Core Procedures In Plastic Surgery: Cẩm Nang Các Quy Trình Cốt Lõi Trong Phẫu Thuật Tạo Hình

239
Operative techniques
Figure 15.10  Blood supply to the breast.
Lateral thoracic artery
Thoracodorsal
artery
Anteromedial intercostal perforators
Anterolateral intercostal
perforators
Internal mammary
perforators
Figure 15.11  Blood supply to the breast – cross-sectional view.
Lateral intercostal
perforator
Intercostal artery
Lateral thoracic artery
Internal mammary artery
Anterior intercostal perforator
Rib 2
Pectoralis
major
Pectoralis
minor
Deep fascia
Second superficial branch
internal mammary artery
Fifth superficial branch
internal mammary artery
Cooper’s
ligaments
Duct
Gland
Internal intercostal
External intercostal
Fourth deep
branches of
mammary vein
and artery
Würinger’s septum
Figure 15.12  Profile anatomic view of the hemisected human breast. The
ligaments described by Sir Astley Cooper are clearly demonstrated to run from the
posterior, or deep, breast fascia, which is intimately associated with the pectoralis
major muscle fascia, to the anterior, or superficial, breast fascia, and insert into
the dermis. The parenchyma, which is encapsulated within these fascial borders,
changes with aging, implants, weight changes, and pregnancy. These types of
parenchymal changes result in alterations to the integrity of Cooper’s ligaments, the
breast’s fascial components, and the overlying skin and fat.
• In general, the base diameter and projection of implants
chosen for augmentation-mastopexy procedures are
smaller than in implants chosen for standard
augmentation procedures.
• Textured implants may assist in avoiding malposition,
especially when the subglandular plane is selected. If the
parenchymal volume is deficient in the upper pole (<3 cm
pinch thickness), then we prefer a subpectoral placement.
• The inverted T-scar technique is reserved for those
women with moderate to severe breast ptosis with a large
excess of skin and a moderate amount of glandular
tissue.
• Advantages: ability to excise all excess skin, ability to see
the final shape of the breast while the patient is still on
the operating table leading to a decreased chance for
revision.
• Disadvantages: Increased length of the incisions/scars;
the breast shape is supported mainly by the skin
envelope which increases the chance of recurrent ptosis
during the subsequent months and years.
Operative techniques
Concentric mastopexy without parenchymal
reshaping
• The amount of skin to be excised is determined by the
position of the nipple-areola complex.
• Excise only the amount of skin necessary to raise the
nipple-areola complex to the proper level for correction
of the ptosis.
• The lines of excision are marked on the breast with the
patient in a sitting or standing position in the
preoperative area.

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15
■ The new meridian is often medial to the breast
meridian approximately 6 cm from the midline.
■ Mark the future superior border of the areola, point A,
on the meridian approximately 2 cm above the anterior
projection of the inframammary fold.
■ Mark the future inferior border of the areola, point B,
approximately 5–12 cm above the inframammary fold
on the basis of the estimated final breast volume and
the expected skin retraction.
■ Mark the medial and lateral limits of the new areola,
points C and D, on the basis of estimates of the final
breast volume. These limits are equidistant from the
previously-marked meridian, and point C averages
8–12 cm from the midline (Fig. 15.14).
■ The opposite breast is marked with reference to the
already marked breast.
■ The preoperative markings are verified by pinching
together the superior and inferior points and then the
medial and lateral points, ensuring that enough skin
will remain to adequately cover the breast tissue
without tension.
• The desired areolar diameter is marked, and the
periareolar ellipse is de-epithelialized. The
de-epithelialized dermis is incised from the 2 o’clock to
the 10 o’clock position. The dissection is extended toward
the inframammary fold in the subcutaneous plane (Fig.
15.15). The dissection continues to the upper outer
quadrant of the breast and becomes more superficial to
preserve the vessels coming from the lateral thoracic
artery.
• Glandular dissection is initiated with a semicircular
incision approximately 3 cm from the inferior areola edge
to preserve innervation and blood supply to the areola.
• Symmetry is checked by comparing sternal notch to
nipple distance and sternum to nipple distance.
• In the operating room, the amount of the areola that is to
remain is marked on the stretched breast with an areolar
marker or “cookie-cutter”.
• The skin between these two marks is infiltrated with 0.5%
lidocaine with 1 : 200 000 epinephrine to facilitate
de-epithelialization.
• Once the skin is removed, the edge of the dermis can be
elevated. At the same time, the remaining skin around
the exposed dermis can be elevated off the gland for a
short distance superiorly.
• A purse string suture of 4-0 Gore-Tex or Mersilene is then
placed in the deep dermis of the skin edge. This is then
cinched to the approximate size of the areola and tied.
• The areola is then approximated to the skin with half-
buried horizontal mattress sutures, followed by a
running, subcuticular 4-0 Monocryl or polydioxanone
closure.
Periareolar Benelli mastopexy
• The Benelli mastopexy technique is an extension of the
donut mastopexy with modifications that allow the
periareolar techniques to be used on larger breasts with
increasing degrees of ptosis.
• The fundamental concept behind the Benelli mastopexy is
treatment of the skin and the gland as two separate
components.
• Preoperative markings:
■ Mark the midline and the estimated meridian of the
newly shaped breast.
Figure 15.14  Markings for Benelli mastopexy. (A) Future superior point of the
nipple; (B) future inferior point of the nipple; (C) medial limit of the nipple; (D)
lateral limit of the nipple. Point C averages 8–12 cm from the midline. S is the
point where the breast meridian intersects the inframammary fold. (Redrawn after
Benelli L. A new periareolar mammaplasty: the “round block” technique. Aesthetic
Plast Surg. 1990;14:93–100.)
A
B
C
D
S
Figure 15.13  Periareolar design guides as described by Spear et al. D, diameter.
(Modified from Michelow BJ, Nahai F. Mastopexy. In: Achauer BM, Erikson E,
Guyuron B, et al., eds. Plastic surgery: indications, operations and outcomes. Vol. 5.
St Louis: Mosby; 2000.)
Outside D.
Final D.
Original D.
Inside D.

241
Operative techniques
Dissection is continued to the prepectoral space in the
avascular central space, preserving the peripheral blood
supply.
• The inferior glandular flap is then cut vertically beyond
the breast meridian up to the fascia.
Figure 15.15  Dissection of the breast during Benelli mastopexy. Incision of
dermis from the 2 o’clock to the 10 o’clock position with dissection to the
inframammary fold subcutaneously. (Redrawn after Benelli LC. Periareolar Benelli
mastopexy and reduction. In: Spear SL, ed. Surgery of the breast: principles and art.
Philadelphia: Lippincott-Raven; 1998:685.)
A
B
C
D
Figure 15.16  Four flaps of the Benelli mastopexy: superior
dermoglandular flap supporting glandular medial and lateral
flaps, and detached skin flap. (Redrawn after Benelli LC.
Periareolar Benelli mastopexy and reduction. In: Spear SL, ed.
Surgery of the breast: principles and art. Philadelphia:
Lippincott-Raven; 1998:685.)
Lateral flap
Superior flap
Medial flap
Keel-like resection
• Four flaps will have thus been created: a superior
dermoglandular flap supporting the areola, a glandular
medial flap, a glandular lateral flap, and the detached
skin flap (Fig. 15.16).
• The glandular flaps will be reassembled and repositioned
to decrease the base of the breast, thus promoting the
lifted appearance. If necessary, these flaps can be
trimmed to reduce unwanted fullness. Volume reduction
should be performed at the distal ends of the flaps to
limit their length.
• Once the appropriate resection is complete, the gland is
lifted and reshaped:
■ A stitch is placed in the glandular tissue of the
superior flap and fixed to the pectoralis fascia
(Fig. 15.17), elevating the areola and causing an
exaggerated convexity in the superior pole of the
breast (Fig. 15.18) that will eventually disappear
within a few weeks secondary to gravity and the
weight of the breast.
■ The medial and lateral flaps are folded over
one another and sutured in place. Because most
ptosis involves a lateral migration of the breast,
the goal here is to medialize the breast. Therefore,
the crisscross mastopexy is begun by rotating and
folding the medial flap behind the areola, fixing
its distal portion to the pectoralis muscle with
superficial stitches (Fig. 15.19). The lateral flap is
then crossed over and fixed to the medial flap
(Fig. 15.20) thereby reducing the breast base and
forming a glandular cone on which the areola is
placed (Fig. 15.21).
■ The areola is fixated to the superior border of the
ellipse through a 1 cm dermal incision made near the
superior skin edge (Fig. 15.22).

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15
Figure 15.17  Benelli mastopexy. Attachment of the superior flap to the chest wall
by the pectoralis fascia. (Redrawn after Benelli LC. Periareolar Benelli mastopexy
and reduction. In: Spear SL, ed. Surgery of the breast: principles and art.
Philadelphia: Lippincott-Raven; 1998:685.)
Figure 15.18  Benelli mastopexy. Superior flap attached to the chest wall
demonstrating areolar elevation and exaggerated convexity of superior pole.
(Redrawn after Benelli LC. Periareolar Benelli mastopexy and reduction. In: Spear
SL, ed. Surgery of the breast: principles and art. Philadelphia: Lippincott-Raven;
1998:685.)
Figure 15.19  Benelli mastopexy. Medial glandular flap affixed to the underlying
pectoralis muscle. (Redrawn after Benelli LC. Periareolar Benelli mastopexy and
reduction. In: Spear SL, ed. Surgery of the breast: principles and art. Philadelphia:
Lippincott-Raven; 1998:685.)
Lateral flap
Medial flap
Figure 15.20  Benelli mastopexy. Lateral flap is affixed to the medial flap.
(Redrawn after Benelli LC. Periareolar Benelli mastopexy and reduction. In: Spear
SL, ed. Surgery of the breast: principles and art. Philadelphia: Lippincott-Raven;
1998:685.
■ Support for the breast shape is achieved by full-breast
lacing in which braided polyester suture on a long
straight needle is used to place inverted sutures along
the underside of the gland. These sutures should be
applied without tension, as overly tight sutures can
result in glandular necrosis.
■ The skin is redraped over the breast, and a round
block cerclage stitch is passed in the deep dermis in
pursestring fashion (Fig. 15.23) and cinched around a
tube of the desired diameter.
■ A diametrical transareolar U suture is placed to serve
as a barrier and help prevent areola protrusion (Fig.
15.24). It can also be used to give a circular shape to
the areola in those patients in whom it tends to be
ovoid.
The Goes periareolar technique
with mesh support
• Also called the “double skin” technique, the basic
principle involves formation of a resistant lining of the
breast by the use of a layer of prosthetic mesh which acts
as an internal brassiere to provide increased breast

243
Operative techniques
■ Point C is the distance from the medial breast border
to the medial aspect of the new areola at the level of
the nipple (average 9 cm).
■ Point D is the distance from the anterior axillary line to
the lateral aspect of the new areola at the level of the
nipple (average 12 cm).
• The area between the areola and the skin marking is
de-epithelialized.
• An incision is made along the outer ellipse, and the skin
flap is developed.
• The superior dissection proceeds along the base; the
thickness of the subcutaneous fat tissue is progressively
increased as one gets closer to the base of the breast and
undermining continues over the pectoral fascia for
approximately 5 cm superiorly and then inferiorly under
the gland approximately one-third of the way into the
retromammary space.
• Care should be taken to identify and preserve all
perforating vessels (Fig. 15.26).
support during the healing and skin contraction
processes.
• The primary indication for this method is the correction
of ptosis or a slight reduction of hypertrophy with or
without ptosis. Reductions from each breast ideally
should be no more than 500 g.
• Preoperative markings include four cardinal points
(Fig. 15.25):
■ Point A is the level of the top of the new areola.
■ Point B marks the distance from the inframammary
fold to the bottom of the new areola (average 7 cm).
Figure 15.21  Benelli mastopexy. Plication invagination of the gland to form a
conical shape. (Redrawn after Benelli LC. Periareolar Benelli mastopexy and
reduction. In: Spear SL, ed. Surgery of the breast: principles and art. Philadelphia:
Lippincott-Raven; 1998:685.
Figure 15.22  Benelli mastopexy. Fixation of areola to the superior border of the
ellipse. (Redrawn after Benelli LC. Periareolar Benelli mastopexy and reduction. In:
Spear SL, ed. Surgery of the breast: principles and art. Philadelphia: Lippincott-
Raven; 1998:685.)
Figure 15.23  Benelli mastopexy round block suture. (Redrawn after Benelli LC.
Periareolar Benelli mastopexy and reduction. In: Spear SL, ed. Surgery of the breast:
principles and art. Philadelphia: Lippincott-Raven; 1998:685.)
Figure 15.24  U stitches to help prevent areolar herniation and aid in producing a
round shape in the Benelli mastopexy. (Redrawn after Benelli LC. Periareolar Benelli
mastopexy and reduction. In: Spear SL, ed. Surgery of the breast: principles and art.
Philadelphia: Lippincott-Raven; 1998:685.)

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15
Figure 15.25  Four cardinal points for the Goes mammaplasty. (Redrawn after
Goes JC. Periareolar mastopexy and reduction with mesh support. In: Spear SL, ed.
Surgery of the breast: principles and art. Philadelphia: Lippincott-Raven; 1998:697.)
19
9
7
12
A
D
C
B
Figure 15.26  Goes technique. Dissection of the gland to separate it from the skin
along with lines of excision of the gland. Note the formation of the internal skin
lining. (Redrawn after Goes JC. Periareolar mastopexy and reduction with mesh
support. In: Spear SL, ed. Surgery of the breast: principles and art. Philadelphia:
Lippincott-Raven; 1998:697.)
Wedge of upper
hemisphere to be
resected
Wedge of upper
hemisphere to be
resected
External
skin lining
Internal
skin lining
Pectoralis
fascia
Pectoralis
major muscle
Figure 15.27  Goes technique. Lines of resection from the superior and inferior
hemispheres to narrow the base. Note that mastopexy alone, these regions can
simply be imbricated rather than resected. (Redrawn after Goes JC. Periareolar
mastopexy and reduction with mesh support. In: Spear SL, ed. Surgery of the
breast: principles and art. Philadelphia: Lippincott-Raven; 1998:697.)
External
skin lining
External
skin lining
• Once the skin and the gland are separated, wedges of
tissue can be removed superiorly and inferiorly to
accomplish any needed reduction of breast tissue.
The base of the mammary gland should not be
disturbed.
• To reassemble the gland, any superior excisional defect is
closed, and the gland is fixed to the thorax in a way that
fills and elevates the upper pole of the breast (Fig. 15.27).
The lower hemisphere excisional defect is then closed
and secured to the intramammary connective ligaments
and the anterior pectoral fascia.
• The dermal flap, which has been undermined to the
areola, is gently stretched over the gland; it is attached
inferiorly to the anterior pectoral fascia when possible
and superiorly to the connective ligaments. This
dermal component is the so-called internal skin lining
(Fig. 15.28).
• Next, the mixed mesh (polyglactin mesh with Dacron
filaments), woven mesh (polyglactin/polypropylene), or
biologic mesh is applied over the dermal flap as a
brassiere. It is used to give an ideal shape to the
parenchymal cone and to elevate the breast slightly. It is
sutured to the anterior pectoral fascia.

245
Operative techniques
Grotting sculpted vertical pillar mastopexy
(Video 15.1)
• Modification of the Lassus technique that allows resection
of glandular tissue, if desired, and/or also the insertion
of an implant in either the subglandular or the
subpectoral plane if more volume is required.
• Preoperative markings include:
■ The IMF.
■ The future nipple position – determined by many
reference points including transposition of the IMF
onto the anterior surface of the breast, pinching/
gathering of the lower breast to simulate the
mastopexy in order to determine if the nipple elevates
to the mark, cross-checking against the midhumeral
line, and measuring the notch to new nipple position
(typically 20–23 cm) (Fig. 15.29).
■ If parenchymal volume asymmetry exists, it is often
necessary to mark the superior border of the nipple
position, the A point, a centimeter or so lower on the
larger side than the smaller side, in order to account
for skin recoil after tissue resection.
• The next mark is the breast meridian, marked on its
anterior surface. The midpoint of the inframammary fold
is measured and will be the reference point for creating
the marks for the medial and lateral pillars that will
approximate at this point after completing the vertical
closure.
• It is preferable to use the standard superior pedicle for
the nipple-areolar complex, but if the density of the gland
or distance of elevation appears restrictive, the
superomedial pedicle recommended by Elizabeth Hall-
Findlay is used.
• The medial and lateral pillar lines are drawn by manually
distracting the breast tissue medially and laterally. These
marks are joined inferiorly by a parabolic line whose
lowest-point of the curve is approximately 2–3 cm above
the inframammary fold (Fig. 15.30).
• Superiorly, the vertical lines are curved up to the new
nipple point. Small inflections of the lines to create a
mosque-dome effect can be used to accentuate the future
6 o’clock position on the areolar closure if desired.
• The top of the vertical closure at this point is pinched
approximated to ensure adequate skin will remain for
closure.
• From the top of the vertical closure, one measures down
5–6 cm and makes another mark that will represent the
approximate position of the new inframammary fold.
• The breast tissue below that point will comprise the
bottom of the future superiorly-based dermoglandular
flap (if the intention of the surgeon is to autologously-
augment the patient) or be resected (as in small
reductions, with or without an implant).
• Preaxillary fullnesses and lateral chest rolls may need
liposuction to contour and should be marked.
• The nipple areola is marked with an appropriate sized
nipple marker, and then lidocaine 0.5% with epinephrine
1 : 200 000 is infiltrated in the intended lines of incision,
areas to be de-epithelialized, as well as beneath the
gland.
• The external skin lining is brought up over the breast
mound and closed around the areola with a circular
continuous deep intradermal suture of Mersilene 2-0 on a
straight needle. A continuous, intradermal Monocryl 4-0
suture is used to fix the areola skin to the external skin
lining.
• Dressings consist of triangular pieces of Micropore tape
covering the whole gland, which is left in place for 20
days. Tegaderm also works well for this purpose. Suction
drains are removed after approximately 5 days.
Figure 15.28  Goes technique. (A) The breast projects anteriorly and superiorly
after formation of the cone and reinforcement of the breast with mesh. (B)
Schematic for the placement of mesh. The polyglactin–Dacron composite mesh of
Goes’ original description is replaced with a Vicryl–Prolene composite. (Redrawn
after Goes JC. Periareolar mastopexy and reduction with mesh support. In: Spear
SL, ed. Surgery of the breast: principles and art. Philadelphia: Lippincott-Raven;
1998:697.)
A
B
Video
15.1

246
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15
Figure 15.29  (A–H) Authors’ preferred modification of vertical technique, preoperative markings. The midline and inframammary folds are marked. Point A, the transposed
location of the inframammary fold, is marked on the breast anteriorly, as is the breast meridian. The breast is then manually distracted laterally and then medially to estimate
and mark the medial and lateral vertical limbs, respectively. Points C and D are the cephalic extents of these vertical limbs and will become the bottom of the new areola.
Often the vertical limbs can be manually approximated to simulate the mastopexy. The upper curved line represents the new areola boundary and is usually 12–14 cm in
length.
A
B
C
D
E
F
G
H

247
Operative techniques
• After de-epithelialization of the periareolar skin and that
between the medial and lateral pillar marks, the lower
pole of the breast is undermined in the subcutaneous
plane over that portion of the breast to be resected
inferiorly, if any (Fig. 15.31).
• The gland is then undermined at the level of the
pectoralis fascia from the inframammary fold inferiorly to
the superior pole to establish space into which to fold the
superiorly based inferior flap.
• At this point, the bases of the pillars can be trimmed if
needed.
• The flap is sutured into an appropriate position.
However, if no flap is used and the tissue is resected
between the medial and lateral pillars, then a suture is
Figure 15.30  Note the bottom of the incision line coming to a V approximately
2 cm above the inframammary fold (point B). The hatched lines show the location
of the glandular resection at the bases of the medial and lateral pillars. A
superiorly-based flap can be created from the tissues between the marked medial
and lateral pillars, rotated retro-areolarly, and then sutured to the pectoralis fascia to
improve upper pole fill.
Figure 15.31  The lower pole of the breast has been detached. The resulting flap
may be transposed into the retro-areolar location to augment the upper pole or
resected in cases such as a small reduction or when an implant is to be added
(addition–subtraction concept).
Figure 15.32  Temporary closure of the breast.
used from the undersurface of the gland beneath the
nipple-areola complex to the pectoral fascia as high up in
the upper pole as possible.
• In cases where no implant is planned, a “lateral shaping
suture” is used to bring the lateral parenchyma at the
anterior axillary fold toward the midline of the breast to
form an aesthetic curve to the lateral portion of the
breast.
• The medial and lateral pillars are then simply
reapproximated with 2-0 Vicryl sutures in the
parenchyma and 3-0 polydioxanone as a layered and
running skin closure.
• The nipple-areola complex is exteriorized in its virtual
position with the patient sitting up in the operating room
(Fig. 15.32).
• The “on the table” shape is usually one of a flattened
lower pole and a rounded upper pole with the nipple
pointing slightly inferiorly, creating the so-called “upside-
down breast” (Fig. 15.33).
Augmentation mastopexy
• Any of the previously discussed mastopexy techniques
can be combined with augmentation.
• In general, this technique is most useful for those women
with a deficit of glandular tissue regardless of the size of
the skin envelope.
• Another good indication is asymmetry when one breast
is hypoplastic and the other is ptotic.
• Augmentation mammaplasty proceeds with marking and
incisions according to the mastopexy technique chosen.
Once the breast tissue or muscle is exposed, the pocket
for the implant, either submuscular or subglandular, can
be formed and the implant inserted. The mastopexy can
then be completed.
• It is critical to insert the implant prior to performing the
mastopexy to avoid over-resection and undue tension on
the closure, and provide better control to nipple areolar
complex positioning.

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15
Figure 15.33  (A,B) Authors’ preferred technique. Rounded superior pole, flat
lower pole, and slightly downward pointing nipple.
A
B
• If there is the suggestion of nipple or skin flap
compromise at the conclusion of the procedure, the
following steps can be taken:
■ Removing the periareolar skin sutures.
■ Removal of the implant (Fig. 15.34).
Mastopexy postexplantation
• When an implant is removed, the breast may assume
an excessively lax and ptotic position. The potential
for this postexplantation result should be included
when the explantation procedure is discussed with a
patient.
• A particularly useful technique in the case where
mastopexy is planned postexplantation of saline-filled
implants is the intentional deflation of the implants
preoperatively, which can be performed in the office
using a sterile 18 G needle (Fig. 15.35).
• As with mastopexy procedures in general, the most
important component in determining the ability to
reshape the gland is the amount of glandular tissue
available.
• The next issue that needs to be addressed is whether to
perform capsulectomy or capsulotomy.
• In general, capsulectomy should be performed in patients
with ruptured silicone gel implants, in patients with
severe capsular contracture, or when the capsule contains
large amounts of calcium deposits. Otherwise, the
capsule, with or without additional capsulotomy
incisions, may be left in place to add bulk to the
glandular reconstruction.
• Before removal of the implant, the new areolar border is
marked.
• De-epithelialization is performed on the basis of the
mastopexy technique and any of the previously discussed
mastopexy procedures may be used.
• It is usually easier to perform the initial mastopexy
maneuvers with the implant in place.
• An incision is usually made in the inframammary fold,
but a periareolar incision can occasionally be used to gain
access to the implant or capsule.
• The capsule can be dissected and removed if necessary at
this time, otherwise it is entered to allow removal of the
implant.
• Reshaping of the gland can then be accomplished.
• Drains are placed, the skin envelope is closed and the
nipple is repositioned and sutured into place.
Inverted-T technique
• Markings proceed with the standard Wise pattern:
■ The meridian line of the breast is marked.
■ The new position of the nipple is marked along this
line at the anterior projection of the IMF.
■ A wire keyhole pattern is spread to allow it to just
encompass the original areola.
■ The superior aspect of the pattern is placed
approximately 2 cm above the location of the projected
nipple position.
■ The vertically-oriented keyhole markings are extended
laterally and medially on the breast to converge with
the IMF.
• The portion of the areola to be preserved is marked with
an appropriate diameter.
• The area within the preoperative marks is
de-epithelialized.
• Transdermal incisions are made along the upper portion
of what would be the vertical bipedicle flap of a
reduction mammoplasty on either side of the nipple-
areola complex.
• If planning to perform an auto-augmentation, and there
is an abundance of de-epithelialized breast tissue below
the inframammary fold, dissection of the gland off the
pectoralis muscle is undertaken starting from the
inframammary fold and proceeding upward to establish
a superiorly based dermoglandular pedicle.
• The dissection continues until the pocket can accept the
excess inferior glandular tissue. This tissue is folded
behind the breast and attached to the pectoralis fascia

249
Postoperative considerations
high enough to eliminate gross glandular redundancy
creating an auto-augmentation.
• Skin closure is accomplished in standard fashion
with little or no further undermining. The nipple-
areola complex is positioned and sutured into place
(Fig. 15.36).
Postoperative considerations
• Following the vertical mastopexy technique, the
use of Tegaderm to support the final shape is an
important aspect of postoperative care (Fig. 15.37).
It should be left on for up to 2 weeks, at which point
a bra should be used day and night for 6–8 weeks
(Figs 15.38, 15.39).
• Postoperative brassieres are used for at least 8 weeks
after surgery, in an effort to support the new breast as the
postoperative edema begins to egress.
Figure 15.34  (A,B) Preoperative views of a 44-year-old female postlapband and a 60 lb weight loss. She had previously-placed oversized subpectoral implants.
(C,D) Postoperative views after bilateral removal of implants and replacement with subglandularly-placed silicone gel implants in combination with parenchymal resection
(addition–subtraction concept).
A
B
C
D
Figure 15.35  Preoperative saline implant deflation. The right hand guides the
needle, holding it in place within the implant cavity, while the left hand compresses
the implant and displaces it inferiorly.

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•
• Mastopexy
15
• Full-on running or activities that tend to cause vigorous
up and down motion of the new breasts are restricted
until 8 weeks postoperatively.
Complications and outcomes
• One of the most devastating complications of mastopexy
is nipple loss, with an incidence reported to be less than
10%, usually in the range of 0–5%.
• Risk factors include technical errors, smoking, diabetes,
obesity, and hypertension.
• In high-risk patients (smokers, patients with diabetes
or obesity, or those with severe ptosis), a free nipple
graft technique is an option that can be considered
and is also a possibility intraoperatively or
postoperatively if the viability of the transposed nipple
appears compromised.
• The nipple-areolar complex may be converted to a
free nipple graft up until approximately 12 h
postoperatively.
• After 12 h, conservative treatment of any nipple necrosis
should be undertaken, including release of sutures,
topical nitropaste or leeches, greasy dressings, hyperbaric
Figure 15.36  (A–C) A 35-year-old patient with bilateral breast pseudoptosis and asymmetry of parenchymal volume. (D–F), Postoperative views after inverted-T technique
mastopexy and asymmetric small reduction of the inferior pole parenchyma.
A
B
C
D
E
F
Figure 15.37  Final closure and cover with Tegaderm dressing.

251
Complications and outcomes
Figure 15.38  (A–C) Preoperative views of a 31-year-old patient with moderate to severe ptosis. (D–F) Postoperative views after vertical mastopexy via the authors’
technique.
A
B
C
D
E
F
oxygen therapy (if available), and appropriate antibiotic
therapy.
• Many times, conservative treatment and closure by
secondary intention produce a satisfactory result.
If healing does not produce a satisfactory result,
the nipple-areola complex can be reconstructed by
standard reconstruction techniques ranging from simple
tattooing of the areola to flap reconstructions of the
nipple itself.
• Prominent scars may first receive a trial of vitamin E,
compression with tape or silicone sheeting, laser
treatment, or intralesional triamcinolone (Kenalog)
injections.
• It is preferable to assess patients for scar revision after 1
year.
• Flap necrosis can occur by virtue of the flaps used,
especially when the inverted-T or Wise-pattern
mastopexy technique is used.
• Treatment is similar to that of the ischemic nipple: greasy
dressings, hyperbaric oxygen, or antibiotics.
• Debridement of large areas of flap necrosis should be
undertaken when they are clearly demarcated and
delayed closure can be performed, thereby avoiding
weeks or months of caring for an open breast wound.
• Small areas of skin necrosis (1–2 cm) may be treated
conservatively, especially along the inframammary fold.
• The nipple should be properly situated on the breast, at
or near the point of greatest projection, with ample but
not an excessive amount of tissue underneath it.
• When malposition of the nipple occurs, one can attempt
to reposition it; however, one should wait at least several
months to allow complete healing of the breast and
nipple-areolar complex.
• It is easier to raise the nipple-areolar complex than to
lower it.
• Nipples that appear too high can be caused by
one of two situations: bottoming out or incorrect
positioning.
• If bottoming out has occurred, simple tissue resection can
be performed inferiorly.
• If incorrect positioning has occurred, attempts to lower
the nipple include V-Y advancements inferiorly,
transposition as a flap, or transfer as a graft.
• Over-resection, under-resection, and healing
complications can contribute to cosmetic
disappointments.
• Other complications can include infection and
hematoma.

252
•
• Mastopexy
15
Hall-Findlay EJ. A simplified vertical reduction
mammaplasty: shortening the learning curve. Plast
Reconstr Surg. 1999;104:748–763.
Hall-Findlay EJ. Pedicles in vertical breast reduction and
mastopexy. Clin Plast Surg. 2002;29(3):379–391.
Lassus C. Breast reduction: evolution of a technique.
A single vertical scar. Aesthetic Plast Surg. 1987;
11:107.
Patients had become more critical about the result of
a breast reduction operation over the past 20 years.
Natural and lasting shape, as well as minimal residual
scarring, is now expected by most of the patients
undergoing that surgery. In 1969, the author described a
vertical technique that achieved reduction and good shape
but the end of the vertical scar could be seen below the
brassiere line. In 1977, the author modified the technique by
adding a small horizontal scar that eliminated the visible
part of the vertical scar. In this article, the author
demonstrates that the same technique he described in 1969
and modified in 1977 can produce a single residual vertical
scar if properly used.
Lejour M. Vertical mammaplasty and liposuction of the
breast. Plast Reconstr Surg. 1994;94:100–114.
Further reading
Benelli L. A new periareolar mammaplasty: the “round
block” technique. Aesthetic Plast Surg. 1990;14:93–100.
The round block acts as a keystone element to support the
reshaped breast. The keystone relies on a crisscross
mastopexy and by a circular nonresorbable suture of woven
nylon included in the periareolar circular dermal scar. The
crisscross mastopexy is achieved via dermis-to-dermis,
gland-to-gland, and gland-to-musculoperiosteal unions, all
of which are fixed definitively with nonresorbable suture.
This technique can be used in many different breast cases,
such as that for correction of ptosis, hypertrophy, or
hypomastia, among others. In cases of hypomastia, the use of
the round block technique permits easy access for insertion
of the prosthesis as it simultaneously corrects ptosis. In
cases of tumor excision, the round block produces a discrete
scar and a more regular breast contour. In all types of
mammaplasty, the main goal is to limit the scar.
Gées JC. Periareolar mammaplasty: double skin technique
with application of polyglactine or mixed mesh. Plast
Reconstr Surg. 1996;97(5):959–968.
Figure 15.39  (A–C) Preoperative views of a 37-year-old female with bilateral breast ptosis with asymmetric nipple position but similar parenchymal volumes. (D–F)
Postoperative views after bilateral vertical mastopexy via the authors’ technique.
A
B
C
D
E
F

253
Further reading
From 1989 to 1994, the author has used vertical
mammaplasty without a submammary scar for all breast
reductions. Using a technique relying on adjustable
markings, an upper pedicle for the areola, and a central
breast reduction with limited skin undermining, the author
achieves a breast whose shape is created by suturing the
gland and does not rely on the skin. A personal series of 100
consecutive patients (192 breasts) operated on from 1990
through 1992 is reviewed, and mastopexy was performed in
39 breasts. Among the 153 breasts that required reduction,
liposuction was attempted as a complementary procedure
before the surgical reduction in the 120 fattest breasts.
Between 100 and 1000 cc of fat (mean 300 cc) was
suctioned in 86 breasts. This figure represents 50% of the
large breasts in patients under 50 years old and 100% of the
breasts in patients older than 50 years. There were few
complications, and none required early reoperation. This
series proves that vertical mammaplasty can be used in all
cases of breast reduction, producing consistently good, stable
results with limited scars. The adjunctive use of liposuction
in fatty breasts can be considered safe and efficient.
Marchac D, Olarte G. Reduction mammaplasty and
correction of ptosis with a short inframammary scar.
Plast Reconstr Surg. 1982;69:45.
Spear SL, Kassan M, Little JW. Guidelines in concentric
mastopexy. Plast Reconstr Surg. 1990;85(6):961–966.
In an effort to limit complications associated with
periareolar mastopexy techniques, Spear et al. designed a
series of rules to follow. Rule 1: Doutside ≤ Doriginal + (Doriginal
− Dinside). The amount of nonpigmented skin excised should
be less than the amount of pigmented skin excised. This
should prevent a postoperative areola larger than the
original. Rule 2: Doutside < 2 × Dinside: the design of the
outside diameter should be no more than two times the
inside diameter in order to minimize the discrepancy in
circle sizes, thereby reducing tension on the closure. This
should prevent an overly ambitious plan to remove skin,
and, as a result, limit the risk of poor scars and overly-
flattened breasts. Rule 3: Dfinal = 12(Doutside + Dinside). This
final rule helps predict the final areolar size, which is
particularly useful in asymmetry cases, as well as those in
whom no round block suture is employed.
Steinberg JP, Braun BI, Hellinger WC, et al. Timing of
antimicrobial prophylaxis and the risk of surgical site
infections: results from the Trial to Reduce
Antimicrobial Prophylaxis Errors. Ann Surg.
2009;250(1):10–16.
von Heimburg D, Exner K, Kruft S, et al. The tuberous
breast deformity: classification and treatment. Br J Plast
Surg. 1996;49:339–345.
Wise RJ, Gannon JP, Hill JR. Further experience with
reduction mammaplasty. Plast Reconstr Surg.
1963;32:12.
In 1955, the senior author (Wise) presented a new
technique for reduction mammaplasty using special
patterning devices, and this publication demonstrates the
further experiences of the authors. The author’s technique
allows rapid design of skin flaps and predictable size,
contour, symmetry, and nipple position, all of which are
difficult to achieve using a free-hand design. A four
quadrant form is placed after designing and shaping the
skin flaps, and the excess breast tissue is removed via
wedge-shaped excisions. Care is taken not to remove too
much from the central breast axis and the nipple, as well as
not to undermine the skin flaps, to maintain perfusion of all
these areas. The results allow for correction of varying
degrees of ptosis and breast hypertrophy, as evidenced by
case examples.

©2014, Elsevier Inc. All rights reserved.
Chapter
16 
Reduction mammaplasty
• Spear describes the reduction mammaplasty as “the
clearest example of the interface between reconstructive
plastic surgery and aesthetic plastic surgery.”
• This chapter seeks to demonstrate the most popular
techniques for reduction mammaplasty. The key point for
choosing the reduction mammoplasty technique is
finding what works for you, the surgeon, and what gives
your patients the best results.
• As breast reduction procedures have evolved, certain
goals have been consistent:
■ Aesthetic, natural breast shape.
■ Maintainance of shape long term.
■ Reducing scar length.
Preoperative considerations
• Careful consideration of the factors that compel patients
to seek reduction mammaplasty are key in the plastic
surgeon’s assessment of patients with mammary
hypertrophy.
• A thorough history of symptoms associated with
mammary hyperplasia should be recorded.
• A personal and family history of breast disease and
surgery should be recorded, and the results of any
testing, such as mammography, breast ultrasound or
MRI, and BRCA testing should be obtained prior to
surgical intervention.
• In addition to screening, a thorough physical examination
should be performed as well, noting any relevant points
of the patient’s general condition as well as an
examination of the breast. In the USA, only some breast
reduction procedures are considered medically necessary.
• Such salient general points relate to the patient’s height,
weight, and habitus, and these measures are often
mandatory for insurers to calculate the amount of breast
This chapter was created using content from
Neligan & Grotting, Plastic Surgery 3rd edition,
Volume 5, Breast, Chapter 8.1, Reduction mamma­
plasty, Jack Fisher and Kent K. Higdon.
Brief introduction
• Patients with mammary hypertrophy can present with a
variety of symptoms.
• Physical complaints include neck and back pain, shoulder
grooving from bra-straps indenting the skin, headaches,
difficulty finding well-fitted clothes and limited ability to
exercise, intertriginious skin maceration and rashes.
• Psychosocial issues include embarrassment, especially
teenagers and elderly women.
• Though the symptomatic improvement of patients
suffering from mammary hypertrophy is the primary
goal of reduction mammaplasty, there is another goal that
is nearly as equally important – creating a more aesthetic
breast.
SYNOPSIS
■ Macromastia, or mammary hypertrophy, is a disease process
which can result in physical and psychological symptoms.
■ Macromastia symptoms rarely improve without surgical
intervention, which typically results in significant improvement in
the patient’s quality of life.
■ Reduction mammaplasty techniques have evolved over millennia,
with particularly great strides made in the last 100 years.
■ Currently, there exist several well-designed techniques based on
sound surgical principles to address macromastia via reduction
mammaplasty.

255
Operative techniques
• If the inframammary fold to nipple distance is >22 cm,
there may be difficulty with inferior pedicle or central
mound techniques.
Operative techniques (Video 16.1;
Video 16.2; Video 16.3)
General concepts
• Reduction mammaplasty is performed by combining a
skin incision/resection with a parenchymal resection.
• There have been many techniques described for incision
placement, parenchymal resection, and dermoglandular
pedicled position. And in general, any combination of
these techniques can be utilized for a successful
reduction.
• Preoperative markings and measurements are placed
with the patient standing or seated in an upright
position. This includes:
■ The midline from sternal notch to xyphoid.
■ The midclavicular and breast meridian line.
■ The projection of the inframammary crease
superimposed onto the midclavicular line.
■ The appropriate skin incision pattern i.e., vertical,
Wise, etc.
• The patients are placed in the supine position, under
general anesthesia.
• Make certain the patients hips are placed at the break in
the bed to allow for the head to be raised during the
surgery to assist with determination of symmetry.
• Lidocaine with epinephrine is infiltrated along the
incisions and into the planned parenchymal resection.
■ Infiltration of local anesthetic into the dermoglandular
pedicle should be avoided.
• Some authors have combined suction lipectomy with
reduction mammaplasty techniques to assist with
postoperative breast contour and reduction of axillary
fullness or lateral chest rolls.
■ Care must be taken to avoid infiltration of tumescent
solution or passage of suction cannulas into the
planned dermoglandular pedicle.
• A nipple-areolar complex marker or cookie cutter
of desired size is used to mark the periareolar
incisions.
• The peri-areolar incision is performed first and the
surrounding areas of the pedicle are de-epithelialized.
■ Care must be taken to avoid getting too deep as direct
injury to the subdermal plexus could lead to vascular
compromise of the nipple.
• The remaining skin incisions are made and skin flaps
created.
• After parenchymal resection and excess skin is removed,
meticulous hemostasis should be obtained.
• Closure often involves a combination of deep shaping
sutures within the remaining parenchyma, followed by
layered closure of the skin.
• The new nipple areolar complex position is marked using
the nipple areolar complex marker of desired size.
tissue they require for the reduction procedure to be
covered.
• This amount of tissue can, however, vary from state to
state and from insurer to insurer.
• A focal breast exam is mandatory as well, evaluating for
any masses of the breast, axilla, and supra- and
infraclavicular fossae. The nipple-areolar complex should
be assessed for changes or discharge, as well as its
preoperative sensitivity.
• Some women have decreased sensitivity due to prior
surgery, but often there is decreased sensitivity due
to the excess weight of the breast causing traction
injury to the cutaneous innervation of the nipple-areolar
complex.
• The skin of the breast should be scrutinized to assess for
stigmata of previous operations or physiologic changes,
such as scars or striae, which should be pointed out to
the patient preoperatively.
• Finally, shape and symmetry of the breasts preoperatively
must also be assessed and pointed out to the patient,
especially in cases of very large breasts, because some
degree of asymmetry will virtually always remain
postoperatively.
• Breast measurements, such as the sternal notch to nipple
distance, the nipple to inframammary fold distance, and
the nipple to nipple distance, must be documented
preoperatively.
Anatomical pearls
• The pathophysiology of mammary hypertrophy is
thought to be the result of an abnormal response of the
breast to circulating estrogens, causing breast
proliferation which is predominantly fibrous tissue, fat,
and, to a lesser degree, glandular tissue.
• Most women with mammary hypertrophy have normal
circulating levels of estrogen as well as normal numbers
of estrogen receptors in the breast tissue.
• Cases of juvenile virginal hypertrophy of the breast can
be seen as early as late childhood and often is present in
the age range of 11–14 years of age.
• Gigantomastia is a condition in patients with mammary
hypertrophy that is defined by their need to have over
1800 g of tissue resected.
• Increasing sternal notch to nipple distances portend a
decreased likelihood for success using a superiorly-based
pedicle.
• Vertical short-scar techniques can be performed
comfortably if the sternal notch to nipple distance is
<38 cm.
• In cases where the sternal notch to nipple distance
exceeds 40 cm, plastic surgeons should seriously consider
lower pole breast amputation via a Wise pattern skin
resection with either free nipple grafting or immediate
nipple reconstruction with subsequent tattoo of the
areola.
• Longer inframammary fold to nipple distances
ultimately may preclude the use of an inferior pedicle
technique.
Video
16.1
Video
16.2
Video
16.3

256
•
• Reduction mammaplasty
16
Figure 16.1  (A–C) Passot technique of nipple transposition. (Redrawn after Lickstein LH, Shestak KC. The conceptual evolution of modern reduction mammoplasty. Operat
Tech Plast Reconstr Surg. 1999;6:88–96.)
A
B
C
a
b
Figure 16.2  (A–D) Schwarzmann reduction with superomedial dermoglandular pedicle. (Redrawn after Lickstein LH, Shestak KC. The conceptual evolution of modern
reduction mammoplasty. Operat Tech Plast Reconstr Surg. 1999;6:88–96.)
Resected
breast
De-epithelialized
skin
Breast
thinned
Deep de-epithelialized
pedicle
A
B
C
D
• The nipple areolar complex is inset into its new position
and secured using a combination of dermal and
subcuticular closure.
Specific techniques (Figs 16.1–16.9)
Postoperative considerations
• Most patients can be discharged home on the same day
following reduction mammaplasty.
• Depending on the size of the parenchymal resection,
some authors advocate the use of closed suction drains.
• When used, drains are typically removed on
postoperative day 1.
• In Wise pattern skin incision techniques, postoperative
brassieres containing underwires should be avoided for
6–8 weeks to prevent direct pressure over incisions.
• Full-on running or activities that tend to cause vigorous
up and down motion of the new breasts are restricted
until 8 weeks postoperatively.
• Nipple-areolar complex sutures are generally removed on
the 10th day.
Complications and outcomes
• One of the most devastating complications of reduction
mammaplasty is nipple loss.
• Risk factors include technical errors, smoking, diabetes,
obesity, and hypertension.
• In high-risk patients (smokers, patients with diabetes
or obesity, or those with severe ptosis), a free nipple
graft technique is an option that can be considered and
is also a possibility intraoperatively or postoperatively
if the viability of the transposed nipple appears
compromised.

257
Complications and outcomes
Figure 16.3  (A–E) Biesenberger reduction – degloving the breast with inverted T closure. (Redrawn after Lickstein LH, Shestak KC. The conceptual evolution of modern
reduction mammoplasty. Operat Tech Plast Reconstr Surg. 1999;6:88–96.)
A
B
C
D
E
Resected breast
Pedicle rotated
Skin flaps elevated
Skin excision
Figure 16.4  (A–C) Strombeck horizontal bipedicle technique. (Redrawn after Lickstein LH, Shestak KC. The conceptual evolution of modern reduction mammoplasty. Operat
Tech Plast Reconstr Surg. 1999;6:88–96.)
De-epithelialized
skin
Resected
breast
a
b
c
a
b
c
A
B
C

258
•
• Reduction mammaplasty
16
A
B
C
D
E
F
a
b
c
d
e
f
Lateral
Medial
Figure 16.5  (A–N) McKissock vertical bipedicled dermoglandular flap with Wise-pattern skin excision. (Redrawn after Lickstein LH, Shestak KC. The conceptual evolution
of modern reduction mammoplasty. Operat Tech Plast Reconstr Surg. 1999;6:88–96.)
• The nipple-areolar complex may be converted to a free
nipple graft up until approximately 12 h postoperatively.
• After 12 h, conservative treatment of any nipple necrosis
should be undertaken, including release of sutures,
topical nitropaste or leeches, greasy dressings, hyperbaric
oxygen therapy (if available), and appropriate antibiotic
therapy.
• Many times, conservative treatment and closure by
secondary intention produces a satisfactory result. If
healing does not produce a satisfactory result, the
nipple-areola complex can be reconstructed by standard
reconstruction techniques ranging from simple tattooing
of the areola to flap reconstructions of the nipple itself.
• Hypertrophic and/or prominent scars may be treated
with compression, silicone sheeting, laser treatment, or
intralesional triamcinolone (Kenalog) injections.
• Tension free closure can minimize the risk of hypertophic
scarring.
• It is preferable to assess patients for scar revision after 1
year.
• Flap necrosis can occur, especially when the inverted-T or
Wise-pattern technique is used.
• Treatment includes vaseline gauze dressings, antibiotics,
and selective debridement.
• Small areas of skin necrosis (1–2 cm) frequently occur
along the inframammary fold at the T-junction and may
be treated conservatively.
• Malposition of the nipple can sometimes be corrected
with repositioning; however, one should wait at least
several months to allow complete healing of the breast
and nipple-areolar complex.
• Over-resection, under-resection, and healing
complications can contribute to cosmetic
disappointments.
• Other complications can include infection, hematoma,
seroma, and fat necrosis.

G
I
K
J
H
a
b
L
N
M
a
a
b
b
c
d
d
f
Figure 16.5, cont’d

Figure 16.6  Inferior pedicle technique with Wise-pattern skin excision.
Gland/fat specimen removed
Figure 16.7  McKissock vertical dermoglandular flap with Wise-pattern skin
excision. (Redrawn after Lickstein LH, Shestak KC. The conceptual evolution of
modern reduction mammoplasty. Operat Tech Plast Reconstr Surg. 1999;6:88–96.)
De-epithelialized skin
Inframammary crease
Resected breast
Figure 16.8  (A–I) Central mound technique popularized by Hester. (Redrawn from Hester TR Jr, Bostwick J III, Miller L. Breast reduction utilizing the maximally
vascularized central pedicle. Plast Reconstr Surg. 1985;76:890–900.)
Closure of horizontal limb from
periphery towards center to eliminate
dog ears
Excision of excess skin from vertical
limb and nipple placement
De-epithelialization
Superior
skin flap
Lateral
skin flap
Medial
skin flap
Central
breast pedicle
Tissue to be
resected
Temporary
closure of
vertical limb
Measurement
and excision of
medial and
lateral dog ears
A
B
C
D
E
F
G
H
I

261
Further reading
Figure 16.9  (A–D) Superomedial pedicle with Wise-pattern skin closure.
A
B
C
D
a
b
c
d
Back cut
a
b
b
c
c
d
d
Further reading
Adams F. The seven books of Paulus Aegineta. [Translated from
the Greek.] With a commentary embracing a complete view
of the knowledge possessed by the Greeks, Romans, and
Arabians on all subjects connected with medicine and
surgery. Vol 2. London: Kessinger;
2009;(1844–1847):334–335.
Appel 3rd JZ, Wendel JJ, Zellner EG, et al. Association
between preoperative measurements and resection
weight in patients undergoing reduction
mammaplasty. Ann Plast Surg. 2010;64(5):512–515.
Appel et al. performed a retrospective analysis of 348
patients undergoing bilateral reduction mammaplasty (696
breasts) between October 2001 and March 2009. The
association between resection weight and sternal notch to
nipple distance (SNN), inframammary fold to nipple
distance (IMFN), and body mass index (BMI) was assessed.
The authors concluded that resection weight correlates
strongly with SNN, IMFN, and BMI in patients
undergoing reduction mammoplasty and, when considered
together, resection weight can be predicted with a great
degree of accuracy.
Benelli L. A new periareolar mammaplasty: round block
technique. Aesthetic Plast Surg. 1990;14:93.
Blomqvist L, Eriksson A, Brandberg Y. Reduction
mammaplasty provides long-term improvement in
health status and quality of life. Plast Reconstr Surg.
2000;106(5):991–997.
Blomqvist et al. investigated the health status and quality of
life of patients who underwent reduction mammoplasty.
They conducted a prospective four part questionnaire study
in 49 women who were ≥20 years, using preoperative and
postoperative assessments at 6 and 12 months. The authors
found that reduction mammaplasty provided significant
reduction of pain in all locations (p < 0.001), with an
average weight of resected tissue being 1052 g, and the
improvements continued up to 12 months postoperatively.
Postoperatively, patients reported a significantly improved
quality of life. After 1 year, there was no statistically
significant difference between the post-reduction patients
and the age-matched unoperated women, which suggested
those women were normalized in health-related quality of
life.
Dieffenbach JF. Die operative chirurgerie. Vol 2. Leipzig:
Brockhaus; 1848:370.
Eliasen CA, Cranor ML, Rosen PP. Atypical duct
hyperplasia of the breast in young females. Am J Surg
Pathol. 1992;16(3):246–251.
Eliasen et al. demonstrated a predominance of atypical
ductal hyperplasia in nine patients with macromastia, who
ranged in age from 18 to 26 years (average 21 years).
Though unable to find any significant gross abnormalities
within the resected breast tissue except for two
fibroadenomas, the authors were able to demonstrate that
each case had a continuum of microscopic ductal changes,
which ranged from partial to complete involvement by
micropapillary and lactiform epithelial hyperplasia.
Hall-Findlay EJ. A simplified vertical reduction
mammaplasty: shortening the learning curve. Plast
Reconstr Surg. 1999;104(3):748–763.
Hester Jr TR, Bostwick III J, Miller L. Breast reduction
utilizing the maximally vascularized central pedicle.
Plast Reconstr Surg. 1985;76:890.
Lassus C. Breast reduction: evolution of a technique – a
single vertical scar. Aesthetic Plast Surg.
1987;11(2):107–112.
Lejour M, Abboud M. Vertical mammaplasty without
inframammary scar and with breast liposuction.
Perspect Plast Surg. 1990;4:67.
Netscher DT, Meade RA, Goodman CM, et al. Physical and
psychosocial symptoms among 88 volunteer subjects
compared to patients seeking plastic surgery
procedures to the breast. Plast Reconstr Surg.
2000;105:2366–2373.
Netscher investigated the relationship between macromastia
and physical and psychosocial symptoms. A total of 21
augmentation mammaplasty patients and 31 breast
reduction patients were graded on their somatic and
psychosocial symptoms and compared with a control group

262
•
• Reduction mammaplasty
16
of 88 female university students. The study’s purpose
was to discover which complaints were most common
among women presenting for reduction mammaplasty and
to determine whether body mass index and chest
measurements affected their symptoms. The authors
concluded that patients who present with symptomatic
macromastia seeking reduction mammaplasty have a
disease-specific group of physical and psychosocial
complaints that are more directly related to large breast size
than to being overweight.
Orlando JC, Guthrie Jr RH. The superomedial pedicle for
nipple transposition. Br J Plast Surg. 1975;28:42.
Passot R. La correction esthetique du prolapsus mammaire
par le procede de la transposition du mamelon. Presse
Med. 1925;33:317.
Penn J. Breast reduction. Br J Plast Surg. 1955;7:357.
Pitanguy I. Surgical correction of breast hypertrophy. Br J
Plast Surg. 1967;20:78.
Schnur PL, Hoehn JG, Ilstrup DM, et al. Reduction
mammaplasty: cosmetic or reconstructive procedure?
Ann Plast Surg. 1991;27(3):232–237.
In the study by Schnur et al., 92 of 220 plastic surgeons
that responded to their survey included information (height,
weight, and amount of breast tissue removed) from 600
women regarding the last 15–20 reduction mammaplasties
by each surgeon. A second survey followed to estimate
percentages of women who sought reduction mammaplasties
for purely cosmetic reasons, for mixed reasons, and for
purely medical reasons, and 132 of the same 220 surgeons
responded.
Wise RJ. A preliminary report on a method of planning the
mammaplasty. Plast Reconstr Surg. 1956;17:367.

©2014, Elsevier Inc. All rights reserved.
Chapter
17 
Implant based breast reconstruction
Brief introduction
• With increasing recognition of the value of immediate
reconstruction for the mastectomy patient, the option of
expander-implant became more practical for
incorporation into techniques for reconstruction.
• The first stage is insertion of the expander either at the
time of mastectomy or delayed until the patient is
referred or presents for reconstruction. If not performed
at the time of the mastectomy, it is preferable to delay
reconstruction by a minimum of 3 months and until
adjuvant treatments are completed.
• Capsular contracture has been widely investigated as the
major trade-off of prosthetic reconstructions.
• The beneficial effects of the acellular dermal matrix in the
prevention of long-term complications such as capsular
contracture or poor morphological results may be
hindered by a higher percentage of short-term severe
complications, including seroma and infection.
• Advantages of the expander-implant technique for breast
reconstruction include the following:
■ Minimal morbidity.
■ Reduced operative time.
■ Although there are usually two procedures involved,
each is relatively short and may or may not require a
hospital stay.
■ No donor site morbidity.
■ If the patient becomes dissatisfied with the result, all
pre-existing flaps are still available.
• Disadvantages of the expander-implant technique for
breast reconstruction include the below.
This chapter was created using content from
Neligan & Grotting, Plastic Surgery 3rd edition,
Volume 5, Breast, Chapter 14, Expander-implants
breast reconstruction, Maurizio B. Nava, Giuseppe
Catanuto, Angela Pennati, Valentina Visintini
Cividin and Andrea Spano, Chapter 15, Latissimus
dorsi flap breast reconstruction, Scott L. Spear and
Mark W. Clemens.
SYNOPSIS (IMPL ANT-BASED RECONSTRUCTION)
■ Implant-based breast reconstructions can be employed in all
patients, provided that they have not been previously irradiated.
■ Medium size anatomically-shaped permanent silicone implants can
be employed to reconstruct virtually all breasts, irrespective of
shape and size.
■ A contralateral adjustment should be part of the reconstructive
project.
■ Breast reconstruction in the large breast can be accomplished in
one stage (“Skin reducing mastectomy”).
SYNOPSIS (L ATIS SIMUS FL AP RECONSTRUCTION)
■ The latissimus flap includes a large well-vascularized flat muscle
that is well suited for dealing with poorly-vascularized or radiated
defects, contour deformities following breast conservation therapy,
or for covering an implant.
■ Placement of a tissue expander under the latissimus muscle allows
postoperative adjustment of breast volume and ultimately better
symmetry with the opposite breast.
■ Complete mobilization to reach medial breast defects may require
the partial release (90%) of the latissimus dorsi insertion. This
helps avoid the displeasing bulge in the low axilla; however, care
must be taken to protect the thoracodorsal vessels.
■ The extended latissimus dorsi flap is a reliable method for totally
autologous breast reconstruction and can be considered a primary
choice for breast reconstruction, particularly in women who
otherwise are at high risk for a TRAM flap or an implant procedure.

264
•
• Implant based breast reconstruction
17
• Complications inherent to implant use are:
■ Implant deflation or malfunction.
■ Capsular contracture.
■ Fear of adverse interactions between the patient’s
immune system and the device.
■ Contour irregularities visible on skin surface due to
the underlying implant.
• The implant will not behave like normal vascularized
tissue:
■ It will remain cooler than adjacent body parts when
ambient temperature is low.
■ The reconstructed breast will not develop natural
ptosis with advancing age.
• As the number of breast cancer cases continues to rise,
progressively more of these women are receiving
adjunctive radiation and may not be candidates for
implant alone reconstructions.
• While the main workhorses of autologous reconstructions
are abdominal based flaps, the latissimus dorsi
myocutaneous flap is an essential reconstructive option
and has gained renewed interest due to its reliability, ease
of dissection, versatility, and minimal donor site
morbidity (Fig. 17.1).
Preoperative considerations
For expander/implant reconstructions
• General criteria for implant-expander reconstruction
include an adequate skin envelope to support the
expander-implant.
Figure 17.1  (A) Preoperative appearance of a 48-year-old female with left breast cancer requiring radiation. (B) Postoperative; patient is 2 months post-left mastectomy
with reconstruction with a left latissimus dorsi flap and expander. (C) Postoperative; patient is 3 months post-left nipple construction and exchange of expander to silicone
implant. (D) 1-year postoperatively.
A
B
C
D
• The patient must be well informed about all options for
breast reconstruction.
• The patient must be willing to accept the use of a
permanent prosthesis.
• Relative contraindications to implant based
reconstructions include previous radiation, skin fibrosis
or scleroderma, and smoking as these all portend a
higher risk of complications (e.g., infection, capsular
contracture, expander/implant failure).
• Postoperative radiotherapy is controversial and the
timing of expander-implant exchange with the adjuvant
radiotherapy is often site/surgeon specific.
For latissimus flap reconstructions
• Particular attention is given to the amount of skin and
subcutaneous tissue obtainable in the dorsal region.
■ A good indication is given by pinching the lateral
dorsal pad to estimate the thickness of the adipose
layer.
■ It is vital to compare the mass available with that
which will be needed to achieve a suitable breast size.
■ It is also important preoperatively to assess the
function of the latissimus dorsi muscle.
■ Denervated and non-functional muscle after an
axillary dissection increases the risk of damaged
thoracodorsal vessels or inadequate circulation.
■ In this instance, the latissimus dorsi must be elevated
on an intact serratus collateral pedicle.
■ Functioning muscle is most often a favorable sign for
the integrity of the pedicle; however, it does not
guarantee intact thoracodorsal vessels.

265
Operative techniques
• Near its insertion, the muscle becomes a 3 cm broad
tendon.
• Action: to adduct, extend and internally rotate the upper
extremity. It also assists in securing the tip of the scapula
against the posterior chest wall.
• It is an expendable muscle because function is preserved
by the remaining synergistic shoulder girdle muscles.
• Vascular supply: type V muscle according to the Mathes
and Nahai classification.
• Dominant pedicle: the thoracodorsal artery, two venae
comitantes, and the thoracodorsal nerve.
• The length of the thoracodorsal artery is 8 cm with a
diameter of 2.5 mm.
• Along with the circumflex scapular artery, it is a branch
of the subscapular artery arising from the axillary artery.
• Gives off a branch to the serratus muscle shortly after
entering the underside of the latissimus muscle in the
posterior axilla 10 cm inferior to the muscle insertion into
the humerus (Fig. 17.2).
• Even when the thoracodorsal pedicle has been divided, a
reversal of flow through the patent serratus branch can
provide adequate blood flow to the flap.
• Secondary segmental pedicles: enter the underside of the
muscle through the lateral perforators row off the
posterior intercostal arteries 5 cm from the posterior
midline and through the medial perforators row off the
lumbar artery adjacent to the site of muscle origin.
• These perforators allow the use of the latissimus dorsi as
a foldover flap to cover midback defects.
• Once it is in the muscle, the vascular pedicle bifurcates
into a large lateral descending branch and a smaller
transverse branch.
• This bifurcation makes it possible to split the muscle for
use as a double flap or to preserve half of the muscle to
maintain function.
• Numerous musculocutaneous perforators extend from
the rich intramuscular vascular network into the
overlying skin and subcutaneous tissue, allowing skin
islands to be safely designed anywhere within the margin
of the muscle.
• The largest perforators branch from the lateral branch of
the thoracodorsal artery, making safest the skin island
located in a lateral vertical orientation.
• At the level of the 10th–11th rib, there is a firm, thick
aponeurotic attachment between the serratus anterior and
the latissimus.
• These attachments must be divided to prevent
inadvertent elevation of the serratus anterior muscle
along with the latissimus dorsi flap.
Operative techniques
Expander/implant reconstruction
Stage I: expander insertion (Video 17.1)
• Dissection starts from the lateral border of the pectoralis
major muscle and it follows in the subpectoral plane
superiorly, medially, and inferiorly (Fig. 17.3).
• Indications for latissimus flap reconstruction include:
■ Breast reconstruction after a skin-sparing mastectomy
when a breast prosthesis is part of the plan.
■ Partial mastectomy or lumpectomy deformities.
■ Patients who are not candidates for a TRAM flap.
■ Women who have had a previous abdominoplasty or
TRAM flap, women with insufficient abdominal skin
or fat, women who smoke, have diabetes, or are obese
and may be considered to be too high risk to undergo
a TRAM flap.
■ Previous irradiation during breast conservative
therapy.
■ Excessively thin or unreliable skin flaps over an
implant.
■ After a previous mastopexy or reduction as the skin
flaps in these patients may be unreliable.
■ Women who have had breast augmentation previously
may select a skin-sparing mastectomy with a
latissimus flap over their breast prosthesis.
■ Large ptotic breasts.
■ Contraindications to latissimus flap reconstruction
include:
■ Previous posterolateral thoracotomy in which the
latissimus muscle had been divided.
■ An atrophic latissimus muscle after division of the
thoracodorsal nerve during an axillary dissection.
■ Immediate latissimus reconstruction before radiation
therapy.
Anatomical/technical pearls
Expander/implant selection
• The size of the device used is largely based on breast
width, size and shape of the contralateral breast. It must
also take into account the patient’s wishes on
contralateral symmetrization procedures.
• The expander should be usually the same height as the
contralateral breast.
• The projection of tissue expanders is normally variable
and depends on the level of inflation and amount of
projection desired.
Latissimus flap anatomy
• The latissimus dorsi muscle is a large, flat, triangular
muscle measuring approximately 25 × 35 cm and
covering the posterior inferior half of the trunk.
• Origin: the iliac crest, the posterior layer of the
thoracolumbar fascia, the lower six thoracic spines, and
the lower third to fourth ribs laterally, where it is closely
associated with some origins of the external oblique
muscle.
• Insertion: intertubercular groove of the humerus.
• Near the tip of the scapula, it converges in a spiral
fashion and joins with fibers of the teres major to form
the posterior axillary fold.
Video
17.1

266
•
• Implant based breast reconstruction
17
Figure 17.3  Expander positioning: dissection of the lateral border of pectoralis
major.
Figure 17.4  Muscular fibers detached from the rib insertion: perforator vessels of
pectoralis major muscle can be isolated and diathermized.
Serratus artery
Thoracodorsal
artery
Lumbar perforators
Intercostal perforators
Figure 17.2  The blood supply to the latissimus dorsi muscle.
• The sternal attachments of the pectoralis major are
detached from the second intercostal space to the inferior
edge of the pocket (Fig. 17.4).
■ The pocket should be completely sub-muscular except
at the inframammary fold where, if this has been
correctly preserved, it should extend into the deep
fascial layer avoiding direct continuity with the
mastectomy site (Figs 17.5–17.7).
■ In circumstances where the muscular fascia is injured,
the inferior pectoralis attachments are disrupted, or
there is a relative excess of skin which would
accommodate greater intraoperative expansion,
acellular dermal matrices (ADMs) may be used as an
inferior sling to create a larger subpectoral pocket and
assist with inferior pole expander coverage.
○
The ADM is secured inferiorly to the rectus fascia,
laterally to the serratus fascia, and superiorly to
the inferior border of the pectoralis.
• Once the pocket is created and hemostasis obtained,
the expander is introduced and correctly oriented
(Figs 17.8, 17.9).
• Subcutaneous drains of the mastectomy pocket should be
inserted.
• The sub-muscular pouch is closed with absorbable
interrupted sutures, and the skin is closed in layers.

267
Operative techniques
• The expander can be inflated to the maximal amount
without causing undue tension on the skin closure.
Typically, one can inflate the expander up to around 50%
of the overall volume.
Stage II: expander/implant exchange (Video 17.2)
• Commonly performed 6 months after the end of tissue
expansion which allows tissue stretching and provides an
initial degree of ptosis to the reconstructed breast as well
as completion of adjuvant therapies when needed.
• The mastectomy scar can often be removed and a new
access is created in the same place (Fig. 17.10).
• The subcutaneous layer is then dissected from the
muscular fibers and the muscle is incised and split in the
orientation of its anatomical direction.
• The expander is removed and replaced by the permanent
implant of choice. In some cases, a total capsulectomy
must be performed.
Figure 17.5  The totally submuscular pouch is made up of pectoralis major and
serratus.
Figure 17.6  Complete dissection of the inferomedial fibers of pectoralis major.
Figure 17.7  Final aspect of the pouch.
Figure 17.8  A closed suction drain is visible in the pouch.
A
B
Video
17.2

268
•
• Implant based breast reconstruction
17
Figure 17.9  (A) The expander is partially inflated with saline. (B) The expander is
correctly positioned. (C) The expander is now easily accommodated inside the
pouch.
C
A
B
Figure 17.10  Second stage; change of tissue expander for permanent implant.
Incision along the previous mastectomy scar.
■ The capsule work can be performed with the expander
in situ or after expander removal.
• Once the expander is removed, refinements to the
capsule/pocket are performed to create a more natural
contour.
• The permanent implant is inserted and the wound closed
in layers with care to re-approximate the muscular
incision using absorbable suture.
Postoperative considerations
Expander implant reconstruction
• Prophylactic antibiotics with activity against
staphylococcal bacteria should be routinely administered
and therefore postoperative administration is not
required without clinical signs of infection.
• A well-fitting sports bra should be worn following
reconstruction and contralateral surgery.
• Intensive exercise should be avoided for 2–3 weeks,
although arm and shoulder mobilization is important
following formal axillary dissection.
• Inflation of the prosthesis should be carried out weekly,
beginning only after the initial mastectomy incisions have
healed.
• Drains are left until output reaches 30–40 mL per day.
• Most surgeons keep patients on oral antibiotic therapy
while drains are in place.
• Expansion usually occurs weekly or every other week in
60–100 cc increments of saline solution.
• In general, the second stage of the operation is not
performed until 4–6 months after the initial surgery or
following adjuvant radiotherapy.
• Follow-up after the second stage follows the course
for traditional augmentations. An ultrasound scan

269
Outcomes and complications
can be diagnostic in case of implant ruptures. However,
the MRI scan is the “gold standard” to diagnose shell
ruptures.
Outcomes and complications
Expander/implant reconstruction
• Hematoma incidence ranges from 0% to 5.8%. In the
setting of expanding hematomas or hematoma in the
vicinity of an expander/implant, operative evacuation
and exploration is warranted.
• Stable hematomas or those remote from the expander/
implant pocket (i.e., axilla) can sometimes be managed by
sterile aspiration.
• Erythema (Fig. 17.11) is a frequent response of the skin to
dissection and it will often resolve spontaneously.
• If erythema is associated with symptoms of infection
(malaise, fever, or an increase in drainage through the
suction catheters), intravenous antibiotic therapy either
on an inpatient basis or via a home-care service, should
be provided.
• Failure of cellulitis to resolve indicates peri-implant
infection. Expander removal is required with a repeat of
stage 1, in 3–6 months.
• Infection rates range from 0% to 15%.
• After 10 days, wound contamination at the drain exit site
becomes a real risk.
• If serous accumulation is extensive, reoperation with
culture of the expanders, irrigation of the space, and
insertion of new drains are appropriate.
• Skin envelope necrosis may occur in the range of 0% to
21%. When necrotic complications occur, the expansion
process has to be delayed pending healing of areas of
partial or complete skin loss.
• If partial or complete skin necrosis at the suture line
is observed, muscle coverage of the expander in this
Figure 17.11  Skin cellulitis inflammation.
region is generally provided by the pectoralis major
muscle or a segmental rectus muscle flap. Thus, for small
areas of necrosis, conservative measures or the use of
topical antibiotics and local wound care are generally
adequate.
• In cases of evident deep skin necrosis, serial debridement
can be performed and salvage of the implant sometimes
obtained.
• If there is concern about impending expander exposure,
options include:
■ Excision of the area of skin necrosis and advancement
of the remaining envelope for closure and implant
closure and implant coverage.
■ Use of an autologous flap such as the latissimus dorsi
flap.
■ Expander removal with plans for delayed
reconstruction.
■ Expander-implant reinsertion can be scheduled after a
minimum of 3–6 months, depending on the status of
the overlying skin envelope.
• Expander failure or malfunction (Figs 17.12, 17.13) may
occur if there has been an injury to the expander wall
integrity – expander replacement is required in this
instance.
• Late complications primarily involve complications
related to the prosthesis including deflations and rupture,
capsular contracture, and wrinkling.
• In a study comparing three consecutive study groups,
there was no significant difference in major and minor
complication rates between autogenous and non-
autogenous reconstruction (Table 17.1).
• The total time for expander-implant procedures remains
much less than for flap procedures, but the average
number of procedures is greater (Table 17.2).
• Implant based two stage breast reconstructions generate
high satisfaction rates.
• The Achilles’ heel of this strategy is the difficulty in
reaching a satisfactory symmetry.
Figure 17.12  Skin necrosis and implant exposure.

270
•
• Implant based breast reconstruction
17
Figure 17.13  Expander malpositioning and rotation.
Table 17.1  Frequency of complications by type of reconstruction
Complication
Implants
Pedicle TRAM flaps
Free TRAM flaps
n
(%)
n
(%)
n
(%)
Back pain
1
1.3
4
2.2
4
6.0
Hernia/abdominal wall laxity
–
14
7
8
8
11.9
Lymphedema
33
8
10
5.6
3
4.5
Capsular contracture
12
15.2
–
–
Implant shift
1
1.3
–
–
Wound dehiscence
3
3.8
10
5.6
1
1.5
Partial flap loss (fat necrosis)
5
6.3
29
16
21
14.9
Total flap loss
0
2
1.1
1
1.5
Anastomotic thrombosis
–
–
4
6.0
Implant failure
3
3.8
–
–
Infection
28
35.4
21
11.7
12
17.9
Clostridium difficile colitis
0
1
0.5
0
Hematoma/seroma of the breast
4
5.1
7
3.9
6
9.0
Hematoma/seroma of the abdomen
–
7
3.9
3
4.5
Abdominal wall necrosis
–
3
1.7
0
Cardiac/pulmonary complications
1
1.3
6
3.4
6
9.0
Reproduced with permission from Wilkins EG, Cederna PS, Lowery JC, et al. Prospective analysis of psychosocial outcomes in breast reconstruction: one-year
postoperative results from the Michigan Breast Reconstruction Outcome study. Plast Reconstr Surg. 2000;106:1014–1027.
Operative technique
Latissimus dorsi flap reconstruction
(Video 17.3)
• Before designing the flap itself, examine the patient’s
back and mark the lateral margin of the latissimus
dorsi muscle along the posterior axillary line down
to the posterior iliac crest by supporting the patient’s
abducted arm and palpating the muscle laterally as the
patient pushes downward (Fig. 17.14). The superior
margin of the flap is identified by locating the tip
of the scapula, with the patient’s arms at their sides
(Fig. 17.15).
Table 17.2  Average operative time for each technique and
average number of procedures for final result
Average
operative
time by
technique
(h)
Average number
of proceduresa
on reconstructed
breast by
technique
Implant (n = 82)
1.2
1.8
Staged tissue expander-
implant (n = 142)
3.2
2.4
Latissimus dorsi implant
(n = 107)
3.8
1.7
TRAM flap (n = 106)
5.5
1.2
Free flap (n = 12)
9.0
1.2
Operative techniques have improved with experience, and time required for free
flaps has been reduced by 3 h on average.
aDoes not include nipple-areola reconstruction.
(Reproduced with permission from Trabulsy PP, Anthony JP, Mathes SJ.
Changing trends in postmastectomy breast reconstruction: a 13-year
experience. Plast Reconstr Surg. 1994;93:1418–1427.)
Video
17.3

271
Operative technique
• The skin island may be designed laterally, obliquely in a
natural skin line along the lower midback, or transversely
where the scar can be hidden within the confines of the
bra straps (Fig. 17.16).
• Scar location is an important consideration when
performing breast reconstruction using the latissimus
dorsi flap.
• The low transverse incision (below the level of the
inframammary fold) is preferred by most women,
Future skin island
Areas to be
de-epitheliarized
Figure 17.14  Common placement of the skin island in planning of latissimus
dorsi flap reconstruction with a prosthesis.
Figure 17.15  When total autogenous latissimus breast reconstruction is planned,
the skin island is designed to include all available excess back skin and fat.
Figure 17.16  The latissimus dorsi skin paddle may be designed transversely
(lower, middle, and upper), obliquely, or vertically. Each design has distinct
advantages and disadvantages to dissection exposure, amount of harvestable tissue,
and final scar contour and location.

272
•
• Implant based breast reconstruction
17
• The entire surface of the muscle to be used is exposed in
this same plane.
• Dissection then proceeds laterally to identify the lateral
border of the latissimus dorsi muscle.
• The latissimus muscle is separated from the
serratus anterior, and the flap is elevated along
its lateral edge.
• The lumbosacral fascia is divided at the level of
the posterior axillary line, then the latissimus fibers
of origin are separated from the paraspinous muscle
fascia.
• Care must be taken to avoid incising through the
paraspinous fascia because this makes identification of
the proper plane of dissection difficult.
• The remaining fibers of origin are divided medially from
the vertebral column.
• The large intercostal perforating vessels in this region
should be carefully controlled to prevent bleeding and
postoperative hematoma formation.
• Superomedially, the covering fibers of the trapezius
muscle are identified and elevated away from the
underlying latissimus muscle.
• After the superior border of the latissimus is identified,
dissection is carried out laterally toward the axilla,
separating away the fibers of the teres major muscle that
diffuse with those of the latissimus.
• The entire muscle flap is then elevated toward the axilla
(Fig. 17.19A).
• The thoracodorsal artery and vein are identified at the
point of entrance into muscle.
• The serratus branch is easily identified and may be left
intact, especially if the patient had axillary dissection in
which the thoracodorsal artery may have been injured.
The additional blood inflow through the serratus branch
may be critical.
• It is desirable in most patients to divide the latissimus
dorsi muscle near its insertion at its attachment to the
humerus.
• Release of the insertions helps avoid the displeasing
bulge in the low axilla that is sometimes seen when the
insertion is left intact.
• Care must be taken during this step to preserve the
thoracodorsal vessels. A small cuff of muscle, 10–20%,
may be preserved to help protect from traction on the
pedicle.
Figure 17.18  In the autogenous latissimus flap, the deep fat is
left attached to the muscle as the dissection is carried out just
beneath the fascia superficialis. This ensures adequate volume
for reconstruction and preservation of the dorsal skin flaps.
Skin
Superficial fat layer
Deep fatty layer
Muscle
Superficial fascia
Figure 17.17  The patient is positioned in the lateral decubitus position for
latissimus flap elevation. This allows easy access to the entire muscle and its
insertion.
followed by the middle transverse incision (at the level of
the inframammary fold), the upper transverse incision
(above the level of the inframammary fold), and lastly the
vertical and oblique incisions.
• While this is compelling, it must be balanced against the
needs of the breast reconstruction.
• Latissimus flap elevation is performed in the lateral
decubitus position (Fig. 17.17).
• Dissection is often carried out just beneath the superficial
fascia, leaving the deep fat attached to the surface of the
muscle (Fig. 17.18).

273
Operative technique
• The muscle is sutured medially and inferiorly to the
underlying muscle and fascia to help establish those
borders of the breast.
• Superiorly, marionette half-mattress sutures are
used between the overlying breast skin and the
edge of the latissimus muscle to help cover the entire
mastectomy defect with the latissimus muscle. Not tying
these sutures provides access for placement of the
expander.
Delayed reconstructions
• The latissimus flap is used both for inferior pole
fullness and to cover an expander or implant.
• In most cases, an incision is made at or just above
the predetermined inframammary fold along a
line from the lateral sternal border to the anterior
axillary line.
• The superior chest wall skin flap is elevated, usually in
the subcutaneous plane, and the latissimus flap is
brought through the tunnel and into the defect.
• Suturing of the muscle at or near the anterior axillary
line should be performed to prevent lateral migration of
the flap and implant and to protect the pedicle from
tension.
• The best projection is achieved when the pectoralis major
muscle is left intact and the expander or prosthesis is
• The flap is then transferred to the mastectomy defect
through a subcutaneous tunnel high in the axilla to
further prevent an unnatural lateral bulge and to fill the
axilla (Fig. 17.19B).
• Suturing of the muscle at the anterior axillary line
should be performed to prevent lateral migration
of the flap and implant and to protect the pedicle from
tension.
• The back incision is closed over suction drains. Some
surgeons utilize quilting sutures, fibrin sealant adhesives,
or barbed sutures during this closure to eliminate or
minimize dead space. Skin closure is performed in layers
including 2-0 polydioxanone to the fascia superficialis
followed by interrupted and running intradermal 3-0
Monocryl to the dermis.
• The inset/placement of the flap depends on the particular
circumstances of the reconstruction.
Immediate reconstructions
• When the latissimus flap is used over an expander, it is
easier and quicker to leave the pectoralis major muscle
intact and to place the expander between the latissimus
and pectoralis major muscles (Fig. 17.20).
• The muscle is typically inset just beneath the upper
mastectomy skin flap which helps achieve some soft
tissue filling of the upper breast pole.
Figure 17.19  (A) Elevation of the latissimus dorsi musculocutaneous flap and the underlying anatomy. (B) After division of the muscle insertion, the latissimus flap is
transposed anteriorly to the mastectomy defect through a subcutaneous tunnel high in the axilla.
A
B

274
•
• Implant based breast reconstruction
17
• Various moldings can be tried until one arrives
at a satisfactory shape for the rebuilt breast. This
procedure of molding is crucial to the final quality
of the result, and one must understand how to achieve
the different arrangements necessary for a good
morphologic result.
Postoperative considerations
Latissimus flap reconstruction
• Patients will have two back drains and one to two breast
drains.
• A loose circumferential dressing or surgical bra
may be used with placement of axillary gauze
for padding, however, care should be taken to
avoid any direct compression over the vessels in the
axilla.
• Length of hospitalization is on average three days and
patients can expect to return to normal work function
from 3–6 weeks.
• Suction drains will remain in place until output
is <30 mL/day, with back drains in place up to
3–4 weeks.
placed between the latissimus and pectoralis major
muscles.
• The muscle is sutured medially and inferiorly to the
underlying muscle and fascia in such a way as to help
form those borders of the breast and superiorly,
marionette half-mattress 3-0 Prolene sutures are placed
between the overlying breast skin and the edge of the
latissimus muscle to help cover the entire mastectomy
defect with the latissimus muscle.
• The expander is inserted from above and may be
filled with several hundred milliliters of saline because
there is generally no tightness to the sub-latissimus
pocket.
• Postoperatively, the tissue expander is further inflated
until the desired volume is achieved, starting 2 weeks
postoperatively or once the wound is healed.
• The second stage (expander/implant exchange) of the
reconstruction is typically performed after 4–8 months,
allowing adequate healing and settling of the soft
tissue.
• When reconstruction is planned with use of the total
autogenous latissimus dorsi flap, the cutaneous paddle is
molded in the form of an asymmetric U (Fig. 17.21).
• The curved base of the U gives the apex of the breast.
The distal part of the muscle and its underlying fat are
folded under this breast cone to increase the volume and
the projection of the breast.
Figure 17.20  When immediate latissimus flap reconstruction is
planned with a prosthesis for skin-sparing mastectomy, the skin
pattern is designed as a discrete small island. After transposition
of the flap, the expander is placed between the latissimus and
pectoralis major muscles.

275
Further reading
• Migration of the expander or implant through the axilla
and into the back can occur.
• Should be avoidable by suturing the latissimus muscle to
the lateral chest wall.
• Other implant-related complications can occur including
capsular contracture, device failure, periprosthetic
infection, and device extrusion.
Further reading
Bailey S, Saint-Cyr M, Zhang K, et al. Breast reconstruction
with latissimus dorsi flap: Women’s preference
for scar location. Plast Reconstr Surg. 2010;126:
358–365.
Carlson GW, Bostwick 3rd J, Styblo TM, et al. Skinsparing
mastectomy. Oncologic and reconstructive
considerations. Ann Surg. 1997;225:570–575.
This study introduced the basic concepts of skin
preservation. Skin incisions for removal of glandular tissue
are subdivided into four groups.
Chang DW, Youssef A, Cha S, et al. Autologous breast
reconstruction with the extended latissimus dorsi flap.
Plast Reconstr Surg. 2002;110:751.
The authors present their experience with the extended
latissimus dorsi myocutaneous flap for replacement of breast
volume without an implant. A total of 75 extended
latissimus dorsi flap breast reconstructions were performed
in 67 patients (mean age 51.5 years). Flap complications
developed in 21 of 75 flaps (28.0%), and donor-site
complications developed in 29 of 75 donor sites (38.7%).
Mastectomy skin flap necrosis (17.3%) and donor-site
seroma (25.3%) were found to be the most common
complications. There were no flap losses. The study
concluded that patients who are obese are at higher risk of
developing donor-site complications.
Cordeiro PG, Pusic AL, Disa JJ, et al. Irradiation after
immediate tissue expander/implant breast
reconstruction: outcomes, complications, aesthetic
results, and satisfaction among 156 patients. Plast
Reconstr Surg. 2004;113(3):877–881.
The impact of radiation in implant-based reconstruction is
investigated in this study. The authors would support this
technique as a proper alternative to flap-based
reconstructions.
Delay E, Gounot N, Bouillot A. Autologous latissimus breast
reconstruction: a 3 year clinical experience with 100
patients. Plast Reconstr Surg. 1998;102:1461.
Delay et al. presented their technique of autologous breast
reconstruction using the latissimus dorsi flap and studied
the results that can be expected. A consecutive sample of
100 patients was studied (average follow-up 20 months).
Supplementary volume of the latissimus dorsi was obtained
from five fatty zones: fat on the cutaneous paddle, fat taken
from the surface of the muscle, the scapular fat pad, the
anterior fatty zone, and the supra-iliac fat pad. The authors
found the following complications: 1% partial necrosis, 1%
total necrosis of the flap, and seroma 79%, most regularly in
obese patients. The level of patient satisfaction was high.
• Upper extremity strengthening and range-of-motion
exercises are begun 2 weeks postoperatively assuming
sufficient progression of healing.
Outcomes and complications
Latissimus flap reconstruction
• Breast reconstruction with the latissimus dorsi
musculocutaneous flap has been associated with
significant patient satisfaction.
• The latissimus dorsi flap is a hardy flap that has an
excellent and reliable circulation with minimal risk of flap
necrosis even in smokers and diabetics.
• Significant flap necrosis is unusual and nearly always
associated with injury to the vascular pedicle.
• Partial flap necrosis has been noted in up to 7% of
patients but is more common when an extended flap has
been elevated.
• The most common complication is seroma at the back
donor site.
• Other donor site problems include dorsal skin flap
necrosis, loss of shoulder mobility, shoulder weakness,
winging of the scapula, and dorsal hernia.
Figure 17.21  For total autogenous latissimus reconstruction, the flap is folded
into a cone shape to increase the volume and projection of the reconstructed
breast.
Flap pedicle

276
•
• Implant based breast reconstruction
17
Laitung JKG, Peck F. Shoulder function following the
loss of the latissimus dorsi muscle. Br J Plast Surg.
1985;38:375.
Losken A, Carlson GW, Bostwick 3rd J, et al. Trends in
unilateral breast reconstruction and management of
the contralateral breast: The Emory experience. Plast
Reconstr Surg. 2002;110:89–97.
McCraw JB, Papp C, Edwards A, et al. The autogenous
latissimus breast reconstruction. Clin Plast Surg.
1994;21:279.
Moore TS, Farrell LD. Latissimus dorsi myocutaneous flap
for breast reconstruction: long term results. Plast
Reconstr Surg. 1992;89(4):666–672.
Nava MB, Spano A, Cadenelli P, et al. Extra-projected
implants as an alternative surgical model for breast
reconstruction. Implantation strategy and early results.
Breast. 2008;17(4):361–366.
A new reconstructive paradigm is introduced in this paper.
Breast reconstructions aim to rebuild a bilateral breast
mound of a medium size, with extra-projection and
cosmetically pleasing.
Neumann CG. The expansion of an area of skin by
progressive distention of a subcutaneous balloon. Plast
Reconstr Surg. 1957;19:124.
An historical study on tissue expansion.
Papp C, McCraw JB. Autogenous latissimus breast
reconstruction. Clin Plast Surg. 1998;25:261.
Radovan C. Breast reconstruction after mastectomy using
the temporary expander. Plast Reconstr Surg.
1982;69:195.
Russell RC, Pribaz J, Zook EG, et al. Functional evaluation
of latissimus dorsi donor site. Plast Reconstr Surg.
1986;78:336.
Saint-Cyr M, Nagarkar P, Schaverien M, et al. The pedicled
descending branch muscle-sparing latissimus dorsi
flap for breast reconstruction. Plast Reconstr Surg.
2009;123(1):13–24.
Schneider WJ, Hill HL, Brown RG. Latissimus dorsi
myocutaneous flap for breast reconstruction. Br J Plast
Surg. 1977;30:277.
Schwabegger AH, Harpf C, Rainer C. Muscle-sparing
latissimus dorsi myocutaneous flap with maintenance
of muscle innervation, function, and aesthetic
appearance of the donor site. Plast Reconstr Surg.
2003;111:1407–1411.
Serra-Renom JM, Muñoz-Olmo JL, Serra-Mestre JM. Fat
grafting in postmastectomy breast reconstruction with
expanders and prostheses in patients who have
received radiotherapy: formation of new subcutaneous
tissue. Plast Reconstr Surg. 2010;125(1):12–18.
This study investigates the effects of fat grafting in the
treatment of radio-induced dermatitis. This is the largest
series currently available in literature.
Spear SL, Clemens MW, Boehmler J. Latissimus dorsi flap in
reconstruction of the radiated breast. In: Spear SL, ed.
Surgery of the Breast: Principles and Art. 3rd ed.
Amsterdam: Wolters Kluwer; 2010.
Indications for this technique include, when one can bury
the cutaneous paddle: cases of skin-sparing mastectomy and
cases of conversion of implant reconstruction to an
autologous reconstruction.
Delay E, Jorquera F, Lucas R. Sensitivity of breasts
reconstructed with the autologous latissimus dorsi
flap. Plast Reconstr Surg. 2000;106:302–309.
Fraulin FOG, Louie G, Zorrilla L, et al. Functional
evaluation of the shoulder following latissimus dorsi
muscle transfer. Ann Plast Surg. 1995;35:349.
Fraulin et al. looked at the functional effects of latissimus
dorsi muscle harvest on shoulder strength and mobility.
This was a study of 26 patients (10 males, 16 females) who
underwent a pedicled or free vascularized latissimus
dorsimuscle transfer. Muscle testing was performed using a
Kinetic Communicator machine (Kin Com) and the
Baltimore therapeutic equipment (BTE) work simulator. The
female unilateral pedicle group (n = 13) showed a significant
difference between operated and nonoperated shoulders for
both peak torque (power) and work (endurance)
measurements of shoulder adduction and extension
(mean ratios operated/non-operated shoulders, 55–69%).
The male free vascularized group (n = 10) similarly showed
a significant deficit of both peak torque and work for
shoulder extension and adduction (mean ratios, 74–84%).
The paper concluded that dynamic muscle tests demonstrate
a deficit of muscle power and endurance of shoulder
extension and adduction following latissimus dorsi muscle
transfer.
Hammond DC. Latissimus dorsi musculocutaneous flap.
Plast Reconstr Surg. 2009;124:4.
The author presents his extensive experience with the
latissimus dorsi musculocutaneous flap in both immediate
and delayed breast reconstruction. Five technical
modifications in surgical technique are introduced including
orientation of the skin island along the relaxed skin tension
lines, harvesting the deep layer of fat with the flap, cutting
the thoracodorsal nerve, partially dividing the insertion of
the muscle, and using a staged expander/implant sequence.
These principles result in a thin line and smooth donor-site
scar. The flap advances completely to the breast because of
the partial release of the insertion of the muscle, and the
volume provided by the flap is increased by keeping the deep
layer of fat attached to the flap. Breast animation is
minimized as a result of sectioning of the thoracodorsal
nerve, and the consistency and quality of the result are
improved by using a staged tissue expander/implant
strategy.
Handel N, Silverstein MJ. Breast cancer diagnosis and
prognosis in augmented women. Plast Reconstr Surg.
2006;118(3):587–596.
Herborn CU, Marincek B, Ermann D, et al. Breast
augmentation and reconstructive surgery: MR imaging
of implant rupture and malignancy. Eur Radiol.
2002;12:2198–2206.
Krueger EA, Wilkins EG, Strawderman M. Complications
and patient satisfaction following expander/implant
breast reconstruction with and without radiotherapy.
Int J Radiat Oncol Biol Phys. 2001;49:713–721.

277
Further reading
The authors reviewed their experience with the latissimus
dorsi flap and a prosthesis in reconstruction of the
previously irradiated breast. Twenty-eight patients all had
soft breasts at follow up, with no evidence of capsular
contracture. Donor-site complications included five donor-
site seromas. The majority of patients (65%) underwent a
planned two-stage reconstruction, and the majority of the
revision operations were for exchanges to smaller implants.
The overall satisfaction rating was 8.8 of 10. The authors
concluded that although purely autologous reconstructions
may be the best choice for many irradiated breasts, it has
been shown in this study that a cosmetically acceptable
reconstruction with manageable risk can be performed using
a prosthesis combined with a latissimus dorsi flap. The
study concluded that with advancements in surgical
technique and improvements in tissue expander and implant
design, outstanding results can be obtained using the
latissimus dorsi flap in breast reconstruction.
Tobin GR, Moberg AW, DuBou RH, et al. The split
latissimus dorsi myocutaneous flap. Ann Plast Surg.
1981;7:272–280.

©2014, Elsevier Inc. All rights reserved.
Chapter
18 
Autologous breast reconstruction using abdominal flaps
Brief introduction
• While the free technique utilizing the inferior epigastric
vessels undoubtedly provides additional blood flow to
the transferred abdominal tissue, it carries with it the
need for advanced microsurgical training and, in most
hands, a significantly longer operative time.
• Abdominal tissue based breast reconstructions (pedicled
TRAM, free TRAM, DIEAP) can be safely performed in
either an immediate or delayed fashion with respect to
the mastectomy.
This chapter was created using content from
Neligan & Grotting, Plastic Surgery 3rd edition,
Volume 5, Breast, Chapter 16, The bilateral pedicled
TRAM flap, L. Frankyn Elliot, John D. Symbas and
Hunter R. Moyer, Chapter 17, Free TRAM breast
reconstruction, Joshua Fosnot, Joseph M. Serletti,
Chapter 18, The deep inferior epigastric artery
perforator (DIEAP) flap, Phillip N. Blondeel, Colin
M. Morrison and Robert J. Allen.
SYNOPSIS (PEDICLED TRAM)
■ The pedicled TRAM flap is still the most popular way of
transferring abdominal tissue to the breast.
■ This technique, introduced by Dr Carl Hartrampf, is consistently
successful if it is performed properly.
■ The muscle and fascial sparing technique ensures abundant
vascularity to the TRAM flap, while allowing secure and
complication free closure of the abdominal wall.
■ The shaping of the breast using the pedicled TRAM flap is
enormously simplified in the immediate reconstructive setting.
■ We recommend utilizing the pedicled TRAM flap for bilateral
reconstruction and the free TRAM flap for unilateral reconstruction.
SYNOPSIS (FREE TRAM)
■ The free TRAM is one tool in an entire armamentarium used for
breast reconstruction.
■ Although controversial, the free TRAM likely limits donor site
morbidity and ischemic complications when compared with the
pedicled TRAM.
■ Free TRAM reconstruction can be performed safely in an
immediate or delayed fashion.
■ For the most part, radiation therapy after reconstruction
yields more unpredictable results than radiation before
reconstruction.
■ Free TRAM flap breast reconstruction requires intraoperative
attention to detail and postoperative vigilance.
■ Although revision is not uncommon, the free TRAM provides for
excellent, predictable aesthetic results with a high degree of patient
satisfaction.
SYNOPSIS (DIEAP)
■ The deep inferior epigastric artery perforator (DIEAP) flap provides
a large volume of soft, malleable tissue that resembles the natural
consistency of the breast.
■ DIEAP flap dissection is comparable to conventional
myocutaneous free flap surgery, once the initial learning curve is
overcome.
■ The main advantage of the DIEAP flap is the preservation of full
rectus abdominis muscle function translating into less donor site
morbidity.
■ In experienced hands, the DIEAP flap loss rate is less than 1%.
■ The DIEAP flap is the perforator flap of choice for autologous
breast reconstruction.

279
Preoperative considerations
■ MS0: complete transection of the muscle.
■ MS1: transection of most of the muscle.
■ MS2: harvest of only the central portion of the muscle.
■ MS3: complete muscle sparing (DIEAP).
• Although sacrificing the rectus muscle will not leave a
patient completely disabled, patients may notice a
considerable difference in flexion strength and abdominal
contour when the rectus muscles are sacrificed.
• Objective measures of abdominal wall strength after
pedicled or free TRAM reconstruction have consistently
shown a deficit in strength which may persist long term;
however, multiple head to head studies have not shown a
significant difference in long-term abdominal wall
function.
Preoperative considerations
• Given that most women undergoing mastectomy and
reconstruction are young and healthy without significant
co-morbidities, it is exceedingly rare for a woman to be
considered too high risk for surgery. However, it is
important to know the risk factors for poor postoperative
outcomes.
• There is an increased risk of wound infection,
mastectomy flap necrosis, abdominal flap necrosis and fat
necrosis in smokers.
• Obese patients are more likely to experience wound
related complications including mastectomy flap necrosis.
• Peripheral vascular disease is a risk factor for wound
infection.
• Prior abdominal operations have been shown to increase
the risk of complications associated with TRAM flap
reconstruction.
• Techniques for minimizing risk include skewing the
abdominal flap away from the previous scar, using
hemiflaps, minimizing flap undermining, and
supercharging.
• A prior abdominoplasty is generally considered an
absolute contraindication to TRAM flap reconstruction
because the prior skin flap sacrifices all perforating
vessels.
• Patients should not only be made aware of the inherent
risks of the surgery including the possibility of
complications, they should be educated as to the
limitations of reconstructions as well.
• It is helpful to point out asymmetries preoperatively.
• Scarring is an unfortunate phenomenon of which patients
should have expectations postoperatively.
• Patients should be told of the likelihood of significant
sensory loss – although some sensation may return most
women never achieve a fully sensate mound.
Procedure selection
• Reconstruction of a breast mound using autologous
tissue can be performed using multiple techniques, but
there is no one perfect flap which can be used in all
circumstances. Ultimately, deciding whether to use a
• Immediate reconstruction has several advantages:
■ Patients benefit from only needing one operation.
■ Most surgeons find that immediate reconstruction is
easier to perform.
■ The mastectomy skin flap envelope is more
predictable.
■ Skin sparing or nipple sparing mastectomy techniques
are options in some patients to minimize the loss of
the native envelope.
• Many patients present in a delayed fashion, either
because they did not undergo any reconstruction at the
time of mastectomy or because they had prosthetic
reconstruction which subsequently failed.
• Generally speaking, delayed reconstruction should not be
undertaken sooner than 6 months following mastectomy
due to immature scar formation; however, there is no
temporal limit.
• Delayed reconstruction requires re-elevation of the skin
flaps which are often scarred and less compliant. The
mastectomy scar should be completely excised and if
radiation injury is evident, this should be excised as well.
Scarred or radiated skin can result in inadequate ptosis
and poor symmetry over time.
• When designing a DIEAP flap, the main factor is the
amount of viable tissue that can be harvested on a
particular perforator.
• The most accurate indicator of this is preoperative
localization of the dominant source of blood inflow by
duplex Doppler or CT imaging.
• In addition to defining the “safe” flap territory, these
techniques provide a degree of reassurance by avoiding
intraoperative surprises and considerably reduce
operative time.
The pedicled versus free TRAM/DIEAP
• The main issues at stake when comparing these two
techniques are: the technical aspects of the operation, the
long-term results, and the donor site morbidity.
• The pedicled TRAM requires complete dissection of the
rectus muscle up to the level of the xiphoid. Because the
flap and pedicle are turned over, there is the risk of
twisting; thus, the insetting of the flap itself can be quite
challenging.
• The free TRAM or DIEAP on the other hand requires the
additional expertise of a microanastomosis; however,
once the pedicle is created, the insetting of the flap tends
to be less problematic.
• Aside from the technical aspects of the two operations,
one must compare the long-term results weighed against
the donor site morbidity.
• Due to the reliance on “choke” vessels for flap survival in
the pedicled TRAM, there is a theoretical increased risk
of ischemic complications such as partial or total flap loss
and fat necrosis.
• For free TRAMs, there have been various muscle
sparing (MS) iterations described, and surprisingly,
much of the literature has suggested that as the degree
of muscle sparing increases, so does the rate of fat
necrosis.

280
•
• Autologous breast reconstruction using abdominal flaps
18
pedicled versus a free TRAM or DIEP mostly has to do
with surgeon training, preference and hospital resources
such as an operating microscope and microsurgical
instruments.
• There are certain circumstances where the free flap
techniques should be considered superior.
■ Smoking increases the risk of wound related
complications and fat necrosis. Therefore, smokers
(even if they quit) should probably be offered a free
TRAM rather than pedicled TRAM or DIEP flap.
■ When a larger volume flap is needed for
reconstruction, this pushes the vascular supply of the
pedicled TRAM and DIEP to its limits. As a result, the
free TRAM is likely the better choice.
■ Any patient with a history of previous upper
abdominal surgery which may have created a scar in
the rectus sheath or destroyed the superior epigastrics
should be offered a free flap preferentially.
■ The DIEP and SIEA flaps are excellent options utilizing
the same lower abdominal island of tissue – the
benefits being less abdominal wall invasion and
resultant long-term abdominal wall function. The
downside of course is the more tenuous blood supply.
Anatomical pearls
• The anatomy of the abdominal wall is critical to a
complete understanding of the differences between
various forms of abdominal based breast reconstruction
such as the pedicled TRAM, free TRAM, deep inferior
epigastric perforator (DIEP), and superficial inferior
epigastric artery (SIEA) flaps (Figs 18.1, 18.2).
• The TRAM flap is based on the blood supply from the
perforating vessels through the rectus abdominis muscle
and the deep epigastric system.
• The arcuate line marks a critical landmark as it
represents the point where the inferior epigastric vessels
perforate the rectus muscle.
• The anatomy of the perforating vessels is somewhat
variable and may be predominantly along the lateral
third of the muscle, in the central third of the muscle, or
even in the medial third (Fig. 18.3).
• There are generally three basic arterial schemata:
■ Type I pattern: a single intramuscular vessel extends
from the superior epigastric artery to the deep inferior
epigastric artery.
■ Type II (majority): the inferior epigastric artery
branches into two vessels at the arcuate line and
communicates with the superior epigastric through
anastomosing choke vessels.
■ Type III: exhibited three branches of the inferior
epigastric at the arcuate line. On average shows an
even greater number of anastomoses with the superior
epigastric artery.
• Perforators through the rectus muscle cross the anterior
rectus sheath generally in two rows, one medial and one
lateral.
• The rectus abdominis muscle is a type III muscle, in
addition to the superior and inferior epigastric vessels,
circulation includes branches of the 8th, 9th, 10th, 11th,
and 12th intercostal vessels which penetrate the
posterior rectus sheath just medial to the linea
semilunaris.
• The circulation from either rectus muscle across the lower
abdomen is divided into four zones. The circulation is
best in zone I, somewhat variable in zones II and III, and
usually poor in zone IV, particularly with a pedicled
TRAM flap (Fig. 18.4).
■ Zone I: zone immediately overlying the rectus muscle.
■ Zone II: zone immediately across the midline.
■ Zone III: ipsilateral zone just lateral to the rectus
muscle border.
■ Zone IV: contralateral zone lateral to the contralateral
rectus border.
■ Blood supply is improved to some degree in each zone
after a delay procedure.
Operative techniques
Pedicled TRAM (Fig. 18.5; Video 18.1)
• The patient is marked in the preoperative area. The
abdominal flap is designed with the lower transverse
incision located two fingerbreadths above the pubic
symphysis and the upper incision usually just at the
upper border of the umbilicus.
• The lower incision extends out laterally and crosses
over the anterior superior iliac spine and angles cephalad.
• The upper incision is essentially level extending laterally
until it meets the rising lower incision (Fig. 18.6).
• The superior skin incision is made first and the dissection
continues through the fat, beveled superiorly to recruit
additional fat into the flap.
• Once the fascia is reached, the upper abdominal flap is
elevated suprafascially up to and over the costal margins
bilaterally for about 2 cm while the dissection in the
midline continues up to the xiphoid.
• The subcutaneous tunnel (or tunnels in bilateral cases) is
then created to allow transfer of the flaps into the
mastectomy defects (Fig. 18.7). These tunnels should be
made at the 5 o’clock and 7 o’clock positions through the
right and left inframammary folds respectively.
• On average, each tunnel needs to accommodate
approximately four fingers to allow passage of each
hemiflap.
• Once the superior flap is elevated, it can be pulled
inferiorly to confirm the position of the appropriate
inferior incision line. This maneuver will help determine
whether the original incision marking is appropriate to
allow abdominal closure without undue tension.
• Once confirmed, the lower incision is then made, straight
down to the underlying fascia.
• No attempt is made to bevel inferiorly as the fat in the
prepubic region is probably not as reliable based on the
superior epigastric system as we would like to think.
• The umbilicus is circumscribed and left in position with
some surrounding fat.
Video
18.1

281
Operative techniques
Figure 18.1  The anatomy of the abdominal wall. In particular, note the parallel nature of the rectus abdominis muscles with their dual blood supply from both the inferior
and superior epigastric vessels. Multiple layers of muscle and fascia contribute to the overall strength of the abdominal wall. (Netter illustration from
©Elsevier Inc. All rights reserved.)
Superior
epigastric vessels
External
oblique muscle
(cut away)
Rectus abdominis
muscle
External oblique
aponeurosis (cut)
Internal oblique
aponeurosis (cut)
Transversus
abdominis muscle
Internal
oblique muscle (cut)
Posterior layer
of rectus sheath
Arcuate line
Inferior
epigastric vessels
Anterior superior
iliac spine
Superficial
circumflex iliac
Superficial epigastric
Superficial
external pudendal
arteries (cut)
Inguinal falx
(conjoint tendon)
Reflected
inguinal ligament
Pubic tubercle
Cremaster muscle and fascia
External spermatic fascia (cut)
Anterior layer of
rectus sheath (cut)
Linea alba
Anterior layer of
rectus sheath
Transversus abdominis
muscle (cut)
Transversalis fascia
(opened on left)
Extraperitoneal
fascia (areolar tissue)
Medial umbilical
ligament (occluded part
of umbilical artery)
Inferior epigastric
artery and vein (cut)
Site of deep inguinal
ring (origin of internal
spermatic fascia)
Cremasteric and pubic
branches of inferior
epigastric artery
Femoral sheath
(contains femoral
artery and vein)

Fat in retropubic space
(of Retzius)
Pectineal fascia
Internal spermatic fascia
Deep (Buck’s)
fascia of penis
Superficial fascia
of penis and
scrotum (cut)
Cremaster muscle and fascia (cut)
External spermatic fascia (cut)
4
5
6
7
8
9
10
Inguinal ligament
(Poupart’s)
Pectineal ligament
(Cooper’s)
Lacunar ligament
(Gimbernat’s)
Pectineal ligament
(Cooper’s)
Lacunar ligament
(Gimbernat’s)
Inguinal ligament
(Poupart’s)

282
•
• Autologous breast reconstruction using abdominal flaps
18
• Proposed markings of the boundaries of the left and right
rectus sheaths, as well as the costal margin can be made
in the superior epigastrium using methylene blue.
• One must carefully observe the degree of the diastasis
recti (Fig. 18.8A).
• The sterile Doppler is now used to locate the position
of the superior epigastric artery as it passes from deep to
the costal margin. This location is important as it should
become the center of the muscle portion that is harvested
superiorly (see Fig. 18.8B).
• The proposed muscle and fascial harvest is drawn in
using methylene blue incorporating the emanation of the
superior epigastric vessels superiorly and harvesting
approximately one-third to one-half of the central rectus
fascia as the proposed muscle and fascial flap pedicle (see
Fig. 18.8).
• Dissection begins at the costal margin laterally and
extends through the fascia for 2–3 cm caudal to the costal
margin.
• At this point, the anterior fascia is elevated laterally to
confirm the position in the muscle relative to its lateral
border. We try to leave 1–2 cm of muscle and, more
importantly, fascia laterally. One must confirm though
that the dissection is not too far lateral or too far
medial high up before the dissection continues inferiorly
(Fig. 18.9A).
• The dissection then continues using the cautery on the
blend setting. It is important to be sure that the patient
has complete muscular paralysis during this
intramuscular dissection.
• The dissection can then continue expeditiously through
the overlying fascia and underlying muscle down to and
below the level of the umbilicus.
• Small oblique vessels will be noted but are only
perineural vessels accompanying the lower abdominal
wall nerves to the rectus segments reminiscent of
intercostal nerves more cephalad.
• If bilateral pedicled TRAM flaps are being performed, the
flap is split in the midline down to the deep fascia to aid
in dissection.
• In unilateral pedicled TRAM procedures, the midline
should not be incised.
• In unilateral cases, the dissection proceeds from lateral to
medial until the lateral row of perforators is encountered.
• In bilateral cases, the dissection can proceed from medial
to lateral on each side until the medial row of perforators
is encountered.
Figure 18.2  The same anatomical structures as explained in Figure 18.1 but seen
in a paramedian sagittal view.
Subdermal plexus
Umbilicus
SIEV
SIEA and venous
comitants
DIEA and venous
comitants
Scarpa’s fascia
Rectus
abdominis
Caudal
Cranial
Figure 18.3  The different types of perforators that can be found at the lower
abdominal wall. (1) The branches of the superficial inferior epigastric artery are
direct perforators that vascularize the subcutaneous fat and skin after perforating
the deep and superficial fascia. All other perforators are indirect perforators;
(2) perforators that have a predominant vascularization of the subcutaneous fat
tissue and skin with few muscular branches; (3) perforators that branch off of side
branches that have a predominant goal of nourishing the muscle; (4) perforators
that pass through the rectus abdominis muscle without branching; (5) perforators
that pass through the septum or around the rectus abdominis muscle with the sole
goal of vascularizing the subcutaneous tissues.
Figure 18.4  The standard elliptical design of a TRAM flap with Zones I through IV.
(A) Zone I lies directly over the vascular pedicle and is the most reliable. Zones II
and III are generally reliable; however, zone IV should be approached with caution
due to its distance from the vascular pedicle. (B) In bilateral reconstruction, the
majority of each hemiflap is used.
A
B
Unilateral
I
II
III
IV
I
II
III
IV
Bilateral

Figure 18.5  (A–D) Pre- and postoperative photographs of a patient who underwent bilateral pedicled TRAMs.
A
B
C
D
A
B
C
Figure 18.6  (A–C) Abdominal markings.

284
•
• Autologous breast reconstruction using abdominal flaps
18
• The location of the inferior epigastric vessels is in a
relatively constant position two-thirds of the way
caudad from the umbilicus to the pubic symphysis.
Dissection through the muscle proceeds more cautiously
until the inferior epigastric vessels are located (see Fig.
18.9B).
• The muscle can also be elevated from lateral to medial
and the vascular hilum of the inferior epigastric vessels
entering into the muscle might be noted prior to
seeing the inferior epigastric vessels inferiorly (see
Fig. 18.9C,D).
• As the central segment of the muscle is elevated out of its
bed inferiorly it can also be elevated superiorly and the
superior epigastric vessels can also be visibly identified.
• The muscle is now well mobilized, and the inferior
epigastric vessels are identified. They are clipped and
transected with a medium clip applier or ligature.
• The medial dissection on the fascia and muscle can now
be performed. With one hand behind the muscle, one can
Figure 18.7  Tunnel locations.
A
B
C
Figure 18.8  (A) Marking extent of recti. (B) Proposed fascial strip centered over
SEA signal. (C) Final markings of fascial and muscle strip.

285
Operative techniques
• The superior dissection medially is now completed by a
vertical incision up towards the costal margin. The
superior epigastric vessels have been visualized as well
as located using the sterile Doppler so this dissection
continues up without threat of injury to these vessels.
This intramuscular dissection is facilitated by controlling
the muscle and fascial pedicle with one hand, placing
hemostats on the medial fascia for counter-traction and
performing the medial intramuscular dissection with
cautery (Fig. 18.12).
• The incision in the fascia continues up over the costal
margin and meets the original lateral incision in the
fascia; however, muscle is left intact for about 1–2 cm
establish the location of the medial border of the muscle.
Once again, we shift laterally for 1–2 cm where an
incision in the fascia and underlying muscle is made.
This is usually first performed at the level of the
umbilicus (Fig. 18.10).
• Dissection then continues vertically inferiorly and is
curved just below the level of the inferior epigastric
vessels to meet the lateral dissection.
• The muscle and overlying flap must be controlled at all
times by the surgeon as he conducts the fascial and
muscle dissection (Fig. 18.11). At this point, the flap is
freed up inferiorly essentially up to the level of the
umbilicus.
Figure 18.9  Lateral muscle dissection. (A) Identifying lateral extent of rectus muscle as a landmark. (B) Careful intramuscular dissection around DIEA. (C) Identifying DIEA
hilum entering inferolateral edge of muscle. (D) Clipping the DIEA.
A
B
C
This is the level of
the costal margin
IEA hilum entering
the muscle belly
D
IEA clipped
at this level

286
•
• Autologous breast reconstruction using abdominal flaps
18
• Ipsilateral transfer is often preferred in bilateral cases and
avoids crossing the pedicles in the midline.
• In unilateral cases, use of the contralateral flap may be
more beneficial to allow a more gentle rotation of the
pedicle. However, it is probably safe to use either
technique.
• It is helpful to use a towel clip on the lateral tip of the
TRAM flap which passes through the tunnel first. It is
also helpful then to either work the superior corner or the
inferior corner first through the tunnel, the other corner
then follows easily.
• Once the flap is in the chest pocket the pedicle is
carefully adjusted at the costal margin so that it turns
around the costal margin and does not flip over the costal
margin.
• If the pedicle flips over the costal margin it causes two
major twists in the pedicle which are unnecessary if the
gentle turning of the pedicle is instead employed (Figs
18.15–18.17).
• The flap is secured to the chest using skin staples and
attention is turned to abdominal wall closure. This will
allow time for any vascular compromise to the flaps to
occur and be observed.
Abdominal closure
• After the TRAM flap is harvested, a fascial defect remains
in the lower abdominal wall. Depending on the amount
of fascia sacrificed, various techniques may be employed
for closure.
• An MS-3 or MS-2 flap typically has a very small resultant
fascial defect which may be closed primarily without
tension.
• A pedicled TRAM, MS-1 or MS-0 free TRAM defect on
the other hand, may preclude apposition of the free
fascial edges. In this case, mesh is routinely employed.
caudal to the costal margin medially which thins the
muscle proximally at the costal margin to 1–2 cm in
width. This is safe because the presence and location of
the superior epigastric pedicle is confirmed with the
sterile Doppler, direct vision, and/or palpability.
• This creates a muscular-fascial pedicle length of usually
≥8–9 cm (Fig. 18.13).
• The distance from the costal margin to the inframammary
line of the breast is only about 5–6 cm, so 8–9 cm is more
than an adequate length of muscle pedicle to easily reach
the chest area (Figs 18.13B, 18.14).
• The flap skin is moistened and the flap is gently passed
through the preformed tunnel.
Figure 18.10  Medial dissection maintaining control of flap at all times with
opposite hand.
Figure 18.11  Inferomedial dissection to meet inferolateral dissection.
Figure 18.12  Control of muscle and fascial pedicle and use of countertraction on
the fascia during superomedial dissection.

287
Operative techniques
proceeds inferiorly in tandem being careful to include
both the external and internal oblique components of the
anterior rectus sheath. These two components become
very obvious at and below the level of the umbilicus (Fig.
18.19).
• It is extremely important to include both of these
components, particularly the internal layer which
probably accounts for the most important strength of the
closure.
• The most difficult part of the abdominal closure is below
the umbilicus and attention to detail must be stressed
here to be sure that the closure is sound. Each bite is at
• Polypropylene mesh remains the most common subtype
employed for fascial closure in a clean wound (Fig.
18.18).
• In unilateral reconstruction, after closure of the fascia, the
abdominal wall and midline may no longer be
symmetrical. As a result, some surgeons recommend
plication of the fascia on the contralateral side. Care must
be taken, however, to not add to the tension of the fascial
repair.
• The closure typically begins superiorly using double
stranded 0-nylon sutures. The double stranded suture is
looped and avoids a knot superiorly. The closure then
Figure 18.13  (A,B) Demonstrating width and length of fascial and muscle strip and extent of dissection up over costal margin.
A
B
Costal margin
Level of transverse
fascial incision over
costal margin
Medial and
lateral edges
of muscle and
fascial sparing
pedicle
Figure 18.14  Further demonstrating that pedicle length is more than adequate to
reach chest wall defect.
Figure 18.15  Gently turning the pedicle around the costal margin avoids two kinks
which result if the pedicle is flipped.
Flipped
Turned