excised, no
skin excision is expected, 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). In
addition, nippleareola complex (NAC) recentralization is
performed if deformity is expected. Level II techniques
are to be undertaken when 2050% of the breast volume is
to be extirpated in which skin will also be removed in
order to reshape the breast (1). We propose to add a third
level to this algorithm: Level III techniques are to be used
for oncoreductive procedures in which the ipsi- and/or
contralateral breast will undergo reduction as well as extirpation of the tumor. Level I procedures do not require specific training in plastic surgery; level II and III procedures
require the practitioner to have training in oncoplastic
technique. See Figure 7.1 for a visual representation of
when to perform the various techniques of OPS.
The position of the skin incision is very important in
level I OPS. We typically utilize curvilinear incisions in
the upper outer quadrant and in the superior central area,
whereas horizontal incisions in the superior medial quadrant or radial incisions in the remainder of the breast are
otherwise employed. If the lesion is close to the NAC or
significant undermining of the NAC will be necessary for
recentralization, we will often extend the radial incision
along the areolar margin and on both sides of the radial
incision. The area of undermining should be reduced if a
history of smoking, obesity, or fatty composition of the
breast is present, as each is a risk factor for fat necrosis (1).
Although some authors have described de-epithelialization
for NAC repositioning, we find it rarely necessary. During
the flap development, the NAC is completely freed from
the deeper parenchyma similar to a subcutaneous mastectomy. After the tissue has been reapproximated, the NAC
is allowed to fall back down to its central position. Patients
for whom this technique cannot be performed are those
who have previously undergone circumferential incisions
around the NAC; 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. 7.3 and 7.4).
Level II OPS procedures depend on the position of the
tumor and the extent of excision volume. Clough et al.
have provided an excellent atlas based on tumor location,
which will be briefly summarized. The locations in the




< 20%

>= 20%



Level I

Breast Size

Large or

Large or
ptotic breast

Fatty Breast


Fatty Breast


Level III

Level I

Level II

Level I

Level II

Figure 7.1

Level III

Oncoplastic algorithm.

mammoplasty or
modified round


or batwing



or medial


Superior pedicle
mammoplasty with
inverted-T or
vertical scar

Figure 7.2

Procedures for areas of the breast.


Figure 7.3

Figure 7.4


Level I OPS in lower inner quadrant, 5 months after radiation of the breast and internal mammary chain.

Level I OPS in lower inner quadrant, 5 months after radiation of the breast and internal mammary chain (side view).

breast will be referred to as one would the face of a clock,

oriented for the left breast.
Lesions in the lower pole (5 to 7 oclock) have a high
risk of birds beak deformity. The technique of choice
for tumors in this location is a superior pedicle mammoplasty
with inverted-T or vertical scar; this is similar to the technique used for breast reduction. 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. An inframammary incision is then completed, followed by undermining of the
breast tissue off the pectoralis fascia and finally en bloc

removal of the tumor. Once the resection is complete, the

breast is reshaped by re-approximation of the medial and
lateral glandular tissue to the midline, followed finally by
NAC recentralization.
Tumors of the lower inner quadrant (79 oclock) are
more difficult due to the paucity of excess breast tissue
medially. A V-mammoplasty has been proposed, involving pyramidal excision of the gland down to the pectoralis
fascia followed by rotation of the lateral glandular flap to
fill the defect.
Cancers of the upper inner quadrant (1011 oclock)
may be some of the more challenging to extirpate due to


the extremely low amount of nearby tissue free for flapping. Silverstein et al. described a batwing excision pattern, while Berry et al. describe an omegaplasty for lesions
in this area (6,14).
Tumors of the upper pole (111 oclock) rarely cause
deformity, as one can perform a vertical based mammoplasty re-approximating the medial and lateral breast
tissue with or without a partial breast lift. Clough has
described a round block technique in which concentric
periareolar incisions are made (1). We find it usually
unnecessary to incise the NAC circumferentially. Rather,


a crescent shape incision from 39 oclock of the areola

is sufficient (Figs. 7.5 and 7.6).
Tumors of the upper outer quadrant (13 oclock) have
the lowest associated risk of deformity unless more than
20% of the breast volume is resected (1). A racquet mammoplasty can be used for resection of tumors in this location. 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.
NAC undermining and repositioning are also undertaken
during this procedure (Figs. 7.7 and 7.8).

Figure 7.5 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).

Figure 7.6 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).


Cancer of the lower outer quadrant (45 oclock) may

have a J-type mammoplasty performed in order to avoid
lateral retraction or deviation of the breast. This entails
de-epithelializing the nipple-areola complex while allowing it to retain blood flow from a superior pedicle. Two
incisions are then made from the NAC to the inframammary fold, both slightly curving to the lateral side of the
breast. The medial and lateral glandular tissues may then
be approximated with concurrent lift of the NAC into the
superior pedicle of the breast.
Finally, retroareolar masses may also be removed via
oncoplastic surgery. A Lejour vertical mammoplasty excising

Figure 7.7

Figure 7.8


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. The nipple and
areola can be reconstructed at a later date.
Figure 7.2 shows a visual representation of the procedures one may perform for each area of the breast.
Level III oncoreductive techniques can be employed in
patients who may have larger tumors in large-sized or pendulous breasts. In those cases the oncologic resection is
combined with a bilateral breast reduction, usually through
a classic inverted-T technique (Figs. 7.9 and 7.10). 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.

Level II OPS of the upper outer quadrant of the right breast 2 years after surgery (side view).



Figure 7.9 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. Panthaki).

Figure 7.10

Postoperative view of patient in Figure 7.9 (courtesy of Zubin J. Panthaki).

of radiation therapy by reducing the exposure of intrathoracic structures to the radiation fields and by optimizing the homogeneity of the radiation, both significant
concerns in large and pendulous breasts. The exact timing
of the contralateral breast reduction remains controversial
because, although a bilateral procedure will achieve the
best immediate symmetry, long-term results are difficult to
predict after radiation therapy to the affected breast which
typically ends up more edematous and less pendulous. The

alternative is to delay the creation of symmetry of the

contralateral breast until the post-radiation changes have
reached final form. Regardless, when the contralateral
side is operated simultaneously, compensation for future
changes in the radiated breast should be taken into account.
A completely different approach to OPS is the performance of volume replacement surgery rather than volume
displacement surgery (1517). There are four main
approaches to volume replacement surgery: the use of


silicone implants, myocutaneous latissimus dorsi flaps,

myosubcutaneous latissimus dorsi flaps, and lateral
adipose tissue flaps.
Silicone implants have fallen out of favor among oncoplastic surgeons due to high rates of capsule formation and
local deformity (1819). These changes can be attributed to
the use of post-operative radiotherapy, which may speed
formation of the scar tissue surrounding an implant as well
as cause soft tissue atrophy in the tissues surrounding the
implant (1820). Further, 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 (21,22).
Myocutaneous latissimus dorsi flaps and myosubcutaneous latissimus dorsi flaps are useful for upper and lower
pole defects, particularly of the lateral side of the breast
(7,2327). The former carries an added skin paddle, which
is both boon and detrimentit adds to the replacement
volume, but due to the difference in skin quality between
the breast and the skin overlying the latissimus dorsi, the
cosmetic result may be lacking. A myosubcutaneous flap
avoids the problems associated with cosmesis of a myocutaneous flap, and can be made thicker through harvesting
of surrounding adipose tissue.
Adipose tissue flaps may be considered as an additional
technique for volume replacement surgery of the breast
(15,16). However, the low vascularity encountered in most
adipose tissue causes these flaps to be difficult to work
with. Many flaps will undergo necrosis or involution after
manipulation, leaving the patient with a cosmetic defect.
Hence, these flaps are not favored by us in our practice.
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. Commonly, a latissimus dorsi mini-flap is performed in those cases. The disadvantage is that in case of a local recurrence the latissimus
will not be available for whole breast reconstruction.
Complications arising in oncoplastic surgery can be divided
into two broad categories: oncologic and surgical.
With appropriate oncoplastic technique, a relatively low
local recurrence rate may be achieved. Furthermore, the
long-term survival and oncological safety of breast cancer
patients treated with OPS is comparable with the survival
and safety of conventional BCS. In a study by Clough
et al., 100 patients undergoing level II OPS demonstrated a
5-year overall survival of 95.7% and a 5-year disease-free
survival rate of 82.8% (28). A study by Staub et al. demonstrated 5-year recurrence-free and overall survival rates of
93.7% and 94.6%, respectively, for patients treated with


OPS (29). These studies clearly show that oncologic compromise does not occur while using OPS techniques. The
issue of positive margins is one that merits some additional
discussion. Because OPS enables much wider lumpectomies, the rate of margins involvement has been lower than
reported with routine BCS (30). Studies have demonstrated
reoperation rates for margin involvement ranging from
8.9% to 20%, depending on size of the study and the experience of the surgeons (5,29,3235). Proficiency at OPS
technique will spare the patient from undergoing a repeat
procedure. This includes ensuring adequate surgical margins through intra-operative frozen pathologic sections. At
the University of Miami, we routinely use intraoperative
ultrasound to guide the lumpectomy and assess margins. A
recent study by Olsha et al. has demonstrated that careful
use of the ultrasound as an adjunct tool in the operating
room can significantly decrease the positive margin rate
(36). Unfortunately, however, 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. 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 others principles. The oncoplastic surgical
team should always keep in mind a possible positive margin to enable a re-excision if necessary. At the beginning of
our experience we were recommending mastectomies for
patients with positive margins after level II or III OPS procedures. We have since changed this approach and reexcised positive margins even after those major tissue
displacements with excellent oncologic results.
Surgical complications of oncoplastic surgery include
skin necrosis, either partial- or full-thickness, fat necrosis,
seroma at a flap donor site, infection, hematoma, flap loss,
and poor cosmesis (5,29,3135). 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). A study by Pinsolle et al. demonstrated the most
frequent complications to be, in order, seroma of the flap
donor site, capsular contracture if a prosthesis was
implanted, skin necrosis, and hematoma (35). Risk factors
for complications of OPS are smoking, obesity, and radiotherapy, which affect rates of skin necrosis, infection, and
capsular contracture, respectively (5,29,3135).
Skin necrosis may be avoided by ensuring adequate
vascular supply of all areas, particularly to the NAC; if
needed the necrotic skin may be resected and the healthy
edges apposed. Partial thickness skin necrosis will
typically revascularize in time with little to no detriment
to cosmesis (28). Fat necrosis is associated with extensive
mobilization of fat-replaced breast tissue that has a poor
blood supply. Although this is not problematic in the
immediate postoperative phase, it will lead to a nodular
breast parenchyma, poorer cosmetic appearance with


local deformities, and can occasionally become a

diagnostic problem for the oncologic follow up on clinical
exam and on imaging studies (28). For that reason breast
density should be a major determinant of the OPS
approach. Donor site seromas may be treated by needle
aspiration of the seroma fluid. Wound infection
unfortunately needs to be treated with re-operation, and
the wound must be allowed to heal by secondary intention;
cosmetic reconstruction of the breast may be undertaken
at a later date. Flap loss, like skin necrosis, may be
avoided by ensuring adequate vascular supply to the
pedicle through meticulous operative technique.
Cosmetic complications may take many forms, from
frank deformity of the breast to mild breast asymmetry
without any deformity. Clough et al. classified three types
of cosmetic complications: type I, II, and III (28). Type I
complications involved an asymmetry in the volume or
shape between the breasts without any deformitygenerally the unoperated breast was larger and more ptotic than
the operated breast. Type II complications involve deformities of the operated breast that could be corrected by
partial breast reconstruction, even utilizing irradiated
breast tissue in the reconstruction. Type III complications
involve major deformities or diffuse painful fibrosis of the
treated breast; these complications require a mastectomy
with immediate breast reconstruction. In all of these cosmetic complications, the most important factor to consider
is the symmetry of the breasts. While in some cases immediate surgical symmetry has been advocated, a three- to
six-month delay is recommended after the completion of
adjuvant radiation therapy prior to reoperation to create
cosmetically symmetrical breasts (28,35). 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. Generally, radiation therapy is delayed
until after surgery (28,35,37). 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,
and in the event that breast surgery is contemplated after
previous radiation extreme, caution should be exercised in
terms of OPS (28,35).
Oncoplastic surgery is a burgeoning field in the United
States that has already been established as a standard for
care in Europe. 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. The
techniques of OPS allow the woman affected by breast
cancer to undergo adequate surgery both oncologically
and cosmetically. The importance of such a procedure


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. 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.
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of a randomized trial comparing two conservative strategies for small size breast cancer. Eur J Cancer 1998; 149:
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after wide local excision of the breast. Br J Surg 1993; 80:
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Lumpectomy and radiation therapy
Onelio Garcia Jr., Roberto Comperatore, and Nuria Lawson


inability to obtain clear surgical margins, and patients

unable to undergo radiation therapy. Avoiding the dreaded
local recurrence of the cancer begins with obtaining clear
resection margins during the lumpectomy. Several authors
have identified risk factors that help in identifying patients
at high risk for positive margins following lumpectomy
for breast cancer (69). These risk factors include younger
age, large tumors, lymph node involvement, invasive lobular carcinoma, tumors displaying extensive intraductal
components, lymphovascular invasion, and family history.
Although most studies support the notion that local recurrences per se do not adversely influence long-term survival, there are studies that report that local recurrences
are independently associated with an increased incidence
of systemic recurrences (10). Prevention is by far the best
approach when it comes to local tumor recurrence following BCT, for that reason a clear resection margin confirmed histologically by permanent section remains the
gold standard of care.

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 (1,2). 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 (3,4). 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.
Although the survival rates may be equal for these two
treatment modalities, the local recurrence rate was found
to be twice as high in the BCT patients as opposed to the
mastectomy patients (1). The less tissue margin removed
around the tumor, the higher the recurrence rate (13.3%
for lumpectomy versus 5.3% for quadrantectomy) (5). The
local recurrence rate was also affected by radiation (39.2%
for lumpectomy alone versus 14.3% for lumpectomy plus
radiation). Pre-menopausal women and those with tumors
displaying an extensive intraductal component had the
worst prognosis for local recurrences.
Patient selection is of paramount importance when
considering BCT as a treatment option for breast cancer.
First and most important is tumor size in relation to breast
size. Patients with small breasts and large tumors are not
good candidates for BCT. Other contraindications for
BCT include multicentric tumors, inflammatory cancers,


Some of the most challenging reconstructive surgeries
that plastic surgeons frequently encounter are the postradiation, partial mastectomy defects. On occasion, the
breast is so distorted by the lumpectomy or the radiation
damage is so extensive, that the only means of achieving
acceptable aesthetic results is to complete the mastectomy


and perform a total breast reconstruction. These reconstructions can be quite complex since these cases often
exhibit radiation damage with significant soft tissue fibrosis (Fig. 8.1 A). When the radiation damage is extensive,
adequate recipient vessels for autologous, free-tissue transfer may not be available and the tissue replacement needs


can be significant. While autologous tissue transfer remains

the first reconstructive choice for the radiated mastectomy
defect, patients with limited autologous donor tissue volumes may require a combination of flap transfer plus prosthesis to complete the reconstruction (Fig. 8.1 BF). The
use of acellular dermal matrix is useful in these cases to







Figure 8.1 (A) Extensive radiation damage to right chest after mastectomy for failed lumpectomy. (B) Pre-operative planning. (C) A
contralateral, muscle-sparing, pedicle TRAM flap was used due to extensive damage to recipient vessels. (D) Intra-operative flap inset.
(E) Acellular dermal matrix was used to line the subpectoral-sub-TRAM flap pocket for the prosthesis. (F) 3-year postoperative result.


provide support for the expander/implant and to better

delineate the inframammary and lateral mammary folds.
Oncoplastic surgery, frequently used in Europe for
BCT, 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. Werner Audretsch
introduced the concept of oncoplastic surgery in 1998 (11)
and since then several authors have made significant contributions to the field, including methods for classification
of the partial breast defects as well as reconstructive algorithms (1215). Some of the earlier classifications of partial mastectomy defects took into account the condition of
the nippleareola complex (NAC), degree of radiation
deformity, local tissue deficiency, and degree of breast
retraction (16). Subsequently, Slavin and collaborators (17)
proposed a simpler classification that considered only the
skin, loss of parenchyma, and condition of the nippleareola.
Currently, most of the proposed classifications of partial
mastectomy defects are based on three factors; the size of the
breast, the size of the defect, and the location of the defect.
These classifications are further subdivided based on breast
shape (presence of ptosis) and associated skin deficiency.
Recently, different classification systems for partial mastectomy defects have been proposed by Munhoz et al. in
2008 (12), as well as Losken and Hamdi in 2009 (15).
These classifications have led to the development of logical algorithms for the reconstruction of partial mastectomy
defects (12,13,18).
Reconstruction following BCT can be performed immediately at the time of the lumpectomy (immediate reconstruction), months or years after the radiation is completed
(delayed reconstruction) or several days or weeks following the lumpectomy but prior to radiation (immediatedelayed reconstruction). Prior to the advent of breast
oncoplastic surgery, the great majority of the partial mastectomy defects underwent delayed reconstruction, usually years after the completion of the radiation (17).
Currently, most authors cite the benefits of immediate
reconstruction prior to the radiation (12,19,20).
Immediate Reconstruction
Whenever possible, performing the reconstruction immediately following the lumpectomy, avoids the difficulties
of operating on a breast that exhibits fibrosis and cicatricial contracture from the previous surgery or radiation.
Indeed several authors have reported decreased surgical
complications and improved aesthetic results when performing immediate reconstructions (12,1821). The disadvantage of immediate reconstruction is the potential for


Table 8.1

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. 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. Several authors have
reported certain conditions associated with an increased
incidence of positive margins (69) (Table 8.1). Patients
exhibiting those conditions which have been previously
discussed in this chapter are not ideal candidates for immediate reconstruction.
Delayed Reconstruction
A significant number of partial mastectomy defects are
reconstructed years after the completion of the radiation.
Many delayed reconstructions are still performed in the
United States where surgeons have been slower in incorporating oncoplastic techniques than in Europe. The timing of
delayed reconstruction should take into account when the
post-surgical and post-radiation changes have stabilized.
Although there is an advantage to operating on a patient
who has been recurrence free for several years, the higher
surgical complications associated with surgery on irradiated tissue remains a significant disadvantage of delayed
reconstruction (18,19). Several authors have reported
poorer aesthetic outcomes in these cases (12,1820).
Although the delayed approach avoids the possibility that a
surgical complication may delay the start of adjuvant therapy, several studies have reported that immediate reconstruction as a general rule does not compromise the timing
of chemotherapy or radiation (2224).
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 reconstruction in these cases is
performed several days after the lumpectomy, allowing
time for histological examination of the margins by permanent sections. A disadvantage of this staged approach
is the need for a second operation within several days of
the first one, repeating the physical and mental discomfort associated with surgery as well as the additional


expense. This approach should be reserved for those

cases who present a high risk for positive resection margins following lumpectomy. The author also believes
that it is prudent to use this staged approach in cases
where the reconstruction involves distant tissue transfer.
Patient satisfaction with the cosmetic result of BCT and
radiation is of course subjective, but it is often influenced
by the degree of radiation-induced breast retraction. This
process tends to be progressive and may worsen with the
passage of time. Early in the post-radiation timeline we
may see edema and hyperpigmentation, followed later by
fibrosis and soft tissue retraction. These changes tend to
stabilize after several years. The degree of radiationinduced breast distortion is often influenced by the radiation technique employed.
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. Recently, the
technique of accelerated partial breast radiation (APBI)
has been gaining popularity (2527). APBI may be
given with interstitial catheter placement or by a balloon
catheter placed within the cavity. Its goal is to deliver a
higher dosage of radiation up to one centimeter beyond
the cavity walls within a shorter time frame. Recently,
the MammoSite applicator (Hologic Inc., Bedford, MA)
has simplified the process of insertion and dosage
planning (28) (Fig. 8.2 AC).
It is important to understand that these modalities are
associated with different tissue complications. Whole
breast radiation diffusely affects the entire mammary
gland whereas APBI generates a more intense, local tissue
reaction (Fig. 8.3). In fact persistent, 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 margins cannot
be rearranged by oncoplastic techniques. 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. If oncoplasty is performed during
the lumpectomy, then whole breast radiation becomes the
obligatory modality.
Another radiation alternative currently under development is intraoperative radiation therapy. With this method
a short interval of radiation is given intraoperatively during the lumpectomy with an electron beam source. This
treats up to 2 cm of breast tissue surrounding the lumpectomy cavity, similar to APBI. This technique allows for
oncoplastic tissue rearrangement to be performed, melding
lumpectomy, radiation, and reconstruction within the same


When post-surgical ABPI is planned, the degree of the

eventual distortion can be decreased by careful design of
the lumpectomy. Use of intraoperative sonography allows
the surgeon to estimate the tumor margins more accurately
avoiding excessive tissue removal. For non-palpable
tumors, not visualized by ultrasound, accurate preoperative wire localization will also limit unnecessary tissue
excision. It is also of paramount importance to maintain a
spacing of 710 mm between the cavity wall and the overlying skin in order to decrease the amount of dermal damage and radiation-induced dermatitis.
Trying to minimize the breast deformity while respecting oncologic principles remains an ongoing endeavor.
Newer, less invasive surgical and radiation modalities
should improve the cosmetic outcomes of BCT.
The administration of pre-operative chemotherapy has
been shown to decrease tumor size. 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). Based on a
series of 173 patients with advanced breast cancer treated
with pre-operative chemotherapy, McIntosh et al. (30)
concluded that BCT could be safely offered to selected
patients with positive response to the chemotherapy.
Soucy et al. (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. 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. The decision to
follow with BCT should be based on the response to the
chemotherapy. Because the new tumor margin following
chemotherapy induced regression is sometimes difficult to
detect, the reconstructive procedure should be staged
(immediate-delayed reconstruction) to allow assessment
of the margins by permanent sections.
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. Regarding the quantity of breast tissue,
patients considering BCT with large ptotic breasts can
tolerate a relatively large lumpectomy. In these cases,
there is enough remaining breast tissue that a reconstruction with breast tissue rearrangement through reduction






Figure 8.2 (A) MammoSite breast brachytherapy applicator (Hologic, Inc., Bedford, MA) (B) Inflating MammoSite balloon. (C)
Balloon inflated within the lumpectomy cavity.

mammaplasty techniques (Fig. 8.4) can provide an acceptable aesthetic result (Fig. 8.5 AD). On the other hand, a
small breast can suffer significant deformity following a
small to moderate lumpectomy. The limited amount of
remaining tissue may not be sufficient to reconstruct an

aesthetically pleasing breast. These patients may necessitate reconstruction with techniques that replace the
missing volume such as distant flaps, or in some cases
completing the mastectomy and performing a total breast
reconstruction. Another consideration in these cases is the



Figure 8.3 Patient following upper pole, right breast lumpectomy followed by accelerated partial breast irradiation (APBI) using a
MammoSite device. Arrow points to irradiated area.

Figure 8.4

Pre-operative markings for breast conservation therapy on a patient with large, ptotic breasts and lateral tumor location.

quality of the remaining tissue following the lumpectomy.

An integral part of BCT is radiation therapy. Patients who
present for delayed reconstruction of partial mastectomy
defects have undergone breast radiation therapy. Occasionally, the radiation damage can be so extensive and the
quality of the remaining tissue so poor, 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.
Meticulous planning is imperative when volume replacement is under consideration. For example, when distant
flap transfers become necessary for tissue replacement,
one must account for the radiation-induced tissue retraction that occurs over time and transfer enough volume to



overcorrect the defect. Frequently, the reconstructive

options in these cases are limited due to significant radiation damage to potential recipient vessels at the site (32).
Fortunately for most patients, the acute radiation changes

significantly improve over the first year following completion of their treatment (Fig. 8.6A, B).
Algorithms for reconstruction of the partial mastectomy defect provide very useful guidelines for the surgical





Figure 8.5 (A, B) Pre-operative appearance. (C, D) Post-operative appearance following BCT by means of reduction mammoplasty.



Figure 8.6

(A) Acute radiation changes following BCT. (B) Appearance 1 year after completion of the radiation.


approach to these difficult cases. The surgeon should be

familiar with the algorithms and employ them in the surgical planning, however, keeping in mind that the partial
mastectomy defect is a unique deformity that requires an
individualized treatment plan. Often, modifications of the
algorithms are necessary.
Isolated deformities located laterally can be usually
reconstructed in an acceptable fashion with local tissue
advancement. Occasionally a small prosthesis can be useful for improving breast projection and shape. 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. 8.7 A, B).
Lateral defects created by large lumpectomies often
cause significant breast deformities as well as asymmetry
with the contralateral breast. These defects can be reconstructed by adjacent breast advancement flaps (3). 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. Often, a medial, 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. 8.8 AD).
Women with relatively large or ptotic breasts are good
candidates for lumpectomy through breast reduction or
mastopexy incisions. This oncoplastic technique using different variations of a Wise pattern mammoplasty has been
extensively described in the literature (13, 3338). 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). The use of mammoplasty



techniques in BCT requires that the surgeon be familiar

with the different options for pedicle design to maintain
nippleareola viability. This is a very versatile approach to
BCT in that it allows for large tumor resections in different
locations within the breast. Familiarity with the different
approaches to reduction mammoplasty is of paramount
importance when employing this approach in BCT. The
ability to base the NAC circulation on an inferior pedicle,
superior pedicle, superomedial pedicle or central mound
techniques of reduction mammoplasty will allow the surgeon to reconstruct most defects while maintaining nipple
areola viability. An oncoplastic approach using an inferior
pedicle reduction mammoplasty technique, in a patient
exhibiting a superior-central tumor of the left breast is
depicted in (Fig. 8.9 AD). Occasionally, the tumor resection interferes with the creation of a safe vascular pedicle
option, in which case the surgeon may resort to a free nippleareola graft technique. This technique is also useful for
delayed BCT reconstruction. Spear et al. (40) noted that
reduction mammoplasty could be safely performed in the
previously irradiated breast if certain technical variations
were employed, such as shorter, broader pedicles, and minimal breast flap undermining.
Breast reconstruction of the complex, irradiated, partial
mastectomy defect with significant soft tissue loss, can be
one of the most challenging situations that plastic surgeons
may face following BCT. As previously noted, in some
cases the best approach is to complete the mastectomy and
perform a total breast reconstruction with autologous tissue transfer. This approach, although sometimes necessary,
is devastating to the patient who had chosen BCT over a
mastectomy in the first place to avoid a major surgical procedure. The fact that she has now been subjected to breast
irradiation makes the mastectomy and reconstruction


Figure 8.7 (A) Right breast deformity following lateral lumpectomy and radiation. (B) Correction of lateral breast deformity with
adjacent tissue advancement, implantation of acellular dermal matrix, and prosthetic breast augmentation.







Figure 8.8 (A, B). Right breast deformity and breast asymmetry following BCT. (C, D). Appearance following right breast
advancement flaps and left reduction mammoplasty for symmetry.

procedures far more complex and more prone to complications (20,22,41,42).

Traditionally, these complex defects have been reconstructed with distant, autologous flap transfers to replace the
tissue deficiency (43). 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. 8.10 AD).
Using the latissimus dorsi for these partial defects, leaves
the abundant abdominal tissue intact and available for a
future reconstruction should the patient at some point
require a total mastectomy.
Occasionally, 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.
Typically, the mindset of many of these patients is that
they wish to avoid major surgical procedures, particularly

outside the affected breast, which is why they chose BCT

in the first place. 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 (4448). These matrixes may be prepared from
cadaver donor tissue allografts or porcine-derived xenografts, although the human-derived matrixes are most frequently used in breast reconstruction. 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 use of ADM has expanded the breast reconstruction options for patients who desire implant-based
reconstruction. The literature reports good outcomes in
selected patients treated with radiation who undergo
implant reconstruction (49,50); however, it is generally
accepted that implant procedures in irradiated patients are
associated with higher complication rates and poorer









Figure 8.9 (A, B) Pre-operative appearance of patient with superior, central location of tumor on left breast. (C, D) Intra-operative
resection margins and central lumpectomy defect. (E, F) Post-operative appearance following left BCT with oncoplastic reconstruction.

cosmetic results (5052). Many of the problems associated with implant reconstruction of the irradiated breast
are related to radiation-induced capsular contracture.
Recently, there has been experimental evidence reported
in the literature regarding the lack of peri-prosthetic

capsular contracture in ADM-assisted surgery using

implants (53,54). 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. Our experience in breast







Figure 8.10 (A, B) Appearance following right breast lumpectomy and MammoSite local irradiation. (C) Markings include the extent
of radiation-affected tissue. (D) Latissimus dorsi musculocutaneous flap used for soft tissue replacement.

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.
Although implant-based reconstruction is not my ideal
choice for reconstructing the irradiated breast, 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. 8.11 A, B). Occasionally, when
reconstructing with an expander in an irradiated field, I
will perform a complete lining of the pocket with ADM
as a means of avoiding capsular contracture (Fig. 8.11 C,
D) The successful use of ADM in these cases is very technique dependent. In cases where all or most of the
expander pocket is lined with ADM, 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. 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. 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; however, 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. 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. 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. 8.11 E, F).
One of the most dreaded complications of oncoplastic surgery for BCT is the subsequent finding of positive tumor
margin. This can sometimes be the result of an inadequate
resection or poor patient selection such as in young patients









Figure 8.11 (A, B) Left breast deformity following BCT with radiation induced periprosthetic capsular contracture in a patient
reluctant to undergo autologous tissue transfer. (C, D) Acellular dermal matrix was used to line the revised dual plane subpectoral pocket.
(E, F) Postoperative appearance following tissue expansion and insertion of gel breast prosthesis.

with large tumors who are associated with a higher incidence of positive margins following BCT. Munhoz and
collaborators (7) have reported a 5.5% incidence of positive margins on permanent sections following examination

of lumpectomy specimens that had negative margins on

frozen section submitted during surgery. Several other
authors have reported that the need for a second surgery
following BCT in order to achieve negative margins ranges


from 6.2% to 19.6% (5658). 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.
A correlation between positive margins and increased incidence of local tumor recurrence has been reported by
Leong et al. (59). For all these reasons, it is imperative that
negative tumor margins be achieved during the primary
lumpectomy procedure. 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).
Since all of the BCT patients will require radiation and
in some cases also chemotherapy, it is of paramount
importance that surgical complications that may occur as
a result of the reconstructive procedures, do not delay the
initiation of the adjuvant therapy. 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 (12,23,24,61,62).
Aesthetic outcomes in BCT are frequently influenced
by the patient's response to the radiation therapy. Unfortunately, radiation changes occur over time and are often
unavoidable. Clough et al. (63) reported significantly
worse aesthetic outcomes in BCT patients who received
their radiation preoperatively versus postoperatively. Several authors have also correlated large volume resections
with unsatisfactory cosmetic results, particularly in small
or moderate size breasts (64,65). A retrospective analysis
of over 100 BCT patients reported lower complication
rates for BCT when compared to mastectomy (66). The
aesthetic outcome failure rate for that series was 18% and
correlated highly with radiation-induced breast retraction.
Breast-conservation therapy offers select breast cancer
patients another viable treatment option. Appropriate
patient selection and determining the best surgical procedure for a given defect are of paramount importance to the
success of BCT. Not everyone is a candidate for BCT and
patients at high risk for local tumor recurrences should
undergo alternative total mastectomy and reconstruction.
Patients with small breasts often cannot tolerate moderate
to large lumpectomies and will achieve better aesthetic
results from skin sparing mastectomy and reconstruction.
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. Most large series report that the
majority of patients undergoing BCT are satisfied with
their breast appearance. Advances in oncoplastic surgical


techniques and breast radiation technology are certainly

going to improve the oncologic efficiency and aesthetic
outcomes of BCT.
Mentor Corporation (Santa Barbara, CA) - Consulting
agreement, recipient of investigational grant, and participates in company's speakers bureau.
C.R. Bard (Davol) Inc. (Warwick, RI) - Participates in
investigational studies funded by the company and participates in company's speakers bureau.
Sound Surgical Technologies (Louisville, CO) - Participates in investigational studies funded by the company
and participates in companys speakers bureau.
Excaliard Pharmaceuticals (Carlsbad, CA) Participates in
investigational studies funded by the company.
The Disclosures only apply to the lead author Onelio
Garcia Jr., M.D.
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Preoperative evaluation for post-mastectomy reconstructive surgery
Charles R. Volpe, Paul Yang, and Zubin J. Panthaki


reconstructive procedure chosen should be specifically tailored to the individual patients needs and the surgeons
clinical experience. To achieve the highest satisfaction,
the patients concerns and expectations must be addressed.
Additional time must be spent educating the patient about
the various surgical options including the safety and limitations of each procedure. Most importantly, the surgeon
must properly evaluate the patient and select the appropriate reconstructive procedure in an effort to minimize postoperative complications and improve patient outcomes.

As of 2010, more than 2.5 million women in the United

States can be considered breast cancer survivors, and that
number is predicted to increase by 30% by 2015 (1).
Despite the ever-increasing therapeutic options, mastectomy continues as the mainstay of breast cancer treatment much as it has for over a century. 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). As a
result, a greater demand for breast reconstruction can be
Breast reconstruction has come a long way since the
first procedure performed by Czerny in 1895 (3). Initial
attempts involved several disfiguring operations that produced largely unsatisfactory results. As the understanding
of breast cancers natural history increased, refinements in
surgical technique and oncologic principles occurred (e.g.,
pectoralis muscle preservation and skin-sparing mastectomy) allowing improved functional outcomes. With these
improvements, a wide variety of post-mastectomy reconstructive procedures have emerged over the years. These
include tissue expander and/or implant reconstruction,
pedicle flap reconstruction with or without implant placement, and free myocutaneous or fasciocutaneous flap
At present, no single procedure has become the gold
standard of post-mastectomy reconstruction. Rather, the

A thorough medical history is of utmost importance during the preoperative evaluation and should be performed
for all patients. The medical history should include a
detailed account of past and coexisting medical problems,
past surgical procedures, family history, social history
(e.g., alcohol or tobacco use), current medication and vitamin use, and any relevant allergies. In addition, detailed
understanding of the patients oncologic treatment plan is
needed. Access to and involvement with an institutional
tumor board is an invaluable asset to the preoperative
planning. Neoadjuvant chemotherapy, post-operative chemotherapy, and radiation treatment protocols need to be
known for each patient. Information gleaned from this
interrogation may influence the decision to proceed with
reconstruction and/or the type of procedure offered to the


Systemic Illnesses
Comorbid medical conditions such as retinopathy, nephropathy, peripheral vascular disease, cerebral vascular disease,
hypertension, coronary artery disease, chronic obstructive
lung disease, arrythmia, and congestive heart failure should
be identified early in the medical history taking process. 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. However, well-controlled diabetes should not, in
and of itself, be considered a contraindication to autologous
free flap reconstruction. Comparable rates of anastomotic
patency, blood vessel thrombosis, fat necrosis, and free flap
loss have been found when comparing well-controlled diabetic (Type 1 or 2) to non-diabetic cohorts (4). 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). However, poorly controlled or undiagnosed
diabetes can present significant problems. Studies have
shown that poorly controlled diabetes can result in wound
healing problems following cardiac and non-cardiac surgery
(68). 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. 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). Recognition of a poorly controlled diabetic
state may warrant performing a delayed reconstruction when
the patients medical condition improves.
Smoking is universally accepted to be a risk factor for
postoperative complications. Cigarette smoking increases
platelet aggregation and the risk of flap thrombosis (10,11).
In addition, nicotine causes cutaneous vasoconstriction
thus reducing capillary blood flow (12), and carbon monoxide binds hemoglobin resulting in tissue hypoxia (13).
Patients who currently smoke tobacco should be advised
to quit for at least one month prior to scheduled surgery.
The actual incidence of complications attributed to be
active during breast reconstruction varies considerably
between studies and between the methods of reconstruction offered. Known complications of smoking include
skin flap necrosis (14), wound infection (15), as well as fat
necrosis, flap loss, and wound dehiscence (16). Due to the
increased incidence of flap and abdominal donor site complications, active smoking has long been considered a
relative contraindication to performing pedicled TRAM
flap reconstruction (17,18). Spear et al. reviewed their


experience with pedicled TRAM flap procedures and

found that active smokers had a statistically significant
increased risk of multiple flap complications, higher rate
of flap infection, and a higher rate of delayed wound healing as compared to non-smokers (19). 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, especially
delayed wound healing caused by smoking (20). The incidence of complications following tissue expander/implant
breast reconstruction is also significantly higher with
active smokers. 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).
Long-time smokers may also present with chronic
obstructive pulmonary disease (COPD) and lack the capacity to tolerate a lengthy operation. Clearance from the
patients pulmonary specialist should be considered especially if free-flap breast reconstruction is entertained.
Medications that affect hemostasis should be discontinued
before surgery. Aspirin should be routinely discontinued 57
days prior to surgery (21). Non-steroidal anti-inflammatory
drugs (NSAIDs), such as ibuprofen or naproxen, should be
discontinued between 2 and 7 days, preoperatively (22).
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. However, if warranted,
cessation of Clopidogrel 7 days prior to breast reconstruction
is recommended (23). Homeopathic medications such as
garlic, ginseng, St. Johns wort, 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).
Breast-related History
Special attention should be given to the patients breastrelated history during the initial evaluation for reconstructive breast surgery. The clinician should obtain a
detailed history of previous breast disease, as well as
gather a complete family history of cancer. Patients presenting to the office for delayed reconstruction should
provide detailed operative reports from prior surgical
procedures, especially related to the mastectomy. Status
of the pectoralis major muscle should be determined.
Mastectomies involving pectoralis major muscle resection pose a greater reconstructive challenge due to the
lack of remaining tissue. Implant reconstruction may be
difficult if not impossible given this situation.


Two topics deserve careful consideration when discussing the patients breast-related history. Significant
family history of breast or ovarian cancer may suggest a
genetic predisposition to breast cancer through the
BRCA gene. Testing for BRCA1 and BRCA2 genotypes
should be made available to these patients. Confirmed
carriers of the BRCA 1/2 genes should be offered bilateral prophylactic mastectomy along with bilateral breast
reconstruction. Bilateral prophylactic mastectomy has
been shown to reduce the risk of breast cancer in this
patient population by 90% (25). 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. Patients with biopsyproven LCIS are at increased risk of developing an invasive breast cancer in either breast. The minimum risk of
developing invasive breast cancer after the diagnosis of
LCIS is 7.1% at 10 years (26). Currently, the most common clinical recommendation for women with LCIS is
close follow-up combined with chemoprevention (e.g.,
Tamoxifen) (27,28).
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. Therefore, proper clinical staging
of the patients breast cancer should be made prior to the
evaluation for reconstructive surgery. Clinical staging
affords the reconstructive surgeon an understanding of the
patients chemotherapy and/or radiation therapy requirements along with a timeline for the administration of these
treatments. Armed with this information, the reconstructive
plan can be appropriately determined. For example, 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. Studies have shown that radiation exposure following implant-based reconstruction is associated with
delayed wound healing, capsular contractures, high rate of
implant extrusion or malposition, and infection (29).
Similarly, if postoperative radiotherapy is warranted, it
may be wise to delay autologous breast reconstruction
until after the therapy is completed (30,31). Complication
rates for immediate autologous breast reconstruction followed with post-operative radiation therapy range from
60 to 87.5% (32,33). Known complications related to
radiation therapy include acute changes such as mild to
brisk erythema and flap skin desquamation. Long-term
changes include volume loss secondary to fat necrosis or
parenchymal fibrosis, alteration in flap contour, and loss
of symmetry (34).


Neoadjuvant chemotherapy administration (Adriamycin + Cyclophosphamide; Paclitaxel for anthracyclic

failures) has been shown to adversely affect breast
reconstruction efforts. 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, fat necrosis, and wound healing problems at
the donor site (35,36). These patients may benefit from
delayed reconstruction when post-mastectomy radiation
therapy is indicated.
Obesity remains a considerable problem in the United
States. In 2000, the prevalence of obesity (BMI 30 kg/m2)
was 19.8% (37). Obese patients have a significantly
increased risk for flap failure (3.2%) and donor-site complications and thus should avoid TRAM flap reconstructions (3840). A BMI greater than 30 has been shown to
increase rates of complications in pedicled TRAM flap
operations as well. Obese patients considered candidates
for pedicle TRAM reconstruction might benefit from flap
delay approximately 14 days prior to the scheduled reconstruction (41). Because of a high incidence of postoperative
complications, morbidly obese individuals are generally
not candidates for autologous reconstruction. The midabdominal TRAM flap, however, has a more favorable
anatomy and may be an alternative method of reconstruction in morbidly obese patients (42). In general, the decision to perform autologous free tissue transfer in obese
patients should be individualized based upon the patients
and the surgeons perspective. 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.
Breast Exam
Breast size, shape, and degree of ptosis should be assessed
preoperatively. Photographic documentation of the patient
should be made with standardized AP, oblique, and lateral
views. Any asymmetries in volume, base diameter, or
nippleareola configuration should be noted (43). Breast
volume can be estimated using bra size, but can be
determined more objectively by direct breast volume
assessment, which uses a simple formula based on anthropomorphic measurements (44). The patients satisfaction
with their current breast size should be determined and
clearly documented. Unrealistic expectations of the reconstructive process must be addressed during the consultation. Patients must be aware that surgical procedures on


the opposite breast may be required to achieve symmetry

with the reconstructed breast. However, the thought of
operating on the remaining normal breast may be a sensitive topic to the patient. In general, if the unaffected
breast is large and pendulous, contralateral reduction
mammaplasty will improve symmetry and facilitate reconstruction. In addition, evidence suggests that a contralateral breast reduction may decrease the risk of subsequent
breast cancer (45,46). If the unaffected breast is small, in
comparison, an augmentation and/or mastopexy may be
required. Ultimately, management recommendations are
best made on an individualized basis noting the patients
desires, the patients body habitus, and the need for treatment beyond the reconstructive period. Clear communication with the patient will improve the likelihood of a
satisfactory outcome.
Chest Wall
A focused exam of the chest and axillae should be performed on all patients during the initial examination. The
chest wall should be examined, noting the condition of the
skin and thickness of the subcutaneous tissue. Prior radiation treatment to the chest wall should be noted along with
the quality of the skin and soft tissue within the radiated
field. Previous mastectomy sites should be examined along
with previous biopsy sites. Locations of all scars and
biopsy incisions should be documented. Oncologic surgeons often request that previous biopsy incisions be
excised at the time of reconstruction. The likelihood of
skin flap compromise with the excision of previous biopsy
scars must be anticipated. The reconstructive efforts
should address this proactively so that the aesthetic results
are not compromised. The presence of any masses, problematic skin lesions, or rashes should be addressed prior to
the planned breast reconstruction.
Donor Sites
Any discussion concerning post-mastectomy reconstructive surgery must cover a comprehensive list of possible
methods to recreate the breast mound. Plastic surgeons
should be able to explain, in detail, each of the reconstructive options afforded to the patient. The surgeon should be
prepared to discuss techniques that he/she does not perform. Full disclosure will allow the patient to make an
educated decision regarding the reconstructive process.
With that in mind, careful consideration to potential
donor sites should be made. Full examination of the chest,
back, abdomen, flank, buttocks, and lower extremities
should be conducted. Careful documentation of previous
surgical procedures and co-existing surgical scars should be
performed as their existence may preclude certain reconstructive options. For example, history of an ipsilateral


thoracotomy or an abdominoplasty would prohibit the use

of a pedicled latissimus dorsi flap, or a tram/diep flap for
breast reconstruction, respectively. 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). Paramedian abdominal
incisions, subcostal or Kocher incisions, and abdominal
scarring can, however, compromise blood supply to the
abdominal wall skin potentially compromising flap outcomes (48). The buttock, flank, and thigh region should
always be evaluated as sources for flap reconstruction in
difficult cases. The Rubens (deep circumflex iliac artery
perforator) flap, the anterolateral thigh flap, superior or inferior gluteal artery perforator flaps (S-GAP and I-GAP), and
transverse proximal gracilis flaps are potential options for
complex breast reconstruction.
Lastly, it is important to determine the patients level of
daily physical activity and involvement in sports. Breast
cancer is an indiscriminate disease process that affects
active women both young and old. Attempts should be
made to provide muscle-sparing breast reconstruction in
these patients. This may have a psychological impact on
the patient, especially if they hope to return to their physically active lifestyle. Fortunately, studies have shown that
return to preoperative levels of physical activity is possible whether muscle-based reconstruction is performed or
not (49,50).
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9. Sheehy AM, Gabbay RA. An overview of preoperative
glucose evaluation, management and perioperative impact.
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postmastectomy breast reconstructions in smokers, ex-smokers
and nonsmokers. Plast Reconstr Surg 2001; 107: 3429.
15. Goodwin SJ, McCarthy CM, Pusic AL, et al. Complications
in smokers after postmastectomy tissue expander/implant
breast reconstruction. Ann Plast Surg 2005; 55: 16.
16. Chang D. W, Reece G. P, Wang B., et al. Effect of smoking
on complications in patients undergoing free TRAM flap
breast reconstruction. Plast Reconstr Surg 2000; 105: 2374.
17. Watterson PA, Bostwick J, Bried JT, Jones G. A comparison
of morbidity from bilateral unipedicled and unilateral, unipedicled TRAM flap breast reconstruction. Plast Reconstr
Surg 1995; 95: 1185.
18. Eberlein TJ, Crespo LD, Smith BL. Prospective evaluation
of immediate reconstruction after mastectomy. Ann Surg
1993; 218: 29.
19. Spear SL, Ducic I, Cuoco F, Hannan C. The effect of smoking on flap and donor site complications in pedicled TRAM
breast reconstruction. Plast Reconstr Surg 2005; 116: 1873.
20. Seidenstuecker K, Munder B, Mahajan AL, et al. Morbidity
of microsurgical breast reconstruction in patients with
comorbid conditions. Plast Reconstr Surg 2011; 127: 1086.
21. Cahill RA, McGreal GT, Crowe BH, et al. Study for determination of the optimal cessation period of therapy with
anti-platelet agents. J Am Coll Surg 2005; 200: 56473;
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22. Goldenberg NA, Jacobson L, Manco-Johnson MJ. Brief
communication: duration of platelet dysfunction after a 7-day
course of Ibuprofen. Ann Intern Med 2005; 142: 5069.
23. Chernoguz A, Telem DA, Chu E, et al. Cessation of clopidogrel before major abdominal procedures. Arch Surg 2011;
146: 3349.
24. Muskett A, Barber WH, Lineaweaver WC. The peri-operative
implications of herbal medications. Ann Plast Surg 2005;
54: 570.
25. Rebbeck TR, Friebel T, Lynch HT, et al. Bilateral prophylactic mastectomy reduces breast cancer risk in BRCA1 and
BRCA2 mutation carriers: the PROSE study group. J Clin
Oncol 2004; 22: 105562.
26. Chuba PJ, Hamre MR, Yap J, et al. Bilateral risk of subsequent breast cancer after lobular carcinoma-in-situ: analysis
of surveillance, epidemiology, and end results data. J Clin
Oncol 2005; 23: 552441.
27. Haagensen CD, Lane N, Lattes R, et al. Lobular neoplasia
(so-called lobular carcinoma in situ) of the breast. Cancer
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28. Fisher B, Constantino JP, Wickerman DL, et al. Tamoxifen

for prevention of breast cancer: report of the national surgical
adjuvant breast and bowel project P-1 study. J Natl Cancer
Inst 1998; 90: 137188.
29. Forman DL, Chiu J, Restifo RJ, et al. Breast reconstruction
in previously irradiated patients using tissue expanders and
implants: a potentially unfavorable result. Ann Plast Surg
1998; 40: 360.
30. Kronowitz SJ, Robb GL. Radiation therapy and breast
reconstruction: a critical review of the literature. Plast
Reconstr Surg 2009; 124: 395408.
31. Spear SL, Ducic I, Low M, Cuoco F. The effect of radiaton
on pedicled TRAM flap breast reconstruction: outcomes
and implications. Plast Reconstr Surg 2005; 115: 8495.
32. Tran NV, Evans GR, Kroll SS, et al. Postoperative adjuvant
irradiation: effects on transverse rectus abdominus muscle
flap breast reconstruction. Plast Reconstr Surg 2000; 106:
33. Tran NV, Chang DW, Gupta A, Kroll SS, Robb GL. Comparison of immediate and delayed free TRAM flap breast reconstruction in patients receiving postmastectomy radiation
therapy. Plast Reconstr Surg 2001; 108: 7882.
34. Carlson GW, Page AL, Peters K, et al. Effects of radiation
therapy on pedicled transverse rectus abdominis myocutaneous flap breast reconstruction. Ann Plast Surg 2008; 60:
35. Mehrara BJ, Santoro TD, Arcilla E, et al. Complications
after microvascular breast reconstruction: experience with
1195 flaps. Plast Reconstr Surg 118: 11009, 2006.
36. Albino FP, Koltz PF, Ling MN, Langstein HN. Irradiated
autologous breast reconstructions: effects of patient factors and
treatment variables. Plast Reconstr Surg 2010; 126: 1216.
37. Mokdad AH, Bowman BA, Ford ES, et al. The continuing
epidemics of obesity and diabetes in the United States.
JAMA 2001; 286: 1195200.
38. Chang DW, Wang B, Robb GL, et al. Effect of obesity on
flap and donor-site complications in free transverse rectus
abdominis myocutaneous flap breast reconstruction. Plast
Reconstr Surg 2000; 105: 16408.
39. Kroll SS. Necrosis of abdominoplasty and other secondary
flaps after TRAM flap reconstruction. Plast Reconstr Surg
1994; 94: 637.
40. Kroll SS, Netscher DT. Complications of TRAM flap breast
reconstuction in obese patients. Plast Reconstr Surg 1989;
84: 886.
41. Wang HT, Hartzell T, Olbrich KC, et al. Delay of transverse
rectus abdominis myocutaneous flap reconstruction
improves flap reliability in the obese patient. Plast Reconstr
Surg 2005; 116: 613.
42. Gabbay JS, Eby JB, Kulber DA. The midabdominal TRAM
flap for breast reconstruction in morbidly obese patients.
Plast Reconstr Surg 2005; 115: 76470.
43. Rohrich RJ, Hartley W, Brown S. Incidence of breast and
chest wall asymmetry in breast augmentation: a retrospective analysis of 100 patients. Plast Reconstr Surg 2006;
118(7 Suppl): 7S.
44. Sigurdson LJ, Kirkland SA. Breast volume determination in
breast hypertrophy: an accurate method using two anthropomorphic measurements. Plast Reconstr Surg 2006; 118: 313.

45. Brown MH, Weinberg M, Chong N, et al. A cohort study of
breast cancer risk in breast reduction patients. Plast Reconstr Surg 1999; 103: 1674.
46. Tarone RE, Lipworth L, Young VL, McLaughlin JK. 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; 113: 210410; discussion 21112.
47. Dayhim F, Wilkins EG. The impact of pfannenstiel scars on
TRAM flap complications. Ann Plast Surg 2004; 53: 432.


48. Takeishi M, Shaw WW, Ahn CY, et al. TRAM flaps in
patients with abdominal scars. Plast Reconstr Surg 1997;
99: 713.
49. Blondeel PN, Vanderstraeten GG, Monstrey SJ, et al. The
donor site morbidity of free DIEP flaps and free TRAM flaps
for breast reconstruction. Br J Plast Surg 1997; 50: 32230.
50. Losken A, Nicholas CS, Pinell XA, Carlson GW. Outcomes
evaluation following bilateral breast reconstruction using
latissimus dorsi myocutaneous flaps. Ann Plast Surg 2010;
65: 1722.

Tissue expansion reconstruction
Sheri Slezak and Tripp Holton

According to statistics reported by the American Society

of Plastic Surgeons, 86,424 women underwent breast
reconstruction in 2009 (1). Two thirds of these women
(56,978) opted to have tissue expansion and subsequent
placement of an implant. In a survey of female, boardcertified plastic surgeons in the United States, 66%
reported that they would choose implant-based reconstruction for themselves if they had mastectomies (2). Of
the female plastic surgeons who primarily perform
implant-based surgery, 87% would, themselves, have
expanders. Of the women who do primarily autologous
tissue for their patients, half would still choose expanders
for their own surgery.
There are many reasons that surgeons recommend
and women choose implant-based reconstruction. This
approach has a short procedure length, and it is minimally
invasive. Further, it confers no new scars in other areas of
the body, and there is no risk of hernia or abdominal weakness. Patients are typically hospitalized for 24 hours or
less and the recovery time is generally 12 weeks. Women
can be self-sufficient within a short period of time allowing them to return to work quickly with good levels of
Conversely, patients should be well apprised of the
potential drawbacks of implant-based breast reconstruction. When matching an unoperated contralateral breast,
an implant may fail to produce a comparatively normal
shape. These patients should also recognize that tissue
expansion can be time-consuming and will require future

surgery. Patients need to be informed about standard complications inherent to implants, including rupture, migration, wrinkling, contracture, infection, palpability, rippling,
and exposure and that these are more likely to happen after
radiation therapy.
Cancer surveillance is not adversely affected by the
presence of an expander or an implant since these are
placed beneath the pectoralis major muscle. Therefore, the
deep margin of the resected breast is above the device and
is thus palpable. Many patients worry that reconstruction
will hide a recurrence so this information is comforting.
Implant surveillance should also be discussed. Current
guidelines entail a baseline MRI after three years followed
by MRIs every two years thereafter.
In 1957 Neumann was the first to use tissue expansion for
reconstructive surgery. His use of a rubber balloon to
expand the temporo-occipital skin provided soft tissue
coverage for an ear reconstruction (3). Cronin and Gerow,
soon thereafter, worked with Dow Corning Corporation to
develop the first silicone breast implants. 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 (4,5). Since then,
there has been a steady improvement in both technology
and technique for tissue expansion and implant-based
reconstruction for breast deformities.


Tissue expanders are now manufactured in a wide variety of sizes, shapes and designs. Some surgeons use a
one-shape-fits-all approach whereas others utilize different types for various patient morphologies (Fig. 10.1).
Choices include round, profiled, dual chamber, and
expanders that become permanent implants. Ports can be
integrated or remote.
The simplist device is a round expander with a single
chamber. 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.
In order to expand the skin envelope into the shape of
a natural breast, profiled and dual chamber expanders
were developed. Profiled expanders allow the lower pole
skin to stretch more than the skin of the upper pole, which
enables the expansion to create an envelope that can
house a natural, ptotic-appearing breast. Dual chamber
models have separate anterior and posterior chambers.
The anterior chamber is round and has a port located
superiorlythis is filled intra-operatively. A second
anterior chamber is located only in the lower pole, and
this is filled in the office (Fig. 10.2 AC). Some surgeons prefer to use expandable implants. These salinebased, or silicone/saline hybrid devices are sequentially
inflated via a remote and removable port. Once appropriately expanded, a separate incision is made over the
port and it is removed by pulling the tubing through a
double sealing system. This novel design allows for the


tissue expansion and permanent implants to be delivered

through only one major surgery and a separate minor
Choosing the size of the tissue expander will depend on
the diameter of the patients chest, the shape of her breasts,
and the probable volume of the breast to be reconstructed.
The mastectomy specimen can be weighed intra-operatively
to check the size. 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. 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.
Intra-operatively, it is important to place the bottom of the
expander right at the inframammary fold, and as far medially as possible to maximize medial cleavage and ptosis.
Many models have tabs that can be sewn to the muscle to
prevent displacement.
At this time in the United States breast implants are
saline or silicone-filled and have either textured or smooth
surfaces. Saline implants come in round or profiled shapes.
Silicone implants are round and are offered in various projections. Current silicone implants are made with a cohesive gel filler that has more crosslinking between silicone
molecules than the silicone filler of previous generations.
The FDA is currently studying profiled form-stable cohesive gummy bear silicone implants and these may soon
be available. This technology seeks to increase the life
span of the device, limit silicone leakage and migration

Figure 10.1 (AC) Various breast tissue expanders are available. Pictured here are: (A) A Natrelle expander by Allergan, (B) a
Sientra dual chamber expander, and (C) a Mentor CPX3 profiled expander.


should rupture occur, and offer a more natural, anatomic

shape. While many surgeons have lauded the qualities of
new anatomically shaped expandable implants, Gahm et al.
recently published a study comparing profiled with round
expandable implants and found no difference in cosmetic
outcome or patient satisfaction (6).
Modern implants are vastly superior to those of previous generations. 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



siloxane, which serves to minimize silicone gel bleed.

The strength of these new shells far exceeds the minimum acceptable level set by the American Society for
Testing and Materials.
The patient will ultimately select the type of reconstruction
that she wishes to have based on her health, the shape of
her body, her physical requirements for work, sports, and



Figure 10.2 (AC) A patient undergoing reconstruction with dual chamber expanders. (A) Pre-operative view. (B) Expanded to
volume. (C) On profile view. Note the differential expansion of the lower pole compared to the upper pole.


hobbies, her tolerance for complications, and the length of

the recovery period that she is willing to accept. She will
be guided by advice from doctors, friends, family, and
often information that she discovers on the Internet. Patients
must absorb a lot of information in a short period of time,
and they can feel pressured while doing so because of their
cancer. They must know that no reconstruction at all is a
reasonable and safe option. And while implant-based
reconstruction may seem like the easiest method of reconstruction, it is incumbent upon the reconstructive surgeon
to differentiate the reconstructive process from the implantbased cosmetic augmentation with which most patients are
peripherally familiar. It may take several visits to have all
of their questions answered, but this is time well spent.
Often, the best way to manage complications is to have
helped the patient develop a reasonable set of expectations.
First, patients should not be promised absolute symmetry
or perfection, with no scars or recovery period. Ninety percent of normal non-operated women do not have symmetrical breasts (7). Patients also need to realize that this
surgery has risks. In the Michigan Breast Reconstruction
Outcome Study, both implant-based and autologous breast
reconstruction had complication rates of 52% (8). Patients
must be adequately informed of the possible methods and
complications of breast reconstruction. While it is nearly
impossible to counsel patients without injecting ones own
bias, it may not be worthwhile, for example, to persuade a
patient into implant-based reconstruction if they start with
a clear fear of implants or a desire for autologous reconstruction. Similarly, 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. It is in everyones best interests to have a full discussion of reconstruction methods and complications and to let the patient
decide what reconstruction she will have.
Tissue expansion reconstruction may be started at the time
of mastectomy, or it may be commenced at a later date.
Many women wish to do this at the time of the mastectomy, so that reconstruction is begun with a single operation, anesthesia, and recovery period. 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. The Michigan Breast Reconstruction Outcome Study reviewed psychosocial outcomes at
one and two years. 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 Form36 and the Functional
Assessment of Cancer TherapyBreast (9).


The disadvantages of immediate breast reconstruction

include a longer operative time, fresh mastectomy flaps
which may have unapparent ischemia, uncertainty about
the need for post-operative radiation, and the need to heal
quickly if chemotherapy is recommended. In the study
by Alderman, of the women who elected to undergo
implant-based reconstruction, 82% underwent immediate
reconstruction whereas only 18% selected a delayed
reconstruction (10). 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. Specifically,
major complications occurred in 46% of patients in the
immediate group and in 21% of the patients in the delayed
group. This may be partially explained by the fact that
immediate reconstruction will include the complications
of the mastectomy as well such as seromas, mastectomy
flap necrosis, and axillary infections. Reconstruction is not
a surgery without risks.
Generally, the expander is partially filled in the operating
room. We have the mastectomy specimen weighed, and this
helps us choose the expander and predict the target volume
for expansion. The amount of fill in the operating room can
be varied given the thickness of the flaps, the quality of the
muscle coverage, and the size of the breast. If the mastectomy flaps are thin or of questionable blood supply, then the
expander can be left empty to place less stress on the flaps.
We aim for a 50% fill in the operating roomenough for
the patient to see some shape but not enough to give them
severe pain or to compromise the flaps and incision.
The tissue expanders are then filled in the office by
the physician or by an appropriate physician extender
(Fig. 10.3 AD). The valve is found with a magnet or by
palpation and 30120 cc of fluid is placed per session. If
too much is placed at once, the patient has considerable
pain from stretching of the muscle. Fills are continued
weekly, biweekly, or at the patients preference or convenience. There is no time limit in which expansion
must be completed, and expanders have been left in
place for extended periods without difficulty. 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.
Often, chemotherapy or radiation therapy may be
needed in the postoperative period. Expansion can be continued during chemotherapy, but the shape of the breast
should not be altered during radiation therapy because the
computer-generated dosing plan would be compromised.
Occasionally, a tissue expander must be deflated so that a
radiation beam can be effectively aimed at the internal
mammary nodes.






Figure 10.3 (AD): The process of tissue expansion. (A) Pre-operative view of a patient with left breast cancer. (B) Filling of the left
tissue expander (the right breast has been augmented with a permanent implant). (C) After exchange of the left tissue expander for a
permanent implant. (D) The completed reconstruction with areolar tattooing.

Kronowitz, at M.D. Anderson Cancer Center, first

described the concept of delayed-immediate breast
reconstruction. Since the need for radiation cannot
always be predicted at the time of mastectomy, he proposed the empiric placement of a saline-filled tissue
expander at the time of skin-sparing mastectomy. Should
radiation not be warranted, this expander is replaced
with an implant within two weeks. This approach preserves the skin envelope and the natural ptosis of the
breast while allowing a fully reconstructed breast to heal
promptly. By fast-tracking reconstruction it can prevent

unnecessary delay of adjuvant chemotherapy, if needed.

Should post-mastectomy radiation be recommended, 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. Once radiation is completed, this pre-placed expander is utilized
and the breast skin is recruited in an effort to house an
autologous tissue flap or implant (11). In short, this protocol affords non-radiated breasts the full aesthetic
benefit of a skin-sparing mastectomy while protecting



radiated reconstructions from the problems caused by

radiation delivery to an immediate reconstruction.
The goal of expansion is symmetry with the opposite
breast. For the bilateral patient, the target is symmetry to
the size of their choice. Often, different amounts of fill are
needed on different sides, as the muscle and/or flap is
thicker on one side than the other. Some surgeons prefer
to over-expand patients by 10% or so to increase skin
redundancy and obtain more ptosis.
When the expansion is complete, secondary surgery is
scheduled to remove the expander and place a permanent
silicone or saline implant. We find that a vast majority of
mastectomy patients prefer silicone implants because
these are softer, feel more like normal tissue, move with
the patient, and are more comfortable. At this second operation, capsules may be altered, nipples made, and excess
skin can be revised to complete the reconstruction. This is
generally an outpatient procedure and is very well tolerated by patients. Despite revisions, patients must understand that breasts are sisters, not twins, and that perfect
symmetry is not present in 90% of normal un-operated
Infection remains the most feared complication of implantbased reconstruction because it can cause the loss of the
entire effort (Fig. 10.4). In the Michigan Breast Reconstruction

Figure 10.4

Outcome Study (10) the infection rate was 35.4% whereas

McCarthy (12) found that in 1170 patients who underwent
implant-based reconstruction 3.4% of patients developed an
infection not requiring prosthesis removal and 1.5% of
patients developed an infection necessitating explantation.
Similarly, the Mentor Core Study reported an infection rate
of 5.7% in reconstruction patients (13).
Francis et al. studied post-operative tissue expander
infections and found, using multivariable analysis, that
breast size larger than C, previous irradiation, and repeat
expanders attempts were each significant predictors of
expander infection risk (14). In the series reported by
Throckmorton 60% of breast infections were caused by
staphylococci and the remaining infections involved Gramnegative rods/anaerobes (40%) (15). Importantly, half of
the staphylococcal isolates were drug-resistant. Feldman et
al. also found that two-thirds of breast infection cultures
grew Staphylococcus aureus and that two-thirds of these
were methicillin-resistant (16). These findings should be
considered when choosing an empiric course of antibiotics
for patients with implant-/expanders-related infections.
Superficial cellulitis can be treated with antibiotics,
but if the infection involves the pericapsular space and
implant, it is harder to eradicate. Spear and Seruya studied the treatment of infected implants and found that
64.4% could be salvaged with a combination of operative
treatment and/or antibiotics (17). The authors concluded
that relative contraindications to salvage include atypical
pathogens on wound culture such as MRSA, Candida
parapsilosis, and Gram-negative rods. They also note that
a heightened concern for recurrence should exist for

Infection of a recently placed left tissue expander demonstrating redness and swelling.


patients with prior devise infection/exposure, a history of

radiation or a wound culture demonstrating resistant
Staphylococcus aureus. Yii and Khoo reported salvage
for 9/14 infected implants using a rather austere combination of intravenous antibiotics, surgery and continuous
peri-prosthetic irrigation with saline and intermittent antibiotic infusion. 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). Chun and Schulman similarly
reported the salvage of nine expanders using intravenous
antibiotics, fluid drainage, manual debridement, and
curettage of the infected pocket, device exchange, and
post-operative antibiotics (19). It is important to note that
salvage of a breast reconstruction must be deemed less
important than the treatment of the breast cancer, and
should the time for chemotherapy to start be reached, it is
wise to abandon the reconstruction and restart after the
cancer treatment is complete.
Should infection be severe, it is best to remove the
expander, wait a minimum of two months, and try again if
the patient desires. Removal of the expander is quite easy
as the area is numb, it is 1 or 2 cm from the incision, and it
can be deflated and removed from a small incision. We
often do this in the office. A drain is placed and the infection typically improves rapidly.
Strategies to prevent infection include appropriate use
of antibiotics, use of irrigation solutions, a no-touch
technique, change of gloves and re-prepping, and the use
of infection prevention measures at drain sites. Khan studied implant patients given antibiotics as a pre-operative
dose alone or followed by intermittent post-operative dosing for 24 hours, or 5 days (20). He found that a single
dose of preoperative antibiotics resulted in the lowest
incidence of infection. The findings from Khans 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. It is
essential for the surgeon to ensure that the right antibiotic
is given at the appropriate time interval before skin incision, that the antibiotic is re-dosed throughout the case if
needed and that any peri-operative antibiotics are stopped
on schedule.
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. 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. (21). Mann et al. found a


profound decrease in bacterial colonization for epidural

catheter sites covered with the Biopatch (22). However,
Levys 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). Use of these patches on mastectomy
drains may confer a benefit, but evidence is lacking at
this time.
Topical installation of antibiotic fluid or washing of
implants has been cited as beneficial for infection prevention. This is of dual interest as bacterial infection or colonization of implants has been associated with the
development of capsular contracture. A systematic review
of the literature from 2007 demonstrated that povidoneiodine irrigation compared to saline, water, or no irrigation was beneficial in lowering surgical site infections in
general (24). Further, this solution has been shown to
reduce rates of capsular contracture when used to wash
implant pockets (25,26). Used together, 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). Pfeiffer et al. used cephalothin irrigation for
infection prevention in cosmetic breast augmentation surgeries (28). Compared to those patients who received a
topical antibiotic wash, the cohort denied this treatment
experienced a statistically significant increase in the rate
of infections and seromas. 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. Allergans product insert states: do not
allow the implant to come into contact with povidone
iodine. These recommendations stem from early data
thought to link betadine exposure to implant rupture.
Newer data clearly demonstrates that appropriately utilized topical betadine fails to mediate a deleterious effect
on the integrity of implants (29,30).
Capsular Contracture: Baker Grades III and IV
Capsular contracture has been a vexing complication since
breast implants were introduced in 1960. Historically, the
rate has been reported as high as 40%. In the Inamed Silicone
Breast Implant Core Study, the Baker III/IV capsular contracture rate was 15.9% at 6 years (31). In the Mentor Core
Study it was 8.3% in primary reconstructions and 16.3% in
reconstruction revision patients at 10 years (13). The Michigan Breast Reconstruction Outcome Study found a rate of
15.2% (10).



With the advent of increasingly sophisticated outer

shells, implants were thought to no longer leech significant amounts of silicone into the peri-prosthetic space. It
was thought that this would help decrease the incidence
of capsular contracture. Operative technique adopted to
address capsular contracture revolved around placing the
implants in a submuscular or dual-plane location. Textured implants were also designed during this period and
thought to form a less organized scar. Forceful mechanical disruption of the capsule has been attempted but ultimately not embraced because of fears of also rupturing
the underlying implant. Fifty years later, capsular contracture remains a source of patient and surgeon dissatisfaction (Fig. 10.5 AB).
Various causes for the formation of a contracted capsule have been proposed: silicone bleed, subclinical infection, bacterial biofilm formation, foreign body reaction,
allergy, and patient factors have all been hypothesized. In
Del Pozos study of explanted breast prostheses, those
with capsular contracture had a positive culture rate of
33% whereas those removed for other reasons had a 5%
positive culture rate (32). In that study, cultures were positive for Propionbacterium, Staphylcoccus epidermidis
and Corynebacterium. Schreml found a 66.7% colonization rate for Baker III and IV capsules whereas no colonization was detected for Baker I or II capsules (33).
Tamboto induced a Staphylococcus epidermidis biofilm
layer in a pig model and 80.6% of positive pockets developed capsular contracture (34). Van Heerdens group
investigated numerous antimicrobial agents directed
against the formation of implant-associated biofilms
excreted by Staphylococcus epidermidis. This group,
using an in vitro model, was able to demonstrate that


implants pretreated with topical Chloramex, Fucidin, or

Terramycin all were able to resist biofilm formation at
seven days (35).
Tumor necrosis factor- has been associated with
capsular contracture in seven patients studied on a biochemical level by Tan et al. (36). Hwang found numerous myofibroblasts within contracted capsules and
correlated contractures with the tensile strength of the
studied specimen (37).
Weintraub et al. studied patient factors in capsular contracture and found no effect from smoking, prior radiation,
saline versus silicone, or interval of time between expander
and implant placement. They did, however, find that complications which required the disruption of a capsule
around a permanent implant greatly increased the risk of
developing pathologic contracture (38).
Physicians have tried various treatments: submuscular
or dual-plane implant placement, textured shells, saline
instead of silicone filler, acellular dermal matrix coverage, leukotriene antagonists administration, vitamin E
therapy, and capsulectomy all with various degrees of
success. Treatment with Accolade (zafirlukast), a leukotriene antagonist was studied in a prospective study of
120 women (39). The study group was given Accolade
for 6 months and a control group was given Vitamin E.
There was a significant decrease in firmness at six month
in the Accolate group when measured with a mammary
compliance device. Singulair (montelukast) is also a leukotriene antagonist. It was noted by Huang et al. to
improve and prevent capsular contracture in 83% of
19 patients treated (40). This data is incomplete and the
studies are of insufficient power to prove efficacy. Use of
these drugs for capsular contracture remains an off-label


Figure 10.5 (AB) (A) Left capsular contracture 10 years after reconstruction with a left sided silicone implant. (B) Status post left
capsulectomy and replacement of a new silicone implant and contralateral peri-areolar scar revision.


but promising indication for these agents. Clearly, more

research into the effects of leukotriene inhibitors for the
treatment of capsular contracture is warranted.
Acellular dermal matrix (ADM) has been shown by
several authors to decrease the rate of contracture. 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). Basu also used ADM as a peri-implant
sling and studied the capsule implant at the time of
exchange. Decreased levels of granulation tissue, chronic
inflammatory changes, capsule fibrosis, fibroblast cellularity, and foreign body giant cell inflammation were seen in
the ADM group (42).
Our understanding of capsular contracture has progressed but is still underdeveloped. Rates of contracture
seem to be lower, but we do not yet have a good solution for
patients affected by this vexing complication of implants.
Baker III or IV capsular contracture can substantially undermine a patients satisfaction with reconstruction. Clearly,
more information is needed to determine the cause of capsular contracture, and we need to evaluate the biochemical
modulators within wounds that might create conditions for
this excess scarring.
Mastectomy Flap Ischemia
An expander and subsequent implant can only succeed if
there is an adequate skin envelope to surround it. A mastectomy, by necessity, yields thin flaps since the primary
objective is to eliminate breast tissue. Some surgeons
leave extremely thin flaps whereas others dissect on the
superficial fascia of the breast. Flaps may also vary in
their thickness in different areas. The precision of the dissection and subsequent viability of the flaps hinges on the
skill and experience of the ablative surgeon. The location
of the tumor can also affect the design and integrity of the
mastectomy flaps as well. The perfusion of the flaps
determines the success of the expander. Before placement
of any expander, the flap and muscle coverage must be
assessed. If inadequate, it is better to delay the reconstruction or plan to bring in new tissue with the use of autogenous flaps. 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.
The mastectomy flaps should be examined for thickness,
presence of a layer of fatty subcutaneous tissue on the
underside of the flap, bleeding from the edge of the flap, and
refill with pressure. Questionable areas may be excised as
long as there is adequate skin to close the wound. We vary
the amount of expander fill placed in the operating room
based on the condition of the flaps, from 0 fill to 450 cc.


We place little value on information garnered by fluorescein injection although we have tried this technique
in the past. The SPY Elite Intraoperative Perfusion
Assessment System is becoming increasingly popular
in breast reconstruction. 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 (43,44).
Implant Displacement
With immediate placement of a tissue expander one must
recognize that the ablative surgeon typically opens a wide
pocket, dissecting lateral to the anterior axillary line and
sometimes below the inframammary fold. The tissue
expander must be fixed in place in order to expand the
desired pocket, not the actual pocket. This may be done in
several ways. Submuscular placement of the expander
keeps the upper portion of the expander in place, but if the
muscle is not secured it can contract superiorly and the
expander is easily displaced into the supramuscular plane.
The expander may then sit more laterally than desired and
expand the subaxillary space. The use of ADM has substantially helped the problem of displacement. In this technique, a 6 12 cm piece of medium thickness ADM is
pie-crusted and sewn to the inframammary fold. The
suture catches the ADM, the deep fascia and the dermis of
the fold to secure it to the chest wall at the desired place.
The expander is placed and the ADM is sewn to the upper
edge of the muscle. This keeps the caudal edge of the pectoralis major muscle pulled down over the implant, tightens and fixes the inframammary fold, and allows a
stretchable area in the lower pole. As one expands the
device, the lower pole is more easily expanded and this
gives a better shape. The other option is to secure the
expander to the chest wall by sewing down the tabs that
several of the expander models have. Expander displacement may also be addressed if needed at the second operation during which one exchanges the expander for the
permanent implant. The formed capsule can then be lowered, widened, or plicated, whichever is needed. Plication
involves scoring or damaging the capsule to be closed and
then placing 2-0 Vicryl or Gortex sutures.
Hematoma or Seroma
The risk of hematoma in the Mentor Core Study was 1.3%
in primary reconstruction and 3.5% for revisions (13).
Seromas are much more common (4.9%)especially
when the prosthesis is placed into a fresh mastectomy bed.
Drains are generally needed and some surgeons use two.
We pie-crust the ADM and use only one drain since there
is free communication above and below the sling. It is


Figure 10.6


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, whichever comes first. Persistent and high
drainage may be a sign of a subclinical infection or a lymphatic leak. There is no conclusive data to guide the decision to aspirate secondary seromas or to let them resolve
passively. The increased pressure of the seroma can make
the process self-limiting, but this fluid is also a good media
for infection. There are good aspiration kits for office
placement of drains if the collection is large or persistent.
We use the 14 gauge Blunt Seroma Cath and attach it to
a Sapphire Suction Reservoir (both products: Greer
Medical, Inc., Santa Barbara, CA).

When implanted, 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.
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. Clearly, care must be
taken to avoid puncturing a device with instruments and
needlesthe swedged end of a needle can be as injurious
as the tip. The product inserts from Mentor and Inamed
are replete with helpful suggestions designed to protect
the implants.

Wound Dehiscence

Rippling and Contour Deformities

The success of the reconstruction depends on the success

of the mastectomy flaps. The wound will dehisce if the
flaps are ischemic or if the expander/implant is too large
and puts pressure on the incision. If the flaps are thin and
questionable, it is better to abort the reconstruction or
place no fluid at all in the expander. Late dehiscence is
usually a sign of infection (Fig. 10.6).

Visible rippling or wrinkling was seen in 10% of patients in

the Inamed Core Study and in 37% of reconstructions in
the Mentor Core Study (Fig. 10.7). Many mastectomy flaps
are very thin and the folds in the implant are visiblea
reconstruction is, after all, not real. There are several strategies to correct this. Silicone implants should be used, as
they show less ripples than do saline models. The surgeon
can also disguise ripples by placing ADM beneath the flap
to increase the thickness or tighten the muscle and capsule.
Fat injections into the flaps can also disguise ripples. A latissimus dorsi flap can also be rotated under the skin to provide
more muscle coverage. It is generally only ripples in the
cleavage area that are bothersome to the patient. Most
patients realize that an implant is not real. If this is not
acceptable to the patient then an autologous flap may be a
better choice for them.

Expander Deflation, Failure, and Rupture

The expander can have a mechanical fault, or it can be
accidentally injured at the time of surgery or during
injections in the office. With the double chamber model,
one can merely expand the remaining intact chamber. If
close to the goal volume one may simply proceed to
implant exchange. If not, the expander must be replaced.


Figure 10.7


Wrinkling of the right-sided upper inner pole.


Insufficient Skin and Subcutaneous Tissue to
Support an Implant
In this case, the surgeon needs to add skin and/or muscle to
cover the expander. The latissimus dorsi myocutaneous
flap or the thoracodorsal artery perforator flap can both add
reliable soft tissue to the implant-based breast reconstruction. This can replace skin that is too thin, too radiated, or
unable to stretch. It is important to recognize this patient
preoperatively, so that a failure is prevented. If the volume
of skin is insufficient due to loss of portions of the mastectomy flaps, this is a patient who should leave the operating
room with either no expander or an expander that is completely deflated. If the viability of the flaps is in question,
technology like the SPY can help to better determine that
tissue which should be excised immediately. 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, mastectomy flaps over tissue expanders or
implants must be closed immediately.
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. If a patient has more
volume than this, she needs to consider reduction of the
contralateral side (Figs. 10.8 AB, 10.9 AB and 10.10).
This can be done initially to her desired cup size, and then

aim the reconstructed side to this volume, or the reduction

can be done secondarily at the expander to implant change.
Generally, patients with larger breasts are delighted to
have a reduction, and are very pleased with the new look.
It is less heavy, and they look like they have lost weight.
The pathological examination of the contralateral side is
also comforting to the patient if it is normal. We have
found that 1.78% of reductions in the contralateral breast
of women with cancer have a pathological finding of cancer, despite a normal mammogram (45). It is important to
orient and identify these contralateral specimens so that if
something is found, the surgeon can locate the area in
question for further resection. We label tissue from reductions based on the quadrant of resection.
Inadequate Ptosis
Inadequate ptosis is historically the most common problem after implant-based reconstruction. The implant sits
too high on the chest and has too much upper pole fullness, particularly when compared to a contralateral
mature ptotic breast. This defect can be caused by an
inadequate skin envelope and/or capsular contracture.
The use of ADM slings has substantially decreased this
problem (Fig. 10.11 AC). We use a medium thickness
matrix (approximately 1 mm) because we want this to
stretch easily. Profiled expanders and implants are useful to selectively stretch the lower, rather than the
upper, skin. If available, the choices are further expansion or the addition of skin in the lower pole with a
latissimus dorsi flap. Patients may also consider removal





Figure 10.8 (A, B) (A) Pre-operative patient with previous right lumpectomy and radiation. The breasts were too large to match
without contralateral reduction. (B) Post-operative view with immediate right-sided 800-cc implant and contralateral reduction with
free-nipple graft.



Figure 10.9 (AB) (A) Pre-operative patient with previous lumpectomy and positive margins. (B) Post-operative result after bilateral
expander/implant reconstruction and completion of nipple tattooing.

of the expander and the placement of an autologous tissue flap, as this bridge has not been burned by expander
Radiated, Non-stretchable Skin Envelope

Figure 10.10 Post-operative result after unilateral implant

reconstruction by mastopexy of the contralateral breast.

If the patients skin is radiated and shows severe telangectasis, hyperpigmentation, parenchymal asymmetry, and/or
skin thickening, then it is doubtful that this skin will successfully expand. Alternate methods of reconstruction
should be chosen. However, radiation is not a contraindication for expansion in all cases. Despite what we are
taught about radiation, current evidence is divided with
regard to radiation and the development of complications






Figure 10.11 (AC) (A) Pre-operative patient with significant ptosis. (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. (C) Final post-operative appearance.

during breast reconstruction. In the Michigan Breast

Reconstruction Outcome Study (level II evidence), radiotherapy, both before and after surgery was associated with
at least one complication; however, this trend did not reach
statistical significance (10). McCarthy et al. performed a
retrospective comparative study of 1170 expander/implant
patients over 2 years (Level II), and determined that preoperative or postoperative chest wall irradiation was not
significant predictor of complications (12). Contant et al.
(Level IV) studied 103 women with BRCA gene mutations
undergoing prophylactic mastectomy with immediate
expander/implant reconstruction. Radiation was found to
be a significant risk factor, both for complications and for
implant removal (46). It seems that some radiated patients
do well and others do not.
We use an eight-point system to grade radiation, giving
02 points for each of skin thickness, hyperpigmentation,
telangectasia, and parenchymal shrinkage. Patients with
lower numbers do well with expander reconstruction.
They must, however, be warned that some late capsular
contracture is seen in approximately 40% of these reconstructions. If the contracture is Baker grade II, patients are

not typically distressed by it, but if it is Baker grade III,

they will usually pursue capsulotomy to address the tightness. We have seen great changes in radiation techniques
over the last 20 years. We can, now, often see no residual
changes in a radiated patients skin as compared to her
other breast. Radiation oncologists believe that the tangential beaming targets the breast parenchyma more so than
the skin, giving better long-term results.
Lack of a Crisp Inframammary Fold
The inframammary fold is often obliterated during mastectomy by the general surgeon. This can lead to a displaced and/or detached fold, which is not tightly adherent
like a normal fold. Intraoperatively, the fold should be
sutured to the ADM and fascia in the desired place. We
use 2-0 absorbable sutures, and the suture is brought from
beneath to the deep dermis where it can be seen dimpling
the skin. It is then secured through the ADM and fascia
and tied. This usually gives a good, crisp fold. If the fold
is incorrect after expansion, then it can be revised at the
implant exchange operation. For severe problems, the


Ryan open technique attaches a de-epithelialized section

of dermis to the underlying rib fascia for a secure
fold (47). It is imperative that you discuss the importance
of the fold with your ablative surgeons, so that they are
cognizant of its importance in reconstruction.
There are many advantages of tissue expansion for breast
reconstruction as compared to autologous reconstruction,
and the surgeon and the patient should take full advantage
of them. The short operating and recovery period are the
primary reason that women choose implant-based surgery.
With the use of techniques to give ptosis and a natural
shape, such as ADM slings and profiled expansion, an
excellent outcome can be obtained. Patients are often
happy to alter the opposite breast by reduction or mastopexy if they do not like its appearance. Bilateral expanders
and implants for bilateral mastectomies match, and remain
high and youthful for life without the discomfort of bras.
New memory gel implants have cohesive silicone and do
not leak as much if ruptured. More durable models of
implants are being produced with longer life spans. Infection remains the major complication of implant-based
reconstruction, and more research is needed to identify
and prevent this problem. Implant-based reconstruction is
efficient and cost effective and will continue to be popular
in the evolving health care environment.
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The pedicled TRAM flap
M. Lance Tavana and Paul D. Smith



The pedicled transverse rectus abdominis muscle flap, first

described by Hartrampf in 1982, remains a reliable and
reproducible autologous flap reconstruction of the breast.
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. Several variations
on technique have been developed to improve the viability
of the flap as well as to decrease donor site morbidity,
while aesthetic design has developed in a less formal
The benefits of the pedicled flap in contrast to free technique consist of shorter operative time, consistent anatomy,
no need for microsurgical equipment, and less need for
monitoring of the flaps in the postoperative period. The
weaknesses of the pedicled technique, again in contrast to
free technique, are the need for intact superior epigastric
vessels, sacrifice of the entire rectus muscle, and potential
for greater fat necrosis. While some would argue that free
transverse rectus abdominis myocutaneous (TRAM) reconstruction allows for easier inset of the transferred flap, 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. The complication of
total flap loss when using a pedicled TRAM flap should be
reduced almost to zero, barring unforeseen iatrogenic
injury to the pedicle or poor patient selection.

The patient, in regard to both body habitus as well as medical and surgical history, is a major factor in a successful
outcome. By adequately assessing the risk factors associated with the patient, the proper decision may be made
regarding reconstruction technique.
We have found the ideal candidate for TRAM reconstruction to have the following attributes:
BMI between 25 and 35 with adequate abdominal
No previous incisions on the abdomen interrupting the
superior pedicle
No previous cardiac surgery with IMA harvest
No history of uncontrolled diabetes mellitus, COPD, or
smoking within the last 6 months
Several key anatomic facts guide surgical planning. The
rectus abdominis muscle is a Mathes and Nahai Type 3
muscle with its main blood supply from the superior and
inferior epigastric arteries. The superior pedicle is a termination of the internal mammary vessels, while the inferior
epigastric arises from the external iliac vessels. Innervation of the rectus muscle is from the lower six or seven
intercostal nerves, which are encountered and ligated as
the muscle is raised during harvest.


The skin island is based on medial and lateral rows of

perforator vessels, which are found along the length of the
rectus muscle. The highest concentration of these perforators is surrounding the umbilicus, leading to a greater perfusion of the tissue in the periumbilical area.
The dual blood supply of the rectus muscle leads to a
region of choke vessels in the middle of the muscle. This
anatomy may be used to the surgeons advantage to augment the perfusion of the flap prior to transfer by a delay
procedure. Two weeks prior to the TRAM procedure, the
inferior epigastric vessels may be ligated in order to make
the muscle rely on the superior vessels as the sole blood
supply. The delay procedure reduces the risk of fat necrosis within the flap upon transfer, leading to a softer and
more natural flap.
Taken as separate but related, the abdominal flap and
breast inset markings are essential for planning a successful operation.
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. The aesthetic concern of scar location, while important, is of
secondary concern if delayed wound healing or partial flap
loss is present. By maximally utilizing the periumbilical
perforators, thereby increasing reliable blood flow to the
flap, the surgeon is able to increase the size of viable flap.
The abdomen is first marked with a straight horizontal
line two to three centimeters above the umbilicus extending 22 cm laterally in each direction. Flap width is determined by breast base width and translated to a caudal
vertical distance from the upper abdominal marking. The
inferior marking is then brought from a parallel horizontal
marking centrally to a superiorly curving mark, intersecting the upper marking at a 90 angle. 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.
In a bilateral reconstruction, the central incision is based
in the midline. In a unilateral reconstruction, however, this
marking may extend to the contralateral sideHartrampf
Zone 2in order to increase flap size. Care must be taken
to only extend into Zone 2 a few centimeters, as the vascular
supply may not be ideal when compared to Zones 1 and 3.
We have found less partial flap loss in cases that needed less
of Zone 2 for reconstruction.
The flap inset markings are variable depending on the
type of reconstruction being performed. If an immediate
reconstruction is being planned, 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. A delayed reconstruction presents a greater


challenge to the surgeon, as the need to replace loss of the

skin envelope becomes the major goal of reconstruction.
In the face of post-radiation reconstruction, this goal is
even more difficult to achieve.
For immediate reconstruction, we have found a vertical
reduction pattern incision to be the most reliable. This
allows an inferiorly based scar that the patient prefers
while providing a means to reduce the skin envelope. In
concert with the surgical oncologist, the mastectomy is
typically performed through a skin-sparing technique.
This allows for ease in preoperative marking as it only
consists of a periareolar marking. Should the surgical
oncologist require a larger incision, a vertical incision to
the inframammary fold may be used. This should allow
enough exposure for sentinel node biopsy, should that
need to be performed. For small breasted women, the flap
volume may be more than adequate the fill the breast
space. The nippleareola complex can then be replaced
with flap skin. Should the natural breast be larger than the
expected transposed flap, a vertical skin reduction is performed intraoperatively to conform to the flap size.
For delayed reconstruction, as most surgical oncologists use a transverse incision, the previous mastectomy
scar is used as the superior inset marking. This marking is
continued medially to 12 cm of the midline, depending on
whether the contralateral breast is a natural breast or to be
reconstructed as well. This marking is then brought inferiorly at a 90 angle and gradually curved to stay 1 cm above
the inframammary fold. About 12 cm lateral to the midclavicular line, the marking is curved superiorly and meets
the upper marking to taper into the axillary tail at its most
prominent point. This axillary tail marking is carried for
56 cm superolaterally, though the amount of this marking
used as a releasing incision is determined at the time of
inset, depending on contour.
The abdominal incision is first made at the superior marking. Care should be taken to bevel the dissection cephalad
so that the superior perforators in the flap are conserved.
Dissection is carried suprafascially to the xiphoid process
medially and the costal margin laterally. 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. At this point, the cautery power is reduced in half
and dissection carried close to the lateral row of perforators. Once close, sharp dissection using a #10 blade scalpel
is performed to skeletonize the perforators. A small split
in the fascia can be noted prior to exposing each perforator, thereby reducing the chance of injury to the vessel.
Once the lateral row is exposed, the umbilicus is marked
with an orientation stitch at the inferior portion so that that
the stalk is not twisted on later inset. The umbilicus is


incised in a circular fashion without pulling too much tension on the stalk, as this may shorten the stalk and provide
for more difficult inset. Metzenbaum scissors can be used
to dissect the umbilical stalk down to fascia, then the
midline incision is performed and carried down to fascia.
The medial perforators are exposed in a fashion similar to
the lateral row. By careful exposure of the perforators, the
extent of fascia needed to be included with the flap is minimized. By doing this, the closure of the fascia is made
easier later in the case.
A 1-cm strip of fascia is outlined from the superior
aspect of the adipocutaneous flap in between the lateral
and medial perforators. This strip is continued up to the
costal margin, but left intact superiorly to provide a tether
so that the muscle and pedicle are not stretched. This superior strip also provides a tight closure of the upper abdomen after the rectus is transferred, thereby decreasing
abdominal wall bulge superiorly. A scalpel is used to
incise the anterior rectus fascia along the strip then medially and laterally, sparing the perforators but leaving
behind as much fascia as possible. The muscle is dissected
medially and laterally from the fascia, with dissection
starting between the muscle inscriptions for ease then
taken to the inscriptions in the same plane.
The inferior pedicle is identified and ligated with clips,
leaving as much of a pedicle length as possible as a lifeboat should the superior pedicle be accidentally injured
during harvest. This allows for a free-flap reconstruction
using the inferior pedicle to still be an option. The inferior
aspect of the rectus muscle is divided below the pedicle by
electrocautery and the muscle raised inferior to superior.
Once the muscle is raised to the level of the superior aspect
of the cutaneous flap, the muscle is sutured to the adipose
tissue of the flap using a running absorbable stitch medially, inferiorly, and laterally. This allows the myocutanous
flap to be moved en block without increased risk of avulsing the perforators.
The superior muscle dissection is carried on its anterior
surface to the costal margin, taking care to sufficiently release
the muscle medially for mobility. Blunt dissection is used
under the muscle to protect the pedicle from injury, which
should be easily visualized as the muscle is raised. Once the
flap is completely dissected, the lateral tip (Zone 3) of the
adipocutaneous portion of the flap is sharply excised. This
allows flap perfusion to be assessed by the rate of bleeding
and the color of the blood. By excising an appropriate amount
of zone 3, the flap bulk is reduced for an easier flap transfer
while also immediately reducing the metabolic demands of a
larger flap. For a unilateral case, zone 4 and a majority of
zone 2 is immediately removed for the same reason.
We have found that a lateral tunnel for flap transfer
advantageous over a traditional medial tunnel. First, the
muscle is rotated through a broader arc, thereby reducing
the likelihood of kinking of the pedicle. Second, a lateral


tunnel allows the early bulk of the muscle to remain lateral to the midline of the breast, thereby leaving the
medial inframammary fold intact and aesthetically pleasing. The dissection is carried from the abdominal space to
the breast pocket completely lateral to the midline of the
breast. The flap is then rotate laterally and up into the
breast pocket. We have also found that a 180-flap rotation produces the best position for the muscular pedicle to
be loose without strain on the pedicle, while a 90 rotation
allows for greater upper pole fullness. This decision is
made interoperatively.
On a bilateral case, each flap is dissected, transferred
completely and the fascia closed before the other flap is
dissected. This allows for an easier fascial closure. This is
performed one of two ways, with several interrupted figure
of eight sutures or a running barbed suture. Once fascial
closure is complete, onlay mesh is used to augment the
strength of the abdominal wall. 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. The mesh is sutured with either a
running nonabsorbable monofilament or running barbed
Closed suction drains are placed through the dependent
portion of the abdominal space. The umbilicus is delivered
through the abdominal flap while the central abdominal
incision is temporarily closed with staples in order to provide proper position. 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.
Flap inset is variable case to case, but can be generalized
to be for immediate or delayed reconstruction. In immediate reconstruction using a skin sparing technique, the flap
is oriented in the breast pocket for the best volume filling
of the space. In smaller breasts, or in breasts in which the
flap volume is greater than the mastectomy volume, the
flaps may be inset without reducing the breast skin volume
(Fig. 11.1). The flap is de-epithelialized except for the areola replacement, a drain is placed, the areola is inset and
the mastectomy flap incision closed. When the flap volume
is less than the mastectomy volume, the vertical reduction
is performed on the breast skin (Fig. 11.2). 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. The flap is de-epithelialized except for
the areola replacement, a drain is placed, the areola is inset
and the mastectomy flap incision closed.
In delayed reconstruction, the flap is inset to replace the
loss of skin from contraction and/or radiation (Fig. 11.3).
The inferior and medial inset margins are created without
undermining the mastectomy flaps, creating a greater fold
inferiorly and appropriate central cleavage. The inferior
inset is performed with a 2:1 ratio of TRAM skin to fold
skin, thereby creating a greater amount of skin on the newly





Figure 11.1 (A) Preoperative right immediate skin-sparing mastectomy reconstruction. (B) Twelve-month follow-up after right
nipple-areolar reconstruction.



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.





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.
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 patients 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 1014 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.
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 surgeons
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


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
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


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
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 patients medical history, such as smoking or diabetes.
Proper patient selection will decrease a surgeons 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
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
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: 3514.
Baldwin BJ, Schusterman MA, Miller MJ, et al. Bilateral breast
reconstruction: conventional versus free TRAM. Plast Reconstr Surg 1994; 93: 141016.
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: 16408.
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:
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: 82841.

Hartrampf CR, Bennett GK. Autogenous tissue reconstruction in
the mastectomy patient: a critical review of 300 patients. Ann
Surg 1987; 205: 50812.
Hartrampf CR, Soneflan M, Black PW. Breast reconstruction
with a transverse abdominal island flap. Plast Reconstr Surg
1982; 69: 21625.
Moon HK, Taylor GI. The vascular anatomy of rectus abdominis
musculocutaneous flaps based on the deep superior epigastric system. Plast Reconstr Surg 1988; 82: 81532.


Scheflan M, Dinner MI. The transverse abdominal island flap: I.
Indications, contraindications, results, and complications.
Ann Plast Surg 1983; 10: 2435.
Seljavaara S, Svartline NE. Cutaneous blood flow in the TRAM
flap. Br J Plast Surg 1992; 45: 2619.

Transverse rectus abdominis myocutaneous (TRAM) flap and deep
inferior epigastric artery perforator (DIEP) flap breast reconstruction
John C. Oeltjen and Haaris Mir


based on the superior epigastric vessels to cover an

upper abdomen traumatic injury (7). In 1979, Robbins
described using a vertical rectus abdominis muscle
(VRAM) flap for breast reconstruction (8). Driver (9),
Dinner (10)(11,) and Sakai and colleagues all published
their refinements on the VRAM flap for breast reconstruction (12,13). In 1982, Hartrampf and colleagues
described an elliptical shaped flap based on a single rectus abdominis muscle. 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). The transverse rectus abdominis
muscle (TRAM) flap has remained the gold standard
for pedicled breast reconstruction. With refinements in
microsurgical techniques, advances in imaging technology and the goal of reducing morbidity and mortality,
the free TRAM flap with different degrees of muscle
sparing were developed. In describing complete rectus
muscle preservation in 1989, Koshima and Soeda developed the deep inferior epigastric artery perforator (DIEP)
flap and superficial inferior epigastric artery (SIEA)
flaps (15,16). In 1991, Grotting coined the term free
abdominoplasty flap when he used the SIEA flap for
breast reconstruction (17).

The concept of breast reconstruction with autologous

tissue is a concept that has been present for over a century. In 1896 Tansini published a paper describing an
autoplastic flap which was a random, narrow based
skin flap from the back transferred to the anterior chest
wall defect. This allowed chest wall coverage as well as
the axillary wound after cancer extirpation. Tansini felt
bringing distant tissue would be less likely to contain
cancer (1). As early as 1959 it was recognized by Gilles
that breast reconstruction was an important for the psychological well being of a female (2). Prior to this in
1942 Gilles performed two breast reconstruction cases
using a unilateral flap from the abdomen based on the
flank. In 1957, Millard described a tubed abdominal flap
incorporating the umbilicus and then waltzing it to the
chest via the forearm (3,4). In 1963, Cronin and Gerow
described a delayed single-staged breast reconstruction
using a silicone-gel-filled prosthesis. At that time, radical mastectomy was a popular technique for breast
cancer surgery. Patients frequently required skin grafts
for coverage for the pectoralis major muscle as well as
wound defects. Placement of the implant alone resulted
in an aesthetically poor breast with an unnatural breast
mound. Flap coverage was required prior to implant
placement (5,6). Mathes, in 1977, published a case
report on a myocutaneous rectus abdominis muscle flap


The lower abdominal wall receives its perfusion through
two different arterial systems. The vascular supply can be
divided into a superficial system as well as a deep system.
Contributions from intercostal segmental vessels and
superior epigastric vessels are also made.
In 1975 Taylor and Daniel performed cadaveric dissections and were able to define the anatomy of the superficial
system to the lower abdomen. Three patterns of arterial
perfusion based on the SIEA were identified:
1. In 17% of cadavers the SIEA was found to arise from
the common femoral artery. The vessel was noted to
have a mean diameter of 1.1 mm (0.81.8 mm).
2. In 48%, the SIEA shared a common trunk with the
superficial circumflex iliac artery. The mean diameter
was noted to be 1.4 mm (0.83.0 mm).
3. In 35% of cadavers the SIEA was absent, however a
large compensatory circumflex iliac artery was found
with a mean diameter of 1.4 mm (0.83.0 mm) (18).
The landmark for the SIEA at the inguinal ligament is
the midpoint between the pubic bone and the anterior
superior iliac spine, or even slightly lateral to this point.
The artery originates from the anterior surface of the femoral artery 45 cm below the inguinal ligament (19).
The vascular supply to the SIEA flap arises superficial
to the rectus sheath. When dissecting out the flap, there is
no violation of the abdominal wall musculature or fascia.
Allen noted no hernias or abdominal wall weakness in
elevating an SIEA flap (20).
The TRAM and the DIEP flaps both rely on their perfusion via the deep system. 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).
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%, middle third 78%, and 5%
in the upper third (21). Within the rectus abdominis muscle, the deep inferior epigastric artery usually divides into
a non-dominant medial branch and a dominant lateral
branch. The artery has also been found to have a dominant
medial branch (18%) or a central course with multiple
small branches (28%) (22).
Using color duplex ultrasonography, 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 0.5 mm in diameter. The approximate
site of the perforators was noted to be 26 cm caudal and
16 cm lateral to the umbilicus (23).
Medial perforators:
Long, oblique and complicated, intramuscular route
with numerous subsidiary muscular branches.


Greater likelihood of providing perfusion to the contralateral abdomen.

Lateral perforators:
Direct perpendicular course through rectus abdominis
Vessels are accompanied by large sensory segmental
Motor branches originating from the intercostals cross
superficial to the main branches of the deep inferior
epigastric vessels (15).
Across the midline of the abdomen, Blondeel and colleagues noted venous drainage was unreliable. The venous
drainage of the DIEP flap is dependent on the small perforating veins; however, in some patients a superficial venous
drainage system maybe dominant. During dissection and
elevation of a DIEP flap, if a large medial or superficial
epigastric vein is noted, 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).
TRAM Flap Nomenclature and Classification
Successful TRAM flaps may be raised with differing
amounts of muscle with them. 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. Nahabedian
and colleagues developed a classification system to demonstrate the degree of muscle sparing in a free TRAM flap
elevation. The classification is as follows:
MS-0: Sacrifice of the entire width of the rectus abdominis with preservation of partial length.
MS1: Lateral segment of rectus abdominis preserved.
MS2: Preservation of both the medial and lateral segments of the rectus abdominis.
MS3: Preservation of the entire muscle (equivalent to a
DIEP flap) (25).
With relevance to the MS-1 group, 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,
respectively (26).
Perfusion Zones
Scheflan and Dinner studied the perfusion of the TRAM flap
(14,27), however, it became better known after Hartrampf
described his work on the TRAM flap (Fig. 12.1) (4). The
initial description of the perfusion zones divided the abdominal ellipse into four equal parts with perfusion decreasing as
the zone number increased. This was based on the original
description of Scheflan and Dinner.




Figure 12.1 Hartrampf perfusion zones. Perfusion in Zones I and II was thought to be the best, less in Zone III, and the poorest in
Zone IV with the most likelihood of flap necrosis.

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 (28,29). In 1983 Dinner suggested that the
ipsilateral hemiabdomen does indeed have better perfusion
than the segment across the abdominal midline. Perfusion
was better in Zone III than in Zone II, thus he advocated
changing the initial classification (Fig. 12.2) (11).
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. 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, and
finally, if the abdomen is appropriate, the decision has to

be made between a free-TRAM, muscle-sparing TRAM,

versus DIEP breast reconstruction. The amount of muscle
removed in the process of the tissue transfer is variable
and dependent on a combination of factors including the
patients anatomy, unilateral versus bilateral reconstruction, patient preference, and surgeon experience and skill
When a patient presents for consultation for breast
reconstruction, three goals for that reconstruction help
shape the treatment course. The first goal of breast reconstruction is to no interfere with the patients cancer treatment. For this reason it is the reconstructing surgeons
responsibility to understand the pathology of the patients
cancer, proposed treatment course for the patient, 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. Inherent in this is communication between the reconstructive
surgeon and the patients medical and surgical oncologist.
The second goal for reconstruction is to recreate a breast




Figure 12.2

True perfusion of lower abdominal wall.

mound that appears normal in clothing and will allow the

patient to continue wearing the clothing that she has previously. The third goal for reconstruction is to reconstruct a
breast mound that appears normal out of clothing, a reconstruction that replaces the breast well enough that the
observer cannot tell that the patient has had surgery.
Although this is the ideal, the reality needs to be stressed
to the patient that surgery involves scars, and scars may
fade with time but never disappear. Often in a mastectomy, the scars are on the anterior most aspect of the breast
and thus impossible to hide in any folds. Additionally, it is
important for the patient to understand that a mastectomy
includes removal of the sensation to the skin of the breast.
Although this sensation may return with time, it is not
regularly reconstructed during the breast reconstruction
process. Once the goals are elucidated, the process of evaluating the patient for the reconstructive course proceeds.
One early consideration in the evaluation process is
radiation treatment of the patient for the breast cancer. If
the patient is being seen in evaluation for an immediate
reconstruction following mastectomy and there is a strong
likelihood for postoperative radiation, the physician should

recommend delaying an autologous tissue reconstruction

until after the radiation is completed. Radiation to the free
flap breast reconstruction has been shown to result in
higher rates of fat necrosis, volume loss, and contracture
of the reconstruction in comparison to a delayed reconstruction (30). In contrast, if the patient is being seen in
evaluation for a delayed reconstruction after completion of
radiation, the physician needs to consider the amount of
time to wait after the radiation before proceeding. Although
the immediate inflammation from the radiation subsides in
the several months following radiation, the fibrosis and
other associated changes never recover. Traditionally, a
minimum of six months have been allowed for optimum
recovery of the patients tissues before proceeding with
reconstruction however a lower complication rate has
been shown by waiting at least a year (31). It is often difficult, however, in a patients wish to return to a feeling of
normalcy, to ask them to wait an additional year before
proceeding with reconstruction.
Although the consulting physician can have an understanding of a treatment course prior to interviewing the
patient, the patients goals are equally as important in


determining the reconstructive course. The patients

desired breast mound size after reconstruction, patients
willingness to accept placement of an implant, the
patients constraints on recovery that can include the
need to return to work or physically demanding activity
such as childcare, and the patients willingness to accept
scars on sites other than the breasts all are important in
determining the course. 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. 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 patients
health. Autologous tissue-based breast reconstructions are
longer operations relative to implant-based reconstruction.
The patient must be stable enough to undergo a lengthy
period of general anesthetic followed by prolonged recovery with abdominal wall morbidity. 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- and post-operatively. Additionally comorbidities such as hypercoagulability, chronic
obstructive pulmonary disorder, and back instability can
likely contribute to a complicated postoperative course
with possible flap failure. Finally, 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.
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. 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. These sites cannot have previously undergone surgery that will have interrupted the
blood supply. In the case of the abdomen, a previous
abdominoplasty is a definite contraindication for a free
TRAM or DIEP flap. Other relative contraindications
include previous abdominal suction-assisted lipectomy,
previous abdominal incisions including cesarean sections,
hysterectomy, open cholecystectomy, laparotomy, and
colostomies. Although the obstetric/gynecologic Pfannensteil incision routinely does not include ligation of the
deep inferior epigastric artery, damage to these vessels
during the procedure is possible. In contrast, the subcostal
open cholecystectomy scar interrupts the blood supply that
is important for donor site closure. If the abdomen is void
of scars or the scars present do not prelude the use of the
abdominal tissue, the patient must have sufficient mass or
thickness to the infraumbilical fat pad to reconstruct a


breast mound and sufficiently laxity in the abdominal wall

skin to close the donor site after harvest.
Finally, as mentioned previously, the consideration of
the muscle and fascial sparing approaches to the abdominal free flap breast reconstruction is dependent on multiple
variables. With todays availability of information on the
Internet, patients will often present to the physician
requesting a specific type of flap reconstruction, namely
a DEIP flap. It is important for the requesting physician
to explore the myths and realities behind the patients
request. Since the advent of the muscle- and fascia-sparing
approaches, the advantages and disadvantages of the different approaches have been examined and reexamined.
The free TRAM, 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, especially when
compared with bilateral pedicled TRAM breast reconstruction (32). Additionally, there is no data comparing the
DIEP flaps where one versus two or more perforators is
harvested. 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, morbid obesity with the transfer of a
large flap, or the need for zones 1, 2, and 3 to provide a
reconstruction of adequate size. In contrast, DIEP flap
reconstruction is generally indicated in patients undergoing bilateral reconstruction. More importantly, though, 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 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. As mentioned
earlier, the patients comorbidities need to be evaluated and
optimized in preparation for a long surgical course and
postoperative recovery. In patients of relevant concern, the
nutritional status should be investigated and optimized to
ensure that the patient is in an anabolic state. A recent
completion of chemotherapy warrants an analysis of the
patient for anemia, thrombocytopenia, leukocytopenia,
liver function, coagulation cascade function, and cardiac
performance when cardiotoxic chemotherapy has been
administered. Any abnormalities should either be corrected
or the patients surgery be postponed until the values
normalize. Additionally, hormonal chemotherapy is associated with hypercoagulability. The medications should be



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 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. With a
properly adjusted protocol, 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. 12.3). 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, (2)
preoperative localization of any dominant perforators to the
abdominal wall, (3) the ability to choose from the larger
perforators that appear to vascularize a majority of the proposed flap tissue. 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). With
increased experience by the surgeon, however, the amount
of operative time saved with the availability of CTA or
MRA data, decreases. The disadvantages of the imaging
include the cost of the studies, the toxicities associated with
the dyes, and the increased radiation exposure as associated
with the CTA.
In the preoperative staging area, the patient is marked
in preparation for the surgery. A midline marking from

sternal notch to pubic symphysis helps localization of the

umbilicus along the midline during donor site closure. 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 standard flap design entails two 12-cm horizontal
incisions, one just above the umbilicus and one approximately 7 cm above the superior limit of the vaginal cleft.
The inferior incision should be placed just above the hirsute limit of the mons pubis and incorporate any previous
Pfannensteil incisions. Laterally the horizontal incisions
are joined by oblique incisions to approximately 3 cm lateral to the anterior superior iliac spine. Prior to being
transported to the operating room, 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. If not, the inferior incision can be raised and the superior incision lowered however it is preferably kept above
the umbilicus.
As to the chest, 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. In a delayed reconstruction, 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. Additionally, an excision line for the inferior mastectomy flap is designed
above the planned inframammary fold approximately




Figure 12.3



CTA of the abdomen demonstrating a right-sided dominant periumbilical perforator.


1.5 cm above the inframammary fold at the breast meridian tapering medially and laterally to meet the inframammary fold (Fig. 12.4). Finally, the manubrium is marked
along the midline as a landmark for the second rib.
With completion of the markings, the patient can be
taking to the operating room. As should be standard protocol, the patient should have bilateral sequential compression devices and warming device placed prior to receiving
any anesthesia. Additionally, prophylactic fractionated or
unfractionated heparin and prophylactic antibiotics are
administered prior to induction. 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.
In an immediate reconstruction, 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. The
flap is incised as marked with continued dissection through
the subcutaneous tissues down to the fascia. Inferiorly in
patients who have not had a Pfannensteil incision, dissection


above Scarpas 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. Even in the absence of a sufficient artery,
the vein can be preserved for possible venous rescue of the
flap; a 23-cm length of vein can provide a flap lifeboat.
Once dissected down to the fascia, dissection continues in a
lateral to medial direction. Dissection can proceed with ease
up to the lateral edge of the rectus muscle. In a bilateral flap
procedure, the midline can be incised, isolating the umbilicus on its stalk with a healthy cuff of tissue to ensure its
survival. Dissection from the midline in a lateral direction
can proceed with care understanding that the medial row
perforators are often within the first 12 cm of the midline.
Once the medial and lateral edges of the rectus muscle
are encountered, the decision for a free TRAM versus
muscle sparing versus DIEP must be made. If a freeTRAM flap is the decided approach, the fascia is incised
and the muscle along with the deep inferior epigastric
artery is isolated. If muscle and fascial sparing is the
decided approach, the perforators are meticulously and

Proposed removal
of interior mastectomy
flap (dashed)
Proposed new
fold (solid)



Figure12.4 Graphic (A) and pictorial (B) demonstration of preoperative markings for a free flap breast reconstruction. Note the right
(A) and left (B) planned lower mastectomy flap excision is marked approximately 1.5 cm above the proposed inframammary fold.


carefully dissected free of the surrounding tissue at the

interface between the fascia and overlying fat and skin utilizing loupe magnification. In instances where preoperative imaging has identified the dominant perforators, the
dissection can be less meticulous however there is always
a risk of discrepancy between the imaging data and reality.
After isolation, 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. 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. In
instances where both medial and lateral row perforators
appear sufficient, harvesting of the medial row perforator
is thought to preserve more innervation and functionally
intact muscle. No difference, however, has been seen in
abdominal wall morbidity in follow-up when comparing
patients who have undergone medial or lateral row perforator harvest (35). Once the flap is isolated on its blood supply, it can be observed while preparing the recipient vessels
for any signs of compromised blood supply. Any evidence
of compromise should be addressed and if not repairable,
abandonment of the flap should be considered.
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. As alluded to previously, the internal mammary


artery and venae comitantes have become the preferred

recipient vessels for free autologous flap reconstruction of
the breast. 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, not damaged by lymph node dissection,
and its position allows for less restriction of flap position
inset (36). Additionally, preservation of the thoracodorsal
pedicle allows for use of the latissimus dorsi myocutaneous
flap in instances of failed free flap breast reconstruction.
The vessels are generally harvested at the level of the third
rib where the balance between branching and vessel size is
optimum (37). The vessel can be found beneath the intercostal muscle and the cartilaginous medial ribs. 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. The pectoralis muscle
is incised medially and rotated laterally or split longitudinally to expose the rib and interspaces. Dependent upon
surgeon preference, 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). The vessels are carefully isolated from
each other and prepared under the microscope for anastomosis (see Fig. 12.5).
The microsurgical anastamosis is performed in standard fashion and is highly operator dependent upon the
approach. 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 12.5 Internal mammary vessel exposure. The medial third rib has been removed. 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).


distal internal mammary artery to provide perfusion to distant structures. The venous anastamosis can be hand sewn
however a high success rate has been noted with the use of
the venous coupler (Synovis, Birmingham, AL) with experienced microsurgeons (39). 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 DIEP flap can tolerate longer ischemia due to the
absence of muscle (40).
The abdominal donor site is closed similar to an abdominoplasty. The donor site incisions are closed primarily in
the muscle- and fascia-sparing approaches and often primarily with free TRAM approaches. In primarily closing
larger unilateral fascial defects, care must be taken to not
translocate the umbilical stalk too far off from the midline
resulting in an asymmetrically placed umbilicus. For
larger defects and in thinner fascia with risk of dehiscence
and possible hernia, the abdomen can be reinforced with
insertion of either a biologic or synthetic mesh. A synthetic mesh will provide the most strength but has a higher
morbidity compared to biologics when it becomes infected.
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. Once such published report,
noted the benefit using AlloDerm (Lifecell, Inc., Branchburg, NJ) in reinforcement of an abdominal repair but a
high rate of bulge recurrence if used to try to primarily
repair the fascia (41). Multiple less elastic biologic products for repair of abdominal hernias are available but published comparisons of the products are not yet available.
The inset of the breast is performed after assuring an
appropriate vascular supply. In the immediate reconstruction, the skin from the abdomen replaces the areola
removed during the mastectomy while de-epithelializing
the remainder of the flap. Careful design of the skin paddle
that includes Dopplerable signals provides a method by
which the flap can be monitored. In the delayed reconstruction, once the flaps vascular supply is verified, the
inferior mastectomy flap is excised and sent for pathology.
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. Again,
the skin paddle can be designed to include Dopplerable
signal to provide a means to monitor the flap. Deep shaping of the mound can be achieved with absorbable sutures
tacking the flap to the surrounding fascia. During inset,
attention is paid to creating medial fullness and ptosis
equivalent to that of the contralateral breast in a unilateral
Monitoring of the flap can be accomplished in multiple
ways. The presence of a skin paddle in all but nipple sparing approaches allows for direct visualization of the flap


for color, warmth, and turgor. Any changes in these

parameters require immediate investigation and possible
exploration. As alluded to above, the presence of Dopplerable signals allows for evaluation of continued presence of
inflow. Venous outflow monitoring is accomplished with
implantable Dopplers.
Complications of breast reconstruction via a TRAM,
muscle-sparing TRAM, or DIEP flap can be divided into
two broad categories: technical complications and aesthetic complications. Technical complications include
difficulties encountered with any surgery, difficulties with
the microsurgery, difficulties with the breast recipient
site, and difficulties with the abdominal donor site. Aesthetic complications include poor cosmetic results in the
breast and abdomen.
General Surgical Complications
General surgical complications encountered include infection, hematoma, seroma, poor wound healing, deep vein
thrombosis, and pulmonary embolus. Each of these can
often be prevented with proper planning.
In regards to infection, the surgery is considered a
clean surgery and warrants perioperative antibiotics, a
first-generation cephalosporin or clindamycin for penicillin allergies. Per accepted surgical recommendations
for clean surgery, these antibiotics should not be continued in the post-operative period. Consideration may be
given to continuing the antibiotics for 48 hours postoperatively in irradiated breast reconstruction; however,
this is purely at the discretion of the surgeon and no specific recommendations exist.
Hematoma and seromas can occur at either the breast
or abdominal surgical sites. The internal mammary perforators and mastectomy flaps in the breast and the perforators of the abdominal wall are common sites of hematoma
formation. Although drains and quilting sutures in the
abdominal closure are not guaranteed prevention of seromas and hematomas, their use will help to prevent the
occurrence (42). When they occur, small hematomas and
seromas can be observed. Larger and/or expanding accumulations, especially in the breast where they can cause
enough pressure on the free tissue transfer to cause constriction and loss of perfusion, warrant operative drainage
and achievement of hemostasis.
Poor wound healing can be a result of multiple different factors including poor perfusion, smoking, and poor
nutrition. Poor perfusion can be the result of previous
scars on the abdomen, microsurgical technical difficulties,
thin mastectomy flaps, and radiation. Prevention is the


best approach to poor wound healing management but

once the healing issues arise, local wound care including
debridement, dressing changes, negative pressure wound
therapy and in the case of irradiated tissue, hyperbaric
oxygen therapy, make up the armamentarium of the treating surgeon. If the mastectomy flaps appear too thin, 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).
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). Smoking has been shown to be more deleterious on the healing
of the donor site than on the microsurgical transfer (45,46).
The patient should be encouraged to undergo smoking
and nicotine cessation at least 3 weeks prior to the surgery. In a delayed elective reconstruction, the surgeon
may require the patient to stop smoking and confirm this
with urine or serum tests prior to performing the surgery.
In an immediate reconstruction, 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. This would and commit
the patient to a delayed reconstruction. Finally, nutrition
should be optimized in all patients. As with smoking,
delayed reconstruction can be further delayed until the
patient is nutritionally optimized; however, in immediate
reconstruction the need to proceed with the extirpation
takes priority.
The length of the surgery, decreased activity associated
with the postoperative recovery due to abdominal discomfort, the patient history of cancer, 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. Deep vein thrombosis prophylaxis for
a moderate risk patient includes perioperative heparin
(unfractionated or low molecular weight) prophylaxis,
sequential compression devices along with early ambulation. The index of suspicion for a pulmonary embolus
should be high in patients who postoperatively desaturate
or exhibit sudden hypotension and tachycardia.
Microsurgical Complications
Although entire texts are devoted to microsurgery and its
complications, a short summary in regards to breast reconstruction with abdominal free flaps can highlight some
of the more common intricacies and difficulties. As with
all microsurgery, dependable patency of the venous and


arterial supply is crucial to success and venous failure is

more common than arterial. Exposure for the anastamosis
is critical, as poor exposure makes a technically demanding procedure more difficult. Whether using the internal
mammary or thoracodorsal vessels as recipients, liberal
use of temporary sutures and urologic fish hooks or skin
hooks to retract muscle, soft tissue, and skin in preparation
for the anastamosis will make the procedure more straightforward (Fig. 12.5). Additionally, 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.
Utilization of the internal mammary artery and vein
provides a good arterial size match for the deep inferior
epigastric artery. Additionally, should the proximal internal mammary artery become damaged or for some other
reason not be adequate for anastamosis, the distal internal
mammary artery has sufficient reverse flow to perfuse an
abdominal free flap (48). Additionally, the internal mammary artery vena comitantes anatomy allows for both
anterograde and retrograde venous anastamoses (49). 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. Additionally
when utilizing the internal mammary system, the pedicle
can become kinked as it passes over the edge of any
excised rib or split pectoralis major muscle. Finally, as
mentioned previously, an expanding hematoma within the
breast pocket can eventually compress the pedicle resulting in vascular compromise necessitating early diagnosis,
evacuation, and hemostasis.
As venous insufficiency of the free flap is more common,
the surgeon must have a number of venous rescues in his/
her armamentarium. These include the retrograde anastamosis to the internal mammary vena comitante referred to
above, utilization of the thoracodorsal, thoracoacromial, or
cephalic veins, preservation of a segment of the superficial
inferior epigastric artery vena comitant to utilize for anastamosis, 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. 12.6) (50,51).
Probably more demanding than the actual anastamosis
in a DIEP flap reconstruction, is the dissection of the perforators. A long intramuscular course or serpentine course
within the inscription of the perforators adds technical difficulty. As has been documented, the learning curve is
steep (52). 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, the perforators still must be dissected out of the
muscle unharmed to provide perfusion to the free flap.



Figure 12.6 Post-operative day one congestion of a left breast free flap after bilateral deep inferior epigastric artery free-flap delayed
breast reconstruction. Note increased edema, dark coloration of peripheral flap, and darkened serosanguinous drainage at the pin prick
(arrow). The patient was returned emergently to the operating room and the flap was salvaged with venous anastomosis to the
thoracodorsal pedicle.

The dissection must be performed meticulously and gently and should an injury to the vessels occur, the small
caliber of the vessels makes repair difficult. The preservation of several perforators or preservation of the contralateral flap until dissection of the chosen perforators is
completed may rescue a doomed reconstruction. Alternatively, attempts can be made to repair the injured vessels
primarily or with interposition grafts if necessary.
Breast and Abdominal Technical Complications
The technical complications that fall outside of the realm
of microsurgery include both the donor and recipient sites.
As to the chest/breast recipient sites and reconstruction,
difficulties include partial free flap necrosis and/or fat
necrosis, mastectomy flap necrosis, pneumothorax, and
cancer recurrence. Despite what appears to be adequate
perfusion of the TRAM or DIEP flap at the time of harvest, the entire flap may not be perfused well enough to
prevent partial flap loss or necrosis. As the number of perforators harvested for the DIEP flap decreases, 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. Additionally, attempts to utilize more of lateral
Zone II and any of Zone IV of the Hartrampf zone perfusion description (14,23,27) will increase the likelihood of
fat necrosis. 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. Routinely when fat necrosis or partial flap
necrosis occurs, it can be treated conservatively with serial
office debridements and wound care followed eventually
by scar and breast reconstruction revision. Larger areas of
necrosis may require operative debridement of the necrotic
tissue and flap shape revision. Finally, localized areas of
presumed fat necrosis within the flap parenchyma can be
observed in the hopes that they will completely reabsorb.
However, 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.
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.
Unfortunately, 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.
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 (37,54). 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. Postoperative chest radiographs should


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.
Despite a thorough preoperative work up by the patients medical oncologist as is recommended for a delayed
reconstruction, diagnosis of a cancer recurrence at the time
of a delayed reconstruction is always a possibility. Any tissue abnormalities encountered in the chest wall dissection
can be investigated with intraoperative frozen sections.
Excised mastectomy flaps and internal mammary lymph
nodes removed in harvesting the internal mammary artery
can be sent for permanent pathology. 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.
Technical complications associated with the abdominal
donor site include hernia, bulging, or weakness of the
abdominal wall, partial abdominal flap necrosis resulting
in abdominal incision healing difficulties, and loss of the
umbilicus. The literature reported incidence of abdominal
wall bulge, laxity, weakness, and hernia is dependent on
the harvest of unilateral and bilateral flaps and the degree
of muscle sparing approach utilized. In a meta-analysis of
the published literature, the incidence of abdominal bulge,
laxity, and weakness was 5.9 percent in free TRAM versus 3.1 percent in DIEP flap breast reconstruction. Additionally, the incidence of abdominal hernia was 3.9 percent
in free TRAM versus 0.8 percent in DIEP flap breast
reconstruction (55). Despite adequate closure, a hernia/
bulge/or weakness may occur. Many reconstructive surgeons will routinely utilize either a biologic or synthetic
mesh to prevent hernias however all meshes have inherent risks of infection, seroma formation, and failure. 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. Finally, the repair of hernias resulting from
free-flap harvest also varies but a majority will require
insertion of mesh.
Similar to difficulties encountered in the mastectomy
flap healing due to poor perfusion, difficulties with healing
of the abdominal donor site are also related to perfusion.
Perfusion can be compromised by smoking, undermining,
and excessive tension on the abdominal flap. As mentioned
previously, 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. 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. Addi-


tionally, undermining should only be performed to the

extent that it is required to close the defect. 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. Although not optimal aesthetically, 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. In instances where the incision breaks
down due to partial necrosis, serial debridement and wound
care including negative pressure wound therapy will often
heal the site without the need for a skin graft.
Finally, umbilical loss is related to poor perfusion from
excessive dissection during the abdominal flap harvest or
excessive tension from the inset. Usually serial debridement with wound care and time will result in a healed
Breast and Abdominal Aesthetic Complications
Although the microsurgical portion of the case including the
harvest of the flap and the anastamosis is technically demanding, the inset of the flap and closure of the donor site require
as much surgical focus to achieve the optimum result.
Improvement of results comes with experience along with
continued critical assessment of ones own results coupled
with intraoperative adjustments. Aesthetic complications of
the breast reconstruction include poor shape, improper location, superior pole hollowing, and asymmetry. 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. 12.7).
Caveats for improvement upon the breast inset include
attention to the placement and re-establishment of the
inframammary fold, recreation of the tail of Spence fullness of the breast reconstruction, 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. The inframammary fold
placement is dependent upon the contralateral breast if
present and at the mid-humeral level. In an immediate
reconstruction, 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. 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. Finally symmetry is dependent upon the amount
of tissue provided by the free flap and the survival of that
tissue. In unilateral reconstruction, over-shooting the
amount of tissue needed is preferable to having less than
needed, as postoperative flap debulking in a revision
procedure is fairly straightforward. Alternatively, implants,
tissue expanders, and fat grafting in a flap revision setting






Figure 12.7 Preoperative (A, B) and 6-month postoperative (C, D) photographs of a right immediate DIEP free flap breast
reconstruction. Note the larger reconstructed breast size in comparison to the native left breast, abdominal incision dog ear deformities
and umbilicus inset to the left of the midline. The patient elected to not undergo any nipple reconstruction or revisions.

can provide additional breast mound size for improved

Finally, the closure of the abdominal donor site provides
an opportunity for the reconstructive surgeon to utilize the
experiences and techniques of the aesthetic surgeon. Limited adjunctive liposuction, central plication, 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.
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. In careful
planning and a thorough knowledge of approaches to man-

agement of complications associated with the abdominal

free flap, the reconstructive surgeon can provide a return
of normalcy to the breast cancer patient.
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40. Converse JM, McCathy JG, Brauer RO, Ballantyne DL.
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after microvascular breast reconstruction: experience with
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Other free flaps in breast reconstruction
Brian A. Mailey and Gregory R. D. Evans


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 patients 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 (911).
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


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.
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,


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
47 cm with a variable vessel diameter of <1.03.1 mm. Flap dimensions can be as large as 15 30 cm, however, perfusion is only to
ipsilateral hemiabdominal tissues.



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 12 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 08 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.




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 2224 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 Scarpas 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





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.



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,
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


anterior branch of the superficial branch of the superior

gluteal artery (26). Identification and use of the lateral
septocutaneous pedicle result in a longer pedicle, which
increases ease of microvascular anastomosis (27). 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, candidates for SGAP flaps are those with
large, pear-shaped buttocks, B-sized breasts and in whom
abdominal donor tissue cannot be used. This may be
because of previous abdominoplasty or liposuction or those
who only have excess tissue in the buttock area. 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). In the right candidate, the SGAP can provide a significant amount of harvested tissue with average weights
greater than mastectomy specimens (24).
SGAP flaps remain second choice procedures because
of increased complexity in surgical dissection, donorrecipient vessel size discrepancy potentially requiring
additional vein grafting, resultant buttock asymmetry,
and intraoperative positioning inconveniences (7,18).
These difficulties have caused many surgeons to abandon the SGAP as a breast reconstructive option (28). A
relatively short vascular pedicle is also frequently
encountered and thus further limiting this flaps popularity (24,29). Contraindications to the flap include patients
with unsuitable vascular anatomy or inability to tolerate
frequent repositioning. Previous liposuction is also a
concern, however liposuction of the upper buttock is
uncommon and does not often affect harvesting of the
SGAP flap (24).
Bilateral simultaneous SGAP flaps can be performed
with two microsurgery teams (30,31). However sitting on
the healing incision sites is painful, especially when the
patient cannot shift weight to a non-operated side. This
may increase wound complications, including dehiscence
in the early postoperative period (24). The sciatic nerve is
not usually a problem, however small sensory nerves are
divided with flap harvest.
The incidence of complications is low. In a review of
170 gluteal artery perforator flaps, the overall take-back
rate was approximately 8%, with a 6% rate of vascular
complications (8). The total flap failure rate was approximately 2%. Donor site seroma occurred in 2% of patients
and approximately 4% of patients required revision of
the donor site (8). The most common reason for donorsite revisions of the SGAP flap is contour deformity of
the upper buttock. Complications at the recipient-site
include a fat necrosis rate of 8%. Breast flap contour
causing asymmetry and requiring revision or fat grafting
occurred in approximately 10% of cases (24).



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. 13.4).
For bilateral SGAP planning the patient is marked in the
prone position. Anatomic locations are planned with the
femur in a slightly flexed and inward rotated position. A
line is drawn from the posterior superior iliac spine to the
posterior superior angle of the greater trochanter (24). The
SGAP is based on perforators from the superior gluteal
artery and vein. 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 (8,24). The pedicle is
found with the Doppler probe usually one third the distance
from the posterior superior iliac spine to the greater trochanter. 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. The artery is short
and runs dorsally between the lumbosacral trunk and the
first sacral nerve emanating from the pelvis, where it
divides into both superficial and deep branches. The deep
branch travels between the iliac bone and gluteus medius
muscle. The superficial branch continues to give off contributions to the upper portion of the gluteus muscle and overlying fat and skin. Additional perforators may be found
slightly more lateral from above. These laterally located
perforators produce longer pedicles. Septocutaneous perforators are the most lateral and course between the gluteal
maximus and medius muscles. If possible, a two-team
approach simultaneously prepares the recipient vessels,
while the SGAP flap is harvested. The internal mammary
vessels are generally required for anastomosis due to the
shorter SGAP pedicle length. These recipient vessels also
allow for medialization of the flap when it is inset.
The skin incisions are made and electrocautery used to
dissect to the gluteus maximus muscle. Beveling is used
superiorly and inferiorly to harvest adequate tissue for
good breast reconstruction. By beveling superiorly, a
nicely shaped flap with less contour deformity can be
obtained. The flap is elevated from the muscle in the subfascial plane and the perforators approached lateral to
medial. A single larger perforator is preferred, although
several perforators in the same plane can be taken together
as well. Subfascial elevation is performed from medial to
lateral to ensure the largest perforator is found until the
flap is islanded out. 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. The arterial



Figure 13.4 Illustration of the superior gluteal artery perforator flap (SGAP) skin island markings. The design can be oriented in a
variety of fashions. The SGA originates from the internal iliac artery, exits the pelvis through the greater sciatic foramen and travels with
the superior gluteal nerve. Pedicle lengths are usually 35 cm, but can be as long as 8 cm. The vessel diameters are 2.02.5 mm and
3.04.5 mm for the artery and vein, respectively. Flap dimensions can be up to 12 32 cm.

perforator is preserved as it enters the main superior gluteal artery. The artery and vein diameters for anastomoses
are 2.02.5 mm and 3.04.5 mm, respectively, with a pedicle 58 cm in length (24). On average, the flap height is
710 cm and the flap length is 1822 cm.
When the recipient chest vessels are ready, the gluteal
artery and vein are divided and the flap harvested. The
recipient site is either definitively closed or temporarily
stapled closed with a sterile occlusive dressing used to
cover the wound.
The patient is then repositioned supine on the operating
table and the recipient site is again prepped and draped.

The flap is inset and the anastomosis performed to the

internal mammary vessels under the operating microscope.
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.
Lastly, if not already completed, the definitive closure
of the donor site is performed. 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 donor site is
closed in layers over a suction drain, approximating the
fascia and skin separately.


In the postoperative period, ambulation is encouraged

once the patient is transferred out of the ICU. The pain is
generally less than with a TRAM flap reconstruction (24).
Oral pain meds are given on postoperative day one.
Patients are discharged when pain is controlled with PO
medications and able to ambulate. This typically occurs on
the fourth to fifth postoperative day. The gluteal drain is
left in place for several days longer than an abdominal
donor site and removed in clinic.
In 1978 Le-Quang performed the first reported breast
reconstruction with an inferior gluteal myocutaneous free
flap (32). 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). Few additional reports (33) included the


IGAP as a reconstructive option until 1989 when Paletta

et al. revived the IGAP option in response to a short SGAP
pedicle (34). However, it was not until 2004 that the flaps
popularity rose as a preferred option when the abdominal
wall is not a suitable donor site (8,35). The inferior gluteal
artery perforator flap relies on the inferior gluteal artery for
its blood supply and resembles the SGAP; however, it uses
tissue from the lower part of the buttock (36) with the donorsite scar concealed in the natural inferior crease (Fig. 13.5).
The IGAP flap has a longer pedicle than the SGAP that will
reach the thoracodorsal vessels if needed.
Abdominal tissue is generally preferred for breast
reconstruction, although when unavailable, gluteal tissue
offers a viable alternative. Good candidates for the IGAP
flap are patients with excess buttock tissue and a saddle
bag deformity (7,35). By harvesting tissue from the lower
buttock and beveling inferiorly, 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 13.5 Illustration of the inferior gluteal artery perforator flap (IGAP) design. Pedicle lengths are generally longer than its
superior counterpart. The IGA branches from the internal iliac artery and exits the pelvis through the greater sciatic foramen. IGA travels
with the greater sciatic nerve inferior to the piriformis muscle. Vessel diameters are similar to the SGAP, but the pedicle lengths are
710 cm with flap dimensions of 8 18 cm.


gluteal crease, which prevents the scooped-out appearance

seen when the upper buttock donor site is used. Donor-site
morbidity is generally low and no sacrifice of muscle is
Difficulties and problems associated with the IGAP
include potential exposure of the sciatic nerve, which has
been associated with postoperative pain when sitting (34).
Microsurgical expertise, intraoperative patient repositioning, and lengthy procedures have also limited its popularity.
In contrast, champions of the inferior gluteal myocutaneous
flap (34) consider its favorable attributes, including consistent vascular anatomy and adequate perforator length, to be
more important factors. Additionally, the associated morbidity can be decreased by preservation of the lighter-colored
medial, ischial fat pad preventing the discomfort when sitting (20,34,35).
Contraindications to the IGAP include previous liposuction of the saddlebag area, which may affect the IGAP
flap viability. Overall complications are low. In a review of
almost 500 gluteal artery perforator flaps, the overall takeback rate for vascular complications was 6 percent, with
4% and 2% being venous and arterial, respectively (24).
Total flap failure rate was 2%. Donor-site seromas requiring aspiration occurred in 15% of patients and 20%
required donor-site revisions at the time of second-stage
breast reconstruction (8,24). The most common revision
for the IGAP donor site is contouring of the lateral trochanter, which can generally be accomplished by liposuction.
Complications at the recipient-site include a fat necrosis
rate requiring revision of 8%. Contour asymmetry of the
breast flap requiring fat grafting or revision occurred in
10% of cases. In appropriate candidates, the in-the-crease
IGAP flap provides excellent breast reconstruction with
well-concealed scars.
Anatomic landmarks are drawn with the patient in the
standing position. The gluteal fold is noted and the inferior
limit of the flap is approximately 1 cm inferior and parallel
to it. In the operating room, the patient is placed in a lateral
decubitus position for unilateral reconstruction and prone
for bilateral. A line is drawn between the posterior superior
iliac spine and the outer part of the ischial tuberosity. The
inferior gluteal perforators are located and marked using
the Doppler probe. 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. The remainder of the skin paddle is drawn
in an elliptical fashion to include the perforators. The
dimensions are approximately 8 18 cm (24). Skin markings can be customized to correct a saddlebag deformity by


shifting the pattern laterally (24). Care must be taken to

avoid harvesting the fat pad over the ischial tuberosity,
medial to the gluteus maximus muscle. This fat pad is
often lighter colored. Its preservation will prevent donorsite discomfort when sitting.
The inferior gluteal artery branches from the internal
iliac artery and exits the pelvis through the greater sciatic
foramen inferior to the piriformis muscle. The artery travels with the greater sciatic nerve, the internal pudendal
vessels, and the posterior femoral cutaneous nerve. The
inferior gluteal vessels course obliquely through the gluteus maximus and therefore, have a longer pedicle length
than their superior gluteal counterparts. A number of inferior gluteal artery perforators will supply both the medial
and lateral aspects of the buttocks. The inferior gluteal
vasculature exits the pelvis caudal to the piriformis muscle
and continues toward the skin by perforating the sacral
fascia. Laterally positioned vessels perforate the gluteus
maximus more obliquely and are generally longer than the
medial ones. Therefore, if similar in caliber, pedicles
based on lateral perforators are longer and chosen over the
ones more medial. The length of the inferior gluteal artery
perforator and resultant pedicle length is 710 cm for the
IGAP flap.
Skin incisions are made and electrocautery used to
divide the flap to the gluteus maximus muscle. Beveling is
used to affect the amount of tissue harvested, in particular,
this is done both superiorly and inferiorly over the lateral
aspect of the muscle. This technique provides width and
volume for a natural breast shape. The in-the-crease IGAP
flap can allow for more beveling superior and inferior
because a soft-tissue deficiency in the crease is normal.
Lateral thicker fat from the trochanteric area can increase
flap volume and decrease a saddlebag deformity (24). The
perforators are approached both lateral to medial and
medial to lateral as the flap is elevated off the muscle in
the subfascial plane. One single large perforator or several
smaller perforators, which lie in the same plane and the
direction of the gluteus maximus muscle fibers, can be
used. 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 limiting
factor in this dissection is frequently the artery. The perforator or perforators are followed until entering the main
descending inferior gluteal artery. A 2.02.5 mm artery
and 3.04.0 mm vein are required for anastomosis (24).
Once the mastectomy is completed and recipient vessels prepared, the gluteal artery and vein are divided. The
flap is harvested and the donor site is closed in layers with
absorbable suture. 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. A suction drain is placed and skin
closure is performed with nonabsorbable sutures.


The flap is then inset onto the chest, which may be done
horizontally, vertically, or obliquely, as long as the vascular pedicle is not twisted or kinked. The vascular anastomosis is performed with loupe magnification or preferably
under the operating microscope. A suction drain is placed
into the breast pocket.
In unilateral procedures, the recipient vessels can be
prepared by a second team while the flap is harvested. The
internal mammary vessels or their perforators allow easier
medialization of the flap when it is inset. However, the
inferior gluteal pedical is often long enough to reach to the
thoracodorsal vessels, if necessary. For bilateral simultaneous procedures using gluteal artery perforator flaps, the
patient starts supine for mastectomy and recipient vessel
preparation. The patient is then positioned for flap harvest
and repositioned supine for anastomosis and insetting.
When using the internal mammary perforators as recipient
vessels, a shorter pedicle and smaller artery may suffice
and thereby simplifying flap harvest.
The gracilis myocutaneous muscle flap was first described
using a longitudinal skin island in 1976 (37,38). Concerns
over skin paddle necrosis due to uncertain cutaneous perfusion resulted in limited use (11,39,40). Further investigations demonstrated the presence of perforators running
in both transverse and longitudinal directions, which led to
the use of a transversely based gracilis flap in 1992 by
Yousif et al. (11) Using the concept that the blood supply
to the muscle and its overlying skin is synonymous, they
deduced that complete muscle survival would result in
complete survival of all the overlying skin (11). Their anatomic study also included two cases, one of which was for
breast reconstruction (11). Several subsequent series have
described the musculocutaneous graciliis flap with high
success rates in both transverse and longitudinal based
skin islands (9,41). In the late 1990s the gracilis myocutaneous flaps popularity increased using a smaller transverse component and a larger longitudinal one (42). This
configuration provides a reliable vascular anatomy with
the needed tissue bulk for creating the breast mound. The
resultant reconstruction has been promoted as soft and
supple with a well-concealed scar. These factors have contributed to this flaps increasing popularity in Europe (42).
The gracilis flap is suited for patients desiring autologous breast reconstruction without available abdominal
donor tissue. Ideal candidates are thin patients with small
to medium-sized breast, as this flap does not yield an
excessive amount of tissue. Functional deficits are minimal and asymmetry of the thigh in unilateral cases is not
usually apparent. Intraoperative repositioning is also not
necessary. Overall flap success rates are high with many
series reporting 100%, despite occasional intraoperative


arterial thrombosis (43). Harvest times are reported to be

as low as forty-five minutes with flap weights ranging
from 220420 g (9,41). The median hospital stay is 5 days.
The IMA is the preferred recipient vessel, but the thoracodorsal vessels are also used with good success. Postoperative surveys demonstrate high satisfaction rates with
the gracilis free flap, with most patients willing to undergo
it again (41). At a mean follow-up of 6 months, almost all
surveyed patients were regularly exercising and sexually
active (41).
Donor-site complications are uncommon, but when
occur most commonly include hematoma, hyperesthesia
or a tight feeling at the thigh which usually resolves in
23 weeks (41). Donorsite infections are infrequent.
Other minor complications include delayed healing on
the donor site or mastectomy skin, fat necrosis, and small
wound dehiscence, which can be managed in the outpatient setting (43). Complete or partial flap loss is a rare
event (41). Adjuvant chemo- or radiotherapy does not
interfere with the reconstructed breast flap (41). Overall,
the gracilis myocutaneous free flap allows for a moderate
breast volume harvested in a reasonable amount of time
in the supine setting. Other notable attributes, include
consistent anatomy, acceptable donor-site morbidity and
a pleasing breast contour. 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, athletic patients with smaller breasts
and minimal excess abdominal tissue desiring autologous
tissue reconstruction.
Surgical technique varies slightly depending on skin island
design (e.g., transverse vs. longitudinal vs. combination of
both) and if the gracilis muscle is utilized in the reconstruction. Preoperative marking of the skin paddle and
gracilis muscle are performed with the patient in the standing position. For the transversely oriented design, the flap
is harvested contralateral to the mastectomy site for a better pedicle orientation and contour match when anastomosing with the internal mammory vessels. The ventral
limit of the transverse flap is the greater saphenous vein
and the posterior margin the midline of the inferior gluteal
fold. The skin island can be harvested to a width up to
30 cm and a height of 10 cm (41). A minimum of 6 cm is
needed to include perforators supplying the skin (41). The
limits of the transverse portion can be estimated by palpating the thigh laxity as it courses posterior into the infragluteal fold area.
For the longitudinal design, an ellipse is designed over
the course of the gracilis muscle. This is located by drawing a line from the pubic tubercle to the medial tibial


prominence. The gracilis muscle lies approximately 2.5 cm

posterior to this line. The proximal end of the skin island
is planned at least 23 cm distal to the pubic bone. Flap
width is determined by approximating the amount of skin
laxity and underlying fat, with usual dimensions varying
between 5 and 9 cm. This is correlated with the skin
requirement at the recipient site. The length of the skin
paddle can be 1018 cm and is determined by the amount
deemed necessary to close the resultant defect without creating skin excess. Flap dimensions are generally reported
from 5 10 to 9 18 (9), however, anatomic studies
define a vascular territory of 18 15 cm. The length can be
extended distally to 27 cm by including a constant intramuscular anastomosis (44).
In the operating room, 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. The flap is centered on the pedicle with the
skin paddle boundaries varying by surgeon choice of
transverse versus longitudinal. The skin is incised and the
deeper subcutaneous tissues elevated in a beveled fashion



away from the flap to provide bulk and shape. The vascular pedicle is followed to its takeoff from the profunda
femoral vessels or occasionally the medial circumflex
femoral vessels (44). The pedicle enters the gracilis muscle 912 cm distal to the public tubercle dividing in a consistent pattern into ascending, descending and transverse
branches (44). A doubled main vascular pedicle can be
encountered. When this occurs, it is usually from a common profunda takeoff; when separate the proximal pedicle
is dominant in size and number of perforators (44).
The transverse myocutaneous gracilis crescent
shaped skin paddle is oriented in an anteroposterior
direction (Fig. 13.6 A). The skin markings can be
thought of as nearly identical to the properative markings of a classic medial thigh lift. Flap harvesting is
commenced near the groin, where the adductor longus
tendon can be palpated. 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. The anterior portion of the
skin island is lifted off the adductor longus muscle and


Figure 13.6 (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. 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. Usual flap dimensions are 59 cm in width and 1018 cm
in length, but can extend up to 27 cm. The vascular pedicle length and vessel diameter are 68 cm and 1.02.5 mm, respectively,
regardless of skin paddle design.


the muscle retracted anteriorly, increasing exposure of

the flap pedicle. 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.
For the longitudinally based flap (Fig. 13.6 B), the distal aspect of the incision is made first to locate the gracilis
muscle. The paddle design can then be adjusted over the
gracilis muscle (9). The posterior aspect is incised and
subcutaneous tissue beveled obliquely until muscle
encountered. The flap is elevated over the fascia and the
main vascular pedicle exposed as it enters underneath the
gracilis muscle. The vascular pedicle is followed to its
takeoff from the profunda femoral vessels or occasionally
the medial circumflex femoral vessels (44). The pedicle is
left in its investing fascia during dissection to the profunda
vessels. 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. After
completion of the mastectomy, the IM vessels (or thoracodorsal) are prepared. The IM vessels at the third to
fourth interspace allow for the best size match between the
donor and recipient vessels, as the caliber of the gracilis
vessels are 1.52.5 mm (43). 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. A vein coupler
is utilized and the artery sewn with 9-0 nylon suture. The
flap is rolled into the upper pole of the breast to allow for
a natural breast shape. The buried skin is de-epithelialized
under the mastectomy flaps over one to two suction drains.
A perforator signal on the skin paddle is marked with a
prolene suture for postoperative Doppler monitoring. The
donor site is closed in two layers with 2-0 monocryl and
3-0 monocryl over two bulb suction drains. The donor leg
is wrapped in an ace bandage and the patient is permitted
to ambulate on POD#1.
Additional flaps attempted in breast reconstruction have
included the Rubens flap (45), from the outer hip area; the
ALT (10) free flap from the anterior thigh and the TAP
(5,6) flap from the back. Dissection of these flaps is often
more difficult and time consuming than dissection of the
other flaps described in this chapter; and the tissue volumes are also often less abundant and more difficult to
shape into a breast (39,46,47). Nonetheless, less conventional sources of autogenous tissue may be preferred in
select circumstances. The Rubens flap is based on the deep
circumflex iliac artery and uses the flank skin and fat for
reconstructing the breast (45,48) (Fig. 13.7). Patients considered for this flap are generally thin or those with previous abdominal surgery (48). Advantages include a reliable


amount of soft tissue volume that is usually present in this

region of most female patients. Harvesting can be done in
the supine position producing average pedicle lengths
around 610 cm (45,48). This length allows recipient anastomisis to either the internal mammary or thoracodorsal
vessels (49). A drawback to the Rubens flap is considered
the tedious process required for flap harvest, which often
times results in donor site asymmetry and leads to additional contralateral flank contouring procedures to achieve
a symmetric appearance (48). Additionally, perforators
may be small or in spasm, making identification difficult
even with an intraoperative Doppler assessment (45). Closure at the level of the internal oblique and transversus
abdominis muscles is important for abdominal wall integrity, but can be challenging and lead to postoperative morbidity. It has been described as the most exacting portion
of the operation and the key to its ultimate success (48). A
modification of the flap developed to make closure of the
donor site easier with less chance of morbidity is the
Rubens II flap (50,51). It is based on the 4th lumbar perforator located posterior to the posterior axillary line. Muscle harvesting is not required, but dissection is described
as difficult with small diameter vessels.
The TAP was first described in 1995 as the latissimus
dorsi musculocutaneous flap without sacrificing the latissimus muscle (52). The nomenclature was changed to
more accurately represent the actual tissue harvested and
its vascular supply (53). The TAP flap offers distinct
advantages, including a large flap dimension (25 15 cm),
a customizable flap thickness, and a variable pedicle length
that is readily tailored to the recipient status (54). When
available the TAP produces minimal donor site morbidity
with good flap shaping and aesthetic results. Conversely,
the perforator is inconsistent in size, quality and location,
which gives this flap a reputation for being difficult to dissect (46,53). Additionally, a close relationship to the thoracodorsal nerve branches and inconsistent venous
drainage contribute to the complexity (46,52,55). The
TAP flap has not gained wide popularity compared to
other perforator flaps.
Alternatively, 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 operative technique and anatomical
basis were initially described by Baek and Song et al. in
1983 and 1984, respectively (56,57). Advocates for the
ALT flap, including the Fu-chan Wei group in Taipei,
have achieved a good volume match for this flap in
Asian women (10). Promoted for pliable skin quality
and underlying fat, the ALT flap is described as similar
to tissue of the lower abdominal flaps and superior to
that in gluteal flaps (10). The volume of the ALT flap
may not be adequate without an additional prosthetic in
Western and African populations. In those situations this



Figure 13.7 A depiction of makings for the Rubens flap over the iliac crest. The vascular supply is from the deep circumflex iliac
artery. The soft tissue dissection provides large flaps from this region with weights of 6001,200 g. Pedicle dissection can be taken off
the origin of the iliofemoral vessels, allowing a pedicle length of 6 to 10 cm with vessel diameters of 1.53 mm.

flap can still be augmented with a prosthesis or require

the use of tissue from both legs (58). Other disadvantages of the flap are scar and contour defects at the donor
site. Additionally, if the transverse component is more
than 9 cm, a primary closure is difficult (10,59). 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). This vascular
pedicle is usually long with a moderate thickness and a
large cutaneous distribution. However, anatomic variations are frequently encountered and occasionally may
require conversion to an alternate flap (e.g., tensor fasciae latae, anteromedial thigh, or contralateral ALT flap)
(60). Opponents to the ALT flap also describe the vascular dissection as tedious, yielding limited tissue volumes
with unpredictable outcomes (46). Nonetheless, the
ALT can be a practical solution in select circumstances,

including bilateral simultaneous reconstruction, as repositioning of the patient between the harvesting and insetting of the flap is not required.
In the postoperative period, patients are observed in a
monitored bed (ICU or flap monitoring unit) for two to
three nights. Hourly flap circulation monitoring is performed for the first 24 hours, then spaced out to every
2 and 4 hours for postoperative days 2 and 3, respectively.
The following day, patients are transferred to the floor for
pain control, monitoring of drain output and continued
flap checks every 4 hours. The patient is discharged once
ambulating and pain is controlled on PO medications.
This typically occurs on the 4th or 5th postoperative day.
The breast and donor-site drains are taken out at the first


or second clinic visit. Nipple creation and additional contouring procedures are performed at a later date, usually in
23 months.
The Womens 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 (61,62). This reconstructive
equality has increased the availability of autogenous
reconstruction to a greater number of women. It has also
contributed to an increase in surgeon experiences with
soft tissue transfer and created new challenges, which in
turn allowed novel strategies to be developed for re-creating the breast.
The abdominal flap continues to be the standard autogenous tissue for breast reconstruction. A majority of
patients will qualify for this approach; however, approximately 15% of patients are not good abdominal donor-site
candidates (63). These include thin patients or patients
with contraindications to a lower abdominal flap (e.g., previous liposuction, abdominoplasty, etc.). Decision between
one of the secondary options (e.g., buttock, thigh, or back
tissue) for autogenous soft tissue transfer requires an individualized approach. Many of these strategies are extensively studied and offer excellent, reliable options for
creating a natural appearing breast. Others have limited
published data and require more investigation to establish
their place as a practical solution. The individuals body
fat distribution influences the ultimate decision, as the
lipodystrophy of the thigh, buttocks, or back can vary
largely between individuals. The quality of the skin and fat
pad also need to be considered, as do the donor-site morbidity and resultant scars and tissue defects. Rank orders
published by highly experienced centers will vary slightly,
but generally list the abdomen as the preferred site followed by the buttock, thigh, then back. As breast reconstruction strategies and preoperative vascular imaging
advances, surgeons will continue to have additional options
for creating a near-normal-appearing breast.
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Nippleareola complex reconstruction
Matthew E. Hiro and Deniz Dayicioglu

Surgical creation of a nipple and areola represents the final

step in breast reconstruction. After creation of a breast
mound using autologous tissue flap techniques, expander/
implant techniques, or a combination of both, adding a surgically created nipple and areola completes the reconstruction, transforming the mound into an actual breast. When
done correctly with appropriate preoperative planning and
design, nipple and areola complex reconstruction can lead
to higher patient satisfaction rates and improved outcomes.
Overall, the procedures described have relatively low
morbidity. However, complications do exist and can lead
to difficult surgical dilemmas and unhappy patients. The
following chapter will help guide the plastic surgeon in the
principles of successful nipple and areola complex reconstruction including:

1. Reduction in womens preoccupation with life-threatening

2. Facilitation of wardrobe flexibility formerly restricted
to wearing a prosthesis
3. Elevation of dysphoric mood and diminished anxiety
4. Enhancement of body image
5. Improvement in sexual responsivity



The benefits of breast reconstruction have been well

documented in the literature (14). As summarized by
Wellisch (5), the benefits of replacing the lost breast have
been shown to include:

In most patients, the procedure can be completed in

the office setting under local anesthesia with or without
sedation. General anesthesia may be required for certain

Similarly, reconstructing a pleasing nippleareola complex (NAC) leads to improved quality of life (QOL) outcomes. Several studies have demonstrated this benefit
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





The nipple and areola, with its central location and hyperpigmentation, represent the most important aesthetic unit
of the breast (8). Therefore, placement of an anatomically
accurate surgically created nipple and areola are paramount for proper aesthetics. Ideally, the aesthetically
pleasing nipple is located on the central, most projecting
portion of the breast mound, along the breast meridian.
Numerous studies have looked at the relationship of the
nipple and areola in relation to the surrounding breast
mound (915). However, these studies generally included
patients with aesthetically perfect breasts or patients being
evaluated for breast reduction surgery. Smith included all
patients measuring 55 consecutive female volunteers (13).
Results showed the nipple to inframammary fold distance
was 7.45 1.99 cm on left and 7.44 1.86 cm on the right,
and nipple to midline distance was 11.83 1.46 cm on the
left and 11.14 1.44 cm on the right.
Sanuki measured 600 breasts and showed an average
areola diameter 4.0 1.0cm, an average nipple diameter
of 1.3 0.3 cm and an average nipple projection of
0.9 0.3 cm (16). Hauben measured the breast proportions
in 37 women and showed a proportional ratio for the areola
to the nipple as 3.00:1 and for the breast mound to the areola as 3.34:1 (15).
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 14.1

for reconstruction. Before proceeding with nipple and areola complex reconstruction, the patient should be reevaluated and an appropriate physical should be completed with
particular attention to the reconstructed breast mound.
Often, additional therapies, including chemotherapy and
radiation, should have been completed since the original
cancer surgery. 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. The soft tissue envelope of the reconstructed breast should have adequate thickness, mobility
and vascularit,y. The chest wall should be without infection or open wounds. The overall health of the patient
should be addressed and all medical comorbidities should
be optimized before surgery (Fig. 14.1).
How to Avoid Errors in Timing of Surgery
Ideally, the nipple and areola reconstruction is attempted
when the breast mound is complete and all revision procedures are finalized. Although some surgeons advocate
immediate nipple reconstruction at the time of breast mound
reconstruction, most recommend a period of 36 months
before proceeding (17,18).
The final shape of the breast mound may change in the
post-operative period due to gravity, tissue healing, scar
contracture and resolution of edema. Adjuvant therapy
may also lead to implant capsular contracture leading to
nipple asymmetry and malposition. These potential complications may be limited, or avoiding completely, with
appropriate delay before proceeding with nipple and areola reconstruction (18).

Nipple flap necrosis in a smoker patient.


How to Avoid Malposition of the NAC

Additionally, strict adherence to measurements and anatomic landmarks may be misleading and lead to nipple
malposition. Placement of the nipple and areola should
include a discussion between the surgeon and the patient
to optimize results.
How to Avoid Malposition in Unilateral
In unilateral reconstructions, the native nipple serves as a
template for the reconstruction (17). Careful attention to
the position, size, shape, and projection must be made in
designing the new nipple. It is often helpful to cover the
native breast and mark the center point for the reconstructed nipple without bias. Then, the native breast can be
exposed and slight adjustments can be made for symmetry
that most resembles the contralateral nipple (Fig. 14.2).
How to Avoid Malposition in Bilateral
In bilateral reconstructions, the nipple position is placed
using a combination of aesthetic preferences of the patient,
anatomic landmarks of the chest wall, location of scars
and skin paddles, and residual asymmetries between the
breast mounds. As in unilateral reconstructions, it is often
helpful to mark each breast individually and then make
adjustments for symmetry.
Patient input is very helpful in determining location of
the new nipple. Circular adhesive bandages, electrocardiogram leads, or prosthetic nipple/areolas can be sent home
with the patient. These can then be placed by the patient

Figure 14.2


using a mirror, in the privacy of the home in various positions until the patient is satisfied. These areas can be
marked the night before surgery (Fig. 14.3).
How to Avoid Malposition in Autologous
Reconstructions with Existing Skin Paddles
Skin paddles on the breast mound deserve special mention.
With the increase in use of skin-sparing mastectomy (19),
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. Ideally, the nipple and areola reconstruction could
then be designed using only the skin paddle of the flap
resulting in a scar-less reconstruction. Although this often
leads to superior aesthetic results (8), the nipple position
should not be jeopardized by strict adherence to the skin
paddle position. With settling of the breast mound, the skin
paddle may no longer be in the ideal position. Here, 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. 14.4).
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). All can be categorized
into different types: local skin flaps, free tissue grafts
(including fat, cartilage, bone), and soft tissue fillers and
First described by Diperro (21), local flaps for nipple
reconstruction have evolved to include numerous
designs with various long-term results. The goal in the

Nipple can be marked with a bandaid or an ECG lead.



Figure 14.3

Patient should assess the position of the nipples and participate in the discussion.

Figure 14.4 If skin paddles have acceptable positions, they should be used for reconstruction template; this patient had bilateral latissmus
dorsi reconstruction.

design of local flaps is the creation of a three-dimensional

construct using a two-dimensional segment of skin and
soft tissue (18). The focus will be on the more common
flaps that have been adequately reviewed in long-term
studies (17,20). 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. Also, before final

closure, the skin edges of the flaps should be judged for

appropriate viability. All areas of poor vascularity should
be excised before final closure.
Skate Flap
First described by Little (22), the skate flap has become
the most popular technique for nipple reconstruction. The



Figure 14.5 Skate flap and full thickness skin graft technique.

skate flap includes a vertical skin and fat flap with subdermal wings which wrap around the central core. The
width of the horizontal line determines the diameter of the
created nipple. The vertical extent of the flap below this
horizontal determines the projection
Authors Preferred Steps for Skate Flap Technique
1. Mark center position of new position of nipple
2. Use appropriately sized cookie cutter to mark the
new areolar border. In unilateral reconstructions,
this should be roughly equal to the normal, contralateral nipple. In bilateral reconstructions, a 3545 mm
cookie cutter should be used based on the breast
mound size.
3. Mark the base of the flap. This can be oriented in any
direction but should avoid the mastectomy scar to preserve blood supply. The base should be marked slightly
off the central diameter of the flap to ensure a central
position once the flap is raised.
4. Incise the skin along the periphery of the flap. Deepethilialize the portion skin that will not be included
in the flap. This preserves the subdermal blood supply
to the flap.
5. Raise the lateral wings preserving a few millimeters of
subdermal fat to protect the blood supply. In order to
adequately raise the flaps, the incision must extend
along the lateral aspects of the base protecting the central portion.
6. As the flaps are elevated centrally, dissect slightly
deeper including more subdermal fat with the flap. The
vascular core must be preserved.

7. Once the flaps are adequately elevated, they are rotated

centrally and sutured together. The vertical excess of
the flap is trimmed to the final desired height. Here, it
is important to remember the final height should be
23 times longer than expected to account for tissue
8. A full thickness skin graft is used to close the donor
site and de-epithelialized area. Possible donor sites
include the upper medial thigh, lower abdominal area,
standing cutaneous deformities associated with previous flap donor sites and excess breast skin along the
axilla (Fig. 14.5).
Star Flap
The star flap, designed by Anton and Hartrampf (23), utilized a similar design as the skate flap. However, the three
flap design allowed for primary closure of the donor site.
The width of the core flap determines the diameter of the
resulting nipple. The length and width of the lateral skin
arms contributes to flap projection. Closure of the arms in
primary fashion can lead to some flattening of the central
aspect of the breast mound, which should be expected with
this flap.
Authors Preferred Steps for Star Flap Technique
1. Mark the center of the new position of the nipple
2. Mark the base of the flap and three laterally designed
arms at 90 to each other. Again, be careful to avoid
crossing scars with the base of the flap.
3. The lateral arms are incised and raised toward the base.
Like the skate flap, a few millimeters of subcutaneous



Figure 14.6

Star flap technique with CV flap modification markings.

fat should be left on the wings to protect the blood supply. The vascular core is protected beneath the central
part of the flap. Avoid all undermining in this area.
4. 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. The middle arm
becomes the cap of the nipple.
5. The donor sites are closed primarily with absorbable or
permanent suture. Care should be taken to avoid closing the donor site too tightly along the vascular core of
the flap.
Star Flap Modifications
In subsequent years, several modifications were made to
the star flap. Although some differences do exist, the
three-flap design with central cap and lateral arms is the
same. In these designs, like the star flap, the diameter of
the cap determines the diameter of the nipple and the projection is determined by the width of the lateral arms. Primary closure of the donor site may lead to flattening of the
central portion of the breast mound. These modified star
flaps include the CV flap by Bostwick (24), the cylindrical
flap by Thomas (25), the top-hat flap by Hamori and
LaRosa (26) and the arrow flap by Guerra (27).
The surgical technique of the modified star flaps is similar to the description above. The differences lie in the
design and closure of the lateral arms and the shape of the
central cap (Figs. 14.6 and 14.7).
Other modifications to the typical star flap include the
purse-string modification by Hammond and Weinfeld (28,29).

Here, a cylindrical flap is designed in the standard fashion.

The areola is similarly marked in an oval fashion with the
long axis perpendicular to the lateral arms of the cylindrical
flap. Once the cylindrical flap is raised, superior and inferior
dermal areolar flaps are advanced to close the donor site. This
creates a circular neoareola. To create areola projection, the
areolar border is marked, incised, and mobilized from the surrounding breast skin beveling away from the areola, as in a
periareolar mastopexy. This periareolar skin is then closed
using a purse string technique using a Gore-tex suture. This
leads to slight areola projection, which closely resembles that
of a real areola (Fig. 14.8).
Double Pedicled Flaps
Double pedicled flaps were designed for situations in
which the mastectomy scar traversed the central position
of the nipple reconstruction. In these cases, the blood supply for the single pedicled flaps, as described above, would
compromise the blood supply and lead to tissue necrosis.
The double pedicled flaps include two flaps of skin, which
are oppositely based. The flaps are raised in the subdermal
plane, transposed across the mastectomy scar and sutured
together to create a projecting nipple. They include the
S flap by Cronin (30) and the double opposing tab flap by
Kroll (31). The width and length of the flap design determines the ultimate projection of the nipple. The final nipple shape may appear more oval (Fig. 14.10).





Figure 14.7 (A) Star flap technique with CV flap modification. Note the ischemic appereance immediately after CV flap reconstruction
on the left. (B) Note the partial flap necrosis on the left. This was corrected later by debridement and secondary suturing.

Figure 14.8

Periareolar goretex suture technique.

The use of two flaps increases the bulk to the flap and
increases the blood supply. However, transposing the two
flaps can lead to tension during closure, increasing the
restrictive forces on the flaps and leading to loss of projection (17). Originally these flaps were designed as deepithelialized dermal flaps that were covered with a full thickness
skin graft. Later modifications changed the design with
transposition of skin flaps that allowed primary closure of
the donor site (32,33).

Authors Preferred Steps for Double Pedicled Flap

1. Mark the center of the new position of the nipple
2. Draw the central common limb of the two flaps through
the center of the new nipple. 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. Most recommend a width of



1822 mm. 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.
3. Incise the skin around both flaps and the central common limb.

4. The flaps are raised in the subdermal plane preserving

some fat on the flaps to protect the blood supply. Again,
care is taken to avoid undermining past the central vascular core of each flap. Contrary to the star and skate
flaps, the core in this flap is lateral, beneath the base of
each flap.
5. The flaps are rotated centrally to form a cylindrical,
projecting nipple and sutured together. The distal portions of each flap become the most projecting portion of
the nipple.
6. The donor sites are closed primarily taking care to
avoid tension (Fig. 14.11).
Postoperative Care

Figure 14.9 Most common nippleareola reconstruction techniques are depicted.


Figure 14.10

After nipple reconstruction using local flaps with primary

closure of the donor site, the incisions are dressed with
antibiotic ointment and a non-adherent dressing. The
dressing should be bulky enough to protect the entire
projecting portion of the nipple. The dressing should be
taped down and left in place for 57 days. Once the
dressing is removed, antibiotic ointment and a light
dressing is used along the incisions for an additional
7 days. The patient is instructed to wear light, loose
fitting clothes and chamisoles to avoid pressure on the
nipple. Sometimes it is advisable to avoid wearing a bra
for 2 months or wearing a protective hard splint to cover
the nipple.
Others recommend using the base of a 12-cc syringe to
place around the new nipple. This can be secured to the
breast skin with tape forming a rigid protective dressing
around the entire nipple. In these patients, a bra may be worn
during the immediate post-operative period (Fig. 14.12).
If a skin graft is used for the areola, the undersurface of
the graft should be irrigated with saline to evacuate any


(A) Double S flap technique immediate postoperative period. (B) Double S flap technique late postoperative period.


hematoma. The graft is then covered with xeroform with a

small hole for the base of the nipple. Moist cotton gauze is
then placed over the xeroform and a suture tie-over bolster
is tightened over the graft. Attention should be given not
to pressure the nipple itself but the areola by the bolster
dressings. The bolster is removed in 57 days. Afterwards,
antibiotic ointment and a light dressing are used for an
additional 7 days. All patients may shower once the postoperative dressing is removed.
Results with Local Flaps
Successful nipple and areola reconstruction requires attention to size, shape, position, color, texture, sensitivity,

Figure 14.11



symmetry, and projection. However, most outcomes articles in nipple and areola reconstruction tend to focus on
long-term projection as the primary result of interest (34).
Free Tissue Grafts
The use of free tissue grafts were some of the earliest
described techniques for nipple reconstruction. Many different types of tissues were used, including mucous membrane, toe pulp, labia minora, and banked nipple areola,
most of which have been abandoned with the use of local
flaps. However, recent evidence has shown that tissue
grafts may lead to aesthetically pleasing results and be a
reasonable option in certain patients.

Skate flap technique.


Figure 14.12

(A) Protection of the nipples with syringes. (B) Protection of the nipples with donut-shaped cushions.


Nipple banking, one of the original techniques described

for nipple and areola complex reconstruction, 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. In theory, nipple banking represents an attractive
option in unilateral reconstructions, as it offers a potential
exact match in regards to size, texture, color and shape.
Wirth, in 2009, analyzed the use of nipple and areola
(NAC) replantation and nipple only replantation 7 days
after reconstruction (41). The risk of total or partial graft
necrosis was higher in the NAC group (69%) compared to
the nipple only group (26%). Depigmentation was also
seen in 52% of grafts. Corrective surgery was necessary in
11 of 52 patients. In eight cases, the subareolar tissue was
positive for tumor and the graft was discarded. Only one
case of local recurrence was observed. The authors conclude that nippleareola banking is oncologically safe if the
subareolar tissue is negative for tumor, although the aesthetic results may not be appropriate for most patients.
Nipple Sharing
Nipple sharing is another technique that offers very similar graft characteristics. This is a useful technique in
unilateral reconstructions where the native nipple is
large or has excessive projection. Again, this technique
was originally described in the 1970s, but few were willing to use the contralateral normal nipple as a donor site.
Zenn reexamined the use of nipple sharing in 2008 (42).
Here, grafts were harvested using approximately 50% of
the donor nipple, utilizing either a coronal or inferior
tissue harvest. Results were analyzed with patient questionnaires. In this study, patient satisfaction was high
and most would undergo the procedure again. Most
importantly, sensation and erectile function was retained
in 35% and 42% of patients, respectively. Donor site
complications including total loss of sensation were seen
in only a few patients (3.5%). There was no total graft
loss and no cases of hypopigmentation.
Autologous Fat Grafting
Autologous fat grafting can also be useful in nipple reconstruction, particularly where the soft tissue envelope is
deficient in subcutaneous fat. The amount of fat that is
included within the local flap is paramount in achieving
long-term projection. In tissue expander-implant reconstruction, the amount of subcutaneous fat may be inadequate to support a local flap. In these cases, autologous fat
placed beneath the area of proposed flap design may augment the amount of tissue recruited into the flap leading to
improved results. This technique may also be useful in
patients who have previously failed one local flap in whom
another flap is planned (43).


Cartilage Grafts
Cartilage grafts have been used as soft tissue fillers with
local flaps since the 1970s (44). Reports have described
placing the auricular cartilage grafts within a flap in the
subcutaneous space (44), or placing the graft on the dermis and wrapping the graft in centrally based flaps with
full thickness skin grafts (45). Placing the tissue in the
subcutaneous space did not guarantee long-term projection, but supporting the graft on the dermis showed
excellent results with no necrosis or skin graft loss and
maintenance of projection.
Soft Tissue Fillers/Substitutes
Free tissue grafts offer adequate results when appropriate,
but may cause donor site morbidity. The use of soft tissue
filler and substitutes, in design, offers the same benefits of
free tissue grafts, without the sacrifice of donor sites.
Artificial bone (hydroxyapatitetricalciumphosphate)
has been used in a similar fashion as rolled auricular cartilage (46). Here, the substance is shaped into a column
and placed on deepithelialized dermis and wrapped in
centrally based flaps. The construct is then covered with a
full thickness skin graft. Histology of the specimen
showed a mild inflammatory response with typical capsule formation around the artificial bone. Complications
were minimal with 5% graft exposure and 5% partial flap
loss. There was no total flap loss or graft loss. Projection
was maintained in 100% of patients.
Acellular dermal matrix has been used in both primary and secondary reconstructions (4749). When used
for primary reconstructions, a small piece of thick acellular dermal matrix was cut to a 1.5 4.5 cm piece and
rolled into a barrel shape. The construct was placed into
the central core of a modified star flap and sutured into
position. Twelve-month maintenance of projection was
56% in TRAM patients and 47% in tissue expanderimplant patients (48). Small (2 6 mm) pieces of acellular
dermal matrix were also used in secondary reconstructions
after failed primary local flap (projection 02 mm) with
C-V flaps. Four of five patients demonstrated maintenance
of adequate projection (45 mm) at 612 months (49).
The cost of the acellular dermal matrix may be prohibitive however (47).
Soft tissue fillers have been used to augment nipples
reconstructed with local flaps or tissue grafts and in secondary reconstructions with loss of projection (5052).
Injectable calcium hydroxyapatite (Radiesse, Merz Inc,
San Mateo California) was used in six patients (volume
0.41.0 cc) with 100% patient satisfaction and minimal
loss of projection. Similarly, injectable polymethylmethacrylate in 3.5% bovine collagen (Artecoll, Pulmon
Medical, Scottborgh South Africa) was used to increase



projection after local flaps. Two injections were used

3 1 months apart with statistically significant increase
in projection (1.60 1.24 mm). Lastly, a mixture of
hydroxyethylmetacrylate, ethylmetacrylate in a hyaluronic acid suspension (Dermalive, Dermatech, Bella
Vista, Australia) was injected at three separate time points
(0, 2, and 5 months) after labia minora graft or nipple
sharing. Results at 12 months showed improved increase
in projection in the labia minora graft group compared to
the nipple-sharing group (80% vs. 4%).
Tissue engineering and creation of surgically implantable tissue may represent the future of plastic surgery. In
a porcine model, an autologous chondrocytes were suspended in a copolymer gel and injected into a previously
isolated area of dermis on the ventral abdominal wall.
Three weeks after 1012 injections, the injected implant
grossly resembled a human female nipple and histologically demonstrated elastic cartilage (53). This technique
has yet to be attempted in a human model.

the technique with refinement in technique and presentation of larger case series (5659).
Although some recommend tattooing before or during
flap reconstruction (60,61), areola tattooing is best reserved
until approximately 612 weeks after nipple reconstruction to allow for appropriate healing and maturation of the
flap or graft (58). Tattooing can either be used as primary
areola reconstruction directly on the skin of the new breast
mound, or to achieve improved color match after graft
Although not always necessitated, local anesthesia
should be used to help with patient discomfort during the
procedure. Color choice is important. Slightly darker pigments are encouraged, as fading of the tattoo will inevitably occur (54). Patients may also be encouraged to
participate in choosing the pigment with the surgeon.
Attention must be placed to adequate depth of pigment
introduction. Pigments placed too superficial are subject to
loss after desquamation of the epidermis. Deeper pigment
is taken up in lymphatics (17). Both will lead to early fading of the areola. Nipple tattooing follows the areola.
Some authors recommend slightly darker pigments in this
area (58) (Fig. 14.13).

Areolar Reconstruction
After nipple reconstruction, the areola must then be reconstructed to create the final form. As with nipple reconstruction, several different techniques have been described. The
two most common are intradermal tattooing and tissue
Bunchman first described the use of intradermal tattooing to recreate the areola after nipple reconstruction (54).
Rees then described the use of intradermal tattoo to
achieve color symmetry in areola reconstruction using a
skin graft (55). Becker and Spear then further popularized


Authors Preferred Steps for Tatooing

1. Mark the areolar border using an appropriately sized
cookie cutter to match the native contralateral nipple.
Slight adjustments may be required to closely match
the natural appearance and shape. In bilateral reconstructions, a 3545 mm cookie cutter is used according
to patient and breast mound characteristics.


Figure 14.13 (A) Tattooing-related complication: On a double S flap technique; note the superficial skin loss on the right side; this
patient healed by secondary intention with good color match. (B) Tatooing set for the plastic surgeon.


2. Anesthetize the area with 1% lidocaine with epinephrine

3. If a skin graft has been used (ie with a skate flap), the
borders of the skin graft often contract asymmetrically, creating an oval shape. In these instances, we
follow the circular shape of the cookie cutter, not the
skin graft border, to create a more natural appearing
4. A Permark (PMT/Permark, Inc., Chanhassen, MN)
micropigmentation system is used with a #6 flat needle
pack. We feel this gives superior control and consistent
pigment delivery. We generally use one pigment for all
areas along the nipple and areola for simplicity.
5. The areola is tattooed starting at the periphery and
moving centrally with deliberate strokes. Care is taken
along the areolar border, along previous scars and along
the projecting nipple, as these areas are more difficult
to get adequate pigment take.
6. Endpoints are consistent with the appearance of pigment in the deep dermis or punctate bleeding.
Postoperative Care
After tattooing, the residual pigment is painted on to the
raw surface to increase the amount of pigment that might
be taken up by the tissues. The area is then dressed with a
non-adherent dressing and tape. This is left in place for
35 days. Then the dressing is removed and the patient is
allowed to clean the area with soap and water. Antibiotic
ointment is used for an additional 7 days to keep the raw
area moist while it epithelializes. The patient is reevaluated in 6 weeks for any skin slough or pigment loss.
Long-term outcomes with areola tattooing have been
excellent. Benefits over other techniques include short
procedure time, simplicity, and lack of distant donor site.
However, some risks do exist. In a large review of 151
patients with mean follow-up of 25.2 months, Spear (59)
showed excessive fading in 10% of patients. These
patients required retattooing for improved color match.
Other complications included infections (3%), rash (<1%),
and skin slough (<1%). Hypopigmentation was seen in
60% of reconstructed NAC, though 57% of women
reported similarity in color with the native nipple. Eightyfour percent of tattoos were rated as satisfactory. To
achieve improved color match, ODonoughue (62) recommends tattooing the native nipple with the same pigment
with excellent results.
Use of tissue grafts is another common way to reconstruct the areola after nipple reconstruction. Some nipple
reconstruction techniques require skin graft from closure
(i.e., skate flap). In other flaps, it serves as an excellent
option to recreate the shape and texture of a native nipple.
The surrounding scar of the graft recreates the natural transition expected between the areola and the surrounding
breast skin (8). Also, irregular healing of the graft creates


slightly raised and irregular surface similar to native areola. 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. However, tissue grafts
require additional surgical donor sites and further scarring.
Historically, donor grafts were taken from the labia
majora, upper eyelid, retroauricular area, perineum/upper
thigh, suprapubic area and others (17). Color match again
is paramount. The upper thigh skin is a popular donor site
due to its hidden location and close color match. However,
the development of intradermal tattooing allows any skin
to serve as potential donor site. Any residual color mismatch after grafting can be corrected with appropriate tattooing. Little data exists comparing complications with
grafting in areola reconstruction. However, the complication rate should be similar to other tissue grafts in other
Secondary Procedures After Nipple Areola
The most common complications after nippleareola reconstruction are loss of projection, wound healing complications at donor site, partial flap/graft loss and loss of areola
pigmentation after tattooing. Each of these complications
can lead to poor patient satisfaction and need for revision
surgery. As demonstrated in long-term studies, the final
outcome may not be evident until a year (or longer) after
surgery (see Table 14.1). Therefore, patients should be followed at regular intervals to evaluate for the presence of
expected outcomes and patient satisfaction. If complications arise, or a patient is unhappy with final result, secondary reconstruction offers a reasonable option for salvage.
Numerous techniques are available for secondary reconstruction including:

secondary attempt with local flaps;

reduction of the existing nipple projection;
use of autograft (i.e., fat or cartilage);
use of alloplastic materials/soft tissue fillers;
repeat tattoo (Figs. 14.1414.17).

The decision to proceed with secondary reconstruction

after failed nipple areola reconstruction should be made on
an individual basis based on patient preference. Some
patients may not wish to proceed with further surgery. Others may have issues with autologous tissue harvest and
additional donor sites. Expectations with secondary reconstruction should be realistic. After primary nipple areola
reconstruction, additional scar tissue is formed creating
additional retractive forces making secondary reconstruction more challenging and subsequent results less predictable. Additional thought should be directed towards
possible causes of the failed primary surgery to avoid repeat
occurrences. With careful surgical planning, secondary



Table 14.1 Summary of studies demonstrating quantitative results with different flap techniques for nipple reconstruction.
Complications were not listed for all studies. RCT = randomized controlled trial; * = p < 0.05; **p < 0.05 comparing bell flaps to
skate and star flaps. No significant difference between skate and star flaps.


Details of study

Rubino (35)

32 pts RCT

Alfano (36)

30pts RCT

Shestak (37)

74 nipples Retrospective

Kroll (33)
Farace (34)
Zhong (38)

Losken (39)
Few (40)

Flap types


Average Residual
Projection (% of
initial size or mm)


Arrow Flap vs. Star

Skate flap vs. Star
Skate flaps Star flaps
Bell flaps

1 year

153 nipples Retrospective

40 nipples Prospective
76 nipples Retrospective

Double opposing tab

flap vs. star flaps
Arrow flap

Mean 2.27 years

3 years

Skate flap

Mean 3.7 years

Arrow: 49.1% Star:

Skate: 57% Star
Skate 59.1% Star
56.6% Bell
Tab: 2.43 mm Star:
1.97 mm*
46.55% at 2 yrs
45.7% at 3 yrs
2.5 mm

14 nipples Retrospective
93 nipples Prospective study

CV flap

Mean 5.3 years

3.87 mm

7.2%; 3.1% skin

graft donor site
dehiscence; 2.1%
partial skin graft

Star flap

Mean 2.1 years

59% at 1 yr

1 year
1 year


12% open wound at

suture line




Figure 14.14 (A) Loss of projection of nipple. (B) Loss of projection of nipple. (C) Recreation of the nipple using the CV flap
technique to regain projection.


Figure 14.15


Tattooing-related complication: Incisional scars not taking tattoo pigment well; this patient needed re-do tattooing.

Figure 14.16

Areolar irregularity after tattooing necessitating re-do tattooing.

Figure 14.17

Dehiscence of the CV flap due to improper suture selection.


reconstruction offers a reasonable option for patients to

achieve their reconstructive goals. 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.
NAC reconstruction represents an important final stage of
breast reconstruction. As shown above, numerous techniques are available to reconstruct the nipple and areola,
and the ideal technique has yet to be discovered. It is
important for all plastic surgeons to be comfortable with
several techniques to adequately address the individual
needs of each patient. Proper patient counseling, preoperative planning and surgical technique are paramount in optimizing results. Although minor complications may occur,
patient satisfaction after NAC reconstruction remains high
and should be encouraged.
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50. Panettiere P, Marchetti L, Accorsi D. Filler injection
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Pusic AL. The efficacy of Artecoll injections for the augmentation of nipple projection in breast reconstruction. Eplasty
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Managing the unfavorable result in breast surgery
Charles R. Volpe, Alexander Nguyen, and Zubin J. Panthaki


result was a risk or complication of the given procedure,

will typically respond with hostility and anger. In addition,
the patient will view the physicians explanation as dishonest and accusatory. Therefore, full disclosure of the potential risks and complications of the planned procedure
should be presented to the patient prior to entering the
operating theater. Ideally, this should be presented in both
a written and verbal manner to maximize patient comprehension. Direct lines of communication must be established
between the patient and the physician prior to the surgical
date. By achieving this goal, any untoward or adverse
events that occur postoperatively may be dealt with in a
satisfactory manner for both patient and physician.

Breast surgery can impart considerable anxiety upon

patients regardless of whether the surgery is performed for
oncologic purposes or for aesthetic reasons. Though never
intended nor expected, poor outcomes or unfavorable
results from these procedures do occur. These complications can and will happen amongst even the most talented
and skilled of surgeons. When an unfavorable result does
occur, the patients feelings of stress and anxiety may
become feelings of distress, dissatisfaction, and despair.
Proper handling of the patients poor outcome becomes of
utmost importance to the operative surgeon to prevent
feelings of distrust, resentment, and anger that could result
in medico-legal action. 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.


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
(1,2). 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). Though preservation of the breast
provides many women with a psychological sense of being
whole, the resulting cosmetic appearance can be quite
disfiguring. The potential for unfavorable aesthetic outcomes has increased as a growing number of breast cancers

Untoward results in surgery occur in an unpredictable manner. However, the patients response to an unfavorable
result follows very predictable lines. 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. Patients
who are informed postoperatively that their unfavorable


are now being treated with breast conserving therapy

(BCT) including larger tumors and tumors in unfavorable
locations (4,5). Interestingly, only five to forty percent of
patients receiving BCT report a poor aesthetic outcome
caused by a significant breast deformity (6). 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. These patients possibly fear additional surgical
procedures, may be unaware that reconstructive techniques
are available to treat their deformity, or simply may be too
embarrassed to seek improvement (7).
Reconstructive techniques to correct a BCT defect
can be applied in three settings: the immediate, the
delayed-immediate, and the delayed time frame. Immediate
reconstructions occur at the time of BCT. Delayed-immediate
reconstruction occurs once final margin status has been
confirmed, but prior to the delivery of radiation therapy.
Delayed reconstruction by definition refers to all reconstructions that occur after BCT and whole-breast radiation
has been completed. The majority of patients presenting
with poor outcomes following BCT do so after the delivery
of radiation therapy (delayed group).
The treatment options for patients who have yet to radiation include local tissue rearrangements that remodel the
breast tissue (8), and breast reduction techniques based upon
the standard inferiorly based dermoglandular pedicle (9).
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).
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 treatment options for previously radiated BCT
defects include pedicle reconstructions with the latissimus
dorsi myocutaneous flap or thoracodorsal artery perforator
(TAP) flaps. These flaps prove advantageous in the
reconstruction of lateral breast defects and in cases where
a deficient breast envelope exists. The contracted, irradiated skin can be replaced with healthy skin and subcutaneous tissue (12). In complex cases, reduction mammoplasty
of the unaffected breast may be the best option to achieve
a symmetrical, favorable outcome. Some authors advocate
the use of lower abdominal flaps [transverse rectus
abdominus myocutaneous (TRAM), deep inferior epigastric perforator (DIEP), or superficial inferior epigastric
artery (SIEA)] and recommend the creation of mini
flaps to reconstruct the BCT defects (13). These flaps
should be avoided on several accounts. First, a significant
portion of the raised abdominal flap tissue will be discarded to reconstruct a small defect. Second, the reconstructed breast tissue remains at oncologic risk. Finally,


the previously radiated skin envelope must be incorporated

in the repair. 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. The cosmetic appearance
will be superior and oncologic control will be maximized.
Autologous fat grafting provides an additional means
of correcting small contour deformities. Minor complication rates following fat grafting of 8.511% have been
reported (14). These complications included erythema, fat
necrosis, keloid scarring, and pain. Repeat fat injection to
correct contour deformities can be performed and is likely
in patients with a history of radiation therapy (15).
Unfavorable results following expander or implant-based
reconstructions can be difficult to deal with and often
require multiple procedures to adequately correct. Common complications seen after expander/implant reconstruction include capsular contracture, infection, implant
exposure, and malposition of the implant.
Baker class III and IV capsular contracture (severe) following breast reconstruction has been reported to occur in
056% of patients following breast reconstruction (16,17).
Treatment options for capsular contracture depend, in part,
on the method of primary reconstruction. General principles in managing capsular contracture should focus on
capsulectomy NOT capsulotomy, preservation of thick
NOT thin soft tissue flaps, and avoidance of severe bleeding or hematoma formation.
Every attempt should be made to remove the offending
capsule particularly when a contracture formed around an
older style silicone implant. Silicone gel bleed from the
implant may have facilitated capsular contracture in this
circumstance. Consideration should be given to the placement of closed suction drains to minimize the accumulation of blood following capsulectomy. 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 (18,19). Treatment of the
most severe or recurrent forms of capsular contracture
should focus on implant removal, especially when pain is
the primary complaint. Autologous breast reconstruction
should be evaluated as an alternative means of reconstruction, if possible.
Infection of an implant typically occurs around the time
of placement and is commonly related to mastectomy skin
flap necrosis. Reported rates of infection following
expander/implant reconstruction range from 1.8 to 35.4%
(20,21). Minor infections can occasionally be treated
conservatively without removal of the implant. McCarthy
et al. found a 3.4% incidence of infections managed


without removal of the implant (22). For more significant

infections, treatment requires prompt removal of the
implant, along with targeted antibiotic treatment based
upon intra-operative cultures from the implant pocket.
Common bacterial isolates include Staphylococcal species,
Klebsiella, Pseudomonas, and Enterococci species (23).
Any attempt to replace the implant should be delayed for
3 to 6 months after implant removal.
Exposure of expander/implants in reconstructed breasts
usually occurs secondary to mastectomy skin flap necrosis.
Exposure of the implant can be linked to infection as previously discussed. Management of the exposed implant in the
most conservative fashion is explantation. However,
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. The authors found
that only 42% of patients managed with implant removal
returned for secondary reconstruction. Therefore, they
argue that aggressive measures should be taken to salvage
the exposed implant (24). If a conservative approach is followed, 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. 15.1). Capsule
formation prevents the implant/expander from responding

Figure 15.1


to non-operative maneuvers such as taping or manual

displacement of the implant. Proper management is to
identify the correct location for the implant, divide the
capsule, and reposition the implant after creating the
proper soft tissue pocket.
Autologous reconstruction of the breast is dominated by
use of abdominal myocutaneous TRAM and fasciocutaneous DIEP and SIEA flaps. Interestingly, the TRAM flap
was originally described by Holmstrom as a free flap, but
was later popularized as a pedicled flap by Hartrampf in
the 1980s (25,26). The modern evolution of breast reconstruction has moved toward the greater use of the free
abdominally based fasciocutaneous flaps, as well as, an
increasing use of fasciocutaneous flaps derived from the
flank, buttock, and proximal thigh. For the sake of brevity,
the focus of this chapter will be with unfavorable outcomes related to the abdominally based pedicle and free
flap reconstructions of the breast.
Poor outcomes related to TRAM and DIEP flap breast
reconstruction can be broken down into donor site and
recipient site complications. Common donor site complications include contour abnormalities of the abdominal
wall and hernia formation, as well as abdominoplasty flap
necrosis. Common recipient site complications include
partial and complete flap necrosis, mastectomy skin flap
necrosis, and fat necrosis.

Asymmetryimplant malposition can result from capsular contracture, overdissection of the pocket, or migration of the


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. These defects when appreciated postoperatively are exceedingly difficult to correct. Therefore, prevention is the key to avoiding unfavorable contour
deformities. 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). The addition of mesh reinforcement to
the abdominal wall should be considered when risk of hernia is evident. 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).
DIEP flap reconstructions have evolved as the gold
standard by which all other flap reconstructions are
compared. This is partially due to the decreased abdominal wall morbidity associated with the procedure. However, 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). Key anatomical points to the elevation of the
DIEP flaps deserve mention. First, 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). Preservation of
these nerve branches should be made whenever possible.
Second, surgeons should recognize that a large motor
nerve to the rectus, at the level of the arcuate line, is
typically present and should be preserved. Studies have
implicated division of this nerve branch a major cause of
lower abdominal weakness and bulge formation following DIEP harvest (30,31).
Abdominal flap necrosis is a devastating problem that
can be prevented by limited abdominal flap elevation. Pedicled TRAM flap dissections are at greatest risk for this
complication as the abdominal flap elevation is the most
extensive. Limiting dissection to the lateral border of the
rectus sheath can minimize the risk of flap necrosis. History of previous abdominal surgery, particularly presence
of a subcostal incision, has been shown to increase the risk
of abdominal wall flap necrosis in both TRAM and DIEP
flap reconstruction (32,33). Patients should be informed
that increased donor site complications can occur given
the history of previous abdominal surgery. Despite this,
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).
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.


Primary free flap failure rates between 0.3% and 6.0%

have been reported in the literature (21,35). Management
of acute flap failure is beyond the scope of this chapter and
will be discussed in greater detail elsewhere. The decision
to proceed with a second free flap should be made only
after critical evaluation of the primary surgical procedure
occurs. Attempts to elucidate the causative factors for the
flap failure, re-evaluation of the necessity for free flap
reconstruction, and careful consideration of the patients
psychosocial needs should be achieved prior to proceeding with secondary reconstruction. In addition, critical
appraisal of ones surgical skill should be performed
with consideration given to referral to another surgeon
for treatment. If cause for failure of the primary flap
cannot be determined, one must consider rare hemolytic
disorders as the source. A vascular workup for an
antiphospholipid syndrome should be considered (36).
This is a rare condition where antibodies (lupus anticoagulants, anticardiolipin, or anti-2-glycoprotein I) predispose to thrombosis (37). Other conditions such as
protein S deficiency (38), activated protein C resis (factor V Leiden) (39), and anti-thrombin III deficiency (38)
should also be excluded. Baumeister et al. present an
excellent self-critical checklist that should be reviewed
prior to secondary free flap reconstruction (40).
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. 15.2 and 15.3). For severe deformities, consideration should be given for second free flap reconstruction,
provided the patient is a good candidate for a second procedure and that the surgeon is confident that success flap
creation can be achieved. Revisions needed for mastectomy flap necrosis should be focused on removal of the
scar tissue that results from delayed closure. Attempts to
correct acute wounds with split thickness skin grafting
should be avoided as the graft will provide a poor color
match. In addition, skin grafts will prevent wound contracture making cosmetic improvements through secondary
procedures more difficult.
Fat necrosis is a rather common complication following
autologous breast reconstruction. Reported rates of fat
necrosis following DIEP flap reconstruction range from 6
to 17.4% (41,42). Though it is a common occurrence following autologous tissue transfer, fat necrosis can lead to
considerable patient anxiety because it can be confused
with recurrent breast cancer. Small areas of fat necrosis
can be managed conservatively as they will resolve with
time and massage. Direct excision of the larger areas of fat
necrosis may require extensive dissection and result in a
significant contour deformity. Minimally invasive techniques such as ultrasound assisted liposuction (43) (UAL)
and the needle aeration method (44) have been described


Figure 15.2

Figure 15.3


TRAM contour deformity resulting from fat necrosis.

TRAM contour deformity can be corrected with placement of a small implant or fat grafting.

to treat larger lesions after recurrent breast cancer has been

clinically ruled out by surgeon/oncologist or ultrasound
examination (45).
The 2011 FDA Update on the Safety of Silicone GelFilled Breast ImplantsExecutive Summary suggest that
2040% of breast augmentation patients will require reoperation within 810 years based upon recent data collected
from the core studies of the major implant manufacturers
in the United States (46). Based on these findings, the
FDA recommends that patients be informed that complications including capsular contracture, implant rupture,

wrinkling, asymmetry, scarring, and infection can occur.

Patients should also be informed that implants are not lifetime devices. The longer implants remain, the greater the
risk of complications and the greater the chances of
implant removal. 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.
Capsular contracture, as graded by the Baker classification system (47), remains a leading reason for revision
augmentation. Historically, rates of capsular contracture
are higher among silicone gel implants as compared to
saline implants (48). Though the etiology of capsular contracture is poorly understood, silicone bleed from gel
implants is thought to contribute significantly to the


increased contracture rates. Newer cohesive gel implants

may demonstrate decreased risk of capsular contracture as
the cohesive gel does not migrate or bleed (49). Capsular
contracture, when it occurs, should be treated with a
change in implant position. Current trends are for placement of the implant in a dual plane position with partial
submuscular coverage (50), and creation of an acellular
dermal matrix sling for implant coverage of the subglandular component (51). Complete capsulectomy should be
considered when it can be performed safely. Otherwise,
partial capsulectomy can be performed. There is no roll for
closed or open capsulotomy in the treatment of capsular
contracture (52,53).
Implant rupture can present in a readily apparent manner with saline implants or in an insidious, silent manner
with silicone gel implants. Current recommendations from
the FDA encourage women to have MRI studies of their
silicone implants 3 years after placement and every two
years thereafter. Implant removal and replacement is recommended for any compromised saline implant. Silicone
implant rupture with extracapsular spread requires removal
of the implant and complete capsulectomy, if technically
possible. Risk of injury to the chest wall, risk of pneumothorax, or risk of excessive blood loss is indicative of partial capsulectomy in the submuscular position. Partial
capsulectomy should be considered when removal of a
subglandular capsule will result in thin, subcutaneous coverage or when excessive blood loss is encountered. More
controversial is the need for implant removal and capsulectomy for asymptomatic, intracapsular silicone implant
ruptures. To date, there is little evidence to support the
mandatory removal of these implants, but it seems prudent
to offer explantation to concerned patients. In addition,
those electing to keep the implants should be followed
with regular clinical examinations, including evaluation
for signs of silicone migration (54).
Skin wrinkling and implant palpability have become
significant reasons for unfavorable aesthetic outcomes following augmentation. Most surgeons performing breast
augmentation through the era of the silicone implant moratorium know that saline implants are intimately associated with skin wrinkling. Skin wrinkling is considered one
of the more significant disadvantages to the use of saline
implants for aesthetic augmentation. However, patients
should be aware that skin wrinkling can occur with the use
of silicone implants, as well. The causes of skin wrinkling
include the implant position (whether subglandular or submuscular), the fill volume of the implant, whether the
implant is smooth-walled or textured, and the general
body habitus of the patient (how much breast tissue the
patient has).
From an engineering standpoint, skin wrinkling and
implant palpability result from folding of the implant
shell. Folding is directly related to the viscosity of the fluid


within the implant shell. Low viscosity fluids (saline)

allow the shell wall to deform easily, whereas high viscosity fluids (silicone) do not. In addition to viscosity, the
total volume of fluid within the shell will determine how
much shell folding can be achieved. This, in part, explains
how silicone implants allow shell folding to occur. 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 patients with severe skin wrinkling and/or palpable implants should address all of the
risk factors mentioned previously. Therefore, treatment
options become multifactorial. For instance, implants
placed in the subglandular position should be repositioned
in a retro-pectoral fashion, if possible. Saline implants can
be exchanged for silicone implants, or textured implants
can be exchanged for smooth-walled implants, etc. There
are situations where consideration for non-operative management or even explantation should be considered. Thin
patients, with submuscular implants, who complain of
severe implant palpability and/or wrinkling may not benefit from placement of implants in a subglandular position.
The likelihood of increased palpability and wrinkling is
considerable in this patient population. Efforts should be
directed toward implant removal in this difficult patient
Implant asymmetry or malposition can be related to
capsular contracture as previously discussed. However,
poor surgical decision-making and technical erros can
occasionally be associated. One example worthy of discussion is the development of symmastia after primary
augmentation. Symmastia is an aberrant communication
of the breasts across the midline caused by medial migration of one or both breast implants following augmentation. 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. 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
patients body habitus (Volume >400 cc or implant diameter 14 cm (57) (Fig. 15.4). Symmastia can occur in
either a subcutaneous or submuscular plane. Treatment
options for symmastia vary by author, but in general, the
conservative recommendation for implant removal without revision cannot be discounted (58). If revision is
offered, altering the plane of implant placement should
be considered (e.g., submuscular to subglandular location and vice-versa) (56,59). Suture repair of the midline
defect can be accomplished in any number of ways.
Some of the more innovative techniques involve the use
of the implant capsule to reattach the pectoralis muscle to


Figure 15.4


Symmastiaimproper pocket dissection can lead to webbing across the midline of the chest.

the sternal periosteum (56), and creating an acellular dermal matrix sling to prevent the medial migration of the
replaced implants (60).
Scarring can be a significant source of anxiety for
patients undergoing an aesthetic procedure such as augmentation mammoplasty. Careful evaluation of the patient
preoperatively is necessary to assess the risk of poor
wound healing. Patients at risk of adverse wound healing
(e.g., hypertrophic scarring, keloid scarring) should be
approached with caution. Patients presenting with hypertrophic or keloid scarring should treated as directed in the
reduction mammaplasty section (see below).
Infection following breast augmentation is a rare reason
for revision augmentation, but it does occur. Primary management of the patient with an active implant related infection involves determining the extent of infection. Superficial
infections, limited to mild cellulitis and erythema may be
treated with antibiotics, cautious incision and debridement,
and wound culture. Staphylococcal species are the most common isolates associated with implant related infections (61).
Deep infections involving the implant necessitate expeditious removal of the implant, irrigation of the implant pocket,
and placement of closed suction drains, as needed. Capsulectomy should routinely be avoided given the risk of significant
bleeding in the setting of severe infection. Intravenous antibiotics should be tailored to the wound cultures collected
during implant removal. Replacement of the implant should
occur in conservative fashion and correspond with absolute
resolution of the infection. Most surgeons would consider
waiting 36 months before replacing the implant in the setting of previous infection.

Reduction mammoplasty is one of the most common procedures performed in plastic surgery. Patient satisfaction is
generally high with up to 93% of patients reporting that they
would undergo the procedure again (62). Despite the high
level of satisfaction, unfavorable results and complications
do occur following reduction mammoplasty. These include
scars, fat necrosis, breast and scar asymmetry, over-reduction,
under-reduction, nippleareola problems, and epidermal
cysts. Prior to treating any of the aforementioned complications, the surgeon needs to get a clear understanding of the
patients complaints as well as their expectations from revision surgery. Bear in mind that, 11% of plastic surgeons
polled stated that a dissatisfied patient had sued them at least
once following breast reduction surgery (63).
Scar formation following reduction mammoplasty can
be a significant problem especially when hypertrophic
scarring or keloid scarring results. Careful questioning
and physical examination of the can often determine
which patients are prone to hypertrophic or keloid scar
formation. Treatment of the abnormal scarring should
occur as soon as it is recognized. Treatments include intralesional injection of corticosteroid alone or in combination with 5-fluorouracil (64). Patients should be warned
that hypo-pigmentation, subcutaneous tissue atrophy, and
contour depressions might occur following intralesional
corticosteroid administration. Intralesional treatments can
be repeated at 6-week intervals for 23 cycles. Silicone
sheeting has been advocated, though the mechanism of
action is poorly understood.


Fat necrosis presents as a focal area of firm or hard tissue and is seen most commonly in obese patients. Superficially located areas of fat necrosis are easy to diagnose
whereas deeper areas may require confirmation with ultrasonography (45), as discussed previously in this chapter.
Needle aspiration of focal areas of fat necrosis should be
performed to rule out the possibility of malignancy. Excision of the lesions that persist after several months should
be considered.
Breast asymmetry often goes unrecognized by patients
preoperatively. Preoperative breast asymmetry should be
identified and addressed with the patient. These pre-existing
asymmetries may have a significant impact on the postoperative results. The patient should be informed that scar
length discrepancies and breast asymmetry might occur
given the baseline asymmetries noted before surgery. Any
persistent dissatisfaction with the resultant scarring and
contour deformities should be managed expectantly for
1824 months. Once scar remodeling has stabilized, corrective adjustments can be made on both breasts, as needed
to achieve symmetry. Liposuction can be used as a useful
adjunct for treating minor contour irregularities or volume
discrepancies (65,66).
Over-reduction is an extremely compromising problem
to correct. 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, and (3) attempts to create
pre-determined breast size set by the patient. The only
treatments for over-reduction are breast augmentation or
augmentation/mastopexy. Patients should be informed
that the later might provide a superior cosmetic result.
Irrespective, revision should be deferred for 612 months


to provide time to educate the patient about the risks and

complications associated with breast implants (67).
Under-reduction typically represents discordant perceptions of the aesthetic ideal between surgeon and patient.
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. Return to the operating theater
should be deferred for at least 1218 months. Repeat
reduction procedures similar to the primary operation can
be performed. Informed consent should include the possibility of pedicle transection with the attendant need for
free nipple grafting (68).
Nippleareola complex (NAC) problems can range
from nipple necrosis, malposition of the NAC, residual
areola, and irregular pigmentation. Nipple necrosis seen
acutely should be managed with conservative wound care
and debridement limited to truly non-viable tissue. Serial
debridements may be necessary and these patients should
be followed closely. Reconstructive efforts should be
delayed until full wound maturation has been achieved.
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.
Malposition of the NAC is considered an error in preoperative planning in which the resultant NAC can be
placed too high or low, or with convergence or divergence,
(Fig. 15.5). All of these unfavorable positions should be
recognized and corrected at the time of the primary reduction when possible. Patients referred or presenting in a
delayed fashion with nipple malposition can be difficult to
treat, especially in situations where the nipple has been
placed too high. Treatment options for high placement of
the nipple include surgical repositioning of the nipple with
its pedicle in a lower position. The scar left from the donor

Figure 15.5 NAC malposition in reconstruction can be a technical error or can result from further settling of the implant leading to
late asymmetry.


position should be closed in an oblique manner toward the

axilla so that the resultant scar can be hidden under clothing. Occasionally, free nipple grafting may be required to
achieve an aesthetically pleasing correction. Small corrections of nipple placed too low, medial or lateral can be
corrected with elliptical skin excisions in the direction the
nipple needs to be transferred. Larger movements may
require more formal mastopexy type procedures to correct.
Women with excessively large areolar tissue are at risk
of residual areola incorporated in the vertical limb of their
reduction. These patients should be warned that this is
unavoidable but correctable with time. An unfavorable
outcome will result from the temptation to excise all of the
residual areolar tissue at the time of primary reduction.
High tension will be placed along the vertical limb risking
dehiscence, widened scarring and an overall poor outcome. Pigmentation problems following reduction mammoplasty are not uncommon. Irregular pigmentation or
hypo-pigmentation can result in dark skinned individuals
and is seen most frequently when nipple grafting is
required. Patients should be clearly informed of this possibility. Tattooing can be offered for small areas of depigmentation whereas larger areas respond more favorably to
excision and primary closure.
Epidermal cysts following breast reduction occur due to
incomplete de-epithelialization of the dermoglandular pedicle. Needle aspiration of these cysts can be attempted in
the office with the caveat that recurrence is possible. Definitive treatment for problematic cysts is direct excision.
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67. Colwell AS, Slavin SA, May JW. Breast augmentation after
reduction mammaplasty: getting the size right. Ann Plast
Surg 2008; 60: 3724.
68. Hudson DA, Skoll PJ. Repeat reduction mammaplasty.
Plast Reconstr Surg 1999; 104: 4018.

Optimizing long-term outcomes in breast surgery
Anuja K. Antony, Benjamin Liliav, Victor J. Hassid, and Mimis N. Cohen


dissection (1,4). Patient selection criteria have evolved

with tissue-based planning focused on the optimal
approach within a framework of realistic expectations (1).
Thus, our ability to deliver reproducible and predictable
outcomes has improved, and demand for primary breast
augmentation continues to rise (5). However, outcomes of
breast surgery are still not always perfect (6). Many of the
imperfections are related to symmetry, contour irregularities, and volume discrepancies. Implant displacement, rippling, wrinkling, capsular contractures, deflation, rupture,
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 womans

psychological well-being. Along with a positive body image,
high quality breast surgery whether for reconstructive or cosmetic reasons can improve a womans self-confidence and
interpersonal relationships. Optimizing long-term outcomes
is a goal for both the reconstructive and aesthetic surgeon.
However, 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



Patient education is a key component when dealing with

a breast augmentation patient. Unfavorable results typically occur when patient expectations do not match the
patients anatomy. Patients who desire replication of
results seen in popular media should be made aware of
achievable, realistic outcomes and potential limitations.
The patient should be informed that tissue quality, body
type, and overall anatomy vary between different individuals and affect end results. In addition, existing asymmetries should be pointed out, as they are often accentuated
after augmentation. Actively involving the patient in the
planning process permits shared responsibility for the final
outcome (7). Furthermore, the patient should be educated

Breast augmentation is one of the most commonly performed cosmetic procedures in the United States. Since
the introduction of silicone implants in the early 1960s,
our understanding of breast augmentation has continued to
expand with greater appreciation for implant technology,
surgical techniques, and patient selection criteria (1,2).
Breast implants have improved with modifications in the
implant shell, filler materials, and available sizes and
shapes (3). Surgical techniques emphasize the importance
of absolute sterility, meticulous hemostasis, and careful


with regards to implant selection based on her specific

anatomical dimensions, soft tissue quality, and personal
expectations and preferences (8). She should also be educated regarding the recommendations for long-term care
of silicone breast implants. 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, in order for a
silicone leak to be identified in a timely fashion (9). However, the recommendations for long-term care after silicone implants are still evolving and long-term studies are
ongoing by the manufacturing companies. Additionally,
as with any surgical procedure, a patient should be made
aware of all possible complications and adverse sequellae
associated with breast augmentation. As of this writing,
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). However, both the FDA and the American Society of Plastic Surgeons (ASPS) are confident that breast
implants remain safe and effective (; www
Optimal Planning Based on Tissue Assessment
Although breast augmentation is a very common procedure, the rate of long-term complications has been
reported to be as high as 1418% (10). Tissue-based preoperative planning has been proposed to avoid long-term
unfavorable results (11). In order to obtain reliable and
reproducible results in breast augmentation, the surgeon
must be familiar with preoperative tissue assessment. Prerequisites for creation of an attractive breast include accurate assessment of the footprint of the breast, the breast
cone, the quality and quantity of the breast envelope (skin
and subcutaneous tissue), as well as the implant type and
size, the position of the inframammary fold, and the type
of incision that will be used (12,13).
Effects of Implant Pocket Plane
Various techniques exist for implant placement in breast
augmentation. The subglandular plane (SG) is a good
option in patients who have adequate breast tissue and
subcutaneous fat, which can provide soft tissue coverage
of the implant (14). However, if the patient does not have
enough soft tissue for coverage, and the skin thickness is
<1.52 cm, there is higher risk for implant visibility as
well as capsular contracture, and therefore a different
implant pocket should be used (1214). The submuscular
approach (SM), in which total muscle coverage of the
implant is provided, results in less visibility and palpability as well as decreased rate of capsular contracture,


especially when silicone implants are being used (15,16).

Potential disadvantages of this approach are the possibility of a high riding implant, inadequacy of inframammary fold, and lower pole definition, 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 subpectoral (SP)
implant plane, in which the implant is placed partially
under the muscle, has the advantages of less capsular
contracture than subglandular placement, and improved
upper pole breast contour (17). Lastly, the recently
described dual plane (DP) technique creates a desirable
breast shape using the subpectoral in conjunction with
the subglandular planes. This approach allows for soft
tissue redraping, which in turn creates a more aesthetically pleasing lower pole contour (18).
Implant Selection
When choosing a breast implant for breast augmentation,
the surgeon and the patient must consider silicone versus
saline implant, smooth versus textured, and round versus
anatomic types (Fig. 16.1) (4,8). Previous concerns
regarding the deleterious effects of silicone on patients
health have been unsubstantiated, and implants are felt to
be safe and effective (19). However, the FDA has
recently identified a potential association between silicone breast implants and anaplastic large cell lymphoma
(ALCL) (20,21). As of this writing, 34 unique cases of
ALCL have been identified in the 510 million women
with breast implants worldwide; additional information
is need to fully understand this possible relationship.
(; site accessioned on April 19, 2011)
Patients should be informed that although older generation silicone implants have been historically associated
with a high rate of capsular contracture, in general,
silicone-filled implants feel more natural, are less palpable, and tend to have softer consistency (16,22). Another
inherent difference is that with implant rupture, newer
generation cohesive gel silicone implants do not deflate
when cut or ruptured, while saline implants decompress
and older generation implants leak. In terms of implant
texture, 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 (16,22). Some
surgeons feel that anatomic implants provide better lower
pole fullness; However, they can be associated with malrotation (23,24); Textured anatomic implants are a viable
option for patients, provided that a meticulous pocket
dissection is performed (23). Our institutional preference
is to use smooth, round implants to avoid malrotation



Incision Type in Breast Augmentation

Patients in general are concerned about and conscious of
their scars following any surgery. Currently there are
four different incision sites that can be utilized to augment the breast. Each type confers its own advantages
and disadvantages, which must be considered with the
patient preoperatively. The patients anatomic variables
and wishes in terms of scarring should determine which
type of incision will be undertaken. Hence, surgeons
should be skilled in several approaches in order to provide an optimal outcome.
Periareolar incisions give central access to the breast
and may be used with various implant types and planes of
dissection. This is a good approach for a patient with tuberous breast deformity who will require breast parenchyma
alterations. Areolar diameter may be a limiting factor in

patients who have light-colored areolas with indistinct

margins, which will make the scar more conspicuous. Also,
some reports in the literature suggest nipple sensation alterations with this approach (25).
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. A common
pitfall, while using this incision, is placing the inframammary incision too low or too high, resulting in misplaced
and more visible scar after implant insertion. In order to
avoid this error, one should consider the desired final location of the scar. Placing the incision 12 cm below the
inframammary crease, will allow for final scar position in
the crease, realizing that the scar will migrate several centimeters after implant insertion (Figs. 16.2 and 16.3).
However, if one chooses to have the scar on the inferior




Figure 16.1 Implant selection: (A) round, smooth silicone implant. (B) Round, smooth saline implant. (C) Round, textured silicone


Figure 16.2 Inframammary incision placed 12 cm below IMF.


pole of the breast, placing the incision at the IMF will have
the final scar at the inferior pole, 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. Moreover, the use of an endoscope has been
shown to enhance visualization and prevent implant malrotation by careful and accurate dissection of the pocket,
provide better hemostasis, and facilitate complete transection of the muscle fibers (26). However, there are some
limitations associated with this approach. It is less suitable
for silicone gel implants, as a small incision may fracture
the implant during placement, and it may be associated
with more asymmetry postoperatively (27,28).
The transumbilical approach (TU) is associated with
high rate of implant malposition as it confers less control
and accuracy in placing the implant. Additionally, silicone
implants cannot be placed via this approach. Any bleeding
encountered cannot be controlled well. Due to its many
limitations, most plastic surgeons and our institution do
not favor this approach.




Figure 16.3 (A) Preoperative appearance in patient with Polands syndrome (note small areolar diameter on right). (B) Inframammary
insicion with contralateral circumareolar mastopexy. (C) Postoperative result.


Minimizing Complications and Avoiding

Unfavorable Results
The incidence of infection following breast augmentation
is usually very low, and estimated to be 11.5% (29,30).
The most common causative organisms identified in the
literature are staphylococcal species. Besides adhering to
meticulous sterile operative techniques, the current recommendation in regards to breast augmentation with implants,
includes the administration of preoperative prophylactic
dose of antibiotics to cover Gram positive organisms of
the skin, such as first generation cephalosporin given
1 hour prior to surgical incision (31). In patients with penicillin allergies, clindamycin is the recommended prophylactic antibiotic. Typically, a prophylactic dose is sufficient
to almost entirely eliminate risk of surgical site infection.
If infection ensues, it manifests with redness, pain, swelling, and drainage, usually within the first week postoperatively, and necessitates early identification and treatment,
such as administration of broad-spectrum antibiotics and
close monitoring of the patients progress (32). In case of
no response, the patient may require hospitalization for
intravenous antibiotic therapy. Moreover, consultation
with an infectious disease specialist should be sought,
especially if a deep-seated infection is suspected which
will lead to loss of the implant. If signs and symptoms do
not improve despite aggressive treatment and the infection
worsens, the current recommendation is to remove the
implant and tailor the antibiotic regimen based on the
results of intra-operative wound cultures (32). The timing
of such an approach is surgeon-dependent; we prefer to
wait for 4872 hours in case of cellulitis, while the patient
is receiving broad-spectrum antibiotics, prior to proceeding with explantation of the implant. Repeat breast augmentation may be considered, typically several months
later, once there is complete resolution of the infectious
The incidence of hematoma after breast augmentation is
25.5% in the short term, while long-term hematomas are
exceedingly rare (33,34). The culprit is usually a perforating vessel coming off the internal thoracic artery. However, intercostal and lateral vessels can also be injured
during pocket dissection. It is important to confirm absence
of any bleeding history and cessation of anticoagulation
medications prior to operative intervention. The use of
lighted retractors has been recommended for adequate
visualization of encountered vessels. If a definitive hematoma is confirmed in the postoperative setting, the recommendation is to reoperate and evacuate it. In most cases,
the bleeding vessel cannot be located. Once hematoma


control is achieved and the pocket is deemed to be dry

with excellent hemostasis, the pocket should be thoroughly irrigated and the same device may be reinserted;
our institutional preference is to place a drain and administer a short course of antibiotics.
Most female patients are unaware that their breasts or nipple areola complexes may be asymmetric (35). A key to
optimizing the results of breast augmentation is to take into
account any natural preoperative asymmetry, as the asymmetry may be exacerbated by augmentation. In addition, it
is vital to inform the patient preoperatively of the existing
asymmetry and of the possibility that her breast shape may
change with time, aging and gravity, weight fluctuation, or
pregnancy. The role of three-dimensional technology in
the preoperative assessment of breast augmentation candidates is promising but not yet fully determined (36). If
gross asymmetry is encountered preoperatively, one may
choose saline implants of different volumes to compensate, or select different sizes of silicone implants based on
preoperative samples and/or intraoperative sizers. Once
asymmetry is encountered postoperatively, revisional
breast surgery via mastopexy may be needed in order to
achieve better symmetry.
Role of Implant Size in Long-Term Outcomes
Recent literature suggests that implant size correlates directly
to unfavorable long-term results and complications (37).
Any implant greater than 350400 ml is considered large,
and exerts a greater force on the breast tissue, which in turn
will stretch and thin the surrounding soft tissue envelope
over time. Although a large implant may initially look
appealing to the patient and the surgeon, it eventually accelerates the aging process of the breast by accentuating the
gravitational effects. It causes parenchymal and soft tissue
atrophy, and is associated with higher rates of revisional surgeries (13). Thus, 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, and the unfavorable results and complications that may arise.
Soft Tissue Envelope Wrinkling and Rippling
Although some studies cite a wrinkling and rippling incidence of 2030%, the true incidence is unknown (38). The
literature suggests, however, that there is a higher incidence when using textured implants as compared to
smooth implants (39). This is likely secondary to more tissue adhesions leading to a dimple on the skin envelope.
Also, both wrinkling and rippling occur more often with
saline-filled implants than with silicone-filled implants.


This complication is more obvious when the implant is

placed in the subglandular region, and especially when the
implant is not filled to full capacity (38). Rippling may
occur anywhere along the breast, but is noticed most commonly in the superior aspect. The underlying etiology of
rippling depends on soft tissue implant dynamics. When
the implant is overfilled or underfilled, folds and pleats
causing rippling will appear. To treat rippling and wrinkling, the underlying etiology must be considered, for
example, if a superficial saline implant is the reason, one
may elect to replace it with a silicone-based implant and
consider changing the position from subglandular to submuscular. If a textured breast implant has resulted in
rippling, one may consider replacing it with a smooth nontextured implant. Capsulotomy and/or capsulectomy
should be added during implant exchange if a tight capsule
is contributing to implant deformity. Finally, if the patients
skin is overlying the implant is thinner, some authors are
proponents of fat injection into the subcutaneous layer
overlying the capsule (40,41). However, the long-term
implications of this technique are unclear.
Secondary Deformities
Patients who present with breast deformities and contour
irregularities as a result of previous biopsies, soft tissue
infections, or excisions, and are interested in breast augmentation, deserve special consideration. In order to
achieve symmetrical results post augmentation, one must
be familiar with various available correction modalities to
contour these deformities (10). In case of mild irregularities, recontouring the involved breast with the use of fat
grafting has been described and has led to satisfactory outcomes (40). However, if the deformity is severe, as a result
of infection, capsular contracture, or previous breast surgery with subsequent contour distortion, the complexity of
the problem and its treatment increases. Careful planning
and adequate communication with the patient are key factors to successful treatment. Tissue quality, type of
implant, location, and implant volume must all be taken
into consideration. Implant replacement, along with capsulotomy or capsulectomy may alleviate the problem in
cases of capsular contracture. 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 (42,43). In cases of
contour deformity, not amenable to revision with some of
the previously described corrective maneuvers, augmentation with autologous tissue may be considered.
Capsular Contracture
Capsular contracture is the most common long-term complication in both aesthetic and reconstructive breast surgery (44,45). It is also the most common reason for


reoperation following insertion of implants (46,47). The

literature offers multiple explanations for encapsulation,
such as the hematoma, myofibroblast, and infection theories (15). However, most theories lack sound data and the
underlying etiology for capsular contracture is still
unclear (45,48). Most experts support the infection theory, but believe that the etiology is multifactorial (15).
The incidence of capsular contracture in general is 15%
following breast augmentation (15,44,49,50) (allergen
and mentor studies). Many studies confirm that implant
position affects capsular contracture and that submuscular as opposed to subglandular positioning minimizes
contractures (51). Textured surface implants have been
found to minimize capsular contracture when inserted
subglandularly (15,5254).
Sound surgical technique is important in the prevention
of capsular contracture (15). 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.
Additionally, glove changing prior to implant handling has
been shown to minimize capsular contracture. Soaking
implants and washing the pocket with antibiotic solution
has been shown to reduce the capsular contracture rate in
breast augmentation (46,31,55). Cleansing the skin surrounding surgical incisions, avoiding contact between the
implant and surrounding skin, and minimizing manipulation of the implant once inside the pocket have also been
shown to reduce the rate of capsular contracture. Typically, the previously described prophylactic measures are
surgeon dependent. Lastly, the choice of incision may
influence the incidence of contracture. Two recent studies
revealed that the ideal incision should minimize implant
exposure to bacteria, and that the inframammary incision
is associated with a decreased risk of capsular contracture
compared with other incisions (56,57). In particular, the
periareolar incision disrupts ducts that contain bacteria,
likely contributing to a higher incidence of infection and
contracture. Once a patient has developed significant capsular contracture, it should be addressed with open capsulotomy and capsulectomy, replacement of the implant,
with or without a change in implant position from the subglandular plane to submuscular or dual planes. There have
been various attempts with other treatment modalities
such as mechanical implant displacement, vitamin E, steroids, and leukotriene inhibitors (58,59). However, further
studies are necessary in order to define the efficacy of such
In summary, capsular contracture is multifactorial and
adherence to basic surgical techniques with meticulous
dissection and minimization of any inflammatory potentiators are important for its prevention. Timely identification
and appropriate management are necessary for an optimal


Implant Malposition
Implant malposition as a result of capsular contracture is
the most common reason for revision following breast
augmentation (60). Implant malposition is variable and,
depending on the location, may lead to different complications. An inferiorly displaced implant causes obliteration
and change in the position of the inframammary fold compared with the contralateral breast. A medially displaced
implant may cause symmastia; a laterally displaced one
will result in axillary fold bulging, whereas a superiorly
displaced implant will lead to aesthetically unpleasing
asymmetry, with one breast mound sitting higher than the
contralateral one.
The best time to prevent implant malpositioning is during the initial operation. The key is to avoid over-dissection
of the pocket during the initial augmentation procedure,
and to pay close attention to important landmarks, such as
the existing or new inframammary fold (IMF), the sternal
midline, and the anterior axillary line. Dissection past the
midline should be avoided, in order to prevent the development of symmastia, should extend down to the predetermined IMF level, and should not violate the anterior
axillary line. However, the patient and surgeon should be
aware of the fact that even with meticulous surgical technique and adherence to sound principles, implant malpositioning can still occur, and is amenable to multiple
treatment modalities. Revisional surgery, with possible
recreation of the IMF, or the medial origin of the pectoralis
major muscle, in case of inferior or medial displacement,
respectively, could lead to satisfactory results. Use of acellular dermal matrix in order to provide additional support
to the underlying revision is well-documented in the current literature (42,43,61).
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).
The incidence of double bubble deformity is reported in
the literature to be between 2 and 7% (63). One of the
underlying etiologies of double bubble breast deformity is
failure to recognize the risk factors for it preoperatively.
One factor is severe ptosis with loose attachments at the
muscle parenchyma interface. In a subpectoral type augmentation, the breast parenchyma slides in a cephalad
direction over the implant, leading to this deformity.
Another risk factor is use of an implant of insufficient volume and projection in a patient with contracted or tuberous
glandular tissue, along with a short nipple to inframammary fold distance. To avoid double bubble in patients
with tuberous breasts, the gland must be modified with
radial incisions to optimize the transition between implant
and gland and to expand the base of the breast. Accurate


planning in regard to implant selection and pocket dissection can help prevent the development of double bubble
deformity. The pocket plane should be of adequate dimensions in order to be filled by the selected implant; therefore, implant volume, projection, and dimensions must be
carefully selected.
The goals of mastopexy are elevation of the nipple areolar
complex, improvement of projection, aesthetic enhancement
of the breast shape, along with optimal scar quality (64).
Basic principles to follow are accurate assessment of the
degree and nature of ptosis, appropriate procedure selection, adequate preoperative planning and meticulous execution (65). In order to minimize unfavorable results, the
surgeon must be familiar with different techniques of mastopexy that will adequately address the skin envelope and
minimize the need for revisions. It is important to note that
this operation will result in scarring either in the periareolar
region or on the breast itself, which may be considered an
unfavorable result by the patient (66). However, scarring is
the tradeoff for achieving a long-lasting improvement in
the shape and aesthetic appearance of the breast, and
patients should be well-informed prior to proceeding with
Patient Selection and Informed Consent
Accurate patient selection requires careful assessment of
nipple position, degree of ptosis, breast skin elasticity,
nipple asymmetry, and contour irregularities. 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.
Patients must be aware of scar burden and location as
well as the possibility of hypertrophic scar formation.
Moreover, patients should be informed that mastopexy
results may be temporary and with weight fluctuations,
aging, and pregnancy, ptosis may recur.
Procedure Selection
After all contributing factors have been considered, the
appropriate procedure must be undertaken in order to
achieve an aesthetically pleasing outcome. 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). First-degree


ptosis can be corrected with breast augmentation alone

and if the patient has modest amount of excess skin,
choosing a larger implant may produce the desired outcome. In a patient with second-degree ptosis, breast
implant alone will be insufficient and will lead to an
unfavorable aesthetic outcome. In order to correct the
problem in a patient with more pronounced ptosis, the
nipple should be elevated to the desired ideal position at
or slightly above the IMF level. This can be achieved by
periareolar mastopexy if the distance is less than a few
centimeters. However, for patients with a greater degree
of ptosis, 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. In a patient with third degree ptosis and
volume loss, a significant amount of skin excision with a
short vertical scar or inverted-T procedure in conjunction with a subsequent augmentation, and/or plication
may be necessary for correction and optimal outcome
(Fig. 16.4).



Scar Widening and Hypertrophy

When selecting a patient for mastopexy, it is important to
pay utmost attention to the patients skin quality. 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, respectively. 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). In the case of
hypertrophic scar formation, local corticosteroid injections
can be used, along with scar massage, to minimize and prevent bulky scars. If scars persist despite conservative nonoperative measures, scar revision may be undertaken one year
after the initial surgery (69).
Augmentation Mastopexy
Many surgeons advocate placement of subglandular or
subpectoral breast implants in conjunction with mastopexy (70,71). Although performing both procedures in



Figure 16.4 (A) Patient with Grade III ptosis and volume loss. (B) Vertical mastopexy markings with planned plication. (C) Early
3-week postoperative result after vertical mastopexy and parenchymal redistribution with plication.


one setting lowers the overall cost for the patient, from a
physiologic standpoint, both surgeries act in opposition
to each other. Mastopexy repositions the nipple, reshapes
the breast and removes excess skin while limiting tension and scarring, whereas augmentation expands the
skin envelope, and increases the breast volume. This may
lead to wound healing problems and is technically very
challenging. If one chooses to undertake a simultaneous
augmentation-mastopexy, it is generally recommended
that final skin resection follow implant placement to
avoid closure under tension.
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. To avoid unfavorable results
many surgeons recommend performing the mastopexy first
followed by a second stage of breast augmentation (72,73).
The reverse can be performed but is much less common.
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. This will be discussed in other chapters and is beyond
the scope of this chapter.
The beginnings of breast reconstruction date back to more
than 100 years ago with a case by Dr Vincenz Czerny in
1893, who transplanted a lipoma from the buttock to
reconstruct a patients breast (74). Innovation and technical improvements have subsequently brought significant
advancement in breast reconstruction. With the evolution
of breast reconstruction techniques and their increasing
sophistication and technical complexity, the surgeon must
be aware of the potential for complications and unfavorable results. 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.
Fundamental Principles in Breast
The goal in breast reconstruction is to restore absent breast
tissue in a long-lasting and aesthetically pleasing manner and
establish overall symmetry. Careful patient selection and
appropriate use of available reconstructive options with
meticulous surgical technique are prerequisites for a successful outcome. Assessment of a patients candidacy for breast


reconstruction is a critical first step in minimizing complications and optimizing outcomes (75,76). Patient co-morbidities
and poor social habits should be carefully considered when
planning a reconstruction. A positive smoking history is
associated with a 23 fold increase in the incidence of
both major and minor complications in implant-based breast
reconstruction (77,78). Similarly, body mass index (BMI)
greater than 30, as well as history of hypertension contributes
to an increased risk for complications (77). Diabetes and poor
glycemic control contribute to wound healing problems and
increased infection rates (79,80). The role of advanced age as
a risk factor in breast reconstruction has not been clearly
defined (81). Patients should be evaluated in regard to realistic expectations and be informed about the expected results
and limitations of reconstructive techniques. Medical optimization, weight management and tobacco cessation should be
included in the preoperative management of a breast reconstruction patient. Patients in poor general health who cannot
tolerate reconstructive procedures may be better served with
an oncological resection without reconstruction, or can be
fitted with an external prosthetic device. Finally, in cases of
adjuvant or neo-adjuvant chemoradiation, timing, as well as
type of breast reconstruction should be taken into consideration in regard to the patients preoperative planning.
Tissue Expanders and Implants
The advantages of a two-stage tissue expander/implant
breast reconstruction are the relative ease of use, lack of
donor site morbidity, and increased patient involvement in
final volume selection (Fig. 16.5) (82). However, patients
should also be aware of possible complications associated
with use of a device including exposure, infection, extrusion, and capsular contracture, which may require additional
operations (83,84). Furthermore, reconstruction with tissue
expanders requires significant patient commitment to multiple office-based visits in order for the expansion process to
be completed. Single-stage implant reconstruction may
offer the advantages of eliminating multiple expansions but
require careful patient selection, healthy mastectomy flaps
and technical comfort and experience on the part of the
reconstructive surgeon (8587).
Tissue Expander Ports
There are two types of injection ports for a tissue expander:
remote and integrated. A remote port must be placed in the
subcutaneous tissue in a position easy to localize, but distant
enough from the implant to minimize the risk of implant perforation. Remote ports can be associated with port malposition and leakage, and difficulty with localization.
Consequently, many surgeons have moved toward utilizing
integrated ports (Fig. 16.6). When an integrated port is used,
tactile sensation should not be used to localize the port; the





Figure 16.5 (A) Preoperative appearance in patient who desired larger breasts. (B) Postoperative result after bilateral immediate twostage tissue expander and implant breast reconstruction.

Figure 16.6

Tissue expander with integrated port (note large port size).

overlying tissue may be misleading and needle insertion may

lead to puncture of the expander. Localization of the port
with a magnetic finder is recommended to accurately identify
the port site. Integrated ports may be associated with difficulty during radiation therapy and various modifications
have been described to improve the radiation field (88,89).

the different segments of the reconstructive procedure.

Careful expander inflation intraoperatively and in the outpatient setting with accurate identification of the port is
important to prevent puncture of the device. The introduction of newer generation of expanders, which have a larger
port, has decreased the incidence of puncturing during
expansion to approximately 1.5% (65).

Tissue Expander Rupture

Device defects and technical errors are among the most
important causes of tissue expander rupture. 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). It is usually associated with insufficient



soft tissue coverage and/or inadequately perfused mastectomy flaps. Key principles in avoiding exposure include
the creation of mastectomy flaps of adequate thickness and
a subpectoral pocket with full implant coverage (typically,
pectoralis muscle superiorly with serratus fascia and/or
acellular dermal matrix inferolaterally). Additionally,
early recognition and appropriate treatment of surgical site
infections, debridement and revision of wounds with
impending implant exposure, and careful expansion in
order not to compromise mastectomy flap vascular supply
reduce the risk of implant exposure (90). When this complication is encountered, management usually entails
removal of the implant, appropriate wound care and future
reconstruction (91).
Mastectomy Flap Necrosis
Mastectomy flap necrosis is usually related to either inadequate perfusion of the mastectomy flaps, or closure of the
incision under significant tension (Fig. 16.7). In case of
such complication, local wound care with possible debridement of the necrotic skin and future scar revision should
be considered. Timed excision of the mastectomy flap
necrosis with continued expansion may be considered if
full musculofascial coverage of the implant is present (92).
Newer technology incorporating ICG perfusion (SPY
technology, Lifecell Corp.) (65) may facilitate identification of the compromised mastectomy flaps intraoperatively (9397). Close cooperation between the breast and
reconstructive surgeons is necessary for optimization of
the final result.

Figure 16.7

Periprosthetic infection in reconstructive breast surgery
has been reported to be 725% of all cases (44,49,50,98,99).
Failure to adhere to sterile principles in the intraoperative
and postoperative phase and/or presence of multiple
comorbidities affecting the patients immune status can
contribute to a higher infection risk. Obesity (BMI > 30),
poorly controlled diabetes, immunocompromised state
and active smoking have been linked to higher infection
rates (77,7780). Moreover, improper device handling and
failure to comply with sterile principles during tissue
expansion may lead to periprosthetic infection. Once clinical evidence of an infection appears, the patient should be
treated promptly with antibiotics, and in the case of inadequate response, implant removal and delayed reconstruction is advised.
Contour Deformities
Fat injection into the subcutaneous layer overlying the
capsule has been recommended in order to address this
finding. 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. However, the long-term implications of this technique are unclear (40,41,100,101).
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.


capsular contracture. An implant that is initially placed

too high above the inframammary fold may be subject to
future capsular contracture and further implant distortion, leading to an aesthetically displeasing result (84).
Key principles to minimizing the incidence of malposition are precise breast implant selection (appropriate
size, shape and type), accurate preoperative markings,
and careful pocket design. Additionally, early recognition and treatment of capsular contracture may include
revision with capsulotomy, capsulectomy and/or implant
Capsular Contracture
The development of capsular contracture can negatively
affect an otherwise pleasing reconstruction. 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). Use of saline, textured and subpectoral implants has been reported to decrease contracture
rates (15). The major risk factor identified in the development of capsular contracture is radiation (102104).
Capsular contracture rates in the radiated breast are estimated to between 20 and 50%, when compared with nonradiated breasts (78). 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). Avoidance of hematoma, seroma
and infection as well as sterile antibiotic irrigation of the


implant has been suggested to reduce contracture rates

(46,106108). Newer studies suggest that implantation
with acellular dermal matrices (ADM) can deter the
development of capsular contracture (109111).
Role of Biologic Implants in Breast
Acellular dermal matrices (ADM), such as Alloderm,
Strattice, Flex HD, and Allomax and have become
very popular in immediate breast reconstruction. 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, thereby reducing
patient morbidity (Figs. 16.8 and 16.9). ADMs also contribute to aesthetically pleasing inferior pole expansion
and lower the incidence of capsular contracture (112114),
although they have been associated with increased seroma
rates and higher complication rates in patients with
increased age, higher BMI, and axillary dissection
(109,115119). Intraoperative drain placement into the
sub-mastectomy and sub-ADM planes may reduce seroma
rates (115,120,121). Additionally, once a seroma is identified, serial aspirations with careful drainage of the fluid
collection may be required, but is not necessarily associated with higher failure rates (119).
Newer technologies, such as SPY, may prevent complications, such as mastectomy flap necrosis, with subsequent
non-integration of the biologic implant used, and exposure
of the breast device (65,9397).


Figure 16.8


(A, B) Placement of ADM as lower lateral sling.





Figure 16.9

(A, B) Preoperative and postoperative result after ADM-assisted left TE/I breast reconstruction (and right mastopexy).

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, largely due to the like for like
advantage of native tissue and a more natural-feeling
reconstruction for the patient (122124). Smoking history,
morbid obesity, and previous abdominal surgery should be
taken into consideration prior to autologous breast reconstruction (125). Complications related to this type of
reconstruction can be categorized into donor site-related
complications and flap-related complications. Donor site
complications include abdominal bulging, development of
hernia defects, necrosis of skin flaps, wound dehiscence,
and infections. Flap-related complications include flap
loss and fat necrosis, venous congestion, improper insetting of the flap, and scarring. Careful planning of incisions
and optimal planning can prevent many of these complications and affect the overall outcome.
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, patient body habitus and vascular anatomy, tissue volume availability,
donor site morbidity, and patient preference (126). The
transverse rectus abdominus myocutanous (TRAM) flap
has been considered the autologous tissue of choice by
many surgeons for breast reconstruction (127,128). Concerns over abdominal wall morbidity have led to the
evolution of fascial-sparing techniques and perforator
flaps, such as the deep inferior epigastric perforator
(DIEP) flap. The DIEP flap offers less sacrifice of rectus

muscle and fascia, but may be associated with an

increased rate of fat necrosis (129,130). There is ongoing debate with regards to the superiority of the DIEP vs.
TRAM flap (131133). DIEP reconstruction can be considered more ideal in patients with small- to moderatesized breasts and presence of optimal perforator anatomy
(134). In cases of inadequate perforator anatomy, the
muscle-sparing TRAM or free TRAM flap is a reasonable alternative. 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, if autologous tissue is required. In addition, alternatives flaps such as the
superior gluteal artery perforator (SGAP), the inferior
gluteal artery perforator (IGAP), and the transverse
upper gracilis (TUG) free flaps may be used based on
optimal location of adiposity and acceptability of the
donor site defect. Careful flap selection with a thorough
assessment of the patients anatomy, expectations and
potential complications is critical to achieving successful long-term outcomes in breast reconstruction.
Total versus Partial Flap Loss
Technical errors, poor planning, and patient-related factors can lead to flap necrosis and/or loss. Technical
errors, including kinking or twisting of the pedicle, will
lead to vascular compromise of the flap. Additionally,
improper insetting of the flap may lead to venous congestion due to outflow obstruction and resultant flap
compromise. Patient-related factors include a history of
prior abdominal operations such as open cholecystectomy and coronary artery bypass, which may preclude
ipsilateral pedicled TRAM flap reconstruction (135,136).


In addition, morbid obesity, chemotherapy, and prior

surgery, may influence the success of the type of flap
chosen for reconstruction (137).
Key principles to avoid this type of complication
include appropriate lay of the pedicle in order to prevent
kinking, twisting or tension. Methylene blue dye can be
used to maintain the orientation of the pedicle (138). If
venous congestion is evident after insetting, modification of the flap orientation may facilitate better venous
drainage. 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.
Secondary procedures such as fat grafting have been used
to treat late deformities with success. If the flap is unable
to be salvaged, early return to the operating room and
debridement of the necrotic flap should be performed
and may prevent infection and future tissue compromise.
Moreover, once a complete flap loss occurs, a thorough
anticoagulation work- up should be performed and evaluation of alternative recipient vessels may be considered
prior to a second free flap (140). Lastly, it is important
to educate the patient regarding future asymmetry and
need for revisions if partial or full-thickness flap loss
Fat Necrosis
Although a more minor complication, 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). The most susceptible areas to fat necrosis are Hartrampfs zones III and IV
(areas most distant from donor blood supply), which may
need to be resected at the time of operation (142144). As
previously described, ICG perfusion imaging allows identification of areas with compromised blood supply that
may need to be excised (145). Inclusion of more perforators when harvesting DIEP or SIEA flaps reduces the rate
of fat necrosis (142,146). Preoperative mapping of the
abdominal vessels using different imaging techniques,
such as hand-held Doppler, color duplex ultrasound, CT
angiography, and MR angiography has been associated
with lower rate of complications and improved outcomes
(129,130,147,148). Although most cases of fat necrosis
resolve spontaneously with gradual softening of the
affected areas, suction-assisted lipectomy as well as excision of the necrotic tissue are among the suggested treatment options.
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. In cases of this
complication, local wound care with possible debridement


of the necrotic skin and future scar revision should be

considered. 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, although
the feasibility of this approach may be institution specific
Breast Asymmetry
Key principles to optimize obtaining symmetrical results
are choice of appropriate flap, careful insetting, and proper
selection and timing of future procedures on the ipsilateral
as well as contralateral breast. Mastopexy, augmentation,
and reduction mammoplasty, may be required in order to
accomplish symmetry (152). Typically, contralateral
breast surgery is staged at 36 months after the original
autologous reconstruction, and revisional procedures on
the autologous reconstructed breast can be carried out at
the same time (Fig. 16.10) (153).
Abdominal wall morbidity
Traditionally, the most common adverse sequellae associated with an abdominal-based flap is a bulge or hernia,
which can have a negative effect on overall patient satisfaction. Typically, the abdominal bulge occurs at or below
the arcuate line where there is absence of the posterior
rectus sheath (Fig. 16.11). Fascial-sparing techniques and
reinforcement of the abdominal wall are the key methods
to avoiding this complication.
Perforator flaps have become increasingly popular as
our understanding of anatomy improves, as they do not
require the degree of sacrifice of the underlying muscle
and fascia that a TRAM flap does. Some authors suggest
that TRAM flap reconstructions lead to weaker abdominal
wall, while other studies, including a recent meta-analysis,
report only slight increase in morbidity with the TRAM
versus DIEP flap (134,154). 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. Long-term
studies comparing free TRAM to perforator flaps are still
Technical aspects that may reduce the incidence of
abdominal wall morbidity include perforator or fascialsparing methods with clear identification of the perforators, careful tissue re-approximation during abdominal
closure, and a tension-free closure. In cases of increased
tension and inability to fully approximate the fascia, a
mesh should be used to bridge the gap (155,156). Drains
should be used to prevent seroma formation. Once a hernia
occurs, however, it will not improve over time and it must
be repaired. Repair involves imbricating the attenuated
fascia and reinforcing it with the application of an onlay
mesh and/or acellular dermal matrix (156).







Figure 16.10 (A) Preoperative appearance of patient with right breast cancer and breast asymmetry. (B) Postoperative result after
right immediate breast reconstruction using deep inferior epigastric artery perforator (DIEAP) flap. (C) Postoperative result after
contralateral breast reduction. (D) Postoperative result after right NAC reconstruction.

Abdominal Flap Necrosis

Umbilical Deformities and Necrosis

The main blood supply to the abdominal flap comes from

the intercostal, subcostal, and lumbar vessels. Excessive
undermining of the flap or closure under tension can
cause vascular compromise and lead to ischemic changes
of the abdominal flap. This complication is rare, however, once it occurs, the eschar should be debrided to
allow the wound to contract and heal by secondary intention with local wound care. Limiting unnecessary undermining of the abdominal flap, careful incision planning,
and a tension-free closure can help prevent abdominal
wound healing complications.

Careful design of the umbilical stalk is necessary in order

to obtain an aesthetically pleasing, and viable umbilicus
after reconstruction. 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, avoid excessive skeletonization of the
umbilical stalk and dissect carefully around it, in order to
preserve the blood supply necessary to prevent necrosis.
Defatting the umbilical tunnel may be undertaken to allow
easy passage of the stalk. In case of umbilical necrosis and
or loss, local wound care with dressing changes should be







Figure 16.11 (A, B) Preoperative and postoperative result after bilateral immediate breast reconstruction using DIEP and musclesparing TRAM flaps. (C, D) CT angiography demonstrating abdominal vasculature. (Continued)

done and future reconstruction of the neoumbilicus has

been described using various techniques (157161).
Breast Reconstruction with Latissimus Dorsi
and Implant
Because of its versatility and vascularity, the latissimus
dorsi myocutaneous flap is a reliable and reproducible
method to reconstruct a post-mastectomy defect. It can be
used either in an immediate or in a delayed reconstruction,
and either as pedicled or free flap (162). The skin paddle
over the latissimus dorsi muscle bears little hair and is an
excellent color match to the anterior chest skin. This type of

reconstruction often requires incorporation of an implant to

match the opposite breast in size and volume. An ipsilateral
thoracotomy incision is considered an absolute contraindication for latissimus dorsi breast reconstruction. Additionally, athletes who use the latissimus muscle routinely are
less ideal candidates.
In patients who present with a complication from
prior surgery such as winging of the scapula after axillary dissection, 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.






Figure 16.11

(Continued) (EG) Intraoperative views of DIEP and muscle sparing TRAM flaps.

Reconstruction with the latissimus dorsi flap has a

lower complication rate than implant-based reconstruction
alone, particularly for the radiated patient (163). In order
to optimize long-term outcomes, meticulous surgical technique, achievement of adequate hemostasis, drain placement, and other modalities such as using quilting stitches
or fibrin glue to decrease dead space and to reduce seroma
rates are important considerations. Additionally, the scar
can be placed vertically or horizontally along the bra line,
when possible, to conceal the scar. Breast reconstruction
with the latissimus dorsi flap has proved to provide patients
with a high level of satisfaction and predictable and favorable outcomes (123).
Alternate Free Flaps in Breast Reconstruction
Perforator flaps represent the latest in the evolution of softtissue flaps. They allow the transfer of the patients own

skin and fat in a reliable manner with minimal donor-site

morbidity. SGAP, IGAP, 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.
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. Advantages of the SGAP flap include minimal donor site
morbidity, as well as excellent tissue volume. Disadvantages include difficult dissection, patient repositioning,
more globular fat consistency, shorter pedicle length and
small vessel diameter (164,165).
The advantages of the IGAP flap include donor site
defect that can be concealed in the infragluteal crease, and
minimal donor site morbidity. Disadvantages mirror those
of the SGAP flap, as well as potential for buttock effacement and the development of a painful scar (166).





Figure 16.12 (A, B) Preoperative and postoperative appearance of patient who underwent bilateral TE/I breast reconstruction with
radiation (note changes secondary to radiation).

The TUG flap is indicated for women with small

breasts and regional adiposity in the medial thigh region,
who seek primary autologous reconstruction after a skinsparing mastectomy. It is particularly useful for patients
less amenable to scarring on the abdomen, back, or gluteal
region. One advantage of this flap is that it can be raised
simultaneously during mastectomy and recipient vessel
exposure. Disadvantages include variable soft tissue
volume availability, scar migration, wound dehiscence
requiring healing by secondary intention, and labial distortion (167,168).
Radiotherapy and Breast Reconstruction
Radiation therapy, either in a neoadjuvant or adjuvant setting, is an integral part of breast reconstruction in the
multidisciplinary management of breast cancer. 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. Radiotherapy has many deleterious effects
on skin and soft tissue as well as on the vasculature of
tissue. At the soft tissue level radiation resembles a burn
injury and at the vasculature level radiation induces transient microvascular occlusion (Fig. 16.12). Addition of
radiation to the breast cancer treatment protocol and timing of radiation affect the reconstructive plan and options
available (169171).
In general, tissue expansion in the radiated patient
can be difficult. 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). If the soft tissue envelope is inadequate, import of autologous tissue with or without a
prosthetic device is recommended. If radiation is
required after an immediate expander reconstruction,
protocols have been developed with close cooperation
with the radiation oncology specialist with high success
rates (89,88,173,174). With regard to free flap breast
reconstruction, pre-reconstruction radiation therapy
increases the rate of vascular complications in free flap
breast reconstruction, the majority of which appear
intraoperatively. Although radiation does not hinder the
overall success of reconstruction or contribute to postoperative complications, surgeons should be aware that
working in a previously irradiated field carries additional
technical risk (175). In the post-reconstruction patient,
radiation therapy has a deleterious effect on the longterm aesthetic outcome in patients who have undergone
TRAM flap breast reconstruction (176). 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- or implant-based
reconstructive methods.
Optimizing long-term outcomes is a goal for both the
reconstructive and aesthetic surgeon. Careful patient selection, meticulous technique, and appropriate choice of available options are prerequisites for successful breast surgery.
Recognizing and understanding how to minimize complications and avoid unfavorable results are critical aspects to
achieving optimal long-term success after breast surgery.


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Gary Rose

Gynecomastia is hypertrophy of the male breast and can

be either unilateral (Fig. 17.1) or bilateral (Fig. 17.2).
This hypertrophy is of the glandular tissue, not to be confused with pseudogynecomastia which is hypertrophy of
fat contained within the skin envelope of the male breast.
Pseudogynecomastia is seen with obesity and in the
aging male. The normal male breast contains a small
amount of parenchymal tissue and fat. However, a proliferation of the male breast tissue occurs in 5065% of
males during the pubertal years. Most often it is quite
benign and resolves uneventfully, within a year or two.
Persistence of gynecomastia of 3 years or more occurs in
up to 8% of pubertal males. In a study by Nuttall (1), of
306 men, there was a 57% incidence of gynecomastia in
males over the age of 44 years. This was affirmed in a
post-mortem study by Williams (2) of 447 men, with an
incidence of gynecomastia in 44%. 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. The causative agent is the ingestion, application, or
injection of high doses of testosterone for the very effective anabolic effects. With high levels of total testosterone, there is a parallel rise in the amount of free
testosterone. With increasing levels of free testosterone,
there is a parallel aromatic conversion of the free testosterone to estrogen from circulating aromatase, and a
resultant increase in the parenchymal tissue and ducts of

the male breast. This form of gynecomastia is much more

fibrous than the nonsteroid-induced variety of gynecomastia. It is also important to note that there is an extensive centrifugal growth of the parencymal tissue, often
extending from the clavicle to the 78 rib, and sternum to
anterior axillary line.
There have been various techniques that have been
described for the surgical correction of gynecomastia.
Surgical excision has been described since antiquity.
The earliest record is attributed to Paulus Aeginata (3),
who was a seventh century Byzantine physician. Over
the centuries the technique has been reinvented and
refined. Most notable among these was the technique
described by Webster (4) in the 1940s. Basically, all of
the surgical excision techniques have similar characteristics. Most utilize a periareolar, or intraareolar incision. Then a local surgical excision of the gynecomastia
tissue is completed. If it is a small gynecomastia, then
it is essentially the same procedure as a lumpectomy. If
it is a large gynecomastia, the surgery becomes much
more extensive, varying from a segment type of excision, or may progress to a complete subcutaneous mastectomy. In a young male, or very fit older male, and if
there is no major excess of skin, there should be no
problem with the skin envelope shrinking down and
conforming to the shape of the tissue left beneath it.
Of course this also assumes normal skin elasticity, no




Figure 17.1

Unilateral gynecomasty.




Figure 17.2

(AC) Bilateral gynecomasty.


history of trauma or radiation, or previous surgery to

the area.
In the 1980s, Temourian and Pearlman (5), and
Courtiss (6), described limited liposuction of the male
breast for gynecomastia. This was combined with
surgical excision of the gynecomastia tissue. In 1987,
I described the use of liposuction alone (7), without any
surgical cutting, except for a very limited skin incision
of 23 mm, for the correction of gynecomastia in all
ages. Later refinements of instrumentation made this
possible for others to utilize this technique with consistent results (8). The addition of ultrasound enhanced
skin shrinkage in patients with very large gynecomastia
(9). Today, suction lipectomy is utilized more commonly for small- and medium-sized gynecomastia. Skin
excision is limited to those cases where there is a large
amount of skin redundancy.
It is imperative to understand that the vast majority of
pubescent males only require reassurance and understanding. Most will resolve spontaneously with time. For
older men, aromatase inhibitors, blocking the conversion
or testosterone to estrogen, has had limited success in the
correction of gynecomastia. 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. It
appears that prevention is much more successful than
If medical treatment is not an option, or has been unsuccessful, then surgery is a realistic option. As in preparation
for all surgical procedures, a thorough workup is in order,
to determine the underlying cause. If serious endogenous
disease, or exogenous causative agents, has been identified, they must be dealt with. Hormone levels must be
obtained as a baseline.
As with all surgery, the surgeon must be vigilant and compulsive in technique. Infection is the result of poor sterile
technique, or improper understanding and actuation of perioperative instructions by the patient. Cellulitis can be successfully treated by warm compresses and utilization of the
correct antibiotics. Most likely cellulitis will be secondary
to Gram positive organisms that are susceptible to penicillin or vancomycin. Infection with Gram negative organisms is not as common. If there is abscess formation, or
deeper wound infection, additional treatment with drainage
is required. Wound infection can lead to irregularities of the
skin, or surface contour of the breast. Slough of the areola
can also occur.
Although very rarely seen after suction lipectomy for
gynecomastia, post-operative bleeding and hematoma are


common occurrences after surgical excision. The size of

the hematoma correlates with the amount of parenchyma
excised. But note, the incidence of hematoma does not
correlate with size. Any, and all, parenchymal excisions
leave a potential space. The reason that I first thought of
utilizing suction lipectomy for gynecomastia was the
unacceptable incidence of hematoma, even with pressure
dressings and drainage in place. As soon as hematoma is
suspected, it must be drained completely. Otherwise, the
organization of the clot and resultant fibrosis can, and will,
lead to irregularities and deformities of the remaining skin
and breast.
If the surgeon chooses to use surgical excision techniques, he/she must leave behind 1 cm of subareolar tissue to maintain blood supply to the areola. To leave less
of it will often lead to slough and resultant deformity of
the areola. However, as I previously published (10),
gynecomastia has its origin in the immediate subareolar
glandular tissue. As you can easily see, surgical excision
techniques do have a greater potential for recurrence than
does liposuction techniques. (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. Blood supply is not an issue.) In addition to leaving 1 cm of tissue
after the surgical excision, 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, which will result in saucer
Poor planning of the skin incision can lead to distortion
of the areola. This is not very common, but can occur
when unbalanced forces produced by asymmetric healing
pulling the areola in unnatural directions. This can be corrected by local excisions with advancement of the areola,
or with surgical tattooing.
Hypertrophic scarring is always a concern whenever
skin is excised. Occasionally the surgeon becomes a
little too enthusiastic when excising excess skin, and
then is forced to close the skin with excess tension.
This will often result in hypertrophic scarring. Alternatively, poor closing technique can also result in excessive scarring.
Correction of failed previous attempts of gynecomastia surgery is not an easy road to travel, especially with
exceedingly large gynecomastia. Tissue will be distorted,
scar tissue plentiful, and the skin/areola will present in
unusual ways. Figure 17.3 exemplifies many of the
problems discussed. The initial surgical excision was
attempted by a general surgeon. He terminated the case
after completing a subcutaneous mastectomy of the left
breast (Fig. 17.3 A). The patient presented 6 months later
with a huge deformity. The skin was totally contracted
and the areola had sloughed (Fig. 17.3 B). Bilateral






Figure 17.3 Poor technique has resulted in excessive scarring. (A) Failed initial attempt by general surgeon to correct massive
gynecomastia with subcutaneous mastectomy. There was no consideration of the excess skin. (B) Six months later. (C) One year after
correction with bilateral simple mastectomies and excision of excess skin. Areolae were created with tattooing.







Figure 17.4 (A) A 42-year-old male: pre-postoperative view (see also C for side view). (B) One year post-operation: the surgical
correction was made with suction lipectomy without surgical resection (see also D for side view).

mastectomies were then performed. Excess skin was

excised from the right breast, and scar contractures were
released in the left breast. Areolae were created with tattooing (Fig. 17.3 C).
Although I have not seen these complications with suction lipectomy for gynecomastia, there is a potential for
hemorrhage, infection, hematoma, seroma, changes in
sensation, fat necrosis, and gross asymmetry.

The publics awareness of the availability of gynecomastia surgery has made tremendous strides forward. In
fact, it is one of the most commonly performed male plastic surgery procedures today. I strongly recommend the
utilization of suction lipectomy. It is easier and inherently
carries with it much less risk of complication. The other
great advantage is that patients are able to return to full
activities the day after surgery (Figs. 17.4 and 17.5).







Figure 17.5 (A) A 19-year-old male with large tuberous gynecomastia. Pre-operative view (see also C for side view). (B) One year
post-operation: The correction was made with suction lipectomy. No surgical excision was carried out (see also D for side view).


1. Nuttall FQ. Gynecomastia as a physical finding in norrmal
men. J Clin Endocrinol Metab 1979; 48: 338.
2. Williams MJ. Gynecomastia: its incidence, recognition and
host characterization in 447 autopsy cases. Am J Med 1963;
34: 103.
3. Aeginata P. The Seven Books of Paulus Aeginata. Translated
from Greek by Francis Adams. vol 2, book 6, section 46
London: London Syndenham Society, 1848.
4. Webster JP. Mastectomy for gynecomastia through a semicircular intra-areolar incision. Ann Surg 1946; 124: 557.
5. Teimourian B, Pearlman R. Surgeryfor gynecomastia. Aesthetic Plast Surg 1983; 7: 155.


6. Courtiss EH. Gynecomastia: analysis of 159 patients and
current recommendations for treatment. Plast Reconstr Surg
1987; 79: 740.
7. Rosenberg GJ. Gynecomastia: suction lipectomy as a contemporary solution. Plast Reconstr Surg 1987; 80: 379.
8. Rosenberg GJ. A new cannula for suction removal of parenchymal tissue of gynecomastia. Plast Reconstr Surg 1994;
94: 548.
9. Rosenberg GJ, Cabrera RC. External ultrasonic lipoplasty:
an effective method of fat removal and skin shrinkage. Plast
Reconstr Surg 2000; 105: 785.
10. Rosenberg GJ. Gynecomastia. In: Spear SL, ed. Surgery of
the breast: principles and art. Philadelphia: Lippincott-Raven
Publishers, 1998: 831.

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. For the first 25 years of
Medicare, physician payments were based on usual and
customary charges from physicians. Because of the wide
diversity of physicians fees for the same service, Medicare paid markedly different amounts for the same service.
In the mid 1980s Medicare contracted with Drs Hsaio and
Braun at Harvard to create a cross-specialty resourcebased relative value scale. In three different phases the
Harvard study valued services for 33 different specialties.
The AMA was subcontracted to act as a liaison between
the Harvard researchers, organized medicine, and practicing physicians. The AMA worked with national societies
to create Technical Consulting Groups within each specialty. These groups were charged with determining the
services performed within their specialty and then develop
surveys used to value and rank the various services.
The Omnibus Budget Reconciliation Act of 1989, established a resource-based relative value scale for physicians,
eliminating fee based payments. The Harvard-produced
RBRVS was used as the initial scale but has been modified
extensively since then. To maintain the RBRVS system the
AMA set up the RBRVS Update Committee affectionately
know as the RUC. All medical specialties are represented
at the RUC and the process still involves surveys completed by physicians who perform that service (1).
Readers should understand that the RBRVS is only a
scale, attempting to relate the magnitude and intensity of

services across specialties. It is not a payment schedule.

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. Even though
insurance carriers, other than Medicare, may use the
RBRVS, the conversion factor used is negotiable.
The value assigned to any CPT code includes three parts:
(1) the physician work (including the immediate preoperative care, the operation itself, and normal, uncomplicated
follow-up), (2) practice expense, and (3) medical liability
expense. In 1991 Center for Medicare and Medicaid
(CMS) defined the specific services included in the global
surgical package. These services include; preoperative visits the day of or day before surgery, intra-operative services that are normally a necessary part of the procedure;
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.
Initial Evaluation by the Surgeon
The surgeons initial evaluation or consultation is considered a separate service from the surgery and is paid as a
distinct evaluation and management (E&M) service.


Previously, some carriers bundled the initial evaluation into

the global package if it occurred within the week prior to
the surgery. 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, separate payment
is allowed for the visit at which the decision to perform
surgery is made if adequate documentation is submitted
with the claim. Modifier 57 (Decision for Surgery) is used
to indicate an evaluation and management (E/M) service
that resulted in a decision to perform surgery.


performed for a diagnosis which is unrelated to the surgery that was performed. 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.
Staged Procedures

Preoperative visits with the surgeon the day before or the

day of surgery to obtain consent, comply with hospital
rules for an H&P, and to answer any remaining questions
for the patients are included with the global surgical package, assuming that the evaluation and decision to perform
surgery had been made at a previous visit.

Full payment for all procedures is allowed for situations

when distinctly separate but related procedures are performed during the global period of another surgery. When
the decision is made prospectively or at the time of the first
surgery to perform a second procedure, modifier 58 (staged
or related procedure by the same physician during the
postoperative period) should be reported. In the initial
operative report, the surgeon should identify the need for
additional staged procedures and the approximate time
those procedures can be expected.

Complications Following Surgery


If a patient develops a complication following surgery that

requires additional medical or surgical services but, does
not require a return trip to the operating room, these services are considered part of the global surgical package. If,
however, the complication requires a patients return to
the operating room for a medically necessary service,
these services are paid separately from the global surgical
amount. Modifier 78 is used to identify a related procedure that requires an unplanned return to the operating
room. In contrast, 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.

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 surgeons visits or services. These
services include:

dressing changes
local incisional care
removal of operative packs
removal of cutaneous sutures, staples, lines, wires,
tubes, drains, cast, and splints
insertion, irrigation, 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. The CPT code for this
procedure 19357, includes creation of the expander pocket,
elevation of the pectoralis major and serratus anterior
muscles, if performed, placement of the tissue expander,
filling of the expander at the time of the procedure, and
closure of the mastectomy incision. It also includes all of
the postoperative expansions during the 90-day global
period. In fact, 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.
If some type of additional acellular dermal allograft
(such as AlloDerm) is placed at the time of the tissue
expander, this is coded separately. Currently the code for
placement of AlloDerm is 15330 (acellular dermal
allograft, trunk . . . first 100 sq. cm or less). If more than
100 sq. cm of AlloDerm is utilized, then add 15331 (acellular dermal allograft, trunk, each additional 100 sq. cm).
If xenografts are utilized (e.g. Strattice and Surgimend)
use codes 15430 and 15431. Be alert, the section on; acellular dermal replacement grafts, allografts and xenografts,
is being revised and new codes should be available in
2012. If the expansions extend beyond the 90-day global
period, then they can be billed for separately, utilizing the
appropriate E&M code. There is no separate CPT code for
in-office filling of a tissue expander. Instead, use the E&M
code and bill for the supplies separately.
When the patient undergoes the second stage procedure
to exchange the tissue expander for a permanent implant,


the appropriate code is 11970 (replacement of tissue

expander for a permanent prosthesis). If a significant number of capsulotomies are performed to reposition the permanent implant, code 11970, together with 19370
(periprosthetic capsulotomy), add the -59 modifier to indicate separately billable work. 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 . . . in reconstruction) (2). Poll
your most utilized providers preoperatively to determine
their desired coding preference.
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, then use codes 11970
and 19371 (periprosthetic capsulectomy). If, however, a
more substantial procedure is performed to reset the inframammary crease by advancing the upper abdominal tissues,
then this is considered a Ryan flap and is coded with 14001
(adjacent tissue transfer, trunk, 10.1 sq. cm to 30.0 sq. cm).
The local advancement flap, 14001, 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).
If a permanent implant is being placed at the time of
mastectomy or in a delayed fashion, elevation of the pectoralis or serratus muscle does not constitute a muscle
flap as described in 15734. The work of elevating the
muscle is included in the codes 19340, 19342, and also the
breast tissue expander code 19357.
Autologous Tissue Breast Reconstruction
A separate code, 19361, exists for breast reconstruction
utilizing a latissimus myocutaneous flap. This code
includes elevation of a muscle or myocutaneous flap,
transfer of the flap to the breast defect, insetting of the flap
and closure of the donor defect. Previously this code
included placement of an implant, but this separate service
was separated from the code in 2009. Now if a permanent
implant is placed at the time of the latissimus flap then add
code 19340 (placement of an implant, immediate . . . in
reconstruction) to the latissimus flap code. If a tissue
expander is placed, 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. Again, if the expansions continue beyond the 90-day global period they may be billed
for separately using the appropriate E&M code.
Code 19367 describes the procedure for breast reconstruction utilizing a single pedicled TRAM flap. All of the
components of the procedure; harvest of the flap, transfer
to the breast defect, closure of the donor site and insetting
of the flap, are included in the code. If a double pedicle
flap is used then the code is 19369. Because of the more


extensive defect to the abdominal wall fascia with the

double pedicle procedure, the use of mesh to help close the
abdomen is included with code 19369. The use of mesh is
not included with a single pedicle TRAM and therefore
can be coded separately with code 49568 (3). The mesh
code is an add-on code specifically linked to the hernia
codes so a letter of explanation may be required. Check
with your carriers as to how they would like this additional
procedure to be coded.
If a TRAM flap is delayed the correct code to use is
15600 (Delay of flap or sectioning of flap (division and
inset); at trunk). Do not use 19367-59 as this grossly overestimates the work performed. If both inferior epigastic
arteries are ligated then use 15600 twice (3). 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, 19367-58.
All microvascular flap breast reconstructions: TRAM,
Muscle Sparing TRAM, DIEP, TUG, Sup/Inf gluteal
artery flaps etc. are coded with 19364. Harvesting of the
flap, transfer to the breast defect, microvascular anastomoses of one artery and up to two veins, insetting and
closure of the donor site is included in the code (3). Closure of the donor site with mesh is not included and can
be coded separately. If additional arteries or veins are
anastomosed then this extra work can be coded using the
vessel repair code 35206 (repair blood vessel, direct;
upper extremity). Code 35206 should be used for both
internal mammary and thoracodorsal vessels. Code
35316 (repair blood vessel, direct; intrathoracic) involves
a thoracotomy, which is not done routinely. The work to
expose and perform anastomoses with the internal mammaries is much closer to work depicted by 35206. If vein
grafts are needed these can be coded separately with
code: 35236 (Repair blood vessel with vein graft; upper
extremity). Also add code 69990 (use of the operating
room microscope). All of the vessel repair codes are
macrovascular, not microvascular procedures and therefore the surgeon must indicate that the procedure was
performed using microsurgical techniques by appending
the 69990 code. You can only use the code once no matter how many vessels you repair using the microscope.
All microvascular flaps, whether used for breast reconstruction or otherwise are inherently microsurgical and
one should not add the 69990 code to microvascular flap
Many people continue to express their discontent
regarding the value of 19364. While everyone would certainly like to receive more payment for the work they do,
19364 is appropriately valued relative to procedures in
other specialties. (Table 18.1) (4).
Another concern heard frequently is that the value of
19364 does not take into account the extra work involved



Table 18.1 Listing of work RVUs from Current Procedural

Coding 2011.


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


Table 18.2

ASPS 2009 Procedural

Implant alone
Tissue expander
Latissimus flap




in a deep inferior epigastric artery perforator (DIEP) flap.

It is true that 19364 does not distinguish between a standard microvascular TRAM flap and a DIEP flap. 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.
CMS makes the final decisions regarding the values for
codes recommended by the RUC. Because CMS must by
law remain budget neutral, it consistently insists that
changes in values of codes within families of codes
remain neutral. 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.
According to American Society of Plastic Surgeons 2009
statistics (Table 18.2) (5), two thirds of all breast reconstructions are performed with a tissue expander. Reconstruction with a DIEP flap constitutes only 5% of all
reconstructions. 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.
Nipple Reconstruction
The nipple/areola reconstruction code 19350, 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.

The relative value of 19350 includes the work of reconstructing both the nipple and areola. Many surgeons now
reconstruct the nipple alone and then latter color the nipple and create an areola with tattooing techniques. To
code for nipple reconstruction alone, use code 19350 with
the -52 (reduced services modifier). Later when the tattooing is performed use the tattoo codes 11921 (tattooing,
intra-dermal . . . 6.120 sq. cm,) 11922 (tattooing, intradermal . . . each additional 20 sq. cm). To determine the
square centimeters, use the formula A = r2, where r is the
radius (usually 2.5 cm) and is 3.14. The standard 5 cm
areola is 19.62 sq. cm. Some insurance carriers may prefer; that instead of reducing 19350, the value of the code
will stand for both nipple creation and tattooing, instead of
using two separate codes. Poll your insurance carriers
about which method they prefer.
Symmetry Procedures
If breast reduction is performed on the contralateral side
for symmetry it should be coded with 19318 (reduction
mammoplasty). This code includes parenchymal reduction, supplemental liposuction, breast lift, nipple/areola
repositioning, and nipple/areola preservation whether it is
done by pedicle technique or amputation and grafting. If
liposuction is used alone, use code 15877 (suction-assisted
lipectomy; trunk).
If liposuction is used to modify a reconstructed breast,
use the code 19380 (revision of reconstructed breast). Do
not use the liposuction code 15877. Most insurance companies consider this a cosmetic code and do not recognize its use in reconstructive procedures. Do not use
19380 to code for scar revisions of the mastectomy or
reconstruction scar (use 1310X, complex closure), capsulectomies (use 19371), replacement of an implant for a
different size (use code 19340) when these procedures
are performed alone. When performed together on the
same reconstructed breast, it may be appropriate to use
code 19380. If dog ears require resection at the ends of a
TRAM scar and are closed in layers; use the resection
codes (1140X) together with the intermediate closure
codes (1203X) (6).
Fat grafting is sometimes recommended to help correct
contour defects, especially in the area cephalad to the reconstructed breast where the mastectomy continued beyond the
reconstruction. Fat grafting is coded with code 20926 which
includes: harvest of the fat graft, processing of the fat, injection of the fat, closure of the harvest and injection sites and
90 days of postoperative care. The code is not site or volume specific. If separate anatomic areas are treated then
code 20926 for each area. Append the -59 (separately identifiable procedure) modifier. 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).


Partial Mastectomy Defect Reconstruction

Breast cancer surgery, results in defects that can be closed
with straightforward layered closures all the way up to
complete mastectomy defects. The coding of partial mastectomy defects is particularly challenging. Understand
that all extirpative procedures include a straightforward
closure. If the patient wants a plastic surgeon to close the
wound after a procedure then that is cosmetic and should
be handled accordingly. If a large lumpectomy or
quadrantectomy defect requires significant undermining of tissues to achieve closure, then it is coded with
the complex closure codes 1310X. If new incisions must
be made in the breast skin, tissue or both then this constitutes an adjacent tissue transfer and is coded with 1400X
or if greater than 30 sq. cm 14300. If an implant is
required to restore significant volume loss then this is
coded with 19340 (immediate placement of an implant in
reconstruction (8).
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. Insurance carriers will
review this code routinely and clear documentation of the
extra work involved should be included in the op note. 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
the breast defect is closed with standard breast reduction
techniques (preservation of the nipple on a pedicle,
parenchymal reduction, skin rearrangement, then again
use the code 19366. The ICD-9 code should include
breast neoplasm.
The Womens Health and Cancer Rights Act of 1998,
mandates coverage for reconstruction of the breast after
mastectomy and procedures on the contralateral breast
for symmetry. Despite this, it is prudent to obtain in writing pre-authorization from the insurance carrier prior to


performing surgery. This will help avoid the frustration

of multiple appeal letters, if the procedure is denied.
The world of CPT coding is constantly changing and
the reader is encouraged to stay informed and up to date.
The American Society of Plastic Surgeons produces a
monthly newsletter that contains valuable information on;
new codes, code changes and the proper use of current
codes. Numerous societies including ASPS give coding
workshops throughout the year. These courses include
numerous tips on ethical coding and they just might produce enough extra reimbursement to pay for the trip.
Although supplemented with over 15 years of experience
on the ASPS Payment Policy committee, the vast majority
of this information comes from CPT coding articles written by Dr Raymond Janevicius and printed in Plastic Surgery News. The interested reader is encouraged to review
this valuable resource for additional information.
1. Smith SL. ed. Medicare RBRVS The Physicians Guide
2007. Chicago, IL: American Medical Association, 2007.
2. Janevicius R. Breast Reconstruction Coding: Everything
(almost) you need to know. Plastic Surgery News 2009, pg 12.
3. Janevicius R. Clarifying Breast Surgery Coding Confusion.
Plastic Surgery News 2011; pg 10.
4. Holden K, Gabbert W, Kachur KH, Canter KV. eds. Current
Procedural Coding Expert. 2011: Ingenix.
5. American Society of Plastic Surgeons. 2010 Report of the
2009 Statistics, National Clearinghouse of Plastic Surgery
Statistics. Arlington Heights, IL, 2010.
6. Janevicius R. Working with CPT code 19380 need not be
confusing. Plastic Surgery News 2007.
7. Janevicius R. Coding fat grafting procedures is straightforward. Plastic Surgery News 2009.
8. Janevicius R. Partial Mastectomy defect reconstruction
requires coding accuracy. Plastic Surgery News 2009.


Abdominal flap necrosis, 158, 180

Abdominal wall morbidity, 179
Aberrant glandular tissue, 11
Accelerated partial breast radiation
(APBI), 69
Accessory breast tissue, 910
Accolade, 94
Acellular dermal matrix (ADM), 7476,
95, 97, 177
ACR. See American College of Radiology
ACRIN. See American College of
Radiology Imaging Network
ACS. See American Cancer Society
Adipose tissue flaps, 63
ADM. See Acellular dermal matrix
Adult onset hypertrophy, 47
Aesthetic breast surgery
breast augmentation
complications, 170172
implant pocket plane effects, 167
implant selection, 167
incision type, 168169
optimal planning on tissue
assessment, 167
patient education, 166167
breast reconstruction
alternate free flaps, 182183
autologous tissue, 178181
biologic implants, 177
latissimus dorsi and implant, 181182
principles, 174
radiation therapy, 183
tissue expanders and
implants, 174177
skin envelope, 172174
Allergan, 88

AlloDerm, 117, 177, 198

Allomax, 177
ALNs. See Axillary lymph nodes
Alternate free flaps, 182183
Amasia, 11
Amastia, 11
American Cancer Society (ACS), 16
American College of Radiology
(ACR), 16, 18
American College of Radiology Imaging
Network (ACRIN), 16, 18
American Diabetes Association, 82
American Society of Plastic Surgeons, 47,
50, 87, 200201
Anterolateral thigh (ALT) flap, 134135
APBI. See Accelerated partial breast
Areolar reconstruction technique, 149150
Artecoll, 148149
Artificial bone, 148
Aspirin, 82
Athelia, 11
Augmented breast, 2223
Autologous breast reconstruction, 157159
Autologous fat grafting, 13, 148, 156
Autologous tissue breast
reconstruction, 199200
Autoplastic flap, 109
Axilla, 56
Axillary lymph nodes (ALNs), 3
BCS. See Breast conserving surgery
BCT. See Breast conservation therapy
Benign breast tumor, 36
Beveling, 128, 131
Bilateral gynecomastia, 190191


Bilateral hypomastia, 2934

Bilateral macromastia, 2628
Bilateral prophylactic mastectomy, 83
Biologic implants, 177
BIRADS. See Breast Imaging Reporting
and Data System
Blunt Seroma Cath, 96
Bostwick ptosis classification, 38
Brachial plexus, 67
brassiere cup size and reduction
volumes, 49
innervation, 48
shapes and landmark
measurements, 4849
vessels and lymphatics, 48
augmented, 2223
blood supply to, 34
and chest wall, 7
external anatomy, 12
hypertrophy, 47
innervation, 4
lymphatic drainage, 3
microscopic anatomy, 3
parenchyma, 48
and Poland syndrome, 12
reconstructed, 2324
reduction (see Reduction mammoplasty)
skin ptosis, 38
initial evaluation, 7
patient selection, 8
pre-operative considerations, 7
surgically altered, 2122
tissue expanders, 8789

Breast asymmetry
aesthetic breast surgery, 179
benign tumor, 36
and bilateral hypomastia, 2933
and bilateral hypomastia, ptosis, 3334
and breast ptosis, 2829
juvenile macromastia, 3435
and macromastia
adequate contralateral volume, 28
bilateral, 2628
inadequate contralateral volume, 28
preoperative, 162
principles, 26
unilateral hypomastia and contralateral
adequate volume, 34
Breast augmentation
asymmetry, 170
capsular contracture, 171
double bubble deformity, 172
hematoma, 170
implant malposition, 172
implant size, 170
infection, 170
secondary deformities, 171
wrinkling and rippling, 170171
implant pocket plane effects, 167
implant selection, 167
incision type, 168169
management strategies, 159161
optimal planning on tissue assessment, 167
patient education, 166167
Breast conservation therapy (BCT)
complications of, 7678
management strategies, 155156
neoadjuvant chemotherapy, 69
partial reconstruction techniques, 6976
patient selection, 66
radiotherapy techniques, 69
reconstruction following, 6668
reduction mammoplasty, 73
timing of reconstruction
delayed reconstruction, 68
reconstruction, 6869
immediate reconstruction, 68
Breast conserving surgery (BCS), 56
Breast Imaging Reporting and Data
System (BIRADS), 18, 57
Breast-specific gamma imaging
(BSGI), 2021
BSGI. See Breast-specific gamma imaging
Cadaveric acellular dermal matrices, 44
Calcifications, 2122
Calcium hydroxyapatite, injectable, 148
Cancer surveillance, 87
Capsular contracture, 9395, 159160,
171, 177

Capsulectomy, 161
Cartilage grafts, 148
Center for Medicare and Medicaid
(CMS), 197
Chest wall
anatomy of, 4
and breast, 7
and Poland syndrome, 12
Chiari-standardized geometric pattern, 43
Chloramex, 94
Circumareolar scar technique, 41
Clavipectoral fascia, 5
Clinical and Radiographic Poland
Syndrome (CRPS), 12
Clopidogrel, 82
CMS. See Center for Medicare and
Color duplex ultrasonography, 110
Comorbid medical conditions, 82
Congenital breast disorders
embryology, 9
hyperplastic disorders, 911
hypoplastic disorders, 1113
management of complications, 4
tuberous breast deformity, 1314
Contour deformities, 96, 176
Coopers ligaments, 48
CPT coding
autologous tissue breast
reconstruction, 199200
complications following surgery, 198
implant-based breast
reconstruction, 198199
initial evaluation, 197198
nipple reconstruction, 200
partial mastectomy defect
reconstruction, 201
postoperative services, 198
preoperative visits, 198
staged procedures, 198
symmetry procedures, 200
CRPS. See Clinical and Radiographic
Poland Syndrome
Deep inferior epigastric artery perforator
(DIEP) flap
anatomic dissections, 111
autologous reconstruction, 157158
breast and abdominal aesthetic
complications, 120121
breast and abdominal technical
complications, 119120
CPT coding, 200
general surgical complications, 117118
indications, 111113
microsurgical complications, 118119
performance, 113117
perfusion zones, 110111
venous drainage, 110

Delayed reconstruction, 68
Dermal flap, 43
Dermalive, 149
Double bubble deformity, 172
Double pedicled flaps, 144147
Dual chamber tissue expander, 88
Fat grafting, 73, 200
Fat necrosis, 63, 158, 162, 179
Fibroadenoma. See Benign breast tumor
Flex HD, 177
Flowes-Smith modified Wise incision, 44
Free abdominoplasty flap. See Superficial
inferior epigastric artery
Free flaps
anterolateral thigh flap, 134135
DIEP flap (see Deep inferior epigastric
artery perforator flap)
gracilis myocutaneous flap, 132134
inferior gluteal artery perforator
flap, 130132
postoperative management, 135136
Rubens flap, 134135
superficial inferior epigastric artery
flap, 110, 125126
superior gluteal artery perforator
flap, 126130
thoracodorsal artery perforator
flap, 134135
TRAM flap (see Transverse rectus
abdominis myocutaneous flap)
Free nipple grafting, 5354
Free tissue grafts, 147148
Fucidin, 94
Gestational hypertrophy, 47
Gigantomastia. See Breast hypertrophy
Gracilis myocutaneous flap, 132134
bilateral, 190191
hypertrophic scarring, 192193
suction lipectomy, 194195
unilateral, 190191
Halsteads ligament, 5
Hartrampf perfusion zones, 110111
Hematoma, 9596, 170
Homeopathic medications, 82
Hyperplastic breast disorders, 911
Hypertrophic scarring, 5455, 192193
Hypertrophy, 47
bilateral, 2934
unilateral, 34
Hypoplastic breast disorders, 1113
Iatrogenic hypertrophy, 47
IMA. See Internal mammary artery
IMF. See Inframammary fold

Immediate-delayed reconstruction, 6869
Immediate reconstruction, 68
Implant-based breast
reconstruction, 198199
Implant displacement, 95
Implant malposition, 172
Implant rupture, 160
Infection, 9293, 161, 170, 176
Inferior gluteal artery perforator (IGAP)
flap, 130132
Inframammary fold (IMF), 2
Internal mammary artery (IMA), 4
Inverted-T scar technique, 4345
Ipsilateral nipple, 11
Juvenile gigantomastia. See Juvenile
Juvenile macromastia, 3435
Lassus technique, 4142
Lateral perforators, 110
Lateral thoracic artery, 4
Latissimus dorsi flap, 96, 182
Latissimus dorsi musculocutaneous
flap, 74, 97, 181
LCIS. See Lobular carcinoma in situ
Lejour modified Lassuss
technique, 4142
Liposuction, 53
Lobular carcinoma in situ (LCIS), 83
Local flaps, 147
L-shaped scar technique, 43
Lumpectomy, 6869
Lymph nodes, 48
and adequate contralateral volume, 28
bilateral, 2628
and inadequate contralateral volume, 28
juvenile, 3435
Malposition, 141, 162163
MammoSite applicator, 6970
Management strategies
autologous reconstruction, 157159
breast augmentation, 159161
breast conservation therapy, 155156
expanders and implants with
BCT, 156157
general considerations, 155
reduction mammoplasty, 161163
Marcah arched gateway incision, 45
Mastectomy flaps
ischemia, 95
necrosis, 119, 176, 179
aesthetic breast surgery
augmentation mastopexy, 173174
breast reduction, 174
goals, 172

hypertrophy, 173
patient selection and informed
consent, 172
procedure selection, 172173
scar widening, 173
complications, 3839
inverted-T scar technique, 4345
L-shaped scar technique, 43
markings, 37, 39
periareolar scar technique
with asymmetrical areola
shape, 4041
circumareolar scar technique, 41
with symmetrical areola
shape, 4041
physical examination, 38
preoperative assessment, 38
ptosis classification, 38
vertical scar technique, 4142
Medial perforators, 110
Mentor CPX3 profi led expander, 88
Methylene blue dye, 179
Michigan Breast Reconstruction Outcome
Study, 93, 99
Microvascular flap breast
reconstructions, 199
MRI breast imaging technique, 1820
Musculoskeletal thoracic wall, 4
Myocutaneous latissimus dorsi flaps, 63
Myosubcutaneous latissimus dorsi
flaps, 63
Natrelle expander, 88
Neoadjuvant chemotherapy
breast conservation therapy, 69
post-mastectomy reconstructive
surgery, 83
Nicolle modified Wise incision, 45
Nippleareola complex (NAC)
errors in timing of surgery, 140
malposition, 141
patient selection, 140
skate flap techniques, 142143
star flap techniques, 143144
CPT coding, 200
principles of, 139
qualitative benefits, 139
secondary procedures, 150153
areolar reconstruction, 149150
autologous fat grafting, 148
cartilage grafts, 148
double pedicled flaps, 144147
free tissue grafts, 147148
local flaps, 147
nipple sharing, 148
soft tissue fillers, 148149

Nipple banking, 148

Nipple necrosis, 162
Nipple sharing, 148
Non-absorbable mesh, 43
Non-steroidal anti-inflammatory drugs
(NSAIDs), 82
NSAIDs. See Non-steroidal antiinflammatory drugs
Obesity, 83
Omnibus Budget Reconciliation
Act, 197
Oncoplastic algorithm, 58
Oncoplastic surgery (OPS)
cosmetic complications, 64
oncologic complications, 63
purpose of, 5657
surgical complications, 6364
techniques of, 5763
OPS. See Oncoplastic surgery
Over-reduction, 162
Partial mastectomy defect
reconstruction, 201
Partial mastectomy defects, 6976
Pectoralis fascia suspension, 43
Pectoralis major, 45
Pectoralis minor, 45
Pectoralis muscle slings, 43
pedicled Transverse rectus abdominis
muscle (TRAM) flap
anatomic considerations, 102103
complications, 106107
patient selection, 102
postoperative care, 106
preoperative marking, 103
surgical technique, 103106
Peixoto ellipse-rectangle incision, 45
PEM. See Positron emission
Perfusion zones, 110111
Periareolar purse string closure
mastopexy, 41
Periareolar scar technique
with asymmetrical areola shape, 4041
circumareolar scar technique, 41
with symmetrical areola shape, 4041
Periprosthetic infection, 176
Permark micropigmentation system, 150
Pitanguy inverted-T incision, 44
Plastic surgeons, 7
Plavix. See Clopidogrel
Pneumothorax, 119
Poland syndrome, 1113
Polymastia, 910
injectable, 148149
Polythelia, 9, 11
Polythelia areolaris, 11

Polythelia pilosa, 11
Positional ptosis, 38
Positron emission mammography
(PEM), 2021
Post-mastectomy reconstructive surgery
medical history
breast-related history, 8283
medications, 82
neoadjuvant chemotherapy, 83
radiation, 83
smoking, 82
systemic illnesses, 82
physical examination
breast exam, 8384
chest wall, 84
donor sites, 84
obesity, 83
Profiled tissue expander, 88, 97
Pseudogynecomastia, 190
Pseudomamma, 11
Pseudoptosis, 38
Ptosis, 2829, 3334
classification, 38
inadequate in tissue expansion
reconstruction, 9799
Racquet mammoplasty, 60
Radiation oncologists, 99
Radiesse, 148
Radiologic evaluation
augmented breast, 2223
breast-specific gamma imaging
(BSGI), 2021
MRI technique, 1820
positron emission mammography
(PEM), 2021
reconstructed breast, 2324
surgically altered breast, 2122
ultrasound, 1819
X-ray mammography, 1618
RBRVS. See Resource Based Relative
Value Scale
Reconstructed breast, 2324
Reduction mammoplasty
breast anatomy
brassiere cup size and reduction
volumes, 49
innervation, 48
shapes and landmark
measurements, 4849
vessels and lymphatics, 48
in breast conservation therapy, 73
complications, 5455
free nipple grafting, 5354
indications, 4950
liposuction, 53
management strategies, 161163

surgical techniques
vertical scar, 53
Wise pattern, inverted-T, inferior
pedicle, 5052
Regnault-B shaped pattern, 43
Regnault traditional ptosis
classification, 38
Resource Based Relative Value Scale
(RBRVS), 197
Round tissue expander, 88
Rubens flap, 134135
Saline implants, 88
Sapphire Suction Reservoir, 96
Scarring, 161
Secondary deformities, 171
Seroma. See Hematoma
SIEA. See Superficial inferior epigastric
Sientra dual chamber expander, 88
Silicone implants, 63, 88, 96
Singulair, 94
Skate flap techniques, 142143
Skin necrosis, 63
Skin paddles, 141
Smoking, 82
Soft tissue fillers, 148149
SPAIR (short scar periareolar
inferior pedicle reduction)
mammoplasty, 42
SPY Elite Intraoperative Perfusion
Assessment System, 95, 97, 177
Staphylococcus aureus, 9293
Staphylococcus epidermidis, 94
Star flap techniques, 143144
Strattice, 177, 198
Strombeck inverted horseshoe, 44
Suction lipectomy, 194195
Superficial cellulitis, 9293
Superficial infections, 161
Superficial inferior epigastric artery
(SIEA) flap, 110, 125126
Superior gluteal artery perforator (SGAP)
flap, 126130
Supernumerary breast, 1011
Supranumerary nipples, 9
Surgically altered breast, 2122
Surgimend, 198
Symmastia, 160161
Systemic illnesses, 82
Tatooing, 149150
Terramycin, 94
Thoracodorsal artery perforator (TAP)
flap, 97, 134135
Thoracodorsal nerve, 6
Tissue expanders, 8789, 174177

Tissue expansion reconstruction

capsular contracture, 9395
expander deflation, failure, rupture, 96
hematoma, 9596
implant displacement, 95
infection, 9293
mastectomy flap ischemia, 95
rippling and contour deformities, 96
wound dehiscence, 96
filling expander, 9092
immediate vs. delayed reconstruction, 90
patient selection, 8990
crisp inframammary fold, 100
inadequate ptosis, 9799
insufficient skin and subcutaneous
tissue, 97
ptotic breast, 97
radiated, non-stretchable skin
envelope, 99
Transverse rectus abdominis myocutaneous
(TRAM) flap, 23, 199
autologous reconstruction, 157158
breast and abdominal aesthetic
complications, 120121
breast and abdominal technical
complications, 119120
general surgical complications, 117118
indications, 111113
microsurgical complications, 118119
nomenclature and classification, 110
performance, 113117
perfusion zones, 110111
Tuberous breast deformity, 1314
Ultrasound, 1819
Umbilical deformities and
necrosis, 180181
Unilateral gynecomastia, 190191
Vertical rectus abdominis muscle
(VRAM) flap, 109
Vertical scar technique, 4142, 53
Virginal breast hypertrophy. See Juvenile
Virginal hypertrophy, 47
Visible rippling, 96
Volume ptosis, 38
Volume replacement surgery, 6263
Wise pre-patterned curvilinear incision, 44
Womens Health and Cancer Rights
Act, 136, 201
Wound dehiscence, 96
X-ray mammography, 1618

Aesthetic and
Breast Surgery
Solving Complications
and Avoiding
Unfavorable Results
About the book
Breast surgery has important implications for a patients self image and
self esteem. Aesthetic procedures whether augmentation or reduction
remain among the most popular reasons for seeking elective surgery;
and reconstruction after surgery for cancer is an integral part of the
patients treatment and recovery process.
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. As such, this will be an
invaluable succinct guide that all surgical practitioners will want to have
as a ready reference before any consultation or procedure.

About the editors

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
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

Back cover illustrations by permission

of Dr Sheri Slezak and Dr Tripp Holton,
Dr Ada P Romilly, and Dr Mecker G Mller.