Plastic Surgery, Volume Five: Breast (Fourth Edition): Cẩm nang Toàn diện Phẫu thuật Thẩm mỹ và Tái tạo Vú – Maurice Y. Nahabedian & Peter C. Neligan

402
SECTION II
CHAPTER 21.3 • Medial thigh flaps for breast reconstruction
transient sensory deficit over the posterior thigh in a
third of cases.19
The most common drawback of the thigh donor site
is the scar, which is not concealable in underwear and
swimwear8 (Fig. 21.3.24). Infection, seroma, and delayed
wound healing around the groin are well recognized
complications, which may be managed with dressings
alone though re-operation to debride and re-suture the
wounds may be required in a few cases. All patients
should be counseled that some minor delayed healing
is possible.34
A serious complication that the authors have not seen
is the chance of temporary or permanent lymphedema
given that the surgical site is over the lymphatics of the
groin.
More subtle complications that we have noticed
include the abrupt change in color of the groin skin from
the donor site and contour change with the lack of
medial bulging at the superomedial thigh.
The relatively darker skin of the thigh forms a nice
nipple area complex in those patients undergoing
the TUG. The PAP flap, however, does avoid harvesting
muscle and is discussed further in the following chapter
(Fig. 21.3.23).22–27
The donor site morbidity is minimal in our series
although some groups have had higher rates of compli­
cations.28 Locke and colleagues had a 62.5% complica­
tion rate within their donor site including sensory
disturbance within the medial thigh and poor scar
requiring revision. They also noticed deficient flap
volume and contour defects. The complication rates
have been reduced by those units performing large
numbers with the modification of the original descrip­
tion, which includes a skewed flap design, preservation
of the long saphenous vein and associated lymphatics,
fat recruitment from the inferior margin, and minimal
muscle harvest.29–33 In addition, patient selection remains
key to minimizing complications.19 Schoeller presents a
large series of 111 patients with 154 TUG flaps for breast
reconstructions. This series has total and partial flap
failure rates of 2% each, a fat necrosis rate of 5%, delayed
wound healing in 6%, a hematoma rate of 3%, and
Fig. 21.3.16  Step 5 – division of proximal gracilis. (© Nakul Patel and Venkat
Ramakrishnan.)
A
B

403
Outcomes, prognosis, and complications
Fig. 21.3.17  Step 6 – pedicle dissection and flap detachment. (© Nakul Patel and
Venkat Ramakrishnan.)
A
B
Fig. 21.3.18  Step 7 – full-cone shaping of transverse upper gracilis flap with nipple reconstruction created as “V-shaped” flaps that are inset as folded arms (left) and
skin-sparing mastectomy specimen (far right) demonstrates a similar shape to the flap. (© Nakul Patel and Venkat Ramakrishnan.)

404
SECTION II
CHAPTER 21.3 • Medial thigh flaps for breast reconstruction
Fig. 21.3.19  Step 7 – full-cone, half-cone, and un-coned transverse upper gracilis flaps. (© Nakul Patel and Venkat Ramakrishnan.)
A
B

405
Secondary procedures – TUG plus…
Fig. 21.3.20  Step 7 – closure of the donor site. (© Nakul Patel and Venkat
Ramakrishnan.)
Fig. 21.3.21  Step 8 – recipient vessels for
microsurgical anastomoses. (© Nakul Patel and
Venkat Ramakrishnan.)
Fig. 21.3.22  Right transverse upper gracilis donor
site highlights visible scar and lack of fullness in
the upper medial thigh. In comparison to the
normal left side, there is minimal change in overall
volume and position of the gluteal crease.
(© Nakul Patel and Venkat Ramakrishnan.)
immediate skin-sparing mastectomies; however, in
delayed cases, the dark skin paddle can be an obvious
eyesore on the lighter colored chest.
Secondary procedures – TUG plus…
There are several adjunctive procedures that can enhance
the flap and increase its indications in breast reconstruc­
tion. The algorithm in Fig. 21.3.25 describes the circum­
stances in which these additional procedures may be
considered.
Lipofilling
Primary lipofilling of the gracilis muscle and pectoralis
muscle can be useful for small volume differences. The
muscle is an ideal vascular matrix for adipocytes and

406
SECTION II
CHAPTER 21.3 • Medial thigh flaps for breast reconstruction
Fig. 21.3.23  Comparison of the transverse upper
gracilis and transverse profunda artery perforator
flap anatomy and donor sites. (© Nakul Patel and
Venkat Ramakrishnan.)
Fig. 21.3.24  Bilateral transverse upper gracilis flap donor site scars. The scars are stretched and have changed the contour of the upper medial thigh. These are visible in
typical swimwear. (© Nakul Patel and Venkat Ramakrishnan.)
Fig. 21.3.25  Algorithm for additional procedures,
which can be considered during the initial
operation or at a second stage. (© Nakul Patel and
Venkat Ramakrishnan.)

407
Secondary procedures – TUG plus…
Fig. 21.3.26  Primary lipofilling of the gracilis muscle as a vascular matrix transfer. This requires closure of the epimysium prior to lipofilling into the muscle. (© Nakul
Patel and Venkat Ramakrishnan.)
Fig. 21.3.27  Implant placed under a mesh construct to increase the breast
volume. (© Nakul Patel and Venkat Ramakrishnan.)
Fig. 21.3.28  An illustration of typical four-flap
breast reconstruction with both transverse upper
gracilis and deep inferior epigastric perforator flap
stacked reconstructions. (© Nakul Patel and Venkat
Ramakrishnan.)
the authors advocate closure of the epimysium at the
distal end of the muscle prior to fat transfer (Fig. 21.3.26).
The TUG flap can also act as a vascular matrix for effec­
tive secondary lipofilling.
Implant
The use of implants under flaps is well described and is
an excellent tool for allowing greater flexibility to what
can otherwise be achieved.35 Depending on the size of
the device used, moderate to large differences can be
addressed with the use of an implant either in the
primary or secondary setting. We use implants with a
mesh construct to keep the device in place prior to inset­
ting the flap (Fig. 21.3.27).
Two flaps for one breast
Double TUG breast reconstructions are common for the
larger breasted patient and are well described.13,29,33 We

408
SECTION II
CHAPTER 21.3 • Medial thigh flaps for breast reconstruction
suggest that a yin-yang orientation of the flaps with
parallel anastomoses in both the axilla and chest allow
optimum breast shape (see Fig. 21.3.7).
Flap-to-flap anastomoses, also known as “in-series
anastomoses” of the two flaps, are an option when a
sufficient adductor branch of the gracilis pedicle is
available. Hunter and colleagues undertook both a clini­
cal and anatomical study of branching patterns from the
gracilis pedicle and showed that three-quarters of cases
should be suitable for in-series anastomoses.33
If significantly more volume is required and the
patient prefers a totally autologous reconstruction, TUG
with another free flap such as the DIEP can given
significant increase to the volume of the breast recon­
struction (Fig. 21.3.28).
The TUG flap remains a reliable autologous option
for breast reconstruction in those patients where the
abdomen is not available. It is a reliable flap with con­
sistent anatomy and potentially acceptable donor site.
In combination with other procedures it can be used in
those patients with larger breasts.
2. Orticochea M. The musculo-cutaneous flap method: an immediate
and heroic substitute for the method of delay. Br J Plast Surg.
1972;25:106–110. First use of the gracilis musculocutaneous flap to
reconstruct an ankle defect.
3. Harii K, Ohmori K, Sekiguchi J. The free musculocutaneous flap.
Plast Reconstr Surg. 1976;57:294–303. First free gracilis
musculocutaneous flap presented in canine models, cadaver dissections,
and clinical applications for reconstruction of the head and neck and lower
extremity.
9. Arnez ZM, Pogorelec D, Planinsek F, Ahcan U. Breast
reconstruction by the free transverse gracilis (TUG) flap. Br J Plast
Surg. 2004;57:20–26. First early series of seven free TUG flaps was used
for breast reconstruction, of which five were successful.
10. Schoeller T, Wechselberger G. Breast reconstruction by the free
transverse gracilis (TUG) flap. Br J Plast Surg. 2004;57:481–482.
Schoeller and Wechselberger described the use of 12 TUG flaps for breast
reconstruction that were all successful. It is this work that has led to the
popularity for the TUG flap for breast reconstruction.
22. Hunter JE, Lardi AM, Dower DR, Farhadi J. Evolution from the
TUG to PAP flap for breast reconstruction: comparison and
refinements of technique. J Plast Reconstr Aesthet Surg. 2015;68:960–
965. Describes the evolution of the TUG to the PAP flap, which is in the
same region.
29. Fattah A, Figus A, Mathur B, Ramakrishnan VV. The transverse
myocutaneous gracilis flap: technical refinements. J Plast Reconstr
Aesthet Surg. 2010;63:305–313. Describes a number of modifications of
the original description, which includes a skewed flap design, preservation
of the long saphenous vein and associated lymphatics, fat recruitment from
the inferior margin, and minimal muscle harvest to reduce complications
and ease flap harvest.
30. Buchel EW, Dalke KR, Hayakawa TE. The transverse upper gracilis
flap: efficiencies and design tips. Can J Plast Surg. 2013;21:162–166.
Describes reliable and rapid TUG flap harvest and provides a video using
only monopolar cautery for the dissection.
31. Saint-Cyr M, Wong C, Oni G, et al. Modifications to extend the
transverse upper gracilis flap in breast reconstruction: clinical series
and results. Plast Reconstr Surg. 2012;129:24e–36e. Modifications to
increase flap volume by using extended and vertical extended flaps are
described in this paper.
33. Hunter JE, Mackey SP, Boca R, Harris PA. Microvascular
modifications to optimize the transverse upper gracilis flap for
breast reconstruction. Plast Reconstr Surg. 2014;133:1315–1325.
Describes a new classification system for the branching pattern of the
TUG flap pedicle to allow flap-to-flap anastomoses in 75 percent of
patients.
Access the complete reference list online at

Bonus images for this chapter can be found online at

Fig. 21.3.1 Timeline for the TUG flap.

408.e1
References
References
1. Pickrell KL, Broadbent TR, Masters FW, Metzger JT. Construction of
a rectal sphincter and restoration of anal continence by
transplanting the gracilis muscle; a report of four cases in children.
Ann Surg. 1952;135:853–862.
2. Orticochea M. The musculo-cutaneous flap method: an immediate
and heroic substitute for the method of delay. Br J Plast Surg.
1972;25:106–110. First use of the gracilis musculocutaneous flap to
reconstruct an ankle defect.
3. Harii K, Ohmori K, Sekiguchi J. The free musculocutaneous flap.
Plast Reconstr Surg. 1976;57:294–303. First free gracilis
musculocutaneous flap presented in canine models, cadaver dissections,
and clinical applications for reconstruction of the head and neck and lower
extremity.
4. Freshwater MF, McCraw JB. Intraoperative identification of the
gracilis muscle for vaginal reconstruction. Plast Reconstr Surg.
1980;65:358–359.
5. Juricic M, Vaysse P, Guitard J, et al. Anatomic basis for use of a
gracilis muscle flap. Surg Radiol Anat. 1993;15:163–168.
6. Yousif NJ, Matloub HS, Kolachalam R, et al. The transverse gracilis
musculocutaneous flap. Ann Plast Surg. 1992;29:482–490. First use of
the TUG musculocutaneous flap for breast reconstruction.
7. Hallock GG. Further experience with the medial circumflex femoral
(GRACILIS) perforator free flap. J Reconstr Microsurg.
2004;20:115–122.
8. Hallock GG. The conjoint medial circumflex femoral perforator and
gracilis muscle free flap. Plast Reconstr Surg. 2004;113:339–346.
9. Arnez ZM, Pogorelec D, Planinsek F, Ahcan U. Breast
reconstruction by the free transverse gracilis (TUG) flap. Br J Plast
Surg. 2004;57:20–26. First early series of seven free TUG flaps was used
for breast reconstruction, of which five were successful.
10. Schoeller T, Wechselberger G. Breast reconstruction by the free
transverse gracilis (TUG) flap. Br J Plast Surg. 2004;57:481–482.
Schoeller and Wechselberger described the use of 12 TUG flaps for breast
reconstruction that were all successful. It is this work that has led to the
popularity for the TUG flap for breast reconstruction.
11. Peek A, Muller M, Ackermann G, et al. The free gracilis perforator
flap: anatomical study and clinical refinements of a new perforator
flap. Plast Reconstr Surg. 2009;123:578–588.
12. Mathes SJ, Nahai F. Classification of the vascular anatomy of
muscles: experimental and clinical correlation. Plast Reconstr Surg.
1981;67:177–187.
13. Park JE, Alkureishi LW, Song DH. TUGs into VUGs and friendly
BUGs: transforming the gracilis territory into the best secondary
breast reconstructive option. Plast Reconstr Surg. 2015;136:447–454.
14. Bodin F, Schohn T, Dissaux C, et al. Bilateral simultaneous breast
reconstruction with transverse musculocutaneous gracilis flaps. J
Plast Reconstr Aesthet Surg. 2015;68:e1–e6.
15. Dayan E, Smith ML, Sultan M, et al. The diagonal upper gracilis
(DUG) flap: a safe and improved alternative to the TUG flap. Plast
Reconstr Surg. 2013;132:33–34.
16. Natoli NB, Wu LC. Vascular variations of the transverse upper
gracilis flap in consideration for breast reconstruction. Ann Plast
Surg. 2015;74:528–531.
17. Heckler FR. Gracilis myocutaneous and muscle flaps. Clin Plast
Surg. 1980;7:27–44.
18. Lee KT, Mun GH. A systematic review of functional donor-site
morbidity after latissimus dorsi muscle transfer. Plast Reconstr Surg.
2014;134:303–314.
19. Schoeller T, Huemer GM, Wechselberger G. The transverse
musculocutaneous gracilis flap for breast reconstruction: guidelines
for flap and patient selection. Plast Reconstr Surg. 2008;122:29–38.
20. Wechselberger G, Schoeller T. The transverse myocutaneous gracilis
free flap: a valuable tissue source in autologous breast
reconstruction. Plast Reconstr Surg. 2004;114:69–73.
21. McCulley SJ, Macmillan RD, Rasheed T. Transverse upper gracilis
(TUG) flap for volume replacement in breast conserving surgery for
medial breast tumours in small to medium sized breasts. J Plast
Reconstr Aesthet Surg. 2011;64:1056–1060.
22. Hunter JE, Lardi AM, Dower DR, Farhadi J. Evolution from the
TUG to PAP flap for breast reconstruction: comparison and
refinements of technique. J Plast Reconstr Aesthet Surg. 2015;68:960–
965. Describes the evolution of the TUG to the PAP flap, which is in the
same region.
23. Saad A, Sadeghi A, Allen RJ. The anatomic basis of the profunda
femoris artery perforator flap: a new option for autologous breast
reconstruction–a cadaveric and computer tomography angiogram
study. J Reconstr Microsurg. 2012;28:381–386.
24. Haddock NT, Greaney P, Otterburn D, et al. Predicting perforator
location on preoperative imaging for the profunda artery perforator
flap. Microsurgery. 2012;32:507–511.
25. Allen RJ, Haddock NT, Ahn CY, Sadeghi A. Breast reconstruction
with the profunda artery perforator flap. Plast Reconstr Surg.
2012;129:16e–23e.
26. Blechman KM, Broer PN, Tanna N, et al. Stacked profunda artery
perforator flaps for unilateral breast reconstruction: a case report. J
Reconstr Microsurg. 2013;29:631–634.
27. Mayo JL, Allen RJ, Sadeghi A. Four-flap Breast Reconstruction:
Bilateral Stacked DIEP and PAP Flaps. Plast Reconstr Surg Glob
Open. 2015;3:e383.
28. Locke MB, Zhong T, Mureau MA, Hofer SO. Tug ‘O’ war:
challenges of transverse upper gracilis (TUG) myocutaneous free
flap breast reconstruction. J Plast Reconstr Aesthet Surg.
2012;65:1041–1050.
29. Fattah A, Figus A, Mathur B, Ramakrishnan VV. The transverse
myocutaneous gracilis flap: technical refinements. J Plast Reconstr
Aesthet Surg. 2010;63:305–313. Describes a number of modifications of
the original description, which includes a skewed flap design, preservation
of the long saphenous vein and associated lymphatics, fat recruitment from
the inferior margin, and minimal muscle harvest to reduce complications
and ease flap harvest.
30. Buchel EW, Dalke KR, Hayakawa TE. The transverse upper gracilis
flap: efficiencies and design tips. Can J Plast Surg. 2013;21:162–166.
Describes reliable and rapid TUG flap harvest and provides a video using
only monopolar cautery for the dissection.
31. Saint-Cyr M, Wong C, Oni G, et al. Modifications to extend the
transverse upper gracilis flap in breast reconstruction: clinical series
and results. Plast Reconstr Surg. 2012;129:24e–36e. Modifications to
increase flap volume by using extended and vertical extended flaps are
described in this paper.
32. Wechselberger G, Pulzl P, Schoeller T. Re: The transverse
myocutaneous gracilis flap: technical refinements. J Plast Reconstr
Aesthet Surg. 2010;63:e711–e712.
33. Hunter JE, Mackey SP, Boca R, Harris PA. Microvascular
modifications to optimize the transverse upper gracilis flap for
breast reconstruction. Plast Reconstr Surg. 2014;133:1315–1325.
Describes a new classification system for the branching pattern of the
TUG flap pedicle to allow flap-to-flap anastomoses in 75 percent of
patients.
34. Craggs B, Vanmierlo B, Zeltzer A, et al. Donor-site morbidity
following harvest of the transverse myocutaneous gracilis flap for
breast reconstruction. Plast Reconstr Surg. 2014;134:682e–691e.
35. Trignano E, Fallico N, Dessy LA, et al. Transverse upper gracilis
flap with implant in postmastectomy breast reconstruction: a case
report. Microsurgery. 2014;34:149–152.

SECTION II • Reconstructive Breast Surgery
21.4 
Profunda artery perforator flap for
breast reconstruction
James L. Mayo, Z-Hye Lee, and Robert J. Allen Sr
SYNOPSIS
■ The profunda artery perforator (PAP) flap is a favorable flap for
autologous breast reconstruction leaving a donor scar in the upper
medial thigh and inferior gluteal crease.
■ Preoperative imaging with magnetic resonance angiography or
computed tomography angiography is a useful adjunct in surgical
planning and efficiency.
■ The dissection of the PAP flap is straightforward through the adductor
magnus muscle, providing a mean pedicle length of 10 cm and
average flap weight of 360 g.
■ The donor site of the PAP flap has been shown to have an acceptable
complication profile compared with the deep inferior epigastric
perforator (DIEP) flap reconstruction.
■ The PAP flap should be strongly considered when the DIEP flap is not
an option.
Access the Historical Perspective section online at

Introduction
Perforator flap breast reconstruction has evolved into a
reconstructive modality touting the ability to provide
“natural-like” tissue for breast reconstruction with a
low morbidity profile. The deep inferior epigastric
perforator (DIEP) flap first described for breast recon­
struction by Allen in 1992 remains the gold standard.1
Tissue from the abdomen is harvested based on
perforator(s) from the deep inferior epigastric artery
sparing the surrounding rectus abdominis muscle
leaving the patient with a slimmer midline. Outcome
studies have shown this flap to be aesthetically pleasing
while providing limited donor site morbidity.2–7 Algo­
rithms and techniques have evolved from an extensive
background of experience and time aimed to perfect
DIEP free flap breast reconstruction.8,9
While the application of the DIEP for breast recon­
struction has spread with aims of further reducing
complications and perfecting aesthetics, not uncom­
monly does a reconstructive surgeon find the abdomen
to be either insufficient in volume or contraindicated
due to previous surgery. In a review of 20 years per­
forming microsurgical breast reconstruction, the senior
author, Dr Allen, has performed DIEP flaps in 66% of
his reconstructions, leaving one-third of patients in need
of a secondary site. The ideal site would offer an ade­
quate volume of pliable fat and skin with limited donor
site morbidity and a fairly well-hidden scar.
The search for the optimal “secondary” flap for
microsurgical breast reconstruction has been extensive.
Reported flaps have included the superior and inferior
gluteal artery perforator (GAP) flaps, transverse upper
gracilis (TUG) flaps, lumbar artery perforator flaps, and
profunda artery perforator (PAP) flaps.10–14 After early
experience with gluteal flaps, a search for the next flap
option was directed to the thighs. The gluteal flaps were
successful and remain a viable option for breast recon­
struction. However, a difficult dissection and suboptimal
efficiency with patient repositioning seen in the SGAP
can be burdensome. Also, both GAP flaps occasionally
led to donor site contour deformities requiring second­
ary procedures.15,16
The PAP flap offers adequate volume, pliable tissue,
and a donor site well hidden within the upper thigh and
buttock crease (Fig. 21.4.1). Beginning in 2010, the senior

410
SECTION II
CHAPTER 21.4 • Profunda artery perforator flap for breast reconstruction
common femoral artery traveling into the posterior
compartment of the thigh prior to branching into a
lateral and medial branch. The lateral branch provides
perforators to the more lateral/posterior thigh, many of
which are septocutaneous perforators. The medial
branch travels in the adductor compartment sending
musculocutaneous perforators to and through the graci­
lis and adductors.
The ideal perforators identified for the PAP flap are
those found medially piercing the adductor magnus.
Utilizing these perforators allows for harvest of the
flap with the patient in a supine position and gives
ideal pedicle length. Original imaging studies by
author, Dr Allen, has utilized the PAP flap as his
second option for perforator-based breast reconstruc­
tion performing roughly 200 PAP flaps for breast recon­
struction. This chapter discusses the evolution/history
of the PAP flap, reviews pertinent anatomy, and details
operative technique, followed by outlining outcomes
and complications.
Basic science/anatomy
The anatomic vascular basis to the PAP flap has been
well documented by both cadaveric and radiographic
studies.20,22–24 The profunda artery arises from the
Fig. 21.4.1  Anterior view of a 54-year-old BRCA-positive woman. (A) Preoperative and (B) postoperative images
for bilateral nipple-sparing mastectomies and profunda artery perforator flap reconstruction. (C,D) Posteromedial
thigh donor site in the 54-year-old woman who underwent bilateral profunda artery perforator free flap breast
reconstruction. The upper incision is placed 1–2 cm below the thigh crease but can vary based on location of the
key perforator. (Courtesy of Christina Ahn, MD.)
A
B
C
D

410.e1
Historical perspective
Historical perspective
The profunda artery perforator (PAP) flap shares a
common origin with both the posterior thigh flap
and the adductor perforator flap.17,18 The posterior
thigh flap began as a pedicled myocutaneous flap
described by Hurwitz in 1981 for local reconstruction.17
At the time, this flap was based mainly on a descending
branch of the inferior gluteal artery. Song et al. described
various thigh septocutaneous perforators including
the posterior thigh flap based off profunda perforators
between vastus lateralis and biceps femoris.19 Expand­
ing on the use of profunda artery perforators, Angrigiani
et al. described utilizing perforator flaps based on the
adductor magnus perforators, which originate from the
profunda artery.18 These flaps were described as large
rectangular flaps for burn and pressure sore reconstruc­
tion with donor site closure via skin graft.
Focusing on donor site location and availability of
volume for breast reconstruction, Dr. Allen designed a
flap similar to the tissue resection for an upper medial
thigh lift.20,21 First performed in Mexico City in 2010, this
perforator flap spans from an anterior point at the origin
of the adductor longus posteriorly to the end of the
inferior gluteal crease. The flap is designed based on the
first or second perforator off the profunda traveling
through the adductor magnus. Quickly, the benefits of
an average flap volume of over 350 g and a hidden
donor site were realized and a new next-in-line option
to the DIEP for breast reconstruction was realized.

411
Patient selection
or local flaps would be necessary to achieve a higher
volume (Fig. 21.4.3).25–27 As with other autologous flaps,
immediate and delayed reconstructions are both appli­
cable. Avoiding radiating the flap is preferable, so those
patients identified as being higher risk for needing radia­
tion therapy are delayed. Preoperative imaging allows
the identification and localization of the key perforator,
which is then identified in the office via hand-held
Doppler and marked as described below (Fig. 21.4.4).
Allen described a lateral and medial posterior thigh
distribution to the PAPs with the majority being 3.8 cm
from the midline and 5 cm below the gluteal fold (Fig.
21.4.2).20 In further CT angiographic studies, DeLong
et al. confirmed a close to 50/50 distribution between
medially and laterally oriented perforators to the poste­
rior thigh originating from the profunda artery.23 The
average pedicle length (10.7 cm) and distance from the
gluteal crease (6.19 cm) were similar to previous studies.
In a review of the senior author’s (Dr Allen) clinical
experience, average flap weight was 367.4 g, recon­
structing an average mastectomy weight of 321 g. Flap
dimensions averaged 27.2 × 6.3 cm with an average
pedicle length of 10.2 cm. The artery and vein diameters
averaged 2.2 mm and 2.8 mm, respectively (Box 21.4.1
and Table 21.4.1).
Patient selection
The ideal patient for PAP flap breast reconstruction is a
patient with either a paucity of abdominal tissue or
a contraindication to use the abdomen as a donor
for breast reconstruction. She should have small- to
moderate-sized breasts, or planning for additional
volume procedures such as stacking flaps, fat grafting,
Fig. 21.4.2  Coordinates of significant profunda artery perforators found in a review
of 40 preoperative computed tomographic angiographies of the lower extremities.
(Reprinted from: Haddock NT, Greaney P, Otterburn D, et al. Predicting perforator
location on preoperative imaging for the profunda artery perforator flap.
Microsurgery. 2012;32:507–511.)
BOX 21.4.1  Flap characteristics
• Average flap weight: 367 g
• Average flap dimensions: 27 × 6 cm
• Average pedicle length: 10.2 cm
• Average artery diameter: 2.2 mm
• Average vein diameter: 2.8 mm
Table 21.4.1  Average location, size, and consistency of medial,
lateral, and central profunda artery perforators
Medial
Central
Lateral
Size
1.9 ± 0.4 mm
1.8 ± 0.4 mm
1.9 ± 0.4 mm
Location
  X-axis
3.8 cm
6.5 cm
12 cm
  Y-axis
5 cm
4.1 cm
5 cm
Border
muscles
Adductor
Semimembranosus
Biceps
Magnus
Femoris
Semitendinosus
Vastus
Lateralis
Consistency
  Present in
thighs
86.0%
32.7%
65.0%
(Reprinted from: Haddock NT, Greaney P, Otterburn D, et al. Predicting
perforator location on preoperative imaging for the profunda artery perforator
flap. Microsurgery. 2012;32:507–511.)
Fig. 21.4.3  The ideal profunda artery perforator flap candidate: thin, relatively
small to moderate breast size, paucity of abdominal tissue, with available inner
thigh volume.

412
SECTION II
CHAPTER 21.4 • Profunda artery perforator flap for breast reconstruction
drawing the upper incision from the adductor longus
along the thigh crease posteriorly to the end of the
gluteal crease (Fig. 21.4.5). The preoperative magnetic
resonance angiography (MRA) or computed tomogra­
phy angiography (CTA) is reviewed to identify key
perforators. The perforator for each PAP flap is identi­
fied via hand-held Doppler with the patient in a prone
position. The lower incision is placed 6–7 cm at its
lowest point. This is drawn to include the key perforator
in as much of a concentric placement as possible. If the
key medial (adductor magnus) perforator is found to be
too low, a perforator can commonly be found more
posterolaterally based off a descending branch of the
inferior gluteal artery or one of the laterally based
profunda perforators (as described in the anatomy
section above). The perforator at times is best identified
and marked with the patient in the prone position.
In the operating room, the patient is laid supine in a
frog-legged position. The lower extremities are fully
prepped and draped into the operative field. With the
thighs abducted, the flaps are raised in an anterior to
posterior direction with the tip of the flap starting just
behind the lymphatic-rich groin area bordered by the
adductor longus. Superiorly, no beveling of the fat is
performed in an effort to leave the ischial fat pad intact.
Inferiorly, beveling is performed as necessary, based on
volume needs and perforator location.
Once the gracilis is encountered, the fascia is opened
vertically over the posterior portion while retracting the
A
Fig. 21.4.4  (A) Representative preoperative magnetic resonance angiography
mapping out the posteromedial profunda artery perforators. (B) The perforator (pink
arrow) coursing through the adductor magnus posterior to the gracilis muscle. A
significant perforator can be found within 8 cm of the upper thigh/gluteal crease.
B
Fig. 21.4.5  Bilateral profunda artery perforator preoperative markings drawn in the
office the day prior to surgery. The anterior tip of the flap starts at the insertion of
adductor longus. The upper limit of the flap is 1–2 cm below the thigh crease and
travels to the posterior extent of the gluteal crease for around 30 cm length. The
flap width is typically 6–7 cm. These measurements are general guidelines;
incorporating the key perforator in the flap design is paramount.
Patient age averages 48 years and body mass index
22.5. The indications for surgery are mainly reconstruc­
tion after mastectomy for breast cancer, 59.5%. Other
indications include reconstruction after prophylactic
mastectomy (35.7%) and congenital breast deformity
correction (4.8%). Patient demographics include an
18.8% rate of tobacco use, 18% history of radiation
therapy, and 60.4% history of prior abdominal surgery
including abdominoplasty, liposuction, hernia repair,
and C-section.
Immediate
breast
reconstruction
predominated
(52.8%), while reconstruction after failed prior breast
reconstruction also remained a significant indication for
surgery (38.6%), mostly due to failed implant recon­
struction (91.7%). Of the immediate reconstructions,
82.7% were nipple-sparing mastectomies with no inci­
dence of postoperative nipple necrosis.
Surgical technique
The patient is seen in the office the day prior to surgery.
The patient is first marked in a standing position

413
Surgical technique
gracilis muscle anteriorly (Fig. 21.4.6). This maneuver
exposes the adjacent adductor magnus muscle and
allows for dissection through the adductor magnus
fascia in an area safe from injuring the adductor perfora­
tors. Dissection proceeds along a subadductor magnus
fascial plane until the key perforator is identified. The
perforator is then dissected through the adductor
magnus muscle until entering the fatty plane behind the
adductor magnus. Utilizing “fish hook” retractors and
self-retaining retractors at either end of the wound aids
in perforator dissection. The retractors must be reposi­
tioned frequently with attention given to avoiding
narrowing of the field, which would create a hole. The
perforator can be dissected further to its origin at the
profunda vein/artery for added length. A length of
8–12 cm can be reliably harvested.
Once the pedicle is isolated, dissection posteriorly
can be performed in a suprafascial plane to decrease the
area of fascial resection. The posterior skin incision is
then completed with the aid of anteriorly stapling the
flap and adduction of the leg. The flap is then fully
isolated to its perforator. The pedicle is dissected off the
posterior adductor magnus muscle and fully harvested.
With experience, the pedicle can be harvested first then
dissected off the posterior adductor magnus fascia in a
retrograde fashion. The donor site is closed in multiple
layers over a closed suction drain.
The flap is then anastomosed in the chest most com­
monly to the internal mammary vessels, though the
thoracodorsal vessels are feasible recipient vessels. The
match to the internal mammary vessels is favorable with
an average PAP arterial diameter of 2.2 mm and venous
diameter of 2.7 mm. The flap is then coned for inset to
provide projection, and the pocket is contoured to the
flap. When stacked PAP flaps for unilateral reconstruc­
tion, a wider base can be obtained without coning by
suturing the two flaps together with each flap forming a
breast hemisphere. A skin paddle is left for monitoring.
Fig. 21.4.6  Intraoperative images displaying (A) elevation anteriorly of the gracilis
muscle to expose the adductor magnus fascia; (B) incision longitudinally of the
adductor magnus fascia in order to proceed posteriorly in a subfascial plane towards
identifying the key perforator; and, finally, (C) dissecting the key perforator through
the adductor magnus muscle to its origin at the profunda artery and vein.
A
B
C

414
SECTION II
CHAPTER 21.4 • Profunda artery perforator flap for breast reconstruction
seat and discomfort for up to 3 months from sitting on
hard surfaces. No long-term sitting or decreased sensa­
tion has been reported (Table 21.4.2).
Secondary procedures
All patients undergo secondary procedures at as early
as 3 months. To avoid deficient reconstructed breast
volume, the senior author is increasingly performing
two flap breast reconstruction as the primary procedure.
Combinations used include stacked PAP flaps, PAP/
DIEP, and PAP/ICAP. Fat grafting is commonly utilized
at the second stage. Less than 1% of the time, additional
volume is necessary and local flaps (ICAP/TDAP) are
performed at the second stage.28 Also performed at the
second stage are skin island removal, nipple reconstruc­
tion if necessary, mastopexy, and shaping to achieve the
optimal aesthetic result.
Trends/alterations
Variations to the PAP flap have recently evolved, to
maximize reconstructive goals, expand candidate selec­
tion, and decrease complications. The design of the flap
has been configured in a vertical fashion and applied to
other areas of reconstruction.29 This flap has the advan­
tage of choosing from a multitude of PAPs all piercing
the adductor magnus while providing a well-healed
donor site in a configuration that could produce a lower
wound complication profile (Fig. 21.4.7). To date,
patients selected for this configuration have been those
with moderate obesity presenting the potential for
increased donor site wound complications. From a
practical standpoint, the flap orientation should be
designed to fit a specific patient’s perforator anatomy
and maximize volume of tissue harvested and closure
aesthetics.
In cases requiring a significant additional volume
than one flap might offer, stacking flaps can offer this
Table 21.4.2  Complications
(%)
Flap loss
0.5
OR take-back
3
Fat necrosis
7
Donor site seroma
6
Donor site hematoma
2
Donor site infection
2
Lower extremity lymphedema
0
Postoperative care
Patients are sent to the post-anesthesia care unit for
1–2 h postoperatively, followed by transfer to a regular
hospital room. Monitoring of the flap is based mainly
on clinical exam with hand-held Doppler checks adjunc­
tively every 4 h. Pain management consists of intrave­
nous acetaminophen and per os ibuprofen with
intravenous narcotics as needed through the first night
after surgery. Patients are up in a chair and ambulating
in postoperative day 1. The IV line is also removed the
day following surgery, and no routine blood tests are
drawn. Patients shower and are, most commonly, dis­
charged on the third postoperative day. Breast drains
are removed prior to discharge, and donor site drains
are left in place for at least 1 week. A second stage
operation is planned for 3 months after surgery and
includes removal of the skin island previously left for
monitoring; nipple reconstruction if needed; breast flap
revision for symmetry; shape and/or size; and possible
donor site revision.
Outcomes and complications
A review of 200 PAP flaps for breast reconstruction from
2010–2015 was performed by the authors. Flap success
rate was 99.5% after losing one flap. The operating room
take-back rate was 3%. The complication profile includes
a fat necrosis rate of 7%, seroma 6%, hematoma 1.9%,
and donor site infection 1.9%. There were no episodes
of lymphedema. Short-term donor site morbidity
includes tenderness for 7–14 days from sitting on a toilet
Hints and tips
• Imaging protocols for perforator identification (CTA or MRA)
provide useful information for an efficient operation.
• Mark patients in the office the day prior to the procedure in
the prone position using a hand-held Doppler.
• Avoid designing flaps too wide (average 7 cm) to prevent
difficulty with donor site closure.
• Enter the adductor magnus fascia anteriorly juxtaposed to
the gracilis fascia to safely identify the key perforator.
• Avoid beveling superiorly to retain the ischial fat pad and
avoid sitting discomfort.
• Cone the PAP flap for single flap reconstruction to achieve
added projection.
• Lay the PAP flap flat for stacked reconstruction to provide a
wider base diameter.
• Consider two flaps for single breast reconstruction at
primary procedure.

415
Trends/alterations
additional volume, as well as a more favorable volume
distribution. For unilateral reconstruction in which the
abdomen is not available and a single PAP flap is not
sufficient, stacked PAP flaps may be performed. This
may obviate the need for secondary fat grafting or local
flaps (Fig. 21.4.8).25 In cases of bilateral reconstruction
when the abdomen provides insufficient volume, the
senior author, Dr Allen, has historically combined DIEP
and PAP flaps for superior volume and aesthetics.30 The
combination of the DIEP and PAP flaps utilizes the PAP
for inferior pole volume and projection while the DIEP
flap provides necessary superior pole volume. Most
commonly, one flap is anastomosed to the antegrade
internal mammary vessels and the other flap to the
retrograde internal mammary vessels. This combination
has proven to be both safe and successful.
A
Fig. 21.4.7  (A) Design of the profunda artery perforator flap in a vertical fashion.
(B) Intraoperative dissection of the vertical profunda artery perforator flap
perforators. Numerous perforators are available on which to base the flap.
B
Fig. 21.4.8  (A) Intraoperative example of stacking profunda artery perforator flaps
for unilateral breast reconstruction. Specific example is of a stacked vertical PAP
flap with antegrade and retrograde internal mammary vessels used as recipient
vessels. (B,C) Postoperative images of a patient who underwent left unilateral
breast reconstruction with stacked vertical profunda artery perforator flaps. The
patient, prior to left mastectomy for breast cancer, had a history of bilateral
mastopexy and abdominoplasty. Stacking the flaps added the additional volume
necessary to provide an aesthetic, symmetric reconstruction.
A
B
C
Advantages and disadvantages
Advantages
• Easy dissection through the adductor magnus muscle
• Reliable perforator with long pedicle (~10 cm)
• Pliable flap tissue optimal for coning to reconstruct the
breast
• Well-hidden donor site scar within upper thigh and buttock
crease
• Ability to stack with other flaps
Disadvantages
• Not every patient is a good candidate due to body habitus
variations
• Acceptable but not abundant flap volume
• Early donor site discomfort with sitting improved with
positioning modifications.

416
SECTION II
CHAPTER 21.4 • Profunda artery perforator flap for breast reconstruction
Fig. 21.4.9  (A) Preoperative and (B) postoperative photographs of a 38-year-old patient with a history of left breast cancer who underwent a left areola sparing mastectomy
and profunda artery perforator (PAP) free flap reconstruction. (C) Preoperative (superior) and (D) postoperative (inferior) photographs of posteromedial thigh donor site in a
38-year-old patient who underwent unilateral PAP free flap breast reconstruction. (Courtesy of Christina Ahn, MD.)
A
B
C
D
2. Gill PS, Hunt JP, Guerra AB, et al. A 10-year retrospective review of
758 DIEP flaps for breast reconstruction. Plast Reconstr Surg.
2004;113:1153–1160. The authors present one of the largest series of DIEP
flaps for breast reconstruction and provides an in-depth analysis of this
workhouse flap. Overall complication rate was 20.2% with the donor site
complication being 13.6%. Furthermore, the rate of fat necrosis was
12.9% (n = 98). They demonstrate that the DIEP flap has reduced donor
site morbidity compared with the TRAM flap and has evolved to be the
first choice for autologous breast reconstruction.
13. Saad A, Sadeghi A, Allen RJ. The anatomic basis of the profunda
femoris artery perforator flap: a new option for autologous breast
reconstruction–a cadaveric and computer tomography angiogram
study. J Reconstr Microsurg. 2012;28:381–386. This study examined 10
cadaveric thighs to outline in detail the anatomic basis for the profunda
femoris artery perforator flap. They identified key parameters including
length of pedicle, vessel diameters, and flap characteristic. The authors
show the pedicle to be on average 10.6 cm in length, the diameter of the
artery at 2.3 mm, and the vein 2.8 mm. The flap on average measured
28 × 8 cm and weighed 206 g (100–260 g). This study also examined the
CT scans of these cadavers and determined the average location of the
perforators (4.4 cm caudal to gluteal crease and 5.1 cm lateral to midline).
This was the first study to propose the use of the posterior thigh flap based
on the perforators of the profunda femoris artery.
18. Angrigiani C, Grilli D, Thorne CH. The adductor flap: a new
method for transferring posterior and medial thigh skin. Plast
Reconstr Surg. 2001;107:1725–1731. The first flaps from the medial thigh
Access the complete reference list online at

Conclusion
With improvements in surgical techniques and an
expansion of donor site options, autologous breast
reconstruction has evolved into a field of patient-
specific reconstruction. The DIEP free flap remains the
gold standard but at times has either an unavailable
donor site or is insufficient in providing appropriate
volume for reconstruction. The PAP flap offers an
alternative flap for reconstruction as well as an adjunct
to the DIEP in creating an aesthetic breast. With a
multitude of configurations to harvest optimal volume
and minimize donor site morbidity based on a patient’s
specific anatomy and the ability to be stacked with an
additional flap to offer additional volume or improved
aesthetics, the PAP flap represents a safe, effective flap
for any microsurgeons free flap armamentarium
(Fig. 21.4.9).

417
Conclusion
had been primarily based on the gracilis musculocutaneous unit. This was
the first study to delineate an anatomic basis for medial and posterior
thigh flap based PAPs through the adductor magnus muscle. They
examined 20 cadavers and found reliable cutaneous perforators of the
adductor magnus muscle allowing for skin flaps as large as 30 × 23 cm.
They also provided a clinical series of 25 patients in which these adductor
flaps were used, 11 of which were microvascular free flaps. Five of the flaps
were for resurfacing burn scar contractures and six were for
reconstructing lower extremity defects. While they did not use the
posterior thigh flap for breast reconstruction, it was the first study to
demonstrate that the skin of the medial and posterior thigh region can be
successfully transferred based on several different vascular perforators that
are reliable and consistent.
21. Allen RJ, Haddock NT, Ahn CY, et al. Breast reconstruction with
the profunda artery perforator flap. Plast Reconstr Surg. 2012;129:
16e–23e. This was the largest clinical series to date using the PAP flap for
breast reconstruction before our current series. The authors present a
series of 27 flaps and demonstrate the reliability of this flap with a long
pedicle and sufficient vessel caliber. The average weight of the flap was
385 g (range, 235–695 g), average artery size 2.2 cm, and average vein
size 2.8 cm. All PAP flaps were successful with two donor site
complications, one seroma, and one hematoma. One important adjustment
made during their experience with the first 27 flaps was the transition to a
supine frog-leg position from a prone position to avoid intraoperative
repositioning. This was the first large clinical series to describe the
experience using PAP flap for breast reconstruction.
22. Haddock NT, Greaney P, Otterburn D, et al. Predicting perforator
location on preoperative imaging for the profunda artery perforator
flap. Microsurgery. 2012;32:507–511. This radiographic study further
delineated the anatomic details of the PAP flap, especially regarding the
number, location, and size of the perforators. A review of 40 preoperative
posterior thigh CTAs and MRAs demonstrated that suitable PAPs were
present in 98.8% of thighs. The most common perforator was medial (in
85.6% of thighs). Based on this study, the current preference in designing
PAP flaps is to use a medial perforator, although this study found that the
second most common perforator was lateral (present in 65.4% of thighs).
Most importantly, preoperative imaging corresponded well to perforators
intraoperatively during the pedicle dissection.

417.e1
References
References
1. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast
reconstruction. Ann Plast Surg. 1994;32:32–38.
2. Gill PS, Hunt JP, Guerra AB, et al. A 10-year retrospective review
of 758 DIEP flaps for breast reconstruction. Plast Reconstr Surg.
2004;113:1153–1160. The authors present one of the largest series of
DIEP flaps for breast reconstruction and provides an in-depth analysis
of this workhouse flap. Overall complication rate was 20.2% with the
donor site complication being 13.6%. Furthermore, the rate of fat
necrosis was 12.9% (n = 98). They demonstrate that the DIEP flap
has reduced donor site morbidity compared with the TRAM flap
and has evolved to be the first choice for autologous breast
reconstruction.
3. Healy C, Allen RJ. The evolution of perforator flap breast
reconstruction: twenty years after the first DIEP flap. J Reconstr
Microsurg. 2014;30:121–125.
4. Damen TH, Mureau MA, Timman R, et al. The pleasing end result
after DIEP flap breast reconstruction: a review of additional
operations. J Plast Reconstr Aesthet Surg. 2009;62:71–76.
5. Acosta R, Smit JM, Audolfsson T, et al. A clinical review of 9 years
of free perforator flap breast reconstructions: an analysis of 675
flaps and the influence of new techniques on clinical practice.
J Reconstr Microsurg. 2011;27:91–98.
6. Massey MF, Spiegel AJ, Levine JL, et al. Perforator flaps: recent
experience, current trends, and future directions based on 3974
microsurgical breast reconstructions. Plast Reconstr Surg. 2009;124:
737–751.
7. Blondeel PN. One hundred free DIEP flap breast reconstructions: a
personal experience. Br J Plast Surg. 1999;52:104–111.
8. Blondeel PN, Hijjawi J, Depypere H, et al. Shaping the breast in
aesthetic and reconstructive breast surgery: an easy three-step
principle. Part III–reconstruction following breast conservative
treatment. Plast Reconstr Surg. 2009;124:28–38.
9. Damen TH, Morritt AN, Zhong T, et al. Improving outcomes in
microsurgical breast reconstruction: lessons learnt from 406
consecutive DIEP/TRAM flaps performed by a single surgeon.
J Plast Reconstr Aesthet Surg. 2013;66:1032–1038.
10. Allen RJ, Tucker C. Superior gluteal artery perforator free flap for
breast reconstruction. Plast Reconstr Surg. 1995;95:1207–1212.
11. Paletta CE, Bostwick J, Nahai F. The inferior gluteal free flap in
breast reconstruction. Plast Reconstr Surg. 1989;84:875–885.
12. Wechselberger G, Schoeller T. The transverse myocutaneous gracilis
free flap: a valuable tissue source in autologous breast
reconstruction. Plast Reconstr Surg. 2004;114:69–73.
13. Saad A, Sadeghi A, Allen RJ. The anatomic basis of the profunda
femoris artery perforator flap: a new option for autologous breast
reconstruction–a cadaveric and computer tomography angiogram
study. J Reconstr Microsurg. 2012;28:381–386. This study examined 10
cadaveric thighs to outline in detail the anatomic basis for the profunda
femoris artery perforator flap. They identified key parameters including
length of pedicle, vessel diameters, and flap characteristic. The authors
show the pedicle to be on average 10.6 cm in length, the diameter of the
artery at 2.3 mm, and the vein 2.8 mm. The flap on average measured
28 × 8 cm and weighed 206 g (100–260 g). This study also examined the
CT scans of these cadavers and determined the average location of the
perforators (4.4 cm caudal to gluteal crease and 5.1 cm lateral to midline).
This was the first study to propose the use of the posterior thigh flap based
on the perforators of the profunda femoris artery.
14. Peters KT, Blondeel PN, Lobo F, et al. Early experience with the free
lumbar artery perforator flap for breast reconstruction. J Plast
Reconstr Aesthet Surg. 2015;68:1112–1119.
15. Mirzabeigi MN, Au A, Jandali S, et al. Trials and tribulations with
the inferior gluteal artery perforator flap in autologous breast
reconstruction. Plast Reconstr Surg. 2011;128:614e–624e.
16. LoTempio MM, Allen RJ. Breast reconstruction with SGAP and
IGAP flaps. Plast Reconstr Surg. 2010;126:393–401.
17. Hurwitz DJ, Swartz WM, Mathes SJ. The gluteal thigh flap: a
reliable, sensate flap for the closure of buttock and perineal
wounds. Plast Reconstr Surg. 1981;68:521–532.
18. Angrigiani C, Grilli D, Thorne CH. The adductor flap: a new
method for transferring posterior and medial thigh skin. Plast
Reconstr Surg. 2001;107:1725–1731. The first flaps from the medial thigh
had been primarily based on the gracilis musculocutaneous unit. This was
the first study to delineate an anatomic basis for medial and posterior
thigh flap based PAPs through the adductor magnus muscle. They
examined 20 cadavers and found reliable cutaneous perforators of the
adductor magnus muscle allowing for skin flaps as large as 30 × 23 cm.
They also provided a clinical series of 25 patients in which these adductor
flaps were used, 11 of which were microvascular free flaps. Five of the flaps
were for resurfacing burn scar contractures and six were for
reconstructing lower extremity defects. While they did not use the
posterior thigh flap for breast reconstruction, it was the first study to
demonstrate that the skin of the medial and posterior thigh region can be
successfully transferred based on several different vascular perforators that
are reliable and consistent.
19. Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap
concept based on the septocutaneous artery. Br J Plast Surg.
1984;37:149–159.
20. Saad A, Sadeghi A, Allen RJ. The anatomic basis of the profunda
femoris artery perforator flap: a new option for autologous breast
reconstruction – a cadaveric and computer tomography angiogram
study. J Reconstr Microsurg. 2012;28:381–386.
21. Allen RJ, Haddock NT, Ahn CY, et al. Breast reconstruction with the
profunda artery perforator flap. Plast Reconstr Surg. 2012;129:16e–
23e. This was the largest clinical series to date using the PAP flap for
breast reconstruction before our current series. The authors present a
series of 27 flaps and demonstrate the reliability of this flap with a long
pedicle and sufficient vessel caliber. The average weight of the flap was
385 g (range, 235–695 g), average artery size 2.2 cm, and average vein
size 2.8 cm. All PAP flaps were successful with two donor site
complications, one seroma, and one hematoma. One important adjustment
made during their experience with the first 27 flaps was the transition to a
supine frog-leg position from a prone position to avoid intraoperative
repositioning. This was the first large clinical series to describe the
experience using PAP flap for breast reconstruction.
22. Haddock NT, Greaney P, Otterburn D, et al. Predicting perforator
location on preoperative imaging for the profunda artery perforator
flap. Microsurgery. 2012;32:507–511. This radiographic study further
delineated the anatomic details of the PAP flap, especially regarding the
number, location, and size of the perforators. A review of 40 preoperative
posterior thigh CTAs and MRAs demonstrated that suitable PAPs were
present in 98.8% of thighs. The most common perforator was medial (in
85.6% of thighs). Based on this study, the current preference in designing
PAP flaps is to use a medial perforator, although this study found that the
second most common perforator was lateral (present in 65.4% of thighs).
Most importantly, preoperative imaging corresponded well to perforators
intraoperatively during the pedicle dissection.
23. DeLong MR, Hughes DB, Bond JE, et al. A detailed evaluation of
the anatomical variations of the profunda artery perforator flap
using computed tomographic angiograms. Plast Reconstr Surg.
2014;134:186e–192e.
24. Ahmadzadeh R, Bergeron L, Tang M, et al. The posterior thigh
perforator flap or profunda femoris artery perforator flap. Plast
Reconstr Surg. 2007;119:194–200, discussion 201–202.
25. Blechman KM, Broer PN, Tanna N, et al. Stacked profunda artery
perforator flaps for unilateral breast reconstruction: a case report.
J Reconstr Microsurg. 2013;29:631–634.
26. Weichman KE, Broer PN, Tanna N, et al. The role of autologous fat
grafting in secondary microsurgical breast reconstruction. Ann Plast
Surg. 2013;71:24–30.
27. Losken A, Hamdi M. Partial breast reconstruction: current
perspectives. Plast Reconstr Surg. 2009;124:722–736.
28. Levine JL, Soueid NE, Allen RJ. Algorithm for autologous breast
reconstruction for partial mastectomy defects. Plast Reconstr Surg.
2005;116:762–767.
29. Mayo JL, Canizares O, Torabi R, et al. Expanding the applications
of the profunda artery perforator flap. Plast Reconstr Surg.
2016;137:663–669.
30. Mayo JL, Allen RJ, Sadeghi A. Four-flap breast reconstruction:
bilateral stacked DIEP and PAP flaps. Plast Reconstr Surg Glob Open.
2015;3:e383.

SECTION II • Reconstructive Breast Surgery
22 
Secondary procedures following
autologous reconstruction
Joshua Fosnot and Joseph M. Serletti
SYNOPSIS
■ Secondary procedures following autologous reconstruction are
common.
■ Secondary procedures often follow the same principles of other forms
of breast surgery.
■ Common procedures include fat grafting, reduction, augmentation,
nipple areolar reconstruction and refinement of the skin envelope.
■ While uncommon, hernia repair following free TRAM reconstruction is
discussed here as it can be a challenge to correct.
■ Oftentimes, a single secondary operative procedure can combine all
revisions in one and is commonly the last stage of reconstruction.
Access the Historical Perspective section online at

Introduction
Although the pedicled transverse rectus abdominis
myocutaneous (TRAM) flap provided a foundation for
the burgeoning field of breast reconstruction, the overall
contemporary trend has focused on approaches which
provide improved aesthetic outcomes while minimizing
complications and donor site morbidity. Advances in
microsurgical technique have thus led the field toward
the utilization of free flaps, which benefit from a more
profound blood supply while sacrificing less of the
abdominal wall. A spectrum exists which includes the
free TRAM, muscle-sparing free TRAM (MsfTRAM),
deep inferior epigastric perforator (DIEP) and superfi­
cial inferior epigastric artery (SIEA) flaps, all of which
utilize the same transverse island of lower abdominal
wall skin and soft tissue for the recreation of a breast
mound with varying degrees of abdominal wall intru­
sion. In addition, non-abdominal-based flaps have
gained in popularity such as the transverse upper graci­
lis (TUG), superficial circumflex iliac perforator (SCIP),
or posterior thigh flaps. The free flap can be thought of
as importing clay to the sculpting table. In many cases,
the initial flap transfer is sufficient to provide an excel­
lent aesthetic result and one which provides longevity.
However, it is also very common that revisions are
necessary to achieve the optimal outcome and one
which is in line with the desires of the critical patient
and surgeon. Common techniques employed for revi­
sion of the autologous reconstruction are those used
quite frequently for other forms of aesthetic breast
surgery. These techniques include fat grafting, augmen­
tation, reduction and refinement of the skin envelope.
While many of these topics are covered in other chapters
in this book, this chapter will focus specifically on their
use in autologous reconstruction.
Basic science/disease process
One in eight women will suffer from breast cancer over
the course of their lifetime.22 While certainly not every­
one will seek a mastectomy, the frequency of mastectomy
is rising nationally. In addition, the prevalence of pro­
phylactic mastectomy has risen as well. Both implant
and autologous reconstruction each have their own
risks and benefits. While nationally, implant reconstruc­
tion remains more common, in certain geographic loca­
tions free flap reconstruction has become more accessible
and thus relatively commonplace.23 Both often require
secondary procedures; however, autologous revision is

418.e1
Historical perspective
Historical perspective
Autologous reconstruction was accepted slowly in the
United States primarily due to the belief by Halsted that
nothing should be done to the mastectomy site to poten­
tially mask or promote tumor recurrence. As a result,
most of the early pioneering work was done in Europe.
Louis Ombredanne was the first surgeon to describe the
use of a muscle flap to recreate the breast mound.1 He
divided the head of the pectoralis minor muscle and
flipped it over to create a mound. This was followed by
the latissimus myocutaneous flap procedure as described
by Tansini.2 This method fell from favor and was not
recognized again until the 1970s. During the 1940s and
1950s, most breast reconstructions were performed with
breast-sharing procedures; a portion of the remaining
native breast was moved to the mastectomy site in a
series of tubed transfers. This method required multiple
operative procedures over a course of months to achieve
the final result. Thoracoepigastric tube flaps were simi­
larly used to create an autologous breast reconstruction,
again in a series of operative steps. Autologous recon­
struction was supplanted in the 1960s by alloplastic
materials when Cronin and Gerow introduced the sili­
cone gel implant. This was followed in 1982 by Rado­
van’s introduction of the tissue expander.3 These two
devices allowed breast mound reconstruction in fewer
steps and avoided donor site considerations. The use
and relative ease of these devices also helped establish
both delayed and immediate breast reconstruction as
routine surgical procedures.4–7
During the late 1970s, the latissimus dorsi myocuta­
neous flap was reintroduced as a method of autologous
breast reconstruction, used alone or in combination
with an implant.8,9 Perhaps the most monumental con­
tribution to autologous breast reconstruction was Har­
trampf’s introduction of the pedicled transverse rectus
abdominis myocutaneous flap (TRAM) procedure in
1982.10 This technique remains the most common
method of autologous breast reconstruction. Alterations
in the technique for transferring redundant lower
abdominal tissue have subsequently been developed.
More recently, free tissue transfer has become popular
based on the knowledge that tissue can be completely
transferred to another location on the body as long as
an adequate blood supply is re-established via a newly
created vascular pedicle. The use of free tissue transfer
for breast reconstruction followed soon after the birth
of microsurgery. Examples of these include the free
TRAM flap, the deep inferior epigastric perforator
(DIEP) flap and the superficial inferior epigastric (SIEA)
flap.11,12 The first reported use of free tissue transfer for
breast reconstruction was by Fujino in 1976,13 but did
not become popular in the United States until the 1980s
and 1990s. Alterations have been made to improve the
blood supply to the transferred tissue and to limit the
abdominal wall donor defect. Other free autologous
choices include the gluteal flap, the superior or inferior
gluteal artery perforator flaps, the lateral thigh flap, and
the Rubens flap.14–20 These other choices are typically
used in patients who have undergone a TRAM flap
procedure and develop a contralateral breast cancer or
in patients who desire an autologous breast reconstruc­
tion but have inadequate abdominal tissue.
Revision of the autologous reconstruction can employ
multiple modalities described in this history; however,
fat grafting now plays a central role. While the use of
fat grafting dates back to the 19th century, it was not
until the late 20th century that it became truly popular­
ized. Much of this work was pioneered by Sydney
Coleman.21 While the American Society of Plastic
Surgeon (ASPS) formally objected to the use of fat
transfer in the breast in 1987, its use in practice contin­
ued and further research was conducted. In 2009, the
ASPS formally changed their position, stating that fat
injecting was acceptable practice in breast augmentation
and for correction of contour deformities in the breast.
Currently, fat grafting has become one of the most
powerful tools available in breast reconstruction.

419
Diagnosis/patient presentation
these patients may benefit from an immediate balancing
approach. This avoids a patient having to live with a
large discrepancy for several months. In these cases,
however, we recommend telling patients that revision
of either the native or reconstructed side may be neces­
sary in the future in order to fine tune symmetry.
Assessing the problem
Volume
It is useful to categorize deformities based upon patient
and surgeon observations. Firstly, volume asymmetry is
one of the biggest drivers of patient dissatisfaction since
bra fitting is a challenge. In unilateral reconstruction,
usually a short-term undertaking, whereas implant
reconstruction requires maintenance of the implants
over the course of a woman’s lifetime. Revision is not
always necessary, but can be indicated for a number of
problems. Fortunately, multiple modalities exist to
improve the long-term result, which generally speaking
are well tolerated by patients and offer excellent, long-
lasting results.
Diagnosis/patient presentation
The most important step to take before considering
revision of the reconstructed breast is to listen to your
patient. After mastectomy and free flap reconstruction,
some patients are exhausted and others are eager to
proceed. From an aesthetic perspective, some patients
are highly critical and others are content with asym­
metries that you as a surgeon find unacceptable. Listen­
ing to your patient affords the opportunity to make sure
surgeon and patient are in agreement on the need for
further surgery, determine if further surgery is likely to
provide benefit and to refine the surgical plan. Fig. 22.1
provides a general approach to the identification and
correction of chest asymmetry discussed in this chapter.
Timing
Consideration of revision typically is entertained at the
3 month mark. Revision should occur once a relatively
stable breast mound has been achieved and several
months are necessary to get to this point. When radia­
tion is involved, this process takes even longer. The
radiated reconstruction benefits from a recovery time of
up to 6 months after completion of treatments. This may
be almost 9 months after initial reconstruction; however,
an adequate delay allows for more specific and refined
revision. Waiting also allows patients time to decide
what they like and don’t like about their reconstruction.
Some patients initially are happy with their results, but
notice small things bother them in time, while others
initially are unhappy and become more accustomed
with the reconstruction with time, no longer desiring
revision.24 Lastly, there is no temporal limit to waiting,
nor any reason to rush into revision.
Timing of balancing procedures is also important in
unilateral reconstruction. While it is tempting to perform
a balancing procedure during immediate reconstruc­
tion, it is difficult to control all of the variables of per­
forming two different operations from side to side to
achieve symmetry. If mild to moderate asymmetries are
expected based upon ptosis or volume, we usually delay
the balancing procedure until a later date; whereas, if
large changes (such as a large reduction) are necessary,
Fig. 22.1  A general algorithmic approach to the identification and correction of
breast asymmetry following autologous reconstruction. Oftentimes, multiple issues
may coexist, thus necessitating the use of multiple modalities.
Yes
Volume
Too much
Suction-assisted
lipectomy
Suction-assisted
lipectomy
Formal
mastopexy
Adjust
other side
Not enough
Small
irregularities
Lack of central
projection
Lateral
fullness
Contour/
shape
Position
Is there
asymmetry?
General
problem?
Specific
problem?
Intervention
Low
High
Implant
Fat grafting
Fat grafting
Implant
Fat grafting
Skin tightening
Give it time
Direct excision

420
SECTION II
CHAPTER 22 • Secondary procedures following autologous reconstruction
More likely, positional problems arise in patients with
pre-existing ptosis where skin envelope changes are
being made in immediate reconstruction or in delayed
reconstruction where the envelope is being recreated. A
common issue is a vertical discrepancy related to uneven
skin resection from side to side, or vertical discrepancy
in unilateral reconstruction where a contralateral bal­
ancing procedure is needed. Assessing symmetry and
patient satisfaction should be approached similarly to
how a surgeon would assess any breast consultation.
Similar techniques also can be used to improve vertical
positioning such as the vertical mastopexy. Usually,
however, these are skin only procedures as opposed to
formal parenchymal /pillar procedures. In all cases, but
delayed reconstruction in particular, it is important to
ensure enough time has passed to allow the envelope to
relax and drop before revision.
Donor site
The most common donor site for free flap breast recon­
struction is the lower abdomen. While the majority of
patients heal well and are happy with their donor site,
two common complaints/problems can arise. Delayed
wound healing of the central abdomen is unfortunately
a fairly common complication likely a result of tension
or low grade ischemia related to perfusion and/or
comorbidities. While small areas are easily treated with
wet to dry dressing changes, sometimes large dehiscence
occurs. Debridement and VAC therapy is a useful
adjunct; however, early secondary revision and closure
has been shown to be safe and perhaps is a faster way
to achieve completely closed wounds.25 Regardless of
duration of healing, the tension on this wound can lead
to fat necrosis and widened scars. Revision of these
scars should be undertaken only after the scar has sta­
bilized and the soft tissue is lax enough to allow for
excision and reclosure without any tension.
Dog-ear deformities are not uncommon as well.
While every attempt at avoidance should be attempted,
sometimes adequate exposure to the far lateral flank at
the time of free flap harvest is limited. Dog-ear excision
and liposuction of the flanks can help improve lateral
contour. Donor site revision can often be performed at
the same time as breast mound revision or nipple areolar
reconstruction.
Treatment/surgical technique
Fat grafting
The use of fat grafting is quite possibly the most impor­
tant technique available to revise the reconstructed
breast (see Fig. 22.2). An entire chapter is dedicated to
the free flap may be smaller or larger than anticipated;
however, even in bilateral reconstruction, volume
asymmetry occurs. Treatment of volume differences
greatly depends upon patient wishes. Small reductions
in a flap can be easily performed with liposuction,
whereas large reductions may require a more formal
approach with resection. Conversely, augmentation of
the contralateral side can be performed with fat grafting
or implants. Which side to modify greatly depends
upon patient goals.
Contour/shape
Contour irregularities are common following free flap
reconstruction. The cause is multifactorial but most
commonly is a baseline mismatch in size or shape
between the breast tissue removed and the free flap
inset. This can be most notable in the upper pole or tail
of the reconstructed breast mound where a tapered
effect is difficult to achieve primarily. Small areas of fat
necrosis can lead to hollowing or frank masses which
may require revision. In addition, lack of central pro­
jection relative to a natural breast is a common com­
plaint. This is generally due to an inability to completely
cone the central mound in a manner similar to a native
youthful breast. A free flap (particularly a DIEP without
muscle) is often fairly uniform in depth, which can
lead to a flat-appearing breast mound. All of these
issues can be addressed with fat grafting although on
occasion, a small implant centrally can work very well
to add central projection. Oftentimes, however, women
have chosen autologous reconstruction to avoid the
issues associated with implants; thus, staged fat graft­
ing may be a better choice. Fat necrosis can be treated
either by direct excision, liposuction or with an aera­
tion technique which will be discussed later in this
chapter.
Position
Patients with grade I ptosis are rarely subject to prob­
lems with flap position in the postoperative period as
long as the mastectomy pocket remains confined to the
breast tissue. To avoid problems with position, the
mastectomy pocket should be redefined with suturing
prior to inset of the flap. If the pocket is not redefined,
positioning may be wrong, thus resulting in a need to
redefine the inframammary fold (IMF), medial or lateral
borders. Simple changes may be amenable to liposuc­
tion, but generally speaking, major changes require
recreation of the pocket, movement of the flap and
redefining of the pocket. As this is not a minor revision,
every attempt should be made to avoid this problem to
begin with.

421
Treatment/surgical technique
employed to spin the fat down. For larger volumes,
centrifugation is certainly more practical; however, no
one method of preparation has been shown to be the
most effective.31 Several procurement and processing
systems are now on the market to make the process
more efficient and hopefully offer better results, however
this remains to be seen. Research on the quality of the
fat based upon site of harvest and methods of procure­
ment is constantly evolving and at this time not con­
vincing that one method far surpasses another.31
What is likely the most important factor contributing
to long-term survival is the environment in which the
fat is placed. Fat should be placed in small aliquots (no
more than 0.5 cc per pass) using a multipass technique
as described by Coleman. The fat should be placed in
multiple planes even if the defect feels superficial.
Superficial and deep planes allow for placement of each
fat grafting techniques elsewhere in this book (see
Chapter 24); however, some technical points are worth
discussing here. The donor site may play a role in graft
take as some studies have shown the lower abdomen
and inner thighs to be higher in adipose-derived stem
cells.26 These cells are believed to aid in survival;
however, other studies have failed to highlight major
differences in donor site value.27–29 The donor site of
choice is injected with 1% lidocaine with epinephrine.
Fat can be procured using manual aspiration or a formal
liposuction device. Larger cannula diameters may yield
healthier fat cells.30 If a liposuction device is employed,
it is likely that lower aspiration pressures aid in cell
survival, but further research is needed in this area.
Preparation of the fat before use is needed to remove
fluid, debris and free oil. This can be done using filtra­
tion, sedimentation or a centrifugation system can be
Fig. 22.2  (A) This patient has a history of radiation on the right and underwent
bilateral mastectomies with bilateral gluteal artery perforator flap reconstructions. The
right side is smaller and higher than the left. (B) Following revision with right high
volume fat grafting and left refinement of the skin envelope.
A
B
C

422
SECTION II
CHAPTER 22 • Secondary procedures following autologous reconstruction
transitions to the lateral chest wall. Injection of 1%
lidocaine with epinephrine is usually adequate as
opposed to tumescence. Regardless of what indication
it is being used for, one should be aware that a free flap
will quickly lose its volume with SAL; therefore, it is
easy to overshoot the goal unless one is careful.
Skin refinement
Refining the skin envelope is not technically challenging;
however, achieving the desired effect without adding
new scars can be difficult. The most common areas where
the envelope needs revision is the lateral breast mound
as it transitions to the chest wall. This is particularly true
in women who had large ptotic breasts prior to mastec­
tomy. These women would benefit from a Wise pattern
skin reduction at the time of mastectomy, but using this
approach would compromise mastectomy skin flap
perfusion.34 Thus, the correction is often necessary due to
a purposeful cautious approach initially. The correction
simply involves excising the lateral dog-ear similarly to
the lateral extension of a Wise pattern reduction.
The other common problem of the skin envelope is of
undercorrection of the vertical component of a vertical
pattern skin reduction at the time of mastectomy. In a
standard breast reduction or mastopexy, the vertical
component is generally overcorrected. Tension on the
pass into its own space. The pectoralis muscle can be
injected directly into, as it serves as an excellent recipi­
ent site for fat survival. Fat should be injected in multiple
directions as well. This technique requires multiple
access points. As this can be done through 1-mm access
points, scarring should not be a concern. Having a finite
mental image of a three-dimensional crosshatch network
of lines should be the goal, not simply injecting through
convenient locations. When larger volumes are neces­
sary, one must avoid the temptation to try to achieve
perfection in one setting. Overfilling leads to lower
retention rates32 and most patients, if educated properly,
will understand why staged surgical procedures are
necessary and beneficial. Lastly, a radiated bed can still
receive fat grafts; however, retention rates are likely
lower.33 Therefore, one should be aware that fat grafting
may require more stages or even be ultimately less suc­
cessful following radiation therapy.
Liposuction
Standard suction-assisted lipectomy can be very useful
in not only reducing volume, but blending transition
points well (Fig. 22.3). The borders of the flap can feel
like a step-off to patients and gentle liposuction can help
smooth the edges. In addition, the lateral aspect of the
flap can be shaped nicely with liposuction as it
Fig. 22.3  (A) Preoperative photo of a patient with left breast cancer planning on
bilateral mastectomy. (B) Following bilateral DIEP flaps, the patient complained of
being too large and of lateral fullness. (C) Following revision with nipple areolar
reconstruction and suction-assisted lipectomy to reduce volume and lateral fullness.
(Courtesy of Liza Wu, MD, FACS.)
A
B
C

423
Treatment/surgical technique
used for other indications. In thin patients, form stable
implants may have a definitive role to add natural
shape. In most circumstances, however, the implants
used are less than 250 cc where the difference between
a form stable and standard round implant becomes less
noticeable. In these cases, round implants may be a
better choice due to their softer nature. Saline implants
are rarely used. Textured implants may have some
benefit in the irradiated field in trying to reduce the risk
of capsular contracture.35,36 In terms of style, small
implants have a very narrow footprint regardless of
projection. If one is trying to correct an overall volume
discrepancy, a lower profile implant may be a good
choice to fill out as much width as possible, whereas, if
central projection is the main goal, then a higher profile
implant may be warranted. In this case, the pocket
should be left small so as to avoid implant malposition.
From a technical standpoint, we prefer to place implants
in a submuscular plane. This avoids any concern about
dissecting the pedicle off the muscle, and places the
implant into an unoperated tissue plane. When the
internal mammary vessels are used for a recipient site,
this is usually far enough away from the pocket created
to avoid injury. Access to the submuscular plane may
be achievable through existing scars, but a standard IMF
incision is generally the best approach and one that
allows for excellent exposure, ease of dissection and
placement of the implant itself.
Fat necrosis
Small areas of fat necrosis can be treated with excision;
however, larger volumes or areas in the far upper pole
can be difficult to treat with excision without creating
obvious contour deformities or new visible scars.
Contour deformities from excision can be treated with
fat grafting, but this may commit patients to multiple
surgeries. An alternative technique can employ either
liposuction, ultrasonic liposuction or a power dissec­
tor.37 In this technique, the small cannula is used to drill
holes in multiple directions in the area of fat necrosis.
This technique is similar to aerating a green on a golf
course. These small holes often soften the feel of the
necrotic area and may allow for tissue ingrowth which
leads to improvement with time.
Balancing mastopexy/reduction
In general, lifting or reduction techniques should follow
standard techniques such as vertical or Wise pattern
skin resections with standard pedicle design. That being
said, one technical pearl is to keep in mind that one is
trying to match the reconstructed side, not necessarily
perform the standard technique employed elsewhere.
skin is ameliorated somewhat by pillar sutures; however,
this overcorrection relaxes over the next few months.
When a vertical pattern is chosen during a mastectomy,
one does not have the luxury of overcorrection. Tension
on the mastectomy skin flaps can further compromise
already tenuous mastectomy skin flaps. Thus, undercor­
rection of ptosis is common and leads to the necessary
revision as a result of purposeful caution. The surgical
correction is often fairly straightforward – further exci­
sion of the vertical component without changing the
position of the nipple areolar complex (NAC).
Implants
While most women choose autologous reconstruction to
avoid a prosthetic device, implants can play a specific
role in adding overall volume, improving large contour
deformities or adding central projection (Fig. 22.4).
Implant choice follows the same principles as when
A
Fig. 22.4  (A) Preoperative photo of a patient with right breast cancer with
pre-existing asymmetry. (B) Intermediate stage following a right DIEP. The right side
is larger, but the patient preferred this side to her native left side. (C) Following
revision with right nipple areolar reconstruction and a left augmentation with a
submuscular implant. She would likely benefit from a left circumareolar mastopexy
but she did not want additional scars. She is overall very happy with the volumetric
correction.
B

424
SECTION II
CHAPTER 22 • Secondary procedures following autologous reconstruction
tell patients to expect to be back to work within a week,
if not a day or two. Most of the areas treated are lacking
in sensation to begin with, which makes the recovery
fairly reasonable for the patient. Most importantly, we
tell patients to have patience. If fat grafting or liposuc­
tion were employed, the full effects of these treatments
will not be known for a minimum of 3 months. If further
dissatisfaction is noted at that time, then further revi­
sion may be addressed.
Outcomes, prognosis,
and complications
The majority of women require only one revision to
complete their reconstruction. Quite commonly, this
includes nipple areolar reconstruction. In general,
complications are few and far between, but do exist.
Fat grafting can, albeit rarely, result in fat cysts or necro­
sis. This is a result of injecting too much fat into one
area. Oil cysts feel firm but can be aspirated to resolu­
tion. If frank fat necrosis results from fat grafting, the
treatment resorts to that previously described. The most
common “complication” of fat grafting would be volume
loss or lack of effect. Roughly 50% of the injected volume
may be lost with time; thus, multiple sessions of fat
grafting may be necessary to achieve a final acceptable
result.31 Volumetric or positional asymmetry can result
from over- or undercorrecting the original problem.
This would be addressed similarly with another revi­
sion. Implant complications are no different than those
seen with breast augmentation, although irradiated
fields are more likely to experience capsular contracture.
Implant infection and extrusion should be treated
conservatively.
Secondary procedures
The vast majority of patients are happy after one revi­
sion. One major benefit of autologous reconstruction
over implant reconstruction is that autologous tissue
behaves much more naturally with time. As a result,
patients typically become happier with their recon­
struction as the years pass.24 That being said, some
patients return for multiple revisions. Planned staged
fat grafting is one example which can be predictably
necessary and incredibly powerful. When large volu­
metric changes are required, three to five fat grafting
sessions are commonly needed to impact change.
When unplanned multiple revisions are sought by a
patient, one generally needs to be aware of the curve of
diminishing returns. While cancer patients often have
a much more reasonable aesthetic goal than the typical
For instance, a standard vertical mastopexy with a
superior pedicle is often performed by tucking the
central pillar underneath the NAC to add central projec­
tion and create a more coned, youthful breast. Often­
times a reconstructed breast with a free flap lacks this
coned effect. If a patient is happy with the reconstructed
side and just wants balance, then avoiding the central
coning with the mastopexy is beneficial.
Abdominal donor site hernia
The hernia which can arise in the abdominal donor site
is not often addressed in chapters, yet it can be very
challenging to correct. Thus, we thought it worth dis­
cussing here. The most common site for hernia forma­
tion is below the arcuate line. Above this line, the
posterior sheath is not violated in the flap harvest, yet
still has significant strength leading to little risk of
hernia over time. Below the arcuate line, all of the
strength layers of the abdominal fascia are anterior to
the rectus muscles and thus by definition are all violated
in a DIEP/MsfTRAM harvest. The fascia is universally
attenuated in these hernias; thus, primary closure of the
hernia defect would lead to unsatisfactory repair. There­
fore, placement of mesh is a universal tenet. While
biologic mesh may play a significant role in contami­
nated wounds, to date little or no evidence supports
their use over permanent mesh in clean wounds, espe­
cially given their high cost.38,39 The authors therefore
recommend synthetic permanent mesh. As the hernia
defect is commonly under or near the skin incision,
placing any underlay with complete fascial coverage
allows for a two-layered strength closure as well as
complete coverage of the mesh. The hernia is easily
approached via the existing transverse scar. The hernia
sac is dissected in continuity into the preperitoneal
space. This may end up being above or below the rectus
muscle – either is acceptable. The mesh is sewn into
place in this plane and the fascia is closed over the top.
If necessary, release of the external oblique muscles
laterally via component separation allows for midline
advancement of the fascia.
Postoperative care
In general, no specific postoperative care is necessary
following revision. We recommend wearing a support­
ive brassiere which is not tightly compressive for a few
weeks postoperatively. If revision has been coupled
with nipple areolar reconstruction (discussed in Chapter
27), then the patient should avoid tight-fitting clothing
which compresses the NAR flaps. Almost all revision
can be done as an outpatient procedure and we routinely

425
Secondary procedures
cosmetic patient, some patients occasionally have
persistent complaints about their results. One should
approach these patients with caution, always asking
if surgeon and patient both agree on any deformity
and if surgery is likely to be successful in correcting
the problem. Mastectomy and reconstruction can have
a profound effect on self-image and sometimes pur­
posefully drawing out the interval between revisions
21. Coleman SR, Saboeiro AP. Primary breast augmentation with fat
grafting. Clin Plast Surg. 2015;42:301–306. Dr. Coleman is widely
considered to be one the pioneers of fat grafting. In this paper, he discusses
the use of fat grafting for a wide variety of breast procedures including
efficacy, technique and safety.
24. Hu ES, Pusic AL, Waljee JF, et al. Patient-reported aesthetic
satisfaction with breast reconstruction during the long-term
survivorship Period. Plast Reconstr Surg. 2009;124:1–8. There is a
large body of literature on short-term results of breast reconstruction;
however, very little literature is available on the long-term results. This is
an excellent paper looking at the difference in satisfaction rates between
autologous and alloplastic reconstruction in the long term.
25. Mirzabeigi MN, Wilson AJ, Fischer JP, et al. Predicting and
managing donor-site wound complications in abdominally based
free flap breast reconstruction: improved outcomes with early
reoperative closure. Plast Reconstr Surg. 2015;135:14–23. This is a
large retrospective review of donor site complications using free tissue
transfer from the abdomen. It characterizes the donor site complications
and quantifies the impact these complications have on the healthcare
system. It presents data to support early secondary closure of delayed
wound healing and dehiscence.
28. Rohrich RJ, Sorokin ES, Brown SA. In search of improved fat
transfer viability: a quantitative analysis of the role of centrifugation
and harvest site. Plast Reconstr Surg. 2004;113:391–395, discussion
396–397. Much controversy exists on the proper technique involved in fat
graft harvest, preparation and placement. This article discusses some of
the existing data and presents some new data to suggest that many
techniques and harvest sites are likely equivalent.
31. Gabriel A, Champaneria MC, Maxwell GP. Fat grafting and breast
reconstruction: tips for ensuring predictability. Gland Surg.
2015;4:232–243. While much of the existing data remains controversial,
this article summarizes well many articles which have sought to answer
the question as to how to best harvest, process and place fat grafts.
32. Del Vecchio DA, Del Vecchio SJ. The graft-to-capacity ratio:
volumetric planning in large-volume fat transplantation. Plast
Reconstr Surg. 2014;133:561–569. This is a well thought out article
presenting data on how to think about the volume of fat graft relative to
the overlying envelope. The data presented perhaps offers more clarity on
the volume of fat necessary to achieve the desired result while minimizing
complications.
34. Lin IC, Bergey M, Sonnad SS, Serletti JM, Wu LC. Management of
the ptotic or hypertrophic breast in immediate autologous breast
reconstruction: a comparison between the wise and vertical
reduction patterns for mastectomy. Ann Plast Surg. 2013;70(3):264–
270. Often, the existing skin envelope is mismatched with the volume of
the free flap, or there is significant ptosis which requires correction. This
article disccusses how to best manage envelope changes at the time of
mastectomy.
36. Liu X, Zhou L, Pan F, et al. Comparison of the postoperative
incidence rate of capsular contracture among different breast
implants: a cumulative meta-analysis. PLoS ONE. 2015;10:e0116071.
This is a metanalysis of the existing data comparing capsular contracture
rates using smooth versus textured breast implants. Based upon this
article, there is good evidence to support the use of textured implants to
lower the risk of developing capsular contracture.
37. Hassa A, Curtis MS, Colakoglu S, et al. Early results using
ultrasound-assisted liposuction as a treatment for fat necrosis in
breast reconstruction. Plast Reconstr Surg. 2010;126:762–768. Fat
necrosis is an unfortunate complication of autologous reconstruction as it
can bother patients tremendously to feel a firm mass after surviving breast
cancer. This paper offers evidence to support the use of ultrasound-assisted
liposuction to successfully treat these areas and is usually successful in
one to two sessions.
38. Ibrahim AM, Vargas CR, Colakoglu S, et al. Properties of meshes
used in hernia repair: a comprehensive review of synthetic and
biologic meshes. J Reconstr Microsurg. 2015;31:83–94. This article
discusses different types of mesh which can be used for hernia repair.
This review article summarizes existing data and discusses the risks
and benefits of synthetic versus biologic mesh.
Access the complete reference list online at

allows not only for physical evolution of the recon­
struction, but psychological adjustment of the patient
to the surgery. Lastly, like all surgery, if persistent
revision does not yield patient satisfaction, one should
never overlook that referral for a second opinion can
either offer a fresh approach or, at the very least, peace
of mind for the patient that nothing more should
be done.

425.e1
References
References
1. Teimourian B, Adham MN. Louis Ombredanne and the origin of
muscle flap use for immediate breast mound reconstruction. Plast
Reconstr Surg. 1983;72:905–910.
2. Maxwell GP. Iginio Tansini and the origin of the latissimus
dorsi musculocutaneous flap. Plast Reconstr Surg. 1980;65:
686–692.
3. Radovan C. Breast reconstruction after mastectomy using the
temporary expander. Plast Reconstr Surg. 1982;69:195–208.
4. Freeman BS. Subcutaneous mastectomy for benign breast lesions
with immediate or delayed prosthetic replacement. Plast Reconstr
Surg. 1980;65:371–372.
5. Georgiade GS, Riefkohl R, Cox E, et al. Long-term clinical outcome
of immediate reconstruction after mastectomy. Plast Reconstr Surg.
1985;76:415–420.
6. Noone RB, Murphy JB, Spear SL, Little JW 3rd. A 6-year experience
with immediate reconstruction after mastectomy for cancer. Plast
Reconstr Surg. 1985;76:258–269.
7. Snyderman RK, Guthrie RH. Reconstruction of the female breast
following radical mastectomy. Plast Reconstr Surg. 1971;47:
565–567.
8. Olivari N. The latissimus flap. Br J Plast Surg. 1976;29:126–128.
9. Bostwick J 3rd, Nahai F, Wallace JG, Vasconez LO. Sixty latissimus
dorsi flaps. Plast Reconstr Surg. 1979;63:31–41.
10. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a
transverse abdominal island flap. Plast Reconstr Surg. 1982;69:
216–225.
11. Grotting JC, Urist MM, Maddox WA, Vasconez LO. Conventional
TRAM flap versus free microsurgical TRAM flap for immediate
breast reconstruction. Plast Reconstr Surg. 1989;83:828–841,
discussion 842–844.
12. Blondeel N, Vanderstraeten GG, Monstrey SJ, et al. The donor site
morbidity of free DIEP flaps and free TRAM flaps for breast
reconstruction. Br J Plast Surg. 1997;50:322–330.
13. Fujino T, Harashina T, Enomoto K. Primary breast reconstruction
after a standard radical mastectomy by a free flap transfer. Case
report. Plast Reconstr Surg. 1976;58:371–374.
14. Codner MA, Nahai F. The gluteal free flap breast reconstruction.
Making it work. Clin Plast Surg. 1994;21:289–296.
15. Shaw WW. Superior gluteal free flap breast reconstruction. Clin
Plast Surg. 1998;25:267–274.
16. Allen RJ, Tucker C Jr. Superior gluteal artery perforator free flap for
breast reconstruction. Plast Reconstr Surg. 1995;95:1207–1212.
17. Boustred AM, Nahai F. Inferior gluteal free flap breast
reconstruction. Clin Plast Surg. 1998;25:275–282.
18. Elliott LF, Beegle PH, Hartrampf CR Jr. The lateral transverse thigh
free flap: an alternative for autogenous-tissue breast reconstruction.
Plast Reconstr Surg. 1990;85:169–178, discussion 179–181.
19. Hartrampf CR Jr, Noel RT, Drazan L, et al. Ruben’s fat pad for
breast reconstruction: a peri-iliac soft-tissue free flap. Plast Reconstr
Surg. 1994;93:402–407.
20. Elliott LF, Hartrampf CR Jr. The Rubens flap. The deep circumflex
iliac artery flap. Clin Plast Surg. 1998;25:283–291.
21. Coleman SR, Saboeiro AP. Primary breast augmentation with fat
grafting. Clin Plast Surg. 2015;42:301–306. Dr. Coleman is widely
considered to be one the pioneers of fat grafting. In this paper, he discusses
the use of fat grafting for a wide variety of breast procedures including
efficacy, technique and safety.
22. De Angelis R, Tavilla A, Verdecchia A, et al. Breast cancer survivors
in the United States: geographic variability and time trends,
2005-2015. Cancer. 2009;115:1954–1966.
23. Wilkins EG, Alderman AK. Breast reconstruction practices in north
america: current trends and future priorities. Semin Plast Surg.
2004;18:149–155.
24. Hu ES, Pusic AL, Waljee JF, et al. Patient-reported aesthetic
satisfaction with breast reconstruction during the long-term
survivorship Period. Plast Reconstr Surg. 2009;124:1–8. There is a
large body of literature on short-term results of breast reconstruction;
however, very little literature is available on the long-term results. This is
an excellent paper looking at the difference in satisfaction rates between
autologous and alloplastic reconstruction in the long term.
25. Mirzabeigi MN, Wilson AJ, Fischer JP, et al. Predicting and
managing donor-site wound complications in abdominally based
free flap breast reconstruction: improved outcomes with early
reoperative closure. Plast Reconstr Surg. 2015;135:14–23. This is a
large retrospective review of donor site complications using free tissue
transfer from the abdomen. It characterizes the donor site complications
and quantifies the impact these complications have on the healthcare
system. It presents data to support early secondary closure of delayed
wound healing and dehiscence.
26. Padoin AV, Braga-Silva J, Martins P, et al. Sources of processed
lipoaspirate cells: influence of donor site on cell concentration. Plast
Reconstr Surg. 2008;122:614–618.
27. Smith P, Adams WP Jr, Lipschitz AH, et al. Autologous human
fat grafting: effect of harvesting and preparation techniques on
adipocyte graft survival. Plast Reconstr Surg. 2006;117:
1836–1844.
28. Rohrich RJ, Sorokin ES, Brown SA. In search of improved fat
transfer viability: a quantitative analysis of the role of centrifugation
and harvest site. Plast Reconstr Surg. 2004;113:391–395, discussion
396–397. Much controversy exists on the proper technique involved in fat
graft harvest, preparation and placement. This article discusses some of
the existing data and presents some new data to suggest that many
techniques and harvest sites are likely equivalent.
29. Small K, Choi M, Petruolo O, et al. Is there an ideal donor site of
fat for secondary breast reconstruction? Aesthet Surg J. 2014;34:
545–550.
30. Ozsoy Z, Kul Z, Bilir A. The role of cannula diameter in improved
adipocyte viability: a quantitative analysis. Aesthet Surg J. 2006;26:
287–289.
31. Gabriel A, Champaneria MC, Maxwell GP. Fat grafting and
breast reconstruction: tips for ensuring predictability. Gland
Surg. 2015;4:232–243. While much of the existing data remains
controversial, this article summarizes well many articles which have
sought to answer the question as to how to best harvest, process
and place fat grafts.
32. Del Vecchio DA, Del Vecchio SJ. The graft-to-capacity ratio:
volumetric planning in large-volume fat transplantation. Plast
Reconstr Surg. 2014;133:561–569. This is a well thought out article
presenting data on how to think about the volume of fat graft relative to
the overlying envelope. The data presented perhaps offers more clarity on
the volume of fat necessary to achieve the desired result while minimizing
complications.
33. Garza RM, Paik KJ, Chung MT, et al. Studies in fat grafting: Part III.
Fat grafting irradiated tissue–improved skin quality and decreased
fat graft retention. Plast Reconstr Surg. 2014;134:249–257.
34. Lin IC, Bergey M, Sonnad SS, Serletti JM, Wu LC. Management of
the ptotic or hypertrophic breast in immediate autologous breast
reconstruction: a comparison between the wise and vertical
reduction patterns for mastectomy. Ann Plast Surg. 2013;70(3):264–
270. Often, the existing skin envelope is mismatched with the volume of
the free flap, or there is significant ptosis which requires correction. This
article disccusses how to best manage envelope changes at the time of
mastectomy.
35. Wong CH, Samuel M, Tan BK, Song C. Capsular contracture in
subglandular breast augmentation with textured versus smooth
breast implants: a systematic review. Plast Reconstr Surg.
2006;118:1224–1236.
36. Liu X, Zhou L, Pan F, et al. Comparison of the postoperative
incidence rate of capsular contracture among different breast
implants: a cumulative meta-analysis. PLoS ONE. 2015;10:e0116071.
This is a metanalysis of the existing data comparing capsular contracture
rates using smooth versus textured breast implants. Based upon this
article, there is good evidence to support the use of textured implants to
lower the risk of developing capsular contracture.
37. Hassa A, Curtis MS, Colakoglu S, et al. Early results using
ultrasound-assisted liposuction as a treatment for fat necrosis in
breast reconstruction. Plast Reconstr Surg. 2010;126:762–768. Fat
necrosis is an unfortunate complication of autologous reconstruction as it
can bother patients tremendously to feel a firm mass after surviving breast

425.e2
SECTION II
CHAPTER 22 • Secondary procedures following autologous reconstruction
cancer. This paper offers evidence to support the use of ultrasound-assisted
liposuction to successfully treat these areas and is usually successful in
one to two sessions.
38. Ibrahim AM, Vargas CR, Colakoglu S, et al. Properties of meshes
used in hernia repair: a comprehensive review of synthetic and
biologic meshes. J Reconstr Microsurg. 2015;31:83–94. This article
discusses different types of mesh which can be used for hernia repair. This
review article summarizes existing data and discusses the risks and
benefits of synthetic versus biologic mesh.
39. Le D, Deveney CW, Reaven NL, et al. Mesh choice in ventral hernia
repair: so many choices, so little time. Am J Surg. 2013;205:602–607,
discussion 607.

SECTION II • Reconstructive Breast Surgery
23.1 
Introduction to oncoplastic surgery
Maurice Y. Nahabedian
Introduction
Oncoplastic surgery has become a well-recognized
and accepted option for women with breast cancer.
Oncoplastic surgery is defined as wide excision of a
local tumor using oncologic principles followed by
the immediate or staged-immediate correction of the
defect using plastic surgical principles, the benefit
being that the reconstruction is performed prior to
radiation therapy. The feasibility, safety, and efficacy
of oncoplastic surgery stems from our improved
understanding of the biology of breast cancers, appre­
ciation for quality of life, patient satisfaction, and the
wide armamentarium of plastic surgery techniques for
correction.
The evolution of oncoplastic surgery can be traced
back to the origins of breast-conserving therapy (BCT)
for the management of tumors in women that did not
want mastectomy. Prior to oncoplastic surgery, BCT
frequently resulted in breast distortion and asymmetry
that was more notable following radiation therapy,
resulting in many patients who were unhappy with the
outcomes and desired corrective procedures. Corrective
procedures such as reduction mammaplasty, implant
insertion, and tissue rearrangement following radiation
therapy were frequently associated with higher rates of
morbidity that included delayed healing, fat necrosis,
and capsular contracture. Often, the ideal treatment was
to recreate the lumpectomy defect by excision of the scar
and damaged tissue followed by the delayed recon­
struction of the defect with a local flap such as the
latissimus dorsi.
Oncoplastic surgery differs from standard BCT, in
that the margin and volume of excision is typically
greater than that of lumpectomy or quadrantectomy.
Excision margins typically range from 1 to 2 cm and
resection volumes may range from 100 to 300 cm3. The
reconstruction is performed immediately or on a staged-
immediate basis using techniques of tissue rearrange­
ment, volume displacement, and volume rearrangement.
These will be discussed in greater detail in Chapters 23.2
and 23.3.
Safety and efficacy of
oncoplastic surgery
The indications and patient selection criteria are impor­
tant when considering oncoplastic surgery. This is
achieved by adhering to oncologic principles and by
applying appropriate plastic surgical techniques for
restoration. In order for oncoplastic surgery to be safely
and effectively performed, patients should be properly
selected and consented for these procedures. They
should be informed about local recurrence, long-term
survival, donor site considerations, secondary proce­
dures, and effects over time. The application of these
principles for the ablative and reconstructive surgeons
will facilitate the acceptance and success of oncoplastic
surgery.
Safety in oncoplastic surgery requires selection of
proper surgical techniques and attention to detail. The
importance of obtaining a clear margin is especially
important because the consequence of a positive margin
following parenchymal reorganization usually includes

427
Adjacent tissue rearrangement
Reduction mammaplasty
It is generally accepted that the individual credited with
the introduction and popularization of oncoplastic
surgery is Melvin J. Silverstein, MD, in 1982, following
the excision of a fibroadenoma that was immediately
repaired using a reduction mammaplasty approach.9
Several studies over the years have demonstrated
success.7–11 Various reduction mammaplasty techniques
can be used including the short scar or the inverted-T
patterns. Pedicle orientation is usually based on the
location of the tumor excision. For example, a laterally
based defect is usually repaired with a medially based
pedicle. Contralateral reduction mammaplasty is
usually performed at the same time for symmetry.
Outcomes have been favorable, with a 5-year local
recurrence rate of 9.4%; a survival rate of 95.7%; and the
metastasis-free survival rate of 82.8%.10 Satisfactory
aesthetic outcome was achieved in 82% of women.
Complications following oncoplastic reduction mam­
maplasty include local recurrence, fat necrosis, persistent
contour abnormality, delayed healing, loss of nipple
sensation/viability, nipple hypopigmentation, complex
scar; and breast asymmetry.12
Adjacent tissue rearrangement
Adjacent tissue rearrangement is perhaps the most
common method by which the partial mastectomy
defect is reconstructed because the ablative surgeon is
usually able to close the defect using several volume
displacement approaches. These techniques are useful
in situations where there is ample tissue to achieve
closure and minimize distortion. Veronesi et al. intro­
duced the concept of segmental parenchymal wide
excision including the overlying skin.13 These opera­
tions were generally performed using a radial approach
for tumors that were laterally based. An alternative to
the radial approach was the periareolar approach
described by Amanti et al.14 This permitted excisions
that resulted in less conspicuous scars. Periareolar
incisions could be created circumferentially around
the nipple areolar complex and remain relatively
inconspicuous. Silverstein introduced the parallelogram
pattern and batwing mastopexy.9 These parallelogram
incisions permitted wider excision margins and
maintained the natural contour of the breast. The
batwing mastopexy is usually used for centrally located
tumors near the nipple areolar complex. Clough
and colleagues introduced the technique of reduction
mastopexy lumpectomy.10 This technique has been
especially useful for tumors located at the lower pole of
re-operation, breast distortion, or possible mastectomy.
When surgical margins are in question following the
initial ablative procedure, a staged-immediate approach
can be considered.1 With this approach, the defect is
closed following the ablative procedure without formal
reconstruction. The specimen is sent to pathology, and
when final pathologic margins are confirmed, definitive
reconstruction is performed, usually 1–2 weeks later.
The relative risk of a tumor recurrence is 15-fold higher
when the surgical margin is not clear.2 A positive margin
is often related to the size of the primary tumor (T3 >
T2 > T1) and to histologic subtype (lobular > ductal).3
Preoperative identification of these women with infil­
trating lobular carcinoma who may be at higher risk of
a positive surgical margin can sometimes be made via
mammography based on the presence of architectural
distortion.4
Given that larger tumors have an increased likelihood
of a positive margin, the benefit of wide excision with a
1–2 cm margin, compared with lumpectomy with a
1–2 mm margin, is recognized. When resection margins
are increased, the incidence of a positive margin is
reduced when comparing oncoplastic resection to stan­
dard quadrantectomy.5 With oncoplastic tumor excision,
glandular resection is increased, histologic margins are
wider, the need for re-excision is decreased, and mas­
tectomies are fewer.6 As a result, immediate reconstruc­
tion of the partial mastectomy is usually safe; however,
as previously mentioned, when margin status is in ques­
tion, a delayed approach is usually considered.
Immediate reconstruction of the partial
mastectomy deformity
The techniques that are currently used for the recon­
struction of the partial mastectomy defect are based on
two different concepts: volume displacement and
volume replacement. Volume displacement procedures
include local tissue rearrangement, reduction mamma­
plasty, and mastopexy. Volume replacement procedures
include local and remote flaps from various regions of
the body. The indications for each are different, and
various algorithms have been devised to assist with the
decision process.7,8 These options will be described in
the following chapters. In most cases, the specific tech­
nique is based on breast volume and defect size. In
general, women with smaller breasts tend to be consid­
ered for volume replacement procedures, e.g., local flap,
latissimus dorsi, lateral thoracic flap; whereas, women
with larger breasts are better candidates for volume
displacement procedures, e.g., adjacent tissue rear­
rangement, reduction mammaplasty, mastopexy.

428
SECTION II
CHAPTER 23.1 • Introduction to oncoplastic surgery
the breast to minimize inferior displacement of the
nipple areolar complex that was typically seen with
standard lumpectomy.
Local and remote flaps
Local and remote flaps fall within the domain of volume
replacement procedures. These options have been most
useful for defects in which volume displacement proce­
dures would not be adequate due to breast volume
considerations or extent of resection. There are several
options that have been useful. The selection of one
technique versus another will depend upon the abilities
of the reconstructive surgeon and include pedicle or free
musculocutaneous and perforator flaps.
The most commonly used flap for the immediate
reconstruction of the partial mastectomy defect has been
the latissimus dorsi musculocutaneous flap.15–17 This
flap has been effectively used for deformities of the
superior, lateral, and inferior aspects of the breasts. The
latissimus dorsi flap can be harvested via a posterolat­
eral thoracic incision or through an endoscope.17 A
variation of the latissimus dorsi flap is miniflap.15,16 The
advantage of the miniflap is that variable amounts of
the latissimus dorsi muscle can be harvested based on
the volume requirements of the breast. The flap is gener­
ally harvested through an extended anterolateral breast
incision that is also used for the resection.
Outcomes using the latissimus dorsi flap have been
favorable. In a review of 30 patients, Kat et al. demon­
strated total flap survival and favorable aesthetic out­
comes in all.18 Losken et al. reviewed their experience
using the latissimus dorsi muscle flap harvested endo­
scopically in 39 women.15 Donor site morbidities
occurred in 12 women (31%) and included a seroma in
seven women as well as skin necrosis, lymphedema,
dehiscence, hypertrophic scarring, and a persistent
sinus tract.
The miniflaps have also demonstrated success. Rains­
bury feels that it extends the role of BCT and oncoplastic
surgery by enabling reconstruction for defects involving
20–30% of the breast that are located in the central,
upper-inner, and upper-outer quadrant tumors.17 Gendy
et al. used the latissimus dorsi miniflap in 89 women
following oncoplastic surgery demonstrating favorable
outcomes compared with skin sparing mastectomy and
immediate reconstruction.16 Postoperative complica­
tions were fewer (8% vs 14%); surgical interventions
were fewer (12% vs 79%); sensory loss of the nipple
areolar complex was retained in 98%; restricted activi­
ties were fewer (54% vs 73%); and cosmetic outcome
was superior (visual analog score: 83.5 vs 72).
The use of perforator flaps for the reconstruction of
the partial mastectomy has been receiving increasing
attention. There are three flaps that have been used for
this purpose: the thoracodorsal artery perforator flap
(TDAP); the lateral thoracic flap; and the intercostal
perforator flap.19 The TDAP is an adipocutaneous flap
in which the latissimus dorsi muscle is totally spared.
The vascularity of the flap is derived from the perforat­
ing branches of the thoracodorsal artery and vein. The
lateral thoracic flap is a fasciocutaneous flap that is
perfused via either the lateral thoracic, axillary, or tho­
racodorsal artery and vein. The intercostal perforator
flap is usually perfused via a perforating intercostal
artery and vein that is based along the inferior aspect of
the anterior axillary line. These flaps are usually trans­
ferred on a vascularized pedicle but may also be trans­
ferred as a free tissue transfer.
Clinical experience with these flaps has been encour­
aging. Levine and Allen have provided an algorithm for
perforator flap utilization.19 The first choice is the TDAP
flap followed by the lateral thoracic flap, and finally the
intercostal perforator flap. The decision is based on the
quality of the vessels during the operative procedure.
Munhoz et al. used the lateral thoracic flap in 34 women
for partial breast reconstruction.20 Flap complications
included partial necrosis in three (8.8%) that included
fat necrosis that developed in two women. Another
woman developed an infection. Donor site complica­
tions included a seroma in five women (14.7%) and
wound dehiscence in three women (8.8%). Patient sat­
isfaction was achieved in 88% of women with a mean
follow-up period of 23 months.
1. Patel KM, Hannan C, Gatti M, et al. A head to head comparison of
quality of life and aesthetic outcomes following immediate,
staged-immediate, and delayed oncoplastic reduction
mammaplasty. Plast Reconstr Surg. 2011;127:2167–2175. This paper
describes the advantages of waiting 1–2 weeks following the partial
mastectomy before definitive reconstruction. This ensures a clear margin
and obviates the possibility of mastectomy.
2. Schnitt SJ, Abner A, Gelman R, et al. The relationship between
microscopic margins of resection and the risk of local recurrence in
patients treated with breast conserving surgery and radiation
therapy. Cancer. 1994;74:1746–1751. One of the first studies to review
local recurrence associated with extensive intraductal carcinoma managed
with local excision and radiotherapy. It was demonstrated that BCT, in all
patients with uninvolved margins, was a reasonable option for local
control.
4. Moore MM, Borossa G, Imbrie JZ, et al. Association of
infiltrating lobular carcinoma with positive surgical margins
after breast-conservation therapy. Ann Surg. 2000;231:877–882.
This study attempts to assess oncologic safety of lumpectomy based on
tumor type. The incidence of positive margins was greater with
infiltrating lobular carcinoma compared with the infiltrating ductal
carcinoma.
Access the complete reference list online at

429
Local and remote flaps
5. Kaur N, Petit JY, Rietjens M, et al. Comparative study of surgical
margins in oncoplastic surgery and quadrantectomy in breast
cancer. Ann Surg Oncol. 2005;12:539–545. This study compares 30
patients following quadrantectomy with 30 patients following oncoplastic
surgery. It was demonstrated that oncoplastic surgery adds to the
oncologic safety of breast-conserving treatment because a larger volume of
breast tissue can be excised with a wider negative margin.
7. Kronowitz SJ, Feledy JA, Hunt KK. Determining the optimal
approach to breast reconstruction after partial mastectomy. Plast
Reconstr Surg. 2006;117:1–11. The authors compared the results of
immediate and delayed oncoplastic procedures using a tissue
rearrangement, reduction mammaplasty, and flap techniques. It was
demonstrated that immediate repair with tissue rearrangement and
reduction had a lower risk of complications and better aesthetic outcomes
than immediate repair with a latissimus dorsi flap.
8. Losken A, Styblo TM, Carlson GW, et al. Management algorithm
and outcome evaluation of partial mastectomy defects treated using
reduction or mastopexy techniques. Ann Plast Surg. 2007;59:235–242.
This manuscript describes a treatment algorithm based on patient
selection, diagnosis, tumor margins, and recurrence rates for management
of the partial mastectomy defect. Reduction mammaplasty proved to be an
excellent option in women with moderate to severe mammary hypertrophy.
10. Clough KB, Lewis JS, Couturaud B, et al. Oncoplastic techniques
allow extensive resections for breast-conserving therapy of breast
carcinomas. Ann Surg. 2003;237:26–34. In a prospective study of 101
patients, oncoplastic techniques and contralateral breast surgery allows for
an extensive tumor resection resulting in favorable oncologic and aesthetic
outcomes. Oncoplastic surgery is useful in extending the indications for
breast-conserving therapy.
13. Veronesi U, Luini A, Galimberti V, et al. Conservation approaches
for the management of stage I/II carcinoma of the breast: Milan
Cancer Institute trials. World J Surg. 1994;18:70–75. In this study from
the Milan Cancer Institute, from 1973 to 1988, the authors demonstrated
that reducing the extent of surgery from quadrantectomy to lumpectomy
increases the risk of local recurrence by nearly three times, as does
withdrawing radiotherapy.
16. Gendy RK, Able JA, Rainsbury RM. Impact of skin sparing
mastectomy with immediate reconstruction and breast sparing
reconstruction with miniflaps on the outcomes of oncoplastic breast
surgery. Br J Surg. 2003;90:433–439. This study compares 57 skin
sparing mastectomy patients with 49 oncoplastic surgery patients
demonstrating that oncoplastic surgery with latissimus dorsi miniflaps
had more favorable outcomes based on postoperative complications (14%
vs 8%); further surgical interventions (12% vs 79%); nipple sensory loss
(2% vs 98%); restricted activities (54% vs 73%); and cosmetic outcome
by panel assessment.
19. Levine JL, Soueid NE, Allen RJ. Algorithm for autologous
breast reconstruction for partial mastectomy defects. Plast
Reconstr Surg. 2005;116:762–767. The authors describe the use
of lateral thoracic flaps in the reconstruction of partial mastectomy
defects with an emphasis on appropriate patient selection, algorithms,
and technique.

429.e1
References
References
1. Patel KM, Hannan C, Gatti M, et al. A head to head comparison of
quality of life and aesthetic outcomes following immediate,
staged-immediate, and delayed oncoplastic reduction
mammaplasty. Plast Reconstr Surg. 2011;127:2167–2175. This paper
describes the advantages of waiting 1–2 weeks following the partial
mastectomy before definitive reconstruction. This ensures a clear margin
and obviates the possibility of mastectomy.
2. Schnitt SJ, Abner A, Gelman R, et al. The relationship between
microscopic margins of resection and the risk of local recurrence in
patients treated with breast conserving surgery and radiation
therapy. Cancer. 1994;74:1746–1751. One of the first studies to review
local recurrence associated with extensive intraductal carcinoma managed
with local excision and radiotherapy. It was demonstrated that BCT, in all
patients with uninvolved margins, was a reasonable option for local control.
3. Chapgar AB, Martin RC, Hagendoorn LJ, et al. Lumpectomy
margins are affected by tumor size and histologic subtype but not
by biopsy technique. Am J Surg. 2004;188:399–402.
4. Moore MM, Borossa G, Imbrie JZ, et al. Association of infiltrating
lobular carcinoma with positive surgical margins after breast-
conservation therapy. Ann Surg. 2000;231:877–882. This study
attempts to assess oncologic safety of lumpectomy based on tumor type.
The incidence of positive margins was greater with infiltrating lobular
carcinoma compared with the infiltrating ductal carcinoma.
5. Kaur N, Petit JY, Rietjens M, et al. Comparative study of surgical
margins in oncoplastic surgery and quadrantectomy in breast
cancer. Ann Surg Oncol. 2005;12:539–545. This study compares 30
patients following quadrantectomy with 30 patients following oncoplastic
surgery. It was demonstrated that oncoplastic surgery adds to the
oncologic safety of breast-conserving treatment because a larger volume of
breast tissue can be excised with a wider negative margin.
6. Giacalone PL, Roger P, Dubon O, et al. Lumpectomy vs. oncoplastic
surgery for breast-conserving therapy of cancer. A prospective
study about 99 patients. Ann Chir. 2006;131:256–261.
7. Kronowitz SJ, Feledy JA, Hunt KK. Determining the optimal
approach to breast reconstruction after partial mastectomy. Plast
Reconstr Surg. 2006;117:1–11. The authors compared the results of
immediate and delayed oncoplastic procedures using a tissue
rearrangement, reduction mammaplasty, and flap techniques. It was
demonstrated that immediate repair with tissue rearrangement and
reduction had a lower risk of complications and better aesthetic outcomes
than immediate repair with a latissimus dorsi flap.
8. Losken A, Styblo TM, Carlson GW, et al. Management algorithm
and outcome evaluation of partial mastectomy defects treated using
reduction or mastopexy techniques. Ann Plast Surg. 2007;59:235–242.
This manuscript describes a treatment algorithm based on patient
selection, diagnosis, tumor margins, and recurrence rates for management
of the partial mastectomy defect. Reduction mammaplasty proved to be an
excellent option in women with moderate to severe mammary hypertrophy.
9. Anderson BO, Masetti R, Silverstein ML. Oncoplastic approaches to
the partial mastectomy: an overview of volume displacement
techniques. Lancet Oncol. 2005;145–157.
10. Clough KB, Lewis JS, Couturaud B, et al. Oncoplastic techniques
allow extensive resections for breast-conserving therapy of breast
carcinomas. Ann Surg. 2003;237:26–34. In a prospective study of 101
patients, oncoplastic techniques and contralateral breast surgery allows for
an extensive tumor resection resulting in favorable oncologic and aesthetic
outcomes. Oncoplastic surgery is useful in extending the indications for
breast-conserving therapy.
11. Munhoz AM, Montag E, Arruda EG, et al. Critical analysis of
reduction mammaplasty techniques in combination with breast
conservation surgery for early breast cancer treatment. Plast
Reconstr Surg. 2006;117:1091–1103.
12. Spear SL, Pelletiere CV, Wolfe AJ, et al. Experience with reduction
mammaplasty combined with breast conservation therapy in the
management of breast cancer. Plast Reconstr Surg. 2003;111:
1102–1109.
13. Veronesi U, Luini A, Galimberti V, et al. Conservation approaches
for the management of stage I/II carcinoma of the breast: Milan
Cancer Institute trials. World J Surg. 1994;18:70–75. In this study from
the Milan Cancer Institute, from 1973 to 1988, the authors demonstrated
that reducing the extent of surgery from quadrantectomy to lumpectomy
increases the risk of local recurrence by nearly three times, as does
withdrawing radiotherapy.
14. Amanti C, Moscaroli A, Lo Russo M, et al. Periareolar subcutaneous
quadrantectomy: a new approach in breast cancer surgery. G Chir.
2002;23:445–449.
15. Losken A, Schaefer TG, Carlson GW, et al. Immediate endoscopic
latissimus dorsi flap. Ann Plast Surg. 2004;53:1–5.
16. Gendy RK, Able JA, Rainsbury RM. Impact of skin sparing
mastectomy with immediate reconstruction and breast sparing
reconstruction with miniflaps on the outcomes of oncoplastic breast
surgery. Br J Surg. 2003;90:433–439. This study compares 57 skin
sparing mastectomy patients with 49 oncoplastic surgery patients
demonstrating that oncoplastic surgery with latissimus dorsi miniflaps
had more favorable outcomes based on postoperative complications (14%
vs 8%); further surgical interventions (12% vs 79%); nipple sensory loss
(2% vs 98%); restricted activities (54% vs 73%); and cosmetic outcome
by panel assessment.
17. Rainsbury RM. Breast sparing reconstruction with latissimus dorsi
miniflaps. Eur J Surg Oncol. 2002;28:891–895.
18. Kat CC, Darcy CM, O’Donoghue JM, et al. The use of the latissimus
dorsi flap for the immediate correction of the deformity resulting
from breast conserving therapy. Br J Plast Surg. 1999;52:99–103.
19. Levine JL, Soueid NE, Allen RJ. Algorithm for autologous breast
reconstruction for partial mastectomy defects. Plast Reconstr Surg.
2005;116:762–767. The authors describe the use of lateral thoracic flaps in
the reconstruction of partial mastectomy defects with an emphasis on
appropriate patient selection, algorithms, and technique.
20. Munhoz A, Montag E, Arruda EG, et al. The role of the lateral
thoracodorsal fasciocutaneous flap in immediate conservative
breast surgery reconstruction. Plast Reconstr Surg. 2006;116:
1699–1710.

SECTION II • Reconstructive Breast Surgery
23.2 
Partial breast reconstruction using
reduction and mastopexy techniques
Albert Losken and Alexandra M. Hart
SYNOPSIS
■ Breast-conserving therapy increases in popularity, driven by equivalent
survival rates, preservation of body image, quality of life, and reduced
physiologic morbidity.
■ Poor cosmetic results following breast-conserving therapy are not
uncommon and are usually due to breast shape, tumor size, tumor
location, and postoperative radiation.
■ Partial breast reconstruction is indicated whenever the potential for a
poor cosmetic result exists, or for patients with tumors in whom a
standard lumpectomy would lead to breast deformity or gross
asymmetry.
Introduction
Patient presentation/selection
Women with breast cancer who have large or ptotic
breasts are at increased risk for poor cosmetic results,
and it is often difficult to perform total breast recon­
struction on these patients. The emerging popularity of
reconstructing the partial mastectomy defect has shown
to be beneficial in this patient population.1 Reduction
and mastopexy techniques are ideal, given these
patients’ breast shape and the relatively large amount
of breast tissue left behind after partial resection. This
approach has grown in popularity over the last decade
and has been proven to be a safe and reliable option for
women with breast cancer.2–5
Assuming the patient is a candidate for breast-
conserving therapy (BCT), the main indication for using
oncoplastic reduction techniques is to minimize the
potential for a poor cosmetic result. In a subset of
women, oncoplastic reduction may also broaden the
indication for BCT to include women who were not
previously candidates.
The oncoplastic goals are to:
1. Avoid the BCT deformity.
2. Broaden the indications for BCT and avoid
mastectomy in certain patients.
3. Maintain shape, symmetry, and improve ptosis.
4. Maximize resection to reduce the local recurrence.
Poor cosmetic results have been reported in up to 20%
of women following BCT due to breast shape, tumor
size, tumor location, and postoperative radiation (Fig.
23.2.1).6 Traditionally, women with large breasts have
been deemed poor candidates for breast-conserving
surgery because of reduced effectiveness, increased
complications, and worse cosmetic outcome. The post-
radiation sequela in women with macromastia is signifi­
cantly worse, leading to poor long-term symmetry.
Additionally, radiation-induced fibrosis is thought to be
greater in women with larger breasts, given the dosing
inhomogeneity.7,8 Late-radiation fibrosis occurs 36% of
the time in patients with larger breasts, compared with
3.6% with smaller breasts. Furthermore, higher doses of
radiation therapy are often necessary in women with
larger breasts contributing to morbidity and adversely
affecting the appearance.
The cosmetic results following BCT in women with
large breasts are also reduced.9 In an early report, Clarke
et al. have shown excellent results in 100% of women
with A cup breasts following BCT, compared with 50%
in women with D cup breasts.10 Women with central or
lower quadrant tumors have also been shown to have a
worse cosmetic outcome because of tumor location,
especially when a significant amount of skin is removed.
  Access video content for this chapter online at expertconsult.com

431
Surgical technique
Surgical technique
The breast reshaping procedures are all reliant upon
shrinking the defect into a smaller or lifted breast to
improve symmetry and the efficacy of adjuvant radiation
therapy. The ideal patient is one where the tumor can be
excised within the expected breast reduction specimen.
In medium to large or ptotic breasts, sufficient breast
parenchyma remains following resection to reshape
the mound. Masetti et al. describe a 4-step design for
oncoplastic operations: (1) planning skin incisions and
parenchymal excisions following common reduction/
mastopexy templates; (2) parenchymal reshaping after
excision; (3) repositioning the nipple; and (4) correction
of the contralateral breast for symmetry.16 The verti­
cal skin pattern is a reasonable option for women with
smaller breasts who have a tumor in the lower, medial,
or lateral quadrant (Fig. 23.2.2). This is a relatively easy
way to start, since the tumor is often resected as part of
the medial and lateral pillar creation.
The Wise skin pattern tends to be the most versatile
and can be used to reconstruct a partial mastectomy
defect anywhere in the breast. The pedicle type neces­
sary for nipple viability depends on the surgeon’s
preference, the patient’s breast size and shape, and
the location of the defect. For example, the inferior
pedicle can be used in any tumor location except inferior
ones (Fig. 23.2.3). Creative pedicle designs can often be
used to auto-augment the defect by either using an
extended traditional pedicle or by using a secondary
de-epithelialized dermoglandular pedicle.
As with all operations, preoperative planning is essential to
obtaining a good result. Communication between the two
surgical teams is essential. Well planned preoperative mark­
ings are important. Additionally, reviewing the imaging
with the breast surgeon will assist in predicting the loca­
tion and size of the defect relative to the nipple and skin.
Any preoperative asymmetry is also documented to
help guide the amount of tissue resected from each
breast. Resections are performed within the Wise pattern
area to be resected and if possible, without violation of
proposed nipple pedicle. After the resection, the cavity
is inspected, paying attention to the defect location in
relation to the nipple and the remaining breast tissue.
Additional cavity samples are then taken for permanent
pathology, and the cavity is marked with metallic clips
for localization and cancer surveillance. The reconstruc­
tive goals include (1) preservation of nipple viability; (2)
filling the defect; and (3) reducing and reshaping the
breast mound. The nipple and dermoglandular pedicle
is created through de-epithelialization and glandular
dissection. Once it has been determined how the defect
Lower quadrant lumpectomies have been shown to
reduce cosmesis by 50% when compared with other
quadrants. In the past, central breast tumors close to the
areolar have been a contraindication to BCT, but even
these are often able to be reconstructed using oncoplastic
techniques. The tumor to breast ratio is one of the most
important factors when predicting the potential for a
poor outcome. In general, when more than 20% of the
breast is excised with partial mastectomy, the cosmetic
result is likely to be unfavorable.11
In addition to the aesthetic reasons, there have recently
emerged oncologic benefits to choosing the oncoplastic
approach. Larger tumors and patients who have received
neoadjuvant chemotherapy are now considered reason­
able candidates for BCT using the oncoplastic tech­
niques.3,12,13 Another indication is when the surgeon is
concerned about the potential for negative margins with
standard resection. In patients who need a wider excision
based on initial pathology or breast imaging studies,
lumpectomies performed in combination with onco­
plastic reduction have shown a benefit-to-margin control
when compared with standard resection margins
(Table 23.2.1).9,14,15
Fig. 23.2.1  A 42-year-old woman who underwent a 20 g resection from the lower
inner quadrant. Her resultant breast-conserving therapy deformity demonstrates
shape and size distortion 2 years following radiation therapy.
Table 23.2.1  Indications for oncoplastic surgery
Cosmetic reasons
Oncologic reasons
High tumor to breast ratio (>20%)
Tumor location: central, inferior,
medial
Macromastia
Large tumor
Patient desires smaller breasts
Significant ptosis or breast
asymmetry
Concern about clear margins
Wide excision required
Poor candidate for
mastectomy and
reconstruction (i.e., age,
breast size)
Patient desires breast-
conserving therapy

432
SECTION II
CHAPTER 23.2 • Partial breast reconstruction using reduction and mastopexy techniques
Fig. 23.2.2  (A–F) A 53-year-old woman with breast asymmetry and a lower pole invasive ductal CA. She underwent a lumpectomy (65 g). The tumor was within the
reduction specimen, additional tissue was sent (30 g), and a superior pedicle mastopexy was performed. A similar procedure was performed on the contralateral side
removing a total of 110 g. Her early result is shown with improvement of symmetry and shape.
A
B
C
D
E
F

433
Surgical technique
Fig. 23.2.3  (A–E) A 33-year-old woman with stage III breast cancer had a good
response to chemotherapy and desired breast conservation. Her tumor location was
upper quadrant and, in order to minimize the potential for a poor cosmetic result,
she underwent a 100 g lumpectomy with simultaneous bilateral breast reduction. The
total volume including specimen on the left was 250 g, and on the right, 150 g. An
inferior pedicle was used to reposition the nipple and reconstruct the defect. Her
result is shown 1 year following completion of right-sided breast irradiation, with
good symmetry.
A
B
C
D
E

434
SECTION II
CHAPTER 23.2 • Partial breast reconstruction using reduction and mastopexy techniques
is going to be filled, the remaining tissue is resected and
the breast mound is reshaped. Occasionally, additional
dermoglandular or glandular pedicles can be created
from tissue that might otherwise have been resected,
and rotated to auto-augment the defect.
Lower quadrant tumors in women with larger breasts
are ideally suited for the oncoplastic approach.
Quadrantectomy-type resections are possible, removing
skin and parenchyma from this location, reshaping the
breast using a superior or superomedial pedicle. Lower
pole tumors in moderate-sized breasts can be excised
along with skin as needed in the usual vertical pattern,
utilizing a superior pedicle followed by plication of the
vertical pillars, and vertical reduction on the contra­
lateral side (see Fig. 23.2.2). Upper quadrant tumors can be
filled as long as the defect is under the skin (lumpectomy
type). Auto-augmentation techniques have become
popular to fill the dead space and maintain shape. Infe­
rior or medial pedicles allow for safe excisions in the
upper half of the breast without impairing nipple viabil­
ity, and parenchyma is often rearranged when insuffi­
cient tissue remains in the upper pole to maintain the
desired fullness. However, when skin is resected in the
upper half of the breast, such remodeling techniques are
not possible. Lateral or upper-outer quadrant defects allow
parenchymal remodeling using the superomedial
pedicle. These types of reconstructions become difficult
when skin is resected with the specimen and are better
suited for the lumpectomy type defects. In women with
medium-sized ptotic breasts, the superomedial pedicle
can be extended down to the inframammary fold as an
auto-augmented pedicle. This can then be rotated to fill
a lateral volume void. The vertical pillars are then pli­
cated in the usual fashion to maintain shape. If tissue is
removed from above the Wise pattern markings, a flap
is often required. In women with macromastia, a reduc­
tion can still be performed utilizing the inferior pedicle
skin to replace missing breast skin even when above the
Wise markings.
In the past, central tumors have been considered rela­
tive contraindications to BCT; however, with the onco­
plastic approach in women with macromastia, the tumor
and nipple areolar complex can be widely excised and
reconstructed using a variety of techniques. The mound
can be remodeled in the inverted-T closure pattern,
similar to breast amputation reduction techniques. The
nipple is then reconstructed later using the reconstruc­
tion technique of choice. Another option, if the tumor is
located more superiorly or lateral, is to perform a central
elliptical excision of skin, nipple, and parenchyma, and
mirror image contralateral reduction for symmetry. A
third option includes creation of a skin island on a
dermatoglandular pedicle to rotate into the central
defect to allow for shape preservation and nipple recon­
struction. The breast is marked preoperatively for an
inverted-T or a vertical approach, depending on breast
size, and the skin island is brought in from inferior or
medial (Fig. 23.2.4).
Additional mastopexy options exist for oncoplastic
breast conservation.17 The donut mastopexy allows a
breast segment to be removed through a periareolar
incision and is useful for segmentally distributed
cancers in the upper or lateral portion of the breast.
The batwing mastopexy involves a full-thickness excision
of lesions deep within the breast centrally or adjacent
to the nipple areolar complex. The two similar half-
circle incisions with angled wings on either side of the
areolar allow advancement of the fibroglandular tissue
to close the defect. A similar mirror image resection
is often performed on the opposite side for symmetry.
Larger quadrantectomy defects, especially above the
nipple, can be incorporated into a batwing mastopexy
or elliptical type incision and provide preservation or
improvement of shape and elevation of the ptotic breast
along with the tumor resection. Since this removes suf­
ficient breast tissue and skin to alter the size of the
breast and nipple position, a similar contralateral lift is
occasionally required to achieve symmetry.
A contralateral reduction is typically performed for
symmetry using a similar technique on all patients at
the time of the oncoplastic procedure. Additionally, if
the patient is a candidate for BCT and has multiple areas
that need to be resected, as long as sufficient tissue
remains, remodeling techniques can be used in a similar
fashion. The contralateral side is typically kept about
10% smaller in anticipation for radiation fibrosis on the
opposite side. A small revision to the opposite breast
after completion of radiation therapy is occasionally
required (<10%) if asymmetry exists.
Benefits
While initially the driving force behind the use of onco­
plastic reduction techniques was improved cosmesis,
numerous additional benefits have been documented.
The oncoplastic approach has been shown to broaden
the indications for BCT in patients with tumors larger
than 4 cm, locally advanced cancers, and prior neoad­
juvant chemotherapy.12 Additionally, patients with
advanced stage breast cancer can undergo BCT using
this technique.
The amount of tissue resected in patients undergoing
an oncoplastic reduction is significantly greater. Clough
et al. have shown that extensive resections are possible
with this technique, in over 101 patients with the average
specimen weight of 222 g.3 A recent meta-analysis has

435
Surgical technique
A
B
C
D
E
F
Fig. 23.2.4  (A–G) This patient did not want to undergo skin-sparing mastectomy and reconstruction
and, despite having a sub-areolar tumor, elected to have breast preservation. Given the proximity, she
had resection of the nipple areolar complex with her partial mastectomy. An inferior pedicle was
created leaving a skin island appropriately located for nipple areolar replacement. The result is shown
9 months following completion of radiation therapy just prior to nipple areolar reconstruction.
G

436
SECTION II
CHAPTER 23.2 • Partial breast reconstruction using reduction and mastopexy techniques
pathology and potentially reduce cancer risk by remov­
ing additional breast tissue.20
Timing
The oncoplastic reduction is preferably performed at the
time of tumor removal and prior to radiation therapy. It
is easier to preserve breast shape during the initial resec­
tion than to reconstruct a deformity in an irradiated
breast. In the authors’ own patients, it has been shown
that utilization of oncoplastic reduction techniques prior
to radiation therapy results in significantly fewer com­
plications when compared with performing reductions
after completion of radiation therapy (21% vs 57%;
p<0.001).21 Similar results (24% vs 50%) have been shown
by Kronowitz et al.22 The main concern with immediate
reconstruction is the potential for positive margins
requiring re-excision. When there is any concern about
margin status, delayed immediate reconstruction is an
option (Fig. 23.2.5). This postpones the reconstructive
procedure until confirmation of negative margins,
giving the benefit of immediate reconstruction with the
luxury of negative margins. The disadvantage of this is
that it requires two operations. Our institutional prefer­
ence is to minimize positive margins through patient
selection and cavity sampling. Based on our experience
of a critical analysis of failed oncoplastic reduction
techniques, patients at higher risk for positive margins
tend to be women less than 40 years of age with exten­
sive DCIS.23 Other characteristics that may potentially
make it more difficult to obtain negative margins include
infiltrating lobular carcinoma, prior chemotherapy, or
multicentric disease.
Confirmation of margin status prior to reconstruction
may be beneficial for some patients. Preoperative
breast imaging (i.e., MRI, ultrasound, or mammogra­
phy) is often helpful in determining the extent of the
disease to guide the necessary resection. Intraoperative
cavity sampling is another way to minimize positive
margins and the need for re-excision. Sending separate
cavity margins at the time of lumpectomy has been
shown to significantly reduce the need for re-excision.
Using this technique, Cao et al. demonstrated that final
margin status was negative in 60% of patients with
positive margins on initial resection.24 Potential factors
contributing to the false-positive margin status include
seepage of ink into crevices of the specimen promoted
by excessive inking, tumor friability promoting dis­
placement of tumor into ink, and manipulation of
specimens for radiographs and retraction artifact. Addi­
tional intraoperative confirmatory procedures include
radiography of the specimen or intraoperative frozen
sections for invasive cancer.
shown that average resection in these patients is well
over 200 g compared with a typical resection of about
50 g when traditional BCT is performed alone.9 The
ability to perform a generous resection often translates
into superior margin clearance. Although there is a lack
of randomized control data comparing the two groups,
the incidence of positive margins in retrospective com­
parisons is significantly less in the oncoplastic reduction
group compared with BCT alone. Kaur et al. performed
a prospective trial comparing quadrantectomy alone
(n = 30) and resection with oncoplastic reconstruction
(n = 30). They demonstrated that larger resection weights
(200 vs 118 g; p = 0.16) resulted in fewer close or positive
margins (16.7% vs 43.3%; p = 0.5) in the oncoplastic
group.15 Furthermore, ductal carcinoma in situ (DCIS)
histology was more prevalent in the quadrantectomy
alone group and accounted for some of the differences.
Giacalone et al. performed a similar prospective com­
parative study comparing quadrantectomy alone (n = 43)
and resection with oncoplastic reconstruction (n = 31).
The authors found margins ≥5 mm in 67% of oncoplastic
group versus 42% in the quadrantectomy alone group
(p = 0.3).4 Losken et al. demonstrated a lower positive
margin rate (24.1% vs 41.0%; p = 0.01); fewer surgical
re-excisions (12.0% vs 25.9%; p = 0.01); and wider margins
from the tumor edge (4.3 vs 2.8 mm; p = 0.01) when onco­
plastic surgery was performed.14 A recent meta-analysis
also found a reduction in the positive margin rate for
both invasive and in situ disease from 21% with BCT
alone to 12% in oncoplastic excisions.9 The long-term
influence of this on cancer recurrence remains to be seen.
An additional benefit of the oncoplastic approach is
the ease of performing a reduction in women with
macromastia compared with skin sparing mastectomy
(SSM) and immediate reconstruction.14 Lower breast
complication rates (22% vs 50%); no donor site compli­
cations; shorter hospital stay (0.87 vs 3.5 days); and
fewer additional procedures (2.5 vs 5.8) have been
shown following oncoplastic reductions when com­
pared with traditional total reconstruction procedures.
Furthermore, results of patient reported outcomes have
documented an improved quality of life and self-esteem
when the oncoplastic approach is added to BCT.18 Given
the many functional and psychological benefits of a
breast reduction, it is not surprising that women who
had an oncoplastic reduction also report an increase in
their satisfaction with body image, an unexpected
increase in their ability to wear sexually provocative
clothing, and an unforeseen increase in their partners
perception of them as womanly.19
The use of this approach also allows additional sam­
pling of ipsilateral and contralateral breast tissue
with the ability to occasionally diagnose other breast

437
Surgical technique
A
B
C
D
F
E
Fig. 23.2.5  (A–I) A 40-year-old woman with moderate-sized breasts and ptosis desired breast preservation. She has ductal carcinoma in situ medially on the right. Given
oncologic concerns, a decision was made to delay reconstruction until confirmation of clear margins. Her medial defect is demonstrated following 50 g resection. A
decision was made to perform a superolateral pedicle extending the pedicle down to the chest wall. This was then rotated into the medial defect, and the medial and lateral
pillars were plicated. A contralateral symmetry procedure was performed removing 65 g. The result is shown following radiation therapy with breast edema and size
discrepancy. She is then shown 1 year later with good size and symmetry.
Continued

438
SECTION II
CHAPTER 23.2 • Partial breast reconstruction using reduction and mastopexy techniques
will assist with re-excision, as well as guide postopera­
tive surveillance or the need for radiation boost.
Outcomes
Importantly, complications resulting from oncoplastic
techniques should not interfere with the initiation of
adjuvant therapy. A meta-analysis demonstrated an
average complication rate of 16% in the oncoplastic
reduction group. However, there was not a delay in the
initiation of adjuvant therapy.9 Additional procedures
will invariably increase complications; however, most of
these are minor. Some larger series report complications
such as delayed wound healing (3–15%), fat necrosis
(3–10%), and infection (1–5%).18,21,22 In the largest onco­
plastic series of 540 patients, the complication rate was
also 16%.5 The authors found the severity of the compli­
cations requiring surgical intervention in the oncoplastic
groups was approximately 3%. In series of BCT alone,
complications are rarely recorded; however, in one
Management of positive margins
If final pathology reveals positive margins on the
tumor specimen and additional parenchyma was not
removed from around the tumor site as in remodeling
mammaplasty-like techniques, then there are commonly
two options: completion mastectomy or re-excision.
When margins are positive following oncoplastic tech­
niques that produce wide excisions, the extent of disease
will typically dictate that a mastectomy be performed
rather than a re-excision. There is little downside to
completion mastectomy and reconstruction, as the
contralateral symmetry procedure has already been
performed (Fig. 23.2.6). Therefore the typical skin
removal pattern has also been completed, which will
allow for easier reconstruction of a smaller breast.
Depending on the patient, re-excision is possible when
performed in conjunction with both the breast and
reconstructive surgeon, as the cavity architecture might
have been altered during the initial surgery. Intra­
operative cavity clipping during the original resection
G
H
I
Fig. 23.2.5, cont’d

439
Outcomes
adjuvant therapy. Iwuchukwu et al. reviewed oncoplas­
tic reduction techniques in the literature siting a 5–14%
poor cosmetic outcome following these procedures.26
When aesthetic and patient satisfaction was evaluated
in a recent meta-analysis, the overall satisfaction with
BCT alone was 80%, compared with 90% when an
oncoplastic reduction was performed. Patient dissatis­
faction was correlated with postoperative complications
and breast asymmetry.25 Having a 90% satisfaction in
the oncoplastic groups is understandable. These are
self-selected, high-risk patients for poor cosmetic results,
and despite correcting the volume loss secondary to
tumor resection with immediate reconstruction, the
adverse effects of radiation therapy will still persist but
potentially be less obvious.
Local recurrence is an important outcome that needs to
be evaluated. Most reviews in the literature are of inter­
mediate follow-up times (longest = 4.5 years), with local
recurrence rates varying from 0% to 1.8% per year.27
Actuarial 5-year local recurrence rates range from 8.5%
series of 714 patients with BCT alone, the reported
complication rate was 24%.25 Although potentially
higher, studies thus far have failed to show that compli­
cations following oncoplastic reduction result in a nega­
tive impact on the oncologic management of patients.
Appropriate technique and patient selection is required
to minimize morbidity when this approach is selected.
Late complications requiring additional surgery are
usually related to aesthetic outcome, radiation changes,
or recurrence.
Improvement in cosmesis is one of the main driving
forces behind the increasing use of the oncoplastic
approach, and many of the indications for oncoplastic
surgery revolve around predicting high-risk patients
and minimizing the potential for a poor cosmetic result.
Nevertheless, this approach cannot prevent or reverse
the effects of radiation therapy. Given that the majority
of patient’s will receive radiotherapy and the effects will
persist, the assessment of shape and symmetry needs to
be made in the context of long-term changes following
Fig. 23.2.6  (A–C) A 43-year-old woman with right-sided breast cancer who
underwent partial reconstruction using the oncoplastic reduction approach. Her
lumpectomy margins were clear; however, ductal carcinoma in situ was identified in
the additional tissue removed during the right reduction. A decision was made to
perform a right skin-sparing mastectomy, and she underwent a latissimus dorsi
reconstruction with implant.
A
B
C

440
SECTION II
CHAPTER 23.2 • Partial breast reconstruction using reduction and mastopexy techniques
means it might take the oncoplastic reduction patients
slightly longer to reach the point where any change in
mammographic findings might be suspicious for malig­
nancy. The clinical significance of this finding remains
to be seen. An accurate interpretation of mammography
requires familiarity with these temporal changes and
mammograms should be compared over time. These
data need to be taken into consideration when design­
ing the most appropriate surveillance programs for
these patients.
As technology improves, other imaging techniques
such as ultrasound and MRI will likely become
more popular. Microcalcifications and areas of fat necro­
sis are easily identified, and no interference in postop­
erative surveillance has been demonstrated. Although
routine tissue sampling is not recommended for
screening, any clinical concern necessitates fine-needle
aspiration, core-needle biopsy, or surgical biopsy, to rule
out malignancy. Patients who undergo partial breast
reconstruction may have an increase in the amount of
tissue sampling requirements. In the authors’ series,
53% in the oncoplastic group compared with 18% in the
BCT alone group over an average of 7 years required
tissue sampling. In contrast, in a report by Piper et al.,
an age-matched comparison of women following BCT
versus oncoplastic reduction did not show a significant
difference
in
abnormal
mammographic
findings
prompting biopsy or biopsy rates themselves for up to
5 years postoperatively.30 Although these are typically
benign, additional scarring from the reconstruction
might raise clinical suspicion, which is why more biop­
sies are expected in patients who undergo partial breast
reconstruction.
Conclusion
The details differ when dealing with lumpectomy versus
quadrantectomy defects, or whether a two-team or
single surgeon approach is used; however, the principles
are the same. The benefits of using the oncoplastic
reduction techniques have been well demonstrated and
will continue to gain popularity and acceptance in the
future. The options for women with breast cancer are
numerous, and this provides an additional, and often
favorable, choice. Critical evaluations of results measur­
ing functional, oncologic, and aesthetic outcomes are
necessary to establish safe and effective practice guide­
lines to maximize oncologic safety.
to 9.4%. To further evaluate the oncologic outcome,
longer-term studies are required. To date, the largest
series of 540 consecutive patients from the Institute
Curie demonstrated that in women with high tumor-to-
breast volume ratios, use of the oncoplastic approach
provides good outcomes.5 The 5-year local recurrence
(6.8%) and overall survival rates (92.9%) were accept­
able with low complication rates (16%) and good aes­
thetic results at 1 year (97.7%) and at 5 years (90.3%). In
a study of our own patients following oncoplastic
reduction, the 5-year ipsilateral breast tumor control
rates were 91% for DCIS and 93% for invasive cancer.28
Secondary procedures, although not common, are
usually performed for size or shape discrepancies long
term. While the oncoplastic approach minimizes the
potential for poor aesthetic outcomes, the effects of
radiation therapy persist and can contribute to changes
over time. In most circumstances, waiting at least 1 year
following completion of radiation therapy to discuss
revisional procedures is advised. Even with resolution
of acute radiation changes (i.e., erythema, skin break­
down, burns) and tissue edema, it is important to respect
native tissue planes and blood supply, and if possible
keep revisions to a minimum, since it is still an irradi­
ated breast, which carries the associated risks.
Surveillance postoperative care
Original concerns with this approach were that increased
tissue rearrangement, scarring, and disruption of breast
architecture might impair the ability to screen and detect
recurrent breast cancer. Although valid, adherence to
appropriate surveillance and cross-specialty communi­
cation will reduce this issue. The three main tools in
postoperative surveillance include the physical exami­
nation, radiologic imaging, and tissue sampling. It is
important that all members of the team are aware of the
various surgical components, since differences in pre­
sentation of recurrence might exist depending on the
type and technique of reconstruction. In a study at the
authors’ institution it was demonstrated that following
partial breast reconstruction using reduction techniques
mammography was just as sensitive as a screening tool
when compared with patients with BCT alone.29 While
the qualitative mammographic findings were similar in
the two groups over the average 6-year follow-up, there
was a slight trend towards longer times to mammo­
graphic stability in the oncoplastic reduction group of
25.6 versus 21.2 months in the BCT alone group. This

441
Conclusion
1. Losken A, Hamdi M. Partial breast reconstruction: current
perspectives. Plast Reconstr Surg. 2009;124:722–736.
3. Clough KB, Lewis JS, Couturaud B, et al. Oncoplastic techniques
allow extensive resections for breast-conserving therapy of breast
carcinomas. Ann Surg. 2003;237:26–34.
5. Fitoussi AD, Berry MG, Famà F, et al. Oncoplastic breast surgery for
cancer: analysis of 540 consecutive cases [outcomes article]. Plast
Reconstr Surg. 2010;125:454–462.
6. Matory WE Jr, Wertheimer M, Fitzgerald TJ, et al. Aesthetic results
following partial mastectomy and radiation therapy. Plast Reconstr
Surg. 1990;85:739–746.
9. Losken A, Dugal CS, Styblo TM, et al. A meta-analysis comparing
breast conservation therapy alone to the oncoplastic technique. Ann
Plast Surg. 2014;72:145–149.
12. Regaño S, Hernanz F, Ortega E, et al. Oncoplastic techniques extend
breast-conserving surgery to patients with neoadjuvant
chemotherapy response unfit for conventional techniques. World J
Surg. 2009;33:2082–2086.
13. Clough KB, Acosta-Marín V, Nos C, et al. Rates of neoadjuvant
chemotherapy and oncoplastic surgery for breast cancer surgery: a
French national survey. Ann Surg Oncol. 2015;22:3504–3511.
14. Losken A, Pinell-White X, Hart AM, et al. The oncoplastic reduction
approach to breast conservation therapy: benefits for margin
control. Aesthet Surg J. 2014;34:1185–1191.
18. Veiga DF, Veiga-Filho J, Ribeiro LM, et al. Quality-of-life and
self-esteem outcomes after oncoplastic breast-conserving surgery.
Plast Reconstr Surg. 2010;125:811–817.
20. Munhoz AM, Gemperli R, Filassi JR. Occult carcinoma in 866
reduction mammaplasties: preserving the choice of lumpectomy.
Plast Reconstr Surg. 2011;128:816–818.
22. Kronowitz SJ, Kuerer HM, Buchholz TA, et al. A management
algorithm and practical oncoplastic surgical techniques for repairing
partial mastectomy defects. Plast Reconstr Surg. 2008;122:1631–1647.
29. Losken A, Schaefer TG, Newell M, et al. The impact of partial
breast reconstruction using reduction techniques on postoperative
cancer surveillance. Plast Reconstr Surg. 2009;124:9–17.
Access the complete reference list online at

441.e1
References
References
1. Losken A, Hamdi M. Partial breast reconstruction: current
perspectives. Plast Reconstr Surg. 2009;124:722–736.
2. Chakravorty A, Shrestha AK, Sanmugalingam N, et al. How safe is
oncoplastic breast conservation? Comparative analysis with
standard breast conserving surgery. Eur J Surg Oncol.
2012;38:395–398.
3. Clough KB, Lewis JS, Couturaud B, et al. Oncoplastic techniques
allow extensive resections for breast-conserving therapy of breast
carcinomas. Ann Surg. 2003;237:26–34.
4. Giacalone PL, Roger P, Dubon O, et al. Comparative study of the
accuracy of breast resection in oncoplastic surgery and
quadrantectomy in breast cancer. Ann Surg Oncol. 2007;14:605–614.
5. Fitoussi AD, Berry MG, Famà F, et al. Oncoplastic breast surgery for
cancer: analysis of 540 consecutive cases [outcomes article]. Plast
Reconstr Surg. 2010;125:454–462.
6. Matory WE Jr, Wertheimer M, Fitzgerald TJ, et al. Aesthetic results
following partial mastectomy and radiation therapy. Plast Reconstr
Surg. 1990;85:739–746.
7. Zierhut D, Flentje M, Frank C, et al. Conservative treatment of
breast cancer: modified irradiation technique for women with large
breasts. Radiother Oncol. 1994;31:256–261.
8. Brierley JD, Paterson IC, Lallemand RC, et al. The influence of
breast size on late radiation reaction following excision and
radiotherapy for early breast cancer. Clin Oncol (R Coll Radiol).
1991;3:6–9.
9. Losken A, Dugal CS, Styblo TM, et al. A meta-analysis comparing
breast conservation therapy alone to the oncoplastic technique. Ann
Plast Surg. 2014;72:145–149.
10. Clarke DH, Lê MG, Sarrazin D, et al. Analysis of local-regional
relapses in patients with early breast cancers treated by excision
and radiotherapy: experience of the Institut Gustave-Roussy. Int J
Radiat Oncol Biol Phys. 1985;11:137–145.
11. Cochrane RA, Valasiadou P, Wilson AR, et al. Cosmesis and
satisfaction after breast-conserving surgery correlates with the
percentage of breast volume excised. Br J Surg. 2003;90:1505–1509.
12. Regaño S, Hernanz F, Ortega E, et al. Oncoplastic techniques extend
breast-conserving surgery to patients with neoadjuvant
chemotherapy response unfit for conventional techniques. World J
Surg. 2009;33:2082–2086.
13. Clough KB, Acosta-Marín V, Nos C, et al. Rates of neoadjuvant
chemotherapy and oncoplastic surgery for breast cancer surgery: a
French national survey. Ann Surg Oncol. 2015;22:3504–3511.
14. Losken A, Pinell-White X, Hart AM, et al. The oncoplastic reduction
approach to breast conservation therapy: benefits for margin
control. Aesthet Surg J. 2014;34:1185–1191.
15. Kaur N, Petit JY, Rietjens M, et al. Comparative study of surgical
margins in oncoplastic surgery and quadrantectomy in breast
cancer. Ann Surg Oncol. 2005;12:539–545.
16. Masetti R, Pirulli PG, Magno S, et al. Oncoplastic techniques in the
conservative surgical treatment of breast cancer. Breast Cancer.
2000;7:276–280.
17. Anderson BO, Masetti R, Silverstein MJ. Oncoplastic approaches to
partial mastectomy: an overview of volume-displacement
techniques. Lancet Oncol. 2005;6:145–157.
18. Veiga DF, Veiga-Filho J, Ribeiro LM, et al. Quality-of-life and
self-esteem outcomes after oncoplastic breast-conserving surgery.
Plast Reconstr Surg. 2010;125:811–817.
19. Hart AM, Pinell-White X, Egro FM, et al. The psychosexual impact
of partial and total breast reconstruction: a prospective one-year
longitudinal study. Ann Plast Surg. 2015;75:281–286.
20. Munhoz AM, Gemperli R, Filassi JR. Occult carcinoma in 866
reduction mammaplasties: preserving the choice of lumpectomy.
Plast Reconstr Surg. 2011;128:816–818.
21. Egro FM, Pinell-White X, Hart AM, et al. The use of reduction
mammaplasty with breast conservation therapy: an analysis of
timing and outcomes. Plast Reconstr Surg. 2015;135:963e–971e.
22. Kronowitz SJ, Kuerer HM, Buchholz TA, et al. A management
algorithm and practical oncoplastic surgical techniques for
repairing partial mastectomy defects. Plast Reconstr Surg.
2008;122:1631–1647.
23. Losken A, Styblo TM, Carlson GW, et al. Management algorithm
and outcome evaluation of partial mastectomy defects treated using
reduction or mastopexy techniques. Ann Plast Surg. 2007;59:
235–242.
24. Cao D, Lin C, Woo SH, et al. Separate cavity margin sampling at
the time of initial breast lumpectomy significantly reduces the need
for reexcisions. Am J Surg Pathol. 2005;29:1625–1632.
25. Waljee JF, Hu ES, Newman LA, et al. Correlates of patient
satisfaction and provider trust after breast-conserving surgery.
Cancer. 2008;112:1679–1687.
26. Iwuchukwu OC, Harvey JR, Dordea M, et al. The role of
oncoplastic therapeutic mammoplasty in breast cancer surgery–a
review. Surg Oncol. 2012;21:133–141.
27. Spivack B, Khanna MM, Tafra L, et al. Margin status and local
recurrence after breast-conserving surgery. Arch Surg.
1994;129:952–957.
28. Eaton BR, Losken A, Okwan-Duodu D, et al. Local recurrence
patterns in breast cancer patients treated with oncoplastic reduction
mammaplasty and radiotherapy. Ann Surg Oncol. 2014;21:93–99.
29. Losken A, Schaefer TG, Newell M, et al. The impact of partial
breast reconstruction using reduction techniques on postoperative
cancer surveillance. Plast Reconstr Surg. 2009;124:9–17.
30. Piper M, Peled AW, Price ER, et al. Mammographic changes after
oncoplastic reduction mammoplasty. Ann Plast Surg. 2015;
doi:10.1097/SAP.0000000000000484.

SECTION II • Reconstructive Breast Surgery
23.3 
Pedicled and free flaps in
oncoplastic surgery
Moustapha Hamdi and Jana Van Thielen
SYNOPSIS
■ Breast-conserving therapy (BCT) is applied to most early stages of
breast cancer.
■ Oncoplastic surgery within a multidisciplinary approach is the gold
standard in BCT.
■ Using pedicled flaps is indicated in high tumor/breast size ratio.
■ Partial breast reconstruction with a pedicled flap is alternative to
mastectomy in selected patients.
■ Overcorrection is essential when a pedicled flap is used in partial
breast reconstruction.
■ Perforator or muscle-sparing latissimus dorsi flaps is the first choice
of flap surgical technique.
■ Fat grafting and contralateral breast remodeling may be required to
achieve breast symmetry at long-term follow-up.
Access the Historical Perspective section online at

Introduction
■ Breast-conserving therapy (BCT) with tumor
resection and radiotherapy is a valuable component
of breast cancer treatment, with an equivalent
survival outcome to that of mastectomy.
■ Quadrantectomy or partial mastectomy offers
wider, safe margins and reduces the rate of local
recurrence.
■ Partial breast reconstruction is required in most of
the cases of quadrantectomy to avoid post BCT-
breast deformity.
■ Every case requiring partial breast reconstruction
should be addressed within a multidisciplinary
approach.
■ Local flaps are required in partial reconstruction of
small-to-moderate size breasts.
■ Pedicled perforator flaps provide adequate partial
breast reconstruction with minimal donor site
morbidity.
Basic science
Partial mastectomy combined with radiotherapy, often
referred to as breast-conserving therapy (BCT) followed
by breast irradiation, has replaced modified radical
mastectomy as the preferred treatment for early stage
invasive breast cancer in many patients. The 5-year
survival rate of partial mastectomy with radiation is not
statistically different when compared with mastectomy
alone in patients with stage I or II breast cancer.5,6
Women diagnosed at early stages of invasive breast
cancer have equivalent outcomes when they are treated
with lumpectomy and radiation therapy or modified
radical mastectomy.7
It is interesting to point out that the surgical clearance
of pathologic margins has the most significant impact
upon local recurrence in patients treated with BCT and
RT. The presence of ductal carcinoma in situ (DCIS) at
the surgical margin is associated with the identification
of residual DSIC in 40–82% of re-excised specimens and
is correlated with margin widths of 41% at 1 mm, 31%
at 1–2 mm, and 0% with 2 mm of clearance.5 A recent
meta-analysis concluded that a margin width was sig­
nificantly superior to lesser margins.8
A further recent meta-analysis by Losken et al. showed
lower positive margins after oncoplastic surgery (12%)