Professional Documents
Culture Documents
Reconstructive
Breast Surgery
Solving Complications
and Avoiding
Unfavorable Results
Edited by
Seth Thaller
Zubin J Panthaki
Edited by
Seth Thaller, MD, DMD, FACS
Chief and Professor, Division of Plastic, Reconstructive, and Aesthetic Surgery,
The DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller
School of Medicine, Miami, Florida, USA
Zubin J Panthaki, MD
Associate Professor of Surgery, Division of Plastic, Reconstructive, and Aesthetic Surgery,
The DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller
School of Medicine, Miami, Florida, USA
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Library of Congress Cataloging-in-Publication Data:
Aesthetic and reconstructive breast surgery: Solving complications and avoiding unfavorable results/edited by Seth Thaller
and Zubin J Panthaki.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-84184-847-1 (hb : alk. paper)
I. Thaller, Seth R. II. Panthaki, Zubin J.
[DNLM: 1. Mammoplasty. 2. Breast: surgery. 3. Postoperative complications: prevention and control. 4. Reconstructive
surgical procedures: methods. 5. Reoperation. WP 910]
618.190592--dc23
2011038490
ISBN-10: 1-84184-847-6
ISBN-13: 978-1-84184-847-1
eISBN: 978-1-84184-848-8
Orders may be sent to: Informa Healthcare, Sheepen Place, Colchester, Essex CO3 3LP, UK
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Dedication
I would like to thank my wife and family for supporting and allowing me the time and opportunity to pursue the
best career in the world. I also extend my deepest gratitude to my parents who provided me with the environment
to successfully pursue a career in Plastic Surgery. Lastly, I would like to thank my mentors and colleagues whom
I have had the good fortune to meet and work with throughout my career.
Seth
I would like to dedicate this book to my parents, Nergish and Jal Panthaki, on the occasion of their fiftieth
wedding anniversary. Their love and support is a continuous source of strength and inspiration to me. I would
also like to thank my wife, Dimple, and our sons, Karl and Kayaan, who make it all worthwhile.
Zubin
Contents
Contributors
ix
Acknowledgments
xi
Foreword
xii
Preface
xiii
1 Breast and chest: Applied anatomy, evaluation of the patient undergoing breast surgery,
initial consultation, analysis, and patient selection
16
Ada P. Romilly
4 Breast asymmetry
26
Thomas R. Stevenson
5 Mastopexy
37
6 Reduction mammoplasty
47
56
66
81
87
vii
CONTENTS
viii
102
109
124
139
155
166
17 Gynecomastia
190
Gary Rose
197
Index
203
Contributors
Bassan J. Allan
The DeWitt Daughtry Family Department of Surgery,
University of Miami Leonard M. Miller School of
Medicine, Miami, Florida, USA
Peter J. DiPasco
Division of Surgical Oncology, The DeWitt Daughtry
Family Department of Surgery, University of Miami
Leonard M. Miller School of Medicine, Miami,
Florida, USA
Anuja K. Antony
Division of Plastic, Reconstructive and Cosmetic Surgery,
University of Illinois at Chicago Medical Center,
Chicago, Illinois, USA
Gregory R. D. Evans
Aesthetic and Plastic Surgery Institute, University of
California, Irvine, California, USA
Eli Avisar
Division of Surgical Oncology, The DeWitt Daughtry
Family Department of Surgery, University of Miami
Leonard M. Miller School of Medicine, Miami,
Florida, USA
Onelio Garcia Jr
Division of Plastic, Reconstructive, and Aesthetic
Surgery, The DeWitt Daughtry Family Department of
Surgery, University of Miami Leonard M. Miller
School of Medicine, and Division of Plastic Surgery,
Palmetto General Hospital, Hialeah, Florida, USA
Keith Brandt
Division of Plastic and Reconstructive Surgery,
Washington University, St Louis, Missouri, USA
Bulent Genc
Istanbul Aesthetic Surgery, Istanbul, Turkey
Eric Chang
Columbia Aesthetic Plastic Surgery, Columbia,
Maryland, USA
Robert A. Grossman
Division of Surgical Oncology, The DeWitt Daughtry
Family Department of Surgery, University of Miami
Leonard M. Miller School of Medicine, Miami,
Florida, USA
Mimis N. Cohen
Division of Plastic, Reconstructive and Cosmetic Surgery,
University of Illinois at Chicago Medical Center,
Chicago, Illinois, USA
Victor J. Hassid
Division of Plastic, Reconstructive and Cosmetic Surgery,
University of Illinois at Chicago Medical Center,
Chicago, Illinois, USA
Roberto Comperatore
Department of Surgery Nova-Southeastern University of
Health Sciences Ft. Lauderdale, Florida and Department
of Surgery Palmetto General Hospital
Hialeah, Florida
Matthew E. Hiro
Department of Surgery, Division of Plastic Surgery,
University of South Florida College of Medicine, Tampa,
Florida, USA
Deniz Dayicioglu
Department of Surgery, Division of Plastic Surgery,
University of South Florida College of Medicine, Tampa,
Florida, USA
Tripp Holton
Breast Reconstruction, University of Maryland Medical
Center, Baltimore, Maryland, USA
ix
CONTRIBUTORS
David M. Kahn
Division of Plastic and Reconstructive Surgery, Stanford
University, Palo Alto, California, USA
Nuria Lawson
Department of Surgery Nova-Southeastern
University of Health Sciences Ft. Lauderdale,
Florida and Department of Surgery
Palmetto General Hospital
Hialeah, Florida
Benjamin Liliav
Division of Plastic, Reconstructive and Cosmetic Surgery,
University of Illinois at Chicago Medical Center,
Chicago, Illinois, USA
Brian A. Mailey
Department of Surgery, University of California, Irvine,
California, USA
Haaris Mir
Division of Plastic, Reconstructive, and Aesthetic
Surgery, The DeWitt Daughtry Family Department of
Surgery, University of Miami Leonard M. Miller
School of Medicine, Miami, Florida, USA
Subhasis Misra
Division of Surgical Oncology, The DeWitt Daughtry
Family Department of Surgery, University of Miami
Leonard M. Miller School of Medicine, Miami,
Florida, USA
Mecker G. Mller
The DeWitt Daughtry Family Department of Surgery,
University of Miami Leonard M. Miller School of
Medicine, Miami, Florida, USA
Alexander Nguyen
Division of Plastic Surgery, Jackson Memorial Hospital,
University of Miami, Miami, Florida, USA
Scott Oates
Department of Plastic Surgery, MD Anderson Cancer
Center, University of Texas, Houston, Texas, USA
John C. Oeltjen
Division of Plastic, Reconstructive, and Aesthetic
Surgery, The DeWitt Daughtry Family Department of
Surgery, University of Miami Leonard M. Miller School of
Medicine, Miami, Florida, USA
Zubin J. Panthaki
Division of Plastic, Reconstructive, and Aesthetic
Surgery, The DeWitt Daughtry Family Department of
ix
Acknowledgments
xi
Foreword
xii
Preface
Seth Thaller
Zubin J. Panthaki
xiii
1
Breast and chest: Applied anatomy, evaluation of the patient undergoing
breast surgery, initial consultation, analysis, and patient selection
Bassan J. Allan, Angela T. Prescott, and Mecker G. Mller
INTRODUCTION
and open onto the nipple (Fig. 1.1). One pair of the mammary
buds persists in the chest, while the others involute. When the
embryologic bands do not involute, individuals present with
variants of small accessory nipples, nippleareolar complexes,
or breast tissue along the embryologic mammary line, including the axilla (2).
After birth further development of the lobular components of the breast is regulated by sex steroids with the
onset of puberty. The accessory breast tissue remnants can
also become hormonally active in females during pregnancy or during the menstrual cycle.
GROSS ANATOMY
BREAST DEVELOPMENT
Fat lobules
Mammary vessels
Mammary glands
Areola
Nipple
Pectoralis minor muscle
Pectoralis major muscle
Intercostal muscle
Inframammary fold
Figure 1.1
A
B
C
D
E
Figure 1.2 Picture courtesy of Dr Zubin Panthaki. Variations in size and shape of the female breast. Important gross anatomical
landmarks are depicted in this picture. A: Clavicle, B: Sternal notch, C: Axilla, D: Sternum, E: Nippleareolar complex, F: Inframammary fold, G: Deltopectoral groove.
Figure 1.3 Lymphatic drainage of the female breast. The arrows demonstrate unidirectional flow of most lymphatic fluid toward the
axillary lymph nodes.
MICROSCOPIC ANATOMY
Breasts are considered modified sweat glands; as such
they lie in the superficial fascia. The breasts are composed
of compartments of fatty tissue bounded by fibrous bands
and glandular tissue containing 1520 lactiferous ducts
(Fig. 1.1). The fat lobules are compartmentalized by suspensory ligaments, also known as Coopers ligaments,
which extend from the deep fascia to the deep layer of the
skin and help provide the rounded contour of the breast.
Layers of circumferential and radially arranged fibers of
smooth muscle are found deep to the nipple and lactiferous
control erection after stimulation of sensory nerve endings
located in the dermal papillae. The ducts open onto the
nipple. The glandular tissue of the breast is composed of
tubulo-alveolar structures embedded in loose connective
tissue. The alveolar system is lined by a single layer of
columnar or cuboidal cells. As the alveoli gradually transition into the lactiferous ducts, the composition of the cells
changes to stratified squamous epithelium.
LYMPHATIC DRAINAGE OF THE BREAST
Knowledge of the lymphatic drainage of the breast is
important when treating patients with a history of breast
disease. Lymphatic drainage of the breast is largely to the
axillary lymph nodes (ALN). However, a small percentage
(35%) of tumors located in the medial quadrants can drain
the axillary vein. The intercostal veins drain into the internal
mammary veins, the external mammary veins and the lateral thoracic veins drain into the axillary veins.
The three arterial sources to the breast are the internal
mammary artery (IMA), axillary artery, and the costocervical trunk from the descending thoracic aorta. The
course of the IMA runs beween the superficial parietal
pleura of the lung and the intercostal muscles of the chest
wall. The anterior branches of the IMA (anterior rami
mammary) travel anteriorly to supply the second to fifth
intercostal spaces of the chest wall and enter the breast
approximately 12 cm lateral to the parasternal border.
During a mastectomy, the perforating branches are
encountered at this level, emerging from the pectoral
muscle and into the breast tissue. Awareness of their location helps minimize operative bleeding by ligating or cauterizing this prior to accidentally dividing them.
The lateral thoracic artery (also known as the external
mammary artery/long thoracic artery) arises from the posterior segment of the axillary artery and travels between
the subscapularis muscle anteriorly and the fibers of the
brachial plexus posteriorly. It courses the lateral chest wall
along the lower border of the pectoralis minor, also supplying the pectoralis muscles and serratus anterior. The
lateral thoracic artery also supplies branches to the axilla
and subscapularis muscle. The external mammary branch
also supplies the free edge of the pectoralis major.
A surgeon must have knowledge of breast anatomy,
blood supply, and lymphatic drainage in order to minimize
post-operative risks; including capsular contraction, hematoma, seroma, and skin necrosis (9).
INNERVATION OF THE BREAST
Breast innervation is best understood when subdivided by
structural components: breast parenchyma, breast skin and
nippleareolar complex. The skin around the breast
receives its nervous supply from somatic sensory nerve
roots. The medial and lateral aspects of the breast are
innervated by branches of the thoracic intercostal nerves.
The superior aspect of the breast is innervated by the
supraclavicular nerve off the brachial plexus. The breast
parenchyma is under strict hormonal control and bears no
nervous innervation. The nipple and areola are innervated
by sympathetic autonomic fibers, which upon stimulation
erect the nipple and contract the areola (4).
ANATOMY OF THE CHEST WALL
About 7% of women who present for aesthetic breast surgery will have thoracic wall deformities such as pectus
excavatum (depressed sternum), Polands syndrome (pectoralis hypoplasia, deformed axillary fold, and asymmetric
inframammary fold), pectus carinatum (pigeons chest), or
scoliosis. Careful consideration of the thoracic wall anatomy before and during breast surgery along with surgical
technique and choice of implant in mind is essential in
yielding optimal outcomes (6).
The musculoskeletal thoracic wall is composed of 12 thoracic vertebrae along with 12 ribs, which join anteriorly to
the sternum via 12 costal cartilages. The spaces between the
12 ribs are the 11 intercostal spaces, which carry the external,
internal, and innermost intercostal muscles. Continuous with
the innermost layer of intercostal muscles is the endothoracic
fascia, a fibrous connective tissue plane, which is also continuous with the periosteum of the ribs. Just deep to the
endothoracic fascia is the parietal pleura.
The most superficial layer of muscles is formed by the
external intercostal muscle fibers, which course inferomedially. Lateral to the sternum, between the costal cartilages, this
layer exists as the external intercostal membrane. Deep to the
external intercostal muscles are the internal intercostal muscles fibers, which course inferolaterally. Deep to the internal
intercostal muscle layer is the innermost intercostal muscle
layer (intima of the internal intercostal muscles), which run in
the same direction as the internal intercostal muscle fibers.
This innermost layer is the least developed layer of the three;
however, it is separated from the internal intercostal layer by
the presence of the intercostal arteries, veins, and nerves.
The subcostalis and transversus thoracis muscles lie in
the same plane as the innermost intercostal muscles on the
internal surface of the thoracic wall. Anteriorly, the transversus thoracis muscle fibers originate from the medial border of the sternum and course superiorly and laterally to
enter the costal cartilages of the second to sixth ribs. Parallel
to the lateral sternal border exits the internal thoracic (mammary) arteries, veins, and lymphatic channels. The transversus thoracis muscle fibers run deep to the internal thoracic
vessels and lymphatic channels. The subcostalis muscle lies
on the posterior thoracic wall and is thought to be the posterior extension of the innermost internal costal muscles;
however, these fibers span at least two intercostal spaces.
PECTORALIS MAJOR AND MINOR
Pectoralis major is a fan-shaped muscle with two divisions:
the clavicular division and the larger sternocostal division
(Fig. 1.3). The clavicular division originates from the clavicle
while the sternocostal division originates at the sternum and
costal cartilages of the second to the sixth rib. The pectoralis
major muscle fibers then join each other traversing laterally
to enter the greater tubercle of the humerus along the lateral
bicipital groove. The pectoralis major is enclosed by pectoral
fascia, and is innervated by the medial and lateral pectoral
nerves, which arise from the medial and lateral cords of the
brachial plexus, respectively. The clavicular division is innervated by C5C6, whereas the sternocostal division is
innervated by C7, C8, and T1. During surgical identification
and the clavicle, and is also an important landmark in axillary surgery, as it lies anterior to the subclavian vessels as
they transition to axillary vessels.
AXILLA
The axilla is a pyramid-shaped compartment between the
upper extremity and the thoracic wall, with a base, four
walls, and an apex. With the upper extremity relaxed at the
side of the chest wall, the base of the axilla is made of
axillary fascia, subcutaneous tissue, and more superficially
is the dome-shaped area that bears hair after puberty, commonly termed as the armpit. The apex is located in the
posterior triangle of the neck in the cervicoaxillary canal.
The boundaries of the cervicoaxillary canal are the middle third of the clavicle anteriorly, the superior border of
the scapula posteriorly, and the lateral border of the first rib
medially. The anterior wall of the axilla is made of the pectoralis major and minor muscles with their associated fasciae. The posterior wall of the axilla is made up largely of
the subscapularis muscle anterior to the scapula, and also
by the teres major, and latissimus dorsi muscles. The lateral
wall of the axilla is defined by the bicipital groove of the
upper extremity. The medial border of the axilla is the serratus anterior muscle (covering the thoracic wall spanning
the first to the fifth ribs). The inferior border of the axilla is
defined by the apical intersection of the latissimus dorsi
and the serratus anterior muscles. During axillary dissection, however, the upper extremity is abducted, which
slightly alters the borders of the axilla. During axillary surgery, the base of the axilla (superior skin flap overlying the
armpit) is retracted laterally for exposure. The superiormost landmark is the axillary vein, the posterior border is
largely the subscapularis muscle, and the latissimus dorsi
becomes the lateral border of the axilla. The medial and
inferior borders of the axilla remain the same (Fig. 1.5).
BRACHIAL PLEXUS
The medial, lateral, and posterior cords of the brachial
plexus are named according to their relationship to the
axillary artery, and give many branches within the axilla.
The medial cord of the brachial plexus usually gives five
branches, the medial pectoral nerve (supplying the
pectoralis major muscle and the majority of innervation
to the pectoralis minor muscle), the median brachial
cutaneous nerve, the medial antebrachial cutaneous
nerve, the ulnar nerve (a terminal branch) and the lateral
root of the median nerve (a terminal branch). The posterior cord of the brachial plexus has five branches: the
upper subscapular nerve, the thoracodorsal nerve, the
lower subscapular nerve, the axillary nerve (a terminal
branch), and the radial nerve (a terminal branch). The
lateral cord of the brachial plexus has three branches: the
lateral pectoral nerve (innervating the pectoralis major
muscle), the musculocutaneous nerve, and the lateral
root of the median nerve.
The thoracodorsal nerve originates from cervical
branches of the spinal cord (C6C8) as well as the posterior cord of the brachial plexus and enters the axilla deep
to the axillary vein. The thoracodorsal nerve travels on the
posterior aspect of the axilla, over the subscapularis muscle and courses anteromedially over the latissimus dorsi
muscle, innervating this large muscle (Fig 1.6). Injury to
the thoracodorsal nerve results in weakness of arm extension, adduction, and medial rotation of the humerus. During climbing or pull-ups, for example, a thoracodorsal
nerve injury would result in weakness when attempting to
bring the thoracic wall toward the arms.
The long thoracic nerve arises from C5C7 of the spinal cord and enters the axilla through the cervicoaxillary
canal. It travels along the medial wall of the axilla, within
the fascia of the serratus anterior muscle, innervating this
powerful muscle of the thoracic wall (Fig. 1.6). The serratus anterior fascia may be resected during axillary
dissection, inadvertently injuring the long thoracic nerve.
Injury to this nerve results in inability to keep the scapula
opposed to the thoracic wall, difficulty with scapular rotation, and extreme weakness when attempting to raise the
arm above the level of the shoulder.
The most prominent sensory nerve of the axilla is the
intercostobrachial nerve, which is formed from the lateral cutaneous branch of the second intercostal nerve
joining with the medial cutaneous nerve of the arm. This
large nerve supplies the sensation to the skin over the
floor of the axilla and the medial aspect of the upper
arm. A second intercostobrachial nerve may be present
during axillary surgery, which may form from the anterior branch of the third lateral cutaneous nerve. Disruption of these cutaneous nerves results in sensory deficits
overlying the skin of the axilla, upper medial aspect of
7
Pectoral nerve bundle
Pectoralis muscles
Axillary vein
Thoracodorsal bundle
Intercostobrachial nerve
Subscapularis muscle
Latissimus dorsi muscle
Long thoracic nerve
Serratus anterior muscle
Figure 1.6 Anatomy of the thoracic wall and axilla of a female after undergoing a mastectomy, with the upper extremity (left)
abducted with 90 shoulder extension. Courtesy of Dr. Mecker G. Mller.
the arm, and the lateral chest wall around the second and
third ribs.
FASCIAL PLANES INVOLVING THE BREAST
AND CHEST WALL
The breast tissue is located in the hypodermis or superficial fascia of the anterior chest wall. An avascular
plane exists just deep to the dermis that a surgeon may
dissect, which will leave the blood vessels and lymphatics of the deeper layer of the superficial fascia undisturbed. In thin individuals, this provides for a two- to
three-millimeter-thick skin flap that may be thicker in
obese individuals. Anterior to the breast, fibrous processes, called the suspensory ligaments of Cooper, are
continuous with the septa that divide the lobules of the
breast and enter the skin. The retro-mammary space or
bursa exists between the posterior aspect of the breast
and the deep layer of the pectoralis major fascia. During
total mastectomy, this layer is usually included as part
of the specimen. Posterior suspensory ligaments also
extend from the posterior surface of the breast to the
deep pectoral fascia, requiring removal of some adjacent
pectoralis muscle during breast resection. Surgical consideration must also be taken with the suspensory ligaments of Cooper and the retro-mammary space due to its
contribution to the mobility of the breast tissue against
the thoracic wall. Two thirds of posterior breast tissue
overlies fascia of the pectoralis major. The remaining
posterior breast tissue extends over abdominal oblique
muscles superiorly and the fourth to seventh parts of the
serratus anterior muscle. Laterally, breast tissue also
overlies the axillary fascia.
Anatomical considerations of the submammary, subfascial and submuscular planes are also important in the
setting of optimizing aesthetic outcomes. The submuscular plane beneath the pectoralis muscle results in less
5.
6.
7.
8.
9.
10.
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EMBRYOLOGY
Breast growth begins at the fifth week of gestation
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10
Figure 2.1
Figure 2.2
Supranumerary nipple.
Figure 2.3
11
Poland syndrome.
12
(A)
13
(B)
Figure 2.4
(A) Type 2 tuberous breast preop. (B) Type 2 tuberous breast postop.
14
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19. Dos Santos Costa S, Blotta RM, Mariano MB, et al. Aesthetic improvements in Polands syndrome treatment with
omentum flap. Aesthetic Plast Surg 2010; 34: 6349.
20. Pinsolle V, Chichery A, Grolleau JL, Chavoin JP. Autologouc fat injection in Polands syndrome. J Plast Reconstr
Aesthet Surg 2008; 61: 78491.
21. Delay E, Sinna R, Chekaroua K, et al. Lipomodeling of
Polands syndrome: a new treatment of the thoracic deformity. Aesthetic Plast Surg 2010; 34: 21825.
22. Rees TD, Aston SJ. The tuberous breast. Clin Plast Surg
1976; 3: 33947.
23. Grolleau J, Lanfrey E, Lavigne B, et al. Breast base anomalies: treatment strategy for tuberous breast deformities and
asymmetry. Plast Reconstr Surg 1999; 104: 20408.
24. Ribeiro L, Canzi W, Buss A, et al. Tuberous breast: a new
approach. Plast Reconstr Surg 1998; 101: 4250.
25. Mandrekas AD, Zambacos GJ, Anastasopoulos A, et al.
Aesthetic reconstruction of the tuberous breast deformity.
Plast Reconstr Surg 2003; 112: 1099108.
26. Versaci AD, Rozzelle AA. Treatment of tuberous breasts utilizing tissue expansion. Aesthetic Plast Surg 1991; 15: 30712.
27. Serra-Renom JM, Munoz-Olmo J, Serra-Mestre JM. Treatment of grade 3 tuberous breasts with Pucketts technique
(modified) and fat grafting to correct the constricting ring.
Aesthetic Plast Surg 2011; March 17 Epub.
28. Hammond D, Khuthaila D, Kim J. The interlocking GoreTex suture for control of areolar diameter and shape. Plast
Reconstr Surg 2007; 119: 8049.
29. Tebbetts JB. A system for breast implant selection based on
patient tissue characteristics and implant-soft tissue dynamics. Plast Reconstr Surg 2002; 109: 1396409.
30. Handel N. Managing complications of augmentation mammaplasty. In: Spear SL, Willey SC, Robb GL, Hammond
DC, Nahabedian MY, eds. Surgery of the Breast: Principles
and Art. 2nd edn. Philadelphia: Lippincott-Raven, 2006:
141735.
31. Mandrekas A, Zambacos G. Aesthetic reconstruction of the
tuberous breast deformity: a 10-year experience. Aesthet
Surg J 2010; 30: 68092.
32. Maxwell G, Gabriel A. The neopectoral pocket in revisionary breast surgery. Aesthet Surg J 2008; 28: 4637.
3
Radiologic evaluation of the breast
Ada P. Romilly
X-RAY MAMMOGRAPHY
There has been a significant decrease in breast cancer mortality by approximately 30% since 1990 and this is due in
large part to the use of X-ray mammography for breast
screening. Evidence to support regular screening comes
from the results of multiple randomized controlled trials
(5,6). This imaging method remains the gold standard for the
detection of breast cancers in both symptomatic and asymptomatic patients. X rays are used to penetrate the compressed
breast tissue in two projections for screening examinations;
craniocaudal and mediolateral oblique. The resultant image
is the result of how the breast tissue attenuates the X-ray
beam and is displayed in either film or digital format. Dense
tissue attenuates the X-ray beam more than fatty tissue and
appears white whereas fatty tissue causes less attenuation
and is dark on the image. These images are the result of a
composite of all the structures in the breast. In some instances
where the breast tissue is very dense, the difference in attenuation of the X-ray beam between a tumor and surrounding
dense tissue is so little that there is lack of visualization of
the tumor. The American College of Radiology Imaging
Network (ACRIN) digital mammographic imaging screening trial study showed a significantly higher accuracy rate
for breast cancer detection on digital versus screen film
mammography in patients with dense breasts (7). Digital
images undergo image processing and lesion conspicuity
can be increased by contrast manipulation.
16
17
If a screening examination is abnormal or when mammograms are needed to evaluate specific symptoms, a diagnostic examination is performed which may include
targeted views of the areas of interest. Breast cancers are
seen as discrete masses, areas of asymmetric density, architectural distortion, or microcalcifications (Fig. 3.1 AD).
The composition of the tissue in the breast can vary with
age and hormonal status. Breast density has been shown to
(A)
(C)
(B)
(D)
Figure 3.1 (A) X-ray mammogram spot compression views of two adjacent non-palpable malignant masses in a fatty breast. The
larger mass has irregular margins and contains pleomorphic calcifications. The smaller mass is lobulated with indistinct margins.
Pathologyinvasive ductal carcinoma. (B) Ultrasound images of the masses seen in Figure 3.1 A. Both masses are solid. (C) X-ray
mammogramDense breast with a cluster of new pleomorphic microcalcifications. Pathologyductal carcinoma in situ. (D) X-ray
mammogramArea of architectural distortion on screening mammogram. Pathologytubular carcinoma.
18
Predominantly fatty
Scattered fibro-glandular tissue
Heterogeneously dense
Extremely dense
19
(A)
(B)
(C)
(E)
(D)
Figure 3.2 (A) Ultrasound of a palpable mass in a young patient. Benign appearing solid mass. Pathologyfibroadenoma.
(B) Mammograms of palpable mass in the left breast. Mass shows irregular borders. (C). Ultrasound of mass in Figure 3.2 B. Irregular
solid mass. Pathologyinvasive ductal carcinoma. (D) X-ray mammogram of a palpable left breast mass. Mass is not well defined.
(E) Ultrasound of the mass in Figure 3.2 D shows a simple cyst.
20
(A)
(B)
Figure 3.3 (A) MRI shows a lobulated contrast-enhancing mass in the right breast. An 8-mm enhancing mass is seen in the left breast.
Pathology of right breast massinvasive ductal carcinoma. Pathology of left breast massatypical ductal hyperplasia. (B) MRI breast
screening for a high-risk patient. Left breast shows 5-mm contrast-enhancing mass. Pathologyductal carcinoma in situ.
(A)
21
(B)
(C)
Figure 3.4 (A) Calcifications in an implant capsule which appeared similar to calcifications within the breast. (B) X-ray mammogram
(MLO view) with history of implant rupture and replacement with a silicone implant. Residual silicone decreases mammography
sensitivity. (C) MRI shows an intact implant and no contrast-enhancing masses.
22
(A)
prepectoral implants and allow for more tissue to be evaluated. In a study by Silverstein et al. (32) measurements of
the visualized breast tissue were compared between the preand post-augmentation mammograms. Routine views and
implant displacement views were performed and there was
a decrease of 1525 percent of visualized tissue depending
on whether the implants were subglandular or submuscular
with more breast tissue seen with submuscular implants.
In some cases calcifications of the capsule of the implant
occurs and makes displacement of the implant extremely
difficult. Calcifications of the implant capsule may also be
mistaken for suspicious microcalcifications in the breast
which may result in unnecessary surgery. (Fig. 3.4 A)
Ultrasound is used to evaluate all palpable abnormalities. Although MRI is a more expensive imaging modality,
it allows a more complete evaluation of the breast tissue
and is recommended for high-risk patients and in patients
with suspected rupture of silicone implants (Fig. 3.4 B, C).
Other materials also have been used for augmentation
of the breast such as the injection of fat and the injection
of silicone. Silicone injections, which are no longer performed in the United States, result in the formation of silicone granulomas which create non-diagnostic images on
X ray and ultrasound. The silicone granulomas are usually
palpable and make it clinically difficult to differentiate
from malignant masses. MRI imaging is currently the
most accurate method for detecting malignant masses in
these patients (Fig. 3.5 A, B).
(B)
Figure 3.5 (A) X-ray mammogram craniocaudal, (cc) view shows multiple silicone granulomas. (B) MRI shows multiple masses with
no contrast enhancement and low signal intensity on the T1 images.
23
(A)
(A)
(B)
(B)
(C)
Figure 3.7 (A, B) Recurrent CA in a reconstructed breast. CT scan shows a mass just posterior to an intact implant. (C) Ultrasound
of the mass seen in Figure 3.7 B.
24
contrast-enhancing masses. Studies have shown that ultrasound is valuable in the assessment of both palpable and
clinically occult recurrent breast cancers in patients with
autogenous myocutaneous flaps (34). The technique is useful in patients on whom MRI cannot be performed. Masses
can also be detected on CT scans of the chest which can then
be confirmed with ultrasound or MRI (Fig. 3.7 AC).
SUMMARY
It is important to understand the multiple imaging methods
that are used to evaluate the breast and the accuracy and
limitations of each procedure. As stated in this chapter,
breast density plays a significant role in determining breast
cancer risk and diminishes the accuracy of X-ray mammography. Adjunctive methods of imaging such as ultrasound,
MRI, PEM, and BSGI complement X-ray mammography
by providing additional diagnostic information. Guidelines
for the use of these imaging methods for both screening and
diagnosis have been provided by the ACR and are a great
tool for determining how patients should be evaluated with
the currently available imaging methods.
REFERENCES
1. Lee CH, Dershaw D, Kopans D, et al. Breast cancer
screening with imaging: recommendations from the society of breast imaging and the ACR on the use of mammography, breast ultrasound, and other technologies for the
detection of clinically occult breast cancer. J Am Coll
Radiol 2010; 7: 1827.
2. Smith R, Cokkinides V, Brooks D, et al. Cancer screening in
the United States, 2011. A review of the current American
cancer society guidelines and issues in cancer screening.
CA Cancer J Clin 2011; 61: 830.
3. Newell M, Birdwell R, DOrsi C, et al. ACR appropriateness
criteria on nonpalpable mammographic findings (excluding
calcifications). J Am Coll Radiol 2010; 7: 92030.
4. Cardenosa G, Mendelson E, Bassett L, et al. Appropriate
imaging work up of breast microcalcifications. American
college of radiology appropriateness criteria. Radiology
2000; 215(Suppl): 97380.
5. Nystrom L, Andersson I, Bjurstam N, et al. Long-term
effects of mammography screening: updated overview of
Swedish radomised trials. Lancet 2002; 359: 90919.
6. Otto SJ, Fracheboud J, Looman CW, et al. Initiation of
population-based mammography screening in Dutch
municipalities and effect on breast-cancer mortality: a
systematic review. Lancet 2003; 36: 141117.
7. Pisano E, Acharyya S, Cole E, et al. Cancer cases form
ACRIN digital mammographic imaging screening trial:
radiologist analysis with use of a logistic regression model.
Radiology 2009; 252: 34857.
8. Loehberg CR, Heusinger K, Jud SM, et al. Assessment of
mammographic density before and after first full-term pregnancy. Eur J Cancer Prev 2010; 19: 40512.
25
31. Eklund GW, Busby RC, Miller SH, Job JS. Improved imaging of the augmented breast. AJR Am J Roentgenol 1988;
151: 46973.
32. Silverstein MJ, Handel N, Gamagami P, et al. Breast cancer
diagnosis and prognosis in women following augmentation
with silicone gel-filled prostheses. Eur J Cancer 1992; 28:
63540.
33. Helvie MA, Bailey JE, Roubudoux MA, et al. Mammographic screening of TRAM flap breast reconstructions for
detection of nonpalpable recurrent cancer. Radiology 2002;
224: 21116.
34. Kang BJ, Jung JI, Park C, et al. Breast MRI findings after
modified radical mastectomy and transverse rectus abdominis myocutaneous flap in patients with breast cancer. J magn
Reson Imaging 2005; 21: 78491.
35. Eideiken BS, Fornage BD, Bedi DG, et al. Recurrence in
autogenous myocutaneous flap reconstruction after mastectomy for primary breast cancer: US diagnosis. Radiology
2003; 227: 5428.
4
Breast asymmetry
Thomas R. Stevenson
INTRODUCTION
CLINICAL PRESENTATIONS
Bilateral Macromastia and Asymmetry
We define macromastia as a state wherein the patients
breasts are larger than would be ideal and cause the patient
symptoms of back, neck, or shoulder pain. Large breasts
26
BREAST ASYMMETRY
27
(A)
(B)
Figure 4.1
(A)
Figure 4.2
(B)
Bilateral macromastia and asymmetry. (A) Preoperative, nipples displaced medially. (B) Postoperative, 11 months.
28
(A)
Figure 4.3
(B)
Bilateral macromastia and asymmetry. (A) Preoperative, nipples displaced laterally. (B) Postoperative, 4 months.
marking determines ultimate nipple position and dimensions of skin excision. If the nipple is not displaced
medially or laterally in the preoperative state, the scar
beneath the nipple is oriented vertically and intersects the
inframammary fold perpendicularly. Correcting medial
or lateral nipple position operatively results in the vertical reduction scar being tilted medially or laterally,
respectively.
A preoperative estimate of necessary proportional skin
and tissue excision is always made, including weight of
breast tissue to be excised from each breast (12). That estimate is confirmed intraoperatively. The tissue resected (fat
and breast parenchyma) from each breast is weighed and
compared. Discrepancies are corrected by immediate additional excision. In spite of our best efforts, postoperative
asymmetry may occur, usually commensurate with the
preoperative disparity (Fig. 4.1).
Macromastia and Adequate Contralateral
Volume
A patient may develop unilateral macromastia in the
face of an adequately proportioned contralateral breast
(Fig. 4.4) (13). In this circumstance, unilateral breast
reduction decreases the size asymmetry. We prefer the
inferior pedicle technique and Wise (inverted T) skin
pattern. Over time, nipple size does not appear to
increase significantly on the reduced side, nor does the
nipple descend significantly on that side. Volume symmetry may be achieved, although postoperative skin
stretching on the reduced side can produce some recurrent asymmetry (Fig. 4.4, center and right).
In some cases, the patient may present with unilateral
macromastia and contralateral breast ptosis (Fig. 4.5).
BREAST ASYMMETRY
29
(A)
(B)
(C)
Figure 4.4
Macromastia and adequate contralateral volume. (A) Preoperative. (B) Postoperative, 1 year. (C) Postoperative, 2 years.
30
(A)
(B)
Figure 4.5
Macromastia and adequate contralateral volume. (A) Preoperative. (B) Postoperative, 4 months.
(A)
(B)
Figure 4.6
Macromastia and inadequate contralateral volume. (A) Preoperative. (B) Postoperative, 3 months.
BREAST ASYMMETRY
31
(A)
(B)
Figure 4.7
Macromastia and inadequate contralateral volume. (A) Preoperative. (B) Postoperative, 9 months.
(A)
(B)
Figure 4.8
32
(A)
(B)
Figure 4.9
(A)
(B)
Figure 4.10
placement of implants. Inflatable sizers were inserted bilaterally and filled differentially with saline until the volume
asymmetry was corrected to the extent possible. Sizers
were removed and bilateral saline implants were placed.
Based on the sizer volumes, a 360-cc implant was inserted
on the right and 270 cc on the left. Postoperatively, the
breast volume discrepancy was decreased, but asymmetry
in nipple size and inframammary fold contour persist.
Variation in inframammary fold position can be
addressed by dissecting one side slightly lower than that
on the opposite. It is easier operatively to lower an
inframammary fold, thus matching the contralateral inframammary fold, than to attempt to elevate a fold. Not infrequently, attempts at elevating an inframammary fold fail
to produce a durable result. In Figure 4.11, the surgeon
placed the subpectoral implant slightly lower on the right,
improving the preoperative asymmetry.
Patients with small breasts who desire breast augmentation also may evidence disparate skin excess. If the
patient presents with physical findings demonstrating
the center of the nipple to be at or above the level of
the ipsilateral inframammary fold, breast augmentation
BREAST ASYMMETRY
33
(A)
(B)
Figure 4.11
(A)
(B)
Figure 4.12
without mastopexy is an acceptable alternative. Performance of breast augmentation alone may be used to treat
individuals with mild (Fig. 4.12) to moderate (Fig. 4.13)
skin excess in the face of hypomastia.
Bilateral Hypomastia, Ptosis, and Asymmetry
Involutional breast changes occur after pregnancy and
delivery, and are exacerbated by breast feeding. These
changes, characterized by a deflated breast appearance,
nipple descent, and nipple enlargement, are often accompanied by asymmetry. Performing a mastopexy, to reduce
the amount of skin excess and nipple diameter, may contribute to a decrease in breast asymmetry. As a treatment
alternative, many patients select mastopexy and breast
augmentation. Mastopexy may be performed several
months prior to breast augmentation. In selected patients,
it is appropriate to augment the breasts simultaneous with
mastopexy. The likelihood of subsequent revision is
increased if augmentation and mastopexy are done at the
same time. This patient (Fig. 4.14) underwent mastopexy
and bilateral subpectoral breast augmentation at a single
setting, with improvement in breast contour and diminution of asymmetry.
34
(A)
(B)
Figure 4.13
(A)
(B)
Figure 4.14
Bilateral hypomastia, ptosis, and asymmetry. (A) Preoperative. (B) Postoperative, 8 months.
Juvenile Macromastia
As they pass through puberty and adolescence, a few women
experience juvenile macromastia (also termed juvenile
gigantomastia or virginal breast hypertrophy). This form of
macromastia may be associated with significant asymmetry.
In most circumstances, patients with rapid breast growth
should be treated medically or expectantly. Surgical intervention is better undertaken when the period of rapid breast
growth and inflammation have subsided. When initially
seen, the patient in Figure 4.16 (left) had been suffering
very rapid and uncomfortable breast enlargement. Six
months later (Fig. 4.16, center), her rapid breast size increase
had subsided. Differential bilateral breast reduction relieved
her of the symptomatic macromastia (Fig. 4.16, right).
BREAST ASYMMETRY
35
(A)
(B)
Figure 4.15
Unilateral hypomastia and contralateral adequate volume. (A) Preoperative. (B) Postoperative, 7 months.
(A)
(B)
(C)
Figure 4.16
Juvenile macromastia. (A) Six months preoperative. (B) Immediately preoperative. (C) Postoperative, 7 months.
36
(A)
(B)
Figure 4.17
Benign tumor
A benign breast tumor or fibroadenoma may develop in
the juvenile or young adult breast, resulting in marked
asymmetry (16). Smaller adenomas may be removed without an effect on symmetry. Larger benign tumors may produce such marked asymmetry, in terms of nipple size,
position, and skin excess, that a staged correction is preferred. Our patient (Fig. 4.17) first underwent tumor resection, tailoring of skin excess, and nipple repositioning,
followed in one year by unilateral left breast augmentation
for symmetry.
REFERENCES
1. Reilley A. Breast asymmetry: classification and management. Aesthet Surg J 2006; 26: 596600.
2. Araco A, Gravante G, Araco F, et al. Breast asymmetry:
a heterogeneous condition. Plast Reconstr Surg 2006;
118: 563.
3. Scutt D, Lancaster G, Manning J. Breast asymmetry and
predisposition to breast cancer. Breast Cancer Res 2006; 8:
17.
4. Novakovic M, Lukac M, Kozarski J, et al. Principles of surgical
treatment of congenital, developmental, and acquired female
breast asymmetries. Vojnosanit Pregl 2010; 67: 31320.
5. Juri J. Mammary asymmetry: a brief classification. Aesthetic Plast Surg 1989; 13: 4753.
5
Mastopexy
Deniz Dayicioglu and Bulent Genc
MASTOPEXY
MASTOPEXY MARKINGS
The patient is marked preoperatively in the standing
upright position.
Marking should be symmetrical and equal on both
breasts (1).
The mid-axial line of the breast (breast meridian) is
marked in reference to sternal notch and mid-clavicular
point. This line can be adjusted depending on nipples
placed centrally or divergent (5).
Existing inframammary fold is marked.
The proposed new nipple location is determined just
above the inframammary fold (2 cm) (10).
Four-finger test is one of the most commonly used methods. Four finger tips are placed in the inframammary fold
and the thumb tip is placed in opposition to the middle
finger tip (11).
38
Table 5.1
Table 5.3
Physical Examination
Table 5.2
Preoperative Assessment
Table 5.4
Complications
Mastopexy Techniques
Mastopexy Complications: (49)
Widened areolar diameter
Areolar herniation: This is due to the areolar skin having
more elasticity compared to breast skin. Is overcome by
reducing the diameter of the areola.
Hematoma
Infection
Nipple areolar necrosis: diversity of nippleareolar
circulation source mandates inclusion of as many arteries
as possible. Some authors advise including dual blood
supply for the nipple by use of at least two/three of the
following: internal thoracic artery, lateral thoracic artery,
and anterior intercostal artery (10).
Nipple and breast asymmetry (Fig. 5.1)
Asymmetrical areolar shape (Fig. 5.2)
Nipple too lowcan be corrected easily by crescentric
excision (11) (Fig. 5.3)
Nipple too highnecessitates complicated procedures
including an expander (11).
Nipple too medial or too lateralUp to 1 cm can be
acceptable per the patient (11)
Overall absence of longstanding breast shape and contour
Flat non-projecting breast
Lack of upper fullness
Lack of medial fullness
Recurrent ptosis
Bottoming out: Gravity as well as skin elasticity is
responsible. May be prevented by removing lower breast
tissue or by suspending it with a sling (7)
Diminished or absent nipple sensation
Inability to breast feed
(Continued)
MASTOPEXY
Table 5.4
(Continued)
Flat nipples
Patient dissatisfaction
Persistent periareolar wrinkling (12)
Purse string suture rupture
Suture exposure
Need for suture removal
Need for periareolar scar revision
Boxy square-shaped appearance
Asymmetry
Wound dehiscence
Fat necrosis
Hematoma
Scar-related complications
Hypertrophic scar
Widened areola
Flap necrosis
Hypertrophic scar formation (13)
Cellulitis abscess
Lipomatous cyst
Suture complications
Suture spitting (12)
Foreign body reactions
Too long T scars
Need for reoperations
Interference with breast cancer screening (10)
Table 5.5
(A)
39
(B)
Figure 5.1 (A) Patient with right breast cancer was reconstructed with postop adjustable saline implant. (B) Complication: For
symetry left vertical mastopexy was performed. Note the asymetry and size mismatch.
40
(A)
(B)
Figure 5.2 (A) Patient with left breast cancer who was reconstructed with tissue expander. (B) Tissue expander exchanged to silicone
implant and right mastopexy was performed. Note the hypertrophic scarring of the right areolar scar.
(A)
(B)
Figure 5.3 (A) Patient with left breast cancer who was reconstructed with left tissue expander. (B) Tissue expander exchanged to
silicone implant and right vertical mastopexy with augmentation was performed. Note the low location of the right nipple and boxy
appereance on the right.
MASTOPEXY
41
42
Figure 5.6
Lassuss technique.
Figure 5.7
In Lejour and Lassus, skin is resected in the lower portion of the breast where the nipple is receiving its blood
supply superiorly. The breast parenchyma is shaped by
central tissue sutured to the pectoralis fascia and medial
and lateral parenchymal pillars sutured together. These
techniques are designed for overcorrection and will achieve
their final results months later.
Hall-Findlay modified Lejour by medial pedicled NAC,
no skin undermining, targeted liposuction, and no pectoralis fascia sutures.
Asplound-Davies modified Lassus technique by minimizing tension around the areola, resulting in a more cosmetic scar.
Biggs and Graf described an inferior pectoralis major
sling to support an inferiorly based parenchymal flap.
MASTOPEXY
Figure 5.9
43
Most breast reduction techniques are applicable to mastopexy. As in reduction mammoplasty, mastopexy relies on
specific nippleareola circulation patterns in order to prevent partial or total flap necrosis. Nipple necrosis in breast
reduction and mastopexy has been reported at 7.3% (10).
Reliable NAC transposition, maximal parenchymal support,
and minimal scars are the major goals in mastopexy.
Figure 5.10
44
Figure 5.11
Figure 5.13
Figure 5.12
Figure 5.14
MASTOPEXY
Figure 5.15
45
Figure 5.17
REFERENCES
Figure 5.16
1. Ritz M, Silfen R, Southwick G. Fascial suspension mastopexy. Plast Reconstr Surg 2006; 117: 8694.
2. Aston SJ. ed. Aesthetic Plastic Surgery. Saunders Elsevier,
2009.
3. Hammond DC. The atlas of aesthetic breast surgery.
4. Rohrich RJ, Thornton JF, Jakubietz RG, Jakubietz MG,
Grunert JG. The limited scar mastopexy: current concepts
and approaches to correct breast ptosis. Plast Reconstr Surg
2004; 114: 162230.
5. Nicolle F. Improved standards in reduction mammaplasty
and mastopexy. Plast Reconstr Surg 1982; 69: 4539.
6. Bostwick J, 3rd.
7. Graf R, Biggs TM. In search of better shape in mastopexy
and reduction mammoplasty. Plast Reconstr Surg 2002;
110: 30917; discussion 1822.
8. Khan UD. Vertical scar with the bipedicle technique: a
modified procedure for breast reduction and mastopexy.
Aesthetic Plast Surg 2007; 31: 33742.
9. Puckett CL, Meyer VH, Reinisch JF. Crescent mastopexy and augmentation. Plast Reconstr Surg 1985; 75:
53343.
10. van Deventer PV, Graewe FR. Enhancing pedicle safety
in mastopexy and breast reduction procedures: the posteroinferomedial pedicle, retaining the medial vertical
ligament of Wuringer. Plast Reconstr Surg 2010; 126:
78693.
11. Gulyas G. Marking the position of the nipple-areola complex for mastopexy and breast reduction surgery. Plast
Reconstr Surg 2004; 113: 208590.
12. Rohrich RJ, Gosman AA, Brown SA, Reisch J. Mastopexy
preferences: a survey of board-certified plastic surgeons.
Plast Reconstr Surg 2006; 118: 16318.
13. Handbook of plastic surgery. Marcel Dekker, 2004.
46
14. Spear SL, Kassan M, Little JW. Guidelines in concentric
mastopexy. Plast Reconstr Surg 1990; 85: 9616.
15. Grabb and Smith Plastic Surgery.
16. Adams WP. Reduction Mammaplasty and Mastopexy.
Selected Readings in Plastic Surgery 2002; 9: 29.
17. Hammond DC, Alfonso D, Khuthaila DK. Mastopexy using
the short scar periareolar inferior pedicle reduction technique.
Plast Reconstr Surg 2008; 121: 15339.
18. Jones GE. ed. Bostwicks Plastic and Reconstructive Breast
Surgery. 3rd edn. St Louis, Missouri: Quality Medical Publishing, 2010: 641729.
6
Reduction mammoplasty
Rosiane Roeder and Seth Thaller
INTRODUCTION
47
48
This chapter will highlight relevant anatomy, indications, and pre-operative evaluation for surgery, most commonly performed techniques, post-operative care, and
complications.
ANATOMY OF THE BREAST
Overview
Adult breasts are located between the second and the sixth
ribs just lateral to the sternum and medial to the midaxillary line. They overlie three different muscles: the pectoralis major inferiorly, the serratus anterior inferiorlateral,
and the rectus sheath at its most caudal portion. The
axillary tail of Spence is the breast tissue that extends
superiolaterally into the axilla. Coopers ligaments are
collagen-rich structures that maintain breast shape. They
extend transversely from the dermis and the pectoralis fascia. Pectoralis fascia overlies the pectoralis major muscle
and is covered by a layer of loose connective tissue that
allows for movement of breast tissue. The nipple lies at the
level of the fourth intercostal space. The distance between
the NAC and the sternal notch measures, on average,
21 cm, a distance that can be significantly greater in
women with macromastia and/or ptosis. This is an important reference measurement for the future repositioning of
the nipple during reconstructive surgery.
Breast parenchyma is composed of fatty and glandular tissue. The ratio between these two components
changes in females in relation to stage of development
and hormonal shift during pregnancy and senescence.
Embryologically, it arises from a milk streak in the torso
spanning from the axilla to the groin. This eventually
regresses to form paired nipple and breasts. About 1520
lactiferous ducts are present that covalence at the nipple
at birth. Breast buds may be enlarged in the neonate due
to maternal estrogens that remain in circulation immediately after birth. Breast tissue remains otherwise
underdeveloped until puberty when the ducts proliferate
in response to estrogen and progesterone. There is
engorgement of the fatty and glandular tissue. During
pregnancy, there is further proliferation of glandular and
secretory epithelium that allows for lactation. With the
onset of menopause, there are significant changes in
breast tissue. Glandular tissue is replaced by fatty tissue
and/or significant decrease in breast size occurs in
addition to decreased amounts of collagen. All contribute
to ptosis associated with aging.
Sensory nerve supply to the breast and the NAC, in particular, is of great importance. Innervation to the female
breast and overlying skin is derived from cutaneous
branches of the first to the seventh intercostal nerves.
Nerves penetrate the deep fascia at the mid-axillary line
and lateral to the sternum. They reach the surface from
each side anastomosing around the midline. Supply to
the nipples may have contributions from the anterior and
lateral branches of the third, fourth, and fifth intercostal
nerves. However, the fourth intercostal branches are the
ones thought to always be involved (8). Specifically, the
anterior cutaneous branch of the fourth intercostal is
primarily involved. Nonetheless, several observations
report the eventual recovery of loss sensation from the
breast after a period of 6 months from the initial surgery
(5). There may be a certain degree of regeneration of
these cutaneous nerves. Size of resection may also affect
sensation, despite the pedicle used. Conservation of the
anterior branch of the fourth intercostal nerve should
guarantee sensory supply to the NAC from its most
reliable source.
REDUCTION MAMMOPLASTY
49
Cup Size
1
2
3
4
5
6
7
8
9
10
A
B
C
D
DD or E
DDD or F
G
H
I
J
1 Cup
2 Cups
3 Cups
4 Cups
3234 inches 100 grams 200 grams 300 grams 400 grams
3638 inches 200 grams 400 grams 600 grams 800 grams
4042 inches 300 grams 600 grams 900 grams 1200 grams
50
(A)
(B)
(C)
Figure 6.1 Indications for reduction mammoplasty. (A) Enlarged breasts (macromastia/gigantomastia). (B) Should groove from bra
strap. (C) Intertigimous dermatitis.
Table 6.3
SURGICAL TECHNIQUES
Wise Pattern, Inverted-T, Inferior Pedicle
Numerous breast reduction techniques have been reported
over the years resulting in over one hundred different procedures (12). This chapter will describe two of the most
common techniques and briefly refer to some that may be
used on specific occasions.
REDUCTION MAMMOPLASTY
51
Figure 6.2 Inverted-T scar. Note scar around areola, vertical scar from midline areola to the inframammary line, and inframammary
scar extending toward the axilla.
52
(A)
(B)
(C)
Figure 6.3 Pre-operative marking for inferior pedicle inverted-T scar with Wise pattern. (A) Line establishing the midline. X indicates
new nipple position based on transposition of IMF at breast median. (B) Use of measuring tape around the neck to determine the breast
midline (mid-clavicle to nipple). (C) Wise pattern.
Figure 6.4
REDUCTION MAMMOPLASTY
53
54
Free nipple grafting today is reserved for specific indications. These include older, high-risk patients with
expected resection of more than 2 kg per breast (21). Many
glandular pattern of glandular and skin resection can be
used. Pre-operative marking should follow that of the chosen dermatoglandular pattern to be followed. NAC final
positioning should again be estimated from a projection of
the inframammary fold onto the midline of the breast
superiorly at a distance of approximately 21 cm from the
mid-clavicular line.
Harvest of the free-nipple graft should be accomplished
first. Diameter of the graft should be about 4.5 cm. Thereafter, the surgeon will proceed with parenchymal resection
according to the desired breast reduction technique of
choice. However, a de-epithelialized pedicle should be
used to receive the nipple graft. There should be minimal
undermining in the superior flap so that the remaining
breast will have adequate projection.
Usually, the surgeon will close the breast mount, leaving a centrally located position for placement of the nipple
graft. After the nipple graft is in place, it is sutured and
held in position with a tie-over bolster.
COMPLICATIONS
Breast reduction surgery is generally a very safe procedure. Complication rates occur in about 520% of cases
depending on the series and definition of complication
(5,12,2224). Deaths have been rarely recorded. Most
common complications are seroma, hematoma, wound
infection, wound dehiscence, fat necrosis, necrosis of the
NAC, loss of sensation and erectile function of the nipple,
and hypertrophic scarring (Table 6.4).
In order to detect early seroma or hematoma formation,
many surgeons use drains. These are left for about 24
hours post-operatively. However, if a seroma or hemaroma is detected, immediate drainage is required to avoid
suppurative infection, build up of pressure that can compromise blood supply to the NAC, and wound dehiscence.
Table 6.4
Surgery
Seroma
Hematoma
Wound infection
Wound dehiscence
Fat necrosis
Necrosis of NAC
Loss of sensation of NAC
Loss of erectile function of NAC
Hypertrophic scarring
REDUCTION MAMMOPLASTY
55
11. Regnault P, Daniel RK. Breast reduction. In: Regnault P,
Daniel RK, eds. Aesthetic Plastic Surgery: Principles and
Techniques. Boston: Little Brown, 1984.
12. Daane SP, Rockwell WB. Breast reduction techniques and outcomes: a meta-analysis. Aesthetic Surg J 1999; 19: 293303.
13. Ribeiro L. A new technique for reduction mammaplasty.
Plast Reconstr Surg 1975; 55: 3304.
14. Lickstein LH, Shestak KC. The conceptual evolution of
modern reduction mammaplasty. Operat Tech Plast Reconstr Surg 1999; 6: 8896.
15. WISE RJ. A preliminary report on a method of planning the
mammaplasty. Plast Reconstr Surg (1946) 1956; 17: 36775.
16. Lassus C. A technique for breast reduction. Int Surg 1970;
53: 6972.
17. Lejour M. Vertical mammaplasty and liposuction of the
breast. Plast Reconstr Surg 1994; 94: 10014.
18. Poell JG. Vertical reduction mammaplasty. Aesthetic Plast
Surg 2004; 28: 5969.
19. Jakubietz RG, Jakubietz DF, Gruenert JG, et al. Breast
reduction by liposuction in females. Aesthetic Plast Surg
2011; 35: 4027.
20. Thorek M. Possibilities in the reconstruction of the human
form. Med J Rec 1922; 116: 5723.
21. Restifo R, Lalikos J. Amputation/free nipple graft reduction
mammaplasty. Operat Tech Plast Reconstr Surg 2011; 3:
1848.
22. Freire M, Neto MS, Garcia EB, Quaresma MR, Ferreira LM.
Functional capacity and postural pain outcomes after
reduction mammaplasty. Plast Reconstr Surg 2007; 119:
114956.
23. Henry SL, Crawford JL, Puckett CL. Risk factors and complications in reduction mammaplasty: novel associations
and preoperative assessment. Plast Reconstr Surg J 2009;
124: 10406.
24. Shah R, Al-Ajam Y, Stott D, Kang N. Obesity in mammaplasty: a study of complications following breast reduction.
J Plast Reconstr Aesthet Surg 2011; 64: 50814.
25. Throckmorton AD, Boughey JC, Boostrom SY, et al. Postoperative prophylactic antibiotics and surgical site infection
rates in breast surgery patients. Ann Surg Oncol 2009; 16:
24649.
26. Mandrekas AD, Zambacos GJ, Anastasopoulos A, Hapsas
DA. Reduction mammaplasty with the inferior pedicle
technique: early and late complications in 371 patients. Br
J Plast Surg 1996; 49: 4426.
27. Freire M, Neto MS, Garcia EB, Quaresma MR, Ferreira
LM. Quality of life after reduction mammaplasty. Scand
J Plast Reconstr Surg Hand Surg 2004; 38: 3359.
28. Klassen AF, Pusic AL, Scott A, Klok J, Cano SJ. Satisfaction and quality of life in women who undergo breast surgery: a qualitative study. BMC Wom Health 2009; 9: 11.
7
Oncoplastic surgery of the breast
Robert A. Grossman, Peter J. DiPasco, Subhasis Misra, and Eli Avisar
Oncoplastic surgery (OPS) has emerged as the latest paradigm in the treatment of cancer of the breast. Prior to the
development of OPS, the surgeon could provide either a
modified radical mastectomy or a segmental excision with
subsequent radiation to the breast cancer patient (1). With
integration of plastic surgical techniques into the repertoire of the breast surgeon, a new way to treat women with
early-stage cancer of the breast has emerged. Oncoplastic
surgery allows the surgeon to perform larger resections of
the breast with better cosmetic outcome while adhering to
oncologic principles (15). The goal of this chapter is to
explain the concepts of OPS as well as to familiarize the
reader with the most common oncoplastic techniques in
the approach to early-stage breast cancer.
OPS stems from breast conserving surgery (BCS), in
which the goal is complete excision of the tumor with
adequate surgical margins while maintaining the natural
structure and form of the breast (1). BCS combined with
radiation therapy to the breast has demonstrated low local
recurrence rates and equivalent survival outcomes as mastectomy for early-stage breast cancer. Breast conserving
surgery, however, has limitations: it is often difficult
to completely excise the tumor and maintain the natural
shape of the breast, and BCS does not always produce acceptable cosmetic results (1). A few very distinct
differences in the surgical principles characterize OPS
as a separate technique. Traditionally, BCS includes no
56
57
58
Breast
Cancer
< 20%
Volume
>= 20%
Volume
Poor
Location
Good
Location
Level I
Procedure
Normal
Breast Size
Large or
PtoticBreast
Large or
ptotic breast
Fatty Breast
Dense
Breast
Fatty Breast
Dense
Breast
Level III
Procedure
Level I
Procedure
Level II
Procedure
Level I
Procedure
Level II
Procedure
Figure 7.1
Level III
Procedure
Oncoplastic algorithm.
Verticle
mammoplasty or
modified round
bloc
Verticle
mammoplasty
Omegaplasty
or batwing
excision
Racquet
mammoplasty
Lateral
mammoplasty
V-mammoplasty
or medial
mammoplasty
J-mammoplasty
V-mammoplasty
Superior pedicle
mammoplasty with
inverted-T or
vertical scar
Figure 7.2
Figure 7.3
Figure 7.4
59
Level I OPS in lower inner quadrant, 5 months after radiation of the breast and internal mammary chain.
Level I OPS in lower inner quadrant, 5 months after radiation of the breast and internal mammary chain (side view).
60
the extremely low amount of nearby tissue free for flapping. Silverstein et al. described a batwing excision pattern, while Berry et al. describe an omegaplasty for lesions
in this area (6,14).
Tumors of the upper pole (111 oclock) rarely cause
deformity, as one can perform a vertical based mammoplasty re-approximating the medial and lateral breast
tissue with or without a partial breast lift. Clough has
described a round block technique in which concentric
periareolar incisions are made (1). We find it usually
unnecessary to incise the NAC circumferentially. Rather,
Figure 7.5 Level II OPS in superior central right breast with concomitant matching of the left side and 3 years after radiation of the
right breast (note the slight drop of the left breast).
Figure 7.6 Level II OPS in superior central right breast with concomitant matching of the left side and 3 years after radiation of the
right breast (note the slight drop of the left breast) (side view).
Figure 7.7
Figure 7.8
61
the NAC with the tumor can often be performed and will
maintain a better projection of the breast than a classic horizontal fish mouth incision around the NAC. The nipple and
areola can be reconstructed at a later date.
Figure 7.2 shows a visual representation of the procedures one may perform for each area of the breast.
Level III oncoreductive techniques can be employed in
patients who may have larger tumors in large-sized or pendulous breasts. In those cases the oncologic resection is
combined with a bilateral breast reduction, usually through
a classic inverted-T technique (Figs. 7.9 and 7.10). This
procedure presents an advantage also from the standpoint
Level II OPS of the upper outer quadrant of the right breast 2 years after surgery.
Level II OPS of the upper outer quadrant of the right breast 2 years after surgery (side view).
62
Figure 7.9 Preoperative view of level III OPS for a tumor in the left breast which is more pendulous than the right breast (courtesy
of Zubin J. Panthaki).
Figure 7.10
of radiation therapy by reducing the exposure of intrathoracic structures to the radiation fields and by optimizing the homogeneity of the radiation, both significant
concerns in large and pendulous breasts. The exact timing
of the contralateral breast reduction remains controversial
because, although a bilateral procedure will achieve the
best immediate symmetry, long-term results are difficult to
predict after radiation therapy to the affected breast which
typically ends up more edematous and less pendulous. The
63
OPS (29). These studies clearly show that oncologic compromise does not occur while using OPS techniques. The
issue of positive margins is one that merits some additional
discussion. Because OPS enables much wider lumpectomies, the rate of margins involvement has been lower than
reported with routine BCS (30). Studies have demonstrated
reoperation rates for margin involvement ranging from
8.9% to 20%, depending on size of the study and the experience of the surgeons (5,29,3235). Proficiency at OPS
technique will spare the patient from undergoing a repeat
procedure. This includes ensuring adequate surgical margins through intra-operative frozen pathologic sections. At
the University of Miami, we routinely use intraoperative
ultrasound to guide the lumpectomy and assess margins. A
recent study by Olsha et al. has demonstrated that careful
use of the ultrasound as an adjunct tool in the operating
room can significantly decrease the positive margin rate
(36). Unfortunately, however, after major breast tissue displacement it might often be difficult if not impossible to
re-excise a positive margin forcing mastectomy as the only
viable option. This is especially true when the oncologic
and the plastic components are not performed in a comprehensive team approach where each discipline is very familiar with the others principles. The oncoplastic surgical
team should always keep in mind a possible positive margin to enable a re-excision if necessary. At the beginning of
our experience we were recommending mastectomies for
patients with positive margins after level II or III OPS procedures. We have since changed this approach and reexcised positive margins even after those major tissue
displacements with excellent oncologic results.
Surgical complications of oncoplastic surgery include
skin necrosis, either partial- or full-thickness, fat necrosis,
seroma at a flap donor site, infection, hematoma, flap loss,
and poor cosmesis (5,29,3135). Skin necrosis was found
to be the most common complication of OPS followed by
seroma at the latissimus donor site in a study by Slavin
et al (34). A study by Pinsolle et al. demonstrated the most
frequent complications to be, in order, seroma of the flap
donor site, capsular contracture if a prosthesis was
implanted, skin necrosis, and hematoma (35). Risk factors
for complications of OPS are smoking, obesity, and radiotherapy, which affect rates of skin necrosis, infection, and
capsular contracture, respectively (5,29,3135).
Skin necrosis may be avoided by ensuring adequate
vascular supply of all areas, particularly to the NAC; if
needed the necrotic skin may be resected and the healthy
edges apposed. Partial thickness skin necrosis will
typically revascularize in time with little to no detriment
to cosmesis (28). Fat necrosis is associated with extensive
mobilization of fat-replaced breast tissue that has a poor
blood supply. Although this is not problematic in the
immediate postoperative phase, it will lead to a nodular
breast parenchyma, poorer cosmetic appearance with
64
65
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
8
Lumpectomy and radiation therapy
Onelio Garcia Jr., Roberto Comperatore, and Nuria Lawson
INTRODUCTION
and perform a total breast reconstruction. These reconstructions can be quite complex since these cases often
exhibit radiation damage with significant soft tissue fibrosis (Fig. 8.1 A). When the radiation damage is extensive,
adequate recipient vessels for autologous, free-tissue transfer may not be available and the tissue replacement needs
67
(A)
(B)
(C)
(D)
(E)
(F)
Figure 8.1 (A) Extensive radiation damage to right chest after mastectomy for failed lumpectomy. (B) Pre-operative planning. (C) A
contralateral, muscle-sparing, pedicle TRAM flap was used due to extensive damage to recipient vessels. (D) Intra-operative flap inset.
(E) Acellular dermal matrix was used to line the subpectoral-sub-TRAM flap pocket for the prosthesis. (F) 3-year postoperative result.
68
Age < 40
Large tumor size
Lymph node involvement
Lobular carcinomas
Extensive intraductal invasion
Lymphatic or vascular extension
Hereditary factors
69
70
(A)
(B)
(C)
Figure 8.2 (A) MammoSite breast brachytherapy applicator (Hologic, Inc., Bedford, MA) (B) Inflating MammoSite balloon. (C)
Balloon inflated within the lumpectomy cavity.
mammaplasty techniques (Fig. 8.4) can provide an acceptable aesthetic result (Fig. 8.5 AD). On the other hand, a
small breast can suffer significant deformity following a
small to moderate lumpectomy. The limited amount of
remaining tissue may not be sufficient to reconstruct an
aesthetically pleasing breast. These patients may necessitate reconstruction with techniques that replace the
missing volume such as distant flaps, or in some cases
completing the mastectomy and performing a total breast
reconstruction. Another consideration in these cases is the
71
Figure 8.3 Patient following upper pole, right breast lumpectomy followed by accelerated partial breast irradiation (APBI) using a
MammoSite device. Arrow points to irradiated area.
Figure 8.4
Pre-operative markings for breast conservation therapy on a patient with large, ptotic breasts and lateral tumor location.
72
significantly improve over the first year following completion of their treatment (Fig. 8.6A, B).
Algorithms for reconstruction of the partial mastectomy defect provide very useful guidelines for the surgical
(A)
(B)
(C)
(D)
Figure 8.5 (A, B) Pre-operative appearance. (C, D) Post-operative appearance following BCT by means of reduction mammoplasty.
(B)
(A)
Figure 8.6
(A) Acute radiation changes following BCT. (B) Appearance 1 year after completion of the radiation.
(A)
73
(B)
Figure 8.7 (A) Right breast deformity following lateral lumpectomy and radiation. (B) Correction of lateral breast deformity with
adjacent tissue advancement, implantation of acellular dermal matrix, and prosthetic breast augmentation.
74
(A)
(B)
(C)
(D)
Figure 8.8 (A, B). Right breast deformity and breast asymmetry following BCT. (C, D). Appearance following right breast
advancement flaps and left reduction mammoplasty for symmetry.
75
(A)
(B)
(C)
(D)
(E)
(F)
Figure 8.9 (A, B) Pre-operative appearance of patient with superior, central location of tumor on left breast. (C, D) Intra-operative
resection margins and central lumpectomy defect. (E, F) Post-operative appearance following left BCT with oncoplastic reconstruction.
cosmetic results (5052). Many of the problems associated with implant reconstruction of the irradiated breast
are related to radiation-induced capsular contracture.
Recently, there has been experimental evidence reported
in the literature regarding the lack of peri-prosthetic
76
(A)
(B)
(C)
(D)
Figure 8.10 (A, B) Appearance following right breast lumpectomy and MammoSite local irradiation. (C) Markings include the extent
of radiation-affected tissue. (D) Latissimus dorsi musculocutaneous flap used for soft tissue replacement.
a result of placing an implant that is too large or overzealous filling of an expander may lead to mastectomy flap
necrosis; however, creation of an empty space between
the matrix and the mastectomy flap inevitably leads to
seroma formation which in most cases prevents integration of the ADM. Avoidance of these complications
requires the surgical judgment to strike that fine balance
of initial expander volume fill that avoids the empty space
while not jeopardizing the circulation to the mastectomy
flap. Adhering to these technical principles will allow the
surgeon to achieve acceptable breast reconstruction
results in these difficult cases where the use of autologous
donor tissue may not be an option (Fig. 8.11 E, F).
COMPLICATIONS OF BREAST CONSERVATION
THERAPY
One of the most dreaded complications of oncoplastic surgery for BCT is the subsequent finding of positive tumor
margin. This can sometimes be the result of an inadequate
resection or poor patient selection such as in young patients
77
(A)
(B)
(C)
(D)
(E)
(F)
Figure 8.11 (A, B) Left breast deformity following BCT with radiation induced periprosthetic capsular contracture in a patient
reluctant to undergo autologous tissue transfer. (C, D) Acellular dermal matrix was used to line the revised dual plane subpectoral pocket.
(E, F) Postoperative appearance following tissue expansion and insertion of gel breast prosthesis.
with large tumors who are associated with a higher incidence of positive margins following BCT. Munhoz and
collaborators (7) have reported a 5.5% incidence of positive margins on permanent sections following examination
78
from 6.2% to 19.6% (5658). Performing re-excisional surgery in these cases can be difficult once the breast parenchyma has been re-arranged by the oncoplastic procedure
since it may not be possible to determine the original location of the tumor margins within the reconstructed breast.
A correlation between positive margins and increased incidence of local tumor recurrence has been reported by
Leong et al. (59). For all these reasons, it is imperative that
negative tumor margins be achieved during the primary
lumpectomy procedure. Pre-operative imaging may be
helpful in evaluating the extent of the tumor and currently
magnetic resonance imaging (MRI) appears to provide the
most accurate evaluation in this respect (60).
Since all of the BCT patients will require radiation and
in some cases also chemotherapy, it is of paramount
importance that surgical complications that may occur as
a result of the reconstructive procedures, do not delay the
initiation of the adjuvant therapy. Several authors have
reported that the surgical complications associated with
properly planned oncoplastic techniques are relatively
minor and usually are not associated with a delay in the
initiation of the adjuvant therapy (12,23,24,61,62).
Aesthetic outcomes in BCT are frequently influenced
by the patient's response to the radiation therapy. Unfortunately, radiation changes occur over time and are often
unavoidable. Clough et al. (63) reported significantly
worse aesthetic outcomes in BCT patients who received
their radiation preoperatively versus postoperatively. Several authors have also correlated large volume resections
with unsatisfactory cosmetic results, particularly in small
or moderate size breasts (64,65). A retrospective analysis
of over 100 BCT patients reported lower complication
rates for BCT when compared to mastectomy (66). The
aesthetic outcome failure rate for that series was 18% and
correlated highly with radiation-induced breast retraction.
SUMMARY
Breast-conservation therapy offers select breast cancer
patients another viable treatment option. Appropriate
patient selection and determining the best surgical procedure for a given defect are of paramount importance to the
success of BCT. Not everyone is a candidate for BCT and
patients at high risk for local tumor recurrences should
undergo alternative total mastectomy and reconstruction.
Patients with small breasts often cannot tolerate moderate
to large lumpectomies and will achieve better aesthetic
results from skin sparing mastectomy and reconstruction.
Reconstructive surgeons need to take into account the
radiation-induced tissue retraction that occurs over time
when planning volume replacement techniques and
overcorrect the defects. Most large series report that the
majority of patients undergoing BCT are satisfied with
their breast appearance. Advances in oncoplastic surgical
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
79
27. King TA, Bolton JS, Kuske RR, et al. Long term results of
wide-field brachytherapy as the sole method of radiation
therapy after segmental mastectomy for T(is,1,2) breast
cancer. Am J Surg 2000; 180: 299304.
28. Keisch M, Vicini F, Kuske RR, et al. Initial clinical experience with the MammoSite breast brachytherapy applicator
in women with early-stage breast cancer treated with breast
conserving therapy. Int J Radiat Oncol Biol Phys 2003; 55:
28993.
29. Wolmark N, Wang J, Mamounas E, et al. Pre-operative chemotherapy in patients with operable breast cancer: nine year
results from the national surgical adjuvant breast and bowel
project B18. J Natl Cancer Inst Monogr 2001; 30: 96102.
30. McIntosh SA, Ogston KN, Payne S, et al. Local recurrence in
patients with large or locally advanced breast cancer treated
with primary chemotherapy. Am J Surg 2003; 185: 52531.
31. Soucy G, Belanger J, Leblanc G, et al. Surgical margins in
breast-conservation operations for invasive carcinoma: does
chemotherapy have an impact? J Am Coll Surg 2008; 206:
111621.
32. Temple CF, Strom FA, Youssef A, et al. Choice of recipient
vessels in delayed TRAM flap breast reconstruction after
radiotherapy. Plast Reconstr Surg 2005; 115: 10513.
33. Anderson BO, Masetti R, Silverstein MJ. Oncoplastic
approaches to partial mastectomy: an overview of volume
replacement techniques. Lancet Oncol 2005; 6: 14557.
34. Masetti R, Pirullo PG, Mango S, et al. Oncoplastic techniques in the conservative treatment of breast cancer. Breast
Cancer 2000; 7: 27680.
35. Clough KB, Nos C, Salmon RJ, et al. Conservative treatment of breast cancer by mammaplasty and irradiation: a
new approach to lower quadrant tumors. Plast Reconstr
Surg 1995; 96: 36370.
36. Munhoz AM, Montag E, Arruda EG, et al. Critical analysis
of reduction mammaplasty techniques in combination with
conservative breast surgery for early breast cancer treatment. Plast Reconstr Surg 2006; 117: 1091107.
37. Kronowitz SJ, Hunt KK, Kuerer HM, et al. Practical guidelines for repair of partial mastectomy defects using the
breast reduction technique in patients undergoing breast
conservation therapy. Plast Reconstr Surg 2007; 120: 1.
38. Spear SL, Pelletiere CV, Wolfe AJ, et al. Experience with reduction mammaplasty combined with breast conservation therapy
in breast cancer. Plast Reconstr Surg 2003; 111: 110210.
39. Spear SL, Patel KM, Parikh PM. Reduction mammaplasty
as part of breast conservation therapy of the large-breasted
patient. In: Spear SL, Willey SC, Robb GL, Hammond DC,
Nahabedian MY, eds. Surgery of the Breast: Principles and
Art. 3rd edn. Philadelphia: Lippincott Williams & Wilkins,
2011: 21317.
40. Spear SL, Burke JB, Forman D, et al. Experience with
reduction mammaplasty following breast conservation surgery and radiation therapy. Plast Reconstr Surg 1998; 102:
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41. Clough K, Kroll S, Audretsch W. An approach to the repair
of partial mastectomy defects. Plast Reconstr Surg 1999;
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42. Hamdi M, Wolfli J, Van Landuyt K. Partial mastectomy
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43. Petit JY, De Lorenzi F, Rietjens M, et al. Technical tricks to
improve the cosmetic results of breast-conserving treatment. Breast 2007; 16: 1316.
44. Breuing KH, Warren SH. Immediate breast reconstruction
with implants and inferolateral AlloDerm slings. Ann Plast
Surg 2005; 55: 2329.
45. Salzberg CA. Nonexpansive immediate breast reconstruction using human acellular dermal matrix graft (AlloDerm).
Ann Plast Surg 2006; 57: 15.
46. Gamboa-Bobadilla GM. Implant based reconstruction using
acellular dermal matrix. Ann Plast Surg 2006; 56: 225.
47. Zienowics RJ, Karacaoglu E. Implant based reconstruction
with allograft. Plast Reconstr Surg 2007; 120: 37381.
48. Spear SL, Parikh PM, Reisin E, Menon NG. Acellular dermis-assisted breast reconstruction. Aesthetic Plast Surg
2008; 32: 41825.
49. Jugenberg M, Disa JJ, Pussic AL, et al. Impact of radiotherapy on breast reconstruction. Clin Plast Surg 2007; 34:
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50. 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: 930.
51. Spear SL, Jespersen MR. Prosthetic reconstruction in the irradiated breast. In: Spear SL, Willey SC, Robb GL, Hammond
DC, Nahabedian MY, eds. Surgery of the Breast: Principles
and Art. 3rd edn. Philadelphia: Lippincott Williams & Wilkins,
2011: 46075.
52. Evans GR, Schusterman MA, Kroll SS, et al. Reconstruction and the radiated breast: is there a role for implants?
Plast Reconstr Surg 1995; 96: 1111.
53. Komorowska-Timek E, Kerby CO, A-Timek A, et al. The
effect of AlloDerm envelopes on periprosthetic capsular
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2009; 123: 80716.
54. Stump A, Holton LH, Connor J, et al. The use of acellular
dermal matrix to prevent capsule formation around implants
in a primate model. Plast Reconstr Surg 2009; 124: 82.
55. Salzberg CA, Koch RM. Direct to implant breast reconstruction with acellular dermal matrix. In: Spear SL, Willey
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9
Preoperative evaluation for post-mastectomy reconstructive surgery
Charles R. Volpe, Paul Yang, and Zubin J. Panthaki
INTRODUCTION
reconstructive procedure chosen should be specifically tailored to the individual patients needs and the surgeons
clinical experience. To achieve the highest satisfaction,
the patients concerns and expectations must be addressed.
Additional time must be spent educating the patient about
the various surgical options including the safety and limitations of each procedure. Most importantly, the surgeon
must properly evaluate the patient and select the appropriate reconstructive procedure in an effort to minimize postoperative complications and improve patient outcomes.
MEDICAL HISTORY
A thorough medical history is of utmost importance during the preoperative evaluation and should be performed
for all patients. The medical history should include a
detailed account of past and coexisting medical problems,
past surgical procedures, family history, social history
(e.g., alcohol or tobacco use), current medication and vitamin use, and any relevant allergies. In addition, detailed
understanding of the patients oncologic treatment plan is
needed. Access to and involvement with an institutional
tumor board is an invaluable asset to the preoperative
planning. Neoadjuvant chemotherapy, post-operative chemotherapy, and radiation treatment protocols need to be
known for each patient. Information gleaned from this
interrogation may influence the decision to proceed with
reconstruction and/or the type of procedure offered to the
patient.
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Systemic Illnesses
Comorbid medical conditions such as retinopathy, nephropathy, peripheral vascular disease, cerebral vascular disease,
hypertension, coronary artery disease, chronic obstructive
lung disease, arrythmia, and congestive heart failure should
be identified early in the medical history taking process. A
history of diabetes and coronary artery disease may suggest
widespread vascular involvement that may preclude a patient
from a lengthy procedure such as autologous breast reconstruction. However, well-controlled diabetes should not, in
and of itself, be considered a contraindication to autologous
free flap reconstruction. Comparable rates of anastomotic
patency, blood vessel thrombosis, fat necrosis, and free flap
loss have been found when comparing well-controlled diabetic (Type 1 or 2) to non-diabetic cohorts (4). Higher rates
of local complications including wound healing problems
and implant extrusion have been found in diabetic patients
undergoing concomitant implant and TRAM flap reconstructions (5). However, poorly controlled or undiagnosed
diabetes can present significant problems. Studies have
shown that poorly controlled diabetes can result in wound
healing problems following cardiac and non-cardiac surgery
(68). Current recommendations from the American Diabetes Association include preoperative fasting blood glucose or
HbA1c (a marker of glycemic control for the previous
3 months) for all surgical patients who have not been previously screened or have risk factors for diabetes. Any patient
found to have an abnormal test should have an HbA1c drawn
in the hospital and should receive follow-up testing as an
outpatient (9). Recognition of a poorly controlled diabetic
state may warrant performing a delayed reconstruction when
the patients medical condition improves.
Smoking
Smoking is universally accepted to be a risk factor for
postoperative complications. Cigarette smoking increases
platelet aggregation and the risk of flap thrombosis (10,11).
In addition, nicotine causes cutaneous vasoconstriction
thus reducing capillary blood flow (12), and carbon monoxide binds hemoglobin resulting in tissue hypoxia (13).
Patients who currently smoke tobacco should be advised
to quit for at least one month prior to scheduled surgery.
The actual incidence of complications attributed to be
active during breast reconstruction varies considerably
between studies and between the methods of reconstruction offered. Known complications of smoking include
skin flap necrosis (14), wound infection (15), as well as fat
necrosis, flap loss, and wound dehiscence (16). Due to the
increased incidence of flap and abdominal donor site complications, active smoking has long been considered a
relative contraindication to performing pedicled TRAM
flap reconstruction (17,18). Spear et al. reviewed their
Two topics deserve careful consideration when discussing the patients breast-related history. Significant
family history of breast or ovarian cancer may suggest a
genetic predisposition to breast cancer through the
BRCA gene. Testing for BRCA1 and BRCA2 genotypes
should be made available to these patients. Confirmed
carriers of the BRCA 1/2 genes should be offered bilateral prophylactic mastectomy along with bilateral breast
reconstruction. Bilateral prophylactic mastectomy has
been shown to reduce the risk of breast cancer in this
patient population by 90% (25). The diagnosis of lobular
carcinoma in situ (LCIS) presents a second scenario in
which bilateral mastectomy and breast reconstruction
can be offered in select cases. Patients with biopsyproven LCIS are at increased risk of developing an invasive breast cancer in either breast. The minimum risk of
developing invasive breast cancer after the diagnosis of
LCIS is 7.1% at 10 years (26). Currently, the most common clinical recommendation for women with LCIS is
close follow-up combined with chemoprevention (e.g.,
Tamoxifen) (27,28).
Radiation and Chemotherapy
Discussions concerning the reconstructive options for
patients with breast cancer must address the potential need
for neoadjuvant chemotherapy and/or post-operative chemotherapy and radiation. Therefore, proper clinical staging
of the patients breast cancer should be made prior to the
evaluation for reconstructive surgery. Clinical staging
affords the reconstructive surgeon an understanding of the
patients chemotherapy and/or radiation therapy requirements along with a timeline for the administration of these
treatments. Armed with this information, the reconstructive
plan can be appropriately determined. For example, radiotherapy planned in the immediate post-operative period for
a patient with a large tumor and positive axillary nodes
might sway the decision to provide delayed reconstruction
rather than immediate reconstruction with an expander/
implant. Studies have shown that radiation exposure following implant-based reconstruction is associated with
delayed wound healing, capsular contractures, high rate of
implant extrusion or malposition, and infection (29).
Similarly, if postoperative radiotherapy is warranted, it
may be wise to delay autologous breast reconstruction
until after the therapy is completed (30,31). Complication
rates for immediate autologous breast reconstruction followed with post-operative radiation therapy range from
60 to 87.5% (32,33). Known complications related to
radiation therapy include acute changes such as mild to
brisk erythema and flap skin desquamation. Long-term
changes include volume loss secondary to fat necrosis or
parenchymal fibrosis, alteration in flap contour, and loss
of symmetry (34).
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45. Brown MH, Weinberg M, Chong N, et al. A cohort study of
breast cancer risk in breast reduction patients. Plast Reconstr Surg 1999; 103: 1674.
46. Tarone RE, Lipworth L, Young VL, McLaughlin JK. Breast
reduction surgery and breast cancer risk: does reduction
mammaplasty have a role in primary prevention strategies
for women at high risk of breast cancer? Plast Reconstr
Surg 2004; 113: 210410; discussion 21112.
47. Dayhim F, Wilkins EG. The impact of pfannenstiel scars on
TRAM flap complications. Ann Plast Surg 2004; 53: 432.
10
Tissue expansion reconstruction
Sheri Slezak and Tripp Holton
surgery. Patients need to be informed about standard complications inherent to implants, including rupture, migration, wrinkling, contracture, infection, palpability, rippling,
and exposure and that these are more likely to happen after
radiation therapy.
Cancer surveillance is not adversely affected by the
presence of an expander or an implant since these are
placed beneath the pectoralis major muscle. Therefore, the
deep margin of the resected breast is above the device and
is thus palpable. Many patients worry that reconstruction
will hide a recurrence so this information is comforting.
Implant surveillance should also be discussed. Current
guidelines entail a baseline MRI after three years followed
by MRIs every two years thereafter.
TISSUE EXPANDERS AND BREAST IMPLANTS
In 1957 Neumann was the first to use tissue expansion for
reconstructive surgery. His use of a rubber balloon to
expand the temporo-occipital skin provided soft tissue
coverage for an ear reconstruction (3). Cronin and Gerow,
soon thereafter, worked with Dow Corning Corporation to
develop the first silicone breast implants. But it was not
until the mid-to-late 1970s that Radovan and Austad independently reported their respective experiences using tissue expansion for breast reconstruction (4,5). Since then,
there has been a steady improvement in both technology
and technique for tissue expansion and implant-based
reconstruction for breast deformities.
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Tissue expanders are now manufactured in a wide variety of sizes, shapes and designs. Some surgeons use a
one-shape-fits-all approach whereas others utilize different types for various patient morphologies (Fig. 10.1).
Choices include round, profiled, dual chamber, and
expanders that become permanent implants. Ports can be
integrated or remote.
The simplist device is a round expander with a single
chamber. An advantage of this round expander is that they
tend to provide a uniform and reproducible result and if
they rotate it does not distort the shape of the skin envelope.
In order to expand the skin envelope into the shape of
a natural breast, profiled and dual chamber expanders
were developed. Profiled expanders allow the lower pole
skin to stretch more than the skin of the upper pole, which
enables the expansion to create an envelope that can
house a natural, ptotic-appearing breast. Dual chamber
models have separate anterior and posterior chambers.
The anterior chamber is round and has a port located
superiorlythis is filled intra-operatively. A second
anterior chamber is located only in the lower pole, and
this is filled in the office (Fig. 10.2 AC). Some surgeons prefer to use expandable implants. These salinebased, or silicone/saline hybrid devices are sequentially
inflated via a remote and removable port. Once appropriately expanded, a separate incision is made over the
port and it is removed by pulling the tubing through a
double sealing system. This novel design allows for the
Figure 10.1 (AC) Various breast tissue expanders are available. Pictured here are: (A) A Natrelle expander by Allergan, (B) a
Sientra dual chamber expander, and (C) a Mentor CPX3 profiled expander.
(A)
89
(B)
(C)
Figure 10.2 (AC) A patient undergoing reconstruction with dual chamber expanders. (A) Pre-operative view. (B) Expanded to
volume. (C) On profile view. Note the differential expansion of the lower pole compared to the upper pole.
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(A)
(B)
(C)
(D)
Figure 10.3 (AD): The process of tissue expansion. (A) Pre-operative view of a patient with left breast cancer. (B) Filling of the left
tissue expander (the right breast has been augmented with a permanent implant). (C) After exchange of the left tissue expander for a
permanent implant. (D) The completed reconstruction with areolar tattooing.
92
Figure 10.4
Infection of a recently placed left tissue expander demonstrating redness and swelling.
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(A)
(B)
Figure 10.5 (AB) (A) Left capsular contracture 10 years after reconstruction with a left sided silicone implant. (B) Status post left
capsulectomy and replacement of a new silicone implant and contralateral peri-areolar scar revision.
95
We place little value on information garnered by fluorescein injection although we have tried this technique
in the past. The SPY Elite Intraoperative Perfusion
Assessment System is becoming increasingly popular
in breast reconstruction. This technology provides an
accurate and real-time assessment of skin flap viability
during immediate implant-based breast reconstruction
and can also be utilized during microvascular breast
reconstructions (43,44).
Implant Displacement
With immediate placement of a tissue expander one must
recognize that the ablative surgeon typically opens a wide
pocket, dissecting lateral to the anterior axillary line and
sometimes below the inframammary fold. The tissue
expander must be fixed in place in order to expand the
desired pocket, not the actual pocket. This may be done in
several ways. Submuscular placement of the expander
keeps the upper portion of the expander in place, but if the
muscle is not secured it can contract superiorly and the
expander is easily displaced into the supramuscular plane.
The expander may then sit more laterally than desired and
expand the subaxillary space. The use of ADM has substantially helped the problem of displacement. In this technique, a 6 12 cm piece of medium thickness ADM is
pie-crusted and sewn to the inframammary fold. The
suture catches the ADM, the deep fascia and the dermis of
the fold to secure it to the chest wall at the desired place.
The expander is placed and the ADM is sewn to the upper
edge of the muscle. This keeps the caudal edge of the pectoralis major muscle pulled down over the implant, tightens and fixes the inframammary fold, and allows a
stretchable area in the lower pole. As one expands the
device, the lower pole is more easily expanded and this
gives a better shape. The other option is to secure the
expander to the chest wall by sewing down the tabs that
several of the expander models have. Expander displacement may also be addressed if needed at the second operation during which one exchanges the expander for the
permanent implant. The formed capsule can then be lowered, widened, or plicated, whichever is needed. Plication
involves scoring or damaging the capsule to be closed and
then placing 2-0 Vicryl or Gortex sutures.
Hematoma or Seroma
The risk of hematoma in the Mentor Core Study was 1.3%
in primary reconstruction and 3.5% for revisions (13).
Seromas are much more common (4.9%)especially
when the prosthesis is placed into a fresh mastectomy bed.
Drains are generally needed and some surgeons use two.
We pie-crust the ADM and use only one drain since there
is free communication above and below the sling. It is
96
Figure 10.6
Thinned scar and wound dehiscence with exposure of underlying implant during chemotherapy.
Wound Dehiscence
Figure 10.7
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98
(A)
(B)
Figure 10.8 (A, B) (A) Pre-operative patient with previous right lumpectomy and radiation. The breasts were too large to match
without contralateral reduction. (B) Post-operative view with immediate right-sided 800-cc implant and contralateral reduction with
free-nipple graft.
(A)
(B)
Figure 10.9 (AB) (A) Pre-operative patient with previous lumpectomy and positive margins. (B) Post-operative result after bilateral
expander/implant reconstruction and completion of nipple tattooing.
of the expander and the placement of an autologous tissue flap, as this bridge has not been burned by expander
reconstruction.
Radiated, Non-stretchable Skin Envelope
If the patients skin is radiated and shows severe telangectasis, hyperpigmentation, parenchymal asymmetry, and/or
skin thickening, then it is doubtful that this skin will successfully expand. Alternate methods of reconstruction
should be chosen. However, radiation is not a contraindication for expansion in all cases. Despite what we are
taught about radiation, current evidence is divided with
regard to radiation and the development of complications
(A)
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(B)
(C)
Figure 10.11 (AC) (A) Pre-operative patient with significant ptosis. (B) Acellular dermal matrix sling allows the tissue expanders
to sit low in order to expand the lower poles thus creating an age-appropriate ptotic appearance. (C) Final post-operative appearance.
100
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
101
37. Hwang K, Sim HB, Huan F, Kim DJ. Myofibroblasts and
capsular tissue tension in breast capsular contracture. Aesthetic Plast Surg 2010; 34: 71621.
38. Weintraub JL, Kahn DM. The timing of implant exchange
in the development of capsular contracture after breast
reconstruction. Eplasty 2008; 8: 30311.
39. Scuderi N, Mazzocchi M, Rubino C. Effects of zafirlukast
on capsular contracture: controlled study measuring the
mammary compliance. Int J Immunopathol Pharmacol
2007; 20: 57784.
40. Huang CK, Handel N. Effects of singulair (montelukast)
treatment for capsular contracture. Aesthetic Surg J 2010;
30: 4048.
41. Spear SL, Seruya M, Clemens MW, Teitelbaum S,
Nahabedian MY. Acellular dermal matrix for the treatment and prevention of implant-associated breast deformities. Plast Reconstr Surg 2011; 127: 104758.
42. Basu CB, Leong M, Hicks MJ. Acellular cadaveric dermis
decreases the inflammatory response in capsule formation
in reconstructive breast surgery. Plast Reconstr Surg 2010;
126: 18427.
43. Komorowska-Timek E, Gurtner GC. Intraoperative perfusion mapping with laser-assisted indocyanine green imaging can predict and prevent complications in immediate
breast reconstruction. Plast Reconstr Surg 2010; 125:
106573.
44. Pestana IA, Coan B, Erdmann D, et al. Early experience
with fluorescent angiography in free-tissue transfer reconstruction. Plast Reconstr Surg 2009; 123: 123944.
45. Slezak S, Bluebond-Langner R. Occult carcinoma in 866
reduction mammaplasties: preserving the choice of lumpectomy. Plast Reconstr Surg 2011; 127: 52530.
46. Contant CM, Menke-Pluijmers MB, Seynaeve C, et al.
Clinical experience of prophylactic mastectomy followed
by immediate breast reconstruction in women at hereditary
risk of breast cancer (HB(O)C) or a proven BRCA1 and
BRCA2 germ-line mutation. Eur J Surg Oncol 2002; 28:
62732.
47. Ryan JJ. A lower thoracic advancement flap in breast reconstruction after mastectomy. Plast Reconstr Surg 1982; 70:
15360.
11
The pedicled TRAM flap
M. Lance Tavana and Paul D. Smith
OVERVIEW
PATIENT SELECTION
The patient, in regard to both body habitus as well as medical and surgical history, is a major factor in a successful
outcome. By adequately assessing the risk factors associated with the patient, the proper decision may be made
regarding reconstruction technique.
We have found the ideal candidate for TRAM reconstruction to have the following attributes:
BMI between 25 and 35 with adequate abdominal
tissue
No previous incisions on the abdomen interrupting the
superior pedicle
No previous cardiac surgery with IMA harvest
No history of uncontrolled diabetes mellitus, COPD, or
smoking within the last 6 months
ANATOMIC CONSIDERATIONS
Several key anatomic facts guide surgical planning. The
rectus abdominis muscle is a Mathes and Nahai Type 3
muscle with its main blood supply from the superior and
inferior epigastric arteries. The superior pedicle is a termination of the internal mammary vessels, while the inferior
epigastric arises from the external iliac vessels. Innervation of the rectus muscle is from the lower six or seven
intercostal nerves, which are encountered and ligated as
the muscle is raised during harvest.
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103
104
incised in a circular fashion without pulling too much tension on the stalk, as this may shorten the stalk and provide
for more difficult inset. Metzenbaum scissors can be used
to dissect the umbilical stalk down to fascia, then the
midline incision is performed and carried down to fascia.
The medial perforators are exposed in a fashion similar to
the lateral row. By careful exposure of the perforators, the
extent of fascia needed to be included with the flap is minimized. By doing this, the closure of the fascia is made
easier later in the case.
A 1-cm strip of fascia is outlined from the superior
aspect of the adipocutaneous flap in between the lateral
and medial perforators. This strip is continued up to the
costal margin, but left intact superiorly to provide a tether
so that the muscle and pedicle are not stretched. This superior strip also provides a tight closure of the upper abdomen after the rectus is transferred, thereby decreasing
abdominal wall bulge superiorly. A scalpel is used to
incise the anterior rectus fascia along the strip then medially and laterally, sparing the perforators but leaving
behind as much fascia as possible. The muscle is dissected
medially and laterally from the fascia, with dissection
starting between the muscle inscriptions for ease then
taken to the inscriptions in the same plane.
The inferior pedicle is identified and ligated with clips,
leaving as much of a pedicle length as possible as a lifeboat should the superior pedicle be accidentally injured
during harvest. This allows for a free-flap reconstruction
using the inferior pedicle to still be an option. The inferior
aspect of the rectus muscle is divided below the pedicle by
electrocautery and the muscle raised inferior to superior.
Once the muscle is raised to the level of the superior aspect
of the cutaneous flap, the muscle is sutured to the adipose
tissue of the flap using a running absorbable stitch medially, inferiorly, and laterally. This allows the myocutanous
flap to be moved en block without increased risk of avulsing the perforators.
The superior muscle dissection is carried on its anterior
surface to the costal margin, taking care to sufficiently release
the muscle medially for mobility. Blunt dissection is used
under the muscle to protect the pedicle from injury, which
should be easily visualized as the muscle is raised. Once the
flap is completely dissected, the lateral tip (Zone 3) of the
adipocutaneous portion of the flap is sharply excised. This
allows flap perfusion to be assessed by the rate of bleeding
and the color of the blood. By excising an appropriate amount
of zone 3, the flap bulk is reduced for an easier flap transfer
while also immediately reducing the metabolic demands of a
larger flap. For a unilateral case, zone 4 and a majority of
zone 2 is immediately removed for the same reason.
We have found that a lateral tunnel for flap transfer
advantageous over a traditional medial tunnel. First, the
muscle is rotated through a broader arc, thereby reducing
the likelihood of kinking of the pedicle. Second, a lateral
tunnel allows the early bulk of the muscle to remain lateral to the midline of the breast, thereby leaving the
medial inframammary fold intact and aesthetically pleasing. The dissection is carried from the abdominal space to
the breast pocket completely lateral to the midline of the
breast. The flap is then rotate laterally and up into the
breast pocket. We have also found that a 180-flap rotation produces the best position for the muscular pedicle to
be loose without strain on the pedicle, while a 90 rotation
allows for greater upper pole fullness. This decision is
made interoperatively.
On a bilateral case, each flap is dissected, transferred
completely and the fascia closed before the other flap is
dissected. This allows for an easier fascial closure. This is
performed one of two ways, with several interrupted figure
of eight sutures or a running barbed suture. Once fascial
closure is complete, onlay mesh is used to augment the
strength of the abdominal wall. A single 20 30 cm piece
of marlex mesh is used to cover the abdominal wall from
external oblique fascia bilaterally to the superior and inferior extent of dissection. The mesh is sutured with either a
running nonabsorbable monofilament or running barbed
suture.
Closed suction drains are placed through the dependent
portion of the abdominal space. The umbilicus is delivered
through the abdominal flap while the central abdominal
incision is temporarily closed with staples in order to provide proper position. The patient is flexed at the hips to
bring the abdominal wound closed with the least amount
of tension and the incision closed in multiple layers.
Flap inset is variable case to case, but can be generalized
to be for immediate or delayed reconstruction. In immediate reconstruction using a skin sparing technique, the flap
is oriented in the breast pocket for the best volume filling
of the space. In smaller breasts, or in breasts in which the
flap volume is greater than the mastectomy volume, the
flaps may be inset without reducing the breast skin volume
(Fig. 11.1). The flap is de-epithelialized except for the areola replacement, a drain is placed, the areola is inset and
the mastectomy flap incision closed. When the flap volume
is less than the mastectomy volume, the vertical reduction
is performed on the breast skin (Fig. 11.2). The mastectomy flaps are tailor tacked to reshape the skin envelope to
the volume of the TRAM flap and the areola location
marked on the flap. The flap is de-epithelialized except for
the areola replacement, a drain is placed, the areola is inset
and the mastectomy flap incision closed.
In delayed reconstruction, the flap is inset to replace the
loss of skin from contraction and/or radiation (Fig. 11.3).
The inferior and medial inset margins are created without
undermining the mastectomy flaps, creating a greater fold
inferiorly and appropriate central cleavage. The inferior
inset is performed with a 2:1 ratio of TRAM skin to fold
skin, thereby creating a greater amount of skin on the newly
(A)
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(B)
Figure 11.1 (A) Preoperative right immediate skin-sparing mastectomy reconstruction. (B) Twelve-month follow-up after right
nipple-areolar reconstruction.
(A)
(B)
Figure 11.2 (A) Preoperative right delayed reconstruction with left immediate skin sparing reconstruction. (B) Sixteen-month
follow-up after bilateral nipple-areolar reconstruction with tattooing.
106
(A)
(B)
Figure 11.3
(A) Bilateral delayed reconstruction. (B) Nine-month follow-up after nipple-areolar reconstruction.
legs. The patients foley catheter is removed the morning after surgery and ambulation is started shortly
thereafter. Physical therapy assists the patient with
ambulation with a walker in order to keep the hips
flexed. This position is kept for a period of 1014 days
and then slowly increased as the patient becomes more
comfortable with the tension of the abdomen and as
wound strength increases. All drains are kept until they
are draining less than 30 cc over a 24-hour period for
two straight days, or until a period of three weeks,
whichever is sooner.
COMPLICATIONS
With proper surgical planning and postoperative management, most complications can be avoided. Total or
partial flap loss, fat necrosis, contour deformity, wound
healing delay, and abdominal wall laxity can all be attributed to several factors within and beyond the surgeons
control.
Vascular supply, both arterial and venous, can be affected
by numerous technical mistakes. First, an error in judgment
in patient selection can doom the outcome of the surgery
from the outset. Prior mammary artery harvest or a subcostal incision across the epigastric artery should be ruled out
prior to planning for a pedicled TRAM flap. In these
patients, a free TRAM or deep inferior epigastric artery perforator using the inferior vessels should be considered, if
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Hartrampf CR, Bennett GK. Autogenous tissue reconstruction in
the mastectomy patient: a critical review of 300 patients. Ann
Surg 1987; 205: 50812.
Hartrampf CR, Soneflan M, Black PW. Breast reconstruction
with a transverse abdominal island flap. Plast Reconstr Surg
1982; 69: 21625.
Moon HK, Taylor GI. The vascular anatomy of rectus abdominis
musculocutaneous flaps based on the deep superior epigastric system. Plast Reconstr Surg 1988; 82: 81532.
12
Transverse rectus abdominis myocutaneous (TRAM) flap and deep
inferior epigastric artery perforator (DIEP) flap breast reconstruction
John C. Oeltjen and Haaris Mir
HISTORY
110
ANATOMY
The lower abdominal wall receives its perfusion through
two different arterial systems. The vascular supply can be
divided into a superficial system as well as a deep system.
Contributions from intercostal segmental vessels and
superior epigastric vessels are also made.
In 1975 Taylor and Daniel performed cadaveric dissections and were able to define the anatomy of the superficial
system to the lower abdomen. Three patterns of arterial
perfusion based on the SIEA were identified:
1. In 17% of cadavers the SIEA was found to arise from
the common femoral artery. The vessel was noted to
have a mean diameter of 1.1 mm (0.81.8 mm).
2. In 48%, the SIEA shared a common trunk with the
superficial circumflex iliac artery. The mean diameter
was noted to be 1.4 mm (0.83.0 mm).
3. In 35% of cadavers the SIEA was absent, however a
large compensatory circumflex iliac artery was found
with a mean diameter of 1.4 mm (0.83.0 mm) (18).
The landmark for the SIEA at the inguinal ligament is
the midpoint between the pubic bone and the anterior
superior iliac spine, or even slightly lateral to this point.
The artery originates from the anterior surface of the femoral artery 45 cm below the inguinal ligament (19).
The vascular supply to the SIEA flap arises superficial
to the rectus sheath. When dissecting out the flap, there is
no violation of the abdominal wall musculature or fascia.
Allen noted no hernias or abdominal wall weakness in
elevating an SIEA flap (20).
The TRAM and the DIEP flaps both rely on their perfusion via the deep system. The origin of the deep inferior
epigastric artery is from the external iliac artery deep to the
inguinal ligament along with the venae comitantes (15).
Milloy was able to demonstrate that as the deep inferior
epigastric artery traveled from the external iliac vessel to
the umbilicus it pierced the rectus abdominis muscle at
various levels: Lower third 17%, middle third 78%, and 5%
in the upper third (21). Within the rectus abdominis muscle, the deep inferior epigastric artery usually divides into
a non-dominant medial branch and a dominant lateral
branch. The artery has also been found to have a dominant
medial branch (18%) or a central course with multiple
small branches (28%) (22).
Using color duplex ultrasonography, Blondeel was able
to demonstrate that on each side of the anterior rectus fascia there are between two and eight paraumbilical perforators each greater than 0.5 mm in diameter. The approximate
site of the perforators was noted to be 26 cm caudal and
16 cm lateral to the umbilicus (23).
Medial perforators:
Long, oblique and complicated, intramuscular route
with numerous subsidiary muscular branches.
111
Rectus
abdominis
muscle
Figure 12.1 Hartrampf perfusion zones. Perfusion in Zones I and II was thought to be the best, less in Zone III, and the poorest in
Zone IV with the most likelihood of flap necrosis.
Anatomic dissections of DIEP flaps with special attentions to angiosomes by Taylor and colleagues demonstrated
that the zones of perfusion for free-tissue transfer from the
lower abdomen are in fact different from their original
descriptions (28,29). In 1983 Dinner suggested that the
ipsilateral hemiabdomen does indeed have better perfusion
than the segment across the abdominal midline. Perfusion
was better in Zone III than in Zone II, thus he advocated
changing the initial classification (Fig. 12.2) (11).
INDICATIONS
The abdominal free flap breast reconstruction utilizes the
deep inferior epigastric artery vascular supply to transfer
and skin and fat from the abdomen to the chest region in
order to replace the tissue removed in a mastectomy. There
are multiple decisions made to arrive at a free autologous
tissue reconstruction of the breast after which the decision
has to be made about which donor site to be used, and
finally, if the abdomen is appropriate, the decision has to
112
Rectus
abdominis
muscle
Figure 12.2
113
114
discontinued 2 weeks prior to the operation and extra attention given to the administration of perioperative anticoagulation therapy in order to minimize the risks (33).
The increasing popularity of abdominal wall fascia and
rectus abdominis muscle preservation techniques along
with technological advances in imaging have led to the use
of either computed tomography angiograms (CTA) or magnetic resonance angiography (MRA) to map the abdominal
wall vasculature in preparation for the operation. With a
properly adjusted protocol, the individual perforators to the
abdominal wall skin and subcutaneous tissue can be visualized as they branch off the rectus abdominis muscle vasculature and arborize throughout the subcutaneous tissue
(Fig. 12.3). The advantages of the imaging include: (1) the
ability to determine if the deep inferior epigastric artery
blood supply was interrupted by any previous surgeries, (2)
preoperative localization of any dominant perforators to the
abdominal wall, (3) the ability to choose from the larger
perforators that appear to vascularize a majority of the proposed flap tissue. The general consensus is that preoperative imaging decreases the intraoperative time that was
previously spent searching for the dominant perforators
through dissection and direct visualization (34). With
increased experience by the surgeon, however, the amount
of operative time saved with the availability of CTA or
MRA data, decreases. The disadvantages of the imaging
include the cost of the studies, the toxicities associated with
the dyes, and the increased radiation exposure as associated
with the CTA.
In the preoperative staging area, the patient is marked
in preparation for the surgery. A midline marking from
[R]
[L]
Applied
Figure 12.3
[P]
C50
W380
1.5 cm above the inframammary fold at the breast meridian tapering medially and laterally to meet the inframammary fold (Fig. 12.4). Finally, the manubrium is marked
along the midline as a landmark for the second rib.
With completion of the markings, the patient can be
taking to the operating room. As should be standard protocol, the patient should have bilateral sequential compression devices and warming device placed prior to receiving
any anesthesia. Additionally, prophylactic fractionated or
unfractionated heparin and prophylactic antibiotics are
administered prior to induction. Placement of the patient
on the operative room table should allow for intraoperative flexion while also accommodating a possible lymph
node dissection by the surgical oncologist.
In an immediate reconstruction, harvesting of the
abdominal flap can proceed concomitantly with the mastectomy if the reconstructive surgeon is sure that reconstruction will proceed regardless of findings of the surgical
oncologist including positive sentinel lymph nodes. The
flap is incised as marked with continued dissection through
the subcutaneous tissues down to the fascia. Inferiorly in
patients who have not had a Pfannensteil incision, dissection
115
Proposed removal
of interior mastectomy
flap (dashed)
Proposed new
inframammary
fold (solid)
Rectus
abdominis
muscle
Proposed
abdominal
flap
(A)
(B)
Figure12.4 Graphic (A) and pictorial (B) demonstration of preoperative markings for a free flap breast reconstruction. Note the right
(A) and left (B) planned lower mastectomy flap excision is marked approximately 1.5 cm above the proposed inframammary fold.
116
Figure 12.5 Internal mammary vessel exposure. The medial third rib has been removed. The superior mastectomy flap (star) has been
retracted superomedially with skin hooks and sutures and a laterally based pectoralis flap has been rotated laterally (solid arrow) to
expose the internal mammary artery and vein (hollow arrow).
distal internal mammary artery to provide perfusion to distant structures. The venous anastamosis can be hand sewn
however a high success rate has been noted with the use of
the venous coupler (Synovis, Birmingham, AL) with experienced microsurgeons (39). The ischemic time of the flap
ideally should be under 1 hour however the muscle can
tolerate up to 2 hours safely without any untoward effects.
The DIEP flap can tolerate longer ischemia due to the
absence of muscle (40).
The abdominal donor site is closed similar to an abdominoplasty. The donor site incisions are closed primarily in
the muscle- and fascia-sparing approaches and often primarily with free TRAM approaches. In primarily closing
larger unilateral fascial defects, care must be taken to not
translocate the umbilical stalk too far off from the midline
resulting in an asymmetrically placed umbilicus. For
larger defects and in thinner fascia with risk of dehiscence
and possible hernia, the abdomen can be reinforced with
insertion of either a biologic or synthetic mesh. A synthetic mesh will provide the most strength but has a higher
morbidity compared to biologics when it becomes infected.
There are several different biologic meshes available for
repair of the abdominal wall however few published
reports of their use in abdominal wall repair in the context
of free TRAM flaps exist. Once such published report,
noted the benefit using AlloDerm (Lifecell, Inc., Branchburg, NJ) in reinforcement of an abdominal repair but a
high rate of bulge recurrence if used to try to primarily
repair the fascia (41). Multiple less elastic biologic products for repair of abdominal hernias are available but published comparisons of the products are not yet available.
The inset of the breast is performed after assuring an
appropriate vascular supply. In the immediate reconstruction, the skin from the abdomen replaces the areola
removed during the mastectomy while de-epithelializing
the remainder of the flap. Careful design of the skin paddle
that includes Dopplerable signals provides a method by
which the flap can be monitored. In the delayed reconstruction, once the flaps vascular supply is verified, the
inferior mastectomy flap is excised and sent for pathology.
The flap skin from the abdomen is then tailored to comprise the entire inferior aspect of the reconstructed breast
while de-epithelializing the superior aspect of the flap and
placing it underneath the superior mastectomy flap. Again,
the skin paddle can be designed to include Dopplerable
signal to provide a means to monitor the flap. Deep shaping of the mound can be achieved with absorbable sutures
tacking the flap to the surrounding fascia. During inset,
attention is paid to creating medial fullness and ptosis
equivalent to that of the contralateral breast in a unilateral
reconstruction.
Monitoring of the flap can be accomplished in multiple
ways. The presence of a skin paddle in all but nipple sparing approaches allows for direct visualization of the flap
117
118
119
Figure 12.6 Post-operative day one congestion of a left breast free flap after bilateral deep inferior epigastric artery free-flap delayed
breast reconstruction. Note increased edema, dark coloration of peripheral flap, and darkened serosanguinous drainage at the pin prick
(arrow). The patient was returned emergently to the operating room and the flap was salvaged with venous anastomosis to the
thoracodorsal pedicle.
The dissection must be performed meticulously and gently and should an injury to the vessels occur, the small
caliber of the vessels makes repair difficult. The preservation of several perforators or preservation of the contralateral flap until dissection of the chosen perforators is
completed may rescue a doomed reconstruction. Alternatively, attempts can be made to repair the injured vessels
primarily or with interposition grafts if necessary.
Breast and Abdominal Technical Complications
The technical complications that fall outside of the realm
of microsurgery include both the donor and recipient sites.
As to the chest/breast recipient sites and reconstruction,
difficulties include partial free flap necrosis and/or fat
necrosis, mastectomy flap necrosis, pneumothorax, and
cancer recurrence. Despite what appears to be adequate
perfusion of the TRAM or DIEP flap at the time of harvest, the entire flap may not be perfused well enough to
prevent partial flap loss or necrosis. As the number of perforators harvested for the DIEP flap decreases, the potential for partial flap loss due to inadequate perfusion
increases (53) however the use of a non muscle-sparing
TRAM will not necessarily avoid all difficulties with fat
necrosis. Additionally, attempts to utilize more of lateral
Zone II and any of Zone IV of the Hartrampf zone perfusion description (14,23,27) will increase the likelihood of
fat necrosis. Intraoperative evaluation for proper perfusion
beyond the standard observation for active bleeding at the
120
be routine in free flap breast reconstruction cases to evaluate for pneumothorax and the index of suspicion should
be high in patients who experience postoperative difficulties in adequate ventilation.
Despite a thorough preoperative work up by the patients medical oncologist as is recommended for a delayed
reconstruction, diagnosis of a cancer recurrence at the time
of a delayed reconstruction is always a possibility. Any tissue abnormalities encountered in the chest wall dissection
can be investigated with intraoperative frozen sections.
Excised mastectomy flaps and internal mammary lymph
nodes removed in harvesting the internal mammary artery
can be sent for permanent pathology. Any intraoperative
concern of recurrence is better treated with a further delay in
the reconstruction as opposed to having to remove portions
of a free flap reconstruction if a recurrence is diagnosed.
Technical complications associated with the abdominal
donor site include hernia, bulging, or weakness of the
abdominal wall, partial abdominal flap necrosis resulting
in abdominal incision healing difficulties, and loss of the
umbilicus. The literature reported incidence of abdominal
wall bulge, laxity, weakness, and hernia is dependent on
the harvest of unilateral and bilateral flaps and the degree
of muscle sparing approach utilized. In a meta-analysis of
the published literature, the incidence of abdominal bulge,
laxity, and weakness was 5.9 percent in free TRAM versus 3.1 percent in DIEP flap breast reconstruction. Additionally, the incidence of abdominal hernia was 3.9 percent
in free TRAM versus 0.8 percent in DIEP flap breast
reconstruction (55). Despite adequate closure, a hernia/
bulge/or weakness may occur. Many reconstructive surgeons will routinely utilize either a biologic or synthetic
mesh to prevent hernias however all meshes have inherent risks of infection, seroma formation, and failure. The
author prefers to utilize a biologic mesh to reinforce only
those fascial repairs that demonstrate a poor integrity
either as thin fascia or easy tearing during the insertion
of sutures. Finally, the repair of hernias resulting from
free-flap harvest also varies but a majority will require
insertion of mesh.
Similar to difficulties encountered in the mastectomy
flap healing due to poor perfusion, difficulties with healing
of the abdominal donor site are also related to perfusion.
Perfusion can be compromised by smoking, undermining,
and excessive tension on the abdominal flap. As mentioned
previously, insistence on smoking cessation by the surgeon
should be strongly considered in the delayed reconstruction setting and may be considered dependent upon timing
in the immediate reconstruction setting. Undermining of
the superior abdominal flap in preparation for closure
should be performed primarily centrally releasing the
strong adhesions along the linea alba up to the level of the
xiphoid while attempting to preserve the perforators from
the rectus abdominis muscle to the abdominal flap. Addi-
121
(A)
(B)
(C)
(D)
Figure 12.7 Preoperative (A, B) and 6-month postoperative (C, D) photographs of a right immediate DIEP free flap breast
reconstruction. Note the larger reconstructed breast size in comparison to the native left breast, abdominal incision dog ear deformities
and umbilicus inset to the left of the midline. The patient elected to not undergo any nipple reconstruction or revisions.
122
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25. Nahabedian MY, Momen B, Galdino G, et al. Breast reconstruction with the free TRAM or DIEP flap: patient selection,
choice of flap, and outcome. Plast Reconstr Surg 2002; 110:
46675; discussion: 4767.
26. Bajaj AK, Chevary PM, Chang DW. Comparison of the
donor-site complications and functional out comes in free
muscle-sparing TRAM flam and free DIEP flap breast
reconstruction. Plast Reconstr Surg 2006; 117: 73746;
discussion: 74750.
27. Scheflan M, Dinner MI. The transverse abdominal island
flap: part II. surgical technique. Ann Plast Surg 1983; 10:
1209.
28. Taylor GI, Palmer JH. The vascular territories (angiosomes)
of the body: experimental study and clinical applications.
Br J Plast Surg 1987; 40: 11341.
29. Moon HK, Taylor GI. The Vascular anatomy of rectus
abdominismusculocutaneous flaps based on deep superior
epigastric system. Plast Reconstr Surg 1988; 82: 81532.
30. Tran NV, Chang DW, Gupta A, Kroll SS, Robb GL. Comparison of immediate and delayed free TRAM flap breast
reconstruction in patients receiving postmastectomy radiation therapy. Plast Reconstr Surg 2001; 108: 7882.
31. Baumann DP, Crosby MA, Selber JC, et al. Optimal timing
of delayed free lower abdominal flap breast reconstruction
after postmastectomy radiation therapy. Plast Reconstr Surg
2011; 127: 11006.
32. Selber JC, Nelson J, Fosnot J, et al. A prospective study
comparing the functional impact of SIEA, DIEP, and muscle-sparing free TRAM flaps on the abdominal wall: part I.
unilateral reconstruction. Plast Reconstr Surg 2010; 126:
114253.
33. Lemaine V, McCarthy C, Kaplan K, et al. Venous thromboembolism following microsurgical breast reconstruction:
an objective analysis in 225 consecutive patients using
low-molecular-weight heparin prophylaxis. Plast Reconstr
Surg 2011; 127: 1399406.
34. Ghattaura A, Henton J, Jallali N, et al. One hundred cases of
abdominal-based free flaps in breast reconstruction. The
impact of preoperative computed tomographic angiography.
J Plast Reconstr Aesthet Surg 2010; 63: 1597601.
35. Garvey PB, Salavati S, Feng L, Butler CE. Abdominal
donor-site outcomes for medial versus lateral deep inferior
epigastric artery branch perforator harvest. Plast Reconstr
Surg 2011; 127: 2198205.
36. Saint-Cyr M, Youssef A, Bae HW, Robb GL, Chang DW.
Changing trends in recipient vessel selection for microvascular autologous breast reconstruction: an analysis of 1483 consecutive cases. Plast Reconstr Surg 2007; 119: 19932000.
37. Dupin CL, Allen RJ, Glass CA, Bunch R. The internal
mammary artery and vein as a recipient site for free-flap
breast reconstruction: a report of 110 consecutive cases.
Plast Reconstr Surg 1996; 98: 6859.
38. Sacks JM, Chang DW. Rib-sparing internal mammary vessel harvest for microvascular breast reconstruction in 100
consecutive cases. Plast Reconstr Surg 2009; 123: 14037.
39. Jandali S, Wu LC, Vega SJ, et al. 1000 consecutive venous
anastomoses using the microvascular anastomotic coupler
in breast reconstruction. Plast Reconstr Surg 2010; 125:
7928.
123
49.
50.
51.
52.
53.
54.
55.
13
Other free flaps in breast reconstruction
Brian A. Mailey and Gregory R. D. Evans
INTRODUCTION
provide donor tissue; or the SGAP (7), the IGAP (8), or the
gracilis myocutaneous flap (9,11) when it is not. The
Rubens, anterolateral thigh (ALT) and thoracodorsal artery
perforator (TAP) flap are also alternate flaps described in
breast reconstruction. This chapter will review these lesser
common flaps with an emphasis on proper patient selection.
SUPERFICIAL INFERIOR EPIGASTRIC
ARTERY FLAP
Grotting et al. described the SIEA flap for breast reconstruction in a 1991 case report (4). Promoted as the next
level of abdominal wall preservation, it avoids excising the
rectus abdominis fascia or muscle. The donor tissue is the
same site for breast reconstruction as the DIEP flap. The
vascular pedicle is the superficial inferior epigastric artery,
125
Figure 13.1 Depiction of the superficial inferior epigastric artery (SIEA) flap markings. The design is similar to an abdominoplasty.
The SIEA comes off the femoral artery and anastomoses with branches of the superficial circumflex iliac artery. Pedicle lengths are
47 cm with a variable vessel diameter of <1.03.1 mm. Flap dimensions can be as large as 15 30 cm, however, perfusion is only to
ipsilateral hemiabdominal tissues.
126
127
(B)
(A)
Figure 13.2 (A) Photograph of a patient with previous right mastectomy interested in delayed autologous breast reconstruction.
(B) Three-month postoperative picture from delayed reconstruction using a superior gluteal artery perforator flap.
(A)
(B)
Figure 13.3 (A) Pre-operative photograph of patient to undergo superior gluteal artery perforator flap. (B) Three-month postoperative
picture of donor site. The scar is well-concealed by undergarments or bathing suits.
either nutrient vessel for its blood supply. These are known
as the superior and inferior gluteal artery perforator flaps,
respectively.
A number of variations on skin island orientations,
and dimensions have been described, each with advantages and disadvantages. An oblique or horizontal
ellipse totally over the muscle oriented in the direction
of the muscle fibers was first described (7). This provided an adequate perforator directly under the flap.
Reported skin island sizes vary from 10 25 to 12 32
with flap weights between 210 and 820 g (7). With
greater confidence in perforator harvesting and preoperative angiographic assessment of vascular anatomy, a
more individualized skin island design emerged (24).
These variations helped allow the limited pedicle length
to be maximized and design the scar to be better concealed. CT or MR angiograms allow visualization of key
musculocutaneous or septocutaneous perforators along
with caliber, location, and course. Generally, septocutaneous branches pass between the gluteus maximus and
medius muscles. Basing the SGAP flap on these perforators is possible, which frequently originate from the
128
129
Figure 13.4 Illustration of the superior gluteal artery perforator flap (SGAP) skin island markings. The design can be oriented in a
variety of fashions. The SGA originates from the internal iliac artery, exits the pelvis through the greater sciatic foramen and travels with
the superior gluteal nerve. Pedicle lengths are usually 35 cm, but can be as long as 8 cm. The vessel diameters are 2.02.5 mm and
3.04.5 mm for the artery and vein, respectively. Flap dimensions can be up to 12 32 cm.
perforator is preserved as it enters the main superior gluteal artery. The artery and vein diameters for anastomoses
are 2.02.5 mm and 3.04.5 mm, respectively, with a pedicle 58 cm in length (24). On average, the flap height is
710 cm and the flap length is 1822 cm.
When the recipient chest vessels are ready, the gluteal
artery and vein are divided and the flap harvested. The
recipient site is either definitively closed or temporarily
stapled closed with a sterile occlusive dressing used to
cover the wound.
The patient is then repositioned supine on the operating
table and the recipient site is again prepped and draped.
130
Figure 13.5 Illustration of the inferior gluteal artery perforator flap (IGAP) design. Pedicle lengths are generally longer than its
superior counterpart. The IGA branches from the internal iliac artery and exits the pelvis through the greater sciatic foramen. IGA travels
with the greater sciatic nerve inferior to the piriformis muscle. Vessel diameters are similar to the SGAP, but the pedicle lengths are
710 cm with flap dimensions of 8 18 cm.
131
132
The flap is then inset onto the chest, which may be done
horizontally, vertically, or obliquely, as long as the vascular pedicle is not twisted or kinked. The vascular anastomosis is performed with loupe magnification or preferably
under the operating microscope. A suction drain is placed
into the breast pocket.
In unilateral procedures, the recipient vessels can be
prepared by a second team while the flap is harvested. The
internal mammary vessels or their perforators allow easier
medialization of the flap when it is inset. However, the
inferior gluteal pedical is often long enough to reach to the
thoracodorsal vessels, if necessary. For bilateral simultaneous procedures using gluteal artery perforator flaps, the
patient starts supine for mastectomy and recipient vessel
preparation. The patient is then positioned for flap harvest
and repositioned supine for anastomosis and insetting.
When using the internal mammary perforators as recipient
vessels, a shorter pedicle and smaller artery may suffice
and thereby simplifying flap harvest.
GRACILIS MYOCUTANEOUS FLAP
The gracilis myocutaneous muscle flap was first described
using a longitudinal skin island in 1976 (37,38). Concerns
over skin paddle necrosis due to uncertain cutaneous perfusion resulted in limited use (11,39,40). Further investigations demonstrated the presence of perforators running
in both transverse and longitudinal directions, which led to
the use of a transversely based gracilis flap in 1992 by
Yousif et al. (11) Using the concept that the blood supply
to the muscle and its overlying skin is synonymous, they
deduced that complete muscle survival would result in
complete survival of all the overlying skin (11). Their anatomic study also included two cases, one of which was for
breast reconstruction (11). Several subsequent series have
described the musculocutaneous graciliis flap with high
success rates in both transverse and longitudinal based
skin islands (9,41). In the late 1990s the gracilis myocutaneous flaps popularity increased using a smaller transverse component and a larger longitudinal one (42). This
configuration provides a reliable vascular anatomy with
the needed tissue bulk for creating the breast mound. The
resultant reconstruction has been promoted as soft and
supple with a well-concealed scar. These factors have contributed to this flaps increasing popularity in Europe (42).
The gracilis flap is suited for patients desiring autologous breast reconstruction without available abdominal
donor tissue. Ideal candidates are thin patients with small
to medium-sized breast, as this flap does not yield an
excessive amount of tissue. Functional deficits are minimal and asymmetry of the thigh in unilateral cases is not
usually apparent. Intraoperative repositioning is also not
necessary. Overall flap success rates are high with many
series reporting 100%, despite occasional intraoperative
(A)
133
away from the flap to provide bulk and shape. The vascular pedicle is followed to its takeoff from the profunda
femoral vessels or occasionally the medial circumflex
femoral vessels (44). The pedicle enters the gracilis muscle 912 cm distal to the public tubercle dividing in a consistent pattern into ascending, descending and transverse
branches (44). A doubled main vascular pedicle can be
encountered. When this occurs, it is usually from a common profunda takeoff; when separate the proximal pedicle
is dominant in size and number of perforators (44).
The transverse myocutaneous gracilis crescent
shaped skin paddle is oriented in an anteroposterior
direction (Fig. 13.6 A). The skin markings can be
thought of as nearly identical to the properative markings of a classic medial thigh lift. Flap harvesting is
commenced near the groin, where the adductor longus
tendon can be palpated. Flap dissection proceeds from
anterior to posterior in a subfascial plane until the intermuscular septum between the adductor longus and the
gracilis muscle is encountered. The anterior portion of the
skin island is lifted off the adductor longus muscle and
(B)
Figure 13.6 (A) Demonstration of the skin island design for the transverse upper gracilis flap along with the gracilis muscle and
vascular supply via the ascending branch of the medial circumflex femoral artery. Flap dimensions are as large as 10 30 cm. (B) The
skin island can be designed in a longitudinal fashion or a combination of both. Usual flap dimensions are 59 cm in width and 1018 cm
in length, but can extend up to 27 cm. The vascular pedicle length and vessel diameter are 68 cm and 1.02.5 mm, respectively,
regardless of skin paddle design.
134
135
Figure 13.7 A depiction of makings for the Rubens flap over the iliac crest. The vascular supply is from the deep circumflex iliac
artery. The soft tissue dissection provides large flaps from this region with weights of 6001,200 g. Pedicle dissection can be taken off
the origin of the iliofemoral vessels, allowing a pedicle length of 6 to 10 cm with vessel diameters of 1.53 mm.
including bilateral simultaneous reconstruction, as repositioning of the patient between the harvesting and insetting of the flap is not required.
POSTOPERATIVE MANAGEMENT
In the postoperative period, patients are observed in a
monitored bed (ICU or flap monitoring unit) for two to
three nights. Hourly flap circulation monitoring is performed for the first 24 hours, then spaced out to every
2 and 4 hours for postoperative days 2 and 3, respectively.
The following day, patients are transferred to the floor for
pain control, monitoring of drain output and continued
flap checks every 4 hours. The patient is discharged once
ambulating and pain is controlled on PO medications.
This typically occurs on the 4th or 5th postoperative day.
The breast and donor-site drains are taken out at the first
136
or second clinic visit. Nipple creation and additional contouring procedures are performed at a later date, usually in
23 months.
CONCLUSION
The Womens Health & Cancer Rights Act of 1998
requires medical insurance providers covering mastectomy to authorize coverage for all stages of ipsilateral
reconstruction and contralateral procedures for creating
a symmetrical appearance (61,62). This reconstructive
equality has increased the availability of autogenous
reconstruction to a greater number of women. It has also
contributed to an increase in surgeon experiences with
soft tissue transfer and created new challenges, which in
turn allowed novel strategies to be developed for re-creating the breast.
The abdominal flap continues to be the standard autogenous tissue for breast reconstruction. A majority of
patients will qualify for this approach; however, approximately 15% of patients are not good abdominal donor-site
candidates (63). These include thin patients or patients
with contraindications to a lower abdominal flap (e.g., previous liposuction, abdominoplasty, etc.). Decision between
one of the secondary options (e.g., buttock, thigh, or back
tissue) for autogenous soft tissue transfer requires an individualized approach. Many of these strategies are extensively studied and offer excellent, reliable options for
creating a natural appearing breast. Others have limited
published data and require more investigation to establish
their place as a practical solution. The individuals body
fat distribution influences the ultimate decision, as the
lipodystrophy of the thigh, buttocks, or back can vary
largely between individuals. The quality of the skin and fat
pad also need to be considered, as do the donor-site morbidity and resultant scars and tissue defects. Rank orders
published by highly experienced centers will vary slightly,
but generally list the abdomen as the preferred site followed by the buttock, thigh, then back. As breast reconstruction strategies and preoperative vascular imaging
advances, surgeons will continue to have additional options
for creating a near-normal-appearing breast.
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60. Koshima I, Fukuda H, Utunomiya R, Soeda S. The anterolateral thigh flap; variations in its vascular pedicle. Br J
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14
Nippleareola complex reconstruction
Matthew E. Hiro and Deniz Dayicioglu
Similarly, reconstructing a pleasing nippleareola complex (NAC) leads to improved quality of life (QOL) outcomes. Several studies have demonstrated this benefit
(57).
The goals of nipple and areola reconstruction include
optimal surgical design and technique to create a construct
with appropriate
139
Position
Symmetry
Shape
Projection
Texture
Color
Size
Sensitivity
140
ANATOMY
The nipple and areola, with its central location and hyperpigmentation, represent the most important aesthetic unit
of the breast (8). Therefore, placement of an anatomically
accurate surgically created nipple and areola are paramount for proper aesthetics. Ideally, the aesthetically
pleasing nipple is located on the central, most projecting
portion of the breast mound, along the breast meridian.
Numerous studies have looked at the relationship of the
nipple and areola in relation to the surrounding breast
mound (915). However, these studies generally included
patients with aesthetically perfect breasts or patients being
evaluated for breast reduction surgery. Smith included all
patients measuring 55 consecutive female volunteers (13).
Results showed the nipple to inframammary fold distance
was 7.45 1.99 cm on left and 7.44 1.86 cm on the right,
and nipple to midline distance was 11.83 1.46 cm on the
left and 11.14 1.44 cm on the right.
Sanuki measured 600 breasts and showed an average
areola diameter 4.0 1.0cm, an average nipple diameter
of 1.3 0.3 cm and an average nipple projection of
0.9 0.3 cm (16). Hauben measured the breast proportions
in 37 women and showed a proportional ratio for the areola
to the nipple as 3.00:1 and for the breast mound to the areola as 3.34:1 (15).
How to Select Patients to Avoid Complications
Nipple and areola reconstruction is an elective procedure
that should be only offered in patients who are healthy
enough for surgery and have tissue characteristics suitable
Figure 14.1
for reconstruction. Before proceeding with nipple and areola complex reconstruction, the patient should be reevaluated and an appropriate physical should be completed with
particular attention to the reconstructed breast mound.
Often, additional therapies, including chemotherapy and
radiation, should have been completed since the original
cancer surgery. The impact of these therapies cannot be
overlooked as they may change the tissue characteristics
of the breast reconstruction or contribute to the health status of the patient. The soft tissue envelope of the reconstructed breast should have adequate thickness, mobility
and vascularit,y. The chest wall should be without infection or open wounds. The overall health of the patient
should be addressed and all medical comorbidities should
be optimized before surgery (Fig. 14.1).
How to Avoid Errors in Timing of Surgery
Ideally, the nipple and areola reconstruction is attempted
when the breast mound is complete and all revision procedures are finalized. Although some surgeons advocate
immediate nipple reconstruction at the time of breast mound
reconstruction, most recommend a period of 36 months
before proceeding (17,18).
The final shape of the breast mound may change in the
post-operative period due to gravity, tissue healing, scar
contracture and resolution of edema. Adjuvant therapy
may also lead to implant capsular contracture leading to
nipple asymmetry and malposition. These potential complications may be limited, or avoiding completely, with
appropriate delay before proceeding with nipple and areola reconstruction (18).
Figure 14.2
141
using a mirror, in the privacy of the home in various positions until the patient is satisfied. These areas can be
marked the night before surgery (Fig. 14.3).
How to Avoid Malposition in Autologous
Reconstructions with Existing Skin Paddles
Skin paddles on the breast mound deserve special mention.
With the increase in use of skin-sparing mastectomy (19),
transverse rectus abdominis myocutaneous (TRAM) flap
and latissimus dorsi flap reconstructions often result in circular or oval skin paddles inset into the previous areolar
defect. Ideally, the nipple and areola reconstruction could
then be designed using only the skin paddle of the flap
resulting in a scar-less reconstruction. Although this often
leads to superior aesthetic results (8), the nipple position
should not be jeopardized by strict adherence to the skin
paddle position. With settling of the breast mound, the skin
paddle may no longer be in the ideal position. Here, the
nipple should be placed without regard for the position of
the skin paddle even though this design may include only a
portion (or none) of the skin paddle (Fig. 14.4).
How to Avoid Errors with Proper Technique
There are numerous ways to construct a nipple and the
ideal has yet to be discovered as evidenced by the myriad of described techniques (20). All can be categorized
into different types: local skin flaps, free tissue grafts
(including fat, cartilage, bone), and soft tissue fillers and
substitutes.
First described by Diperro (21), local flaps for nipple
reconstruction have evolved to include numerous
designs with various long-term results. The goal in the
142
Figure 14.3
Patient should assess the position of the nipples and participate in the discussion.
Figure 14.4 If skin paddles have acceptable positions, they should be used for reconstruction template; this patient had bilateral latissmus
dorsi reconstruction.
143
Figure 14.5 Skate flap and full thickness skin graft technique.
skate flap includes a vertical skin and fat flap with subdermal wings which wrap around the central core. The
width of the horizontal line determines the diameter of the
created nipple. The vertical extent of the flap below this
horizontal determines the projection
Authors Preferred Steps for Skate Flap Technique
1. Mark center position of new position of nipple
2. Use appropriately sized cookie cutter to mark the
new areolar border. In unilateral reconstructions,
this should be roughly equal to the normal, contralateral nipple. In bilateral reconstructions, a 3545 mm
cookie cutter should be used based on the breast
mound size.
3. Mark the base of the flap. This can be oriented in any
direction but should avoid the mastectomy scar to preserve blood supply. The base should be marked slightly
off the central diameter of the flap to ensure a central
position once the flap is raised.
4. Incise the skin along the periphery of the flap. Deepethilialize the portion skin that will not be included
in the flap. This preserves the subdermal blood supply
to the flap.
5. Raise the lateral wings preserving a few millimeters of
subdermal fat to protect the blood supply. In order to
adequately raise the flaps, the incision must extend
along the lateral aspects of the base protecting the central portion.
6. As the flaps are elevated centrally, dissect slightly
deeper including more subdermal fat with the flap. The
vascular core must be preserved.
144
Figure 14.6
fat should be left on the wings to protect the blood supply. The vascular core is protected beneath the central
part of the flap. Avoid all undermining in this area.
4. Once the flap is raised the two lateral arms are wrapped
around the central core and sutured into position to create the projecting portion of the nipple. The middle arm
becomes the cap of the nipple.
5. The donor sites are closed primarily with absorbable or
permanent suture. Care should be taken to avoid closing the donor site too tightly along the vascular core of
the flap.
Star Flap Modifications
In subsequent years, several modifications were made to
the star flap. Although some differences do exist, the
three-flap design with central cap and lateral arms is the
same. In these designs, like the star flap, the diameter of
the cap determines the diameter of the nipple and the projection is determined by the width of the lateral arms. Primary closure of the donor site may lead to flattening of the
central portion of the breast mound. These modified star
flaps include the CV flap by Bostwick (24), the cylindrical
flap by Thomas (25), the top-hat flap by Hamori and
LaRosa (26) and the arrow flap by Guerra (27).
The surgical technique of the modified star flaps is similar to the description above. The differences lie in the
design and closure of the lateral arms and the shape of the
central cap (Figs. 14.6 and 14.7).
Other modifications to the typical star flap include the
purse-string modification by Hammond and Weinfeld (28,29).
(A)
145
(B)
Figure 14.7 (A) Star flap technique with CV flap modification. Note the ischemic appereance immediately after CV flap reconstruction
on the left. (B) Note the partial flap necrosis on the left. This was corrected later by debridement and secondary suturing.
Figure 14.8
The use of two flaps increases the bulk to the flap and
increases the blood supply. However, transposing the two
flaps can lead to tension during closure, increasing the
restrictive forces on the flaps and leading to loss of projection (17). Originally these flaps were designed as deepithelialized dermal flaps that were covered with a full thickness
skin graft. Later modifications changed the design with
transposition of skin flaps that allowed primary closure of
the donor site (32,33).
146
1822 mm. A Z modification may be made at the distal aspect of each flap to allow the two tabs to key-in
and form a more stable construct.
3. Incise the skin around both flaps and the central common limb.
(A)
Figure 14.10
(B)
(A) Double S flap technique immediate postoperative period. (B) Double S flap technique late postoperative period.
Figure 14.11
(A)
147
symmetry, and projection. However, most outcomes articles in nipple and areola reconstruction tend to focus on
long-term projection as the primary result of interest (34).
Free Tissue Grafts
The use of free tissue grafts were some of the earliest
described techniques for nipple reconstruction. Many different types of tissues were used, including mucous membrane, toe pulp, labia minora, and banked nipple areola,
most of which have been abandoned with the use of local
flaps. However, recent evidence has shown that tissue
grafts may lead to aesthetically pleasing results and be a
reasonable option in certain patients.
(B)
Figure 14.12
(A) Protection of the nipples with syringes. (B) Protection of the nipples with donut-shaped cushions.
148
Cartilage Grafts
Cartilage grafts have been used as soft tissue fillers with
local flaps since the 1970s (44). Reports have described
placing the auricular cartilage grafts within a flap in the
subcutaneous space (44), or placing the graft on the dermis and wrapping the graft in centrally based flaps with
full thickness skin grafts (45). Placing the tissue in the
subcutaneous space did not guarantee long-term projection, but supporting the graft on the dermis showed
excellent results with no necrosis or skin graft loss and
maintenance of projection.
Soft Tissue Fillers/Substitutes
Free tissue grafts offer adequate results when appropriate,
but may cause donor site morbidity. The use of soft tissue
filler and substitutes, in design, offers the same benefits of
free tissue grafts, without the sacrifice of donor sites.
Artificial bone (hydroxyapatitetricalciumphosphate)
has been used in a similar fashion as rolled auricular cartilage (46). Here, the substance is shaped into a column
and placed on deepithelialized dermis and wrapped in
centrally based flaps. The construct is then covered with a
full thickness skin graft. Histology of the specimen
showed a mild inflammatory response with typical capsule formation around the artificial bone. Complications
were minimal with 5% graft exposure and 5% partial flap
loss. There was no total flap loss or graft loss. Projection
was maintained in 100% of patients.
Acellular dermal matrix has been used in both primary and secondary reconstructions (4749). When used
for primary reconstructions, a small piece of thick acellular dermal matrix was cut to a 1.5 4.5 cm piece and
rolled into a barrel shape. The construct was placed into
the central core of a modified star flap and sutured into
position. Twelve-month maintenance of projection was
56% in TRAM patients and 47% in tissue expanderimplant patients (48). Small (2 6 mm) pieces of acellular
dermal matrix were also used in secondary reconstructions
after failed primary local flap (projection 02 mm) with
C-V flaps. Four of five patients demonstrated maintenance
of adequate projection (45 mm) at 612 months (49).
The cost of the acellular dermal matrix may be prohibitive however (47).
Soft tissue fillers have been used to augment nipples
reconstructed with local flaps or tissue grafts and in secondary reconstructions with loss of projection (5052).
Injectable calcium hydroxyapatite (Radiesse, Merz Inc,
San Mateo California) was used in six patients (volume
0.41.0 cc) with 100% patient satisfaction and minimal
loss of projection. Similarly, injectable polymethylmethacrylate in 3.5% bovine collagen (Artecoll, Pulmon
Medical, Scottborgh South Africa) was used to increase
149
the technique with refinement in technique and presentation of larger case series (5659).
Although some recommend tattooing before or during
flap reconstruction (60,61), areola tattooing is best reserved
until approximately 612 weeks after nipple reconstruction to allow for appropriate healing and maturation of the
flap or graft (58). Tattooing can either be used as primary
areola reconstruction directly on the skin of the new breast
mound, or to achieve improved color match after graft
reconstruction.
Although not always necessitated, local anesthesia
should be used to help with patient discomfort during the
procedure. Color choice is important. Slightly darker pigments are encouraged, as fading of the tattoo will inevitably occur (54). Patients may also be encouraged to
participate in choosing the pigment with the surgeon.
Attention must be placed to adequate depth of pigment
introduction. Pigments placed too superficial are subject to
loss after desquamation of the epidermis. Deeper pigment
is taken up in lymphatics (17). Both will lead to early fading of the areola. Nipple tattooing follows the areola.
Some authors recommend slightly darker pigments in this
area (58) (Fig. 14.13).
Areolar Reconstruction
After nipple reconstruction, the areola must then be reconstructed to create the final form. As with nipple reconstruction, several different techniques have been described. The
two most common are intradermal tattooing and tissue
grafting.
Bunchman first described the use of intradermal tattooing to recreate the areola after nipple reconstruction (54).
Rees then described the use of intradermal tattoo to
achieve color symmetry in areola reconstruction using a
skin graft (55). Becker and Spear then further popularized
(A)
(B)
Figure 14.13 (A) Tattooing-related complication: On a double S flap technique; note the superficial skin loss on the right side; this
patient healed by secondary intention with good color match. (B) Tatooing set for the plastic surgeon.
150
slightly raised and irregular surface similar to native areola. Use of tissue grafts can also decreases the flattening of
the apex of the breast that may occur with primary closure
of star flaps and star flap derivates. However, tissue grafts
require additional surgical donor sites and further scarring.
Historically, donor grafts were taken from the labia
majora, upper eyelid, retroauricular area, perineum/upper
thigh, suprapubic area and others (17). Color match again
is paramount. The upper thigh skin is a popular donor site
due to its hidden location and close color match. However,
the development of intradermal tattooing allows any skin
to serve as potential donor site. Any residual color mismatch after grafting can be corrected with appropriate tattooing. Little data exists comparing complications with
grafting in areola reconstruction. However, the complication rate should be similar to other tissue grafts in other
areas.
Secondary Procedures After Nipple Areola
Reconstruction
The most common complications after nippleareola reconstruction are loss of projection, wound healing complications at donor site, partial flap/graft loss and loss of areola
pigmentation after tattooing. Each of these complications
can lead to poor patient satisfaction and need for revision
surgery. As demonstrated in long-term studies, the final
outcome may not be evident until a year (or longer) after
surgery (see Table 14.1). Therefore, patients should be followed at regular intervals to evaluate for the presence of
expected outcomes and patient satisfaction. If complications arise, or a patient is unhappy with final result, secondary reconstruction offers a reasonable option for salvage.
Numerous techniques are available for secondary reconstruction including:
1.
2.
3.
4.
5.
151
Table 14.1 Summary of studies demonstrating quantitative results with different flap techniques for nipple reconstruction.
Complications were not listed for all studies. RCT = randomized controlled trial; * = p < 0.05; **p < 0.05 comparing bell flaps to
skate and star flaps. No significant difference between skate and star flaps.
Author
Details of study
Rubino (35)
32 pts RCT
Alfano (36)
30pts RCT
Shestak (37)
74 nipples Retrospective
review
Kroll (33)
Farace (34)
Zhong (38)
Losken (39)
Few (40)
Flap types
Follow-up
Average Residual
Projection (% of
initial size or mm)
Complications
1 year
Skate flap
14 nipples Retrospective
review
93 nipples Prospective study
CV flap
3.87 mm
Star flap
59% at 1 yr
1 year
1 year
NR
(A)
(B)
(C)
Figure 14.14 (A) Loss of projection of nipple. (B) Loss of projection of nipple. (C) Recreation of the nipple using the CV flap
technique to regain projection.
152
Figure 14.15
Tattooing-related complication: Incisional scars not taking tattoo pigment well; this patient needed re-do tattooing.
Figure 14.16
Figure 14.17
153
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TM. A method of assessing female breast morphometry and
its clinical application. Br J Plast Surg 1999; 52: 3559.
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Plast Reconstr Surg 1986; 78: 3315.
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proportion. Ann Plast Surg 2003; 50: 51013.
16. Sanuki J, Fukuma E, Uchida Y. Morphologic study of nippleareola complex in 600 breasts. Aesthetic Plast Surg 2009; 33:
2957.
17. Farhadi J, Maksvytyte GK, Schaefer DJ, Pierer G, Scheufler O.
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18. Vendemia N, Mesbahi AN, McCarthy CM, Disa JJ. Nipple
areola reconstruction. Cancer J 2008; 14: 2537.
19. Patani N, Mokbel K. Oncological and aesthetic considerations of skin-sparing mastectomy. Breast Cancer Res Treat
2008; 111: 391403.
20. Mathes SJHVR. Plastic Surgery. 2nd ed. Philadelphia, PA:
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21. DiPirro ME. Reconstruction of the nipple and areola after a
burn. Case report. Plast Reconstr Surg 1970; 46: 299300.
22. Little JW 3rd. Nipple-areola reconstruction. Clin Plast Surg
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23. Anton M, Eskenazi L, Hartrampf CJ. Nipple reconstruction
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24. Jones G, Bostwick J 3rd. Nipple-areola reconstruction.
Operat Tech Plast Reconstr Surg 1994; 1: 35.
25. Thomas SV, Gellis MB, Pool R. Nipple reconstruction with
a new local tissue flap. Plast Reconstr Surg 1996; 97:
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26. Hamori CA, LaRossa D. The top hat flap: for one stage
reconstruction of a prominent nipple. Aesthetic Plast Surg
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27. Guerra AB, Khoobehi K, Metzinger SE, Allen RJ. New
technique for nipple areola reconstruction: arrow flap and
rib cartilage graft for long-lasting nipple projection. Ann
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28. Hammond DC, Khuthaila D, Kim J. The skate flap pursestring technique for nipple-areola complex reconstruction.
Plast Reconstr Surg 2007; 120: 399406.
29. Weinfeld AB, Somia N, Codner MA. Purse-string nipple
areolar reconstruction. Ann Plast Surg 2008; 61: 3647.
30. Cronin ED, Humphreys DH, Ruiz-Razura A. Nipple reconstruction: the S flap. Plast Reconstr Surg 1988; 81: 7837.
31. Kroll SS, Hamilton S. Nipple reconstruction with the doubleopposing-tab flap. Plast Reconstr Surg 1989; 84: 5205.
32. Weiss J, Herman O, Rosenberg L, Shafir R. The S nippleareola reconstruction. Plast Reconstr Surg 1989; 83: 9046.
154
33. Kroll SS, Reece GP, Miller MJ, et al. Comparison of nipple
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flaps. Plast Reconstr Surg 1997; 99: 16025.
34. Farace F, Bulla A, Puddu A, Rubino C. The arrow flap for
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35. Rubino C, Dessy LA, Posadinu A. A modified technique for
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36. Alfano C, Tenna S, Caggiati A, Campanella A. Nipple
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between star and skate techniques. Acta Chir Plast 2004; 46:
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37. Shestak KC, Gabriel A, Landecker A, et al. Assessment of
long-term nipple projection: a comparison of three techniques. Plast Reconstr Surg 2002; 110: 7806.
38. Zhong T, Antony A, Cordeiro P. Surgical outcomes and
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15
Managing the unfavorable result in breast surgery
Charles R. Volpe, Alexander Nguyen, and Zubin J. Panthaki
INTRODUCTION
GENERAL CONSIDERATIONS
Untoward results in surgery occur in an unpredictable manner. However, the patients response to an unfavorable
result follows very predictable lines. Patients who are properly advised of the potential risks and complications of a
given procedure preoperatively will typically handle an
unfortunate situation with objectivity and reason. Patients
who are informed postoperatively that their unfavorable
155
156
Figure 15.1
implant.
157
Asymmetryimplant malposition can result from capsular contracture, overdissection of the pocket, or migration of the
158
Figure 15.2
Figure 15.3
159
TRAM contour deformity can be corrected with placement of a small implant or fat grafting.
160
Figure 15.4
161
Symmastiaimproper pocket dissection can lead to webbing across the midline of the chest.
the sternal periosteum (56), and creating an acellular dermal matrix sling to prevent the medial migration of the
replaced implants (60).
Scarring can be a significant source of anxiety for
patients undergoing an aesthetic procedure such as augmentation mammoplasty. Careful evaluation of the patient
preoperatively is necessary to assess the risk of poor
wound healing. Patients at risk of adverse wound healing
(e.g., hypertrophic scarring, keloid scarring) should be
approached with caution. Patients presenting with hypertrophic or keloid scarring should treated as directed in the
reduction mammaplasty section (see below).
Infection following breast augmentation is a rare reason
for revision augmentation, but it does occur. Primary management of the patient with an active implant related infection involves determining the extent of infection. Superficial
infections, limited to mild cellulitis and erythema may be
treated with antibiotics, cautious incision and debridement,
and wound culture. Staphylococcal species are the most common isolates associated with implant related infections (61).
Deep infections involving the implant necessitate expeditious removal of the implant, irrigation of the implant pocket,
and placement of closed suction drains, as needed. Capsulectomy should routinely be avoided given the risk of significant
bleeding in the setting of severe infection. Intravenous antibiotics should be tailored to the wound cultures collected
during implant removal. Replacement of the implant should
occur in conservative fashion and correspond with absolute
resolution of the infection. Most surgeons would consider
waiting 36 months before replacing the implant in the setting of previous infection.
REDUCTION MAMMOPLASTY
Reduction mammoplasty is one of the most common procedures performed in plastic surgery. Patient satisfaction is
generally high with up to 93% of patients reporting that they
would undergo the procedure again (62). Despite the high
level of satisfaction, unfavorable results and complications
do occur following reduction mammoplasty. These include
scars, fat necrosis, breast and scar asymmetry, over-reduction,
under-reduction, nippleareola problems, and epidermal
cysts. Prior to treating any of the aforementioned complications, the surgeon needs to get a clear understanding of the
patients complaints as well as their expectations from revision surgery. Bear in mind that, 11% of plastic surgeons
polled stated that a dissatisfied patient had sued them at least
once following breast reduction surgery (63).
Scar formation following reduction mammoplasty can
be a significant problem especially when hypertrophic
scarring or keloid scarring results. Careful questioning
and physical examination of the can often determine
which patients are prone to hypertrophic or keloid scar
formation. Treatment of the abnormal scarring should
occur as soon as it is recognized. Treatments include intralesional injection of corticosteroid alone or in combination with 5-fluorouracil (64). Patients should be warned
that hypo-pigmentation, subcutaneous tissue atrophy, and
contour depressions might occur following intralesional
corticosteroid administration. Intralesional treatments can
be repeated at 6-week intervals for 23 cycles. Silicone
sheeting has been advocated, though the mechanism of
action is poorly understood.
162
Fat necrosis presents as a focal area of firm or hard tissue and is seen most commonly in obese patients. Superficially located areas of fat necrosis are easy to diagnose
whereas deeper areas may require confirmation with ultrasonography (45), as discussed previously in this chapter.
Needle aspiration of focal areas of fat necrosis should be
performed to rule out the possibility of malignancy. Excision of the lesions that persist after several months should
be considered.
Breast asymmetry often goes unrecognized by patients
preoperatively. Preoperative breast asymmetry should be
identified and addressed with the patient. These pre-existing
asymmetries may have a significant impact on the postoperative results. The patient should be informed that scar
length discrepancies and breast asymmetry might occur
given the baseline asymmetries noted before surgery. Any
persistent dissatisfaction with the resultant scarring and
contour deformities should be managed expectantly for
1824 months. Once scar remodeling has stabilized, corrective adjustments can be made on both breasts, as needed
to achieve symmetry. Liposuction can be used as a useful
adjunct for treating minor contour irregularities or volume
discrepancies (65,66).
Over-reduction is an extremely compromising problem
to correct. Common scenarios that lead to over-reduction
are: (1) older patients with marked ptosis where significant breast volume is below the inframammary crease,
(2) attempts to meet the weight requirements imposed
by insurance companies, and (3) attempts to create
pre-determined breast size set by the patient. The only
treatments for over-reduction are breast augmentation or
augmentation/mastopexy. Patients should be informed
that the later might provide a superior cosmetic result.
Irrespective, revision should be deferred for 612 months
Figure 15.5 NAC malposition in reconstruction can be a technical error or can result from further settling of the implant leading to
late asymmetry.
163
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20. Disa JJ, Ad-El DD, Cohen SM, Cordeiro PG, Hidalgo DA.
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31. Gill PS, Hunt JP, Guerra AB, et al. A 10-year retrospective
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34. Parrett BM, Caterson SA, Tobias AM, Lee BT. DIEP flaps
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165
16
Optimizing long-term outcomes in breast surgery
Anuja K. Antony, Benjamin Liliav, Victor J. Hassid, and Mimis N. Cohen
INTRODUCTION
Patient Education
Introduction
Breast augmentation is one of the most commonly performed cosmetic procedures in the United States. Since
the introduction of silicone implants in the early 1960s,
our understanding of breast augmentation has continued to
expand with greater appreciation for implant technology,
surgical techniques, and patient selection criteria (1,2).
Breast implants have improved with modifications in the
implant shell, filler materials, and available sizes and
shapes (3). Surgical techniques emphasize the importance
of absolute sterility, meticulous hemostasis, and careful
166
167
168
(B)
(A)
(C)
Figure 16.1 Implant selection: (A) round, smooth silicone implant. (B) Round, smooth saline implant. (C) Round, textured silicone
implant.
169
pole of the breast, placing the incision at the IMF will have
the final scar at the inferior pole, which will be relatively
inconspicuous as well.
The transaxillary approach has the advantage of not
leaving any scar on the breast and not violating the breast
parenchyma. Moreover, the use of an endoscope has been
shown to enhance visualization and prevent implant malrotation by careful and accurate dissection of the pocket,
provide better hemostasis, and facilitate complete transection of the muscle fibers (26). However, there are some
limitations associated with this approach. It is less suitable
for silicone gel implants, as a small incision may fracture
the implant during placement, and it may be associated
with more asymmetry postoperatively (27,28).
The transumbilical approach (TU) is associated with
high rate of implant malposition as it confers less control
and accuracy in placing the implant. Additionally, silicone
implants cannot be placed via this approach. Any bleeding
encountered cannot be controlled well. Due to its many
limitations, most plastic surgeons and our institution do
not favor this approach.
(B)
(A)
(C)
Figure 16.3 (A) Preoperative appearance in patient with Polands syndrome (note small areolar diameter on right). (B) Inframammary
insicion with contralateral circumareolar mastopexy. (C) Postoperative result.
170
171
172
Implant Malposition
Implant malposition as a result of capsular contracture is
the most common reason for revision following breast
augmentation (60). Implant malposition is variable and,
depending on the location, may lead to different complications. An inferiorly displaced implant causes obliteration
and change in the position of the inframammary fold compared with the contralateral breast. A medially displaced
implant may cause symmastia; a laterally displaced one
will result in axillary fold bulging, whereas a superiorly
displaced implant will lead to aesthetically unpleasing
asymmetry, with one breast mound sitting higher than the
contralateral one.
The best time to prevent implant malpositioning is during the initial operation. The key is to avoid over-dissection
of the pocket during the initial augmentation procedure,
and to pay close attention to important landmarks, such as
the existing or new inframammary fold (IMF), the sternal
midline, and the anterior axillary line. Dissection past the
midline should be avoided, in order to prevent the development of symmastia, should extend down to the predetermined IMF level, and should not violate the anterior
axillary line. However, the patient and surgeon should be
aware of the fact that even with meticulous surgical technique and adherence to sound principles, implant malpositioning can still occur, and is amenable to multiple
treatment modalities. Revisional surgery, with possible
recreation of the IMF, or the medial origin of the pectoralis
major muscle, in case of inferior or medial displacement,
respectively, could lead to satisfactory results. Use of acellular dermal matrix in order to provide additional support
to the underlying revision is well-documented in the current literature (42,43,61).
Double Bubble Deformity
Double bubble deformity is seen in patients in whom the
implant falls below the inframammary crease with glandular breast tissue superior and anterior to the implant (62).
The incidence of double bubble deformity is reported in
the literature to be between 2 and 7% (63). One of the
underlying etiologies of double bubble breast deformity is
failure to recognize the risk factors for it preoperatively.
One factor is severe ptosis with loose attachments at the
muscle parenchyma interface. In a subpectoral type augmentation, the breast parenchyma slides in a cephalad
direction over the implant, leading to this deformity.
Another risk factor is use of an implant of insufficient volume and projection in a patient with contracted or tuberous
glandular tissue, along with a short nipple to inframammary fold distance. To avoid double bubble in patients
with tuberous breasts, the gland must be modified with
radial incisions to optimize the transition between implant
and gland and to expand the base of the breast. Accurate
planning in regard to implant selection and pocket dissection can help prevent the development of double bubble
deformity. The pocket plane should be of adequate dimensions in order to be filled by the selected implant; therefore, implant volume, projection, and dimensions must be
carefully selected.
AESTHETIC BREAST SURGERY: SKIN
ENVELOPE
Mastopexy
Goals
The goals of mastopexy are elevation of the nipple areolar
complex, improvement of projection, aesthetic enhancement
of the breast shape, along with optimal scar quality (64).
Basic principles to follow are accurate assessment of the
degree and nature of ptosis, appropriate procedure selection, adequate preoperative planning and meticulous execution (65). In order to minimize unfavorable results, the
surgeon must be familiar with different techniques of mastopexy that will adequately address the skin envelope and
minimize the need for revisions. It is important to note that
this operation will result in scarring either in the periareolar
region or on the breast itself, which may be considered an
unfavorable result by the patient (66). However, scarring is
the tradeoff for achieving a long-lasting improvement in
the shape and aesthetic appearance of the breast, and
patients should be well-informed prior to proceeding with
surgery.
Patient Selection and Informed Consent
Accurate patient selection requires careful assessment of
nipple position, degree of ptosis, breast skin elasticity,
nipple asymmetry, and contour irregularities. Correct
identification of the above factors will in turn assist the
surgeon in choosing the appropriate procedure in order to
achieve a long-term favorable result.
Patients must be aware of scar burden and location as
well as the possibility of hypertrophic scar formation.
Moreover, patients should be informed that mastopexy
results may be temporary and with weight fluctuations,
aging, and pregnancy, ptosis may recur.
Procedure Selection
After all contributing factors have been considered, the
appropriate procedure must be undertaken in order to
achieve an aesthetically pleasing outcome. Numerous
mastopexy procedures are available for different grades
of ptosis and the surgeon must be cognizant of which
procedure fits the underlying problem of his/her particular patient who presents with ptosis (67). First-degree
(A)
173
(B)
(C)
Figure 16.4 (A) Patient with Grade III ptosis and volume loss. (B) Vertical mastopexy markings with planned plication. (C) Early
3-week postoperative result after vertical mastopexy and parenchymal redistribution with plication.
174
one setting lowers the overall cost for the patient, from a
physiologic standpoint, both surgeries act in opposition
to each other. Mastopexy repositions the nipple, reshapes
the breast and removes excess skin while limiting tension and scarring, whereas augmentation expands the
skin envelope, and increases the breast volume. This may
lead to wound healing problems and is technically very
challenging. If one chooses to undertake a simultaneous
augmentation-mastopexy, it is generally recommended
that final skin resection follow implant placement to
avoid closure under tension.
Augmentation of the ptotic breast is more complex and
many plastic surgeons advise against or recommend caution
when performing this procedure (72). A two-staged approach
is much safer and simpler. To avoid unfavorable results
many surgeons recommend performing the mastopexy first
followed by a second stage of breast augmentation (72,73).
The reverse can be performed but is much less common.
Breast Reduction
Various techniques for breast reduction have been
described in the literature from suction assisted lipectomy
to different resection patterns of breast parenchyma and
skin. This will be discussed in other chapters and is beyond
the scope of this chapter.
BREAST RECONSTRUCTION
Introduction
The beginnings of breast reconstruction date back to more
than 100 years ago with a case by Dr Vincenz Czerny in
1893, who transplanted a lipoma from the buttock to
reconstruct a patients breast (74). Innovation and technical improvements have subsequently brought significant
advancement in breast reconstruction. With the evolution
of breast reconstruction techniques and their increasing
sophistication and technical complexity, the surgeon must
be aware of the potential for complications and unfavorable results. This section will address current thoughts on
how to optimize long-term outcomes by minimizing complications and preventing unfavorable results in the breast
reconstruction patient.
Fundamental Principles in Breast
Reconstruction
The goal in breast reconstruction is to restore absent breast
tissue in a long-lasting and aesthetically pleasing manner and
establish overall symmetry. Careful patient selection and
appropriate use of available reconstructive options with
meticulous surgical technique are prerequisites for a successful outcome. Assessment of a patients candidacy for breast
reconstruction is a critical first step in minimizing complications and optimizing outcomes (75,76). Patient co-morbidities
and poor social habits should be carefully considered when
planning a reconstruction. A positive smoking history is
associated with a 23 fold increase in the incidence of
both major and minor complications in implant-based breast
reconstruction (77,78). Similarly, body mass index (BMI)
greater than 30, as well as history of hypertension contributes
to an increased risk for complications (77). Diabetes and poor
glycemic control contribute to wound healing problems and
increased infection rates (79,80). The role of advanced age as
a risk factor in breast reconstruction has not been clearly
defined (81). Patients should be evaluated in regard to realistic expectations and be informed about the expected results
and limitations of reconstructive techniques. Medical optimization, weight management and tobacco cessation should be
included in the preoperative management of a breast reconstruction patient. Patients in poor general health who cannot
tolerate reconstructive procedures may be better served with
an oncological resection without reconstruction, or can be
fitted with an external prosthetic device. Finally, in cases of
adjuvant or neo-adjuvant chemoradiation, timing, as well as
type of breast reconstruction should be taken into consideration in regard to the patients preoperative planning.
Tissue Expanders and Implants
The advantages of a two-stage tissue expander/implant
breast reconstruction are the relative ease of use, lack of
donor site morbidity, and increased patient involvement in
final volume selection (Fig. 16.5) (82). However, patients
should also be aware of possible complications associated
with use of a device including exposure, infection, extrusion, and capsular contracture, which may require additional
operations (83,84). Furthermore, reconstruction with tissue
expanders requires significant patient commitment to multiple office-based visits in order for the expansion process to
be completed. Single-stage implant reconstruction may
offer the advantages of eliminating multiple expansions but
require careful patient selection, healthy mastectomy flaps
and technical comfort and experience on the part of the
reconstructive surgeon (8587).
Tissue Expander Ports
There are two types of injection ports for a tissue expander:
remote and integrated. A remote port must be placed in the
subcutaneous tissue in a position easy to localize, but distant
enough from the implant to minimize the risk of implant perforation. Remote ports can be associated with port malposition and leakage, and difficulty with localization.
Consequently, many surgeons have moved toward utilizing
integrated ports (Fig. 16.6). When an integrated port is used,
tactile sensation should not be used to localize the port; the
175
(B)
(A)
Figure 16.5 (A) Preoperative appearance in patient who desired larger breasts. (B) Postoperative result after bilateral immediate twostage tissue expander and implant breast reconstruction.
Figure 16.6
Implant Exposure
Implant exposure has a reported incidence of approximately 3% and most commonly occurs at the mastectomy
incision scar (32). It is usually associated with insufficient
176
soft tissue coverage and/or inadequately perfused mastectomy flaps. Key principles in avoiding exposure include
the creation of mastectomy flaps of adequate thickness and
a subpectoral pocket with full implant coverage (typically,
pectoralis muscle superiorly with serratus fascia and/or
acellular dermal matrix inferolaterally). Additionally,
early recognition and appropriate treatment of surgical site
infections, debridement and revision of wounds with
impending implant exposure, and careful expansion in
order not to compromise mastectomy flap vascular supply
reduce the risk of implant exposure (90). When this complication is encountered, management usually entails
removal of the implant, appropriate wound care and future
reconstruction (91).
Mastectomy Flap Necrosis
Mastectomy flap necrosis is usually related to either inadequate perfusion of the mastectomy flaps, or closure of the
incision under significant tension (Fig. 16.7). In case of
such complication, local wound care with possible debridement of the necrotic skin and future scar revision should
be considered. Timed excision of the mastectomy flap
necrosis with continued expansion may be considered if
full musculofascial coverage of the implant is present (92).
Newer technology incorporating ICG perfusion (SPY
technology, Lifecell Corp.) (65) may facilitate identification of the compromised mastectomy flaps intraoperatively (9397). Close cooperation between the breast and
reconstructive surgeons is necessary for optimization of
the final result.
Figure 16.7
Infection
Periprosthetic infection in reconstructive breast surgery
has been reported to be 725% of all cases (44,49,50,98,99).
Failure to adhere to sterile principles in the intraoperative
and postoperative phase and/or presence of multiple
comorbidities affecting the patients immune status can
contribute to a higher infection risk. Obesity (BMI > 30),
poorly controlled diabetes, immunocompromised state
and active smoking have been linked to higher infection
rates (77,7780). Moreover, improper device handling and
failure to comply with sterile principles during tissue
expansion may lead to periprosthetic infection. Once clinical evidence of an infection appears, the patient should be
treated promptly with antibiotics, and in the case of inadequate response, implant removal and delayed reconstruction is advised.
Contour Deformities
Fat injection into the subcutaneous layer overlying the
capsule has been recommended in order to address this
finding. Technologic advances have made the harvesting
and delivery of injectable autologous fat a great tool in the
armamentarium of the plastic surgeon while minimizing
complications such as decreased fat graft take and cyst formation. However, the long-term implications of this technique are unclear (40,41,100,101).
Implant Malpositioning
Implant malpositioning can result from either suboptimal
initial placement of the implant or as a consequence of
Mastectomy flap necrosis in patient who underwent immediate breast reconstruction using TE with latissimus flap.
(A)
(B)
Figure 16.8
177
178
(B)
(A)
Figure 16.9
(A, B) Preoperative and postoperative result after ADM-assisted left TE/I breast reconstruction (and right mastopexy).
179
180
(A)
(B)
(C)
(D)
Figure 16.10 (A) Preoperative appearance of patient with right breast cancer and breast asymmetry. (B) Postoperative result after
right immediate breast reconstruction using deep inferior epigastric artery perforator (DIEAP) flap. (C) Postoperative result after
contralateral breast reduction. (D) Postoperative result after right NAC reconstruction.
(A)
(B)
(C)
(D)
181
Figure 16.11 (A, B) Preoperative and postoperative result after bilateral immediate breast reconstruction using DIEP and musclesparing TRAM flaps. (C, D) CT angiography demonstrating abdominal vasculature. (Continued)
182
(F)
(E)
(G)
Figure 16.11
(Continued) (EG) Intraoperative views of DIEP and muscle sparing TRAM flaps.
(A)
183
(B)
Figure 16.12 (A, B) Preoperative and postoperative appearance of patient who underwent bilateral TE/I breast reconstruction with
radiation (note changes secondary to radiation).
due to radiation (172). If the soft tissue envelope is inadequate, import of autologous tissue with or without a
prosthetic device is recommended. If radiation is
required after an immediate expander reconstruction,
protocols have been developed with close cooperation
with the radiation oncology specialist with high success
rates (89,88,173,174). With regard to free flap breast
reconstruction, pre-reconstruction radiation therapy
increases the rate of vascular complications in free flap
breast reconstruction, the majority of which appear
intraoperatively. Although radiation does not hinder the
overall success of reconstruction or contribute to postoperative complications, surgeons should be aware that
working in a previously irradiated field carries additional
technical risk (175). In the post-reconstruction patient,
radiation therapy has a deleterious effect on the longterm aesthetic outcome in patients who have undergone
TRAM flap breast reconstruction (176). A patient who
requires radiation should be counseled on the risks and
benefits of an immediate versus delayed reconstruction
in the settings of either autologous- or implant-based
reconstructive methods.
CONCLUSION
Optimizing long-term outcomes is a goal for both the
reconstructive and aesthetic surgeon. Careful patient selection, meticulous technique, and appropriate choice of available options are prerequisites for successful breast surgery.
Recognizing and understanding how to minimize complications and avoid unfavorable results are critical aspects to
achieving optimal long-term success after breast surgery.
184
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Gill PS, Hunt JP, Guerra AB, et al. A 10-year retrospective
review of 758 DIEP flaps for breast reconstruction. Plast
Reconstr Surg 2004; 113: 115360.
Chun YS, Sinha I, Turko A, et al. Comparison of morbidity, functional outcome, and satisfaction following bilateral TRAM versus bilateral DIEP flap breast reconstruction.
Plast Reconstr Surg 2010; 126: 113341.
Uppal RS, Casaer B, Van Landuyt K, Blondeel P. The efficacy
of preoperative mapping of perforators in reducing operative
times and complications in perforator flap breast reconstruction. J Plast Reconstr Aesthet Surg 2009; 62: 85964.
Chen CM, Halvorson EG, Disa JJ, et al. Immediate postoperative complications in DIEP versus free/musclesparing TRAM flaps. Plast Reconstr Surg 2007; 120:
147782.
Selber JC, Fosnot J, Nelson J, et al. A prospective study comparing the functional impact of SIEA, DIEP, and musclesparing free TRAM flaps on the abdominal wall: part II.
Bilateral reconstruction. Plast Reconstr Surg 2010; 126:
143853.
188
135. Heller L, Feledy JA, Chang DW. Strategies and options for
free TRAM flap breast reconstruction in patients with midline abdominal scars. Plast Reconstr Surg 2005; 116: 7539;
discussion 7601.
136. Hsieh F, Kumiponjera D, Malata CM. An algorithmic
approach to abdominal flap breast reconstruction in
patients with pre-existing scarsresults from a single surgeons experience. J Plast Reconstr Aesthet Surg 2009; 62:
165060.
137. Mehrara BJ, Santoro TD, Arcilla E, et al. Complications
after microvascular breast reconstruction: experience with
1195 flaps. Plast Reconstr Surg 2006; 118: 11009; discussion 111011.
138. Ardehali B, Mehrara B, Cordeiro P, Mosahebi A. Painting
the pedicle: a twist-proof marking method. J Reconstr
Microsurg 2011; 27: 2078.
139. Wu LC, Iteld L, Song DH. Supercharging the transverse
rectus abdominis musculocutaneous flap: breast reconstruction for the overweight and obese population. Ann
Plast Surg 2008; 60: 60913.
140. Hamdi M, Andrades P, Thiessen F, et al. Is a second free
flap still an option in a failed free flap breast reconstruction? Plast Reconstr Surg 2010; 126: 37584.
141. Bozikov K, Arnez T, Hertl K, Arnez ZM. Fat necrosis in
free DIEAP flaps: incidence, risk, and predictor factors.
Ann Plast Surg 2009; 63: 13842.
142. Bailey SH, Saint-Cyr M, Wong C, et al. The single dominant medial row perforator DIEP flap in breast reconstruction: three-dimensional perforasome and clinical results.
Plast Reconstr Surg 2010; 126: 73951.
143. Bando M, Tanaka S. Breast reconstructionsome refinements of TRAM flap procedure. Gan To Kagaku Ryoho
1994; 21(Suppl 2): 24954.
144. Hartrampf CR Jr. Abdominal wall competence in transverse abdominal island flap operations. Ann Plast Surg
1984; 12: 13946.
145. Quilichini J, Le Masurier P, Guihard T. Increasing the reliability of SIEA flap using peroperative fluorescent angiography with indocyanine green in breast reconstruction.
Ann Chir Plast Esthet 2010; 55: 5318.
146. Rozen WM, Whitaker IS, Chubb D, Ashton MW. Perforator number predicts fat necrosis in a prospective analysis
of breast reconstruction with free TRAM, DIEP, and SIEA
flaps. Plast Reconstr Surg 2010; 126: 22868; author reply
22889.
147. Chernyak V, Rozenblit AM, Greenspun DT, et al. Breast
reconstruction with deep inferior epigastric artery perforator flap: 3.0-T gadolinium-enhanced MR imaging for preoperative localization of abdominal wall perforators.
Radiology 2009; 250: 41724.
148. Rozen WM, Ashton MW, Stella DL, Phillips TJ, Taylor GI.
Stereotactic image-guided navigation in the preoperative
imaging of perforators for DIEP flap breast reconstruction.
Microsurgery 2008; 28: 41723.
149. Atisha DM, Comizio RC, Telischak KM, Higgins JH,
Collins ED. Interval inset of TRAM flaps in immediate
breast reconstruction: a technical refinement. Ann Plast Surg
2010; 65: 5247.
189
172. Percec I, Bucky LP. Successful prosthetic breast reconstruction after radiation therapy. Ann Plast Surg 2008; 60: 52731.
173. Kronowitz SJ, Robb GL. Radiation therapy and breast
reconstruction: a critical review of the literature. Plast
Reconstr Surg 2009; 124: 395408.
174. Pusic AL, Cordeiro PG. An accelerated approach to tissue
expansion for breast reconstruction: experience with intraoperative and rapid postoperative expansion in 370 reconstructions. Plast Reconstr Surg 2003; 111: 18715.
175. Fosnot J, Fischer JP, Smartt JM Jr, et al. Does previous
chest wall irradiation increase vascular complications in
free autologous breast reconstruction? Plast Reconstr Surg
2011; 127: 496504.
176. Carlson GW, Page AL, Peters K, et al. Effects of radiation
therapy on pedicled transverse rectus abdominis myocutaneous flap breast reconstruction. Ann Plast Surg 2008; 60:
56872.
17
Gynecomastia
Gary Rose
190
GYNECOMASTIA
191
Figure 17.1
Unilateral gynecomasty.
(B)
(A)
(C)
Figure 17.2
192
GYNECOMASTIA
193
(B)
(A)
(C)
Figure 17.3 Poor technique has resulted in excessive scarring. (A) Failed initial attempt by general surgeon to correct massive
gynecomastia with subcutaneous mastectomy. There was no consideration of the excess skin. (B) Six months later. (C) One year after
correction with bilateral simple mastectomies and excision of excess skin. Areolae were created with tattooing.
194
(A)
(C)
(B)
(D)
Figure 17.4 (A) A 42-year-old male: pre-postoperative view (see also C for side view). (B) One year post-operation: the surgical
correction was made with suction lipectomy without surgical resection (see also D for side view).
The publics awareness of the availability of gynecomastia surgery has made tremendous strides forward. In
fact, it is one of the most commonly performed male plastic surgery procedures today. I strongly recommend the
utilization of suction lipectomy. It is easier and inherently
carries with it much less risk of complication. The other
great advantage is that patients are able to return to full
activities the day after surgery (Figs. 17.4 and 17.5).
GYNECOMASTIA
195
(A)
(B)
(C)
(D)
Figure 17.5 (A) A 19-year-old male with large tuberous gynecomastia. Pre-operative view (see also C for side view). (B) One year
post-operation: The correction was made with suction lipectomy. No surgical excision was carried out (see also D for side view).
196
REFERENCES
1. Nuttall FQ. Gynecomastia as a physical finding in norrmal
men. J Clin Endocrinol Metab 1979; 48: 338.
2. Williams MJ. Gynecomastia: its incidence, recognition and
host characterization in 447 autopsy cases. Am J Med 1963;
34: 103.
3. Aeginata P. The Seven Books of Paulus Aeginata. Translated
from Greek by Francis Adams. vol 2, book 6, section 46
London: London Syndenham Society, 1848.
4. Webster JP. Mastectomy for gynecomastia through a semicircular intra-areolar incision. Ann Surg 1946; 124: 557.
5. Teimourian B, Pearlman R. Surgeryfor gynecomastia. Aesthetic Plast Surg 1983; 7: 155.
18
Breast reconstruction CPT coding
Keith Brandt and Scott Oates
198
performed for a diagnosis which is unrelated to the surgery that was performed. These services are paid separately by appending modifier 24 (unrelated evaluation and
management service by the same physician during a postoperative period) to the appropriate level of E&M service
and submitting the appropriate documentation.
Staged Procedures
BREAST RECONSTRUCTION
dressing changes
local incisional care
removal of operative packs
removal of cutaneous sutures, staples, lines, wires,
tubes, drains, cast, and splints
insertion, irrigation, and removal of urinary catheters
routine peripheral intravenous lines and nasogastric
and rectal tubes
change and removal of tracheostomy tubes
All E&M services performed during the postoperative
global period are not billable unless the E&M services are
199
200
Descriptor
Work RVU
CABG arterial x 2
Microvascular fibular transfer
Functioning neurovascular muscle tx
Aortic valve replacement
Lung transplant
Microvascular TRAM
Arm replant
CABG arterial x3
39.88
40.26
41.01
41.32
41.61
42.58
42.62
43.98
Table 18.2
Statistics.
Procedure
Implant alone
Tissue expander
TRAM
DIEP
Latissimus flap
Total
Total
9,097
56,978
9,327
4,424
6,598
86,424
10.5
66.0
10.8
5.1
7.6
100.0
The relative value of 19350 includes the work of reconstructing both the nipple and areola. Many surgeons now
reconstruct the nipple alone and then latter color the nipple and create an areola with tattooing techniques. To
code for nipple reconstruction alone, use code 19350 with
the -52 (reduced services modifier). Later when the tattooing is performed use the tattoo codes 11921 (tattooing,
intra-dermal . . . 6.120 sq. cm,) 11922 (tattooing, intradermal . . . each additional 20 sq. cm). To determine the
square centimeters, use the formula A = r2, where r is the
radius (usually 2.5 cm) and is 3.14. The standard 5 cm
areola is 19.62 sq. cm. Some insurance carriers may prefer; that instead of reducing 19350, the value of the code
will stand for both nipple creation and tattooing, instead of
using two separate codes. Poll your insurance carriers
about which method they prefer.
Symmetry Procedures
If breast reduction is performed on the contralateral side
for symmetry it should be coded with 19318 (reduction
mammoplasty). This code includes parenchymal reduction, supplemental liposuction, breast lift, nipple/areola
repositioning, and nipple/areola preservation whether it is
done by pedicle technique or amputation and grafting. If
liposuction is used alone, use code 15877 (suction-assisted
lipectomy; trunk).
If liposuction is used to modify a reconstructed breast,
use the code 19380 (revision of reconstructed breast). Do
not use the liposuction code 15877. Most insurance companies consider this a cosmetic code and do not recognize its use in reconstructive procedures. Do not use
19380 to code for scar revisions of the mastectomy or
reconstruction scar (use 1310X, complex closure), capsulectomies (use 19371), replacement of an implant for a
different size (use code 19340) when these procedures
are performed alone. When performed together on the
same reconstructed breast, it may be appropriate to use
code 19380. If dog ears require resection at the ends of a
TRAM scar and are closed in layers; use the resection
codes (1140X) together with the intermediate closure
codes (1203X) (6).
Fat grafting is sometimes recommended to help correct
contour defects, especially in the area cephalad to the reconstructed breast where the mastectomy continued beyond the
reconstruction. Fat grafting is coded with code 20926 which
includes: harvest of the fat graft, processing of the fat, injection of the fat, closure of the harvest and injection sites and
90 days of postoperative care. The code is not site or volume specific. If separate anatomic areas are treated then
code 20926 for each area. Append the -59 (separately identifiable procedure) modifier. If large areas of the same breast
are injected it may be better to use the code 19380 (breast
revision) to adequately describe the work involved (7).
201
Index
203
204
Breast asymmetry
aesthetic breast surgery, 179
benign tumor, 36
and bilateral hypomastia, 2933
and bilateral hypomastia, ptosis, 3334
and breast ptosis, 2829
juvenile macromastia, 3435
and macromastia
adequate contralateral volume, 28
bilateral, 2628
inadequate contralateral volume, 28
preoperative, 162
principles, 26
unilateral hypomastia and contralateral
adequate volume, 34
Breast augmentation
complications
asymmetry, 170
capsular contracture, 171
double bubble deformity, 172
hematoma, 170
implant malposition, 172
implant size, 170
infection, 170
secondary deformities, 171
wrinkling and rippling, 170171
implant pocket plane effects, 167
implant selection, 167
incision type, 168169
management strategies, 159161
optimal planning on tissue assessment, 167
patient education, 166167
Breast conservation therapy (BCT)
complications of, 7678
management strategies, 155156
neoadjuvant chemotherapy, 69
partial reconstruction techniques, 6976
patient selection, 66
radiotherapy techniques, 69
reconstruction following, 6668
reduction mammoplasty, 73
timing of reconstruction
delayed reconstruction, 68
immediate-delayed
reconstruction, 6869
immediate reconstruction, 68
Breast conserving surgery (BCS), 56
Breast Imaging Reporting and Data
System (BIRADS), 18, 57
Breast-specific gamma imaging
(BSGI), 2021
BSGI. See Breast-specific gamma imaging
Cadaveric acellular dermal matrices, 44
Calcifications, 2122
Calcium hydroxyapatite, injectable, 148
Cancer surveillance, 87
Capsular contracture, 9395, 159160,
171, 177
INDEX
Capsulectomy, 161
Cartilage grafts, 148
Center for Medicare and Medicaid
(CMS), 197
Chest wall
anatomy of, 4
and breast, 7
and Poland syndrome, 12
Chiari-standardized geometric pattern, 43
Chloramex, 94
Circumareolar scar technique, 41
Clavipectoral fascia, 5
Clinical and Radiographic Poland
Syndrome (CRPS), 12
Clopidogrel, 82
CMS. See Center for Medicare and
Medicaid
Color duplex ultrasonography, 110
Comorbid medical conditions, 82
Congenital breast disorders
embryology, 9
hyperplastic disorders, 911
hypoplastic disorders, 1113
management of complications, 4
tuberous breast deformity, 1314
Contour deformities, 96, 176
Coopers ligaments, 48
CPT coding
autologous tissue breast
reconstruction, 199200
complications following surgery, 198
implant-based breast
reconstruction, 198199
initial evaluation, 197198
nipple reconstruction, 200
partial mastectomy defect
reconstruction, 201
postoperative services, 198
preoperative visits, 198
staged procedures, 198
symmetry procedures, 200
CRPS. See Clinical and Radiographic
Poland Syndrome
Deep inferior epigastric artery perforator
(DIEP) flap
anatomic dissections, 111
autologous reconstruction, 157158
breast and abdominal aesthetic
complications, 120121
breast and abdominal technical
complications, 119120
CPT coding, 200
general surgical complications, 117118
indications, 111113
microsurgical complications, 118119
performance, 113117
perfusion zones, 110111
venous drainage, 110
Delayed reconstruction, 68
Dermal flap, 43
Dermalive, 149
Double bubble deformity, 172
Double pedicled flaps, 144147
Dual chamber tissue expander, 88
Fat grafting, 73, 200
Fat necrosis, 63, 158, 162, 179
Fibroadenoma. See Benign breast tumor
Flex HD, 177
Flowes-Smith modified Wise incision, 44
Free abdominoplasty flap. See Superficial
inferior epigastric artery
Free flaps
anterolateral thigh flap, 134135
DIEP flap (see Deep inferior epigastric
artery perforator flap)
gracilis myocutaneous flap, 132134
inferior gluteal artery perforator
flap, 130132
postoperative management, 135136
Rubens flap, 134135
superficial inferior epigastric artery
flap, 110, 125126
superior gluteal artery perforator
flap, 126130
thoracodorsal artery perforator
flap, 134135
TRAM flap (see Transverse rectus
abdominis myocutaneous flap)
Free nipple grafting, 5354
Free tissue grafts, 147148
Fucidin, 94
Gestational hypertrophy, 47
Gigantomastia. See Breast hypertrophy
Gracilis myocutaneous flap, 132134
Gynecomastia
bilateral, 190191
hypertrophic scarring, 192193
suction lipectomy, 194195
unilateral, 190191
Halsteads ligament, 5
Hartrampf perfusion zones, 110111
Hematoma, 9596, 170
Homeopathic medications, 82
Hyperplastic breast disorders, 911
Hypertrophic scarring, 5455, 192193
Hypertrophy, 47
Hypomastia
bilateral, 2934
unilateral, 34
Hypoplastic breast disorders, 1113
Iatrogenic hypertrophy, 47
IMA. See Internal mammary artery
IMF. See Inframammary fold
INDEX
Immediate-delayed reconstruction, 6869
Immediate reconstruction, 68
Implant-based breast
reconstruction, 198199
Implant displacement, 95
Implant malposition, 172
Implant rupture, 160
Infection, 9293, 161, 170, 176
Inferior gluteal artery perforator (IGAP)
flap, 130132
Inframammary fold (IMF), 2
Internal mammary artery (IMA), 4
Inverted-T scar technique, 4345
Ipsilateral nipple, 11
Juvenile gigantomastia. See Juvenile
macromastia
Juvenile macromastia, 3435
Lassus technique, 4142
Lateral perforators, 110
Lateral thoracic artery, 4
Latissimus dorsi flap, 96, 182
Latissimus dorsi musculocutaneous
flap, 74, 97, 181
LCIS. See Lobular carcinoma in situ
Lejour modified Lassuss
technique, 4142
Liposuction, 53
Lobular carcinoma in situ (LCIS), 83
Local flaps, 147
L-shaped scar technique, 43
Lumpectomy, 6869
Lymph nodes, 48
Macromastia
and adequate contralateral volume, 28
bilateral, 2628
and inadequate contralateral volume, 28
juvenile, 3435
Malposition, 141, 162163
MammoSite applicator, 6970
Management strategies
autologous reconstruction, 157159
breast augmentation, 159161
breast conservation therapy, 155156
expanders and implants with
BCT, 156157
general considerations, 155
reduction mammoplasty, 161163
Marcah arched gateway incision, 45
Mastectomy flaps
ischemia, 95
necrosis, 119, 176, 179
Mastopexy
aesthetic breast surgery
augmentation mastopexy, 173174
breast reduction, 174
goals, 172
205
hypertrophy, 173
patient selection and informed
consent, 172
procedure selection, 172173
scar widening, 173
complications, 3839
inverted-T scar technique, 4345
L-shaped scar technique, 43
markings, 37, 39
periareolar scar technique
with asymmetrical areola
shape, 4041
circumareolar scar technique, 41
with symmetrical areola
shape, 4041
physical examination, 38
preoperative assessment, 38
ptosis classification, 38
vertical scar technique, 4142
Medial perforators, 110
Mentor CPX3 profi led expander, 88
Methylene blue dye, 179
Michigan Breast Reconstruction Outcome
Study, 93, 99
Microvascular flap breast
reconstructions, 199
MRI breast imaging technique, 1820
Musculoskeletal thoracic wall, 4
Myocutaneous latissimus dorsi flaps, 63
Myosubcutaneous latissimus dorsi
flaps, 63
Natrelle expander, 88
Neoadjuvant chemotherapy
breast conservation therapy, 69
post-mastectomy reconstructive
surgery, 83
Nicolle modified Wise incision, 45
Nippleareola complex (NAC)
reconstruction
anatomy
errors in timing of surgery, 140
malposition, 141
patient selection, 140
skate flap techniques, 142143
star flap techniques, 143144
CPT coding, 200
principles of, 139
qualitative benefits, 139
secondary procedures, 150153
techniques
areolar reconstruction, 149150
autologous fat grafting, 148
cartilage grafts, 148
double pedicled flaps, 144147
free tissue grafts, 147148
local flaps, 147
nipple sharing, 148
soft tissue fillers, 148149
206
Polythelia pilosa, 11
Positional ptosis, 38
Positron emission mammography
(PEM), 2021
Post-mastectomy reconstructive surgery
medical history
breast-related history, 8283
medications, 82
neoadjuvant chemotherapy, 83
radiation, 83
smoking, 82
systemic illnesses, 82
physical examination
breast exam, 8384
chest wall, 84
donor sites, 84
obesity, 83
Profiled tissue expander, 88, 97
Pseudogynecomastia, 190
Pseudomamma, 11
Pseudoptosis, 38
Ptosis, 2829, 3334
classification, 38
inadequate in tissue expansion
reconstruction, 9799
Racquet mammoplasty, 60
Radiation oncologists, 99
Radiesse, 148
Radiologic evaluation
augmented breast, 2223
breast-specific gamma imaging
(BSGI), 2021
MRI technique, 1820
positron emission mammography
(PEM), 2021
reconstructed breast, 2324
surgically altered breast, 2122
ultrasound, 1819
X-ray mammography, 1618
RBRVS. See Resource Based Relative
Value Scale
Reconstructed breast, 2324
Reduction mammoplasty
breast anatomy
brassiere cup size and reduction
volumes, 49
innervation, 48
shapes and landmark
measurements, 4849
vessels and lymphatics, 48
in breast conservation therapy, 73
complications, 5455
free nipple grafting, 5354
indications, 4950
liposuction, 53
management strategies, 161163
INDEX
surgical techniques
vertical scar, 53
Wise pattern, inverted-T, inferior
pedicle, 5052
Regnault-B shaped pattern, 43
Regnault traditional ptosis
classification, 38
Resource Based Relative Value Scale
(RBRVS), 197
Round tissue expander, 88
Rubens flap, 134135
Saline implants, 88
Sapphire Suction Reservoir, 96
Scarring, 161
Secondary deformities, 171
Seroma. See Hematoma
SIEA. See Superficial inferior epigastric
artery
Sientra dual chamber expander, 88
Silicone implants, 63, 88, 96
Singulair, 94
Skate flap techniques, 142143
Skin necrosis, 63
Skin paddles, 141
Smoking, 82
Soft tissue fillers, 148149
SPAIR (short scar periareolar
inferior pedicle reduction)
mammoplasty, 42
SPY Elite Intraoperative Perfusion
Assessment System, 95, 97, 177
Staphylococcus aureus, 9293
Staphylococcus epidermidis, 94
Star flap techniques, 143144
Strattice, 177, 198
Strombeck inverted horseshoe, 44
Suction lipectomy, 194195
Superficial cellulitis, 9293
Superficial infections, 161
Superficial inferior epigastric artery
(SIEA) flap, 110, 125126
Superior gluteal artery perforator (SGAP)
flap, 126130
Supernumerary breast, 1011
Supranumerary nipples, 9
Surgically altered breast, 2122
Surgimend, 198
Symmastia, 160161
Systemic illnesses, 82
Tatooing, 149150
Terramycin, 94
Thoracodorsal artery perforator (TAP)
flap, 97, 134135
Thoracodorsal nerve, 6
Tissue expanders, 8789, 174177
Aesthetic and
Reconstructive
Breast Surgery
Solving Complications
and Avoiding
Unfavorable Results
About the book
Breast surgery has important implications for a patients self image and
self esteem. Aesthetic procedures whether augmentation or reduction
remain among the most popular reasons for seeking elective surgery;
and reconstruction after surgery for cancer is an integral part of the
patients treatment and recovery process.
This new book provides an expert approach to treating the patient
and handling the operation with maximum attention to areas where
mismatched expectations or technical difficulties may cause later
problems or the need for further revision surgery. As such, this will be an
invaluable succinct guide that all surgical practitioners will want to have
as a ready reference before any consultation or procedure.