Aesthetic and Reconstructive Surgery of the Breast- E Book


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Drs. Hall-Findlay and Evans’ new Aesthetic and Reconstructive Surgery of the Breast has a purely surgical focus that covers the full scope of breast surgery. Coverage of hot topics includes new implant types, gel implants, fat injections to the breast for aesthetic enhancement, and fat injections for reconstruction.The book is organized into seven sections including reduction, mastopexy, augmentation, and more. Expert, international contributors deliver practical advice on the latest techniques, with a special emphasis on what can go wrong and how to avoid it. This full-color, templated reference comes with case studies and 16 video clips with approximately three hours of footage demonstrating key procedures. Video coverage includes form-stable high cohesive silicone gel implants, short scar with inferior pedicle, and sub-fascial breast augmentation. Expert Consult access enables you to search full text online and download images.

  • Get practical advice on handling problems that occur in both reconstructive and aesthetic surgery
  • Study various operative steps in depth with real-life clinical detail
  • Avoid and/or deal with complications by referencing case examples and analyses with expert international counsel



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Aesthetic and
Reconstructive Surgery of
the Breast
Elizabeth J. Hall-Findlay, MD FRCSC
Private Practice, Banff Plastic Surgery, Consulting Staff,
Mineral Springs Hospital, Banff, AB, Canada
Gregory R.D. Evans, MD FACS
Professor of Surgery and Biomedical Engineering, Chief,
Aesthetic and Plastic Surgery Institute, The University of
California, Irvine, Orange, CA, USA
Saunders Ltd.*
Front Matter
Elizabeth J. Hall-Findlay MD FRCSC Private Practice, Ban Plastic
Surgery, Consulting Staff, Mineral Springs Hospital, Banff, AB, Canada
Gregory R. D. Evans MD FACS Professor of Surgery and Biomedical
Engineering, Chief, Aesthetic and Plastic Surgery Institute, The University of
California, Irvine, Orange, CA, USA
Video Editor:
Kenneth K. Kim MD FACS Board Certi ed Plastic Surgeon, Beverly Hills,
Commissioning Editor: Sue Hodgson
Development Editor: Sharon Nash
Editorial Assistant: Kirsten Lowson
Project Manager: Frances Affleck
Design: Charles Gray
Illustration Manager: Merlyn Harvey
Illustrator: EPS Inc.
Marketing Manager (USA): Radha MawrieCopyright
An imprint of Elsevier Limited.
© 2010, Elsevier Limited. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or
by any means, electronic or mechanical, including photocopying, recording, or
any information storage and retrieval system, without permission in writing from
the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as
the Copyright Clearance Center and the Copyright Licensing Agency, can be found
at our website:
This book and the individual contributions contained in it are protected under
copyright by the Publisher (other than as may be noted herein).
Dr Joan Lipa retains the copyright to the images used in Chapter 9.
Dr Aldona Spiegel retains the copyright to the SIEA lm used in Chapter
Dr Craig Rubinstein retains the copyright to the images used in Chapter
Dr J. Peter Rubin retains the copyright to the video images
accompanying Chapter 41.
Knowledge and best practice in this , eld are constantly changing. As new
research and experience broaden our understanding, changes in research
methods, professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and
knowledge in evaluating and using any information, methods, compounds, or
experiments described herein. In using such information or methods they should
be mindful of their own safety and the safety of others, including parties for
whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identi, ed, readers are
advised to check the most current information provided (i) on procedures
featured or (ii) by the manufacturer of each product to be administered, to verify
the recommended dose or formula, the method and duration of administration,
and contraindications. It is the responsibility of practitioners, relying on theirown experience and knowledge of their patients, to make diagnoses, to determine
dosages and the best treatment for each individual patient, and to take all
appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors,
contributors, or editors, assume any liability for any injury and/or damage to
persons or property as a matter of products liability, negligence or otherwise, or
from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.
ISBN: 9780702031809
British Library Cataloguing in Publication Data
Aesthetic and reconstructive surgery of the breast.
1. Mammaplasty.
I. Hall-Findlay, Elizabeth J. II. Evans, Gregory R. D.
618.1′90592 – dc22
ISBN-13: 9780702031809
A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data
A catalog record for this book is available from the Library of Congress

Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1

P r e f a c e
When we were asked to create a breast book for Elsevier, we were both
concerned that this text had to have a di erent approach to similar books recently
released. We hope that we have done this.
Our purpose is to focus on breast surgery – all aspects – from aesthetic to
reconstructive. Instead of giving the reader variations on other texts, this book has
authors whose work is respected around the world. These authors have important
ideas to impart which will be very useful to plastic surgeons.
The book is outlined in several di erent sections and each chapter is designed to
follow a pattern which makes nding relevant information easy. We have tried to
include more controversial and future directions such as fat grafting and
alternatives to traditional breast reduction techniques.
It is our hope that this comprehensive breast book will give the reader some
broader insights into breast surgery along with a better understanding of
appropriate concepts and principles. Techniques are clearly outlined in both the
text and the illustrations to allow the reader to use this as a reference to improve
and alter their own assessment and surgical approach to the breast.
2010List of Contributors
Affonso Accorsi, Jr MD, Plastic Surgeon
Private practice
Rio de Janeiro
Siamak Agha-Mohammadi, BSc MB BChir PhD, Plastic
Hurwitz Plastic Surgery
Newport Beach
Jamil Ahmad, MD, Resident
Department of Plastic Surgery
University of Texas Southwestern Medical Center
Vicenzo Argencio, MD, Plastic Surgeon
Private practice
Rio de Janeiro
Yuko Asano, MD, Department of Plastic Surgery
The University of Tokyo
Hilton Becker, MD FACS FRCS, Private practice
Boca Raton
Thomas M. Biggs, MD, Clinical Professor of PlasticSurgery
College of Medicine
Baylor University
Kristin A. Boehm, MD FACS, Plastic Surgeon
Paces Plastic Surgery
James Boehmler, MD, Assistant Professor Plastic Surgery
Division of Plastic Surgery
The Ohio State University
Patricia A. Bortoluzzi, MD FRCS, Pediatric Plastic and
Reconstructive Surgeon
Hospital Sainte Justine
Craniofacial Clinic
Nathalie Bricout, MD, Plastic Surgeon
Member of the French Society of Plastic Reconstructive
and Aesthetic Surgery
Member of the National Academy of Surgery
Mitchell H. Brown, MD FRCSC, Associate Professor of
Plastic Surgery
Department of Surgery
University of Toronto
Charles E. Butler, MD FACS, Professor of Plastic Surgery
Department of Plastic Surgery
University of Texas
M.D. Anderson Cancer Center
Charbel Chalfoun, MD, Plastic Surgeon
Aesthetic and Plastic Surgery Institute
UC Irvine Medical Center
Bernard W. Chang, MD, Chief of Plastic Surgery, Mercy
Medical Center,
Associate Professor of Surgery, Johns Hopkins School of
Plastic and Reconstructive Surgery at Mercy
David W. Chang, MD FACS, Professor of Surgery
Department of Plastic Surgery
University of Texas M.D. Anderson Cancer Center
Ming-Huei Cheng, MD MHA, Associate Professor and
Chief Division of Reconstructive Microsurgery
Department of Plastic and Reconstructive Surgery
Chang Gung Memorial Hospital
Chang Gung Medical College
Chang Gung University
Xiamen Chang Gung Hospital
Brendan J. Collins, MD, Staff, Plastic and Reconstructive
Surgery Center at Mercy
Weinberg Center for Women’s Health & Medicine
Renee C. Comizio, MD, Assistant Professor of Surgery
Dartmouth Hitchcock Medical Center
Niamh Corduff, FRACS, The Jack Brockhoff
Reconstructive Plastic Surgery Research Unit
Royal Melbourne Hospital
Department of Anatomy and Cell Biology
University of Melbourne
Melissa A. Crosby, MD, Assistant Professor
Department of Plastic Surgery
The University of Texas
M.D. Anderson Cancer Center
Bruce L. Cunningham, MD MS, Professor of Surgery
Chief, Division of Plastic and Reconstructive Surgery
University of Minnesota
USAEmmanuel Delay, MD PhD, Head, Plastic and
Reconstructive Department
Centre Léon-Bérard
Joseph J. Disa, MD FACS, Associate Attending Surgeon
Plastic and Reconstructive Surgery Service
Memorial Sloan Kettering Cancer Center
Assistant Professor of Surgery
Weill Cornell Medical College
New York
Liron Eldor, MD, Fellow in Plastic Surgery
Institute For Reconstructive Surgery
The Methodist Hospital
Robyn Fio, MD, Resident Physician
Emory University
Gilbert P. Gradinger, MD FACS, Clinical Professor of
Division of Plastic and Reconstructive Surgery
University of California, San Francisco (UCSF), School of
San Mateo
Ruth M. Graf, MD PhD, Professor of the Plastic Surgery
Department of Hospital de Clínicas
Federal University of Paraná
Örjan Gribbe, MD PhD, Plastic Surgeon
Jeffrey A. Gusenoff, MD, Assistant Professor of Surgery
Division of Plastic and Reconstructive Surgery
University of Rochester Medical Center
Dennis C. Hammond, MD, Clinical Assistant Professor
Department of Surgery
Michigan State University College of Human Medicine
East Lansing
Associate Program Director
Plastic and Reconstructive Surgery
Grand Rapids Medical Education and Research Center
for Health Professions
Grand Rapids
Center for Breast and Body Contouring
Grand Rapids
Per Hedén, MD PhD, Associate Professor in Plastic
Charles K. Herman, MD FACS, Chief, Division of Plastic
and Reconstructive Surgery
Pocono Health SystemsEast Stroudsburg
Assistant Clinical Professor
Division of Plastic and Reconstructive Surgery
Albert Einstein College of Medicine
New York
Oscar Ho, MD, Plastic Surgery Resident
Dartmouth Hitchcock Medical Center
Jung-Ju Huang, MD, Department of Plastic and
Reconstructive Surgery
Chang Gung Memorial Hospital
Chang Gung Medical College
Chang Gung University
Dennis J. Hurwitz, MD FACS, Clinical Professor of
Surgery (Plastic)
University of Pittsburgh Medical Center
Attending Plastic Surgeon
Magee Women’s Hospital
Hurwitz Center for Plastic Surgery
Carolyn L. Kerrigan, MD FRCSC, Professor of Surgery
Chief and Residency Program Director
Section of Plastic Surgery
Dartmouth Hitchcock Medical Center
USALouise Caouette Laberge, MD, Pediatric Plastic Surgeon
Department of Surgery
University of Montreal
Chief of Plastic Surgery
Hospital Sainte Justine
Don Lalonde, MD FRCSC, Professor of Plastic Surgery
Dalhousie University
Saint John
Jan Lalonde, RN, CPN(C), CPSN, Saint John
Karen Lane, MD FACS, Clinical Director
UCI Breast Health Center
Joan E. Lipa, MD MSc FRCS(C) FACS, Associate Professor
Division of Plastic and Reconstructive Surgery
David Geffen School of Medicine at UCLA
Los Angeles
Frank Lista, MD FRCS(C), Medical Director
The Plastic Surgery Clinic
Albert Losken, MD, Assistant Professor
Emory Division of Plastic and Reconstructive Surgery
Jonathan D. McCue, MD, Plastic Surgery Resident
University of Minnesota
Mark Migliori, MD, Adjunct Assistant Professor of
University of Minnesota
A Aldo Mottura, MD PhD, Plastic Surgeon
Private Practice
Egle Muti, MD, Professor of Plastic Surgery
Department of Plastic Surgery
University of Turin
Foad Nahai, MD FACS, Clinical Professor of Plastic
Emory University
Paces Plastic Surgery
Maria Cecília Closs Ono, MD, Plastic Surgery Resident of
the Hospital de Clínicas
Federal University of Paraná
Brazil.Andrea L. Pusic, MD MHS FRCSC, Assistant Professor of
Plastic Surgery
Plastic and Reconstructive Service
Department of Surgery
New York
Charles Randquist, MD, Plastic Surgeon
Scott L. Replogle, MD, Private Practice
Replogle Plastic Surgery PC
Liacyr Ribeiro, MD, Plastic Surgeon
Private practice
Rio de Janeiro
Roberto Rocha, MD, Plastic Surgeon
Private practice
Rio de Janeiro
Craig Rubinstein, MBBS(Melb) FRACS(Plast) Master of
Surgery(Melb), Epworth Medical District
J Peter Rubin, MD, Director of Body Contouring Program
Associate Professor of Surgery
Division of Plastic Surgery
University of Pittsburgh
Kenneth C. Shestak, Professor of Plastic Surgery
University of Pittsburgh School of Medicine
Chief of Plastic Surgery
Magee Womens Hospital
Aldona J. Spiegel, MD, Director, Center for Breast
Assistant Professor, Cornell University
Institute for Reconstructive Surgery
The Methodist Hospital
Berish Strauch, MD FACS, Professor and Chairman
Division of Plastic and Reconstructive Surgery
Albert Einstein College of Medicine
New York
André Ricardo Dall’Oglio Tolazzi, MD MSc, Plastic
Member of the Brazilian Society of Plastic Surgery
Henry C. Vasconez, MD FACS FAAP, Professor of Surgery
and Pediatrics, Chief of Plastic Surgery
Division of Plastic Surgery
KY Clinic
USAPaul R. Weiss, MD, Clinical Professor of Plastic Surgery
Albert Einstein College of Medicine
New York
Elisabeth Würinger, MD, Plastic Surgeon
Private Practice
Kotaro Yoshimura, MD, Assistant Professor
Department of Plastic Surgery
University of Tokyo School of Medicine
Toni Zhong, MD FRCSC, Clinical Fellow in Microsurgery
and Reconstructive Surgery
Plastic and Reconstructive Surgery Service
Memorial Sloan Kettering Cancer Center
New York
Dedication from Elizabeth Hall-Findlay
To my three children, Jamie, David and Elise, who have become truly enjoyable
young adults.
Dedication from Gregory Evans
To Ruth, Brandon and Brogan – Thank you for your continued love, support
and patience. You make it all worthwhile.
A c k n o w l e d g m e n t s
To my partners for their tireless contributions and to my mentors for their
wisdom and teaching.
I would like to thank my sta for all their support. I have appreciated all those
who have challenged me both in my thinking and my performance.
E H - FTable of Contents
Instructions for online access
Front Matter
List of Contributors
Chapter 1: History and Anatomy
Part 1: Breast Reconstruction
Chapter 2: Oncologic Considerations for Breast Reconstruction
Chapter 3: Adjuvant Therapy and Breast Reconstruction
Chapter 4: Expanders and Breast Reconstruction with Gel and Saline
Chapter 5: Latissimus Dorsi Flap Breast Reconstruction
Chapter 6: TRAM Flap Breast Reconstruction
Chapter 7: TRAM Flap Variations in Breast Reconstruction
Chapter 8: Muscle-Sparing and Free TRAM Flap Breast Reconstruction
Chapter 9: DIEP Flap Breast Reconstruction
Chapter 10: SIEA Flap Breast Reconstruction
Chapter 11: Gluteal Flap Breast Reconstruction
Chapter 12: Fat Injections to the Breast: The Lipomodeling Technique
Part 2: Breast Reduction
Chapter 13: An Overview of the Modern Era of Breast Reduction
Chapter 14: The Central Septum in Breast Reduction and Mastopexy
Chapter 15: Breast Reduction with a Central MoundChapter 16: Subglandular Breast Reduction
Chapter 17: No Vertical Scar Breast Reduction and Mastopexy
Chapter 18: Inferior Pedicle Breast Reduction Using a Circumvertical
Chapter 19: Superomedial Pedicle Breast Reduction Using a Vertical
Chapter 20: Superior and Medial Pedicle Breast Reduction Using a
Vertical Pattern
Chapter 21: Superolateral Pedicle Breast Reduction with Vertical and
Inverted T Patterns
Part 3: Augmentation
Chapter 22: Saline Implants: Getting a Good Result
Chapter 23: Highly Cohesive Textured Form Stable Gel Implants:
Principles and Technique
Chapter 24: Form Stable Shaped High Cohesive Gel Implants
Chapter 25: Subfascial Breast Augmentation
Chapter 26: Fat Injections
Part 4: Mastopexy and Mastopexy-Augmentation
Chapter 27: Primary and Secondary Mastopexy-Augmentation
Chapter 28: Circumvertical Breast Reduction and Mastopexy
Chapter 29: Rotation Mastopexy
Chapter 30: Superior Pedicle Extension Mastopexy
Chapter 31: Superomedial Pedicle Extension Mastopexy
Chapter 32: Inferior-central Flap Mastopexy with Pectoralis Strip
Chapter 33: Periareolar V-T Parachute Mastopexy
Chapter 34: Mastopexy after Implant Removal
Part 5: Developmental Breast Deformities
Chapter 35: Adjustable Breast Implants for Asymmetry and Ptosis
Chapter 36: Breast Asymmetries
Chapter 37: Inferior Flaps for Tuberous Breasts
Chapter 38: Local Flaps for Tuberous and Asymmetric Breasts
Chapter 39: Correction of Breast Asymmetry in TeenagersChapter 40: Surgery of the Breast in Poland’s Syndrome
Part 6: Breast Reshaping after Massive Weight Loss
Chapter 41: Dermal Suspension and Parenchymal Breast Reshaping
after Massive Weight Loss
Chapter 42: Autologous Flap Use in Breast Reshaping after Massive
Weight Loss
History and Anatomy
Gregory R.D. Evans and Elizabeth J. Hall-Findlay
Breast Reconstruction
Breast cancer diagnosis and management have always been an issue in society. If
Cleopatra had developed breast cancer, it would have been treated with cauterization in
the hope of burning out the disease.
Even when breast cancer could be diagnosed, treatment was prevented by a lack of
adequate anesthesia. William Halsted would not have been able to develop his radical
mastectomy procedure without the advent of anesthesia. Unfortunately, breast cancer
recurrence presented in spite of this disfiguring and invasive operation.
In the 1970s most breast surgeons began to favor the modi- ed radical mastectomy
when they realized that removing the pectoralis muscle did not improve the outcome.
This became the gold standard for breast cancer treatment and any suggestions of an
even more ‘modified’ approach were met with derision.
Finally, surgeons began to accept that segmental resections and lumpectomies
combined with chemotherapy and radiation offered realistic alternatives.
Patient requests were rarely considered in the past, but surgeons can now o2er patients
several di2erent options that suit their disease, their genetic and family predisposition
status, their own self body image, and their personal lifestyles.
Initially, diagnosis and treatment were aggressively combined so that patients had their
biopsies booked as possible mastectomies and lymph node dissections. Today, core
sampling can establish the diagnosis and imaging and sentinel node biopsy can further
clarify the extent of the disease.
Chemotherapy can be given before and/or after de- nitive treatment and radiation and,
if used, can be given before or after the reconstruction. Surgery, chemotherapy, and
radiation decisions are not separate issues but can be combined to suit the disease and
patient desires.
Reconstruction following breast cancer was slow to develop. In fact today, even though
our options for reconstruction are multiple and women have signi- cant choices, only
about one-third of the women seeking surgical options for their breast cancer seek
reconstruction. Probably the most common method of reconstruction today occurs with
the placement of a silicone or saline implant. Reconstruction options today are numerous
and there is no correct answer. This is so di2erent from the days when anyone who
questioned radical mastectomy was treated as a pariah. Reconstruction was not evendiscussed back then as a future possibility.
The evolution of the use of autogenous tissue led to more options for women seeking
reconstruction. Further, some women concerned about the use of implants turned to
autogenous reconstruction as a viable alternative. Numerous techniques have evolved to
allow for reconstruction using natural tissues. The earliest utilized muscles to provide
blood 7ow to the skin and create a breast mound. The latissimus dorsi 7ap was the most
popular form of autogenous tissue reconstruction in the 1970s. Although there are
currently still limitations to this form of reconstruction, this option is still utilized today
1-5for patients seeking improved reconstructive outcomes.
In 1982 the - rst transverse rectus abdominis 7ap (TRAM) 7ap procedure was
performed. This transfer of the lower abdominal muscle, fat, and tissue improved the
shape of the breast and allowed a more acceptable donor site for autogenous breast
reconstruction. The 7ap has remained a workhorse for reconstruction but is still
complicated by issues related to blood supply and donor site morbidity. As microsurgical
techniques evolved, our ability to improve the vascular supply of the TRAM 7ap also
increased. As our microsurgical skills improved, further re- nements of 7ap harvest were
performed. The goal was to continue to decrease the potential for donor site morbidity.
Initial attempts included techniques of muscle sparing. This allowed the harvest of part of
the rectus muscle while sparing other components, leaving the rectus muscle intact in
certain locations. Perforator 7aps were introduced in the late 1990s and early 2000s as a
mechanism to decrease the abdominal donor site morbidity. The deep inferior epigastric
perforator 7ap and the super- cial inferior epigastric 7ap allowed transfer of these
autogenous tissues while sparing the harvest of the rectus abdominis muscle. With
improved microsurgical skills, additional locations for reconstruction were examined. The
gluteal artery perforator 7ap allows the use of skin from the buttocks. The gracilis
myocutaneous 7ap allows the use of skin and a portion of muscle from the inner thighs.
The latissimus dorsi was again utilized without harvesting of muscle to supply bulk in the
1-5creation of a breast mound.
Issues today still concern primarily control of the disease. Treatment now needs to be
integrated with various reconstructive decisions, coverage and types of implants when
used, as well as treatment of the skin envelope (excision, skin sparing, mastectomy, and
even nipple-sparing mastectomy).
Plastic surgeons were seeking new options because some of the initial procedures were
disappointing. Now plastic surgeons have a vast array of options available, but there is
still resistance from the general surgeons and oncologists. Not enough patients are being
given the opportunity to participate in decision making and they are not being presented
with all the treatment and reconstructive options available.
Breast Reduction
It has long been recognized that overly large breasts can be a signi- cant burden for
women. Treatment was delayed until the advent of anesthesia.
Initially, amputation techniques were used because they were relatively simple andstraightforward. Surgeons began to understand that resection of parenchyma and skin
should be designed to preserve nipple and areolar circulation. Numerous techniques were
described over the years to reduce bulk, preserve the nipple and achieve an aesthetically
desirable effect. Preservation of sensation and breast feeding potential were secondary.
No perfect design was achieved, but plastic surgeons persisted in trying to improve the
cosmetic results while maintaining some of the successes achieved in the past with
combining resection with preservation of nipple viability. Surgeons attempted to reduce
scars while achieving a good shape and today the controversy persists as to which
procedure or technique is superior.
As with many other decisions in plastic surgery, the answer comes down to surgeon
experience and comfort along with individual patient indications and desires.
The history of mastopexy surgery follows that of breast reduction. Plastic surgeons need
to be able to combine lifting of the breast parenchyma with a reduction of the skin
envelope while still preserving nipple and areolar viability.
There has long been controversy over the use of skin and dermis as a brassiere versus
suture techniques in the parenchyma to hold up the breast. This issue has not been
Breast Augmentation
Patients have long desired an augmentation in breast size because of inadequate
development, asymmetry, or loss of volume after pregnancy.
Breast implants were - rst introduced in the 1960s and numerous shells and - llers have
been tried over the years. Some have been more successful than others in providing a
good shape, acceptable consistency and long lasting results. The FDA in the United States
placed a moratorium on silicone gel - lled breast implants in the 1990s, and for over 10
years Americans were restricted to using saline-- lled implants. The ban was lifted when
studies were finally accepted showing that silicone did not cause disease.
Surgical techniques for breast augmentation are as varied as those for reconstruction
and reduction. No one technique has proven to be superior. Incision location and implant
placement continue to be debated. Implants can be placed above the muscles or in
numerous variations under the muscle. Even subfascial placement has its advocates.
It became accepted over the years that direct injection of even medical grade silicone
was contraindicated because of migration and interference with both clinical diagnoses
and imaging techniques. Injection of various non-medical substances by non-physicians
(such as paraA n and various oils) was a disaster. These days, however, fat injections are
not only becoming acceptable, but proper techniques are proving them to be clinically
viable. The initial prohibition against fat injection because of the possibility of interfering
with diagnosis is being recognized as a non-issue. Mammographers are now consistently
saying that any sequelae of fat injections are not diA cult to distinguish from more
ominous finding suggestive of malignancy.Mastopexy–Augmentation
All of the controversies surrounding mastopexy procedures and breast augmentation
techniques are magni- ed when both are combined. Potential complications are increased
and the surgery is less straightforward.
Lifting the breast tissue and adding an implant are processes that work against each
other, especially over time. The same controversies about skin brassieres and suture
techniques are continuing.
The history of breast surgery is not simple. New techniques are sometimes embraced
too quickly (soybean oil - lled implants) and some standard techniques are only slowly
being adopted (the general surgery resistance to reconstruction). We can look at history
to give us perspective and to help us continue to search for solutions to unsolved
The adult female breasts lie on each side of the anterior thorax with their bases extending
1-8from about the second to sixth ribs. The breasts lie on a substantial layer of fascia
overlying the pectoralis major muscle superomedially, the serratus anterior muscle in the
lower third, and the anterior rectus sheath in the lower medial area. Although these
appear to be the boundaries of the breast, the duct system often extends more widely
than this. In about 15% of the cases, breast tissue extends below the costal margins. It is
critical when performing breast reconstruction that the inframammary fold is maintained
or at least identi- ed and reconstructed if surgical removal of additional breast tissue
below this fold is required. Considerable asymmetry is frequently found among normal
women and the patient may not be aware of this asymmetry or may accept this as a
normal variant. This is important to point out to the patient as autogenous reconstruction
with preservation of the skin envelope may lead to further asymmetry postoperatively.
One-half of the women have a volume di2erence of 10% or more and one-quarter have a
1volume difference of 20% or greater (Fig. 1.1).
Fig. 1.1 Anterior view of breast.
From Drake RL, Vogl AW, Mitchell AWM, et al. Gray’s atlas of anatomy. Edinburgh: Churchill
Livingstone; 2008.
The precise position of the nipple–areola complex varies widely with the fat content of
the breast and the age of the patient. In the nulliparous breast, the nipple position lies
2approximately 19–21 cm from the sternal notch. The amount of fat within the breast
varies widely, as one would expect. The intimacy with which it is mixed with glandular
tissue also varies. Microscopic examination demonstrates that the nipple is composed of
the terminal ducts with a supporting stroma of smooth muscle that are mainly arranged
in a circular fashion with a few arranged radially. Contraction of the circular muscles
causes nipple projection; contraction of the radial fibers causes retraction.
Breast tissue consists of lobes separated from each other by fascial envelopes, usually
15–20 in number. Each lobe is drained by a ductal system from which a lactiferous sinus
opens on the nipple and each lactiferous sinus receives up to 40 lobules. Each lobule
contains 10–100 alveoli which comprise the basic secretory unit (Fig. 1.2).
Fig. 1.2 Lateral view and sagittal section of breast.
From Drake RL, Vogl AW, Mitchell AWM, et al. Gray’s atlas of anatomy. Edinburgh: Churchill
Livingstone; 2008.
The blood supply is from the axillary artery via its thoracoacromial, lateral thoracic
and subscapular arteries, and from the subclavian artery via the internal thoracic artery.
The internal thoracic artery supplies the three large anterior perforating branches
through the second, third and fourth intercostal spaces. The veins form a rich subareolar
plexus and drain to the intercostals and axillary veins and to the internal thoracic veins
(Fig. 1.3).Fig. 1.3 Left, arteries and innvervation of breast. Right, lymphatic drainage of breast.
From Drake RL, Vogl AW, Mitchell AWM, et al. Gray’s atlas of anatomy. Edinburgh: Churchill
Livingstone; 2008.
The lymphatic drainage of the breast is of great importance in the spread of malignant
disease. Several lymphatic plexi issue from the parenchymal portion of the breast and the
subareolar region which drain to the regional lymph nodes, the majority of which lie
within the axilla. Most of the lymph from each breast passes into the ipsilateral axillary
nodes along a chain which begins at the anterior axillary nodes and continue into the
central axillary and apical nodal groups. Further drainage occurs into the subscapular
and interpectoral node groups. A small amount of lymph drains across to the opposite
breast and also downward into the rectus sheath. Some of the medial part of the breast is
drained by lymphatics, which accompany the perforating internal thoracic vessels and
drain into the internal thoracic groups of nodes in the thorax and into the mediastinal
3nodes (Fig. 1.3).
The innervation of the breast is principally by somatic sensory nerves and autonomic
nerves accompanying the blood vessels. In general, the areola and nipples are richly
supplied by somatic sensory nerves while the breast parenchyma is mostly supplied by
autonomic nerves, which appear to be solely sympathetic. No parasympathetic activity
has been demonstrated in the breast. Detailed histological examination has failed to
demonstrate any direct neural end terminal connections with breast ductal cells or
myoepithelial cells, suggesting that the principal control mechanisms of secretion and
milk ejections have a humoral rather than nervous mechanism. (Although personal
experience would intuitively be in con7ict with this statement. EH-F) It appears that theareolar epidermis is relatively poorly innervated whereas the nipple and lactiferous ducts
are richly innervated. The somatic sensory nerve supply is via the supraclavicular nerves
(C3, C4) superiorly and laterally from the lateral branches of the thoracic intercostal
nerves. The medial aspects of the breast receive supply from the anterior branches of the
thoracic intercostal nerves which penetrate the pectoralis major to reach the breast skin.
The major supply of the upper outer quadrant of the breast is via the intercostobrachial
nerve (C8, T1), which gives a large branch to the breast as it traverses the axilla (Fig.
The fascial framework of the breast is important in relation to clinical manifestations of
disease and surgical technique. Ligaments of Cooper provide the supporting framework to
the breast lobes. The skin overlying the breast has been shown to vary in thickness from
0.8 mm to 3 mm on mammograms of normal breasts and tends to decrease
proportionally with increasing breast size.
Although these anatomical points are well delineated, they may change throughout the
woman’s lifetime. Development of the breast during reproductive life, menstrual cycle,
pregnancy, and postlactational involution can change the basic structure of breast tissue.
The breast is a complex organ that undergoes multiple changes throughout a woman’s
life based on hormonal and temporal variations. This complex organ, however,
establishes the femininity identi- ed with women. Our e2orts to reconstruct and restore
form and function can maintain this feminine identity.
1 Harcourt DM, Rumsey NJ, Ambler NR, et al. The psychological effect of mastectomy with
or without breast reconstruction: a prospective, multicenter study. Plast Reconstr Surg.
2 Brandberg Y, Malm M, Blomqvist L. A prospective and randomized study, ‘SVEA,’
comparing effects of three methods for delayed breast reconstruction on quality of life,
patient-defined problem areas of life, and cosmetic result. Plast Reconstr Surg.
3 Breuing KH, Warren SM. Immediate bilateral breast reconstruction with implants and
inferolateral AlloDerm slings. Ann Plast Surg. 2005;55(3):232-239. PMID: 16106158
4 Salzberg CA. Nonexpansive immediate breast reconstruction using human acellular tissue
matrix graft (AlloDerm). Ann Plast Surg. 2006;57(1):1-5.
5 Garramone CE, Lam B. Use of AlloDerm in primary nipple reconstruction to improve
longterm nipple projection. Plast Reconstr Surg. 2007;119(6):1663-1668.
6 Loughry CW, Shelffer DB, Price TE, et al. Breast volume measurments in 598 women using
biostereometric analysis. Ann Plast Surg. 1989;22:380-385.
7 Westreich M. Anthropomorphic breast measurements: protocol and results in 50 women
with aesthtically perfect breasts and clinical application. Plast Reconstr Surg.
8 Suami H, Pan WR, Mann GB, et al. The lymphatic anatomy of the breast and its
implications for sentinel lymph node biopsy: a human cadaver study. Ann Surg Oncol.2008;15:863-871.
Further Reading
Bostwick J. Plastic and reconstructive breast surgery. St. Louis MO: Quality Medical Publishing;
Drake RL, Vogl AW, Mitchell AWM, et al. Gray’s atlas of anatomy. Edinburgh: Churchill
Livingstone; 2008.
Mansel RE, Webster DJT, Sweetland HM. Benign disorders and diseases of the breast, 3rd ed.
New York: Saunders; 2009.
Moses KP, Banks JC, Nava PB, et al. Atlas of clinical gross anatomy. St. Louis: Mosby; 2005.
Standring S, et al. Grays anatomy, 40th ed. Edinburgh: Churchill Livingstone; 2009.Part 1
Breast Reconstruction

Oncologic Considerations for Breast
Charbel Chalfoun, Karen Lane
Breast cancer currently a ects one in eight women in the United States. A diagnosis
of breast cancer presents the patient not only with physical challenges but
emotional concerns with respect to body image and sexuality. With improved
screening and early detection, approximately 80% of these women present with
small tumors that are amenable to breast conservation. Until the 1970s, breast
cancer was treated with radical mastectomy involving removal of the breast,
axillary lymph nodes, and pectoralis muscle. This was extremely dis guring for
patients and did not lend itself to optimal reconstructive options. In the 1970s,
modi ed radical mastectomy was introduced, which preserved the pectoralis
muscle and improved the contour of the chest wall, as well as increased the
reconstructive possibilities. In the 1980s, a large randomized study conducted by
the National Surgical Adjuvant Breast and Bowel Project (NSABP) was able to
prove that breast conservation plus radiation had equivalent outcome to
Since that time, breast conservation has become increasingly popular. As a
personal choice, however, some patients with small tumors still opt for mastectomy.
Many of these women are resistant to radiation as part of therapy and seek to avoid
that by choosing mastectomy. For women with recurrent or multifocal cancer, or a
history of radiation therapy to the breast, mastectomy remains the gold standard.
With the discovery of the BRCA genes and the up-to 85% lifetime incidence of
breast cancer associated with a gene mutation, women carrying a BRCA mutation
often opt for bilateral prophylactic mastectomies. Women with a diagnosis of
breast cancer that are found to carry a BRCA mutation are usually o ered bilateral
mastectomies at the time of diagnosis. It is clear, that in certain cases, mastectomy
is the best surgical option for a subset of patients, and the development of
improved breast reconstruction techniques has signi cantly reduced the
psychological stress faced by patients who often see mastectomy as losing a part of
their body image. It is critical that all breast cancer patients who require a
mastectomy are given the opportunity to consult with a plastic surgeon to discuss
reconstructive options. This chapter will address the oncologic considerations for'

women who opt for breast reconstruction.
Background on the Diagnosis and Treatment of Breast Cancer
Breast cancer may initially present as a mammographic nding or a palpable mass.
It is always optimal to obtain a tissue diagnosis with a core needle biopsy rather
than an open excisional biopsy if at all possible. In this way the diagnosis can be
discussed with the patient prior to any surgical procedures and also no unnecessary
incisions are made in the breast or tissue removed that might impact both the
oncologic and cosmetic outcome. All of our new breast cancer patients undergo
breast magnetic resonance imaging (MRI). This is much more sensitive than
mammogram in measuring the extent of disease as well as multifocal or
contralateral breast cancer. This information is important as it a ects the surgical
recommendations for patients.
Up until the 1970s, breast cancer was treated with radical mastectomy, which
involved removal of the breast, pectoralis muscle, and axillary lymph node levels I
to III. This was quite dis guring for the patient and so in the 1970s, modi ed
radical mastectomy came in to use, which preserved the pectoralis muscle, thereby
improving somewhat the contour of the chest wall. In addition, only level I and II
axillary lymph nodes were removed, which reduced the incidence of lymphedema
in these patients. In the 1980s breast conservation (lumpectomy or partial
mastectomy) combined with radiation therapy to the breast was found to be
equivalent in survival to modi ed radical mastectomy. Today, approximately 80%
of patients are found to be candidates for breast conservation.
In the 1990s, the technique of sentinel lymph node dissection was adopted in
e orts to spare women with negative lymph nodes the morbidity of a full axillary
lymph node dissection. The technique involves injecting radiolabeled colloid
and/or lymphazurin blue dye into the breast and allowing it to travel to the
axillary lymph nodes. All the radioactive and/or blue lymph nodes are removed
and, in our institution, evaluated by frozen section. If these sentinel lymph nodes
do not contain tumor on frozen section, then the patient is spared a complete
axillary lymph node dissection. If the frozen section does reveal cancer in the
sentinel lymph nodes, then a complete axillary lymph node dissection is performed
during the same operation. If a patient has clinically positive lymph nodes before
surgery, a sentinel lymph node dissection is not performed and the patient
undergoes a complete axillary lymph node dissection.
Timing of Reconstruction
Although many patients are able to be treated with breast conservation, a subset of
patients will either require a mastectomy or choose mastectomy as their surgical
option. For these patients, the plastic surgeon is critical in helping the patient'


determine whether they wish to have breast reconstruction. However, controversy
exists regarding the timing of breast reconstruction – immediate versus delayed.
Immediate reconstruction employs the skin-sparing mastectomy technique that was
1developed by Toth and Lappert in 1991 and o ers several advantages. The
reconstructed breast has an improved cosmetic outcome following immediate
reconstruction due to preservation of the skin envelope. Psychologically, the patient
wakes up with a breast mound rather than a : at chest wall. The patient has one
hospital stay and one anesthetic for the majority of the surgery followed by
additional outpatient procedures for revisions, nipple reconstruction, etc. The
skinsparing mastectomy technique has been evaluated from an oncologic perspective
and there does not appear to be any increased risk for local or distant
2-7recurrence. Rozen et al performed a Medline literature review to evaluate the
psychosocial need for immediate breast reconstruction and the issues surrounding
oncologic safety. The authors’ review of previous studies concluded that immediate
reconstruction does not increase local recurrence rates and does not delay the
initiation of adjuvant chemotherapy or radiation. There was not a higher rate of
complications in the setting of chemotherapy although there was a higher rate of
complications in patients receiving adjuvant radiation therapy. Immediate breast
reconstruction did have a positive e ect on psychosocial outcomes including
depression, anxiety, body image, self-esteem, self-image, emotional function, social
8function and sexual function.
The oncologic safety of immediate reconstruction was also reviewed by Taylor et
9al. This was also a literature review and included analysis of 84 papers. The
authors’ analysis concluded that there was not an increased risk of local or distant
recurrence (although the studies reviewed were small and retrospective), and that
detection of recurrence was not impaired by immediate reconstruction. In addition,
no delay in the delivery of adjuvant chemotherapy was identi ed. With respect to
radiation, there was a signi cantly higher rate of complications (capsular
contracture, implant rupture, wound infections) in patients undergoing
mastectomy and expander or implant placement who had radiation before or after
reconstruction. With respect to autologous tissue reconstruction, complication rates
were similar between patients undergoing radiation followed by TRAM
reconstruction versus patients undergoing immediate reconstruction followed by
radiation. However, fat necrosis and : ap volume loss were more common in the
9immediate reconstruction group.
As outlined above, there are several concerns regarding immediate
reconstruction. The major issue involves postmastectomy radiation, which will be
discussed in greater detail in the following section. Immediate reconstruction still
may be undertaken in patients who will more than likely require postmastectomy
radiation. However, the oncologic surgeon and plastic surgeon need to discuss this'

preoperatively and inform the patient of the possible cosmetic sequelae from this
approach. Another concern regarding immediate reconstruction is the possibility of
delay in adjuvant chemotherapy. If a patient undergoes autologous tissue
reconstruction and develops postoperative wound complications, the chemotherapy
may need to be delayed until the wound problems are resolved. Although the
studies detailed above have not found any signi cant delays in adjuvant
chemotherapy, it is unknown what type of impact this might have on a patient’s
overall survival. In our practice, many of our patients with Stage II and certainly
Stage III breast cancer, undergo neoadjuvant chemotherapy, which negates this
concern. We feel that most patients should be considered for immediate
reconstruction and that this should be a joint decision made by the oncologic
surgeon, plastic surgeon, and patient. In: ammatory breast cancer, with its poor
prognosis and rapidity of recurrence, is a subtype of breast cancer that should not
be considered suitable for immediate reconstruction. Additionally, patients with
locally advanced breast cancer who do not undergo neoadjuvant therapy, or those
with a poor response to chemotherapy, may also need to delay their reconstruction.
Delayed reconstruction is a more commonly employed technique. These patients
typically complete their adjuvant therapy and then are evaluated by plastic
surgeons for their reconstruction options. The advantage to this approach is that
the nal pathology is known prior to any reconstructive procedures. If any
additional surgery is required, this can be undertaken without the anatomic or
technical considerations that would result following reconstruction. Patients have
time to consider whether or not they want reconstruction without the uncertainty
of their stage of disease and following completion of therapy. They are able to use a
prosthesis and decide if that is adequate for them.
The disadvantages are the advantages stated above for immediate
reconstruction: possible inferior cosmetic result, additional anesthetic/hospital stay
and the psychological distress of absence of a breast. Postmastectomy radiation
does impact the outcome of the reconstruction and needs to be discussed with the
Postmastectomy Radiation
Current recommendations for postmastectomy radiation include four or more
positive lymph nodes or advanced tumors (T3, T4, skin involvement). Close or
positive margins are another indication for postmastectomy radiation. Based on
recent Danish and Canadian trials, postmastectomy radiation for patients with one
to three positive lymph nodes is becoming more common and therefore the overall
10-12use of postmastectomy radiation is increasing. The radiation may adversely
a ect the cosmetic outcome of the immediate reconstruction (Fig. 2.1) and there is
some concern that the reconstructed breast may result in technical diB culties in'
the delivery of radiation therapy. This includes increased doses of radiation to the
lungs or reduced radiation delivery to the internal mammary lymph nodes. If
breast reconstruction is delayed until after radiation, however, the mastectomy skin
is often compromised, and the shape of the native breast skin envelope lost.
Delayed breast reconstruction with implants following postmastectomy radiation
can result in wound healing problems, capsular contracture with subsequent
10implant displacement, and painful constriction against the chest wall. Many
plastic surgeons will opt for autologous tissue when delayed reconstruction after
radiation is performed.
Fig. 2.1 Radiated TRAM reconstruction.
To address this problem, surgeons at MD Anderson have described and published
their experience with a two-stage approach that they have termed
‘delayedimmediate reconstruction.’ Stage 1 consists of a skin-sparing mastectomy with
subpectoral insertion of a completely lled saline tissue expander to preserve the
shape of the breast skin envelope. After review of the nal pathology, patients who
do not need radiation undergo immediate reconstruction within two weeks from
the time of mastectomy (Stage 2). Patients who require radiation undergo therapy
with the expander de: ated to the chest wall. After radiation is complete, patients
13undergo re-expansion of the preserved breast skin.
Nahabedian and Momen analyzed the local recurrence rate and survival of
patients undergoing radiation therapy either before or after breast reconstruction.
The patient cohort included 146 women who underwent breast reconstruction and
radiation with a follow-up of at least 12 months. Tumor recurrence, survival, loss of
14implant and total : ap necrosis were analyzed. The 59 women who underwent
radiation after breast reconstruction had a higher local recurrence rate versus the
87 women who underwent radiation therapy prior to breast reconstruction (27%
versus 15%). In addition there was a higher loss of life in the group undergoing'

breast reconstruction before radiation versus the group undergoing reconstruction
after radiation (12% versus 7%). This raises concerns regarding the potential
impact of immediate reconstruction on radiation delivery. This is a small study and
it is diB cult to draw de nitive conclusions from this data. These questions may be
better answered by a prospective trial.
B R C A Positive Patients
Women who carry a BRCA1 or BRCA2 mutation have an up-to 85% chance of
developing breast cancer in their lifetime. In addition, there is up to a 65%
cumulative lifetime risk that these women will develop ovarian cancer. The
management of these women involves a multidisciplinary approach among breast
surgeons, plastic surgeons and gynecologists. While many of the patients opt for
aggressive clinical follow-up including physical exams, breast MRI, pelvic
ultrasounds, serum CA-125 levels and possibly tamoxifen, prophylactic surgery is a
reasonable approach that is e ective in signi cantly reducing the risk of breast and
ovarian cancer.
In these women who choose prophylactic surgery, consideration should be given
to a coordinated approach for the mastectomies and bilateral
salpingooophorectomies (BSO). Batista et al identi ed 12 patients who underwent
combined mastectomies and BSO between 1996 at 2003. Ten of these patients
underwent bilateral autologous tissue reconstruction. Six of these ten patients also
underwent total abdominal hysterectomy during the same procedure. In this small
retrospective study, there were no signi cant complications related to the
15gynecologic procedures. Therefore, it is important that these patients are cared
for by a multidisciplinary team who can determine whether a combined approach
is feasible.
Many of the BRCA positive patients are quite young, and given this is a
prophylactic procedure, they are most concerned with the cosmetic results. In this
group, it is critical that the plastic surgeon be able to offer these women any and all
reconstructive options. This should include autologous tissue reconstruction with
latissimus dorsi, transverse rectus abdominis, or possibly gluteal : aps. Tissue
expanders or immediate implant placement are other options to discuss. These
patients need to be counseled that based on their genetic predisposition, there is a
chance that occult cancer will be found at the time of surgery. Therefore, all these
patients should receive preoperative MRI to look for abnormalities and bilateral
axillary sentinel lymph node dissections at the time of mastectomies. It is critical
that the patient and her oncologic and plastic surgeons discuss this preoperatively
in case adjuvant therapy is required that might impact the reconstruction
Many patients have a strong family history of breast cancer but test negative for
the BRCA mutation. This could mean that they have another hereditary cancer
syndrome such as Cowden or Li–Fraumeni, or carry a genetic mutation that has not
yet been discovered. Further, some patients have watched relatives undergo breast
cancer treatment and possible recurrence and wish to have prophylactic surgery to
reduce their risk as much as possible. In these patients, it is important to have a
long discussion about prophylactic surgery and the reconstructive options. If the
patient elects to pursue this option, then it is reasonable to have them meet with
the plastic surgeon. All patients need to know that mastectomy removes
approximately 97% of the breast tissue not 100% of the breast and so they will still
need clinical exams in follow-up for the small amount of tissue remaining.
Young Patients Considering Future Child-Bearing
Young women with breast cancer present additional challenges with respect to
surgical options and reconstruction. Some of these patients will carry a BRCA
mutation and may consider undergoing bilateral prophylactic mastectomy as
discussed earlier. There also exists the issue of future pregnancy after autologous
tissue reconstruction. Collin and Coady reported a case of a 33-year-old female who
underwent a free transverse rectus abdominis myocutaneous (TRAM)
reconstruction and subsequently became pregnant 1 year later. She was able to
successfully carry her infant to term without any abdominal wall complications
16including width of donor site scar. Patients need to be counseled about the
potential risks of pregnancy after TRAM including fascial tears, herniation, and
scar widening. The exact safe time interval between TRAM and pregnancy is
unknown. For breast cancer patients, we generally advise them to wait 2 years post
treatment prior to considering pregnancy.
Locally Advanced Breast Cancer/Inflammatory Breast Cancer
Many patients have concerns regarding the oncologic safety of immediate
reconstruction in the face of locally advanced breast cancer. This was addressed in
a study by Newman et al, in which 540 patients undergoing immediate
reconstruction following mastectomy were evaluated. Fifty of these patients had
locally advanced breast cancer and all underwent postoperative chemotherapy.
Forty percent of these patients underwent postoperative radiation therapy. At
median follow-up of 58.5 months, there was no di erence in local or distant
recurrence between these 50 patients and 72 matched controls with locally
17advanced breast cancer who did not undergo reconstruction.
In today’s paradigm, most patients with locally advanced breast cancer are
treated with neoadjuvant chemotherapy. This allows not only for evaluation of how
the chosen chemotherapy regimen is working on a patient’s particular tumor type,
but it may shrink the tumor such that subsequent surgery is technically easier to

perform. It also eliminates the concern about postoperative wound complications
delaying the delivery of chemotherapy. Patients who develop wound infections or
18necrotic tissue must be completely healed prior to commencing chemotherapy.
In patients with aggressive tumors, this can lead to concern regarding spread of
In: ammatory breast cancer is a very aggressive subtype of cancer with
involvement of the dermal lymphatics. Despite multi-modality treatment of
chemotherapy followed by mastectomy and then radiation, the overall 5-year
19survival is 46%. These patients tend to have a high-rate of local recurrence,
which is why they have traditionally not been considered candidates for immediate
breast reconstruction. Two studies have recently challenged this recommendation.
Slavin et al evaluated 10 patients with in: ammatory breast cancer who underwent
immediate reconstruction with a myocutaneous : ap. Six of these patients
20developed local recurrence, however there was no e ect on patient survival. In
another study by Chin et al, 23 women underwent breast reconstruction after
surgery for in: ammatory breast cancer. Fourteen patients had immediate
reconstruction while 9 patients had delayed reconstruction. At median follow-up of
44 months, there were no di erences in outcome between the two treatment
Despite these small studies with positive results, we are currently not o ering
immediate reconstruction to our patients with in: ammatory breast cancer. If the
patient shows no evidence of disease one to two years post treatment, they are then
referred to a plastic surgeon for discussion of possible reconstruction.
Nipple-sparing Mastectomy
A recent phenomenon is the increased use of nipple-sparing mastectomy or total
skin-sparing mastectomy in patients undergoing either prophylactic surgery or
treatment for breast cancer. This procedure involved ‘coring-out’ the ductal tissue
from within the nipple–areola complex to reduce the likelihood of a recurrence in
the area of the nipple. Recent studies have addressed the concerns regarding
nipple–areola recurrences as well as technical issues related to nipple necrosis.
Sacchini et al analyzed data on 123 patients who underwent nipple-sparing
mastectomy with breast reconstruction. Forty-four patients had invasive cancer, 20
had ductal carcinoma in situ (DCIS), and four had phylloides tumors. There were
two local recurrences with one being DCIS and the other invasive cancer. Two
patients developed breast cancer after prophylactic mastectomy. None of these
recurrences or new cancers was in the nipple–areola complex. Eleven percent of
22patients developed nipple necrosis but this was minimal in 59% of patients. The
authors concluded that local relapse after nipple-sparing mastectomy was very low
and that this procedure might be feasible in select patients.'

Garwood et al recently compared the rst 64 patients undergoing total
skinsparing mastectomy at University of California, San Francisco between 2001 and
2005 to 106 patients undergoing total skin-sparing mastectomy between 2005 and
2007. The rst cohort was analyzed in 2005 and techniques were altered to
minimize risk factors for complications. An incision involving 30% or less of the
nipple areolar complex resulted in improved nipple viability. Between cohort 1 and
cohort 2, nipple survival rates rose from 80% to 95% and complication rates
declined. These included necrotic complications, implant loss and wound
infections. Local recurrence at median follow-up of 13 months was 0.6% with no
23recurrences in the nipple–areolar complex. The authors concluded that total
skin-sparing mastectomy is oncologically safe with high nipple viability.
Patients should be counseled regarding the potential risks and bene ts of
proceeding with nipple-sparing mastectomy. Clearly, technique is critical in
obtaining an optimal cosmetic result. It seems reasonable to be conservative when
o ering this option to women who have a diagnosis of breast cancer as no
de nitive long term data is currently available for this technique. Nipple-sparing
mastectomy appears to be a safe alternative for prophylactic surgery providing that
the ductal tissue within the nipple is removed.
Breast Imaging Following Breast Reconstruction
Confusion exists regarding the role for mammography following bilateral
mastectomies with reconstruction. Many primary care physicians are unclear about
the necessity of routine screening mammography in a patient who clinically
appears to have breasts but has undergone mastectomy and reconstruction
particularly in the case of autologous tissue transfer. A study by Lee et al aimed to
determine the role of mammography after TRAM reconstruction in women treated
for breast cancer. In this retrospective review, 264 patients who had undergone
mastectomy with TRAM reconstruction and subsequent bilateral screening
mammograms were evaluated. Over a median follow-up period of 4.9 years, the
rate of detection of recurrent non-palpable cancer in TRAM reconstructions was
240%. In our practice, we do not perform routine mammograms of a breast that
has undergone mastectomy followed by reconstruction. These patients should have
yearly mammograms on the contralateral breast if prophylactic mastectomy has
not been performed. Women who have undergone mastectomy with reconstruction
have clinical breast exams and diagnostic imaging of any areas of concern. This
imaging may include mammogram, ultrasound or MRI. The management of breast
cancer local recurrence after mastectomy with reconstruction can be challenging
and usually involves a combination of wide local excision, chemotherapy and
ConclusionsThe treatment of breast cancer has become increasingly complex as more options
have become available to patients. A multidisciplinary approach to breast cancer
care, including the involvement of an oncologic surgeon, plastic surgeon, medical
oncologist, radiation oncologist, mammographer, and often genetic counselor, is
critical to ensure that the patient achieves an optimal outcome. The role of breast
reconstruction often plays a crucial role in the patient’s recovery and has a
significant positive impact on their psychological well-being.
1 Warren AG, Morris DJ, Houlihan MY, Slavin SA. Breast reconstruction in a changing
breast cancer treatment paradigm. Plast Reconstr Surg. 2008;121(4):1116-1126.
2 Toth BA, Forley BG, Calabria R. Retrospective study of the skin-sparing mastectomy
in breast reconstruction. Plast Reconstr Surg. 1999;104(1):77-84.
3 Simmons RM, Fish SK, Gayle L, et al. Local and distant recurrence rates in
skinsparing mastectomies compared with non-skin-sparing mastectomies. Ann Surg
Oncol. 1999;6(7):676-681.
4 Carlson GW, Bostwick J, Styblo TM, et al. Skin-sparing mastectomy: oncologic and
reconstructive considerations. Ann Surg. 1997;225(5):570-575.
5 Newman LA, Kuerer HM, Hunt KK, et al. Presentation, treatment, and outcome of
local recurrence after skin-sparing mastectomy and immediate breast
reconstruction. Ann Surg Oncol. 1998;5(7):620-626.
6 Kroll SS, Khoo A, Singletary SE, et al. Local recurrence risk after skin-sparing and
conventional mastectomy: a 6 year follow-up. Plast Reconstr Surg.
7 Slavin SA, Schnitt SJ, Duda RB, et al. Skin-sparing mastectomy and immediate
reconstruction: Oncologic risks and aesthetic results in patients with early-stage
breast cancer. Plast Reconstr Surg. 1998;102(1):49-62.
8 Rozen WM, Ashton MW, Taylor GI. Defining the role for autologous breast
reconstruction after mastectomy: social and oncologic implications. Clin Breast
Cancer. 2008;8(2):134-142.
9 Taylor CW, Horgan K, Dodwell D. Oncological aspects of breast reconstruction.
Breast. 2005;14(2):118-130.
10 Kronowitz SJ, Kuerer HM. Advances and surgical decision-making for breast
reconstruction. Cancer. 2006;107(5):893-907.
11 Overgaard M, Hansen PS, Overgaard J, et al. Postoperative radiotherapy in
highrisk premenopausal women with breast cancer who receive adjuvant
chemotherapy. N Engl J Med. 1997;337(14):956-962.
12 Ragaz J, Jackson SM, Le N, et al. Adjuvant radiotherapy and chemotherapy in
node-positive premenopausal women with breast cancer. N Engl J Med.1997;337(14):956-962.
13 Kronowitz SJ, Robb GL. Breast reconstruction with postmastectomy radiation
therapy: current issues. Plast Reconstr Surg. 2004;114(4):950-960.
14 Nahabedian MY, Momen B. The impact of breast reconstruction on the oncologic
efficacy of radiation therapy. Ann Plast Surg. 2008;60(3):244-250.
15 Batista LI, Lu KH, Beahm EK, Arun BK, Bodurka DC, Meric-Bernstam F. Coordinated
prophylactic surgical management for women with hereditary breast-ovarian
cancer syndrome. BMC Cancer. 2008;8:101-106.
16 Collin TW, Coady MSE. Is pregnancy contraindicated following free TRAM breast
reconstruction? J. Plast Reconstruct Aesthet Surg. 2006;59(5):556-559.
17 Newman LA, Kuerer HM, Hunt KK, et al. Feasibility of immediate breast
reconstruction for locally advanced breast cancer. Ann Surg Oncol.
18 Ananthakrishnan P, Lucas A. Options and considerations in the timing of breast
reconstruction after mastectomy. Cleve Clin J Med. 2008;75(S1):S30-3.
19 Singletary E. Surgical management of inflammatory breast cancer. Semin Oncol.
20 Slavin SA, Love SM, Goldwyn RM. Recurrent breast cancer following immediate
reconstruction with myocutaneous flaps. Plast Reconstr Surg.
21 Chin PL, Andersen JS, Somlo G, Chu DZ, Schwarz RE, Ellenhorn JD. Esthetic
reconstruction after mastectomy for inflammatory breast cancer: is it worthwhile?
J Am Coll Surg. 2000;190(3):304-309.
22 Sacchini V, Pinotti JA, Barros A, et al. Nipple-sparing mastectomy for breast cancer
and risk reduction: oncologic or technical problem? J Am Coll Surg.
23 Garwood ER, Moore D, Ewing C, et al. Total skin-sparing mastectomy:
complications and local recurrence rates in 2 cohorts of patients. Ann Surg.
24 Lee JM, Georgian-Smith D, Gazelle GS, et al. Detecting nonpalpable recurrent
breast cancer: The role of routine mammographic screening of transverse rectus
abdominis myocutaneous flap reconstructions. Radiology. 2008;248(2):398-405.CHAPTER 3
Adjuvant Therapy and Breast Reconstruction
Melissa A. Crosby, David W. Chang
Key Points
1. The safety, efficacy, and timing of breast reconstruction in patients who require
adjuvant therapy must be evaluated to ensure that reconstruction does not delay
adjuvant therapy or negatively affect disease-free interval or overall survival.
2. Neoadjuvant chemotherapy generally is not a contraindication to immediate
breast reconstruction and does not increase the complication rate or significantly
delay further adjuvant therapy. At our institution, we recommend delaying
reconstruction for 3–4 weeks following neoadjuvant chemotherapy to allow the
immunosuppressive effects of the chemotherapy to resolve.
3. Adjuvant chemotherapy: most oncologists prefer to initiate therapy 4–6 weeks
after mastectomy or breast-conservation surgery. Immediate breast reconstruction
does not seem to delay adjuvant chemotherapy or affect overall survival and
recurrence rates.
4. Hormone therapy: because tamoxifen presents a theoretical risk of thrombosis,
it may be appropriate to have the patient stop tamoxifen therapy 10–14 days prior
to undergoing free-flap reconstruction and restart the therapy after breast
5. Radiotherapy: most agree that autologous tissue-based reconstruction tolerates
radiation better with more pleasing aesthetic outcomes and fewer complications
than implant-based reconstruction.
Advances in adjuvant therapies for breast cancer have signi- cantly reduced the
disease’s recurrence rate and associated mortality rate. Adjuvant therapies may
include systemic therapy including cytotoxic, endocrine, or biologic modulators
and/or localized treatment such as radiation therapy.
When considering breast reconstruction for patients who need adjuvant therapy,
surgeons must take into account the potential e2ects of breast reconstruction on
adjuvant therapy, and vice versa. The safety, e3 cacy, and timing of breast
reconstruction in patients who require adjuvant therapy must be evaluated to
ensure that reconstruction does not delay adjuvant therapy or negatively a2ect
disease-free interval or overall survival. The impact of adjuvant treatment on theapproach and overall outcome of breast reconstruction also merits clarification.
Systemic Therapy
Cytotoxic chemotherapy
Cytotoxic chemotherapy generally causes myelosuppression, which may interfere
with wound healing and increase the risk of infections. Several studies have
evaluated the e3 cacy of breast reconstruction in patients who are scheduled to
receive adjuvant chemotherapy. Wound healing problems tend to occur when
drugs are delivered during the 2 weeks before reconstruction or during the - rst
week following reconstruction. As the interval between reconstruction and
chemotherapy increases, the risk of developing wound healing complications
Neoadjuvant chemotherapy
Although it has not been shown to provide survival bene- t compared with
postoperative adjuvant chemotherapy, neoadjuvant chemotherapy has become a
widely accepted treatment option for breast cancer patients. Neoadjuvant
chemotherapy has been shown to reduce tumor size in some patients with large
tumors, thereby facilitating breast-conservation surgery and enabling in vivo
4-6assessment of the tumor’s response to chemotherapy. Many studies have shown
that neoadjuvant chemotherapy followed by mastectomy and immediate breast
reconstruction is safe and viable, does not delay other adjuvant treatment, and can
be used to identify patients who do not respond to chemotherapy, which enables
7-9oncologists to modify post-surgical treatment. In addition, studies have shown
that the complication rate after implant- or autologous tissue-based reconstruction
is not signi- cantly higher in patients who have undergone neoadjuvant
chemotherapy, nor are the local recurrence and disease-free survival rates
Generally, neoadjuvant chemotherapy is not a contraindication to immediate
breast reconstruction and does not increase the complication rate or signi- cantly
delay further adjuvant therapy. At our institution, we recommend delaying
reconstruction for 3–4 weeks following neoadjuvant chemotherapy to allow the
immunosuppressive effects of the chemotherapy to resolve (Fig. 3.1A, B).Fig. 3.1 A This is a 54-year-old woman with left breast multicentric invasive
ductal carcinoma. The patient’s clinical stage at presentation is stage II-A with T2,
N0, M0. She received neoadjuvant chemotherapy consisting of 12 weekly cycles of
Taxol followed by four cycles of FAC. Four weeks after the completion of her
chemotherapy, the patient underwent left mastectomy and immediate
reconstruction with free DIEP Aap. Her postoperative course was uneventful. B At 8
weeks following mastectomy and reconstruction.
Adjuvant chemotherapy
Postoperative chemotherapy is a common adjuvant treatment for breast cancerbecause it reduces the risk of local and systemic recurrence due to occult
micrometastatic disease. Randomized trials and meta-analyses have shown that
post-mastectomy adjuvant chemotherapy reduces recurrence and death rates in
14-16breast cancer patients.
Many researchers have studied whether immediate breast reconstruction a2ects
the timely delivery of adjuvant chemotherapy and whether adjuvant chemotherapy
after reconstruction a2ects wound healing. Allweiss et al compared 49 patients
who underwent mastectomy, immediate breast reconstruction with various
autologous tissue techniques, chemotherapy with 308 patients who underwent
mastectomy alone followed by chemotherapy and found that the type of
reconstruction did not signi- cantly delay chemotherapy and that the time to
chemotherapy was in fact signi- cantly longer in patients who did not undergo
17immediate reconstruction. In addition, Wilson et al compared patients who had
undergone mastectomy with immediate reconstruction, mastectomy with no
reconstruction, or breast-conservation surgery, all followed by adjuvant
chemotherapy, and found no signi- cant di2erences in the time to chemotherapy
18among the three cohorts. At our institution, Mortenson et al found that patients
who underwent immediate breast reconstruction followed by adjuvant
chemotherapy had a higher incidence of wound complications (22.3%) than
patients who did not undergo immediate reconstruction (8.3%) but did not - nd
19that immediate breast reconstruction delayed postoperative chemotherapy.
With regard to implant-based reconstruction, most researchers have found that
adjuvant chemotherapy typically does not increase implant infection or
2,20-22complication rates or a2ect cosmetic outcomes. In addition, no signi- cant
delays in receiving chemotherapy or changes in dose intensity have been
3,20observed. Based on these studies and our experience with implant-based
reconstruction and tissue expansion during chemotherapy, we recommend that
patients undergo tissue expansion and implant placement before starting
chemotherapy. If tissue expansion is not complete before a patient starts
chemotherapy, absolute neutrophil counts should be assessed to make certain that
the patient’s immune system can - ght the bacteria that are introduced during the
expansion process.
Although whether delaying adjuvant chemotherapy a2ects cancer-related
outcomes is not yet de- nitively known, most oncologists prefer to initiate therapy
4–6 weeks after mastectomy or breast-conservation surgery given concerns that
23longer periods may increase recurrence or diminish survival. Immediate breast
reconstruction may increase the risk of complications as a result of the additional
surgical procedures performed, but it does not seem to delay adjuvant
chemotherapy or affect overall survival and recurrence rates.Hormone therapy
Selective estrogen receptor modulators
Tamoxifen has been shown to reduce the risk of recurrence and death in women
with early-stage, hormone receptor-positive invasive breast cancer; reduce the risk
of invasive and non-invasive recurrences in women who undergo breast-conserving
surgery for ductal carcinoma in situ; and reduce the risk of breast cancer in women
who have a high risk for the disease because of personal characteristics or family
16,24history. Despite tamoxifen’s bene- ts, 1–2% of patients may experience
thromboembolic events such as deep vein thromboses, pulmonary embolisms, and
cerebrovascular thrombi. Although the mechanisms by which tamoxifen causes
thromboembolic events are not totally understood, the events are thought to be
related to tamoxifen’s reduction of levels of antithrombin III, and factor V, and
25-27protein C.
Because tamoxifen presents a theoretical risk of thrombosis, it may be
appropriate to have the patient stop tamoxifen therapy 10–14 days prior to
undergoing free-Aap reconstruction and restart the therapy after breast
reconstruction. (This time frame is based on the pharmacokinetics and the
9–1428day terminal half-life of tamoxifen’s major metabolite. ) However, we recommend
consulting with the patient’s medical and surgical oncologists to con- rm that
tamoxifen therapy can be stopped safely without negatively a2ecting the patient’s
cancer treatment.
Aromatase inhibitors
The most common aromatase inhibitors studied in breast cancer patients are
anastrozole and letrozole. In comparison trials, anastrozole was associated with
higher disease-free survival rates, lower breast cancer event rates, and fewer
incidences of contralateral breast cancer than tamoxifen. Also, signi- cantly fewer
venous thrombolic events occurred in the anastrozole group than in the tamoxifen
29group. We currently do not routinely stop aromatase inhibitor therapy prior to
breast reconstruction.
Biological therapy
Trastuzumab, a humanized monoclonal antibody directed against the HER-2
receptor, has been shown to signi- cantly improve survival rates in metastatic
breast cancer patients when used alone or in combination with chemotherapy.
Trastuzumab also has been shown to reduce recurrence rates and improve survival
30in early-stage breast cancer patients.
Patients who receive trastuzumab alone or in combination with other
chemotherapy may experience neutropenia and an increased incidence ofinfections. An increase in the incidence of thrombotic events has also been
31reported. Because of these potential complications, we recommend that patients
complete trastuzumab therapy and undergo immune status evaluation before
undergoing breast reconstruction. And as always, we recommend consulting with
the patient’s medical and surgical oncologists.
Giving adjuvant radiotherapy following mastectomy has been shown to
signi- cantly reduce the risk of locoregional recurrence in early-stage breast cancer
32,33patients with positive lymph nodes. Furthermore, recent prospective trials
have demonstrated improved locoregional control, disease-free survival, and
overall survival rates in node-positive breast cancer patients who receive adjuvant
34,35radiotherapy in addition to mastectomy and chemotherapy. Currently,
postmastectomy adjuvant radiotherapy is recommended for patients with locally
36,37advanced tumors or four or more involved lymph nodes. However, many
institutions are evaluating the e3 cacy of radiotherapy in patients who have T1 or
33T2 disease and one to three involved nodes.
Breast reconstruction in a previously irradiated breast
The negative e2ects of radiation on implant-based breast reconstruction have been
particularly well documented; studies of implant-based reconstruction of previously
irradiated breasts have reported complications including infection, extrusion,
capsular contracture, and failed reconstruction in 20–60% of cases. Thus, most
prefer to use autologous tissue only for breast reconstruction in a previously
irradiated breast. However, recent reports may support that when autologous tissue
Aap and implant are used together in a previously irradiated breast for breast
reconstruction, an autologous tissue Aap may protect the implant from the negative
e2ects of radiotherapy. Spear et al evaluated 28 patients with previously irradiated
breasts who underwent latissimus dorsi (LD) Aap/implant breast reconstruction
and found a 14% implant-related complication rate with a mean cosmetic
satisfaction rating of 8.5 of 10 and mean overall satisfaction rating of 8.8 of 10.
The authors concluded that although breast reconstruction with autologous tissue
alone may be the best choice following radiotherapy, LD Aap/implant
reconstructions provide cosmetically acceptable results and acceptable
38complication rates. In a study from our institution, of patients who received
radiotherapy prior to mastectomy and reconstruction, signi- cantly fewer
reconstructions failed in patients with LD Aap/implant reconstructions (15%) or
transverse rectus abdominis myocutaneous (TRAM) Aap/implant reconstructions
39(10%) than in patients with expander/implant-only reconstructions (42%; p In our experience, an autologous tissue Aap combined with an implant for breast
reconstruction appears to reduce the incidence of implant-related complications in
previously irradiated breasts. A well-vascularized Aap may improve wound healing
and thus reduce the risk of wound breakdown and infection. The Aap also provides
a well-vascularized pocket for the implant, which minimizes the implant’s direct
contact with the surrounding irradiated tissue. Although the implant sits on the
chest wall, covering the implant with well-vascularized tissue may reduce the risk
of capsular contracture associated with radiotherapy. Because free TRAM Aaps and
deep inferior epigastric artery perforator (DIEP) Aaps typically provide more
wellvascularized tissue than LD Aaps, covering the implant with a free TRAM or DIEP
flap may provide better protection.
Immediate breast reconstruction followed by radiotherapy
There are conAicting results in the literature regarding almost all aspects of
immediate reconstruction and radiotherapy. This conAict has clinical rami- cations,
since the - rst step after diagnosing breast cancer is o2ering a patient the best
possible treatment in accordance with her and the tumor’s characteristics. Such
treatment may include immediate breast reconstruction in cases in which
mastectomy is indicated.
The mechanisms and clinical e2ects of radiation on the reconstructed breast
depend on the radiation dose, the use of compensating - lters and wedges, the use
40of bolus dosing to the skin, and the boost to the radiation bed. The variability
among radiation oncologists and centers makes it di3 cult to predict the e2ects
radiotherapy will have on a reconstructed breast. Incompletely understood intrinsic
patient factors can also alter the e2ects of radiotherapy. Immediate breast
reconstruction can create technical challenges in administering adjuvant
radiotherapy and may increase radiation exposure in the mediastinum. A Aat chest
– that is, one without a reconstructed breast – allows for beam angulations that
minimize radiation doses to the heart and lungs while treating the internal
mammary lymph nodes; however, the sloped contour of a reconstructed breast
contributes to less precise geometric matching of the lateral and medial radiation
33,41-43fields, resulting in greater radiation doses in the mediastinum.
Autologous tissue-based reconstruction followed by
Most authors agree that autologous tissue-based reconstruction tolerates radiation
better with more pleasing aesthetic outcomes and fewer complications than
44,45implant-based reconstruction. Jhaveri et al performed a retrospective analysis
of the long-term complication rates and cosmetic results in 69 patients who
underwent immediate tissue expander/implant-based reconstruction with adjuvantradiotherapy and 23 patients who underwent autologous tissue-based
reconstruction with adjuvant radiotherapy. The authors found that the tissue
expander/implant group had a signi- cantly higher rate of severe complications –
those that required surgical intervention or removal and/or replacement of the
implants (33.3%) – than the group who underwent autologous tissue-based
reconstruction (0%). The autologous tissue group also had a higher rate of
46acceptable cosmesis (83%) than the tissue expander/implant group (51%).
However, many feel that irradiating a reconstructed breast may diminish the
aesthetic outcome and thus advocate delay reconstruction in patients who require
adjuvant radiotherapy. Tran et al reported on a series of 41 patients undergoing
immediate TRAM Aap reconstruction (9 pedicled and 32 free) followed by
radiation. No Aap loss was reported; however, 10 patients (24%) required an
additional Aap to correct contracture, and only 9 patients (22%) maintained
normal breast volumes. Hyperpigmentation occurred in 15 patients (37%),
palpable fat necrosis in 14 patients (34%), and a loss of symmetry in 32 patients
47(78%). In a later study, Tran et al evaluated 32 patients who underwent
immediate reconstruction followed by radiotherapy and 70 patients who
underwent reconstruction after radiotherapy. No signi- cant di2erence was found
in early Aap complications between the two groups but signi- cantly higher (87.5%
versus 8.6%) rates of late complications (fat necrosis, Aap volume loss, and Aap
contracture) were noted in patients who received immediate reconstruction prior to
radiotherapy, with 28% requiring an additional Aap to correct deformities (Fig.
483.2A–E). Other studies have found similar results with higher rates of fat necrosis
and necessary additional surgeries or Aaps due to volume loss in patients who
undergo autologous tissue-based reconstructions before adjuvant

Fig. 3.2 A The patient is a 53-year-old woman with left breast invasive mixed
ductal lobular carcinoma and ductal carcinoma in situ. B The patient underwent
left modi- ed radical mastectomy and right prophylactic mastectomy with
immediate reconstruction with free TRAM Aaps. C Pathology review revealed close
surgical margin and patient was treated with 50 Gy in 25 fractions to the left chest
wall and reconstructed breast followed by a 14 Gy electron boost to the skin
overlying the TRAM Aap. D At 12 months following completion of the radiation
therapy. E At 4 years after mastectomy and free TRAM breast reconstruction, and45 months following completion of the radiation therapy.
Meanwhile, for some surgeons, immediate reconstruction with autologous tissue
remains the preferred approach in patients who require adjuvant radiotherapy. In a
series of 25 patients, Soong et al found that radiotherapy did not increase the rate
of complications after immediate reconstruction with TRAM Aaps. The authors
concluded that radiotherapy after reconstruction with TRAM Aaps is well tolerated
53and that cosmetic outcome and local control of the breast cancer are satisfactory.
Other authors have reported similar results with good to excellent cosmetic
54-57outcomes and minimal flap loss and complications.
Implant-based breast reconstruction followed by radiotherapy
Among patients who had immediate implant-based breast reconstruction followed
by radiotherapy, Cordeiro et al found that 68% experienced capsular contracture
after radiotherapy, a rate signi- cantly higher than in patients who did not receive
radiotherapy. Also, the patients who did not receive radiotherapy had a higher
percentage of very good to excellent outcomes of the reconstructed breast than
patients who did receive radiotherapy. Nevertheless, the authors concluded that
immediate reconstruction with expanders and implants is an acceptable option
58when adjuvant radiotherapy is necessary. Hazard et al reached the same
conclusion in a retrospective study in which 85% of patients had good or excellent
59cosmetic outcomes, with an acceptable rate of capsular contracture.
Other authors have reported higher complication, reoperation, and capsular
contracture rates in patients with implant-based reconstructions followed by
adjuvant radiotherapy, resulting in poor cosmetic outcome. Spear et al evaluated
outcomes in 40 patients undergoing two-stage reconstruction with saline implants
and adjuvant radiotherapy with 40 patients undergoing two-stage reconstruction
without radiation and found that the group who received radiation had
signi- cantly more complications (52.5% versus 10.0%), capsular contractures
40(32% versus 0%), and additional procedures (47% versus 10%). Other authors
have come to the same conclusion and even consider the need for radiotherapy to
be a relative contraindication to immediate breast reconstruction with tissue
60-66expanders and implants.
Delayed-immediate breast reconstruction
It remains unclear whether radiation will be required after mastectomy in many
patients. The inability to consistently identify patients who require adjuvant
radiotherapy complicates the decision about whether to perform immediate
reconstruction in many early-stage breast cancer patients.Because of this dilemma, Kronowitz et al described the ‘delayed immediate’
technique, in which a completely - lled textured saline tissue expander is placed
42during mastectomy to preserve the skin envelope. Once the - nal pathology
results are received, patients can undergo delayed reconstruction after they
complete radiotherapy or immediate reconstruction if radiotherapy is unnecessary.
The advantage of this technique is that it preserves the skin to achieve superior
aesthetic outcomes in immediate reconstruction and it enables delay of - nal
reconstruction in patients who are found to need postmastectomy radiation,
thereby avoiding most effects of irradiating a reconstructed breast.
Given reports of the increased risk of capsular contracture associated with
radiotherapy and implant reconstruction and the need for removal or reoperation
despite reported acceptable cosmetic results, we recommend autologous
tissuebased reconstruction instead of implant reconstruction in patients who have
received or will receive radiotherapy. Ideally, delaying reconstruction until after
radiotherapy is prudent and results in less morbidity. In addition, if a patient
receives radiotherapy and desires delayed reconstruction, we believe that
autologous tissue provides the most reliable and best aesthetic results. Although
many centers have reported minimal complications and acceptable cosmetic results
in patients who receive radiotherapy after autologous tissue-based reconstruction,
we believe this risk is unnecessary. Delaying reconstruction until after radiotherapy
decreases the risk of fat necrosis, volume loss, and the need for additional Aaps.
Furthermore, immediate reconstruction may cause technical problems when
designing the radiation fields necessary to deliver adjuvant radiotherapy.
The current approach to breast cancer is multidisciplinary. Breast reconstruction
has become a routine aspect of treatment, and many breast cancer patients who
undergo reconstruction after partial or total mastectomy also require adjuvant
therapy. To plan and provide e2ective multidisciplinary care for breast cancer
patients, plastic surgeons must understand how adjuvant therapy and breast
reconstruction impact each other.
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Expanders and Breast Reconstruction with Gel and Saline
Jonathan D. McCue, Mark Migliori, Bruce L. Cunningham
Key Points
1. The optimal result in implant-based breast reconstruction requires a team approach.
2. With careful selection and preoperative education, the irradiated patient may have a
successful result with implant reconstruction.
3. The base diameter of the breast is the primary determinant of implant selection.
4. Preservation of the inframammary fold or its re-establishment is crucial to appropriately
positioned implants.
5. Starting at the time of tissue expander placement, the implant pocket should be of a size and
position that would be desirable as a final result.
Clinical use of tissue expansion dates back to 1957 where expanded postauricular skin was used
1to reconstruct a traumatic ear defect. Subsequent interest in this technique, and speci cally its
application to breast reconstruction, did not ourish until 20 years later when Radovan and
2Austad developed silicone tissue expanders, independently presenting their results in 1978 and
31979. Radovan described a saline- lled implantable silicone expander utilizing a port; Austad
4described a self-in ating tissue expander including a description of the histological features of
5,6expanded tissue. As the safety and e2 cacy of submuscular tissue expansion has improved,
implant-based breast reconstruction has become one of the most frequently employed
reconstructive techniques in eligible patients. Today, an understanding of implant reconstruction
results through careful planning of tissue expander placement and judicious modi cation of the
pocket at the time of permanent implant exchange is resulting in a more realistic appearance to
the reconstructed breast, while technologic advances in implant design and biologic substitutes
are providing improved soft tissue coverage, contour and a more realistic feel to implant-based
breast reconstruction.
Team Approach to Implant-Based Breast Reconstruction
Achieving an optimal result in implant-based breast reconstruction is dependent on the skill and
diligence of other physicians who ideally have a good understanding of reconstructive priorities.
A mastectomy surgeon who is able to perform a sound oncologic procedure, while preserving
anatomic landmarks that de ne the contours of the original breast, is critical to overall success.
Unnecessarily aggressive surgical resection compromises the ability to reconstruct a natural
appearing breast, limiting aesthetic results and taints the patient’s perception of the plastic+
surgeon’s abilities. With respect to the radiation oncologist, proper titration of therapy is critical
to avoid excessive injury that limits tissue expansion and increases the incidence of
complications. A good working relationship with all disciplines involved allows coordination of
care to minimize the inconvenience for the patient in terms of multiple o2 ce visits and
unnecessary delays in receiving adjuvant therapy.
Indications and Patient Selection
The ideal candidate for implant-based reconstruction is the patient with durable, non-redundant
soft tissue coverage desiring a moderate sized non-ptotic breast (Fig. 4.1). This allows for
exibility in nal size, tends to create a more stylized contour of the breast, and is particularly
well suited to bilateral reconstruction. In unilateral reconstruction the patient must be willing to
entertain the possibility of contralateral breast augmentation, reduction, or mastopexy. These
considerations hold true for immediate or delayed reconstruction patients. However, the delayed
reconstruction patient who has received postmastectomy radiation therapy should be
7approached very cautiously as the complication rate in this setting may be exceedingly high
(Fig. 4.2). Also, large-breasted patients who wish to maintain a large size in their reconstruction
may not be able to achieve this with tissue expansion and implants. Tissue expansion may
altogether be avoided in carefully selected patients who have received a skin-sparing
mastectomy (e.g., prophylactic mastectomy) with unequivocally viable skin aps. However, in
those patients with signi cant soft tissue loss at the time of tumor extirpation, tissue expansion is
usually necessary.

Fig. 4.1 A, B Thin patient with a petite frame and non-ptotic breasts prior to mastectomy and
at completion of C, D first and E, F second stage reconstruction with nipple reconstruction.*
Fig. 4.2 Patient with history of right mastectomy and radiotherapy. An adherent, brotic skin
envelope makes this patient unsuitable for tissue expansion and a latissimus ap with implant is
Radiation Therapy and Implant-Based Reconstruction
Radiation therapy may be administered before mastectomy in the instance of prior breast
conservation therapy, immediately following mastectomy but before reconstruction, coincident
with tissue expansion, or after completion of tissue expansion. Radiation therapy has
traditionally been avoided in patients with T0, T1 or T2 tumors after mastectomy, based on the
8patient’s choice, rather than lumpectomy with radiation as de ned in the NSABP-B-06 trial.
However, an increasing number of patients desiring breast reconstruction are eligible for
radiotherapy due to the increasing prevalence of breast cancer and expanding indications for
9adjuvant therapy. In 1999 the indications for radiation therapy for breast cancer after
mastectomy were expanded to include patients with stage II disease having either a primary
tumor diameter greater than 5 cm (T3) and/or four or more involved lymph nodes (Table
104.1). Currently the e2 cacy of radiation therapy in patients with one to three a> ected lymph
11nodes is in phase III trials (NSABP-B-39).
Table 4.1 Indications for postmastectomy radiation
Tumor >5 cm
T4 tumor
Involvement of 4 or more axillary lymph nodes
Gross extracapsular nodal disease
Residual disease after mastectomy
Additional considerations
Involvement of 1–3 axillary lymph nodes
Gross multifocality
Extension into the nipple or skin+
As such, an understanding of the e> ects of radiation therapy on the reconstructive surgeon’s
strategy has become increasingly important. Radiation therapy by itself is no absolute
contraindication to implant-based reconstruction, but its limitations must be realized, and some
surgeons may wish to avoid attempting to expand skin with anticipated irradiation. While the
need for radiation may be determined prior to mastectomy in a subset of patients, an increasing
number are o> ered postoperative radiation therapy following analysis of the permanent
pathology of lymph nodes or tumor margins. Delayed primary reconstruction, in which the tissue
expander is placed 3 or 4 days after mastectomy, may be performed to ensure negative
pathology and no indication for radiation. In those patients where radiation therapy is indicated
based on intraoperative ndings such as tumor size, narrow margins or sentinel lymph node
status, the reconstructive surgeon should reserve the option to ‘walk away’ from an immediate
reconstruction. Some authors have suggested the use of a delayed-immediate reconstruction
technique, where a partially in ated expander is placed immediately with interval de ation for
12the duration of radiation therapy, if indicated. In this circumstance of postoperative radiation,
we prefer to expedite the expansion process to completion within 4 to 5 weeks, before radiation
therapy is started.
In most centers, radiation oncologists do not perceive the tissue expander as a hazard to good
treatment. If oncologic considerations require radiation prior to that time, delayed reconstruction
is preferred. Those patients who have received even appropriately titrated radiation therapy are
at greater risk for mastectomy ap necrosis, implant exposure or inability to complete tissue
expansion (Fig. 4.3). However, a successful result can nonetheless be obtained (Fig. 4.4). As
such, we often allow patients to ‘prove’ the expander will not work before resorting to autologous
forms of reconstruction. Ultimately, autologous tissue coverage may be required to achieve an
acceptable contour. Spear reviewed a series of saline implant-reconstructed women receiving
radiation therapy at various time points relative to reconstruction and found autologous tissue
was needed in 19 out of 40 (47.5%) patients primarily as a consequence of contracture or
13unsatisfactory implant position. These secondary operations still make use of the expanded
tissue, and may be thought of as an adjunct to implant-based reconstruction, rather than salvage
for a failed operation. No additional operations are required than if the patient had proceeded to
autologous tissue transfer, initially or at a later date; the only disadvantage is the time and
inconvenience for the patient having undergone an expansion process that does not progress to
completion or ultimately fails. In those secondary or delayed reconstruction patients who have
received very high doses of radiotherapy, we do not attempt tissue expansion alone, and proceed
directly to autologous tissue transfer with or without the use of an implant and expander.
Fig. 4.3 Patient after bilateral mastectomy and radiation therapy to the right side, followed bybilateral tissue expansion. Goal tissue expansion could not be achieved in the irradiated side.
Volume has been removed from the right tissue expander and a latissimus flap is planned.

Fig. 4.4 Implant-based reconstruction shown A preoperatively and B following right
mastectomy with tissue expansion and radiation therapy.C Second stage reconstruction with good
result without autologous tissue transfer. A contralateral augmentation for symmetry has been
performed. Note the constricted envelope of the irradiated breast has been lowered to match the
inframammary fold of the left breast.*
Preoperative Marking and Tissue Expander Selection
Preoperative coordination with the surgical oncologist is critical for obtaining a favorably placed
mastectomy scar that can be concealed by clothing with preservation of as much skin envelope
as needed. The importance of preserving the inframammary fold should be appreciated by the
oncologic surgeon. With greater acceptance of skin-sparing and areola-sparing mastectomies,
incisions other than a standard periareolar ellipse may a> ect surgical exposure (Fig. 4.5). In the
large-breasted patient who wants signi cantly smaller breasts and has no indication for
radiation, a mastectomy scar incorporating a vertical component, or based on an inverted ‘T’
incision as seen in Wise pattern breast reductions, may be considered (see Fig. 4.27).

Fig. 4.5 Second-stage reconstruction after nipple-sparing mastectomy.
Preoperative marking for the reconstructive surgeon involves outlining all borders of the breast
to approximate the planned implant or expander pocket space dissection. Any asymmetries are
noted, and the inframammary fold is marked while the patient is in the upright position. The
meridian of the breast is marked at the level of the inframammary fold. At this point it is critical
for the reconstructive surgeon to visualize how the nal reconstruction should appear with
respect to breast diameter and volume, including any planned symmetry procedure. The surgeon
should aspire to estimate the position and size of the permanent implants prior to tissue
expander placement.
With the nal result in mind, tissue expanders of appropriate dimensions are ordered prior to
the surgery. A range of tissue expanders are currently available, including round and contoured
expanders, the latter o> ering the bene t of di> erential, greater lower pole expansion, and an
increasing slope from the upper pole. Most expanders utilize an integrated valve that is located
using a magnetic port nder (Fig. 4.6). If expander positioning is ideal, a remote port
expandable implant provides an option of explanting only the port and interconnecting catheter,
leaving the implant in place as a permanent device. Each tissue expander has a speci c base
diameter, height, contour pro le (e.g., low, moderate, and tall), and maximum recommended
volume (Fig. 4.7). We use base diameter as the primary determinant of implant choice with
volume as the second consideration. The choice of pro le is largely based on the habitus of the
patient, with narrow-chested, thinner patients appearing proportional with low or medium
pro le expanders and heavier patients requiring a tall pro le to o> er projection commensurate
with their larger size.
Fig. 4.6 Use of a magnet to locate the integrated filling port on a tissue expander.+
Fig. 4.7 Packaging label on a Mentor tissue expander indicating the base diameter, implant
contour and maximum recommended filling volume.
Surgeon preference does play a role in the choice; some prefer a tall pro le expander that can
be used to ‘recruit’ superior pole tissue during expansion. While it is aesthetically desirable to
have upper pole fullness, achieving this through initial tissue expansion may result in poorer,
more brotic, tissue quality. For this reason it may be preferable to expand the lower pole and
‘recruit’ unexpanded tissue superiorly by dissecting upwards into the expander pocket at the
time of second stage reconstruction. Although each expander has a recommended ll volume,
strictly limiting expansion to this number is of little importance as the base diameter does not
change significantly with increasing fill, and the devices can easily exceed the stated fill volume.
Operative Technique: Immediate Reconstruction
Patient positioning
Implant-based reconstruction can begin immediately after tumor extirpation with the patient
having been under general anesthesia for anywhere between 1 to 3 hours. Surgical margins of
the tumor specimen would be negative on preliminary examination and sentinel or formal lymph
node dissection would be performed, if indicated, at this point. Although proof of e2 cacy has
not been established, additional wound infection precautions such as re-administration of
prophylactic antibiotics and a second application of surgical prep around the incision may be
done. The arms may be extended or at the sides, depending on preference. We prefer placing the
arms at the sides as this decreases tension on the pectoralis major, facilitating retraction of the
muscle during pocket dissection.
Pocket dissection
As previously mentioned, the option for immediate placement of a permanent implant may be
reasonable only if the mastectomy aps are viable and can accommodate the appropriate
implant size without creating excessive tension on the skin closure. It also necessitates accurate
positioning of the implant and reconstructing the important landmark of the inframammary
fold. In the majority of cases, a staged expansion process is necessary to achieve optimal results.
With the de ciency of soft tissue coverage resulting from the mastectomy, partial or complete
muscle coverage is necessary to limit implant visibility or exposure. We prefer complete
muscular coverage of the expander to maximize the vascularity of the pocket and exclude the
implant from the overlying mastectomy incision. In this technique, the lateral edge of the
pectoralis major muscle is elevated and a submuscular pocket is dissected medially to the sternal
edge and superiorly to the second rib. The superior dissection is made in a relatively avascular
plane between the pectoralis major and minor muscles. Care should be taken to avoid injury to
the thoracoacromial pedicle located on the undersurface of the pectoralis major muscle. A
systemic paralytic may be administered to make the superior dissection easier, as powerful
contractions of the pectoralis major may result from electrocautery dissection near its dominantneurovascular pedicle. Superior dissection may be made bluntly, and while technically easy,
excess dissection in this direction may lead to implant malposition, as the expander is wider than
it is tall. When possible, the large perforator in the medial second interspace is preserved because
of its contribution to the mastectomy flap blood supply (Figs 4.8 and 4.9A–C).
Fig. 4.8 Schematic illustration for raising pectoralis major, serratus anterior and
pectoralserratus fascia to achieve complete coverage for the implant.

Fig. 4.9 A Technique of submuscular pocket dissection: periareolar ellipse mastectomy incision,
B elevation of lateral edge of pectoralis major, C superior pole dissection between pectoralis
major and minor, D elevation of serratus anterior, E elevation of bridging fascia between*
pectoralis major and serratus anterior, F local anesthetic injection into pectoralis major pedicle.
Inferiorly, the pocket dissection is carried down to the top of the sixth rib at the meridian of
the breast. In general, the inframammary fold (IMF) can be reliably reconstructed in this
location. Although the anatomy of the IMF is not rmly established and may vary with age and
body habitus, it is an anatomic landmark with gross anatomic dissections and histologic reports
14suggesting a con uence of organized collagen bers in the dermis and/or an actual ligament
15arising from periosteum and intercostal fascia. With the normal curve of the ribcage, the
medial IMF is predictably located at the bottom of the fth rib and the lateral extent of the fold
is located at the top of the seventh rib (Fig. 4.10). Avoidance of dissection below the fold is the
preferred strategy. Because the pectoralis major muscle inserts at the fth rib, cephalad to the
IMF, it is necessary to detach its inferior origins to position the expander appropriately. When
the mastectomy has not violated the IMF, this release may be carried into the subcutaneous
tissue of the IMF without compromising the expander coverage inferiorly. However, it is often
necessary to elevate a portion of the anterior rectus fascia in continuity with the released
pectoralis to maintain complete expander coverage.
Fig. 4.10 Landmarks on the fifth, sixth and seventh ribs to re-establish the inframammary fold.
The lower slips of the serratus anterior are elevated to cover the infralateral expander (Fig.
4.9D). Maintaining the bridging fascia between the pectoralis major and the serratus anterior is
very helpful in this dissection (Fig. 4.9E). Care must also be taken to avoid dissection through the
intercostal spaces. A complementary adjunct to complete elevation of the serratus anterior is to
elevate the lateral edge of the pectoralis minor in continuity with the lower slips of the serratus
(Fig. 4.11). This has the bene t of better retention of the implant at the superolateral pocket
border, helping to prevent any late migration towards the axilla, particularly after lymph node
dissection. These dissections are performed to match the footprint of the desired expander,
respecting the desired landmarks of the future reconstructed breast. Proper control of the pocket
dimensions will limit the potential for expander malposition or malrotation. When possible,
muscle relaxation provided by the anesthesia team will facilitate the pocket dissection. As an
adjunct to post-operative pain management and to prevent muscle spasms, 0.25% bupivacaine
can be injected near the thoracoacromial pedicle and as a eld block around the perimeter of+
the pocket (Fig. 4.9F).
Fig. 4.11 Technique for raising lateral slips of pectoralis minor to achieve superolateral
muscular coverage.
An alternative to complete muscle coverage of the expander has emerged. An acellular dermal
matrix may be used as a hammock for the expander to avoid the necessity of elevation of the
16rectus fascia, serratus and/or pectoralis minor muscle. It is also useful in those situations
where complete muscle coverage was desired but the mastectomy resulted in loss of fascia or
muscle integrity in the inferior pocket. Typically, an 8 × 16 cm sheet of dermal matrix is
sutured superiorly to the detached pectoralis major muscle edge and medially at the sternal edge
(Fig. 4.12). We use interrupted 2-0 silk sutures for this purpose. Inferiorly and laterally, it is
sutured to the underlying fascia. The IMF landmarks and the desired lateral contours determine
the position. It is recommended that the dermal side of the graft is directed towards the
undersurface of the mastectomy aps to promote vascular ingrowth. While an e> ective
technique without a known increase in complications, the acellular dermal matrix adds
considerable cost and may increase the risk of seroma. In the setting of an ischemic mastectomy
ap, expander protection from infection or exposure may be compromised. Additionally, the
e> ect of post-expansion radiation on the vascularization of the acellular dermal graft is not fully
known. Although it has been successfully used in this scenario, deliberate patient selection is
necessary to achieve optimal results.*
Fig. 4.12 Illustration of dermal matrix in position with underlying implant. Drains may be
placed deep and superficial to the graft.
Expander placement
The expander is removed from the sterile internal packaging only when ready for placement to
reduce the possibility of implant contamination. Hemostasis within the pocket should be assured:
perforating vessels, if visible at the medial pocket edges should be cauterized for risk of avulsion
following future expansion. Prior to the insertion of the expander or a permanent implant, the
pocket is irrigated to remove cautery char, loose fat, and to visualize any remaining bleeding.
Many di> erent irrigant solutions have been proposed: the ‘triple antibiotic’ solution popularized
by Adams contains gentamicin (80 mg), cefazolin (1 g) and bacitracin (50,000 U) in 500 ml of
17normal saline, with vancomycin substituted for bacitracin at some institutions. It must be
noted that the endpoint of this study, capsular contracture in breast augmentation patients, was
based on an etiologic assumption of subclinical pocket infection, which has not been rmly
established. No comparative e2 cacy has been established with any popular irrigation choices
including triple antibiotic, single antibiotic, diluted povidone–iodine or normal saline alone,
particularly in breast reconstruction patients, and the additional cost of these measures should
be considered if implementing them systematically. We do employ well-established barrier
precautions – the operating surgeon applies new sterile gloves and is the only team member to
handle the implant. Some air is present in the expander when removed from the packaging. We
typically evacuate the air maximally to minimize risk of tearing tissues during pocket insertion.
The expander is then positioned so that the integrated valve is at the upper pole. Some
additional pocket dissection may be required to achieve this; however, e> ort is made to keep
within the appropriate base diameter. Certain tissue expander models have a reinforced
orientation tab at the posterior aspect where an absorbable stitch can temporarily secure the
implant to rib periosteum or intercostal fascia to prevent malposition. The expander is then lled
with 60–120 cc of saline from a closed system, based on the condition of the overlying skin and
muscle. This intraoperative expansion allows the lower pole of the implant to unfurl, facilitating
positioning and has the secondary benefit of obliterating any dead space within the pocket.
Once expander position is satisfactory and it is apparent that the implant pocket can be closed*
without excessive tension, the lateral free edge of the pectoralis major is sewn to the free edge of
the serratus anterior and pectoral-serratus fascia in the case of total submuscular placement, or
to the free edge of the dermal matrix if used. The overlying muscle is closed and additional
saline is added using the sterile magnetic port nder to achieve an acceptable amount of tension
on skin and muscle closure (Fig. 4.13). Total intraoperative expansion may range widely
depending on overlying soft tissue laxity, but approximately 20% of the implant volume should
be tolerated in most patients. The use of dermal matrix approximately doubles the intraoperative
volume expansion possible.

Fig. 4.13 A Tissue expander placement technique: complete de ation of expander, B
positioning of de ated expander into submuscular pocket, C closure of edge or pectoralis major
and serratus anterior, D partial intraoperative inflation.
Delayed Reconstruction
Implant-based reconstruction may be delayed to facilitate completion of chemo- or radiation
therapy, but subsequent tissue expansion is usually necessary. Patient marking is done
preoperatively to estimate the boundaries of the ideal implant pocket that will provide the nal
desired result (Fig. 4.14). If the contralateral breast is used as a template, any planned symmetry
procedure should be accounted for in estimation of pocket size. The surgical approach is similar
to that of primary reconstruction. The scar is excised and the skin flaps are elevated although not
to the same extent as would be seen immediately after a mastectomy. After exposure of the
inferior portion of the pectoralis major it is possible to create the submuscular pocket in the same
fashion as previously described by identifying and re ecting its lateral border. Another option is
to create the pocket through a pectoralis muscle-splitting incision (Fig. 4.15). This has the
bene t of preserving functional muscle bers with a natural tendency to close the incision upon
contraction and is less likely to disrupt the inframammary fold. The muscle bers are oriented
perpendicular to the skin incision, providing more durable coverage in the event of skin necrosis,
but more extensive dissection of the skin aps is required. Because the skin aps are functionally
delayed by the prior mastectomy, it is less critical to achieve complete lateral muscular coverage.
It is usually not necessary to elevate the anterior rectus fascia, serratus anterior muscle, or
pectoralis minor muscle to maintain satisfactory coverage of the expander. The same landmarks
are utilized in dissecting the pocket for delayed reconstruction as are used in immediate
reconstruction in terms of the location of the IMF in relation to the underlying ribs. Accurate
pocket dissection is equally important here to reduce the risk of malposition and malrotation.
Primary closure of the muscle splitting incision is performed and expansion under direct
visualization is performed to assess tension. Despite loss of skin domain in the setting of delayed
reconstruction, it can be combined successfully with immediate reconstruction for a reasonably
symmetric result (Fig. 4.16).*
Fig. 4.14 Preoperative markings for delayed rst stage bilateral breast reconstruction. With the
exception of the inframammary fold placement, the planned pocket dissections outlined are not
based on any remaining breast but a goal volume and a base diameter appropriate for the
patient’s chest diameter and habitus.
Fig. 4.15 Use of muscle-splitting incision to access implant pocket in delayed reconstruction.
The superior (small arrow) and inferior (large arrow) edges of the pectoralis major are retracted.*

Fig. 4.16 Second stage result shown A preoperatively, and B-D following delayed
reconstruction of right modi ed radical mastectomy and immediate reconstruction of left*
prophylactic mastectomy.
Drain Management
Drains are typically placed after immediate reconstruction, especially after axillary dissection,
but rarely in delayed or second stage reconstruction. Prior to skin closure, a closed bulb suction
drain is placed over the pectoralis muscle so that it is not in contact with the implant. If dermal
matrix is used, often a well-tunneled drain placed inside the implant pocket may be advisable
18due to reports of increased drainage volumes (Fig. 4.12). Drains are typically removed when
drainage is less than 30 ml over a 24-hour period, with many surgeons removing drains at 7–14
days irrespective of output. Any reaccumulation of uid can be removed postoperatively during
the expansion process by aspirations over the area of the ll port. Patients should not get the
drain sites wet and should sponge bath rather than shower. Good patient education and
meticulous care is essential to prevent an ascending infection originating at the drain site. A
rstgeneration cephalosporin or other empiric coverage for skin organisms is administered for 7–10
The tissue expansion process may begin intraoperatively with 60–1200 cc, or more if dermal
matrix is used. Outpatient expansion begins at 10–14 days postoperatively with each ll ranging
from 60 to 120 cc (Fig. 4.17). The magnetic port nder is used to locate the integrated valve and
a 21-gauge needle attached to IV tubing is used to trans x the valve. Early in the expansion
process, the interposed soft tissue may be thick and a long needle length (5 cm or greater) is
necessary. As more expansion is achieved, the soft tissue thins considerably and a shorter
butter y needle is suitable. Tissue expansion results in temporary ischemia and in ammation
that is minimized with smaller, more frequent lls. Expansion is repeated at 1 to 4 week
intervals and often the patient will determine the rate of expansion, as there is some discomfort
with each fill.
Fig. 4.17 Record of intraoperative and postoperative expansion.
We generally add volume until the patient is satis ed with the size and do not limit them or
encourage them to the complete recommended expander ll volume. One method of
determining this in unilateral reconstructions with planned mastopexy is to see if the expanded
breast matches the volume of the contralateral breast when wearing a bra. We often make note
of this volume if overexpansion is planned. The practice of overexpansion at 110–120% of the
patient’s desired size is intended to create a more natural appearing ptosis resulting from an+
implant smaller than the expanded pocket. This rationale may be based on the high prior
incidence of implant contracture. With a lower rate of capsular contracture in modern implants,
excess overexpansion may also contribute to a loss of implant pocket dimensions and orientation.
Expansion to within 10% of the goal volume is likely all that is necessary with current implants,
especially if capsulotomy will be tolerated by the inferior pocket skin and soft tissue.
Overexpansion is both more necessary and more difficult in previously irradiated patients.
Adjuvant therapy and tissue expansion
Chemotherapy often coincides with the tissue expansion process and is no contraindication to
continued expansion. We have not had signi cant concerns continuing the expansion between
cycles on non-chemotherapy weeks. It is important to make sure the patient has an adequate
absolute neutrophil count.
Radiation therapy is associated with an increased risk of infection, contracture and wound
19complications when combined with prosthetic implants and ongoing expansion places
considerable risk of dehiscence on an irradiated incision. Ideally, tissue expansion should
proceed to completion before initiation of radiation therapy. In our center, radiation therapy
typically begins 6–8 weeks after mastectomy, allowing adequate time for full expansion.
Second Stage Reconstruction
Timing of second stage reconstruction
Generally, second-stage reconstruction is anticipated 6 months after the mastectomy. The
process of tissue expansion, usually taking 2–3 months, results in in ammation that subsides
with time. Patience in this process allows for a more pliable capsule that requires less capsular
modi cation. Additionally, recipients of chemotherapy should have their second stage delayed
for 2 months after their nal treatment. In those patients who have been irradiated, the second
stage may be delayed 1 month for each week of radiation therapy, or 6 months in most cases.
Preoperative markings and implant selection
Ideally, the position of the permanent implant should be no di> erent from that of the tissue
expander, and little or no modi cation is required, but this is rarely the situation. Most patients
bene t from a minor revision of the pocket. In the event of expander migration or rotation, areas
of capsulotomy or capsulorraphy are marked (Fig. 4.18). A superomedial capsulotomy to
enhance cleavage and lateral capsulorraphy to medialize the pocket in the event of lateral
migration are typical adjustments. The base diameter of the breast is again con rmed and is a
primary deciding factor in choice of permanent implants to have in the operating room. It is
important to realize that the tissue expander comprises approximately 65–100 cc of volume and
this should be factored in the permanent implant volume selection.+
Fig. 4.18 Second stage marking: Preoperative marking in expanded patient prior to permanent
implant placement. Capsulotomies are planned to provide superomedial fullness. The
inframammary folds are marked, noting a lower fold on the right.
The choice of saline or silicone implants is left to the patient. Saline implants may o> er greater
projection in the larger patient, while the thin patient likely will prefer the surface camou age
and feel of silicone- lled implants. With respect to adverse events, we use the product
information data provided by the Food and Drug Administration (FDA) on saline and gel
implants to educate the patient regarding risks with emphasis on rupture, Baker grade III/IV
20contracture and overall reoperation (Table 4.2). In preoperative counseling we quote a 1% per
year per breast reoperation rate for contracture, based on the Mentor CPG MemoryGel study that
showed 5.2% rate of Baker grade III/IV contractures at 2 years in 251 primary reconstruction
21patients. For those patients that use a silicone implant, the FDA recommendation of 3 year
post-implant magnetic resonance imaging (MRI) with follow up MRI every 2 years is explained
to the patient, but we candidly recognize the clinical and practical limitations and controversy of
22using MRI as a screening tool for asymptomatic implant reconstructions. In absence of MRI
screening, yearly follow up with clinical exam should be su2 cient and may be the best clinical
Table 4.2 Comparison of 3-year cumulative rst occurrence Kaplan-Meier adverse event risk
ratesa by implant type
The issue regarding the choice of textured versus smooth implants warrants mention. Although
once believed to reduce the incidence of capsular contracture, textured round implants have
been shown to have no better outcomes than smooth devices in this respect, and are regarded by
many to have an increased rate of palpability, rupture, visible wrinkling, and lack of dynamic*
23motion. Form-stable textured implants have been used internationally and are currently under
evaluation in the United States. Although these devices o> er the theoretic advantage of a more
realistic shape, the textured surface necessary to anchor the implant in position may present
aesthetic issues. Also, the form-stable design may be unforgiving of slight degrees of malposition,
and the importance of precise pocket dissection to avoid rotation should be emphasized.
Surgical approach
The second stage approach begins by excising the mastectomy scars that have often widened
after the expansion process. If an identi able muscle layer is present, the muscle-splitting
approach described previously may be used. Often the muscle is attenuated and di2 cult to
identify as a layer distinct from the capsule. In this case the muscle and capsule are divided as
far inferiorly as possible by raising the inferior mastectomy skin ap. This results in optimal
coverage by ‘staggering’ the skin and muscle/capsule layers (Fig. 4.19). A secure multi-layer
closure is particularly critical in patients with poor healing capabilities following radiation. The
expander port is trans xed and partially de ated to allow intact removal without excessive
stretch or tearing of the capsulotomy. This is an important precaution because while the
expander and permanent implant ll volumes may be equivalent, the expander shell is
somewhat bulkier with sti> components, such as the integrated port. The expander shell also
adds approximately 65–100 cc to the ll volume, in comparison to the negligible volume of the
permanent implant silicone shell. Actual total expansion volume can be con rmed by volume
displacement in saline, in addition to what was aspirated from the expander to facilitate its
Fig. 4.19 Layered technique of entering capsule for second stage reconstruction. The muscle
layer incision is a muscle-splitting incision that is directed perpendicular to the skin incision and
is placed as inferior as possible.
Complete capsulectomy at the time of second stage reconstruction is not recommended
because of the loss of soft tissue coverage, possible injury to the blood supply of the overlying
skin and increased in ammation. Rather, directed capsulotomy and/or capsulorrhaphy are used
to provide optimal positioning and shaping. In general, a circumferential capsulotomy into the
subcutaneous fat is performed around the base of the pocket. A ‘zigzag’ inferior pole
capsulotomy will allow for lower pole distension and overhang (Fig. 4.20). When performing
inferior capsulotomies, it is necessary to divide any remaining pectoralis muscle fibers to gain the
necessary relaxation. When acellular dermal matrix has been used to provide lower pole
coverage, it has functionally become a part of the lower pole capsule. It should be incised
similarly if needed to provide the desired contour of the lower pole. In those patients with*
extremely thin lower pole soft tissue coverage, care should be taken to avoid dermal injury or
‘button-hole’ perforation. Upper pole capsulotomies are performed sparingly to prevent bulging
in the upper breast. Additional directed capsulotomies are performed as needed to allow for
expansion of the pocket to achieve the desired contour. Conversely, capsulorrhaphy sutures of
20 silk may be necessary to correct areas of overexpansion and meet the needs of the desired
permanent implant dimension. Accurate pocket positioning is necessary for optimal results.
Control of the pocket with the initial expander placement will obviate the need for signi cant
pocket manipulation at the second stage.

Fig. 4.20 A Schematic of capsulotomy with ‘zigzag’ pattern along inferior pole to allow
natural-appearing ptosis; upper pole capsulotomy is represented, if needed. B Preoperative
capsulotomy markings at second stage reconstruction.
Re-establishing the inframammary fold
Ideally the inframammary fold is preserved following the original mastectomy and, if not, it is
re-established at the time of tissue expander placement. A fold that appears too high may be a
result of insu2 cient inferior pocket dissection and inferior capsulotomy will address this. If the
fold has been lowered by expander migration, it should be re-established internally. From within
the pocket, the undersurface of the mastectomy flap is sutured internally to the expander capsule
at the bottom of the fth rib medially, the middle of the sixth rib at the meridian and the top of
the seventh rib laterally (Fig. 4.10). These static landmarks can be located by identifying the
second rib at the manubriosternal joint (Angle of Louis). Four to ve sutures are needed; braided
sutures such as Vicryl or silk are preferred as they are softer and will be in direct contact with
the prosthesis.
A range of implants should be available, although the base diameter and goal volume should
be known preoperatively. We nd the use of implant sizers helpful to be certain of the correct
volume prior to committing to a permanent device. The recently FDA-approved limited-use
silicone sizers are particularly helpful as they feature the various base diameter and projection
profiles to most closely approximate the appearance of the permanent implant. After final pocket
preparation, the permanent implants are removed from their packaging and inserted ensuring
correct orientation of the implant base. The muscle/capsule layer is closed with interrupted
absorbable mono lament stitches and the skin is closed with a running strong absorbable stitch.
If a contralateral symmetry procedure (e.g., augmentation, reduction, or mastopexy) is planned,*
it is important to nalize the implant positioning rst to establish the ideal breast mound
position against which to match the balancing procedure.
Postoperative Care
Patients are placed on a rst generation cephalosporin for 5 days after second stage
reconstruction. Drains should not be needed unless extensive capsular modi cations have been
made. The wound is checked at 1–2 weeks postoperatively. Implant massage has been employed
in the past to discourage capsular contracture but is likely less important as rates of capsular
contracture decline in incidence and severity. Massage may promote increased discomfort and
seroma formation and may alter the pocket con guration created intraoperatively. A soft
underwire bra is comfortably tted and maintained for 3 weeks postoperatively to support the
internal suturing. Nipple reconstruction, if the overlying soft tissue is adequate, is planned for 2
months after second stage reconstruction when the mastectomy scar has matured and is less of a
barrier to local ap perfusion. Tattooing may be delayed approximately 6 weeks after nipple
Complications and Pitfalls
Asymmetric breasts
Unilateral reconstruction or separately timed reconstruction procedures may result in signi cant
di> erences in size or ptosis that can be corrected at the time of second stage reconstruction. A
contralateral breast reduction, mastopexy (Fig. 4.21), or augmentation mastopexy may be
required and patients should be informed of the likelihood of future revisions to maintain
symmetry. Achieving symmetry with respect to the inframammary fold, nipple position and
overall breast size is challenging, particularly in those patients requiring contralateral
augmentation mammaplasty. One of the more di2 cult scenarios is the expanded breast that has
received radiation therapy and has a somewhat constricted envelope (Fig. 4.4). This may also be
a result of insu2 cient pocket dissection inferiorly and can be addressed by inferior capsulotomy
with avoidance of dissection below the internal rib landmarks.*

Fig. 4.21 Left-sided mastectomy shown A preoperatively and B after second stage
reconstruction with contralateral mastopexy for symmetry.
Loss of pocket control
The implant pocket may be made too large due to excessive tissue expansion or pocket dissection
at either rst or second stage reconstructive procedures (Fig. 4.22). This should be avoided by
adherence to dissection within the breast diameter when performing mediolateral dissection and
preservation of the inframammary fold with its re-establishment at the static rib landmarks if
necessary. Capsulorraphy may be needed for medial or lateral support.*
Fig. 4.22 Poorly positioned permanent implants due to pocket size mismatch.
Implant exposure
In immediate reconstruction, tension and mastectomy ap overdissection are associated with
skin ap necrosis at the incision. One of the bene ts to complete submuscular placement is that
local wound care is all that is necessary provided skin necrosis is minor and healthy muscle is
beneath (Fig. 4.23). When radiation over an expanded implant is poorly titrated, full thickness
skin loss remains a possibility. In severe cases, the expander may need to be removed (Fig. 4.24).
When the underlying device is a tissue expander, continued expansion to the desired volume or
to match a contralateral implant may not be possible and volume must be removed to allow
healing subsequent to any necessary debridement. In the event of permanent implant exposure,
debridement and immediate wound closure is necessary. If enough skin is lost so that primary
closure is not possible, the implant should be removed and additional skin is transferred by
autologous reconstruction (Fig. 4.25).
Fig. 4.23 Minor skin necrosis in this patient after rst stage reconstruction. This was managed
with local wound care without need for implant removal or autologous tissue transfer.+
Fig. 4.24 Skin necrosis during tissue expansion in a breast with prior radiation. Debridement
and autologous tissue transfer were required for salvage.
Fig. 4.25 Implant exposure after second stage reconstruction in a patient who had received
radiation to the left breast. The left implant was removed and a latissimus dorsi ap was
performed to replace irradiated skin on the breast mound.
Contracture and visible wrinkling
Capsular contracture is generally regarded to be a more frequent complication in reconstructive
than in primary augmentation mammaplasty, presumably because of the signi cantly reduced
soft tissue coverage likely increasing the sensitivity for detection if not the primary incidence.
Currently patients are advised that they will likely require a reoperation for contracture at 15
21years with an incidence of 1% per breast per year. Visible wrinkling may occur with silicone
as well as saline implants (Fig. 4.26), but can be best avoided by adequate submuscular implant
Fig. 4.26 Visible wrinkling in a submuscularly placed silicone permanent implant.
Implant infection
24Implant infection (Fig. 4.27) is quoted at 0.2–7% in recent literature. It is presumably higher
than in primary augmentation mammaplasty because of the decreased soft tissue coverage,
longer operating times, and the e> ects of chemoradiation therapy on the host defense system.
Implant removal with drainage and reoperation in 6 months is recommended for severe implant
infection. There are reports of implant salvage in circumstances where no frank pus is identi ed
in the implant pocket, and copious antibiotic irrigation and prolonged postoperative targeted
25,26antibiotic therapy is used. The presence of cellulitis near the incision does not necessarily
mandate operative exploration, and a trial course of antibiotics is reasonable. Antibiotics cannot
be expected to resolve an infected prosthesis or periprosthetic uid, however. In our institution
with a 30% incidence of methicillin-resistant Staphylococcus aureus (MRSA), empiric antibiotic
therapy consists of prolonged (2–6 weeks) of intravenous vancomycin therapy with the addition
of a penicillin for greater bactericidal e> ect in sensitive organisms. Ultimately, empiric therapy
should be tailored according to the prevalence of methicillin resistance at individual institutions.
Intraoperative cultures or periprosthetic fluid withdrawn during expansion in the clinic provide a
basis for any directed therapy. A trial of implant salvage with antibiotic therapy can be
exhausting for the clinician and patient alike, requiring many clinical visits for surveillance of
the breast as well as home intravenous antibiotic therapy. While there is occasional success,
e> orts at salvaging an implant may result in a tremendous expense of time and resources only to
result in explantation. Establishing an ‘end point’ at the initiation of therapy, where the implant
will be removed if certain goals are not achieved is highly recommended for the sake of everyone
Fig. 4.27 Clinical infection following immediate second stage reconstruction. Note the breast
reduction (Wise-pattern) mastectomy incision.*
The re nement of surgical technique, implant technology and a better understanding of
candidate selection are improving the result of the implant-reconstructed breast. The team
approach to implant-based reconstruction is evident as results improve when reconstructive
priorities are observed whenever possible. Of primary importance is the understanding of the
concept of pocket control. Appropriate pocket positioning must be maintained from the time of
mastectomy and expander placement to the placement of the nal implant. The improved
contour and feel of recently FDA-approved silicone gel implants with cohesive gels, as well as
innovative biologic substitutes such as dermal matrix to improve implant coverage are providing
a more realistic reconstruction even in patients with more aggressive surgical resections.
Autologous reconstruction may be considered the gold standard of breast reconstruction with
respect to soft tissue characteristics, and is often necessary in the setting of radiation injury,
where the limitations of implant reconstruction with respect to wound healing, limited expansion
and late contracture must be realized. Implant-based reconstruction, however, should not be
considered a second line of therapy, and in certain characteristic patients might represent the
best option for reconstruction. Indeed, many patients insist upon implant-based reconstruction to
avoid a donor defect, limit recovery time and potential morbidity, and to exercise choice in the
size of the reconstructed breast. With its increasingly patient-driven popularity, it is important
for the reconstructive surgeon to understand the best application of this technique to achieve
ideal results. The ultimate goal of achieving balance and symmetry and of reducing the patient’s
awareness of the mastectomy defect is no less important in expander reconstruction and no less
achievable provided there is a meticulous and well-planned approach.
1 Neumann CG. The expansion of an area of skin by progressive distention of a subcutaneous
balloon. Plast Reconstr Surg. 1957;19:124.
2 Radovan C. Reconstruction of the breast after radical mastectomy using temporary expander.
ASPRS Plast Surg Forum. 1978;1:41.
3 Austad ED, Rose GL. Self-inflating implant for donor tissue augmentation. Presented at the Annual
Meeting of the American Society of Plastic and Reconstructive Surgeons, Toronto, Canada,
4 Austad ED, Rose GL. A self-inflating tissue expander. Plast Reconstr Surg. 1982;70(5):588-594.
5 Austad ED, Pasyk KA, McClatchey KD, Cherry GW. Histomorphologic evaluation of guinea pig
skin and soft tissue after controlled tissue expansion. Plast Reconstr Surg. 1982;70(6):704-710.
6 Pasyk KA, Austad ED, Cherry GW. Intracellular collagen fibers in the capsule around silicone
expanders in guinea pigs. J Surg Res. 1984;36(2):125-133.
7 Kraemer O, Andersen M, Siim E. Breast reconstruction and tissue expansion in irradiated versus
not irradiated women after mastectomy. Scand J Plast Reconstr Surg Hand Surg.
8 Fisher E, Dignam J, Tan-Chiu E, et al. Pathologic findings from the National Surgical Adjuvant
Breast Project (NSABP): eight-year update of protocol B-17. Cancer. 1999;86:429-438.
9 Smigal C, Jemal A, Ward E, et al. Trends in breast cancer by race and ethnicity: update 2006. CA
Cancer J Clin. 2006;56(3):168-183.
10 Harris JR, Halpin-Murphy P, McNeese M, Mendenhall NP, Morrow M, Robert NJ. Consensusstatement on postmastectomy radiation therapy. Int J Radiat Oncol Biol Phys. 1999;15:989.
11 Goldhirsch A, Wood WC, Gelber RD, et al. Progress and promise: highlights of the international
expert consensus on the primary therapy of early breast cancer 2007. Ann Oncol.
12 Kronowitz SJ, Hunt KK, Kuerer HM, et al. Delayed immediate breast reconstruction. Plast Reconstr
Surg. 2004;113(6):1617-1628.
13 Spear SL, Onyewu C. Staged breast reconstruction with saline-filled implants in the irradiated
breast: recent trends and therapeutic implications. Plast Reconstr Surg. 2000;105(3):930-945.
14 Muntan CD, Sundine MJ, Rink RD, Acland RD. Inframammary fold: a histologic reappraisal. Plast
Reconstr Surg. 2000;105(2):549-556.
15 Bayati S, Seckel BR. Inframammary crease ligament. Plast Reconstr Surg. 1995;95(3):501-508.
16 Breuing KH, Colwell AS. Inferolateral AlloDerm hammock for implant coverage in breast
reconstruction. Ann Plast Surg. 2007;59(3):250-255.
17 Adams WP, Rios JL, Smith SJ. Enhancing patient outcomes in aesthetic and reconstructive breast
surgery using triple antibiotic breast irrigation: six-year prospective clinical study. Plast Reconstr
Surg. 2006;117(1):30-36.
18 Glasberg SB, D’Amico RA. Use of regenerative human acellular tissue (Alloderm) to reconstruct
the abdominal wall following pedicle TRAM flap breast reconstruction surgery. Plast Reconstr
Surg. 2006;118(1):8-15.
19 Evans GR, Schusterman MA, Kroll SS. Reconstruction and the radiated breast: is there a role for
implants. Plast Reconstr Surg. 1995;96:1111.
20 Physician product labeling for Mentor™ saline and silicone implants. (updated November 17, 2006, accessed
May 23, 2008)
21 Cunningham B. The mentor study on contour profile gel silicone memorygel breast implants.
Plast Reconstr Surg. December 2007;120(7 Supplement 1):33S-39S.
22 McCarthy CM, Pusic AL, Kerrigan CL. Silicone breast implants and magnetic resonance imaging
screening for rupture: do US Food and Drug Administration Recommendations reflect an
evidence-based practice approach to patient care? Plast Reconstr Surg. April
23 Handel N, Jensen JA, Black Q, Waisman JR, Silverstein MJ. The fate of breast implants: a critical
analysis of complications and outcomes. Plast Reconstr Surg. 1995;96(7):1521-1533.
24 Spear SL, Howard MA, Boehmler JH, Ducic I, Low M, Abbruzzesse MR. The infected or exposed
breast implant: management and treatment strategies. Plast Reconstr Surg.
25 Yii NW, Khoo CT. Salvage of infected expander prostheses in breast reconstruction. Plast Reconstr
Surg. 2003;111(3):1087-1095.
26 Chun JK, Schulman MR. The infected breast prosthesis after mastectomy reconstruction:
successful salvage of nine implants in eight consecutive patients. Plast Reconstr Surg.

Latissimus Dorsi Flap Breast Reconstruction
James H. Boehmler, Charles E. Butler
Key Points
1Latissimus dorsi (LD) myocutaneous aps, rst described by Tassini, have been used in various
reconstructive procedures for decades. In the setting of immediate or delayed breast
2reconstruction LD flaps have several characteristics that can make them excellent options.
1. In part because of their vascular supply from the thoracodorsal vessels, LD flaps have reliable
2. When used as pedicled flaps, LD flaps eliminate the need for microsurgery.
3. LD flaps can be customized, with variations that include full-muscle myocutaneous,
splitmuscle myocutaneous, muscle-only, and skin-and-fat-only flaps.
4. LD flaps are viable options for patients who have undergone radiotherapy.
5. LD flaps are good options for patients who are not candidates for abdominal flap-based
6. LD flaps can be used for chest wall coverage or as salvage therapy after a previous breast
reconstruction has failed.
Patient Selection
Patients who have undergone radiotherapy can also bene t from the use of an LD ap in breast
reconstruction. In these patients, the skin island of an LD ap can replace the constricted,
irradiated skin of the breast; and the muscle of an LD ap can cover an implant, thereby
3-5decreasing the risk of capsular contracture and implant infection. Patients who are at an
increased risk of mastectomy skin ap necrosis, such as tobacco smokers, may also bene t from
an LD ap, which can provide additional muscle coverage of a tissue expander or implant and a
robust skin paddle. Furthermore, focal skin and soft tissue defects caused by previous partial
mastectomy and radiotherapy that cannot be corrected with implants alone often can be
6,7repaired with an LD flap.
Every patient who desires breast reconstruction must undergo a thorough history and
examination to help determine which reconstruction technique should be used. Speci c details
should be obtained regarding previous surgery to the abdomen, chest and axilla, previous history
of radiation, and the patient’s preference for reconstruction method and willingness to undergo
major surgery. Many reconstructive surgeons prefer abdominal aps such as transverse rectus
abdominis myocutaneous, deep inferior epigastric, or super cial inferior epigastric artery aps

for autologous tissue-based breast reconstruction. However, patients may not desire or have
adequate tissue for an abdominal ap harvest. Furthermore, previous abdominal surgeries such
as abdominoplasty, laparotomy, or liposuction may reduce the reliability of an abdominal ap
or preclude abdominal ap-based breast reconstruction. In such cases, an LD ap o7ers a
reliable alternative to an abdominal ap. In addition, if an implant is going to be included in the
reconstruction, using an LD ap over the implant can improve the contour of the reconstructed
8breast, particularly in thin patients, in whom implant-based reconstructions tend to have less
esthetic results (Table 5.1).
Table 5.1 Advantages and disadvantages of latissimus dorsi ap-based breast reconstruction
compared to expander/implant-based reconstruction, and abdominal flap-based reconstruction
Operative Technique
Preoperative evaluation and markings
While the patient is awake and standing or sitting upright, the reconstructive surgeon uses a
provocative maneuver to evaluate the contractility of the LD muscle (Fig. 5.1). The patient
adducts her arm; as the LD muscle contracts, the reconstructive surgeon palpates and marks the
muscle’s anterior border. The tip of the scapula, posterior iliac crest, and midline are also
marked to further delineate the muscle’s topography (Fig. 5.2). If the patient has a history of
lymph node sampling and the LD muscle does not contract when the patient adducts her arm,
the thoracodorsal nerve may be injured or transected, and the adjacent thoracodorsal vascular
pedicle may also be injured.

Fig. 5.1 Forced adduction of the shoulder enables palpation and marking of the latissimus dorsi
muscle’s anterior border.
Fig. 5.2 Topography of the latissimus dorsi muscle. Key landmarks include the tip of the
scapula, the iliac crest, the posterior midline, and the muscle’s anterior border.
If the breast reconstruction requires a skin island, the reconstructive surgeon can design and
transpose a template of the size, shape, orientation, and location of the anticipated skin island
onto the skin that overlies the LD muscle. The location of the anticipated skin paddle is critical in
determining the relative location of the muscle and skin island in the reconstructed breast during
inset. The template should also re ect the 90–110° of rotation the ap will undergo from the
patient’s back to her chest during the reconstruction (Fig. 5.3). Attaching the template to a towel
and using the axilla as a pivot point can help the surgeon con rm the ap will reach its intended
nal location. To ensure that the ap donor site can be closed primarily, the reconstructive
surgeon should pinch together the anticipated incision lines. In most patients, primary closure


without signi cant tension can be performed if the skin island is less than 10 cm wide. If a skin
island is not required for breast reconstruction, the reconstructive surgeon can harvest the LD
ap through a small incision in the posterior axilla and use endoscopy to limit the number of
incisions made on the patient’s back.
Fig. 5.3 Preoperative markings for bilateral immediate breast reconstruction with latissimus
dorsi myocutaneous aps and tissue expanders after skin-sparing mastectomy. The skin paddle is
designed to rotate easily into the mastectomy defect, taking into consideration that 90–110
degrees of rotation will occur.
For unilateral breast reconstruction, an LD ap is commonly harvested and the donor site closed
while the patient is in a lateral decubitus position. The patient who undergoes immediate breast
reconstruction is usually in a supine position during mastectomy, and the reconstructive surgeon
can con rm the integrity of the thoracodorsal vascular pedicle and start the anterior dissection
of the LD ap from this approach; the patient can then be placed in the lateral decubitus
position for ap harvest and donor site closure. Following donor site closure, the patient is then
repositioned in the supine position for implant placement, ap inset, and breast symmetry and
shape examination.
For bilateral breast reconstruction, LD aps can be e ciently harvested while the patient is in
the prone position; however, care must be taken to avoid direct pressure on the mastectomy skin
aps while the patient is prone. Judicious use of padding can prevent breast skin ap
Flap elevation
Full-muscle myocutaneous flap elevation
If the patient has undergone axillary lymph node sampling, the reconstructive surgeon should
identify the vascular pedicle anteriorly though the mastectomy defect while the patient is supine.
Once the pedicle has been identi ed and preserved, the reconstructive surgeon should mobilize
the flap as much as possible from the surrounding soft tissues (Box 5.1).
Box 5.1 Surgical steps in latissimus dorsi (LD) flap harvest
• Create a breast pocket in the chest and a superior tunnel into the axilla
• Identify and confirm the patency of the thoracodorsal pedicle from an anterior approach
• Dissect the thoracodorsal pedicle from surrounding soft tissue using an anterior approach
• Confirm skin paddle markings and simulate transposition
• Incise skin and bevel away from incision line through subcutaneous fat
• If harvesting an extended LD flap, elevate the flap just deep to Scarpa’s fascia
• If harvesting a standard LD flap, elevate the flap at the level of the muscle fascia
• Complete the superficial dissection up to the borders of the LD muscle
• Identify the anterior border of the LD flap superiorly and separate the LD muscle from the
serratus anterior and external oblique muscles
• Elevate the LD muscle off the chest wall from the muscle’s anterior edge posteriorly
• Ligate all lumbar perforating vessels
• Divide the distal muscle from its inferior border
• Divide the medial muscle from the paraspinal fascia, taking care not to injure the fascia
• Separate the LD muscle superiorly from the trapezius and teres major muscles
• Identify the thoracodorsal pedicle on the deep surface of the LD muscle
• If necessary, circumferentially free the LD muscle proximal to the thoracodorsal pedicle and
divide the insertion
• Identify and divide the thoracodorsal nerve
• Transpose the LD flap to the chest and anchor a portion of muscle in the anterior axilla to
prevent traction injury to the vascular pedicle
• Place drains and close the donor site with quilting sutures
• Place the patient in the supine position
• Orient the LD muscle and skin paddle on the chest wall
• Suture the superior and medial aspects of the LD muscle into the edges of the breast pocket
• Place the expander or implant under the LD muscle
• Suture the remaining LD muscle around the expander or implant to provide complete muscle
• Place drains in the breast pocket and irrigate with antibiotic solution
• Suture the skin paddle in place
• Apply sterile dressings
Figure 5.4 shows the dissection planes for the standard myocutaneous and extended
myocutaneous LD aps. To facilitate a smooth transition between the mastectomy skin and the
skin island inset, the reconstructive surgeon incises the skin island at a slight outward angle

through the subcutaneous fat. Su cient subcutaneous fat is preserved at the edge of the donor
site to prevent a depressed scar and/or fasciodesis. When harvesting an extended LD ap, the
reconstructive surgeon creates a plane just deep to Scarpa’s fascia; the ap’s volume is increased
9,10by including a rim of deep fat below Scarpa’s fascia. In contrast, when harvesting a standard
LD myocutaneous ap, the reconstructive surgeon dissects directly down to the investing muscle
fascia. Dissection over the LD muscle is continued to its peripheral margins. The anterior margin
of the LD muscle is identi ed and separated from the serratus anterior muscle. Because the
serratus and external oblique muscles coalesce with the LD muscle inferiorly and posteriorly, it is
easier to identify the anterior border of the LD muscle cephalad and dissect the muscle from the
chest wall caudally. Once the LD muscle’s anterior border is freed, the plane deep to the LD
muscle is developed caudally to avoid injuring the vascular pedicle. The large lumbar and
intercostal perforating vessels entering the posterior surface of the LD muscle are isolated and
Fig. 5.4 Dissection planes for the standard myocutaneous and extended myocutaneous
latissimus dorsi aps. The standard ap dissection plane bevels slightly away from the skin
incision toward the deep investing fascia of the latissimus dorsi muscle. The extended ap
dissection proceeds until the Scarpa’s fascia is identi ed; the ap is raised just deep to this fascia,
leaving deep fat attached to the muscle for added soft-tissue bulk.
Using electrocautery or electrosurgical bipolar scissors, the inferior border of the LD muscle is
divided. In a cephalad direction, the muscle is released from its medial fascial attachments and
elevated o7 the chest wall. The underlying paraspinous fascia is not violated while the muscle is
being detached from the posterior midline. The inferior lateral border of the overlying trapezius
muscle is identi ed and preserved as medial dissection of the LD muscle progresses cephalad.
Once the medial aspect of the LD muscle is freed, the muscle’s superior edge is separated from
the trapezius muscle medially and from the teres major muscle laterally. If a deep fat pad is to
be included with the LD flap, the teres major muscle is not raised with the flap.
Dissection of the LD muscle proceeds cephalad toward the neurovascular bundle, which enters
the deep surface of the LD muscle 8–10 cm inferior to the axillary line and 2–3 cm lateral to the
muscle’s anterior border. The anterior branch of the bundle that supplies the serratus anterior
muscle group is identi ed and preserved unless it prevents adequate ap rotation. The pedicle
dissected is typically 8–10 cm long, but complete dissection of the pedicle often is not necessary
to allow for an adequate arc of rotation; therefore, pedicle dissection should proceed only to a
point that enables adequate flap rotation without tension on the vascular pedicle (Fig. 5.5).

Fig. 5.5 Elevated bilateral myocutaneous latissimus dorsi aps, prior to inset into the
mastectomy defects.
The tendinous insertion into the humerus is exposed by dissecting cephalad and
circumferentially near the LD insertion. The reconstructive surgeon can divide the insertion to
increase the arc of rotation and reduce any axillary bulging that the rotated proximal muscle
11may cause. If the insertion is completely divided, care must be taken to prevent traction injury
to the vascular pedicle.
The thoracodorsal nerve is identi ed, isolated, and divided at the surgeon’s discretion.
Dividing the thoracodorsal nerve helps prevent muscle contraction when the patient attempts
arm adduction and extension. If the nerve remains undivided, muscle contraction may resolve as
the muscle atrophies; however, continued muscle contraction may annoy the patient, and
secondary division of the nerve is difficult.
Two large, closed-suction drains are placed in a dependent location in the donor site. Drains
are typically left in place for 1–3 weeks and removed once the output decreases to fewer than
30 ml of drainage per 24 hours. Placing quilting or progressive tension sutures from the donor
site skin aps to the chest wall may decrease the amount of drainage and incidence of seroma
13formation by closing o7 the dead space left by ap dissection and preventing shear forces.
Primary skin closure can be performed without signi cant tension in almost all cases in which
the skin paddle is less than 10 cm wide (Fig. 5.6).
Fig. 5.6 Primary closure of the donor site usually can be achieved when the skin paddle is less
than 10 cm wide. Pinching together the anticipated incision lines can help determine the amount
of skin that can be removed.

Split LD flap elevation
A split (segmental) LD ap can be useful in reconstructions for partial mastectomy defects. The
14,15anatomical basis for splitting the LD muscle is well established. The skin paddle is marked
as in Figure 5.3 and incised, and the anterior border of the LD muscle is identi ed. The lateral
descending branch of the thoracodorsal pedicle is identi ed on the undersurface of the muscle,
and intramuscular dissection is performed medial to the lateral vascular pedicle. The remaining
muscle’s vascular pedicle is sacri ced to allow for ap rotation; however, the muscle’s nerve
branches are preserved to provide motor function.
Thoracodorsal artery perforator flap elevation
15-18Like a split LD ap, a thoracodorsal artery perforator ap can be used to repair partial
breast defects without compromising function of the remaining LD muscle. Preoperative
ultrasonography or computed tomography angiography is usually used to help identify
perforators on which to base the ap. The LD ap can be based on a row of perforators
approximately 2 cm from the anterior margin of the ap just caudal to its scapular tip. Once the
perforators are identi ed, a skin paddle is designed around the selected perforator. The skin
island should be incised on only one side of the ap, preferably its anterior portion. Once the
perforator is identi ed, the remainder of the skin island is elevated, and intramuscular dissection
proceeds to the point at which the perforator meets with the thoracodorsal vascular pedicle. The
LD muscle’s nerve branches are dissected from the vascular pedicle and preserved. All other
vascular branches are divided until adequate pedicle length is attained. Great care must be
taken to prevent traction injury to the perforators and vascular pedicle.
Flap insetting
A subcutaneous tunnel between the LD muscle donor site and the mastectomy defect should be
created if one is not already present (Fig. 5.7). This tunnel is made as high in the axilla as
possible while still allowing adequate ap insetting to help recreate the breast’s anterior axillary
fold and prevent excessive tissue bulk in the axilla. When an implant is included, the
reconstructive surgeon uses interrupted sutures to attach the edge of the LD muscle to the lateral
chest wall and prevent migration of the implant into the axilla or donor site (Fig. 5.8). Securing
the muscle to the chest wall laterally also helps prevent traction on the vascular pedicle,
particularly if the muscle insertion has been transected.

Fig. 5.7 The subcutaneous tunnel for latissimus dorsi ap rotation should be made high in the
axilla to better de ne the lateral border of the breast pocket and prevent the ap and/or implant
from migrating into the axilla.
Fig. 5.8 The latissimus dorsi ap is brought to the chest through a high subcutaneous tunnel in
the axilla. The proximal muscle is anchored with stitches to the lateral breast pocket to prevent
traction injury to the thoracodorsal vascular pedicle.
Immediate reconstruction
The pectoralis major muscle is often maintained on the chest wall following mastectomy, and an
implant can be placed above or beneath it. We prefer to elevate the pectoralis major muscle and
place the implant beneath it to provide superior implant coverage and improve the contour
transition from the chest wall to the implant along the superior pole of the reconstructed breast.
In this case, the LD muscle is sutured ventral to the elevated pectoralis major muscle in a
‘pantsover-vest’ fashion (Fig. 5.9). The borders of the LD muscle are secured to the chest wall within
the mastectomy pocket. Inserting the transected LD muscle into the pectoralis major tendon can
improve the axillary contour of the reconstructed breast. As much of the ap inset as possible
should be performed before placement of the expander or implant. Carefully insetting the LD

muscle is important to correctly position the reconstructed breast and maximize symmetry
between the reconstructed and contralateral breast. The LD ap inset must also allow the skin
island to be appropriately located on the reconstructed breast to provide skin coverage within
the mastectomy ap skin edges. If the LD ap is not large enough to fully cover the implant, the
LD muscle can be sutured to the inferior border of the elevated pectoralis major muscle to create
adequate submuscular space for the implant. Closed-suction drains are placed between the
subcutaneous mastectomy skin aps and LD muscle and within the submuscular pocket. The
skin edges are trimmed to their nal dimensions, and the skin island is fully inset (Fig. 5.10).
Nipple and areola reconstruction are performed at a later stage (Figs 5.11 and 5.12).
Fig. 5.9 The latissimus muscle is inset to completely cover the implant.
Fig. 5.10 The skin edges of the ap are trimmed and inset only after the mastectomy aps are
trimmed back to viable tissue.

Fig. 5.11 A A preoperative photograph of a patient about to undergo bilateral skin-sparing
mastectomies and immediate breast reconstruction. B The nal postoperative appearance of the
patient after reconstruction with latissimus dorsi aps and implants and subsequent nipple and
areola reconstruction and tattooing.

Fig. 5.12 A A preoperative photograph of a patient about to undergo immediate unilateral
breast reconstruction with a latissimus dorsi ap and implant and contralateral breast
augmentation. B Preoperative markings. C The patient after subsequent nipple reconstruction.
She will eventually receive tattooing to color the areola.
Delayed reconstruction
When LD ap breast reconstruction is performed in a delayed setting, including after previous
expander- or implant-based reconstruction, the pectoralis major muscle can either be left with
the mastectomy ap or placed back on the chest wall depending on the amount of LD muscle
available and the integrity of the mastectomy skin aps. In patients with very thin mastectomy
aps or patients who have undergone radiotherapy or use tobacco, the pectoralis major muscle
should remain attached to the mastectomy ap to help reduce mastectomy skin ap necrosis. In
some patients, the subpectoral space is too tight for implant placement, and the mastectomy ap
may need to be freed from the pectoralis major muscle. If the pectoralis major muscle remains
attached to the mastectomy ap, the LD muscle is attached to the inferior edge of the pectoralis
major muscle and then to the inframammary fold. The LD ap skin island is usually inset at the
re-incised mastectomy scar. If there is lower pole skin de ciency or the inframammary fold is
markedly elevated, the skin paddle can be inset into an inframammary incision. To ensure that
the skin island and LD muscle are correctly oriented in the reconstructed breast, the
reconstructive surgeon should plan the incision and skin paddle inset position and mark the
patient prior to the start of the surgery.
Pitfalls and How to Correct
The large potential space created during LD ap harvest can contribute to donor site seroma, the
5,8,10,13,19most common complication of LD ap-based breast reconstruction. Multiple
long13term drains and quilting sutures can be used to prevent seromas. If a seroma develops after all
surgical drains have been removed, serial aspirations are generally the initial treatment step, and
frequently, the seroma will resolve quickly. If not, a new drain can be placed; often, this
20 21treatment can be supplemented with diluted brin sealant injections, sclerotherapy, or
22steroid injections. Using compression garments or wrapping the donor site with elastic
bandages is an important adjunct to all treatment options. If the seroma persists, surgical
23decortication of the seroma pseudocapsule can be performed with the use of quilting sutures
and closed-suction drains.
Axillary node dissection
Weak or absent LD muscle function in patients who have undergone axillary node sampling is
suggestive of thoracodorsal nerve and/or vascular pedicle injury; however, a functional LD
muscle does not always indicate an intact vascular pedicle. Therefore, in patients who have
undergone axillary node sampling, the reconstructive surgeon should con rm the patency of the
pedicle before elevating the LD ap. If the thoracodorsal vessels have been injured or transected
proximal to the branch to the serratus anterior muscle, an LD ap can be elevated based on this
24serratus branch with retrograde arterial in ow. On the other hand, if the thoracodorsal and
serratus branch vessels have been injured or transected, the reconstructive surgeon may choose
to microsurgically repair the vessels or use a reconstructive technique that does not involve the

ipsilateral LD muscle.
Vascular pedicle injury
Despite preventative measures, vascular pedicle injury can occur in LD ap breast
reconstruction. Common causes include injury caused by traction and inadvertently dividing the
pedicle from the ap while attempting to divide the thoracodorsal nerve. Depending on the
injury, microsurgically repairing the ap vessel to the remaining thoracodorsal vessels can often
be performed. If too much pedicle is sacri ced, converting to a free ap with the internal
mammary arteries used as donor vessels or with the use of vein grafts to the subscapular axis
vessels can be performed. If the injury is proximal to the serratus branch, the LD ap may be
24transferred based on retrograde flow through the serratus branch to provide flap vascularity.
Postoperative Care
Sterile dressings are placed at the end of surgery. Pressure in the axilla needs to be avoided to
prevent vascular compromise of the ap. An abduction pillow can be used to keep the abducted
arm away from the axilla during the early postoperative period. A window in the dressing over
the skin paddle should be created to enable clinical assessment of the flap’s vascularity.
The ap’s vascularity should be evaluated frequently by assessing the paddle’s temperature,
appearance, and capillary re ll color. Twists in the vascular pedicle, position-related tension,
and/or hematoma should be corrected immediately with surgical re-exploration.
To reduce the risk of bleeding and prevent undue tension on the ap inset or vascular pedicle,
patients should limit movement of the arm on the side of the reconstruction for 1–2 weeks.
Thereafter, progressive range of motion exercises are initiated to help prevent shoulder sti7ness.
Prolonged shoulder sti7ness, if it occurs, can be e7ectively treated with physical therapy.
Patients generally regain full shoulder function and are able to resume their normal daily
25,26activities after 3 or 4 weeks.
LD aps have consistent vascular anatomy and do not require microsurgery for transfer; they
also provide good soft tissue coverage over implants that potentially improves the cosmesis of the
reconstructed breast while decreasing the infection and capsular contracture rates associated
with implant-only breast reconstruction. The LD ap’s skin paddle can be used to replace
missing or de cient breast skin and enables immediate breast mound creation without the need
for serial expansion of a tissue expander and subsequent placement of a permanent implant. In
addition, LD ap-based breast reconstruction is an excellent option for women who are not
candidates for or who do not wish to undergo abdominal ap-based breast reconstruction (Fig
12A–C). Variations of the LD ap, including the split-muscle ap and the thoracodorsal artery
perforator flap, can be used to repair partial mastectomy defects with little donor site morbidity.
1 Maxwell GP. Iginio Tansini and the origin of the latissimus dorsi musculocutaneous flap. Plast
Reconstr Surg. 1980;65:686.
2 Bostwick J, Nahai F, Wallace JG, Vasconez LO. Sixty latissimus dorsi flaps. Plast Reconstr Surg.
1979;63:31.3 Spear SL, Boehmler JH, Taylor NS, Prada C. The role of the latissimus dorsi flap in reconstruction
of the radiated breast. Plast Reconstr Surg. 2007;119:1.
4 Chang DW, Barnea Y, Robb GL. Effects of an autologous flap combined with an implant for breast
reconstruction: an evaluation of 1000 consecutive reconstructions of previously irradiated
breasts. Plast Reconstr Surg. 2008;122:356.
5 Pinsolle V, Grinfeder C, Mathoulin-Pelissier S, Faucher A. Complications analysis of 266 immediate
breast reconstruction. J Plast Reconstr. Aesth Surg. 2006;59:1017.
6 Clough KB, Kroll SS, Audretsch W. An approach to the repair of partial mastectomy defects. Plast
Reconstr Surg. 1999;104:409.
7 Kronowitz SJ, Feledy JA, Hunt KK, et al. Determining the optimal approach to breast
reconstruction after partial mastectomy. Plast Reconstr Surg. 2006;117:1.
8 Moore TS, Farrell LD. Latissimus dorsi myocutaneous flap for breast reconstruction: long-term
results. Plast Reconstr Surg. 1992;89:666.
9 Hofkin JAB, Silfverskiold KL. Breast reconstruction without an implant: results and complications
using an extended latissimus dorsi flap. Plast Reconstr Surg. 1987;79:58.
10 Chang DW, Youssef A, Cha S, Reece GP. Autologous breast reconstruction with the extended
latissimus dorsi flap. Plast Reconstr Surg. 2002;110:751.
11 Gerber B, Krause A, Reimer T, Muller H, Friese K. Breast reconstruction with latissimus dorsi flap:
improved aesthetic results after transection of its humeral insertion. Plast Reconstr Surg.
12 Akhtar S. Our early experience in the use of tissue glue to reduce the incidence of seroma
formation from the latissimus dorsi flap donor site. Plast Reconstr Surg. 2005;116:347.
13 Rios JL, Pollock T, Adams WP. Progressive tension sutures to prevent seroma formation after
latissimus dorsi harvest. Plast Reconstr Surg. 2003;112:1779.
14 Tobin GT, Schusterman M, Peterson GH, Nichols G, Bland KI. The intramuscular neurovascular
anatomy of the latissimus dorsi muscle: the basis for splitting the flap. Plast Reconstr Surg.
15 Schaverien M, Saint-Cyr M, Arbique G, Brown SA, Rohrich RJ. Three- and four-dimensional
arterial and venous anatomies of the thoracodorsal artery perforator flap. Plast Reconstr Surg.
16 Heitmann C, Guerra A, Metzinger SW, Levin LS, Allen RJ. The thoracodorsal artery perforator
flap: anatomic basis and clinical applications. Ann Plast Surg. 2003;51:23.
17 Levine JL, Soueid NE, Allen RJ. Algorithm for autologous breast reconstruction for partial
mastectomy defects. Plast Reconstr Surg. 2005;116:762.
18 Hamdi M, Van Landuyt K, Monstrey S, Blondeel P. Pedicled perforator flaps in breast
reconstruction: a new concept. Br J Plast Surg. 2004;57:531.
19 Tomita K, Yano K, Masuoka T, Matsuda K, Takada A, Hosokawa K. Postoperative seroma
formation in breast reconstruction with latissimus dorsi flaps. Ann Plast Surg. 2007;59:149.
20 Butler CE. Treatment of refractory donor-site seromas with percutaneous instillation of fibrin
sealant. Plast Reconstr Surg. 2006;117:976.
21 Shermak MA, Rotellini-Coltvet LA, Chang D. Seroma development following body contouring
surgery for massive weight loss: patient risk factors and treatment strategies. Plast Reconstr Surg.
22 Taghizadeh R, Shoaib T, Hart AM, Weiler-Mithoff EM. Triamcinolone reduces seroma
reaccumulation in the extended latissimus dorsi donor site. J Plast Reconstr Aesth Surg.2008;61:636.
23 Roje Z, Roje Z, Karanovic N, Utrobicic I. Abdominoplasty complications: a comprehensive
approach of chronic seroma with pseudobursa. Aesth Plast Surg. 2006;30:611.
24 Fisher J, Bostwick J, Powell RW. Latissimus dorsi blood supply after thoracodorsal vessel
division: the serratus collateral. Plast Reconstr Surg. 1983;72:502.
25 Russel RC, Pribaz J, Zook EG, Leighton WD, Erikkson E, Smith CJ. Functional evaluation of
latissimus dorsi donor site. Plast Reconstr Surg. 1986;78:336.
26 Spear SL, Hess CL. A review of the biomechanical and functional changes in the shoulder
following transfer of the latissimus dorsi muscles. Plast Reconstr Surg. 2005;115:2070.'
TRAM Flap Breast Reconstruction
Paul R. Weiss
Breast reconstruction after mastectomy had its primitive beginning with an implant
placed subcutaneously in a delayed procedure. The concept of immediate
reconstruction was rejected for numerous unsubstantiated reasons, notably that the
patient should live with the deformity and that early cancer recurrence would be
1masked by the reconstruction. Goin and Goin advocated immediate reconstruction
and emphasized the added bene t of contralateral prophylactic mastectomy when
appropriate. Many specialists who could potentially refer their patients for
reconstruction did not because of these unfounded concerns. In the late 1970s,
2musculocutaneous aps were introduced, o ering rst the latissimus dorsi.
3Several years later, Hartrampf et al presented the rectus abdominis procedure
which o ered completely autologous reconstruction. These new techniques,
together with tissue expanders, now achieved superior aesthetic results with a high
degree of reliability. Despite these facts, convincing the oncologic surgeons to o er
their patients delayed or immediate reconstruction was very di/ cult. With slow
acceptance of delayed procedures, it took much longer for the immediate
procedure to be recognized. Today the surgical armamentarium of aps and tissue
expander/implants makes the prospects of mastectomy for patients much easier to
accept. For surgeons recommending the option of breast conservation versus
mastectomy, the prospect of a satisfactory aesthetic result makes mastectomy more
acceptable, if indicated. This includes those patients with small breasts or tumors
located in the upper quadrants where the aesthetic result after lumpectomy and
radiation often produce less than ideal results.
Patient Selection
The consultation with the plastic surgeon for a patient recently diagnosed with
breast cancer is an emotionally charged experience. The history may reveal
contraindications for a pedicled transverse rectus abdominis myocutaneous
(TRAM) ap and the focus will turn to an alternate and more appropriate choice.
The physical examination may also reveal scars or a body habitus that is&
inappropriate. If the procedure is unilateral, the breast remaining after the
mastectomy must be carefully evaluated. If it is of reasonable size and the degree
of ptosis is such that it is appropriate to match the reconstruction to it, the
assessment is more straightforward. If the breast is either too large or too small, or
if signi cant ptosis is present, the surgeon and patient must collaborate to decide
how the reconstruction can and may be fashioned to achieve the desired end result.
Realistic expectations must also be addressed, in conjunction with the patient’s
overall cancer management and resultant anxiety.
The decision for TRAM reconstruction depends upon the patient’s appropriate
anatomy and medical condition. Signi cant obesity and/or an associated pannus of
redundant skin may compromise the circulation to the abdominal wall or TRAM.
Abdominal wall scars may compromise the circulation of the abdominal skin ap
4resulting in necrosis and delayed healing. The subcostal scar resulting from an
open cholecystectomy is associated with division of the rectus muscle precluding its
use as a pedicle on that side. A modi cation of the skin incision on the right
abdomen to include the subcostal scar with the skin island placed higher eliminates
the problem of an ischemic area below the scar, a potential cause of abdominal
ap necrosis. This modi cation does not interfere with developing a satisfactory
5left-sided pedicle. Vertical midline scars do not allow use of tissue across the scar
unless a bilateral pedicle is employed for unilateral reconstruction. Recently,
Mustoe has demonstrated that a delay procedure allows survival of tissue across a
6vertical midline scar with a unilateral pedicle. Suprapubic scars do not pose a
problem to the blood supply of either donor site or the TRAM musculocutaneous
unit. With a large percentage of patients having undergone prior gynecologic
procedures, the major problem encountered has been a more technically di/ cult
dissection due to scarring. In one case, bowel adherent to the rectus muscle in an
unrecognized midline infraumbilical hernia required a segmental small bowel
resection when the gut wall was injured during a di/ cult dissection. A right lower
quadrant appendectomy scar limits the use of tissue lateral to the scar or favors the
use of a left sided pedicle as an alternative. Subjects who are very thin are still
viable candidates if they have adequate redundant skin to create a TRAM island
and allow closure of the donor site. Here, a prosthesis may be added immediately
or at the time of nipple–areola reconstruction, which is the author’s preference.
Those patients with signi cant lumbosacral disease, that is, spondylolisthesis, are
thought to be further compromised if the rectus muscle is sacri ced. Severe asthma
or chronic obstructive pulmonary disease may compromise the postoperative
recovery, but do not contraindicate the procedure. Ischemic heart disease may
preclude a long surgery and anesthesia. Cardiac decompensation is a pertinent'
consideration for patients who have received prior treatment with cardiotoxic
chemotherapeutic agents. Insulin-dependent diabetics have an increased risk of
complications in general, but of particular concern is the viability of the abdominal
wall where ischemia of the ap may result in fat or skin necrosis and wound
7 8dehiscence. Similar potential problems apply to smokers and obese patients.
The choice of a pedicled TRAM over other autologous methods of reconstruction
or prosthesis-based techniques depends upon many objective factors as described
above. The subjective reasons to choose a particular procedure often involves the
patient, referring oncologic surgeon or other healthcare provider. Experience with
other patients, those of friends or family also often play a role in decision making.
Because autologous reconstruction arguably o ers the best result, it is the author’s
rst choice on the reconstructive ladder. Likewise, immediate reconstruction should
be considered unless postoperative radiation therapy to the chest wall is certain or
there is a possibility that a contralateral mastectomy is considered but refused by
the patient or is not practical at the time. A tissue expander may be placed as a
temporary method of preserving the mastectomy aps as a spacer and leave the
9option open for later autologous reconstruction. Genetic testing has signi cantly
increased the number of patients opting for a prophylactic mastectomy of the
opposite breast when diagnosed with cancer. The importance of family history in
BRCA negative patients has also made prophylactic uni- and bilateral mastectomy
10and reconstruction a common occurrence. Likewise, those patients with strong
family history, positive genetic markers or concerns about cancer detection are
11-13presenting for bilateral mastectomy without a cancer diagnosis. Because the
abdominal donor site can only be used once, risk of future disease in the opposite
breast must be considered as part of the treatment options and informed consent.
Planning mastectomy incisions is a collaborative e ort between the oncologic
and reconstructive surgeon to consider the many options. The position of the tumor
and its relation to the nipple–areola is most important as the skin incision will be
determined by their location. Many surgeons will include the biopsy site in the skin
incision leading to additional skin ap sacri ce. The concept of skin sparing
mastectomy has many interpretations. Preservation of the breast skin usually
facilitates better aesthetic outcomes. When there is enough skin to allow a
completely de-epithelialized TRAM island, minimal scarring usually results and
there is no mismatch of skin color or contour. A transversely oriented scar can later
be disguised if the nipple reconstruction punctuates it. Similarly, when only the
nipple–areola is sacri ced, the scar is minimal as reconstruction of the nipple–
areola will completely obliterate most or all of it. If the breast is large enough and
the tumor position allows preservation of the upper breast skin, a Wise pattern
14(keyhole) mastectomy may be employed. This approach allows contouring to
reduce lateral fullness and very acceptable incision placement. The secondarily&
reconstructed nipple can usually be placed at or near the apex of the vertical limb
of the inverted ‘T.’ A vertical mammaplasty pattern may also be useful in a skin
15,16sparing mastectomy.
The concept of considering the breast as an anatomical unit with regard to scars
calls for sacri ce of the native inferior breast skin ap to the inframammary fold.
This sacri ces sensate skin and may contribute to an unnecessarily tight skin
closure. Compromise of the reconstructed breast shape or incision healing and
scarring may also occur. Salvage situations including a poor outcome resulting
from implant reconstruction may necessitate the sacri ce of skin above or below
the original mastectomy scar, particularly when the previously reconstructed nipple
is malpositioned, or may become malpositioned with alteration of skin anatomy.
Operative Technique I: Planning
Vascular anatomy
The design of the cutaneous component of a pedicle ap must take advantage of
the best blood supply while utilizing the most satisfactory tissue to create a breast
mound. The internal mammary artery descends subcostally dividing into the
musculophrenic and deep superior epigastric branches. The musculophrenic sends
branches to the intercostal vessels. This costomarginal anastomotic circulation is an
alternate one when the internal mammary is divided as a result of previous surgery.
The deep superior epigastric artery emerges under the medial costal margin and
enters the deep surface of the muscle with its accompanying veins. The vessels
course within the body of the muscle. Above the level of the umbilicus, the vessels
become a web of choke vessels, which anastamose with the vascular supply from
17the deep inferior epigastric system. Since the deep inferior epigastric artery that
branches from the internal iliac is the dominant pedicle, there is circulatory
compromise when the artery and its two venae comitantes are divided to allow
pedicle transfer. This is because the skin island is located over the angiosome of the
deep inferior epigastric artery and veins. The venous valves prevent ow superiorly
until dilatation secondary to venous congestion renders them incompetent (Fig.
6.1). Understanding the ow dynamics within the muscle and subcutaneous
components of the ap are best explained in Moon and Taylor’s diagrammatic
representation of the ‘staircase effect’ (Fig. 6.2) Venous return is compromised more
often than arterial and is manifested as venous congestion. When ap circulation is
compromised, a satisfactory solution is decompression of one of the veins. This
18maneuver is described later in this chapter. Moon and Taylor studied the rectus
circulation and describe three patterns of supply from the deep epigastric artery.
The most common type branches into two vessels just below the arcuate line. The
inferior epigastric pedicle most often enters the deep side of the muscle from the
lateral side. Perforating vessels are found in two rows just medial and lateral to the