Grabb’s Encyclopedia of Flaps Upper Extremities, Torso, Pelvis, and Lower Extremities

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used for cutting through the subcutaneous planes to remove the expander and reservoir dome, since the silicone
envelope is resistant to heat. The amount of normal saline in the expander should be calculated, and a smaller
implant should be placed in the pocket to allow mobility and flexibility of the reconstructed breast.
FIGURE 359.3 A: A 54-year-old woman 7 years after a bilateral modified radical mastectomy. B: At the time of
insertion of the expander, extremely tight chest skin would allow injection of only 50 cc normal saline. Expanders
were subsequently injected with up to 450 cc normal saline in eight office visits. C: Both expanders were
replaced with 300-cc mammary implants. Labial grafts were used for nipple reconstruction.
Symmetry and Management of the Opposite Breast
Contralateral round dermal mastopexy with two circumferential periareolar and midbreast incisions has proved
satisfactory to match the hemispheric appearance of the reconstructed breast (5). The mastopexy, by reducing
the skin around the nipple, simultaneously enlarges the areola, and the outer areolar ring is subsequently used
as a graft for reconstruction of the nipple-areola complex of the reconstructed breast (Fig. 359.4). When
indicated, contralateral subcutaneous mastectomy is performed through a similar round dermal pedicle approach
with immediate insertion of an implant.
CLINICAL RESULTS
If a hematoma occurs, flap necrosis may occur. The expander should be removed, the hematoma
evacuated, and hemostasis established.

FIGURE 359.4 A,B: Preoperative views of a 52-year-old woman 2 years after left modified radical
mastectomy. C,D: The temporary expander was filled with 650 cc normal saline and then replaced with a
450-cc gel-filled implant. The right breast subcutaneous mastectomy was performed through the round
dermal mastopexy with immediate reconstruction. Subsequently, the outer ring of the right areola was used
for the left areolar reconstruction. Part of the right nipple was used for the left nipple reconstruction.
A great advantage of this form of reconstruction is that the expander can be deflated if necrosis seems
imminent. If the expanded skin changes color or blisters develop, fluid should be withdrawn immediately.
The needle should be inserted into the reservoir dome until the skin assumes normal color and tension is
relieved. Reexpansion may be resumed 2 to 3 weeks later.
The rate of contracture in these reconstructed breasts is low, a contributing factor being that the initial
pocket is 200 to 300 cc larger than the size of the permanent implant.
SUMMARY
The main goal of this form of breast reconstruction is the recovery of lost tissue by expansion of the
remaining chest skin. This skin is expanded to large proportions, and the breast envelope is then filled with
a small permanent mammary prosthesis.
Because relatively large breasts can be reconstructed using this method, less needs to be done to the
opposite breast to achieve symmetry.
References
1. Radovan C. Reconstruction of the breast after radical mastectomy using the temporary expander. Plast
Surg Forum 1978;1:41.
2. Radovan C. Advantages and complications of breast reconstruction using the temporary expander. Plast
Surg Forum 1980;3:63.

3. Radovan C. Breast reconstruction after mastectomy using the temporary expander. Plast Reconstr Surg
1982;69:195.
4. Austad ED, Rose GL. A self-inflating tissue expander. Plast Reconstr Surg 1982;70:588.
5. Radovan C, Keunen H. Periareolar breast surgery. Presented at the annual meeting of the American
Society of Plastic and Reconstructive Surgeons, Toronto, Canada, 1975.

Chapter 360
Superolateral Pedicle for Breast Surgery
C. K. HERMAN
B. STRAUCH
The evolution of procedures for reduction of breast volume and improvement of breast shape has been ongoing,
based on the rich blood supply that has allowed a plethora of pedicle types. In searching for a technique that
could be tailored for use in almost any breast procedure, including both reduction and mastopexy, the following
goals have been used as guidelines: (a) an adequate and safe reduction of breast volume or modification of
breast shape; (b) correction of ptosis; (c) a lasting and aesthetically pleasing shape with superior pole fullness;
and (d) a nipple-areola complex with retained sensibility and vascularity. The superolateral dermoparenchymal
pedicle has been adapted for surgery on myriad breast types, using differing skin excisions. It has been used in
reduction mammaplasty, mastopexy, and augmentation mastopexy cases.
INDICATIONS
With particular consideration given to the importance of the lateral branch of the fourth intercostal nerve in
supplying sensation to the nipple-areola complex (1, 2, 3), authors have described and used the
superolateral dermoparenchymal pedicle as a basis for surgery on a variety of presenting breast shapes
(4). The technique integrates elements from several other procedures. Strombeck (5) developed a
horizontal bipedicled dermoparenchymal flap in 1960. Skoog (6) is credited with describing the first lateral
pedicle. In 1982, Nicolle (7) presented his experience with the lateral dermoparenchymal pedicle for breast
reduction. Cardenas-Camerana and Vergara (8) described their successful use of the superolateral
dermoglandular pedicle.
A simple classification system that reflects the versatility of the superolateral pedicle operation has been
developed (Figs. 360.1 and 360.2), as follows (4): type I, superolateral dermoparenchymal pedicle using the
modified Wise pattern (9); type Ia, reduction mammaplasty of 1,200 g per patient or more; type Ib,
mastopexy for ptosis, with minimal-to-no reduction of breast parenchyma; type Ic, reduction mammaplasty
with free nipple grafts; type II, superolateral dermoparenchymal pedicle using the vertical pattern; type IIa,
reduction mammaplasty of 1,200 g per patient or less; type IIb.i, mastopexy for ptosis; type IIb.ii, mastopexy
for ptosis, with mammary prosthetic implant.

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FIGURE 360.1 Wise-type pattern variations (above). Superolateral dermoparenchymal resection reserved
for larger reductions (type Ia). The pedicle is well vascularized and contains the main innervation to the
nipple-areola complex. It provides superior-pole fullness and projection (center). Wise-type pattern
resection with superolateral dermoparenchymal resection for mastopexy for correction of ptosis (type Ib)
(below). Wise-type pattern resection with superolateral dermoparenchymal procedure tailored for very
large-breasted women with nipple-areola complexes longer than 40 cm from the sternal notch (type Ic). A
free nipple-areola graft is placed on a dermal bed of the superolateral dermoparenchymal pedicle.

FIGURE 360.2 Vertical pattern variations (above). Vertical reduction by using a superolateral
dermoparenchymal pedicle for moderate to small reductions (type IIa) (center) Vertical mastopexy (type
IIb.i). All tissue is used, except for the skin covering of the tissue between the vertical pillars. The
superolateral dermoparenchymal pedicle and all the attached deskinned tissues are rotated superiorly.
(below) Vertical mastopexy with simultaneous augmentation (type IIb.ii). The vertical pillars are redrawn
after placement of the inflated prosthesis.
ANATOMY
The flap receives its blood supply from its superolateral dermoparenchymal base. Blood supply includes
perforators from the internal mammary artery, lateral thoracic artery, multiple intercostal perforators,
thoracoacromial artery, and thoracodorsal artery. Preservation of a parenchymal attachment of the flap to the
chest wall along its base enhances the nourishment of the flap and nipple-areola complex. Anatomic innervation
to the nipple-areola complex is largely preserved by incorporation of the lateral branch of the fourth intercostal
nerve, which is included in the lateral base of the flap.
FLAP DESIGN AND DIMENSIONS
Modified Wise pattern or vertical mammaplasty markings are drawn on the breast. Markings for nipple placement
are made along the breast meridian at a level that accounts for the patient's breast size and shape, height, and
degree of nipple ptosis. Nipple placement is generally located between 21 and 25 cm from the sternal notch. In
designing the superolateral dermoparenchymal pedicle, the areola is first traced with a 42-mm-diameter washer,
centering the nipple in the hole of the washer. The superolateral flap is then drawn with a 10- to 12-cm width,
starting 2 cm lateral to the meridian and ending 2 to 3 cm lateral to the lower edge of the lateral point of the
vertical marking. Depending on the length of the nipple-areola complex, and extending 1 to 2 cm beyond the new
42-mm areolar border, determine the length of the pedicle (Figs. 360.1 and 360.2). A 1:1 ratio of length to width
is the result.
OPERATIVE TECHNIQUE
The operative procedure involves superior rotation of a superolaterally based dermoparenchymal pedicle,
resulting in a “periwinkle” effect, which provides desirable superior pole fullness and increased projection to the
breast. The superolaterally based flap is created by incising at the borders of the pedicle perpendicularly down
to the level of the pectoralis major fascia. The pedicle is then deepithelialized, leaving the nipple- areola complex
intact (except in cases of free nipple grafts, in which it is removed, thinned, and then suture-bolstered to the
entirely deepithelialized pedicle). In pure mastopexy cases, the breast tissue that otherwise would have been
resected during a reduction mammaplasty is maintained in continuity with the superolateral dermoglandular
pedicle, after removal of the full-thickness overlying skin. Attachment of the pedicle base to the pectoralis fascia
is maintained. The pedicle is then rotated superiorly, and the Wise pattern or vertical mammaplasty flaps are
approximated and closed in layers. Closure of the breast flaps maintains the position of the superiorly rotated
pedicle. It is not necessary to support the pedicle with sutures to the pectoralis major fascia or surrounding
breast parenchyma.
CLINICAL RESULTS
The superolateral pedicle has been used by the authors in more than 1,500 breast operations. Patients
have been followed up for as many as 15 years. Total nipple-areola necrosis was observed in four patients,
two patients with bilateral loss and two with unilateral loss (0.2%). Epidermolysis associated with partial

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areolar loss was seen in three cases (0.2%). Nipple-areola sensitivity was evaluated as normal, or slightly
reduced, at 1-year follow-up in 1,440 patients (96%), with only 60 patients reporting significantly diminished
or absent sensitivity (4%). Long-term follow-up to 15 years has demonstrated that the results of breast
procedures using the superolateral pedicle are maintained well with time (Figs. 360.3 and 360.4).
SUMMARY
The superolateral dermoparenchymal pedicle has fulfilled the goals of successful breast surgery. It is a safe
and effective technique that has provided long-lasting results for patients. The flap design incorporates both
a hearty blood supply and a significant source of innervation to the nipple-areola complex: the lateral branch
of the fourth intercostal nerve. It is a reproducible procedure that can be adapted to a variety of skin-
excision patterns and breast morphologies.
FIGURE 360.3 Wise pattern reduction type Ia. Preoperative (above). Postoperative (below).
FIGURE 360.4 Same patient as in Figure 360.3 at 10 years after operation.
References
1. Cooper A. The anatomy of the breast. London: Longman, 1840.

2. Craig RDP, Sykes PA. Nipple sensitivity following reduction mammaplasty. Br J Plast Surg 1970;23:165.
3. Courtiss EH, Goldwyn RM. Breast sensation before and after plastic surgery. Plast Reconstr Surg
1976;58:1.
4. Strauch B, Elkowitz M, Baum T, Herman C. Superolateral pedicle for breast surgery: an operation for all
reasons. Plast Reconstr Surg 2005; 115:1269.
5. Strombeck JO. Mammaplasty: report of a new technique based on the two pedicle procedure. Br J Plast
Surg 1960;13:79.
6. Skoog TA. technique of breast reduction: transposition of the nipple of a cutaneous vascular pedicle. Acta
Chir Scand 1953;126:453.
7. Nicolle F. Improved standards in reduction mammoplasty and mastopexy. Plast Reconstr Surg
1982;69:453.
8. Cardenas-Camarena L, Vergara R. Reduction mammaplasty with superior- lateral dermoglandular pedicle:
another alternative. Plast Reconstr Surg 2001;107:693.
9. Wise RJ. A preliminary report on a method of planning the mammaplasty. Plast Reconstr Surg
1956;17:367.

Chapter 361
Dermoparenchymal Suspension Flaps for Breast Reconstruction
After Massive Weight Loss
J. PETER RUBIN
EDITORIAL COMMENT
The described dermoparenchymal suspension flaps allow for restoration of breast volume and position with
an “internal brassiere” using tissue that would otherwise be discarded.
INDICATIONS
A dermal suspension mastopexy is indicated for severe breast ptosis with skin envelope deflation, as is
commonly seen in the massive of weight loss (MWL) patient (1, 2, 3, 4, 5, 6, 7, 8). It is especially effective in
eliminating the characteristic lateral roll of skin and fat, commonly observed in the MWL patient adjacent to
the breast. The lateral roll of fat and tissue is mobilized as a fasciocutaneous flap and used to restore the
lateral curvature of the breast while also adding additional volume. Relative contraindications include active
tobacco use, previous breast surgery, and a history of breast radiation.
ANATOMY
Dermal suspension mastopexy is based upon a central pedicle dissection of the breast. The markings are based
on an extended Wise pattern, in which the lateral aspect of the Wise pattern is extended to encompass the
lateral roll of skin and fat on the chest wall. This tissue is mobilized into the breast to establish lateral curvature
and add volume, while eliminating the lateral chest deformity. Excess skin and adipose tissue lateral and
posterior to the edge of the flap can be further excised and discarded to correct the contour.
FLAP DESIGN AND DIMENSIONS
One can note on Figure 361.1 that there is a vertical dermal extension of the Wise pattern, as is commonly seen,
and this vertical dermal extension is used to suspend the breast complex. There should be a sufficient distance
of at least 5 to 7 cm from the top of the keyhole pattern to the areola in order to get an effective suspension. In
addition to the lateral flap, a medial flap is also elevated, although this is not the real “work horse” of the
procedure. It is the lateral flap that provides volume to the breast and enables the development of the lateral
curvature of the breast. Figure 361.1 shows the markings for the operation. The lateral flap is generally 5-8 cm in
vertical height, and can extend to the posterior axillary line. This design has the ability to titrate the amount of
lateral chest wall tissue that will be mobilized into the breast reshaping. Skin can be excised beyond the lateral
margin to adjust contour.
OPERATIVE TECHNIQUE
The area shaded, as shown in Figure 361.1, is completely stripped of epidermis, taking great care to preserve
the dermis, as this will be used for both suspension and breast shaping. Figure 361.2 shows that the central
mound is degloved by elevating a flap 1 to 1.5 cm in thickness. The dissection of that flap is continued up to the
level of the clavicle to provide a generous subcutaneous space into which the breast tissue can be mobilized.
Next, as also shown in Figure 361.2, the lateral fasciocutaneous flap is elevated from the muscle fascia. As the

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perforators are approached, which originate from both the intercostal vessels and branches of the lateral thoracic
system, they are preserved. The perforators will be at the medial aspect of the flap. The flap is mobilized in such
a manner that it can be turned and rotated to reconstruct the lateral curve of the breast. The medial flap is then
elevated as well. Bear in mind that the lateral flap is the important flap for this procedure. Next, the central dermal
extension, representing the top of the keyhole pattern, is then secured to the periosteum of the second rib using
zero-braided nylon suture. This can be lowered to the third rib if the nipple position is too high. Two sutures are
placed at this point as fixation into rib periosteum to reinforce the suspension. Next, as also shown in Figure
361.3, the lateral and medial flaps are
elevated and suspended to the periosteum as well. The lateral flap should reach easily to the periosteum of the
third rib, while the medial flap has a variable placement ranging from the third to the fifth rib. Following
suspension of the central dermal edge of the keyhole, as well as the medial lateral flaps, the broad dermal
surface area is then plicated using braided 2-0 absorbable sutures. Figure 361.4 demonstrates a proposed
pattern of plication. This pattern can be highly variable and should be adjusted for each patient. The plication is
carried out medially, laterally, and inferiorly, in a manner that sets the areolar to inframammary fold (IMF)
distance at 5 cm. As the plication progresses, the breast tissue takes on a well-defined shape, as is shown in
Figure 361.5. Next, attention is paid to the lateral border of the breast, where the lateral dermal edge is secured
to deep fascia using interrupted zero-braided nylon sutures (Fig. 361.6). Four to five sutures are placed along
the lateral curvature; this reinforces the suspension and also defines the shape of the lateral curvature. Next, the
skin envelope is redraped, and the nipple position is assessed. If the nipple is pointing in an inappropriate
direction or otherwise tethered, it can be released by gently scoring the dermis adjacent to the areola with
electrocautery (Fig. 361.7). Because the nipple/areola is based on a central pedicle blood supply, this maneuver
is very safe. The incisions are then closed with monofilament absorbable suture.
FIGURE 361.1 Anterior (A) and lateral skin markings (B) showing planned areas of deepithelialization.

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FIGURE 361.2 A superior pocket is created at the level of the pectoralis fascia. The nipple-areolar complex is
preserved on a central pedicle. Medial and lateral breast flaps are elevated.
CLINICAL RESULTS
Figure 361.8 shows a patient with severe deflation of the breast envelope and a lateral roll following
massive weight loss. Her results are shown 12 months following dermal suspension mastopexy. Note that
the lateral roll has been mobilized to reinforce lateral curvature of the breast and add to the projection.
FIGURE 361.3 The central dermal extension is secured to the periosteum of the second rib. This can be
lowered to the third rib if the nipple position is too high.

FIGURE 361.4 The medial and lateral flaps are secured to the chest wall and extent of plication is planned.
FIGURE 361.5 The breast is shaped by adjusting the plication.
FIGURE 361.6 The dermis of the lateral flap is secured to the chest wall fascia.

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FIGURE 361.7 The nipple-areolar complex can be released and its position adjusted by scoring the dermis.
FIGURE 361.8 Preoperative (A) anteroposterior, (B) oblique, and (Continued)

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FIGURE 361.8 (Continued) (C) lateral views of a patient after massive weight loss showing a deflated skin
envelope, loss of breast projection, and absence of superior pole volume. Postoperative (D)
anteroposterior, (E) oblique, and (F) lateral views of the same patient 12 months after dermoparenchymal
suspension mastopexy.
SUMMARY
In summary, the dermal suspension mastopexy is a very effective technique for mobilizing lateral chest wall
tissue as a fasciocutaneous flap and converting this deformity to an aesthetically pleasing lateral curvature
of the breast. While the primary role of this lateral flap is to provide breast shaping and reinforce the lateral
curvature, it has the ability and potential to add significant volume to the breast. Alternatively, a smaller
amount of tissue can be taken from the lateral aspect based on the desired breast size.
References
1. Bossert R, Rubin JP. Mastopexy with auto-augmentation. In: Strauch B, Herman C, eds. Encyclopedia of
Aesthetic Rejuvenation through Volume Enhancement. New York: Thieme, 2014.
2. Coon D, Michaels J, Gusenoff JA, et al. Multiple procedures and staging in the massive weight loss
population. Plast Reconstr Surg 2010;125(2):691-698.
3. Rubin JP. Mastopexy in the massive weight loss patient: dermal suspension and total parenchymal

reshaping. Aesthetic Surg J 2006;26:214-222.
4. Rubin JP, Gusenoff, JA, Coon D. Dermal suspension and parenchymal reshaping mastopexy after
massive weight loss: statistical analysis with concomitant procedures from a prospective registry. Plast
Reconstr Surg 2009;123(3):782-789.
5. Rubin JP, Hurwitz DJ. Breast reshaping after massive weight loss, autologous tissue techniques. In: Rubin
JP, Jewel M, Richter D, et al., eds. Body Contouring and Liposuction. St. Louis, MO: Elsevier, 2012;122.
6. Rubin JP, Khachi G. Mastopexy in the massive weight loss patient. Clin Plast Surg 2008;35:123-129.
7. Rubin JP, Michaels J. Mastopexy after massive weight loss. In: Strauch B, Herman C, eds. Encyclopedia
of Body Sculpting in the Massive Weight Loss Patient. New York: Thieme, 2011.
8. Rubin JP, O'Toole J, Agha S. Breast surgery after weight loss. In: Rubin JP, Matarasso AM, eds. Aesthetic
Surgery after Massive Weight Loss.. London: Elsevier, 2006.

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Chapter 362
Medial Pedicle Flap for Breast-Reduction Surgery
E. J. HALL-FINDLAY
Breast surgical techniques have focused on altering the size and shape of the breast while preserving and
mobilizing the nipple-areolar complex. Various flaps (or pedicles) have been designed to preserve circulation to
the nipple and areola. These flaps should also preserve sensation and breast-feeding potential when possible.
The medial flap for the nipple and areola provides versatility, when contemplating breast reduction or mastopexy
procedures.
INDICATIONS
The flap was originally described and used by both Strombeck (1) and Skoog (2). Strombeck initially
described the flap as part of a horizontal bipedicle flap, but he would often use it alone in breast surgery.
Skoog would use either the lateral or medial pedicle, and the description in this chapter follows his design
for orientation in breast-reduction surgery. Asplund and Davies (3) used a similar flap, but they used a
dermal flap, rather than a dermal-glandular flap.
ANATOMY
Both dermal and dermoglandular flaps have a good blood supply. As pointed out by Reid and Taylor (4), the
blood supply to the breast is superficial.
Arterial
The main arterial input is from the internal thoracic (mammary) system. The superficial branch of the lateral
thoracic artery supplies a lateral pedicle. The thoracoacromial system is relatively unimportant.
The second or third intercostal branch of the internal mammary artery passes laterally (supplying a deltopectoral
flap), and a strong descending branch supplies a superior pedicle. The intercostal branches come out from
under the lateral border of the sternum, quickly penetrate the breast tissue, and become superficial. The branch
that supplies a superior pedicle passes just medial to the breast meridian, and about 1 cm deep to the skin
surface as it approaches the areola.
The medial pedicle is supplied by the third or fourth intercostal branches of the internal mammary artery. These
branches appear above the pectoralis muscle, just lateral to the sternal border. They immediately enter the
breast parenchyma and become superficial. A medial pedicle can be thinned, as long as the deep tissue close to
the sternal border is preserved. Because these vessels are sometimes damaged in breast-augmentation
procedures, a medial pedicle may not be a good choice in a subsequent mastopexy procedure. In those cases, a
superior pedicle is more likely to still have an intact arterial supply.
The fourth or fifth branches of the internal mammary artery actually run beneath the pectoralis muscle and
perforate the muscle just medial to the breast meridian, about 4 to 6 cm above the inframammary fold. This artery
supplies an inferior or central pedicle. It is the only artery that is accompanied by venae comitantes.

FIGURE 362.1 Venous supply. The veins are clearly seen just beneath the dermis. It is important to try to include
a vein in the base of the pedicle. This is best seen on the left breast.
Venous
Taylor has pointed out that the veins do not accompany the arteries, except for the perforator, which supplies an
inferior pedicle. The veins can often be easily seen just beneath the dermis. They should be noted, and an
attempt should be made to include at least one vein in the base of the pedicle (Fig. 362.1). Because the veins
are superficial, it is not a good idea to infiltrate the incisions for hemostasis, because these veins can be
damaged.
Innervation
It is commonly accepted that the lateral branch of the fourth intercostal nerve supplies sensation to the nipple.
Experience with the medial pedicle shows that this nerve is not exclusive. Schlenz et al. (5) showed that both
medial and superior nerves also supply the breast.
The lateral fourth intercostal nerve has both a superficial and a deep branch. The deep branch passes just
above the pectoralis fascia and then turns immediately upward into the breast parenchyma at the level of the
breast meridian. A full-thickness medial pedicle should be able to preserve this deep branch. An analysis of the
author's patients has shown that the superior, lateral, and medial pedicles all have equivalent sensation.
FLAP DESIGN AND DIMENSIONS
The medial pedicle is often described as “superomedial” because it does seem to take that direction when the
patient is standing. However, the pedicle is technically completely “medial,” because the blood supply comes
from a medial direction. This is more obvious when the patient is lying down. When a patient stands, the breast
sags, but so do the blood vessels.
Designing the base of the pedicle, as Skoog did, with half the base in the areolar opening and half the base in
the vertical aspect of the skin-resection pattern, makes the pedicle easy to rotate into position. The dermis can
be left attached superiorly, to include either arterial input or venous drainage. In this situation, the deep tissue
will have to be resected superiorly, to allow easy inset, but this will not damage the superficial blood supply.
A centimeter cuff of dermis is left around the areola in the pedicle for safety. This is called the Schwartzmann (6)
maneuver and is helpful because the pedicle often appears to be undermined, even when it is carefully created
as a full-thickness pedicle.
There is no scientific basis for knowing how wide to create the base of the pedicle. It should be wide enough that

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it is likely to include at least one of the medial intercostal branches of the internal mammary artery. In a small
breast reduction, the base may be only 6 to 8 cm, and in larger reductions, the base may be 8 to 10 cm.
No definite numbers are known as to how long a medial pedicle can be for viability. Theoretically, the blood
vessels stretch as the pedicle itself stretches with enlargement and sagging of the breast. Conversely, a very
long pedicle will be bulky, and the weight of an overlying large medial pedicle can lead to bottoming out. The
author warns those patients who have long pedicles that a decision will be made intraoperatively as to whether it
would be wise to convert to free nipple grafts.
OPERATIVE TECHNIQUE
A medial flap for the nipple areolar complex can be used with various skin-resection patterns. The medial flap is
based on the keyhole pattern, so it is equally applicable to vertical and inverted-T techniques.
Although the inferior pedicle became the standard after the introduction of the vertical bipedicle approach to
breast reduction by Paul McKissock, using the inferior pedicle means that the heavy inferior breast tissue is left
behind. The medial pedicle allows complete removal of the inferior excess, and the breast tissue that remains is
left attached to the superior, superomedial, and superolateral skin. The author believes that this will lead to fewer
cases of bottoming out.
The pedicle is deepithelialized (Fig. 362.2A) and then created as a full-thickness flap, by using either the scalpel
or cutting cautery (Fig. 362.2B and C). It will be noticed during the dissection that most of the bleeding will be
superficial.
The excess parenchyma is removed en bloc (Fig. 362.2D), and the perforator to the inferior pedicle will be
encountered. If tumescent-type infiltration is used in the base of the breast, the surgeon must carefully seek out
this artery and its venae comitantes to prevent later bleeding and the development of a hematoma. A lateral pillar
of approximately 2 cm of thickness should be left [following the Wise pattern (Fig. 362.2F) attached to the lateral
skin flap]. Excess breast tissue parallel to the chest wall can be removed from under the flap by beveling out
laterally. Some tissue is beveled out medially, as well, just above the inframammary fold. This direct excision can
be followed by liposuction peripherally for final tailoring.
The pillars are brought together and sutured. It is important not to place too much tension on the pillar closure.
Sutures should be placed in the fibrous tissue on either side only sufficiently to approximate the pillars so that
they can heal together.

FIGURE 362.2 Operative technique. A: The medial pedicle is deepithelialized. The hemostat is pointing to a vein
preserved just below the dermis. B: The medial pedicle is created as a full-thickness flap. C: The medial pedicle
is being lifted to show that it appears to be undermined (much as an inferior pedicle), even though it was created
by incising straight down to the chest wall. The pedicle is of full thickness down to the breast meridian. D: The
breast tissue is excised en bloc, and most tissue is removed laterally and inferiorly. Care is taken to stay above
the pectoralis fascia. E: The cross-hatched lines show where liposuction is performed in the lateral chest wall
and preaxillary areas. Note also that the breast tissue that is left behind corresponds to a Wise pattern.
(continued)

FIGURE 362.2 (Continued) F: The deep dermis is closed. G: Final result. The vertical closure is not gathered.
The pucker at the lower end will tuck in as the breast settles.
The dermis is then closed with deep dermal sutures. At this point, liposuction (Fig. 362.2E) is performed to tailor
the shape of the breast, to leave the tissue behind that resembles a Wise pattern (Fig. 362.2F). Liposuction is
also performed for the excess tissue that is often present in the lateral chest wall and the preaxillary areas.
At this stage, it must be determined whether there is sufficient excess skin that needs to be removed in an
inverted T pattern. This will be more likely in patients with extremely large breasts or in patients with poor skin
elasticity. Adding a T is not required as often as surgeons think when they are first learning the vertical
approach. Conversely, if it becomes evident that the skin will not redrape, it may be necessary to excise the
excess.
The skin is then closed (Fig. 362.2G). Drains and dressing are used, as preferred by the surgeon. The author
rarely uses drains. The incisions are covered by paper tape, and a surgical brassiere is applied, not for
compression, but to hold the bandages in place. Patients are encouraged to shower the next day.
CLINICAL RESULTS
Many choices exist for flaps to carry the nipple-areolar complex. The medial pedicle has excellent blood
supply and surprisingly good innervation. It is ideal for breast reduction, because it allows easy access to
the lateral breast tissue where much of the excess lies (7, 8, 9).
Nipple and areolar necrosis can occur with any of the flaps. It is important to include both arterial input and
venous drainage, if at all possible. Unfortunately, Doppler examination is not particularly useful, and
surgeons must rely on the fact that the blood supply is usually fairly reliable. Four main pedicles and four
main blood-supply patterns are found. As often occurs, some variability is seen from one person to another,
and often only three of the main blood supplies may be dominant, with the fourth being absent. Nipple
necrosis may be based more on anatomic variation, rather than on surgeon error.
SUMMARY
The author believes that the medial flap allows the surgeon to resect (in a breast reduction) or rearrange
(as in a mastopexy) parenchyma, as desired. The medial pedicle can be used with various skin-resection
patterns and is not exclusive to vertical approaches. The pedicle also allows the surgeon to remove the
heavy inferior breast tissue and to leave behind the more superior breast tissue. An understanding of the

P.976
blood supply is essential in designing and creating the medial flap for breast surgery.
FIGURE 362.3 Results in the same patient as shown in Figures 362.1 and 362.2. A: Preoperative frontal
view. B: Preoperative lateral view; 275 g was removed from the right breast and 325 g from the left breast;
400 cc of fat was removed with liposuction. C: Frontal view at 2.5 months. D: Lateral view at 2.5 months.
References
1. Strombeck JO. Mammaplasty: report of a new technique based on the two-pedicle procedure. Br J Plast
Surg 1960;13:79.
2. Skoog T. A technique of breast reduction: transposition of the nipple on a cutaneous vascular pedicle.
Acta Chir Scand 1963;126:453.
3. Asplund O, Davies DM. Vertical scar breast reduction with medial flap or glandular transposition of the
nipple-areola. Br J Plast Surg 1996;49:507.

4. Reid CR, Taylor GI. The vascular territory of the acromiothoracic axis. Br J Plast Surg 1984;37:194.
5. Schlenz I, Kuzbari R, Gruber H, Holle J. The sensitivity of the nipple-areola complex: an anatomic study.
Plast Reconstr Surg 2000;105:905.
6. Schwartzmann E. Beitrag zur Vermeidung von Mammillennekrose beieinzeitiger Mammaplastik schwerer
Fälle. (Avoidance of nipple necrosis by preservation of corium in one-stage plastic surgery of the breast.)
Rev Chir Struct 1937;7:206.
7. Hall-Findlay EJ. A simplified vertical reduction mammaplasty: shortening the learning curve. Plast Reconstr
Surg 1999;104:748.
8. Hall-Findlay EJ. Vertical breast reduction with a medially based pedicle: operative strategies. Aesthet Surg
J 2002;22:185.
9. Hall-Findlay EJ. Pedicles in vertical reduction and mastopexy. Clin Plast Surg 2002;20:379.

Chapter 363
Sliding Skin Flap From The Abdomen
J. R. LEWIS JR.
EDITORIAL COMMENT
This is one of the first attempts at using excess skin from the upper abdomen and creating an inframammary
fold by suturing the subcutaneous tissue to the chest wall. Since then there have been modifications, such
as those made by Ryan (3, 4) and by Pennisi (2).
The sliding flap from the abdomen is a method of transferring tissue from the abdomen, where tissue is plentiful,
to the chest when tissue there is insufficient, scarred, and/or damaged (1, 2, 3, 4).
INDICATIONS
I have used this method successfully since 1955 for replacing scar tissue of the anterior chest and for
replacing tissue following mastectomy (see Fig. 363.3) (1, 5, 6, 7, 8). An implant is often utilized in
conjunction with this flap.
ANATOMY
The abdominal sliding flap is a widely based, thick flap of skin and fat that depends on a broad blood supply, not
on a single vessel or even a few discrete vessels. There are two intricate networks of arteries that supply the
anterior abdominal wall.
The deep network of vessels runs deep to the rectus muscle and consists of the deep superior and inferior
epigastric arteries (Fig. 363.1). The superficial network includes both the intercostal and lumbar arteries, as well
as the superficial inferior epigastric, superficial circumflex iliac, and superficial external pudendal vessels (Fig.
363.2).
There are numerous anastomoses between the deep and superficial systems by means of the perforators. There
are a considerable number of cross-anastomoses within and between each system. The anastomoses
connecting all levels are particularly rich about the umbilicus.
Obviously, when an incision is made across the upper abdomen to slide the whole width of the abdominal skin
upward onto the chest wall, it is necessary to sever most of the upper perforators (see Fig. 363.3C). However, it
is possible to stretch these perforators up at the umbilical level and below this level to preserve more circulation
into the flap.
In breast reconstruction, an incision across the upper abdomen is generally not required unless a bilateral
reconstruction is planned. In such a case, the circulation into the flap is quite adequate, because of the
superficial network in the thick skin-fat flap, which is further supplied by the ascending superficial vessels and
deep vessels of the previously described circulation.
Nerve supply in the flap generally is adequate in the lower portion and most frequently will recover to a great
extent, even in the upper portion of the flap, except when the flap is thin and pulled more tightly than is usual.

P.978
FLAP DESIGN AND DIMENSIONS
The flap may be based inferiorly at a level that allows the tissue to be brought upward onto the chest wall
according to the need. The degree of undermining inferiorly depends on the quality and mobility of the skin and
subcutaneous tissue and on the degree of shift required for the chest-wall defect.
An upper abdominoplasty, with tightening of the whole abdominal skin, will require a degree of undermining well
below the umbilicus level, while most sliding flaps, simply to furnish soft tissue to the chest wall, require
undermining only down to the level of the umbilicus or slightly below (Fig. 363.3).
OPERATIVE TECHNIQUE
The sliding abdominal flap is undermined in the deep subcutaneous plane by a sliding motion using curved,
blunt-tipped scissors. The incision of access for undermining is generally by resection of a scar on the chest wall
present from injury or surgery (see Fig. 363.3A). If scars are present only high on the chest wall, it is better to
make the incision along the estimated submammary fold line. This makes both undermining and hemostasis
easier to achieve.
FIGURE 363.1 Superficial abdominal wall circulation. About the umbilicus is the paraumbilical network of
vessels, with communications between the right and left sides and between the superficial and deep vessels.
If relaxation is not adequate, further undermining and stretching upward of the perforating vessels are carried out
to allow the flap to be moved upward onto the chest. There it is secured by deep buried sutures between the flap
and the deep fascia of the chest wall in a semicircular manner to emulate the submammary fold.

P.979
FIGURE 363.2 Deep circulation of abdominal wall. Although shown here with only their major branches, there
are numerous branches that pass across the midline to the opposite vessels in the deep plane and perforating
branches that pass through the rectus muscle and sheath anteriorly into the subcutaneous tissue to
communicate with the superficial vessels. There are further communications with branches of the intercostal and
lumbar vessels and a rich network about the umbilicus.
Obviously, some superior undermining is generally required to give a contour simulating the opposite breast.
After the implant is inserted and the wound is closed, a light pressure dressing is applied across the lower chest
to help maintain the flap upward onto the chest wall and to decrease the tension, but excessive pressure may
endanger the venous return from the flap.
CLINICAL RESULTS
Complications from the abdominal sliding flap have been rare. A few patients have had some degree of
loosening of the support in the submammary fold area, so that the implant tended to slide downward
beneath the flap. These patients were corrected quite easily by secondary suture support through a small
incision securing the flap to the fascia of the chest wall.
The patient is temporarily aware of some increased tightness on one side or the other, depending on
unilateral or bilateral use of the flap. Unilateral advancement is more frequent, but undermining is carried
out across the midline to allow a smoother upward movement without kinking the skin.
The only other problem that has occurred is the general one of tightening about the breast implant. To my
surprise, the degree of tightening about the breast implant with breast reconstruction has been less than
that which follows subcutaneous mastectomy. Such tightening is more frequent than that following simple
augmentation mammaplasty, but it has been a relatively infrequent occurrence, especially to a degree that
has required secondary surgery.

FIGURE 363.3 A: Outline of undermining in the subcutaneous plane of the abdomen to slide the abdominal
flap of skin and fat upward onto the chest for unilateral reconstruction of the breast. The flap slides upward
onto the chest wall and is secured along the proposed submammary crease. B: Undermining bilaterally for
bilateral breast reconstructions. Undermining is generally through two separate scars of the chest wall, one
on each side following bilateral mastectomies. However, the undermining here is shown above the line of
the scar (as in part A), because some undermining beneath the flap superiorly is carried out as well for the
breast pocket. Undermining inferiorly is generally carried out to the level of the umbilicus or slightly below,
leaving the umbilicus in position. C: An incision across the upper abdomen allows for more free sliding of
the abdominal skin upward onto the chest wall. This also accomplishes an abdominoplasty. An incision
about the umbilicus allows pulling of the abdominal skin upward and reinsertion of the umbilicus into a new
opening at a lower level of skin while closing the skin defect as a vertical incision in the midline.
Patients have generally been quite happy with breast reconstruction by this method. Patients with burns of
the chest and breast have been pleased with the relaxation of the tight burned skin and the degree of
breast reconstruction required.
SUMMARY
I feel that this is the simplest method of breast reconstruction of all those I have tried and that the great
majority of patients with radical or modified radical mastectomies can be corrected primarily or secondarily
without more extensive surgery.
References
1. Lewis JR Jr. Use of a sliding flap from the abdomen to provide cover in breast reconstruction. Plast
Reconstr Surg 1979;64:4.
2. Pennisi VR. Making a definite inframammary fold under a reconstructed breast. Plast Reconstr Surg
1977;60:523.
3. Ryan H. A lower thoracic advancement flap in breast reconstruction after mastectomy. Plast Reconstr
Surg 1982;70:153.

4. Ryan JJ. The lower advancement technique in breast reconstruction. Clin Plast Surg 1984;11:277.
5. Lewis JR Jr. Reconstruction of the breast. Proceedings of International College of Surgeons, Vienna,
1964.
6. Lewis JR Jr. Reconstruction of the breast. Surg Clin North Am 1971;51:429.
7. Lewis JR Jr. Presentation and discussion of problem cases in breast surgery. In: Goldwyn RM, ed. Plastic
and reconstructive surgery of the breast. Boston: Little, Brown, 1976;431-440.
8. Lewis JR Jr. Reconstruction of the breasts. In: Lewis JR Jr., ed. The art of aesthetic plastic surgery,
Boston: Little, Brown, 1989;941.

Chapter 364
Transverse Thoracoepigastric Skin Flap
T. D. CRONIN
E. D. CRONIN
EDITORIAL COMMENT
There is a shortage of skin at the site of the mastectomy. To provide additional skin, the thoracoepigastric
flap would have to extend beyond the posterior axillary line, thus making it more risky and requiring delay,
as indicated by the authors.
The transverse thoracoepigastric flap may be the procedure of choice in certain patients in whom additional skin
is needed for breast reconstruction after mastectomy. This might be the case where, for some reason, a
transverse rectus abdominis myocutaneous flap or a latissimus dorsi myocutaneous flap was unsuitable. This
flap is of particular value when the mastectomy scar is oblique or vertical and when the skin flaps are tight but
not excessively thin and adherent to the chest wall (Fig. 364.1).
INDICATIONS
The thoracoepigastric flap has the advantages of technical ease, a local donor area, and the possibility of
closing the donor wound primarily after wide undermining inferiorly. The flap is usually quite thick, and the
scar is usually covered by a bra. The flap can be raised and transposed in one stage if it is not extended
past the midaxillary line (Fig. 364.2). When a modified radical mastectomy has been done, the presence of
the pectoralis major muscle permits subpectoral implantation, with the thoracoepigastric flap supplying
additional skin and permitting better projection.
When the mastectomy scar extends below the inframammary crease, it may indicate that the perforating
branches of the superior epigastric vessels have been taken, and therefore, another method should be
used. If a long flap is required, delay procedures may be necessary.
There are certain disadvantages to the flap. It does not correct the absent anterior axillary fold in a radical
mastectomy (Fig. 364.2), and it usually does not completely correct the infraclavicular hollow, even with
deepithelialization and burying of the tip of a long delayed flap in the infraclavicular area. Sometimes a later
procedure is required to cut across the pedicle of the flap to establish a better inframammary fold.
Although a fairly large thoracoepigastric flap may be raised and inset, it cannot supply additional thickness
to the thin skin flaps on each side of the flap, as can be done when the latissimus dorsi muscle is used.
ANATOMY
The transverse thoracoepigastric flap has an axial blood supply by means of the lateral branch of the superior
epigastric artery (1, 2). The extent of the axial territory, however, is controversial. If the flap includes skin up to
the midaxillary line, the portion between the anterior and midaxillary lines may have a random-pattern blood
supply (3). This flap is also supplied by several intercostal muscular perforators.
FLAP DESIGN AND DIMENSIONS

P.981
With the patient in a sitting position, a piece of cloth 8 × 10 cm is placed with its upper edge at the inframammary
crease and its medial end at the lateral border of the rectus abdominis, which will serve as the base or pivoting
area. The lateral end of the cloth is swung up along the scar as far as needed. It is then swung back to the
horizontal position, and the flap is marked. If the length ends at the midaxillary line, the flap can be moved in one
stage, since this is an arterialized flap (1, 4, 5). Flaps beyond this have a random blood supply and require
delaying procedures (6, 7).
OPERATIVE TECHNIQUE
With the patient half turned to her opposite side and the table flat or slightly extended at its middle, the flap is
raised, beginning laterally, deep to the fascia (7, 8). The more proximal portion of the flap overlies the serratus
anterior. The medial extent of the elevation is to the lateral edge of the rectus abdominis, where several
intercostal muscular perforators are found and must be preserved.
FIGURE 364.1 A: Out to the midaxillary line, the thoracoepigastric flap is arterialized by perforators from the
superior epigastric artery. Longer flaps need to be delayed. The donor site is closed primarily after undermining
inferiorly toward the iliac crest. B: The flap is elevated deep to the fascia and transposed after opening the old
scar. It is most suitable when the mastectomy scar is oblique or vertical. Although many of our patients had
subcutaneous placement of the implant, we would prefer the submuscular position. Access to the submuscular
pocket is either by incision along the fibers of the pectoralis major or its lateral edge. Alternatively, the incision is

P.982
made through the serratus anterior at the seventh rib with dissection upward. C: An implant is then placed in the
subpectoral subserratus space and the muscle incision is closed. D: The flap is then sutured in place. E: When
the flap extends beyond the midaxillary line, it must be delayed. The initial delay consists of incising and
undermining the flap but leaving the central bridge undisturbed. F: The second delay consists of incising and
undermining the central bridge only. Finally, 1 or 2 weeks later, the entire flap is raised, transposed, and inset,
with or without placement of the prosthesis at that time. (From Cronin, ref. 7, with permission.)
For closure of the donor site, the table is flexed with the table back raised somewhat. Wide undermining of the
lower edge, even to the crest of the ilium, may be necessary (8). The patient is then turned on her back.
If there is any question about the viability of the flap, fluorescein is used to test the adequacy of the circulation.
Most areas of mottled yellow-blue will survive (5).
Subcutaneous Implantation
If a radical mastectomy has been done, or if the prosthesis will be placed on top of the pectoralis major muscle,
the scar is excised. The skin flaps are carefully dissected off the pectoralis major muscle or ribs and intercostal
muscles to the sternal
border medially, the midaxillary line laterally, almost to the clavicle superiorly, and to the proposed inframammary
fold inferiorly.
FIGURE 364.2 A,B: A 44-year-old woman 9 years after right radical mastectomy. The patient has circumferential

P.983
tightness, necessitating additional tissue. Note that the mastectomy scar extends below the inframammary
crease, and therefore, the flap base will be more caudal than would be ideal. C,D: The 10 × 24 cm
thoracoepigastric flap was delayed in two procedures and transferred as a third procedure. At a fourth
procedure, a 235-cc low-profile round gel implant was inserted subcutaneously. E,F: The nipple-areola was
reconstructed with full-thickness inner thigh skin for the areola and full-thickness labium minus for the nipple.
Two months later, conchal cartilage was used to obtain more nipple projection.
The thoracoepigastric flap is then sutured into place, except for one area large enough to insert the implant. If
the circulation of the flap is at all questionable, however, insertion of the prosthesis is delayed for a few days or
weeks.
Subpectoral Implantation
If the pectoralis major muscle is present, we usually prefer to place the prosthesis submuscularly for additional
cover. The mastectomy scar is excised, but the skin edges need not be undermined as widely as previously
described. The submuscular plane may be reached by incising the serratus anterior muscle at the level of the
seventh rib and then dissecting superiorly to lift the serratus and pectoralis major muscles off the ribs and
intercostal muscles.
The pectoralis major muscle is separated from the minor muscle, leaving the latter attached to the ribs laterally.
To relax the pectoralis major muscle further, its attachment to the sternum is released from 3 o'clock to 7 o'clock
on the right side.
An alternate subpectoral method is to split through the fibers of the pectoralis major muscle. A large space is
easily separated superiorly, while below, the origin of the pectoralis major muscle and serratus anterior muscle is
separated down to the sixth rib. The pectoralis major muscle is also separated from the sternum from 3 o'clock to
7 o'clock on the right side.
This is followed by placement of a prosthesis of appropriate size in the cavity: Most often we use a textured
saline implant; either round or teardrop shaped.
CLINICAL RESULTS
The most important and serious complication relates to the blood supply of the flap. Out of a total of 40
flaps, there was some circulatory problem with 14. Of these, 5 showed only superficial impairment, as
indicated by irregular partial small losses of skin. Observation for several weeks permitted recovery and full
use of the flap.
On the other hand, full-thickness losses have occurred in nine patients and have required debridement. It
was possible to salvage five such flaps by advancement of the flap near its base. If the thoracoepigastric
flap overlies the pectoralis major muscle, a split-thickness skin graft can be applied directly to the muscle
after the debridement with satisfactory results. When these methods are unsuccessful, recourse to another
method may be tried, such as a free flap.
What can be done to minimize disasters? First, if the scar of the mastectomy, by its location, strongly
suggests that the superior epigastric perforating circulation has been destroyed, it would be advisable to
use another method. If the flap extends beyond the midaxillary line, delaying procedures are indicated. Even
with multiple delays, long flaps tend to be unreliable.
Other complications include malposition of the implant. It may be too low or too high and thus require
reoperation to enlarge the pocket and adjust the position as necessary. The same applies to fibrous

contracture around the implant. Rarely, extrusion of the implant may occur secondary to contracture and
thinning of the tissues, as noted in one patient 5 years later.
A nipple placed at the time of transposition and implantation is likely to be disastrously out of place, since
the contour of the breast changes with healing. Hence, delay placement of the nipple for 2 to 3 months.
There is no satisfactory way to change the position of a misplaced nipple.
SUMMARY
The thoracoepigastric flap is a useful method of supplying additional cover for breast reconstruction,
especially when the mastectomy scar is vertical or oblique. It is best used after a modified radical
mastectomy when the pectoralis major muscle remains.
References
1. Bohmert H. Personal method for reconstruction of the female breast following radical mastectomy. In:
Marchac D, Hueston J, eds. Transactions of the Sixth International Congress of Plastic and Reconstructive
Surgery. Paris: Masson, 1976;542.
2. Bohmert H. Personal communication, 1979.
3. Davis AM, McCraw JB, Carraway JH. Use of a direct transverse thoracoabdominal flap to close difficult
wounds of the thorax and upper extremity. Plast Reconstr Surg 1977;60:526.
4. Becker D, McCraw JB, Horton C. Immediate and delayed use of the thoracoepigastric flap for
reconstruction of the total mastectomy defect. Presented at the annual meeting of the American Society for
Aesthetic Plastic Surgery, Atlanta, Georgia, 1976.
5. McCraw JB, Myers B, Shanklin K. The value of fluorescein in predicting the viability of arterialized flaps.
Plast Reconstr Surg 1977;60:710.
6. Cronin TD, Upton J, McDonough JM. Reconstruction of the breast after mastectomy. Plast Reconstr Surg
1977;59:1.
7. Cronin TD, Cronin ED. The thoracoepigastric flap in breast reconstruction. In: Gant T, Vasconez L, eds.
Post-mastectomy reconstruction. Baltimore: Williams & Wilkins, 1980;238.
8. Tai Y, Hasegawa H. A transverse abdominal flap for reconstruction after radical operations for recurrent
breast cancer. Plast Reconstr Surg 1974; 53:52.

Chapter 365
Composite Cone Flap
A. J. J. EMMETT
EDITORIAL COMMENT
More important than concentrating on the location of the nipple are the author's efforts to cone the breast.
This is accomplished by partly folding the flap in a U-shape.
This is a lateral thoracic flap based on a pedicle of deep fascia and muscle with a variable-width cutaneous
pedicle. It is taken from the side of the chest, brought around to the front, and shortened, turning the flap on itself
to produce a skin cone (1, 2). The deeper muscular tethering laterally facilitates this deliberate shortening and
coning.
The design of the flap is such that the cone produces good breast projection and the tip of the cone lies at a site
comparable to the opposite nipple-areola complex.
INDICATIONS
I have selected this flap particularly for use in the patient who has a larger opposite breast that she wishes
to have matched and is anxious not to have reduced.
ANATOMY
The deeper muscular pedicle is designed according to the muscles that are present (Fig. 365.1A). It commonly
involves the pectoralis major, external oblique, and serratus anterior muscles. Where these muscles are
considered to be deficient or there has been heavy irradiation of the area, the anterior half of latissimus dorsi
may be hinged with the flap (Fig. 365.1B). I usually take the deep fascia of the latissimus dorsi with the fat flap
anyway and, if necessary, can hinge forward the anterior half of the muscle as a secondary muscular pedicle (3).
FIGURE 365.1 A: The muscular pedicles on which the flap is based are shown. Where possible, serratus
anterior, external oblique, and pectoralis major muscles are used (B). The dissection is deep to the muscle
pedicle or in the muscle. Where these muscles are deficient from surgery or irradiation, I add in the anterior half
of latis-simus dorsi (A), hinged from the axilia with its nerve and blood supply. B: When the latissimus dorsi is

used, it is left attached to the distal half of the flap. Deep fascia and the other three muscles are used also in the
proximal half of the pedicle. When fibrotic, these latter muscles need more division for the flap to turn adequately.
FLAP DESIGN AND DIMENSIONS
The flap is designed so that the tip of the cone lies at the same level as the opposite nipple-areola complex. As
the flap is folded on itself, the surgeon attempts to emphasize the coning. The deeper muscular pedicle shortens
the flap on its long axis as it is transposed. By turning the flap on itself, I am able to convert the stress lines in the
skin to more of the semicircular pattern of the normal breast, a practice that gives better projection.
Marking the flap preoperatively is important. This is done with the patient in the sitting position (Fig. 365.2A and
B), so that the vertical line of the nipple position is marked on each side. The horizontal level of the nipple and
the submammary fold are also marked.
FIGURE 365.2 A: The nipple level is marked in vertical and horizontal planes with the patient sitting upright and
arms hanging freely by the sides. The submammary fold level and midline are noted. B: The flap is marked on
the side of the chest. The tip of flap Y is intended to move to position Y on the anterior chest scar when it is
excised and opened out. As the flap shortens, points X on the flap come together to form a prominent cone, as in
part C. Flap M is mobilized and is advanced into the angle, and the tension along this line further emphasizes the
breast coning, making what will later be the lateral fold of the breast. C: The flap is shortened and the cone is
produced. Both donor site and flap are closed. (Figs. 365.1 and 365.2 from Emmett, ref. 2, with permission.)
The flap is then drawn around the side of the chest so that the closure will fit the scar line into the line of the
brassiere strap. The flap is taken as long and as wide as is reasonable for the patient's size and looseness of
chest tissue (Fig. 365.2B). The flap is intended to turn through 60 to 80 degrees to fit into the line of the
preexisting scar, whether that be horizontal, vertical, or oblique. In Figure 365.2B, the oblique scar needs only a
60-degree shift. The tip of flap Y is intended to fit into the scar when opened. Points X in Figure 365.2B come
together at point X in Figure 365.2C as the flap shortens. The secondary triangular flap M advances as far as
necessary into the angle left by turning the flap to assist in closure of the donor site.
OPERATIVE TECHNIQUE
The incision along the flap margins is taken down through the deep fascia into and through muscle, depending
on which muscle is to be moved along with the flap. The muscle pedicle of serratus anterior, external oblique,
and pectoralis major is dissected, stretched, and divided as much as is necessary to move the flap into a position
that will balance the cone of the flap with the nipple prominence of the opposite side. Dissection is deep to the
muscle, which moves with the flap.
The original mastectomy scar is then excised and opened out down to muscle, mobilizing flap M, which opens
out the chest wound to receive the cone flap.

The implant is put in at a second stage. A larger breast can be produced using a two-stage procedure. This is an
advantage for the patient with a large breast who wishes to retain the normal side unaltered. The use of a two-
stage procedure also gives a greater advancement of skin, since the adjacent skin is mobilized in the secondary
procedure. In addition, a thicker cone of tissue is kept in front of the implant from the first stage.
The second stage of the repair is carried out 6 months later, when the implant is inserted beneath the available
skin and muscle to build the contour to that of the opposite side (Figs. 365.3 and 365.4). Usually a standard gel-
or saline-filled implant is used, but I have used a composite implant with a thicker silicone upper part to replace
the pectoral muscle contour in four patients (Fig. 365.5).
CLINICAL RESULTS
In a series of 35 breast reconstructions, the composite cone technique was used in 17 patients. Patients
who have had a satisfactory cone prominence established by this method have usually not asked for a
separate nipple reconstruction. In 4 patients, the cone prominence was sitting laterally and too high. This
was adjusted with a small transposed flap (Fig. 365.5D).
SUMMARY
A chest-wall flap consisting of skin and muscle is used to create a cone shape for postmastectomy
reconstruction.

FIGURE 365.3 A: Transverse chest scar following mastectomy with preservation of pectoralis major and no
irradiation. B: Composite cone flap turned through 150 degrees. Donor site has been closed and the flap
inset with a layer of buried sutures. C: The healed composite cone flap. D: The breast contour filled out
with a 400-cc round gel implant placed behind pectoralis major. The breast remained soft 18 months
postoperatively. E: The cone prominence matches the nipple projection, and the patient asked for no
further nipple repair.

FIGURE 365.4 A: Oblique mastectomy scar. B: Flap has been turned on itself and inset to the line of the
chest-wall scar. Lateral donor site is closed. Lateral flap tip did not reach the angle and will be trimmed and
inset. The cone prominence can be seen. C: Flap filled out with implant. Level of cone matched nipple
prominence. Note lateral breast fold along line of the secondary triangular flap.
FIGURE 365.5 A: Vertical mastectomy scar with absence of pectoralis major. B: Cone flap has been turned
90 degrees to create the excess skin that will later project with an implant at the second stage. Some lateral
muscle tethering is holding it. The secondary triangular flap is inset to the angle of the turn of the cone flap.
C: Breast cone is a little high and lateral. The implant used had an extension to fill out pectoral contour and
was 400 cc in volume. D: Cone prominence has been turned medially and down to correct its position as a
secondary transposed flap. I have done this in four patients in whom the cone did not loosen down in the 6
months after inserting the implant.
References
1. Emmett AJJ. The dog-ear flap for reconstruction of the breast cone following mastectomy. Aus NZ J Surg
1979;49:526.

2. Emmett AJJ. Composite cone breast reconstruction: two-stage repair after mastectomy. Br J Plast Surg
1981;34:272.
3. McCraw JB, Bostwick J, Horton CE. Methods of soft-tissue coverage for the mastectomy defect. Clin Plast
Surg 1979;6:1.

Chapter 366
Lateral Abdominal Skin Flap
J. M. DREVER
The lateral abdominal skin flap was designed primarily for breast reconstruction (1). It is raised mainly from an
area of loose skin. The flap has both a good vascular supply and good sensation.
INDICATIONS
I have used this flap only for breast reconstruction. It is particularly useful when there is considerable
redundancy of tissue around the midabdominal area. It must be noted that a considerable amount of skin
and subcutaneous fat can be transferred with this type of reconstruction, and therefore, the use of silicone
implants can be avoided. Use of this flap will leave the patient with an obvious diagonal scar across the
abdomen, but the new breast mound, without implants or functional disabilities, usually outweighs this
disadvantage (2).
ANATOMY
This is an arterial flap (axial pattern) that carries direct cutaneous arteries (3). These are the lateral cutaneous
branches of the posterior intercostal and subcostal arteries, accompanied by venae comitantes and the
corresponding cutaneous nerves. Coming from the axillary region, the flap also receives the superficial thoracic
and long thoracic arteries, and it is drained by the thoracoepigastric vein (4). This good vascularity enables one
to lift and transpose the flap without a delay procedure.
FLAP DESIGN AND DIMENSIONS
The design of the flap is a spearhead shape. It must have a wide base from the midclavicular to the posterior
axillary line at a height just above the costal margin. Its medial edge goes toward the umbilicus and then straight
down the midline. The lateral edge is placed according to the width of the breast to be reconstructed, usually 20
to 25 cm from its base then tapering downward until it meets the medial edge of the pubis.
OPERATIVE TECHNIQUE
First Stage
The flap is lifted quite easily from the external oblique, but it is slightly more adherent to the rectus abdominis
fascia. The lower end is deepithelialized and tapered to what will form the uppermost part of the new mound.
This area is tucked under an undermined upper edge of the thoracic incision. It is a horseshoe design, and
trapdoor skin is used to line part of the undersurface of the rotated abdominal flap. This arc of rotation has about
100 degrees (Fig. 366.1B-D).
Closure of the abdominal defect is like a “lipectomy done sideways.” After cutting around the umbilicus, the
opposite side of the abdomen is undermined at the fascial level up to the flank. The edges are then sutured
under some tension, and the umbilicus is brought out through a new opening at the corresponding site.
Second Stage
The pedicle is divided 30 to 40 days later. The lower end is defatted slightly and sutured to the horizontal portion
of the T incision. The upper part is marked across what will be the submammary fold, and that portion distal to

this line is deepithelialized. The previous trapdoor is excised and discarded. The cone shape of the breast is
obtained by excising a central wedge, suturing the remaining edges together, and folding that under the rest of
the flap (Figs. 366.1E-G and 366.2).
CLINICAL RESULTS
There have been few complications. Of nine patients, only one had a partial necrosis that was covered with
a skin graft and later revised. Subsequent fat hardening was found in three patients. The patient must be
reassured that it softens after several months. A biopsy is helpful to rule out a recurrence. Infection on the
undersurface of this partially open flap was seen in three patients, was treated, and had no major
consequences or loss of tissue.
SUMMARY
The lateral abdominal skin flap is a reliable flap that can be used without implant in two stages for breast
reconstruction.
FIGURE 366.1 A: Note the preparation of the breast area with an inferiorly based, hinged trapdoor flap and
the undermining above it. The lateral abdominal flap is based at the costal margin, and its end is
deepithelialized. B,C: Flap has been rotated into place with its upper end set into the undermined upper
edge. D: Cross section shows the lining provided by the trapdoor flap. E: Pedicle is sectioned and
deepithelialized from the submammary fold, and a central wedge is removed. F: Trapdoor flap is removed,
and the deepithelialized pedicle is tucked under the rest of the flap. G: Cross section of the same. H: The

remaining scars.
FIGURE 366.2 A: The lateral abdominal skin flap during the first stage. The radical mastectomy included a
wide skin excision and had been skin-grafted. B: Just before the second stage, preoperative markings
should be done on the future submammary fold and the nipple height with the patient standing to compare
them to the normal breast. C,D: Eight months postoperatively. Apart from the hypertrophic scarring, an
adequate mammary volume has been obtained.
References
1. Drever JM. Total breast reconstruction with either of two abdominal flaps. Plast Reconstr Surg
1977;59:185.
2. Drever JM. Total breast reconstruction. Ann Plast Surg 1981;7:54.
3. Daniel RK, Cunningham DM, Taylor GI. The deltopectoral flap: an anatomic and hemodynamic approach.
Plast Reconstr Surg 1975;55:275.
4. Webster JP. Thoracoepigastric tubed pedicles. Surg Clin North Am 1937; 17:145.

Chapter 367
Midabdominal Skin Flap
J. M. DREVER
This skin flap is particularly useful for breast reconstruction when there is a considerable redundancy of tissue
around the midabdominal area (1, 2, 3, 4). It must be noted that a considerable amount of skin and subcutaneous
fat can be transferred with this type of reconstruction, and therefore, the use of implants can be avoided. The
obvious scarring is a disadvantage (5).
ANATOMY
This is a random or cutaneous flap (6) that receives its vascular supply through perforators that arise from the
superior epigastric vessels that pierce the rectus abdominis muscle and fascia to supply an area of skin around
the xiphoid. Some supply comes laterally from the terminal branches of the intercostal vascular bundles. The rest
of the flap is vascularized from the dermal and subdermal plexus.
FLAP DESIGN AND DIMENSIONS
This is a spear-shaped flap based superiorly just at the costal margin. Here it is about 15 to 20 cm in width,
depending on the patient's girth. It tapers down into the pubis, giving it some 25 to 30 cm of total length.
OPERATIVE TECHNIQUE
First Stage
The flap is lifted from the rectus abdominis fascia and delayed for 10 days to the height of the umbilicus, which is
transected and everted. When it survives, it can serve as a nipple. Following this period, the lower end of the flap
is deepithelialized and tapered to what will form the upper extremity of the new breast. This area is tucked under
an undermined upper edge of the thoracic incision. It is a horseshoe design, and its trapdoor is used to line part
of the undersurface of the rotated abdominal flap. This arc of rotation is about 130 degrees (Fig. 367.1B and C).
Closure of the abdominal defect has the effect of a vertical abdominal lipectomy, and a new umbilicus can be
made by a defatted 2-cm Z-plasty at the level, suturing the dermis to the fascia.
Second Stage
The pedicle is divided 30 to 40 days later. The lower end is defatted slightly and sutured to the horizontal portion
of the T incision. The upper part is marked across what will be the submammary fold, and that portion which is
distal to this line is deepithelialized. The previous trapdoor is excised and discarded. The cone shape of the
breast is obtained by excising a central wedge, suturing the remaining edges together, and folding that under the
rest of the flap (Fig. 367.1D-F and 367.2).
CLINICAL RESULTS
Flap necrosis occurred, to some extent, in 5 of my 13 patients. In 1 patient, practically the entire flap was
lost. The other 4 patients developed varying degrees of necrosis at the edge. These patients were
managed by resection of the necrotic area, upward advancement, and reinsertion of the remainder of the
flap. Necrosis of subcutaneous fat alone occurred in two other patients, manifesting as a hardening of the
distal part of the flap. This softened after several months.
One patient had a Pseudomonas chondritis, managed by high doses of carbenicillin. It took several months

to clear. There were two other cases of superficial infection of the raw undersurface of these open flaps, but
fortunately, no consequences occurred. There were no function deficits arising after the completed
reconstruction.
SUMMARY
The midabdominal skin flap can be used without implants as a two-stage procedure for breast
reconstruction.
FIGURE 367.1 A: Note the preparation of the breast area, with an inferiorly hinged trapdoor flap and the
undermining above it. The midab-dominal skin flap end is deepithelialized. B: The flap is hinged at the
xiphoid, twisted about 130 degrees, and inset. C: Cross section shows the undersurface lining provided by
the trapdoor flap. D: The pedicle is sectioned and deepithelialized from the submammary fold, and a central
wedge is removed. E: The trapdoor flap is removed, and the deepithelialized pedicle is tucked under the
rest of the flap. F: Cross section of same. G: Finished reconstruction; the umbilicus can be reformed by a 2-
cm Z-plasty.

FIGURE 367.2 A: Preoperative view. The flap was delayed for 10 days. B,C: Two years postoperatively,
the umbilicus (nipple) reinverted and the pigment partially reabsorbed in the areola that had been tattooed.
The breast mound is soft and natural looking.
References
1. Drever JM. Total breast reconstruction with either of two abdominal flaps. Plast Reconstr Surg
1977;59:185.
2. Gillies H, Millard DR Jr, eds. The principles and art of plastic surgery. Boston: Little, Brown, 1957.
3. Fernandes J. Mammary reconstruction. Bol Trab Acad Argent Cir (Buenos Aires) 1968;52:86.
4. Fernandes J. Mammary reconstruction immediately following a mastectomy. Bol Trab Acad Argent Cir
(Buenos Aires) 1969;53:352.
5. Drever JM. Total breast reconstruction. Ann Plast Surg 1981;7:B54.
6. Daniel RK, Cunningham DM, Taylor GI. The deltopectoral flap: an anatomic and hemodynamic approach.
Plast Reconstr Surg 1975;55:275.

Chapter 368
Contralateral Breast Flap
D. R. MARSHALL
EDITORIAL COMMENT
The editors believe that this procedure has very limited applicability for aesthetic reconstruction of the
breast. This procedure should, however, be considered as an alternative to other techniques for coverage
of radiation defects on the contralateral anterior thorax.
The more commonly performed methods of breast reconstruction involve a replacement of volume by a
prosthesis, with soft-tissue cover provided by various means (1). Prosthetic replacements are satisfactory in the
short term but have significant late complications. Reconstruction using soft tissue alone avoids these
complications, but these methods usually either require multiple stages (2, 3) or are fairly complex (4).
In most breast reconstruction techniques, an integral part of the procedure is a reduction of the normal breast to
achieve symmetry. This otherwise discarded tissue can occasionally be used to reconstruct the missing breast
(5).
INDICATIONS
The operation is possible in patients in whom the remaining breast is large enough to provide for the
reconstruction and in whom there is not a significant risk of the development of a second primary carcinoma
of the breast. The main objection to use of the remaining breast as a donor of tissue is the possibility of
such a cancer developing in women in whom a carcinoma of the breast has already occurred. Second
primary tumors in the remaining breast are statistically more common than in the normal patient (6, 7).
There is considerable difference of opinion concerning the actual risk of carcinoma in the other breast (8).
In the Birmingham group (9), the incidence of carcinoma of the contralateral breast approached that of the
normal population in postmenopausal patients who had survived mastectomy for several years. It is in this
group that the contralateral breast operation can be used for breast reconstruction.
In younger women, in whom the risk of contralateral carcinoma is significant, although not sufficiently high to
justify subcutaneous mastectomy, it is doubtful whether the other breast should be used.
Indications for this method of reconstruction are as follows:
1. Postmenopausal patients in whom there is no family history of cancer of the breast and who have been
free of disease for several years.
2. Patients in whom the pathology has been other than lobular carcinoma and, of lesser importance,
intraduct carcinoma or medullary carcinoma (10, 11, 12, 13).
3. Patients in whom the remaining breast is large enough to produce two breasts of adequate size.
This flap also can be used for resurfacing the chest wall following excision of malignancy or radionecrosis,
either as a primary or a secondary procedure. Its arc of rotation allows it to be transferred either to the lower
or upper portion of the breast.

ANATOMY
The main sources of blood supply are the perforating vessels from the internal mammary chain in the fourth, fifth,
and sixth intercostal spaces. This is an axial-pattern flap (14).
FLAP DESIGN AND DIMENSIONS
Depending on the size of the donor breast, the flap varies in size. In general, however, the flap is approximately
30 cm long and 10 cm wide. The base of the flap is in the medial quadrant of the donor breast and pivots around
the medial point of the submammary skin incision (see Fig. 368.2D). The arc of rotation is through 180 degrees
to allow the flap to reach across to the opposite axilla.
OPERATIVE TECHNIQUE
First Stage
The proposed nipple site is marked on the donor breast approximately 20 cm from the sternal notch, and the skin
incision extends from this point downward along the medial edge of the lateral skin flap of a Strombeck
mammaplasty and then along the inferior border of this flap to meet the submammary groove well out into the
axilla. The incision runs medially along the submammary groove almost to the sternum and extends somewhat
higher than the usual breast reduction (Figs. 368.1 and 368.2A).
FIGURE 368.1 Preoperative photographs of a 60-year-old woman who had a carcinoma of the left breast treated
by modified radical mastectomy 10 years previously. The patient is considerably overweight, and the right breast
consists largely of fat.

FIGURE 368.2 A: Drawing showing the planned incision and the position of the new nipple. The usual markings
of a Strombeck mammaplasty are shown. The incision on the anterior surface of the breast is shown by a broken
line, and the incision in the submammary groove is shown by a dotted line. The flap of deepithelialized skin and
subcutaneous tissue raised above the incision in the planned submammary groove on the mastectomy side is
also shown. B: Photograph from the right side showing the incisions with the nipple close to the base of the flap.
C: Drawing showing the flap sutured in position with the median tunnel. The residual breast on the right side has
been advanced as far medially as possible to allow the flap to extend to the left axilla. The position of the
deepithelialized skin flap in the left breast is also shown. D: Photograph from below showing the shared breast
with the split-thickness skin graft in position covering the raw area on the base of the pedicle. E: Photograph 6
weeks postoperatively showing the flap healed in position. Note that most of the breast at this stage is on the left
side.
FIGURE 368.3 Drawing showing the planned incision for division of the flap. The nipple is removed and is
shared between the two breasts as a whole-skin graft.
Elevation of the flap of skin and breast from the underlying muscle commences in the axilla and proceeds
medially. The breast is transected in a vertical fashion to the new nipple point, and the flap is elevated from the
chest wall as far medially as possible, without disturbing the perforating vessels from the internal mammary chain
in the fourth, fifth, and sixth intercostal spaces.

The breast tissue is divided, as required, without any damage to the subdermal vessels to enable the flap to
reach the opposite axilla. The medial attachment is mobilized, and the skin incisions are extended until there is
no kinking.
A useful modification to the original description of the operation (5) is to leave the nipple undisturbed on the flap
to allow a broader base so that the vascularity of the flap is never in jeopardy (Fig. 368.2B). The base of the flap
is quite mobile, and it is this that allows for the long reach of the flap and for its versatility. The remaining tissue
of the donor breast is advanced as far medially as possible, and the wound is closed as in a standard reduction
mammaplasty.
The flap is applied to the chest wall on the side to be reconstructed, and the lower border is placed along the
planned submammary groove. The arc of inset is marked out, and the epithelium of this area is removed from the
underlying dermis with a skin-grafting knife. An incision is then made in the submammary groove, and this
deepithelialized flap of skin and subcutaneous tissue is elevated from the underlying muscle. The flap is turned
beneath the skin of the upper part of the chest wall to fill out any infraclavicular hollow. The large contralateral
breast flap is then sutured into the residual defect (Fig. 368.2C).
FIGURE 368.4 Drawing showing the end result after the division of the flap and rearrangement of the medial part
of each breast with the final suture line. The nipple has been shared as a free graft.
FIGURE 368.5 Photographs showing the end result 6 months after the second stage of the operation.
The skin removed is used as a graft to cover the raw area at the base of the pedicle, and this achieves complete
closure (Fig. 368.2D).
Second Stage
At the second operation, 4 to 6 weeks later, the pedicle is divided (Figs. 368.2E and 368.3) and the nipple is
removed to be used as a free-nipple graft. The incision in the submammary groove of the donor breast is
completely reopened, and the tissue is allowed to return to its normal position. A reduction and uplift on the
donor breast is then completed, and a nipple reconstruction is carried out using a free-nipple-graft technique on

each side to achieve symmetry.
The medial scars on the reconstructed side are opened, and this part of the flap is inset into the medial portion of
the breast after appropriate deepithelialization (Figs. 368.4 and 368.5). If the areola is small, the skin graft on the
carry portion of the pedicle can be used as a whole-skin graft, and this makes quite a satisfactory areola.
CLINICAL RESULTS
Complications are few. The vascularity of the flap is excellent, providing the base of the pedicle is
sufficiently broad. If the donor nipple is preserved on a separate dermal pedicle, the vascularity of the flap
can be impaired, and under these circumstances, some necrosis of the flap tip may occasionally occur.
The only complication relating specifically to this flap is that of the possibility of a second carcinoma of the
breast, but the risk of this is small if the operation is used selectively.
SUMMARY
The flap provides a satisfactory method of breast reconstruction using soft tissue alone. No prosthesis is
necessary, and the end result is soft, symmetrical breasts.
References
1. Bostwick J, Vasconez LO, Jurkiewicz MJ. Breast reconstruction following mastectomy. Plast Reconstr
Surg 1978;61:683.
2. Holdsworth WG. A method of reconstructing the breast. Br J Plast Surg 1956;9:161.
3. Millard DR. Breast reconstruction after radical mastectomy. Plast Reconstr Surg 1976;58:283.
4. Hartrampf CR Jr, Scheflan M, Buck PW. Breast reconstruction with a transverse abdominal island flap.
Plast Reconstr Surg 1982;69:216.
5. Marshall DR, Anstee EJ, Stapleton MJ. Postmastectomy breast reconstruction using a breast-sharing
technique. Br J Plast Surg 1981;34:426.
6. Haagenson CD, ed. Diseases of the breast, 2d Ed. Philadelphia: Saunders, 1972.
7. Donegan WL, Spratt JS Jr. Cancer of the second breast. In: Spratt JS, Jr., Donegan WL, eds. Cancer of
the breast. Philadelphia: Saunders, 1976.
8. Robbins GF, Berg JW. Bilateral primary breast cancer: a prospective clinico-pathological study. Cancer
1964;17:1501.
9. Prior P, Waterhouse JAH. Incidence of bilateral tumours in a population based on a series of breast cancer
patients: two approaches to an epidemiological analysis. Br J Cancer 1978;37:60.