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

443
Patient selection
Approximately 10–30% of patients are dissatisfied
with the aesthetic result after partial mastectomy with
radiation.12 Although the causes may vary, the factors
that motivate patients to seek corrective surgery after
partial mastectomy are a volume discrepancy, contour
deformity, and nipple malposition.13 The resection of
more than 15–20% of the breast parenchyma in a small-
volume (A or B cup) and more than 30% in the larger
breast will cause volumetric deformities and bilateral
asymmetries. In addition, radiation therapy extenuates
the image of the breast, initially causing breast edema
and skin erythema and eventually causing parenchyma
fibrosis, retraction, skin envelope atrophy, hyperpig­
mentation, hypopigmentation, and telangiectasia. The
long-term final effects of radiation are difficult to predict
but seem to stabilize 1–3 years post-radiation.14,15
The intention of this chapter is not to extend on the
indications of BCT, but to identify the complexity of
partial breast reconstruction, to optimize reconstruction
planning, and to indicate the importance of the use of
local flaps in breast oncoplastic surgery.
Patient selection
The success of this procedure depends on the size of the
cancer, the anatomic position, and the volume of resec­
tion needed to achieve clear margins in relation to the
volume of the breast. Especially in cases of partial breast
reconstruction after the excision of wide localized
tumors, the value of oncoplastic surgery increases.
The choice of the technique used depends on many
factors, including the extent of resection, the time of
surgery, the breast size and tumor location, and patient
preferences.
Type of reconstruction
There are two basic types of surgery techniques in
partial breast reconstruction: volume displacement and
volume replacement.
1. Volume displacement techniques refer to
advancement, rotation, or transposition of large
local breast flaps into the smaller created defect,
redistributing the volume loss. The dissection
involves the advancement of a full-thickness
segment of breast fibroglandular tissue to fill the
dead space. Volume displacement procedures and
surgical scars are optimal when combined with
mastopexy-reduction techniques. The tumor is
excised within the planned markings of the
reduction specimen in medium, large, or ptotic
breasts, and the remaining parenchyma is
sufficient enough to reshape the breast mound.16
compared with breast conservative surgery without
oncoplastic reconstruction (21%).9
The incidence of local recurrence depends upon
certain factors, such as the tumor margin, nuclear grade-
histology, radiation therapy, and patient age. Most local
recurrences occurred at the site of initial tumor excision
(57–88%) or in the same breast quadrant (22–28%). In
general, during the first 10 years after lumpectomy with
radiation, the recurrence rate is 1.4% per year. The treat­
ment of in-breast tumor recurrence in patients is comple­
tion mastectomy.10 Therefore, more radical excision,
including the tumor with large surrounding tissue
(quadrectomy or partial mastectomy), is recommended;
however, it may result in an unacceptable aesthetic
outcome.
Partial breast reconstruction has become a preferable
option for an increasing number of patients. These
techniques allow for local excision with oncologic ben­
efits while avoiding more extensive surgery with higher
complications and increased morbidity rates associated
with total mastectomy and immediate reconstruction.
This chapter discusses the use of the loco-regional
flaps in partial breast reconstruction.
Diagnosis/patient presentation
The decision to undertake a partial mastectomy, or
alternatively a total mastectomy, to treat a patient with
breast cancer is ultimately an oncologic determination.
In cases where the two treatments options are oncologic
equivalent, the patient becomes an active participant in
the decision-making process in order to maximize their
sense of satisfaction with their treatment.
Breast-conserving approaches may be preferable over
a total mastectomy in some cases. This is especially true
for patients with early stage disease, because the major­
ity of the breast can be preserved and the operation is
perceived as less invasive than a mastectomy. Most
early-stage cancers (T1 and T2 cancers with or without
nodal involvement) are indicated for BCT; however,
there are some exceptions. Commonly known reasons
for contraindications are patients with a high probability
for recurrence, especially those with multicentric
disease; those who are pregnant or have collagen vas­
cular disease; or those who have a history of prior radia­
tion therapy.11 Relative contraindications include
patients with a high probability of subsequent cancers
(BRCA mutations) and patients who are likely to have
a poor cosmetic result, which includes patients with a
high tumor/breast ratio, medially-, and inferiorly-based
tumors and tumors that require removal of the nipple
areolar complex (NAC).

444
SECTION II
CHAPTER 23.3 • Pedicled and free flaps in oncoplastic surgery
aesthetic outcomes. In planning the approach on which
method should be used to treat the partial mastectomy
defect, the primary decision that must be made is if
reparative surgery will be needed after the tumor exci­
sion. If oncoplastic surgery is necessary, the next step is
to choose the technique. If there is sufficient tissue,
reshaping the breast, along with reduction of the oppo­
site breast for symmetry, is usually the best option. If
there is not enough tissue left for breast reshaping,
tissue must be added. If the defect is not too large, local
tissue can be used, with simple techniques, such as rota­
tion or transposition fasciocutaneous flaps from the
axillary area or superiorly-based composite flap of skin,
subcutaneous fat, and upper pole breast parenchyma. If
the defect is too large to be filled by local tissue alone,
a loco-regional pedicled or distal pedicled or free flap
will be required (Fig. 23.3.1).
Breast and plastic surgeons must have a thorough
understanding of breast anatomy, physiology, and the
qualities of an aesthetically pleasing breast shape. Sur­
geons using the oncoplastic approach should consider
the aesthetic subunits when planning cosmetic quadran­
tectomy, resections, and reconstructions.19 Also, knowl­
edge of the anatomic landmarks, breast proportions,
and shape is essential in order to achieve a pleasing
outcome.
Preoperative evaluation of the patient and her breasts
must be standard and detailed. The examination must
include evaluation of breast skin, elasticity, thickness,
scars, and any defining marks such as tattoos, stretch
marks, contour irregularities, and previous breast
surgery should be taken into account when planning
BCT. Palpation for masses or abnormalities in the breast
parenchyma, nipple inspection, and detailed documen­
tation of breast sensation are integral. Breast shape,
2. Volume replacement techniques are technically more
difficult and are used in small–moderate size
breasts or when the tumor/breast ratio is large
and the remaining breast tissue is insufficient for
the rearrangement and the replacement of the
defect. Volume replacement with the use of non-
breast local or distant flaps provides both tissue
for the filling of the glandular defect and the skin
deficiency of the reconstructed breast.17
Surgery for volume displacement avoids donor site
morbidity but is associated with ischemia of the dermo­
glandular pedicle and may require contralateral breast
surgery in order to achieve symmetry. The amount of
tissue that is obtained for defect coverage and breast
reconstruction is limited.
Volume replacement techniques maintain the original
size and shape of the breast without the need for any
contralateral breast surgery, but are associated with
longer operation times, require competent surgical
skills, and possible complications in the flap and the
donor site.
Timing of reconstruction
Reconstruction of partial mastectomies can either
include delayed, immediate, or immediate delayed
procedures. In delayed reconstruction, at least 6 months
to a year is allowed to elapse after the last radiation
therapy session, in order to evaluate the deformities of
the breast and plan the appropriate reconstruction
modality. In immediate reconstruction, the goal is to
perform, co-instantaneously, tumor resection with
oncologically appropriate margins and partial breast
reconstruction. Immediate delayed partial breast recon­
struction is actually a two-stage immediate surgical
approach with delayed reconstruction (within a few
days) until the results of the pathology report are known
and the margins of the tumor excision are determined
as sufficient or must be re-excised to clear margins
before reconstruction. The final aesthetic outcomes are
similar to those with immediate reconstruction.18
Immediate breast reconstruction offers many advan­
tages over delayed breast reconstruction, such as a
better aesthetic outcome due to the preservation of the
3D breast skin envelope. The aim of immediate recon­
struction after BCT is essentially to give better aesthetic
results with the same oncologic safety. Our target should
be the reshaping of the treated breast with the alteration
of the opposite breast for better symmetry, as part of the
treatment, when indicated. Immediate reconstruction
before radiation therapy is also preferred because the
breast can be better manipulated before radiation, with
potentially decreased complication rates and improved
Fig. 23.3.1  Breast reconstruction: a decision-making process.
Defect up to 30%
of the breast
Small
breast
Large
breast
Local
flap
Glandular
flap
Defect
> 30%
Mastectomy
Defect
10–20%
Breast defect volume
Free
flap
Pedicled
flap
Bilateral
reconstruction

445
Treatment/surgical techniques
sacrificing the muscle and motor innervations and
minimize seroma formation rate.
Classification and vascular anatomy of flaps
The latissimus dorsi (LD) flap has a constant anatomy.22
The blood supply of the latissimus dorsi comes from a
terminal branch of the subscapular artery (Fig. 23.3.2).
The subscapular artery runs about 5 cm before dividing
into the scapular circumflex and thoracodorsal arteries.
The thoracodorsal artery is about 2–4 mm in diameter,
and it courses along the posterior portion of the axilla
for about 8–14 cm before it pierces the latissimus dorsi
on its costal surface. The thoracodorsal artery gives off
one or two branches to the serratus anterior muscle and
one branch to the skin. The basic pattern of the thora­
codorsal bundle (artery, nerve, and 1–2 venae comitan­
tes) branching is to bifurcate into a lateral (vertical) and
a medial (horizontal) branch. The lateral branch follows
a course parallel to the muscle fibers, 1–4 cm medial to
the free-lateral border of the muscle, and gives off per­
forating vessels that supply the skin. The smaller medial
branch diverges at an angle of 45° and travels medially.
A vigorous blood supply to the muscle is also available
at its origin. Perforating vessels from the intercostal and
lumbar arteries supply the muscle and overlying skin.22,23
The pedicled perforator flaps mostly used in our
hands for partial breast reconstruction, classified accord­
ing to the basic nutrient arteries, and recommended by
the “Gent” Consensus update in 2002 are (Fig. 23.3.3)24:
■ Thoracodorsal artery perforator (TDAP) flap
■ Serratus anterior artery perforator (SAAP) flap
■ Intercostal artery perforator (ICAP) flap
■ Superior epigastric artery perforator (SEAP) flap.
The TDAP flap
The TDAP flap is based on perforators originating from
the descending (vertical) or horizontal branches of the
thoracodorsal vessels. Anatomic studies on cadavers
have reported the presence of 2–3 musculocutaneous
perforators from the vertical branch.25,26 The proximal
perforator enters the subcutaneous plane obliquely
8–10 cm distal to the posterior axillary fold and 2–3 cm
posterior to the anterior border of the muscle. The
second perforator is found 2–4 cm distally to the first
one. Occasionally, a direct cutaneous perforator arising
from the thoracodorsal vessel passes around the anterior
border of the muscle, making flap harvesting easier.
There may not always be a single reliable perforator
for the TDAP flap, due to anatomic variations.27 In these
cases, the surgeon must be aware and be prepared to
modify the flap dissection intraoperatively, as a muscle-
sparing TDAP flap.
grade of ptosis, and size are determinants of success in
surgical treatment.
The base and width of the breast, the width of the
NAC, the height of the nipple, and the distance from the
sternal notch, midline, and inframammary crease must
be recorded in detail.19 Any natural breast asymmetry
should be pointed out to the patient before surgery.
Different body types, skin laxity, and fat distribution are
important factors in the decision-making process.
Treatment/surgical techniques
Large defects in large breasts may be treated by convert­
ing a partial mastectomy into a reduction mammaplasty.
Planning of skin incisions and parenchymal excisions
follow templates using reduction mammaplasty and
mastopexy techniques. The pattern can be rotated later­
ally or medially to fit the location of the defect. The choice
of pedicle is related to the tumor location and the blood
supply of the breast. It is important that skin incisions be
planned so that if mastectomy is ultimately required for
margin control, the incision site can be comfortably
included within the mastectomy skin island.6,16 Relative
contraindications for oncologic reduction mammoplasty
are large tumor/breast size ratio. Oncologic reduction
mammoplasty should also be used cautiously in patients
with DCIS since resection margins are more often posi­
tive compared with invasive carcinoma and often leads
to re-excision or salvage mastectomy.20
When volume replacement is necessary for BCT
reconstruction, the decision of which technique will be
used is determined mostly by the surgeon’s experience
and the size of the defect in relation to the size of the
remaining breast. The use of non-breast locoregional
flaps offer the extra volume needed in large tumor
excisions/quadrantectomies for the replacement of the
breast volume; however, they can be more demanding
procedures and associated with donor site and flap
morbidity.
A small lateral defect can be easily covered with a
skin rotation flap or a lateral thoracic axial flap. Espe­
cially in obese patients (with breast rolls), the lateral
thoracic flap is useful. However, most of these fasciocu­
taneous flaps may be unavailable in the axillary lymph
node dissection patients.
The latissimus dorsi muscle or musculocutaneous
flaps have been very popular as a method of choice in
partial breast reconstruction.21 However, pedicled per­
forator flaps have enabled surgeons to replace large
defects with minimum donor site morbidity. The advan­
tage of perforator flaps, which are skin and subcutane­
ous flaps, is that they offer sufficient coverage without

446
SECTION II
CHAPTER 23.3 • Pedicled and free flaps in oncoplastic surgery
Fig. 23.3.2  (A) Vascular anatomy. TD, thoracodorsal; P, perforator; SA, serratus
anterior; ICN, intercostal nerve. (B) The various nutrient artery sources and
perforator branches are marked. TD, SA, and IC vessels are represented
diagrammatically.
A
B
A
B
Fig. 23.3.3  Classification of flaps: (A) thoracodorsal artery perforator (TDAP) flap; (B) TDAP MS-I flap; (C) TDAP MS II flap; (D) lateral intercostal artery perforator flap;
(E) serratus anterior artery perforator flap.

447
Treatment/surgical techniques
E
Fig. 23.3.3, cont’d
C
D
The TDAP flaps are classified as follows28:
■ TDAP flap, when no muscle component is included
in the flap (Fig. 23.3.3A)
■ TDAP-MS-I, where a small segment of muscle
(4 × 2 cm) kept attached to the back of the perforator
vessels. The muscle segment protects the perforator
from excessive tension and provides more freedom
in flap positioning (Fig. 23.3.3B)
■ TDAP-MS-II is indicated when multiple but small
perforators are encountered. A larger segment, up to
5 cm wide along the anterior border of the latissimus
dorsi muscle, together with the descending branch of
the thoracodorsal vessels is then included within the
flap in order to insure a maximal blood supply to the
skin paddle (Fig. 23.3.3C).
The ICAP flap
The ICAP flap is based on perforators, arising from the
intercostal vessels. The intercostal vessels form an
arcade between the aorta and the internal mammary
vessels and divide in four segments: vertebral, intercos­
tal, intermuscular, and rectus segments.29

448
SECTION II
CHAPTER 23.3 • Pedicled and free flaps in oncoplastic surgery
epigastric artery, and the perforator flaps are named
SSEAP and DSEAP, respectively. As mentioned above,
the superior epigastric artery perforator flap has similar
indications as the anterior intercostal artery perforator
flap33; however, it has a longer pedicle that allows it to
reach the defect with less tension. Pedicled SEAP flaps
should be used only in selected cases, since it excludes
the secondary use of abdominal tissue for autologous
breast reconstruction (DIEAP, SIEAP, TRAM flaps) if
completion mastectomy is later indicated.
Indications for pedicled flaps
The main use for pedicled flaps is partial breast recon­
struction (immediate or delayed) when volume replace­
ment is necessary; however, other reasons include:
■ Salvage procedure after partial/total free flap loss
for breast reconstruction
■ Postmastectomy breast reconstruction in
combination with implant
■ Breast augmentation with autologous tissue
■ Shoulder, back, and chest wall defects.
Contraindications of pedicled flaps
The harvesting of a local perforator flap demands exper­
tise of the technique and sufficient knowledge of the
anatomy of the area. Less experienced surgeons may
choose other reconstructive options to familiarize them­
selves with perforator flap harvesting, such as the deep
inferior epigastric artery perforator, superior gluteal
artery perforator flaps, or transverse myocutaneous
gracilis flap, because the perforators associated with
these flaps are larger and there are more to choose from.
The area of the defect may have limited access, espe­
cially when localized in the inferomedial quadrant, and
is difficult to be reached by a pedicled perforator flap
based on the axillary vessels. However, the AICAP or
SEAP flaps are ideal for such defects.
Previous axillary or thoracic surgery with damage to
the thoracodorsal pedicle is an ideal candidate for using
a LICAP flap, but not for a LD or TDAP flap. Previous
scars and radiation injury to the area may also result in
the limitation of local pedicled perforator flaps.28 When
breast deformity after partial mastectomy with radia­
tion is severe, the optimum choice is to perform a
complete mastectomy and autologous reconstruction
with a free flap transfer.
Flap design
Flap choice
Based on the thoracodorsal–serratus, intercostal, or
superior epigastric vessels, several pedicle flaps can be
The ICAP flaps are classified as follows:
■ The dorsal intercostal artery perforator (DICAP)
flap. The flap is based on perforators originating
from the vertebral segment of the intercostals
vessels
■ The lateral intercostal artery perforator (LICAP)
flap, based on perforators arising from the
intercostal segment (Fig. 23.3.3D)
■ The anterior intercostal artery perforator (AICAP)
flap. The nutrient perforators of this flap arise from
the muscular or rectal segment.
The intercostal segment, which is the longest (12 cm), is
very important because it gives 5–7 musculocutaneous
perforators.30
The LICAP, commonly used in breast surgery, origi­
nates from the costal segment of the intercostals vessels.
The largest perforator is most frequently found in the
6th intercostal space, 0.8–3.5 cm from the anterior border
of the latissimus dorsi muscle.31 The pedicle has adequate
length, allowing the rotation of the flap up to 180°
without tension and with no need to extend the dissec­
tion into the costal groove. An intercostal nerve may be
included in the harvesting as an ICAP-sensate flap.
For small defects, the LICAP is designed on the lateral
aspect of the thorax, and for moderate-large defects the
distal limit of the skin pad can reach the posterior tho­
racic region, planned in a fashion similar to the skin pad
of a LD flap.32
The AICAP flap is outlined over the upper abdomen
so that the final scar will be hidden under the brassier
strap. The donor site can be closed primarily if it is up
to 6 cm wide (preoperative pinch test to be assured), or
else in a reversed abdominoplasty fashion. The advan­
tage of AICAP and SEAP flaps is that the patient is
prepped in a supine position throughout the whole
procedure. These flaps are mostly known for defects in
the inferomedial quadrant of the breast.
The SAAP flap
The SAAP flap is based on a connection between the
thoracodorsal artery branch to the serratus anterior
muscle and the intercostal perforators (Fig. 23.3.3E). It
is not a constant perforator (21%).30 When an appropri­
ately sized perforator is identified in front of the anterior
border of the LD, it can be followed back to the nutrient
artery, which in this case is the serratus anterior branch
by dissecting the pedicle within the fascia and the fibers
of the aforementioned muscle.
The SEAP flap
The SEAP flaps are based on perforators arising from
either the superficial or the deep branch of the superior

449
Surgical technique
latissimus dorsi to include the premuscular perforators
if present. The proximal border of the flap approximates
the inframammary fold (Fig. 23.3.4C). If the defect is
more medially, the flap is designed more distally, further
in the back. The same design is applied for the LICAP,
however, the flap is placed more anteriorly, towards the
breast. The AICAP or SEAP flaps are usually designed
under the inframammary fold along the rib.
Surgical technique
The patient is prepped and positioned in the supine
position for the tumor excision (Fig. 23.3.4D,E). After
the lumpectomy/quadrectomy at clear margins, clips
are placed in the wound bed and left there in order to
indicate the area for future radiation therapy. If the plan
is to proceed with the TDAP, LICAP, or SAAP flap, the
patient is positioned and prepped again in the lateral
position, as in typical LD musculocutaneous flap dissec­
tion. Otherwise, for the AICAP/SEAP flap, the patient
remains in the original position.
The flap harvesting starts with skin incisions. A pos­
terior approach is usually used in the TDAP flap. The
surgeon continues dissection down to the LD suprafas­
cial plane, while beveling in favor of the flap, in order
to gain as much of extra tissue as possible. Harvesting
proceeds from the back towards the axillary region.
Further harvesting under loop magnification continues
meticulously, until the perforator vessel is visualized
(Fig. 23.3.4F). If the perforator is visibly pulsate and
adequate in caliber (>0.5 mm), the dissection continues
along the perforator course up to the nutrient thora­
codorsal pedicle. If a large pedicle length is required,
the TD vessels can be dissected up to their subscapular
vessel origin and included in the flap. If the perforators
have an intramuscular course, dissection is performed
in the direction of the muscle fibers and any nerves that
come across are carefully preserved (Fig. 23.3.4G).
Within the muscle, all the perforator side branches are
either ligated or coagulated. If two perforators are found
along the same course, they can both be included within
the flap, without sacrificing any muscle fibers (Fig.
23.3.4H).
In cases in which the perforators are inadequate in
size, the flap harvesting is continued as a muscle-sparing
LD flap, by including a small segment of the latissimus
dorsi muscle attached to the posterior wall of the perfo­
rators. The most important component of a muscle-
sparing LD flap is to preserve the innervation to the
muscle to avoid compromise of muscle function. This
modification is also useful when the flap is intended for
the medial breast area, because it protects the perfora­
tors from presumed tension.
raised on perforators in the axillary, back, anterior tho­
racic, and upper abdominal regions, depending on the
location of the desired recipient site, the surgeon’s pref­
erence, and other anatomic and surgical indications.34
The pedicled TDAP flap is ideal for partial breast
reconstructions, especially for defects located in the
superior or inferolateral quadrants. The LICAP is a
good alternative to TDAP flap for lateral and inferior
breast defects (Fig. 23.3.4). However, the TDAP flap has
a longer pedicle with a greater arc of rotation and
reaches most of the breast except for the inferomedial
quadrants (Fig. 23.3.5).
Preoperative perforator mapping
Perforator mapping with correct flap design is the
keystone in this technique. To localize the thoracodorsal
perforators, a unidirectional Doppler (8 Hz) ultrasonog­
raphy examination is performed for perforator mapping
in the planned skin flap area. This device, although
quite handy and less costly, has the disadvantage of
generating false-negative and false-positive signals and
provides less detailed anatomic vessel information. This
is due to the misleading background signal from the
thoracodorsal vessels, which can be confusing and dif­
ficult to distinguish from the perforator signal. To avoid
this, the patient is positioned, as in surgery, at a lateral
position with 90° of shoulder abduction and 90° of
elbow flexion. Also, multidetector (MD) row computed
tomography scan can be used with accuracy to localize
the perforator (Fig. 23.3.4C).35
Markings
The patient is preferably marked the day before surgery.
The breast size, tumor size, and location, as well as the
final defect size, are estimated. The incisions for the
tumor resection are chosen from an oncologic aspect but
in the most aesthetically pleasing fashion. The TDAP flap
planned for the partial breast reconstruction is designed
to include the located perforators (one or more) at the
proximal part if feasible, in the directions of relaxed skin
lines, the bra line, or even horizontally according to the
patient’s preference. Skin laxity and fat excess in the
lateral thorax and back area are estimated by the pinch
test. The size of the flap is determined by the need for
defect coverage and is an average of 20 × 8 cm. The skin
drawings are applied at first with the patient in an upright
position, and the anterior border of the LD muscle is
palpated and marked. Then the patient is placed in a
lying position on her side, with the reconstruction side
facing upwards, as in surgery, for the perforator mapping
and the flap design in the lateral thorax. The skin island
is always extended over the anterior border of the

450
SECTION II
CHAPTER 23.3 • Pedicled and free flaps in oncoplastic surgery
A
B
C
D
E
F
G
Fig. 23.3.4  A patient undergoing a quadrantectomy for a tumor of the superolateral quadrant of the left breast. The quadrantectomy specimen weighed 195 g.
Reconstruction is with a completely de-epithelialized thoracodorsal artery perforator flap based on one perforator. (A,B) Preoperative views. (C) Flap design. The dominant
Doppler was preoperatively located using MDCT. (D,E) The quadrantectomy was performed and the skin was closed in order to repositioned the patient. (F) A suprafacial
dissection was performed until the dominant perforator was encountered. (G) The latissimus dorsi muscle is split and the perforator dissected back to the main pedicle.

451
Treatment/surgical techniques
J
K
H
I
L
M
(H) The thoracodorsal artery perforator flap was based on one perforator. (I) The flap is passed through the split latissimus dorsi muscle. The
thoracodorsal nerve is preserved. (J–M) The outcome of the reconstruction and the donor site, 18 months postoperatively.
Fig. 23.3.4, cont’d

452
SECTION II
CHAPTER 23.3 • Pedicled and free flaps in oncoplastic surgery
Chemotherapy when necessary typically starts 3 weeks
postoperatively.
Outcomes, prognosis,
and complications
Complications
Donor site morbidity after harvesting loco-regional
pedicle perforator flaps for partial breast reconstruction
is reduced to a minimum. Only a very limited rate of
seroma formation has been observed and treated mainly
conservatively. Wound dehiscence of the donor site has
only been observed when the wound edges are closed
under tension. This is another infrequent event and is
usually managed with local wound care. Data from a
recent study shows a seroma rate of 5.5% in MS TDAP
II flaps, compared with no seroma formation in perfora­
tor flaps. Other postoperative complications observed
were wound dehiscence (4%), infection (2%), and hema­
toma (2%).36
Partial or total flap losses are very rare incidents, and
one must exclude coagulopathies or other medical dis­
eases and conditions. Palpable (partial) fat necrosis of
the flap has been observed and can be treated, if neces­
sary, by excision and primary closure or reconstruction
by a local flap. If necrosis is too extensive, a mastectomy
with total breast reconstruction may be indicated.36
Unpleasing scars, flap contractures, and volume loss
are less rare sequelae and may need secondary surgical
treatment. Also, flap reconstruction of breast defect may
give a “plugged in” appearance, which seems to slightly
improve after radiation therapy. It is hard to predict the
long-term outcomes of partial breast reconstruction
with pedicled perforator flaps due to the indefinite
impact of irradiation to the final result.
Finally, some patients who undergo partial breast
reconstruction with a TDAP flap document an initial
decrease in forward arm elevation and passive abduc­
tion, which recover over time.37
Prognosis
Many concerns have been raised about oncologic safety
of oncoplastic surgery.
A recent meta-analysis showed that oncoplastic
surgery shows to be an oncologically safe procedure,
with fewer recurrence rates (4%) compared with breast
conservative surgery (7%) alone.9 After oncoplastic
reduction mammoplasty, resection margins are more
often negative, and if recurrences occur, they most often
occur in the preoperative quadrant of the tumor, and
not the location after displacement techniques.20 As
The flap harvesting carries on, with the skin incisions
continued proximal to the axilla and lateral to the LD
and the dissection proceeds anteriorly, until the flap is
freed from the donor site tissues and left connected only
to the vascular pedicle. The pedicle is carefully passed
under a subcutaneous tunnel in the axilla-lateral tho­
racic area that has been previously prepared to the
recipient breast area, avoiding any avulsion of the
pedicle (Fig. 23.3.4I). The donor site is sutured in three
anatomic layers with a drain in place, and the patient is
returned again to the supine position.
Before final closure of the defect, the flap can be
partially or totally de-epithelialized (depending on the
native skin reservations of the recipient site) and folded
accordingly, to give extra projection to the reconstructed
breast mount but always in a tension-free manner.
In LICAP flap dissection (Fig. 23.3.6), an anterior
approach is performed from the breast side towards the
anterior-free border of the LD muscle. Perforator dissec­
tion is done within the serratus muscle until its origin
from the costal grove. Further dissection is usually not
needed.
Postoperative care
Postoperatively, a protocol specific for perforator flap
monitoring is implemented. Patients are administered
low-molecular-weight heparin during the time of rela­
tive immobilization. Patients normally remain in the
hospital until the drains are removed, typically 3–5
days. The arm is positioned in 45° abduction. Arm
stretching is restricted for 1 week. Physiotherapy is
usually initiated after 1 week. Most patients require
between 9 and 14 sessions of shoulder physiotherapy.
Patients treated for BCT with pedicled perforator flaps
have a short rehabilitation course.6
Adjuvant irradiation of the breast, if indicated, can
be started at 6 weeks’ post-reconstruction. However,
most patients in our experience receive adjuvant
chemotherapy first that typically lasts for 6 months.
Fig. 23.3.5  Choosing pedicled perforator flaps for partial breast.
Breast defect
All breast quadrants,
except the median
quadrant
Lateral quadrants
Median quadrant
LD, TDAP,
MS I or II
LD, TDAP, MS I or
II, LICAP or SAAP
AICAP flap or
SEAP flap

453
Postoperative care
A
B
C
D
E
Fig. 23.3.6  A 59-year-old patient was admitted for quadrantectomy with partial
breast reconstruction for right breast cancer located at superolateral quadrant. Two
years previously, the patient had undergone a mastectomy at the left side with an
immediate breast reconstruction using a deep inferior epigastric perforator flap.
(A,B) Preoperative views. (C) A 22 × 9 cm flap was designed with the mapped
perforators. (D) The defect after the quadrantectomy. (E) A preoperative view shows
one intercostal perforator, lateral intercostal artery perforator. The intercostal nerve
was also included in the flap. The flap was completely de-epithelialized and folded
to fill the defect.
Continued

454
SECTION II
CHAPTER 23.3 • Pedicled and free flaps in oncoplastic surgery
asymmetry due to different aging processes between the
two breasts. The non-irradiated side may become more
ptotic as compared with the radiated side. On the other
hand, the irradiated side may show signs of total breast
atrophy. When the breast asymmetry becomes obvious,
fat grafting alone or with contralateral breast remodel­
ing can be considered.
The use of lipofilling technique, alone or most com­
monly in combination with other reconstruction options,
for the treatment of breast defects after tumor resection
is gaining great popularity. In contrast to what was
believed in the past, lipofilling of the breast is proven to
be a safe, reliable method for the transposition of autolo­
gous fatty tissue in contour deformed areas of the breast.40
Fat injections into the breast can significantly improve
small breast defects after limited lumpectomy. In larger
excisions, partial breast reconstruction is preferred using
the tissue replacement techniques described; however,
autologous fat grafting is a useful adjunct to improve the
final outcome. Fat injections can be considered primarily
at the time of the breast conserving therapy to limit
volume discrepancies between the two breasts, to add
stated earlier, if DCIS is present, oncoplastic techniques
should be used cautiously.
Local recurrence rates reported in the literature for
oncoplastic surgery vary from 0% to 7% of the patients.36
Oncologic follow-up
Oncologic follow-up after oncoplastic procedures
remains important. Given the rearrangement of paren­
chymal tissues, scar tissue or fat necrosis is not uncom­
mon and might be suspicious on several radiologic
imaging modalities. Biopsy with fine-needle aspiration,
core biopsy, or excisional biopsy may be necessary to
rule out tumor recurrence (up to 25%).38 The addition of
breast remodeling procedures does not seem to affect
mammographic sensitivity, and qualitative changes are
similar to those found following breast conservation
therapy alone.39
Secondary procedures
Our experience has demonstrated stable long-term
outcomes (Fig. 23.3.7). However, one may expect breast
H
F
G
(F–H) Postoperative views.
Fig. 23.3.6, cont’d

455
Secondary procedures
A
B
C
D
E
F
Fig. 23.3.7  (A–J) A 65-year-old patient who underwent a partial right breast reconstruction with a pedicled serratus anterior artery perforator flap. (A–C) Preoperative
views. (D) A 22 × 8 cm flap was designed with marked perforators. (E) The quadrantectomy specimen (120 g). (F) The flap was based on the communication between
serratus anterior and the intercostal perforator (arrow).
Continued

456
SECTION II
CHAPTER 23.3 • Pedicled and free flaps in oncoplastic surgery
limitation of this technique is that it is time consuming
and prolongs operation time, especially in inexperienced
hands and the requirement of staged applications. Some
concerns about oncologic safety and monitoring of the
breast have been raised. However, a recent meta-analysis
demonstrated no difference in oncologic event rates
after autologous fat grafting compared with non-autolo­
gous fat grafting patients.41 However, fat necrosis after
fat grafting on radiologic imaging might warrant a
biopsy to rule out recurrences.
superomedial fullness for an aesthetically pleasing
breast cleavage or to correct the breast mound and shape;
however, it is most often used secondarily. In second-
stage procedures, fat grafting can be performed to refine
volume, projection, or contour irregularities due to fat
necrosis or flap contractures. Fat grafting has also dem­
onstrated success in the treatment of skin atrophy of the
breast after irradiation. The mechanism of action is
postulated to be mediated by stem cells included
with fat grafting in the intradermal plane. The major
G
H
I
J
(G–J) Postoperative views with the donor site at 3 years postoperatively.
Fig. 23.3.7, cont’d
1. Veronesi U, Cascinelli N, Mariani L, et al. Twenty-year follow-up of
a randomized study comparing breast-conserving surgery with
radical mastectomy for early breast cancer. N Engl J Med.
2002;347:1227–1232.
3. Clough KB, Kroll SS, Audretsch W. An approach to the repair of
partial mastectomy defects. Plast Reconstr Surg. 1999;104:409–420.
7. McCready D, Holloway C, Shelley W, et al. Surgical management of
early stage invasive breast cancer: a practice guideline. Breast
Access the complete reference list online at

457
Secondary procedures
Cancer Disease Site Group of Cancer Care; Ontario’s Program in
Evidence-Based Care. Can J Surg. 2005;48:185–194.
9. Losken A, Dugal C, Styblo T, et al. A meta-analysis comparing
breast conservation therapy alone to the oncoplastic technique. Ann
Plast Surg. 2014;72:145–149.
16. Anderson BO, Masetti R, Silverstein MJ. Oncoplastic approaches to
partial mastectomy: an overview of volume-displacement
techniques. Lancet Oncol. 2005;6:145–157.
17. 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.
19. Peters KK, Losken A. Applied anatomy and breast aesthetics:
definition and assessment. In: Losken A, Hamdi M, eds. Partial
Breast Reconstruction: Techniques in Oncoplastic Surgery. St. Louis:
QMP Inc.; 2009:86.
28. Hamdi M, Van Landuyt K. Pedicled perforator flaps in breast
reconstruction. In: Spear SI, Willey SC, Robb GL, et al., eds. Surgery
of the Breast: Principles and Art. Philadelphia: Lippincott-Raven;
2006:833–844.
34. Hamdi M. Pedicled perforator flap reconstruction. In: Losken A,
Hamdi M, eds. Partial Breast Reconstruction: Techniques in Oncoplastic
Surgery. St. Louis: QMP Inc.; 2009:387.
36. Hamdi M. Oncoplastic and reconstructive surgery of the breast.
Breast. 2013;22:S100–S105.

457.e1
References
References
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a randomized study comparing breast-conserving surgery with
radical mastectomy for early breast cancer. N Engl J Med.
2002;347:1227–1232.
2. Vicini FA, Recht A. Age at diagnosis and outcome for women with
ductal carcinoma-in-situ of the breast: a critical review of the
literature. J Clin Oncol. 2002;20:2736–2744.
3. Clough KB, Kroll SS, Audretsch W. An approach to the repair of
partial mastectomy defects. Plast Reconstr Surg. 1999;104:409–420.
4. Brown IM, Wilson CR, Doughty JC, et al. The future of breast
surgery: a new sub-speciality of oncoplastic breast surgeons? Breast.
2004;13:82.
5. Patani N, Khaled Y, Al Reefy S, et al. Ductal carcinoma in-situ: an
update for clinical practice. Surg Oncol. 2011;20:e23–e31.
6. Hamdi M, Wolfli J, Van Landuyt K. Partial mastectomy
reconstruction. Clin Plast Surg. 2007;34:51–62.
7. McCready D, Holloway C, Shelley W, et al. Surgical management of
early stage invasive breast cancer: a practice guideline. Breast
Cancer Disease Site Group of Cancer Care; Ontario’s Program in
Evidence-Based Care. Can J Surg. 2005;48:185–194.
8. Dillon MF, Hill AD, Quinn CM, et al. A pathologic assessment of
adequate margin status in breast-conserving therapy. Ann Surg
Oncol. 2006;13:333–339.
9. Losken A, Dugal C, Styblo T, et al. A meta-analysis comparing
breast conservation therapy alone to the oncoplastic technique. Ann
Plast Surg. 2014;72:145–149.
10. Osborne MP, Borgen PI, Wong GY, et al. Salvage mastectomy for
local and regional recurrence after breast-conserving operation and
radiation therapy. Surg Gynecol Obstet. 1992;174:189–194.
11. Song HM, Styblo TM, Carlson GW, et al. The use of oncoplastic
reduction techniques to reconstruct partial mastectomy defects in
women with ductal carcinoma in situ. Breast J. 2010;16:141–146.
12. Audretsh WP. Reconstruction of the partial mastectomy defect:
classification and method. In: Spear SI, Willey SC, Robb GL, et al.,
eds. Surgery of the Breast: Principles and Art. Philadelphia:
Lippincott-Raven; 2006:179–216.
13. Beahm EK. Breast-conserving therapy: decision-making and
anticipating the Unfavorable Aesthetic Result. In: Losken A, Hamdi
M, eds. Partial Breast Reconstruction: Techniques in Oncoplastic
Surgery. St. Louis: QMP Inc.; 2009:104.
14. Fehlauer F, Tribius S, Höller U, et al. Long-term radiation sequelae
after breast-conserving therapy in women with early-stage breast
cancer: an observational study using the LENT-SOMA scoring
system. Int J Radiat Oncol Biol Phys. 2003;55:651–658.
15. Slavin SA, Love SM, Sadowsky NL. Reconstruction of the radiated
partial mastectomy defect with autogenous tissues. Plast Reconstr
Surg. 1992;90:854–865.
16. Anderson BO, Masetti R, Silverstein MJ. Oncoplastic approaches to
partial mastectomy: an overview of volume-displacement
techniques. Lancet Oncol. 2005;6:145–157.
17. 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.
18. Kronowitz SJ. Immediate versus delayed reconstruction. Clin Plast
Surg. 2007;34:39–50.
19. Peters KK, Losken A. Applied anatomy and breast aesthetics:
definition and assessment. In: Losken A, Hamdi M, eds. Partial
Breast Reconstruction: Techniques in Oncoplastic Surgery. St. Louis:
QMP Inc.; 2009:86.
20. Eaton B, Losken A, Okwan-Duodu D, et al. Local recurrence
patterns in breast cancer patients treated with oncoplastic reduction
mammoplasty and radiotherapy. Ann Surg Oncol. 2014;21:93–99.
21. Losken A. Endoscopic latissimus dorsi flap reconstruction. In:
Losken A, Hamdi M, eds. Partial Breast Reconstruction: Techniques in
Oncoplastic Surgery. St. Louis: QMP Inc.; 2009:359.
22. Griffin JM. Latissimus dorsi musculocutaneous flap. In: Strauch B,
Vasconez LO, Hall-Finley EJ, et al., eds. Grabb’s Encyclopedia of Flaps.
Vol. 3. 3rd ed. Philadelphia: Lippincott Williams & Wilkins/Wolter
Kluwer; 2009:1026.
23. Johnson D. Latissimus dorsi muscle. In: Standring S, ed. in chief.
Gray’s Anatomy: The Anatomical Basis of Clinical Practice. 40th ed.
London: Churchill Livingstone Elsevier; 2008:810–811.
24. Blondeel PN, Van Landuyt K, Hamdi M, et al. Perforator flap
terminology: update 2002. Clin Plast Surg. 2003;30:343–346.
25. Angrigiani C, Grilli D, Siebert J. Latissimus dorsi musculocutaneous
flap without muscle. Plast Reconstr Surg. 1995;96:1608–1614.
26. Spinelli HM, Fink JK, Muzaffar A. The latissimus dorsi perforator-
based fasciocutaneous flap. Ann Plast Surg. 1996;37:500–506.
27. Hamdi M, Van Landuyt K, Hijjawi JB, et al. Surgical technique in
pedicled thoracodorsal artery perforator flaps: a clinical experience
with 99 patients. Plast Reconstr Surg. 2008;121:1632–1641.
28. Hamdi M, Van Landuyt K. Pedicled perforator flaps in breast
reconstruction. In: Spear SI, Willey SC, Robb GL, et al., eds. Surgery
of the Breast: Principles and Art. Philadelphia: Lippincott-Raven;
2006:833–844.
29. Hamdi M, Van Landuyt K, de Frene B, et al. The versatility of the
inter-costal artery perforator (ICAP) flaps. J Plast Reconstr Aesthet
Surg. 2006;59:644–652.
30. Hamdi M, Spano A, Van Landuyt K, et al. The lateral intercostal
artery perforators: anatomical study and clinical application in
breast surgery. Plast Reconstr Surg. 2008;121:389–396.
31. Losken A, Hamdi M. Partial breast reconstruction: current
perspectives. Plast Reconstr Surg. 2009;124:722–736.
32. Munhoz AM, Montag E, Arruda E, et al. Immediate conservative
breast surgery reconstruction with perforator flaps: new challenges
in the era of partial mastectomy reconstruction? Breast.
2011;20:233–240.
33. Hamdi M, Van Landuyt K, Ulens S, et al. Clinical applications of
the superior epigastric artery perforator (SEAP) flap: anatomical
studies and preoperative perforator mapping with multidetector
CT. J Plast Reconstr Aesthet Surg. 2009;62:1127–1134.
34. Hamdi M. Pedicled perforator flap reconstruction. In: Losken A,
Hamdi M, eds. Partial Breast Reconstruction: Techniques in Oncoplastic
Surgery. St. Louis: QMP Inc.; 2009:387.
35. Hamdi M, Van Landuyt K, Van Hedent E, et al. Advances in
autogenous breast reconstruction: the role of preoperative
perforator mapping. Ann Plast Surg. 2007;58:18–26.
36. Hamdi M. Oncoplastic and reconstructive surgery of the breast.
Breast. 2013;22:S100–S105.
37. Hamdi M, Decorte T, Demuynck M, et al. Shoulder function after
harvesting a thoracodorsal artery perforator flap. Plast Reconstr
Surg. 2008;122:1111–1117.
38. 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.
39. Mendelson EB. Evaluation of the postoperative breast. Radiol Clin
North Am. 1992;30:107–138.
40. Spear SI, Wilson H. Fat injection to correct contour deformities in
the reconstructed breast. In: Spear SI, Willey SC, Robb GL, et al.,
eds. Surgery of the Breast: Principles and Art. Philadelphia:
Lippincott-Raven; 2006:960.
41. Agha R, Fowler A, Herlin C, et al. Use of autologous fat grafting for
breast reconstruction: a systematic review with meta-analysis of
oncological outcomes. J Plast Reconstr Aesthet Surg. 2015;68:143–161.

SECTION II • Reconstructive Breast Surgery
24 
Fat grafting to the breast
Henry Wilson, Scott L. Spear†, and Maurice Y. Nahabedian
SYNOPSIS
■ Autologous fat has demonstrated success when it comes to correcting
mild to moderate contour deformities in reconstructed breasts.
■ Fat grafting may be used safely and effectively for a variety of
reconstructive indications.
■ There is a variety of specific harvesting and processing techniques
available.
■ Fat grafting for breast augmentation is effective, but its precise role in
the cosmetic plastic surgeon’s armamentarium is yet to be defined.
■ Fat grafting to the breast has become common practice for
reconstructive and aesthetic breast surgery; however, it remains
controversial for some indications.
■ Complications are minor and infrequent if a proper technique is
followed.
■ External pre-expansion and adipose-derived stem cells hold promise for
future enhancement of the results and treatment of difficult problems.
Access the Historical Perspective section online at

Introduction
Autologous fat grafting to the female breast has a long
history surrounded by a great deal of controversy. Over
the past decade, there have been numerous clinical
and scientific publications attesting to the risks and
benefits.4–24 Despite the paucity of high-quality pub­
lished evidence and continued disagreement about the
best technique, autologous lipofilling to the female
breast continues to evolve. As with many fundamentally
good ideas in plastic surgery, the concept is elegant in
its simplicity: fat is removed from a location where it is
not needed and used to augment body contour in an
area of need or desire. To be compelling, the procedure
must have a reliable technique and not subject either the
donor or recipient site to unacceptable risk.
This chapter examines the current use of autologous
fat grafting of the breast for a variety of indications,
including filling contour irregularities and supplement­
ing other forms of breast reconstruction after mastec­
tomy in both the radiated and non-radiated breast.
Another indication is the correction of contour abnor­
malities following breast-conserving therapy. Autolo­
gous fat has been used for reconstruction of the entire
breast after mastectomy without requiring either an
implant or a flap.25 Fat grafting has also been described
for correcting congenital anomalies of the breast such
as Poland syndrome, pectus excavatum, and thoracic
hypoplasia. Similarly, autologous fat can be used to
correct acquired deformities of the breast other than
after cancer treatment, such as might occur after previ­
ous implants or other breast surgery. The chapter con­
cludes with an analysis of the controversy surrounding
the use of autologous fat grafts for primary breast
augmentation.5,10,26–30
Of the indications listed above, some are more widely
accepted than others. The issues involving all of these
applications are cost, efficacy, acute surgical risk, inter­
ference with the diagnosis, and treatment of breast
cancer, and the remote possibility of increasing the risk
of neoplasia. Fat grafting as a supplement to other forms
of breast reconstruction after mastectomy is the most
well-accepted application because of its excellent risk
profile, its wide adoption by many surgeons, and the
absence of negative reports.
†Deceased

458.e1
Historical perspective
Historical perspective
Autologous fat grafting was pioneered by European
surgeons in the late 1800s,1 with the first documented
case in the breast being a lipoma autotransplanted to
reconstruct a breast defect, by Czerny in 1895.2 Fat graft­
ing enjoyed intermittent popularity throughout the
early 20th century, with Lexer and others reporting on
its use in the breast. These investigators also studied the
behavior of grafted fat microscopically and developed
some practical guidelines to technique, such as volu­
metric overgrafting to account for resorption. Still, the
practice never became popular until the 1980s, when the
widespread adoption of liposuction by plastic surgeons
resulted in easy access to large volumes of donor fat.
This autologous fat began to be used in normal breast
for breast augmentation, a controversial use because of
the breast’s oncologic potential. Debate followed, result­
ing in an ASPS position paper in 1987 condemning the
use of autologous fat for breast augmentation. The
reasoning behind this judgment was that much of the
grafted fat was thought to necrose, resulting in scarring
and calcifications that were said to obscure the detection
of breast cancer on mammography.
Despite the fact that scarring and calcifications were
also known to result from other accepted breast surgical
procedures, the previously resurgent use of autologous
fat in the breast all but ceased. Its use in the breast was
continued by a few practitioners who advanced the art
without much recognition.3 The practice re-emerged
from the shadows only in 2005–2007, when several
authors published their experiences, including the
potentially restorative effects of adipose-derived stem
cells on radiated breast tissues. Since then, there has
been renewed interest in the techniques and a blossom­
ing of published reports. An ASPS research task force
into autologous fat use in breast and other tissues
reported its results in 2009, finding the practice largely
safe, but lacking in scientific validation.

459
Basic science/disease process
problem, however, so such grafts must be small and are
best suited to craniofacial applications where the defects
are small and the vascularity is high.
Autologous fat grafting with aspirated fat uses fat in
a liquid form, which permits it to be harvested and
deployed with minimal incisions. It also permits its
injection in precise quantities into precisely the area it
is needed, at least in theory. From the procurement at
the donor site to deposition in the grafted area, there are
several steps in processing that must be executed suc­
cessfully. Each step introduces the potential for adipo­
cyte trauma and technical error, so attention to technique
is of paramount importance.
Stem cells and radiation deformities
Adipose-derived stem cells (ADSCs) were first described
in the 1920s, with early research focusing on which cells
survived transplantation and became new host fat cells,
which helped to characterize the process and improve
the survival of fat grafts. More recently, the regenerative
qualities of ADSCs on damaged tissue were found, and
they have potentially dramatic treatment implications
for patients with radiation-induced injury.31 As radiation
is increasingly being used in the breast for aggressive
indications, the average practitioner can be expected to
encounter more and more of these deformities.
Radiation deformities are some of the most challeng­
ing problems the reconstructive breast surgeon encoun­
ters. Radiation-damaged breast tissue has a reduction of
its capillary bed and is relatively hypoxic. The clinical
picture is one of acute injury (radiodermatitis), followed
by subcutaneous fibrosis and skin hyperpigmentation.
There is substantial variability as to the extent to which
an individual patient will exhibit these effects and their
resolution over time. Common presenting problems
after radiation include generalized fibrosis; scar retrac­
tion at lumpectomy defects; capsular contracture around
prosthetic devices, and persistent skin hyperpigmenta­
tion. Uncommonly, radionecrosis occurs, resulting in a
chronic wound.
Traditionally, little in the reconstructive armamen­
tarium has been able to address the primary problem of
tissue damage. Solutions have been centered around
replacement techniques: flaps to replace a retracted
lumpectomy defect or eliminate an implant with sur­
rounding capsular contracture. The promise of ADSCs
lies in their ability to reverse the fibrotic changes of
radiation damage.31 The future may bring more compre­
hensive solutions to breast reconstruction, such as
ADSC-seeded biomaterial constructs13 and fat grafting,
combined with negative pressure external soft-tissue
expansion.25 Presently, the use of fat grafting augmented
with expanded populations of ADSCs is limited to
In 2005, the authors reported on the use of autologous
fat grafting to correct contour deformities in the recon­
structed breasts of 37 patients.4 Most of the 47 treated
breasts (85%) experienced worthwhile improvement
from the procedure, and only 8.5% of the treated breasts
experienced a significant complication (one cellulitis
and three cases of fat necrosis). Based on these results,
fat injection was recommended as a “safe and effective
tool for improving the cosmetic result of either autolo­
gous or implant breast reconstruction”.
More recently, other retrospective reviews have found
similarly good results and low complication rates. In a
2007 retrospective review by Missana et al.,6 of 74 recon­
structed breasts treated with fat grafting, the authors
found good–excellent results in 86.5% and moderately–
good results in an additional 13.5%. Their only compli­
cations were five cases of fat necrosis. In 2009, Kanchwala
et al.9 reported on fat grafting to 110 breast reconstruc­
tion patients, finding good–excellent results in 85% and
reporting no complications other than “minor contour
irregularities”. Reporting in 2009 on 880 patients treated
over 10 years for a variety of reconstructive and cosmetic
breast concerns, Delay et al.10 noted good–excellent
results in the vast majority of patients with complica­
tions, including a 3% rate of fat necrosis and less than
1% infection. None of these review articles found any
correlation of fat grafting with the development of a
new or recurrent breast cancer, and mammographic
abnormalities were confined to calcifications that were
easy for experienced radiologists to distinguish from
neoplastic patterns of calcification.
An understanding of the effective use of fat grafting
in principle is fundamental to the use of fat grafting for
any indication. For this reason, this chapter includes a
detailed discussion of the treatment of generic contour
deformities of the breast for which fat grafting is indi­
cated. Contour deformities after reconstructive breast
surgery for mastectomy are relatively common, and
autologous fat has become a workhorse to correct them
because of its relative simplicity, low cost, and lasting
results.4,5,10 The authors advise the surgeon to achieve
success at fat grafting for these indications, prior to
considering its use in the more controversial areas of
lumpectomy deformities or cosmetic augmentation.
Basic science/disease process
Adipocytes are fragile. Unlike skin, muscle, or bone, fat
lacks unit cohesion, which is perhaps why many early
practitioners used dermal fat grafts. When fat is left
attached to its overlying dermis, it is easier to work
with, since it can be sutured into the desired location.
Oxygen diffusion prior to revascularization remains a

460
SECTION II
CHAPTER 24 • Fat grafting to the breast
pocket, an unnatural “trench” can form at the interface
between the implant and the chest wall. This may be
further accentuated medially by lateral shift of the
implant when the patient is supine. Such deformities
may require a combination of implant exchange to dif­
ferent size, capsulorrhaphy, capsular reinforcement
with acellular dermal matrix, and fat grafting (see Fig.
24.4). These deformities are also encountered in the
slender cosmetic patient, especially when implants are
placed in the subglandular plane.
Contour deformity after flap reconstruction
In the case of flap reconstruction, the border of the flap
is a common location for a depression, often occurring
as a “step-off” where the flap ends and the normal
residual tissue begins.9 Characteristically, this deformity
consists of skin flap directly over the chest wall muscle
or bone, and reflects the step-off that can occur at the
edge of a flap where it is inset to fill a mastectomy defect
or from fat necrosis at the vulnerable edges of the recon­
structive tissue (Figs. 24.3 & 24.4). Deformities intrinsic
to the flap, such as areas of fat necrosis within the sub­
stance of the flap or the periumbilical tissue in a trans­
verse rectus abdominus myocutaneous (TRAM), are
also common indications and may occur within the flap
substance or at the borders.
Contour deformities after implant or flap
reconstructions in a radiated field
Suitable patients with radiation damage have a breast
contour deformity secondary to implant or flap recon­
struction after mastectomy, exacerbated by radiation
changes such as those described in the radiation section
above. These deformities may have components of these
step-off or intrinsic flap deformities, in addition to the
tissue fibrosis, skin changes, or capsular contracture
brought about by radiation (Figs. 24.5 & 24.6). The
complications of flap reconstructions that are the most
difficult to correct tend to occur when the reconstruction
was performed prior to the radiation.34 These include
volume loss, fat necrosis, delayed wound healing, and
fibrosis. While the experience with fat grafting as an
adjunct to other breast reconstructions has been largely
favorable, the evidence is unclear and unconvincing,
when looking specifically at the radiated breast. Radia­
tion introduces added risks, complexities, and problems.
The risks include an increased risk of infection and of
non-healing of the surgical site. The complexities include
the difficulty of creating space for the fat in a badly
radiation-fibrosed recipient site, and the problems are
the lack of both skin elasticity and a fertile recipient site
conducive for the fat grafts to take.
research institutions, but fat grafts harvested and pro­
cessed with the traditional techniques may contain
some stem cells.
Diagnosis/patient presentation
Patients present with contour deformities occurring
after previous reconstructive or cosmetic breast surgery.
Alternatively, a patient may request primary augmenta­
tion for hypomastia or congenital asymmetries such as
tuberous breast or Poland syndrome. A potentially large
patient population who may be served in the future is
the post-mastectomy patient seeking total primary
reconstruction with fat grafting.
Patient selection
Autologous fat grafting is indicated to restore normal
contour in an area of deformity. These deformities
occur commonly in breasts reconstructed with flaps or
implants and also occur as undesirable sequelae of
implants placed for cosmetic breast augmentation (Table
24.1). There now follows a discussion on specific indica­
tions, with examples of each.
Contour deformity after
implant reconstruction
With implant reconstructions, thin overlying tissue can
lead to sharp implant borders (Fig. 24.1) and visible
rippling (Fig. 24.2), both of which can be effectively
softened by fat grafting. These patients are often slender
with relatively little subcutaneous fat, or are patients
whose mastectomy flaps were left very thin by the
breast surgeon. If the implant is very mobile in a large
Table 24.1  Specific indications for fat grafting
Established indications:
safe and effective
Effective and
probably safea
Safe but not
yet proven
Flap border step-off
Depression from fat
necrosis
Irregularities in mastectomy
flap thickness
Augmentation for
inadequate flap volume
Radiation deformity in flap
reconstruction
Sharp implant border
(reconstruction)
Implant rippling
(reconstruction)
Deformity after
lumpectomy
and radiation
Cosmetic
augmentationb
Augmentation
deformities
(rippling,
visible
deformities)
Primary
reconstruction
as the sole
methodc
aDetailed informed consent and IRB approval required.
bBeing evaluated in clinical trials.25,32,33
cBeing evaluated in clinical trials.25

461
Patient selection
Fig. 24.1  A 55-year-old patient who underwent bilateral nipple-sparing mastectomies. (A) Preoperative view; (B) postoperative view after reconstruction with tissue
expanders and acellular dermal matrix illustrates typical marginal contour deformities surrounding a prosthetic device. (C) Preoperative markings and (D) the 3-month
postoperative result for fat grafting to margins with exchange of tissue expanders for permanent implants.
A
B
C
D
Fig. 24.2  (A) Bilateral implant reconstructions with visible implant borders superiorly on both sides and substantial rippling on the left. (B) The 6-month postoperative
results after fat grafting superior poles bilaterally (80 cc right, 50 cc left) and left inferior capsulorrhaphy. Note softening of implant contour bilaterally and resolution of
visible rippling on the left.
A
B

462
SECTION II
CHAPTER 24 • Fat grafting to the breast
Fig. 24.3  (A,B) A 45-year-old patient with flap step-off deformities after bilateral immediate breast reconstruction with pedicled transverse rectus abdominus myocutaneous
flaps. (C,D) At 11 months after bilateral nipple reconstruction with 120 cc of fat grafting to each superior pole. (E,F) The same patient 7 years after fat grafting to flap
step-off deformities of the superior poles bilaterally.
A
B
C
D
E
F

463
Patient selection
Fig. 24.4  A 33-year-old patient with bilateral step-off deformities (most pronounced on the left) treated by fat injection. (A) Preoperative view 2 years after bilateral breast
reconstruction with latissimus flaps and implants. (B) The same patient 3 years after autologous fat grafting of 170 cc to the left upper pole and 50 cc to the right upper
pole.
A
B
A
B
Fig. 24.5  A 51-year-old patient with history of bilateral modified radical mastectomies with postoperative radiation after each mastectomy. (A) The patient preoperatively,
and (B) 3 months after bilateral reconstruction with latissimus flaps and tissue expanders. (C) Preoperative view prior to bilateral exchange of expanders for implants, nipple
reconstructions, and treatment of bilateral upper pole contour deformities with fat grafting and acellular dermal matrix. (D) At 5 months after the operation.
C
D

464
SECTION II
CHAPTER 24 • Fat grafting to the breast
reported an innovative approach to the reconstruction
of radiated mastectomy defects in 2009.35 The authors
reported on 65 patients, whom they reconstructed in
three stages: tissue expander placement, expander
exchange for permanent implant, and nipple recon­
struction. At each stage, an average of 150 cc of autolo­
gous fat was grafted to enhance the volume of the
reconstruction. The authors report excellent results,
with no capsular contracture or other complications.
They conclude that fat grafting enhanced the recon­
struction by improving the skin quality and adding
subcutaneous volume to the breasts.
A review of the literature indicates that experience
with fat grafting in the radiated environment has
only recently been addressed. The 2007 publication by
Rigotti et al. details some cases showing dramatic
improvements to both capsular contracture and
impending implant exposure as a result of stem-cell
enhanced autologous fat grafting.31 In 2009, Delay et al.
reported that fat grafting can improve the quality of
radiation-damaged post-mastectomy skin contributing
to an autologous reconstruction or permitting an
implant reconstruction to be used where it may have
previously been contraindicated.10 Serra-Renom et al.
Fig. 24.6  A 55-year-old patient with a history of left breast lumpectomy and radiation 2 years prior to bilateral nipple-sparing mastectomies and subsequent tissue
expander and implant reconstruction. Bilateral upper pole contour deformities (A,B) were treated with 35 cc right and 85 cc autologous fat injection. (C,D) At 1 year
postoperatively.
A
B
C
D

465
Patient selection
fat grafting these lumpectomy defects is very appealing
because no other techniques are appropriate for most of
these patients and what is missing is usually all, or in
part, fat. Implants perform badly in a radiated environ­
ment, and flaps are often best reserved for total or
subtotal mastectomy defects. The problems and chal­
lenges, however, are similar to those for radiation after
mastectomy. Fibrosis, risk of infection, and a hostile
environment for grafts make the radiated lumpectomy
defect an uncertain, unproven application. This is mag­
nified by the heightened concern for monitoring and
detecting local breast cancer recurrence in these patients.
Lumpectomy deformities
Lumpectomy deformities of up to 10–15% of the breast
volume often result in satisfactory aesthetic results.36
The actual resected percentage, however, may often be
higher with re-excisions or a desire to avoid mastectomy
on the part of the patient or breast surgeon. Although
oncoplastic techniques may result in very good sym­
metry if performed at the time of lumpectomy, they
are not universally utilized or available. Accordingly,
lumpectomy with radiation results in suboptimal aes­
thetic outcomes of up to 30% (Fig. 24.7).37 The idea of
A
B
Fig. 24.7  Right breast contour deformity after breast-conserving therapy. (A,B) Preoperative. (C,D) At 2 months postoperatively, from fat grafting to right lumpectomy
defect and left mastopexy. There has been a modest improvement in the right breast contour seen best on the oblique view.
C
D

466
SECTION II
CHAPTER 24 • Fat grafting to the breast
Congenital deformities
Just as the FDA recognized that certain non-mastectomy
problems were surgically comparable with those caused
by cancer treatment, it is recognized that some con­
genital and other acquired breast deformities can be and
should be treated like those after mastectomy or breast-
conserving therapy. These include Poland syndrome,
pectus excavatum, thoracic hypoplasia, tuberous
breasts, and major asymmetries. Some of these patients
can be treated in whole or in part by other techniques,
but fat grafting brings an additional powerful tool to
help solve the problem, often where nothing else is
practical. This has been shown for the deformity associ­
ated with the tuberous breast.5 It has also been demon­
strated for chest wall deformities where the upper pole
is beyond the reach of the implant.4
Poland syndrome results in absence of the pectoralis
muscles and underdevelopment of the breast gland.
Provided the latissimus is present, an excellent recon­
structive solution involves a latissimus flap with place­
ment of an implant.39 Postoperative deformities in the
infraclavicular hollow may occur and respond well to
fat grafting. Other candidates for fat injection present
with unsatisfactory reconstruction after breast implant
alone, usually with contour deformities laterally accen­
tuated by the absence of the pectoralis. The deformity
resulting from Poland syndrome can also be entirely
reconstructed with fat grafting,10 but it typically requires
multiple sessions of grafting.
Anterior thoracic hypoplasia is characterized by a
normal pectoralis muscle and sternal position, but
a unilaterally depressed chest wall with hypoplastic
breast and superiorly-displaced nipple areolar complex
(NAC).40 Treatment is typically with implant alone,
though residual deformities may occur and respond
well to fat grafting (Fig. 24.8).
There is little in the literature on lumpectomy defor­
mities being reconstructed with autologous fat grafting.
In his 2007 publication detailing the use of adipose-
derived stem cells, Rigotti published impressive photo­
graphs of a patient whose radiated lumpectomy defect
was dramatically improved by stem cell-enriched fat
injection.31 A 2009 report of experience by Delay et al. on
42 patients indicates that the fat grafting is valuable in
the management of moderate deformities resulting from
breast conservation.10,38 The authors caution that the
medico-legal environment surrounding fat grafting for
this indication is treacherous, however, and they use a
very strict protocol involving detailed pre- and post-
procedure imaging, specially trained radiologists, and
management of the patient within a multidisciplinary
team. Delay recommends completing the “learning
curve” for fat grafting prior to using it to reconstruct
radiated lumpectomy defects.10
The concept of immediate fat grafting performed at
the time of the partial mastectomy or lumpectomy has
been described. Biazus et al. treated 20 patients with
autologous fat injected in the subcutaneous and paren­
chymal layers immediately after excision and prior to
radiation.14 The average infiltrate was 121 cc that was
usually twice the volume of the excised specimen. In
total, 19 patients were classified as a BIRADs 2, and one
as a BIRADs 3. Aesthetic outcome was graded as good
to very good in the majority of cases at a minimum
follow-up of 1 year.
Acquired breast deformities from trauma or surgery
often occur in a setting without radiation damage. These
patients may have problems beyond the scope of an
implant correction but be unsuitable for a flap. Some may
have had an implant and be unwilling to have another.
For these patients, fat grafting offers the possibility of an
autologous correction with minimal morbidity.
Fig. 24.8  (A) A patient with thoracic hypoplasia preoperatively. (B) A patient with thoracic hypoplasia after bilateral augmentation only. (C) At 2 years after two separate
procedures of fat injection to right upper pole (140 cc and 150 cc, 14 months apart).
A
B
C

467
Patient selection
prior to the trial in a handful of patients was mixed,
with some having visually significant breast enhance­
ment of up to one cup size (Figs. 24.9 & 24.10). Others
had no discernible long-term benefit, despite several
hours of hard work of obtaining, processing, and infil­
trating the fat in front of and behind the breast paren­
chyma in several different planes (Fig. 24.11).
In a retrospective review published in 2007, Zheng
et al. followed 66 Chinese patients treated with fat graft­
ing for breast augmentation for an average of 37
months.27 Fat grafts were harvested using 3 mm can­
nulas attached to a vacuum pump set to low negative
pressure (−0.5 atm), washed with normal saline, and
spun in a centrifuge at 600 rpm (26 g) for 2 min to isolate
the middle layer, which was used as graft. Graft injec­
tion was performed with a one-holed 3 mm cannula
through two injection sites (periareolar and inframam­
mary), with an average of 174 mL of fat injected into
each breast (101 mL subcutaneous; 73 mL subglandu­
lar). A total of 28 patients had one treatment; 21 patients
were treated twice; and 17 patients three times. Results
were judged by three independent plastic surgeons,
who noted significant improvement in 28 patients
(42.4%); improvement in 24 patients (36.4%); and no
improvement in 14 patients (21.2%). A total of 27 patients
(40.9%) were very satisfied; 26 patients (39.4%) were
satisfied; and 13 (19.7%) were unsatisfied with the
results. The only complications noted were fat necrosis
or cyst formation in 11 patients (16.7%), none of which
interfered with the final contour of the breast.
In another study published in 2008 of purely cosmetic
breast augmentation with fat injection, Yoshimura et al.
treated 40 Japanese patients using a protocol designed
to increase the percentage of ADSCs in the grafted
fat.28 Adipose tissue was harvested using a 2.5 mm
(inner) diameter cannula and conventional liposuction
machine, after which half of the harvested fat was
either washed and placed upright (25% of patients)
or centrifuged unwashed at 700 g for 3 min (75% of
patients). The other half of the liposuction aspirate was
used to isolate the stromal vascular fraction in order to
combine it with the fat to be grafted, a 90 min procedure
designed to enhance the population of ADSCs in the
fat graft. Injection was performed with 150 mm long
18-gauge needles into one of four injection sites (two
periareolar, two inframammary) to distribute fat “on,
around and under the mammary glands and also into
the pectoralis muscles”. An average of 273 mL of fat
was grafted into each breast during a procedure that
required, on average, over 4 h. Results were measured by
the increase in chest circumference, which was between
4 and 8 cm at 6 months, corresponding to a 100–200 mL
increase in the volume of each breast mound or “two to
Tuberous breast deformity features a constricting ring
though which developing tissue herniates, resulting in
an enlarged NAC, narrow mammary base, elevation of
the inframammary fold, and hypoplasia of one or more
breast quadrants. Treatment depends on the presenta­
tion and may result in contour deformities that respond
well to fat grafting. The tuberous breast has also been
treated with fat grafting alone with impressive results.5,10
Primary breast augmentation
Perhaps most controversial is the use of autologous fat
grafting for primary breast augmentation. While efficacy
and safety are issues for all applications, here the issues
are magnified. On the efficacy side, these patients are
generally easily corrected with implants. With a high
degree of reliability and certainty, a woman can enlarge
her breast size by 200–500 cc (1 or 2 cup sizes) with a
1–2 h operation, with well known, well described, and
definable risks. Regarding breast augmentation with
lipofilling, however, the enlargement is less ambitious,
less reliable, and less certain. The authors generally
describe to the patient that it is the hope and intent to
increase the breast by one half to one whole cup size.
This result is clearly dependent on a number of things.
The percentage of fat survival is key, but how to obtain
that survival is still a work in progress. Defining the best
candidate for lipo-breast augmentation is as important
as the technique. Determining what type of fat to
harvest, how to prepare it, where to inject it, and in what
type of breast are all important questions. Regarding
safety, the questions are equally important. These
women have not had breast cancer, but they are at sig­
nificant risk of developing breast cancer, resulting in
concerns about radiographically obscuring or mimick­
ing breast cancer. Of theoretical concern is the possibility
of accelerating or inducing breast cancer in the younger
at-risk women. Nevertheless, the concept of moving fat
from less desirable areas such as the abdomen or thighs
to more desirable areas such as a small breast is so
seductive and compelling that it should be no surprise
that academic-minded surgeons are studying it, entre­
preneurial surgeons are marketing it, and many patients
are very, very interested in it.
Safety issues apply for all of the non-cancer uses of
autologous fat, but they are most acute in the purely
cosmetic patient. For her, the indications for correction
are so elective, the other options so good, and the risk
of disturbance of her normal, healthy baseline are much
greater than, e.g., the previously treated cancer patient.
The authors have had a modest experience in primary
breast augmentation with fat, most of it in a funded,
IRB-approved, controlled clinical trial.32 Our experience

468
SECTION II
CHAPTER 24 • Fat grafting to the breast
Fig. 24.9  A patient with approximately a one cup size increase after autologous fat grafting for breast augmentation. (A,B) Preoperative. (C,D) A 1-year postoperative view
after one session of 300 cc of fat grafting to each breast.
A
B
C
D
three brassiere cup sizes”. The authors state that “almost
all” of the patients were satisfied with their enlarged
breasts but did not quantify this and also did not
have a separate panel to judge the results subjectively.
MRI detected cysts in two patients, and mammog­
raphy found two patients with microcalcifications at
24 months.
In 2008, Zocchi and Zuliani reported on 181 patients
for breast augmentation with fat grafting.41 They injected
processed fat into the retroglandular and periglandular
subcutaneous plane, using a disposable 2 mm cannula
with a single hole for harvesting with negative pressure
generated by a 60 mL syringe. Fat is “processed” only
by vibration of the upright syringes on a special vibrat­
ing table to stratify the fat into layers. Fat is then reim­
planted into the above planes using special 2 mm
cannulas: a flexible 27 cm-long one for the retroglandu­
lar plane and a stiffer 25 cm-long one for the subcutane­
ous plane. They injected an average of 325 mL or 375 mL
of fat into each breast (two different numbers are
reported in their article) and also utilized an external
breast expansion device (BRAVA, Miami, FL) in some
patients. The authors state that some patients did not
comply with external expansion but do not reveal how
many. Rating the aesthetic results, 38 patients (23%)
judged them as excellent; 128 (72%) as good; 10 (6%) as

Fig. 24.10  A 35-year-old patient treated
with autologous fat grafting for breast
augmentation. (A,B) Preoperative views.
(C,D) Postoperative views at 6 months. A
total of 280 cc on each side was used in
the following locations: 50 cc to each
pectoralis muscle, 100 cc in each
subglandular plane, and 130 cc
subcutaneously.
A
B
C
D
Fig. 24.11  (A) Preoperative anterior view of a patient who experienced essentially no discernible benefit from fat grafting for breast augmentation. (B) Preoperative oblique
view. (C) Postoperative anterior view of the patient 1 year after 165 cc autologous fat grafting to each breast. (D) A 1-year postoperative oblique view after grafting.
(E) Anterior view of the patient 1 year postoperatively from bilateral prosthetic augmentation with 339 cc silicone implants. (F) A 1-year postoperative oblique view after
implants.
A
B
C
D
E
F

470
SECTION II
CHAPTER 24 • Fat grafting to the breast
these, 430 breasts were reconstructed using fat graft
only. The average fat infiltration was 225 cc per session.
The number of sessions was 2.7 for the non-radiated
cohort of patients and 4.8 for the radiated cohort of
patients. Complications included five pneumothoraces
and 20 infections. Benign nodules were noted in 12%
of non-radiated breasts and in 37% of radiated breasts.
Patients reported normal and soft breasts with reason­
able sensation.
Treatment/surgical technique
The defect is analyzed, using as much information as is
available, including preoperative photographs, the
contralateral normal breast, the original operative note,
and pathology reports. The latter is especially valuable
when reconstructing lumpectomy defects, since it typi­
cally contains a specimen weight, which can be used to
plan the graft volume. Informed consent is obtained.
Estimates of volume to be grafted are made to assist
with determining what volume to harvest from the
donor site.
The patient is marked in the standing position (Fig.
24.12), when areas of contour irregularity can be most
clearly seen because of shadows created by overhead
lighting. This most important step ensures that areas
noticeable while standing are not overlooked when
the patient is supine, with powerful surgical lights
overhead that obscure shadows. The surgeon estimates
the amount of fat needed for grafting and marks appro­
priate donor sites. After fat harvest and processing per
the surgeon’s preference, grafting is performed in a
manner appropriate to the deformity being treated.
Depressions are treated with multiple tunnels in a
fair; and five (3%) as insufficient. The surgeon judged
them as excellent in 23 cases (13%); good in 123 (69%);
fair in 25 (12%); and insufficient in 10 (6%). The authors
state that an average of 55% of grafted volume persisted
at 1 year but do not state how this was measured.
Complications were not quantified, except to say they
were “minimal and temporary” and that microcalcifica­
tions were found in some patients. While this study
reports on a relatively large number of patients, it is
mostly an informal report of cases.
With little quality data having been published on
breast augmentation with fat grafting,8 several clinical
trials have been started in the US to better study the
issue. Autologous fat grafting for cosmetic augmenta­
tion has been performed under research protocols in
Miami,25 Washington, DC,32 and New Orleans.33 Spear
and Pittman have published a prospective evaluation of
10 women following lipoaugmentation as a sole modal­
ity.42 The average amount of fat injected was 236 cc in the
right breast and 250 cc in the left breast. The mean change
in volume was 85 cc on the right and 98 cc on the left
correlating to a retention volume of 36% and 39%,
respectively. This was assessed using 3D imaging and
MRI volume measurements. Mammographic imaging
demonstrated a BIRADs score of 2 or higher in 50%
of women.
Candidates for lipoaugmentation of the breast should
have low risk factors for breast cancer. In addition, it is
preferred that they have no personal history of benign
breast disease. They must also have sufficient donor
sites to support at least two stages of fat harvest for each
session. Preoperative MRI is recommended as a baseline
as well as a preoperative mammogram if the patient is
aged 40 or over. Finally, a frank discussion with the
patient about potential implications of fat grafting for
cancer screening must occur, and a detailed informed
consent should be included. The authors recommend
that the surgeons performing breast augmentation with
autologous fat grafting do so under Institutional Review
Board oversight.
Total breast reconstruction
For the most ardent advocates of fat grafting of the
breast, the next great opportunity is reconstructing
the entire breast with autologous fat injections. The
authors have never personally performed this, but
total breast reconstruction for the patient with post-
mastectomy or congenital absence of the breast is pos­
sible. Anecdotal cases have been reported at various
symposia and on websites by researchers involved in
clinical trials.25 Khouri et al. have recently reported
their experience using external expansion and autolo­
gous fat grafting in 488 women and 616 breasts.24 Of
Fig. 24.12  Preoperative marking of the same patient as in Fig. 24.2. Areas for
autologous fat grafting are denoted by the blue outline with “+” signs superiorly on
each breast. The patient has also been marked for the left capsulorrhaphy.

471
Treatment/surgical technique
to attempt to stay within the subcutaneous plane and
not within breast parenchyma during graft injection.
Additional volume for augmentation may be grafted
into the subglandular, intramuscular, and submuscular
planes. Minimal “molding” is performed externally; the
emphasis should be on correct and even graft deposi­
tion during cannula withdrawal. When the goal volume
is reached, the injection sites are closed with adhesive
strips and conforming dressing applied to the breast.
Notes on harvesting and processing fat
Appropriate donor site selection includes any area that
has sufficient fat to donate, typically the abdomen, hips,
and thighs. The site selected can be based on ease of
harvest and patient preference, since no studies have
demonstrated superiority of different sites in graft
survival.43
Standard liposuction infiltration is performed with a
dilute epinephrine-containing solution to minimize
blood loss. To harvest the fat, all that is needed is an
appropriate cannula attached to a means of suction and
a collection container. Most practitioners use a 3 mm
multi-hole cannula to harvest fat intended for use in the
cross-hatch fashion (Figs. 24.13 & 24.14), while ridges
and rippling respond best to a few long tunnels below
the longitudinal depression (Fig. 24.15). Depressed areas
with substantial scarring from fat necrosis or radiation
damage may benefit from scar release with specialized
cannulas that have cutting edges (Fig. 24.16). Care must
be exercised when using these instruments – their effect
can be quite destructive to an implant and catastrophic
near a flap pedicle.
Multiple locations are selected as graft insertion sites.
This may be as few as 4–8 around a lumpectomy defect
or as many as 20 for breast augmentation. A blunt-tipped
cannula attached to a 3 mL syringe is used to inject
small volumes of fat during the withdrawal phase of the
cannula movement. The cannula is passed repeatedly in
a radial pattern from each injection site, with the goal
being an interwoven mesh pattern of graft deposition at
multiple levels. For breast augmentation, it is important
Fig. 24.14  A typical contour depression viewed from the side, with the cannula
positioned at the top left near the injection site. Note the changes in directional
vector the cannula must undergo as it traverses the bottom of the defect concavity.
These depend on a rigid cannula and sometimes releasing underlying tethering scar
tissue.
Depressed contour
Cannula vector change
Fig. 24.15  Multiple longitudinal vectors used to treat longitudinal depressions
(such as the edge of a flap or implant). Note vector change to permit multiple
parallel treatment tunnels from a minimum of injection sites.
Cannula vector change
Fig. 24.16  (A,B) V-shaped dissectors. (©Tulip, Byron Medical, with permission.)
A
B
Fig. 24.13  Top view with defect borders marked with the bold line. Multiple
criss-crossing tunnels across a typical small contour deformity, with six separate
injection sites located at the periphery (1–6). Each tunnel may receive different
amounts of graft along its length depending on the needs of the area and amounts
already grafted by previous tunnels originating from other injection sites.
1
2
3
4
5
6

472
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CHAPTER 24 • Fat grafting to the breast
controversy surrounding the use of SVF is that in vitro
studies have demonstrated that progenitor cells present
in the breast have demonstrated enhanced growth in the
presence of SVF.46,47 Clinical studies that have assessed
tumorigenesis in the setting of breast reconstruction and
autologous fat grafting have been favorable, demon­
strating a biopsy rate of 7.4% and no cases of loco-
regional cancer recurrence.48
Coleman’s method
Coleman advocates using a cannula of his design, which
has a blunt tip and two adjacent holes (Fig. 24.19). This
is connected to a 10 mL syringe to which modest suction
is applied when the surgeon’s ring and small fingers
pull back on the plunger. As the cannula is pushed
through the harvest site, a combination of the curetting
action of the cannula and the negative pressure pulls fat
into the syringe. When the syringe is full, it is discon­
nected from the cannula, capped at the Luer connector
end with a sterile cap, and the plunger is removed. The
open end of the syringe may be covered with a Tega­
derm (3M) to maintain sterility of syringe contents after
plunger removal.49 The syringe is placed into a sterile
sleeve in a small centrifuge (Fig. 24.20). Other syringes
are added, and the centrifuge spins the contents at
3000 rpm for 3 min.
breast. Next, the aspirated fat is refined by removing oil,
blood, and infiltrate fluid. The simplest method of this
is to allow the aspiration syringe to stand for 10–15 min
(Fig. 24.17).44 Finally, the processed fat is reinjected (Fig.
24.18) to the intended recipient site using a specialized
injection cannula. Sydney Coleman, MD, was the earli­
est recent practitioner to codify and publish reliable
steps, and his method is detailed below, followed by
alternative methods that have been used successfully by
other practitioners.
Some practitioners are considering the use of stromal
vascular fraction (SVF) for fat infiltration. Essentially,
this involves the enzymatic processing of fat to increase
the concentration of ADSCs. The benefit of SVF is that
the overall fat retention is enhanced and may approach
80% rather than the conventional 40–60%.20,45 The
Fig. 24.17  Aspiration syringe standing upright. Note aqueous layer below
aspirated fat and oil layer above aspirated fat.
Fig. 24.18  Processed fat is grafted into the patient, in this case for breast
augmentation.
Fig. 24.19  Coleman aspiration cannula. (©Byron Medical, with permission.)
Fig. 24.20  Small centrifuge. (Photo courtesy of Thermo Fisher Scientific, Inc.
Reprinted with permission.)

473
Treatment/surgical technique
transferred into 3 mL syringes ready for injection into
the recipient site.
Alternative methods
Critics of Coleman’s method point to the multiple small
harvest syringes and two-hole cannula as unnecessarily
time-consuming. Other practitioners therefore use larger
syringes and multi-hole cannulas (available from Tulip
Medical Products, San Diego, CA) or a modified lipo­
suction set-up with a fat trap,50,51 along with a cannula
with multiple (10–12) holes to speed the process. A
simple method of straining the fat is by using a steriliz­
able kitchen strainer (Fig. 24.22) to remove the aqueous
and oil layers or standing the syringe up to allow the
layers to separate as described above. The fat is then
quickly (to prevent desiccation) transferred to a large
syringe (using a sterile spoon or scalpel handle), from
which point it is distributed to the smaller 3 cc or 1 cc
syringes (using a Luer-to-Luer or 3-way connector) for
grafting back into the patient.
After centrifugation, the syringe contents have been
separated by density. The upper level of oil (ruptured
adipocytes from aspiration) is removed by pouring it off
and then removing any remainder with absorbent wicks
of Telfa (Kendall). The bottom, densest level contains
blood as well as infiltrate and is removed by briefly
removing the cap and allowing it to drain. Using a Luer-
to-Luer connector (Fig. 24.21), the prepared fat is
Fig. 24.21  Luer-to-Luer connector. (©Tulip, Byron Medical, with permission.)
Fig. 24.22  (A) Sterilizable kitchen strainer. (B) A small amount of prepared fat after
straining and washing. Note folded gauze against the fat beneath the strainer; this
quickly wicks moisture from the strained graft. (C) Prepared fat is transferred to a
10 cc syringe for injection.
A
B
C

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SECTION II
CHAPTER 24 • Fat grafting to the breast
and needs to be released, a sharp cannula is used selec­
tively (see Fig. 24.16). An 11-blade may be used to create
the 2 mm hole for introduction of the injection cannula,
which is advanced through an area of the intended fat
grafting. As the cannula is withdrawn, slow and even
pressure on the syringe plunger deposits a fine cylinder
of fat into the tunnel created by introduction of the
cannula.
The proper technique of depositing an even layer of fat
one-handed during cannula withdrawal is a skilled
practice. Some practitioners use an IV extension tubing
to technically separate the process, permitting an assis­
tant to focus only on plunger pressure while they focus
Fig. 24.23  LipiVage fat harvest system. (©Genesis Biosystems, with permission.)
Fig. 24.24  Lipokit 60 cc syringe with suction tubing. (©Medi-Khan, with
permission.)
The harvesting and processing of fat is now being
commercialized, with specialized systems available,
which simplify many of the steps and provide “one-stop
shopping” for the equipment necessary. These systems,
such as those available from LipiVage (Fig. 24.23),
Lipokit (Figs. 24.24 & 24.25), and Cytori (Fig. 24.26),
promise substantial time savings for grafting. These
systems provide standardization and simplicity and
eliminate the need to collect the proper instruments,
sometimes from several sources, to have an effective
set-up. The drawbacks are that they are largely unproven
and their cost is high.
Injection technique
Different cannulas are used for injection to those for
harvesting. Typically, the injection cannula is a blunt
cannula with a single hole for precise fat deposition (Fig.
24.27) and is available in different lengths and flexibili­
ties. The cannula has a Luer connector for fitting to a
syringe containing processed fat. If scarring is present
Fig. 24.25  Lipokit centrifuge. (©Medi-Khan, with permission.)
Fig. 24.26  Cytori Puregraft 250. (©Cytori Therapeutics Inc, with permission.)
Fig. 24.27  Injection cannulae by Tulip (1.4 mm) and Byron (2 mm). (©Byron
Medical, with permission.)

475
Postoperative care
presently underway to quantify these effects,32,33 and
initial results are encouraging.30 If proven effective and
reproducible, this technique may transform autologous
breast reconstruction into a previously impossible
minimally-invasive procedure for patients.
Postoperative care
Skin closure of the 2 mm access slits may be made with
fine suture or adhesive strips, and a loosely supportive
breast garment is fitted with cotton fluffs over grafted
areas. Cool compresses reduce swelling, and the patient
is encouraged to minimize arm movements for a week.
The donor site is treated with a compressive garment
similarly to any area of liposuction.
Acute swelling can be expected for 1–2 weeks but
may persist for months. If a contour deformity remains
after swelling has resolved, we recommend waiting
at least 6 months prior to attempting another round
of grafting. Physical examination and radiographic
follow-up follow the same schedule as for any other
breast surgery.
on a slow and even cannula withdrawal.28 It is here also
that the fat preparation technique may have implications
for the consistent deposition of the grafted fat. The com­
pression that results from a high-speed centrifuge or the
existence of connective tissue clumps may create an
obstacle to the even flow of grafted fat through the
injection cannula. This leads some practitioners to prefer
one preparation technique over another. Open straining
permits removal of aspirated connective tissue clumps,
and a low-speed centrifuge technique (Spingraft) packs
the fat less tightly. Because increased pressure can some­
times clear a clump from the cannula, resulting in sudden
focal overgrafting, it is best to avoid this situation entirely
by stopping the procedure to clear a stoppage.52
The protocol of the senior author of this chapter (S.L.
Spear) in a current clinical trial of breast augmentation
with autologous fat at Georgetown is as follows: low-
pressure vacuum aspiration is used with a 3-hole
cannula to harvest fat from selected sites. Fat is trans­
ferred to 10 cc syringes for centrifuging, after which oil
is decanted from the top and the aqueous component is
poured out of the bottom of the syringe. Using periareo­
lar and inframammary access incisions and a single-hole
2 mm cannula, fat is infiltrated into three planes: the
subcutaneous, subglandular, and intramuscular. The
exact amounts of grafting to each of these planes vary
with the patient.
Brava
The Brava device (Brava LLC, Miami, FL) was initially
developed as an external breast tissue expander, the
goal of which was non-surgical breast augmentation.53
The device consists of two semirigid polyurethane
domes that are placed over each breast and seal at its
periphery with silicone gel-filled donut bladders (Fig.
24.28). A small pump maintains 20 mmHg of negative
pressure inside the domes, which are worn continu­
ously for 10 h a day for a minimum of 10 weeks, if the
device is used alone. One cup size increase can reason­
ably be expected, with the increase in size being main­
tained over time. The limited permanent size increase
and compliance difficulties temper its more widespread
use.
On the other hand, the device causes a temporary
increase in the size of the breasts, past what can be
expected to be maintained, due to swelling. This is
effectively an expansion of the scaffold of soft tissues
that comprise the breast, and is thought to have a salu­
tary effect on fat graft survival. When used before
autologous fat grafting for breast augmentation or
reconstruction (for this indication, only 3–4 weeks is
needed), it is thought to increase both the volume pos­
sible to graft and graft survival percentage. Studies are
Fig. 24.28  BRAVA device. (©BRAVA LLC, with permission.)
Hints and tips
• Use fat grafting on reconstructive contour deformities early
in your experience, preferably while already performing a
different procedure requiring general anesthesia.
• Basic instrumentation and techniques work well, are
inexpensive, and provide an easy way to get started.
• Overgraft less if fat is centrifuged during processing.
• Appropriate patient expectations are important. Impressive
results are possible but may require more than one session
of grafting.

476
SECTION II
CHAPTER 24 • Fat grafting to the breast
performed by poorly-trained practitioners.58,59 Even
when properly performed, however, there are certain
events which occur with enough regularity to be high­
lighted in the informed consent.
Mammographic abnormalities60–65 are relevant in patients
who have not had a mastectomy. After breast augmenta­
tion with fat grafting, the most commonly seen abnor­
malities are calcifications. These come in the form of
either coarse or fine microcalcifications and are thought
to be the result of areas of fat necrosis. They can usually
be readily distinguished from suspicious patterns by an
experienced radiographer; those that cannot should be
biopsied. Mammography can also detect oil cysts, which
may also be palpable on exam. Preoperative mammog­
raphy is recommended prior to autologous fat grafting
to the breast for augmentation for comparison purposes
in the event of any abnormality developing later. With
respect to interference with breast cancer detection, the
ASPS Fat Graft Task Force concluded, in its 2009 report:
“Based on a limited number of studies with few cases,
there appears to be no interference with breast cancer
detection; however, more studies are needed to confirm
these preliminary findings”.8
Liponecrotic cysts or oil cysts, occur in areas of walled-
off liquefaction necrosis. These can be multiple and
small or, on occasion, quite large. A cyst is effectively
treated by surgical excision. Their development probably
correlates with improper technique of inadequately
distributing the grafted fat – or attempting to graft too
much fat into a particular area.66,67 In his experience of
880 patients, Delay reports that approximately 15% of
his patients developed oil cysts on mammogram.10
Infection may occur after fat injection and typically
presents as painful swelling with erythema, warmth,
and sometimes fever. The outcome of infection is vari­
able, with reports of both loss of the grafted fat4 and no
effect on the results,10 but abscess formation with sepsis
has been reported in the literature.68
Persistent swelling. If swelling persists for over 2
months, it may signal the development of fat necrosis
or a liponecrotic cyst. The index of suspicion for either
of these complications is higher with higher volumes of
grafted fat. Watchful waiting is the best course of action,
since early imaging studies can be expected to show
nonspecific inflammation. If a cyst is suspected, it may
be detected with ultrasound.
Neoplasia risk is perhaps theoretical. The same quali­
ties of ADSCs that make them regenerative (such as
angiogenesis) might be shown in the future to increase
the risk of breast cancer for the patient. In a literature
review encompassing 283 patients undergoing fat graft­
ing to the breast for cosmetic and reconstructive pur­
poses, the ASPS Fat Graft Task Force report identified
Outcomes, prognosis,
and complications
Patient outcomes
Outcomes are illustrated in Figs. 24.1–24.11 for each of
the indications listed above.
Graft survival
Early practitioners, using free en bloc fat grafts, noted
substantial resorption of their free fat grafts and tried
various measures to prevent this, such as transplanting
fascia with the fat54 or cutting the graft into several
pieces.55 Early reports of graft survival ranged from 25%
to 50%, so early practitioners began to advocate the
practice of overgrafting.56,57 The modern method of
transplanting fat by injecting it has not altered this
recommendation, though there seems to be no consen­
sus as to how much overgrafting should be done.
Graft survival percentage varies with the methods
used to aspirate, prepare, and transplant the fat. It also
varies with respect to the destination of the graft, with
fat grafted into well-vascularized muscle surviving at a
higher rate than fat grafted into a relatively oxygen-
poor environment such as a depressed breast contour
from fat necrosis of a TRAM flap. Some recent authors
define the amount of overgrafting that should be per­
formed in the breast; for example, Emmanuel Delay,
grafting into reconstructed breasts, writes that he plans
on 30% resorption rate and advocates overgrafting by
40%.10 Kanchwala et al.9 recommend overgrafting by no
more than 10% to avoid fat necrosis and subsequent
calcifications. These authors’ experience supports over­
grafting amounts in these approximate ranges for
contour deformities. Preparation method matters; fat
processed with washing and straining needs more
overgrafting than centrifuged fat. Until more specific
research is performed on the subject, there is no substi­
tute from the personal experience of beginning conser­
vatively. It is recommended that judicious overgrafting
should be performed early in a surgeon’s experience
until one acquires a “feel” for how much overgrafting
should be performed based on the technique being used
and the quality of the recipient bed. Reconstructive
contour deformities in non-radiated fields lend them­
selves well to this early experience.
Complications
There are risks in any surgical procedure, and autolo­
gous fat grafting to the female breast is no exception.
Major complications are rare, and the ones reported in
the literature are often the result of procedures being

477
Conclusions
realistically grafted into each breast at one time to expect
reasonably good take of the graft. This limit varies
patient-to-patient and is probably higher in patients
who have undergone external pre-expansion.
Conclusions
Autologous fat grafting to the female breast is here to
stay and will continue to evolve as practitioners con­
tinue to refine the technique and discover new applica­
tions of the grafted adipocyte. Established indications
include contour deformities in breasts reconstructed by
a variety of methods. No longer are practitioners debat­
ing whether fat grafting works; what is being discussed
is the appropriate role of the more controversial indica­
tions, such as breast augmentation or total breast
reconstruction. The next decade is likely to see more
established protocols for these indications, as well as
further progress defining the potential therapeutic
power of ADSCs.
two cases of breast cancer.8 One was in an area of the
breast that was not grafted, and one was in an area
potentially grafted, but there was no delay in diagnosis
or treatment.5 Only further study will prove or disprove
any correlation between fat grafting and the develop­
ment of subsequent breast cancer; until that time, the
risk of neoplasia must be classified as unknown.
Secondary procedures
Fat grafting may need to be repeated, and it is often
necessary to do so (Fig. 24.29). A recent retrospective
review of 110 patients who underwent fat grafting for
contour deformities in reconstructed breasts found that
55% of the patients required more than one session to
satisfactorily correct the deformities.9 More sessions can
be expected in hostile environments such as irradiated
fields.31 Additional sessions may also be required for
breast augmentation, depending on the goals of the
patient, since there is a limit as to how much fat can be
Fig. 24.29  This 49-year-old patient underwent multiple sessions of autologous fat grafting after bilateral nipple-sparing mastectomies with tissue expander reconstructions.
(A) At 9 months after bilateral immediate breast reconstruction with tissue expanders. (B) The same patient 3 months after bilateral exchange of tissue expanders for 560 cc
gel implants and fat grafting to superior poles; 80 cc right and 40 cc left. (C) A 4 months postoperative view after bilateral exchange to 650 cc gel implants and 75 cc fat
grafting to the superomedial and inferomedial quadrants bilaterally. (D) At 9 months after bilateral breast scar revisions and fat grafting of 35 cc to each upper pole.
A
B
C
D

478
SECTION II
CHAPTER 24 • Fat grafting to the breast
4. Spear S, Wilson H, Lockwood M. Fat injection to correct contour
deformities in the reconstructed breast. Plast Reconstr Surg.
2005;116:1300–1305. This article helped initiate the recent resurgence in
interest in fat grafting to the breast and remains a good overview of
real-world results and typical complications.
5. Coleman SR, Saboeiro AP. Fat grafting to the breast revisited: safety
and efficacy. Plast Reconstr Surg. 2007;119:775–785. This comprehensive
review with impressive results furthered the call to legitimize fat grafting
to the breast and reverse the ASPS’s 1987 condemnation of the practice.
6. Missana MD, Laurent I, Barreau L, et al. Autologous fat transfer in
reconstructive breast surgery: indications, technique and results.
Eur J Surg Oncol. 2007;33:685–690.
8. Gutowski K. Current applications and safety of autologous fat
grafts: a report of the ASPS Fat Graft Task Force. Plast Reconstr Surg.
2009;124:272–280. The ASPS Fat Graft Task Force reports the results of a
critical appraisal of the current literature on indications for autologous fat
grafting and the risks associated with it.
9. Kanchwala SK, Glatt BS, Conant EF, et al. Autologous fat grafting
to the reconstructed breast: the management of acquired contour
deformities. Plast Reconstr Surg. 2009;124:410–418.
10. Delay E, Garson S, Tousson G, et al. Fat injection to the breast:
technique, results, and indications based on 880 procedures over 10
years. Aesthetic Surg J. 2009;29:360–376.
12. Mizuno M, Hyakusoku H. Fat grafting to the breast and adipose-
derived stem cells: recent scientific consensus and controversy.
Aesthetic Surg J. 2010;30:381–387. An accessible current review article
covering complications and ADSCs.
31. Rigotti G, Marchi A, Galie M, et al. Clinical treatment of
radiotherapy tissue damage by lipoaspirate transplant: a healing
process mediated by adipose-derived adult stem cells. Plast
Reconstr Surg. 2007;119:1409–1424. A landmark article reporting
on the efficacy of ADSCs at reversing radiation damage to the breast.
35. Serra-Renom JM, Del Olmo JM, Serra-Mestre JM. Fat grafting in
post mastectomy breast reconstruction with expanders and
prosthesis in patients who have received radiotherapy:
formation of new subcutaneous tissue. Plast Reconstr Surg.
2010;125:12–18.
58. Hyakusoku H, Ogawa R, Ono S, et al. Complications after
autologous fat injection to the breast. Plast Reconstr Surg.
2009;123:360–370.
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478.e1
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SECTION II • Reconstructive Breast Surgery
25 
Radiation therapy considerations in the
setting of breast reconstruction
Elizabeth Stirling Craig and Steven Kronowitz
SYNOPSIS
■ Radiation therapy is a vital component of breast cancer multimodality
treatment with proven benefits in decreasing local recurrence and
improving long-term survival in select breast cancer patient
populations.
■ The negative effects of radiation therapy on short- and long-term
complication rates, aesthetic outcomes, and patient satisfaction pose
challenges for successful breast reconstruction in these patients.
■ Irradiated skin and soft tissue are susceptible to delayed wound
healing and often confer poor cosmetic outcomes and reconstructive
failures.
■ Radiation therapy protocols and specific strategies for breast cancer
must be understood and considered in the treatment planning of
patients who will undergo breast reconstruction.
■ Breast reconstructive procedures, strategies, and techniques in the
setting of radiation therapy must be fully considered in breast cancer
patients to optimize outcomes.
Introduction
Despite the increasing incidence of breast cancer in the
US over the past decade, early detection and more effec­
tive treatments have led to a steady decline in breast
cancer mortality. Radiation therapy is a vital component
of breast cancer multimodality treatment and has shown
benefits in decreasing local recurrence and improving
long-term survival in select breast cancer patient popu­
lations. However, the negative effects of radiation
therapy on short- and long-term complication rates,
aesthetic outcomes, and patient satisfaction all pose
significant challenges for reconstructive surgeons in
planning and performing breast reconstruction in
patients who have had or may need radiation therapy.
In this setting, understanding the specific radiation
treatment protocols and strategies for breast cancer is
paramount to managing the disease, minimizing com­
plications, and maximizing aesthetic outcomes. Simi­
larly, understanding the effects of radiation on specific
breast reconstruction techniques, situations, and timing
is crucial to planning, educating patients, and achieving
the best result. This chapter discusses these important
considerations for planning and delivering radiation
therapy and for performing reconstructive procedures
in patients with breast cancer.
Radiation therapy in breast
cancer patients
The 2014 National Comprehensive Cancer Network
(NCCN) Guidelines recommend post-mastectomy chest
wall and nodal radiation for women at high risk for
local recurrence of breast cancer, in particular those with
close tumor margins (<1 mm), with T3 or T4 tumors, or
with four or more positive axillary lymph nodes. Until
recently, women with 1–3 positive nodes received vari­
able recommendations for adjuvant radiation therapy.
The NCIC-CTG MA.20 trial enrolled 1832 women (85%
of which had 1–3 positive nodes) who underwent breast
conservation, adjuvant chemotherapy, or endocrine
therapy, and had received whole breast irradiation. The
participants were then randomized to receive whole
breast radiation therapy alone or in combination with
regional nodal radiation therapy. There was significant
improvement in disease-free interval and overall sur­
vival for patients who received the additional nodal
radiation therapy. Although these data were derived
from women who underwent breast-conserving surgery,
  Access video lecture content for this chapter online at expertconsult.com

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CHAPTER 25 • Radiation therapy considerations in the setting of breast reconstruction
modulates the intensity of multiple beams by using
dynamic multileaf collimators that shield the various
beams and allow for 3D conformal therapy. This tech­
nique delivers high precision radiation therapy and
reduces treatment time.2
Nodal irradiation requires additional planning and is
included based on previous stated NCCN recommenda­
tions. The lower axilla nodes (level I) are incidentally
covered during standard breast and chest wall irradia­
tion; however, levels II, III, and the internal mammary
(IM) nodes are generally not included.3 Patients with T3
or greater primary disease or those who had four or
more positive lymph nodes and underwent axillary
dissection of level I or II are at highest risk of disease
recurrence in the level III (supraclavicular) area and
should therefore receive targeted supraclavicular irra­
diation.3 However, the apex of the lung receives a full
dose of radiation when treating the supraclavicular
area, and this should be taken into consideration with
previous treatment plans to avoid a double dose of
radiation.
Radiation therapy of the IM nodes is widely debated
in the literature. Despite the Danish and British Colum­
bia trials illustrating improved overall survival when
treating the IM nodes of patients with 1–3 positive
nodes, many radiation oncologists believe that IM node
failures are rare and that the benefit of treatment is not
warranted.3 Treatment of IM nodes can be accomplished
with either extra-wide tangent arrangements or use of
an additional electron field, but both bear significant
risks.2 The concern with using extra-wide tangent tech­
niques is the large radiation dose delivered to the
underlying lung. Using a separate electron beam radia­
tion for treating the IM nodes is an alternative technique
to avoid extra-wide tangents, but does require a flat
surface, has a limited depth of penetration, and can,
therefore, be problematic in obtaining the necessary
dose in cases of immediate breast reconstruction.
Achieving an adequate radiation dose with the electron
beam to the IM nodes while avoiding critical structures,
such as those of the underlying breast reconstruction
(tissue expander, implant, or flap), lung parenchyma,
or the contralateral breast, can be particularly
challenging.2
An additional radiation bolus dose of 10–16 Gy is
often delivered to the tumor bed, scar, or the entire chest
wall in select cases such as in patients with inflamma­
tory breast cancer or those at highest risk of local recur­
rence (patients age <50 years, with positive nodes, with
lymphovascular invasion, or with close tumor margins).
Bolus doses can be delivered with photons, electrons, or
less commonly, with brachytherapy. Controversy exists
as to the optimal method to deliver a radiation boost.
its results are being extrapolated to include benefits for
post-mastectomy patients. As a result, the new NCCN
recommendations are for nodal irradiation for post-
mastectomy women with 1–3 positive lymph nodes.
Breast conservation patients who undergo segmental
mastectomy receive adjuvant whole breast irradiation
as part of their standard treatment unless they are
pregnant, received previous chest wall or breast radia­
tion, or are older than 70 years of age and have hormone
receptor-positive disease. Breast cancer patients who
elect not to undergo adjuvant whole breast radiation
have a three times higher risk of local recurrence and
have a relative risk of death of 1.086, or an 8.6% increased
chance of death when compared with those patients
who do undergo adjuvant radiation therapy.
Locally advanced breast cancer is a collective term
used to describe clinical stage III breast cancers, which
represent either neglected primary tumors that slowly
progress in unscreened patients or aggressive, high-
grade tumors that rapidly proliferate between screening
intervals. Understanding tumor biology and molecular
subtype is paramount to providing targeted, effective
therapy for all breast cancers, but in particular for locally
advanced disease. Inflammatory breast cancer is the
most aggressive subgroup of locally advanced breast
cancers, with an elevated risk of local recurrence and
distant metastasis. This patient population benefits
most from multimodality treatment including neoadju­
vant chemotherapy, surgery, radiation therapy, and
endocrine therapy where indicated. Neoadjuvant che­
motherapy is often necessary to convert these cancers
into resectable tumors or to permit a breast-conserving
approach, provided that the response to therapy is
favorable.1 In such cases, recommendations for adjuvant
treatment, in particular radiation therapy, are made
based on the tumor characteristics before chemotherapy,
irrespective of tumor response. The majority, if not all,
patients with locally advanced breast cancer are advised
to receive adjuvant radiation to both the chest wall and
nodal basins.
Radiation therapy during whole breast radiation is
targeted towards the breast, subcutaneous tissue, chest
wall, scar, and often drain sites. Computed tomography-
based treatment planning assists in delivering the tar­
geted dose of 45–50 Gy while minimizing radiation to
the heart and lungs. Classic radiation techniques include
using medial and lateral beams angled at tangents to
reduce exposure to surrounding structures. Wedges,
shielding blocks, and compensators were previously
used to modify the intensity of the beams and reduce
hot and cold spots; however, today these protective
techniques have largely been replaced with the use of
intensity-modulated radiation therapy (IMRT). IMRT

481
Radiation therapy in breast cancer patients
Bowel Project (NSABP) B-39 is a prospectively, random­
ized phase III trial comparing APBI with traditional
whole breast radiation. Until these results are available,
the American Society of Therapeutic Radiology and
Oncology (ASTRO) has published guidelines for APBI
patient selection (Table 25.1).4
Hypofractionated whole breast radiation entails the
delivery of higher daily fraction doses over a shorter
period of time to reach total doses bioequivalent to
traditional whole breast radiotherapy. Until recently,
conventional radiotherapy was delivered in small daily
fractions to take advantage of the differential in sensitiv­
ity to fraction size between tumor cells and normal
tissue. However, reports recently found conflicting
evidence showing similar sensitivities to dose fraction
size between normal tissue and tumor cells, thus negat­
ing the need for prolonged treatment that delivers small
daily fractions. With the increasing demand for shorter
therapy regimens, trials comparing hypofractionated
regimens with traditional whole breast radiation have
emerged, specifically in regard to local recurrence
control and long-term toxicity. The FAST trial is a ran­
domized trial aimed to compare conventional radiation
with two hypofractionated regimens (30 Gy in five
Boost treatment is often associated with extensive fibro­
sis and, therefore, with compromised cosmesis.2
In an effort to minimize dose-related fibrosis and
compromised cosmesis, hypofractionation and acceler­
ated whole breast radiation have recently emerged as
newer strategies for delivering radiation therapy.
Accelerated partial breast irradiation (APBI) involves
treating the lumpectomy cavity and the surrounding
2 cm margin with larger daily fractions to achieve bio­
logically equivalent total dosages. ABPI offers the
advantages of sparing the remaining breast tissue and
delivering an accelerated daily dose that truncates the
necessary treatment time period. There is a theoretical
concern that when using this technique, an occult
foci of cancer in a remote location from the tumor
cavity could be left untreated and thus increase the risk
of local recurrence; however, fewer than 4% of recur­
rences are found distant to the tumor cavity.4 Several
techniques for delivering APBI are described: interstitial
brachytherapy, balloon brachytherapy, 3D conformal
radiation therapy, and intraoperative radiotherapy, all
of which currently remain experimental with limited
phase III data. The Radiation Therapy Oncology Group
(RTOG)0413/National Surgical Adjuvant Breast and
Table 25.1  ASTRO guidelines for accelerated partial breast irradiation (APBI)
Suitable
Cautionary
Unsuitable
Age (years)
≥60
50–59
<50
BRCA 1/2 mutation
Not present
–
Present
Tumor size (cm)
≤2
2.1–3
>3
T-stage
T1
T0 or T2
T3–4
Margins
Negative by at least 2 mm
Close (<2 mm)
Positive
Grade
Any
–
–
LVSI
No
Limited/focal
Extensive
ER status
Positive
Negative
–
Multicentricity
Unicentric only
–
Present
Multifocality
Unifocal
Clinically unifocal with
total size 2.1–3 cm
Clinically multifocal or
microscopically multifocal >3 cm
Histology
Invasive ductal, mucinous,
tubular, or colloid
Invasive lobular
–
Pure DCIS
Not allowed
≤3 cm
If >3 cm in size
Extensive intraductal component
Not allowed
≤3 cm
If >3 cm in size
Associated LCIS
Allowed
–
–
N-stage
pN0 (i−, i+)
–
pN1, pN2, pN3
Nodal surgery
Sentinel lymph node biopsy or
axillary lymph node dissection
–
None performed
Neoadjuvant therapy
Not allowed
–
If used
BRCA, breast cancer; DCIS, ductal carcinoma in situ; ER, estrogen receptor; LCIS, lobular carcinoma in situ; LVSI, lymphovascular space involvement.
(Reproduced with permission from Moran MS, Rowe BP. Accelerated Partial Breast Irradiation and Hypofractionated Whole Breast Radiation. Oncology & Hematology
Review (US). 2011;07(01):31.)

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CHAPTER 25 • Radiation therapy considerations in the setting of breast reconstruction
the population of the US becomes increasingly obese,
extensive lumpectomy defects can be reasonably
repaired with oncoplastic reductions, provided that
there is remaining redundant breast tissue. This affords
advantages to many patients who wish to preserve their
breast and undergo a breast reduction in cases of mac­
romastia. In addition to the cosmetic advantages,
oncoplastic reduction in patients with macromastia
facilitates the delivery of whole breast radiation without
compromising the long-term oncologic risk.5 In addi­
tion, recent studies have shown that obese patients who
undergo breast conservation with oncoplastic reduc­
tions have fewer postoperative complications than do
patients who undergo tissue expander reconstruction
and autologous reconstructions.5 As a result, breast
conservation is increasing, and more extensive local
resections are being classified in the category of partial
mastectomy.6
Incorporating reparative techniques before adjuvant
radiation therapy represents the ideal scenario in breast
cancer patients; however, there are several important
considerations in this patient population. A manage­
ment algorithm published and described by Kronowitz
et al. provides a useful guideline in the decision-making
process for breast conservation patients (Fig. 25.1).6
For patients who present for breast reconstruc­
tion after partial mastectomy and adjuvant radiation
therapy, the reconstructive method depends largely
on the extent of the deformity, its location on the
breast mound, and the remaining size of the breast.
The advantage for these patients is that the recon­
structive method is not reliant on margin status or
on the risk of repeat excision, as these patients have
already obtained negative margins. However, the
tissues have been subjected to radiation (either partial
or whole breast) and have pre-existing incisions from
the excision, both of which interfere with the pli­
ability of the tissues, wound healing, and potentially
with the design of the dermoglandular pedicle and/
or skin resection pattern. In addition, repair of partial
mastectomy defects following radiation therapy with
local tissue rearrangement or dermoglandular pedicles
carries a 50% risk of complications. However, patients
with smaller (size A or B cup) breasts are not candi­
dates for oncoplastic reduction and benefit most from
recruitment of regional non-irradiated soft tissue to
fill in the defect with either a thoracodorsal artery
perforator flap or latissimus dorsi flap.6 While these
flaps offer additional blood supply and improved
wound healing, the cosmetic outcomes of these more
extensive procedures tend to be inferior compared
with immediate reconstruction that avoids retained
skin paddles and a patchwork pattern with contrasting
fractions and 28.5 Gy in five fractions). Until sufficient
phase III data are available, ASTRO has published
guidelines for patient selection for hypofractionation
radiation therapy (Table 25.2).
Despite the efforts to improve the precision of radia­
tion treatment, irradiated skin and soft tissue remain
highly susceptible to delayed wound healing, have
decreased wound-break strength, and constitute the
number one reason for poor aesthetic outcomes and
reconstructive failures.2 Radiation has acute and chronic
side effects that are a result of the total dose and dose
per fraction delivered. Acute toxicity is reversible
damage that occurs during the daily radiation treatment
as a result of DNA damage and manifests as skin ery­
thema and desquamation. As a result of the DNA
damage, free radicals are released that interfere with the
normal tissues’ ability to repair itself. Transforming
growth factor-β (TGF-β) is then induced by the inflam­
matory cascade, resulting in long-term effects such as
fibroblast differentiation, modulation of the extra-cellu­
lar matrix, and platelet aggregation. As platelets aggre­
gate, they release more TGF-β, in turn setting off a
self-perpetuating release of more TGF-β, thus contribut­
ing to the chronic fibroblastic state characteristic of the
late effects of radiation injury.2 Physiologically, the
optimal time to operate on irradiated skin is the window
between the time that acute reaction has resolved and
before the development of extensive fibrosis.
Breast reconstruction and planning in
the setting of radiation therapy
Repair of partial mastectomy defects
The evolution of oncoplastic techniques has dramati­
cally changed the aesthetic results in patients undergo­
ing partial mastectomy and whole breast radiation. As
Table 25.2  Criteria for hypofractionationa
1.
Age 50 years or older
2.
Pathologic stage T1–2N0 treated with breast-conserving
surgery
3.
Not treated with systemic chemotherapy
4.
Within the breast along the central axis, minimum dose
no less than 93% and maximum dose no greater
than 107% of the prescription dose (±7%) (as
calculated with 2D treatment planning without
heterogeneity corrections)
aPatients should also be otherwise suitable for breast-conserving therapy (not
pregnant, no history of certain collagen-vascular diseases, no prior radiotherapy
to the breast, no multicentric disease).
(Reproduced with permission from Moran MS, Rowe BP. Accelerated partial
breast irradiation and hypofractionated whole breast radiation. Oncology &
Hematology Review (US). 2011;07(01):31.)

483
Breast reconstruction and planning in the setting of radiation therapy
there are several important considerations. The most
important variable is tumor margin status. While it may
seem intuitive to delay reconstruction until negative
margins are confirmed, most patients are at low risk for
positive margins (<5%), and delaying reconstruction
would necessitate a potentially avoidable additional
operation.6 Patients who present with multifocal disease,
however, do benefit from delayed reconstruction owing
color compared with the surrounding irradiated breast
skin.6 Patients who present with significant deformi­
ties that would necessitate a retained skin paddle
may prefer instead to undergo completion mastec­
tomy and total breast reconstruction as opposed to a
partial repair.
Patients who present prior to partial mastectomy
represent the ideal scenario for reconstruction; however,
Fig. 25.1  Algorithm for oncoplastic reduction management based on XRT. (Redrawn with permission from Kronowitz SJ, Kuerer HM, Buchholz TA, Valero V, Hunt KK. A
management algorithm and practical oncoplastic surgical techniques for repairing partial mastectomy defects. Plast Reconstr Surg. Dec 2008;122(6):1631–1647.)
Patient presents after
partial mastectomy and
partial breast XRT
Patient presents after
partial mastectomy
before XRT
Total mastectomy with
immediate breast
reconstruction
Local tissue
rearrangement “breast
remodelling”
Breast reduction
technique†
“7 zone designations”
Latissimus dorsi or
thoracodorsal artery
perforator flap
Total mastectomy with
immediate or delayed
immediate breast
reconstruction
Extensive skin resection
located outside of skin
resection pattern
Breast skin resection
located within wise or
vertical pattern
Patient presents before
partial mastectomy
and XRT
Patient presents after
partial mastectomy and
whole breast XRT
Delayed reconstruction
before XRT
Extent of breast
skin resection
Brassiere
cup size
A- or
B- cup
Large
tumor size
Small
tumor size
No breast
ptosis
Breast
ptosis
D- cup
or larger
C- cup
? Intraoperative
tumor margin
Avoid XRT if
undergoes mastectomy
Requires XRT even
with mastectomy*
Minimal or no
breast
skin resection
Delayed reconstruction
after XRT
Contralateral symmetry
procedure only**
Immediate reconstruction
before XRT
Multifocal disease
Localised disease
*Scenario of patient who undergoes neoadjuvant chemotherapy with reduction of tumor size and becomes amenable to
breast-conserving therapy instead of mastectomy.
**Prior to radiation therapy, only perform the breast reduction on the ipsilateral involved breast, and then 6 months or more
later, use the same pedicle design as used to repair the ipsilateral breast to perform the breast reduction for symmetry on
the contralateral breast.
† Most applicable to patients with partial defects located in zone 6 or 7 of the breast.
When performing a contralateral breast reduction for symmetry procedure only, allow for adequate time for the involved
breast to achieve a steady state with regard to volume before performing a procedure.
XRT = radiation therapy

484
SECTION II
CHAPTER 25 • Radiation therapy considerations in the setting of breast reconstruction
respectively. Kronowitz et al. formulated zone designa­
tions and corresponding dermoglandular pedicles for
reconstruction of partial mastectomy defects (Fig.
25.2).6 Local tissue rearrangement is often used for
reconstruction in moderate-sized breasts with minimal
ptosis or small resultant defects and involves remodel­
ing of the breast without transposing the nipple or
reducing the breast size. Depending on the extent and
location of the defect, the remaining breast parenchyma
is mobilized from the surrounding area into the defect
location to minimize the deformity. The mastectomy
skin is often degloved from the underlying breast
tissue, which remains attached to the underlying
chest wall in order to maintain perfusion to the
to their elevated risk of positive margins and potential
need for further excision.
Immediate reconstruction techniques for partial
mastectomy defects are similar to techniques used in
delayed partial breast reconstruction, but the former
offer superior cosmetic results that maintain the
color, texture, and wound healing capabilities of the
non-radiated breast. The type of reconstruction will
vary depending on the location of the defect, size of
remaining breast, and anticipation of any resected
breast skin. In general, large breasts with a moderate
tumor size to breast:volume ratio are reconstructed
with reduction pattern techniques that use dermoglan­
dular pedicles to lift and reduce the nipple and breast,
Fig. 25.2  Zones of defect and dermoglandular pedicles. (Redrawn with permission from Kronowitz SJ, Kuerer HM, Buchholz TA, Valero V, Hunt KK. A management algorithm
and practical oncoplastic surgical techniques for repairing partial mastectomy defects. Plast Reconstr Surg. Dec 2008;122(6):1631–1647.)
Patient presents after
partial mastectomy and
partial breast XRT
Patient presents after
partial mastectomy
before XRT
Breast reduction
technique*
“7 zone designations”
Breast skin resection
located within wise or
vertical pattern
Zone 1
-Inferomedial pedicle
-Wise skin pattern
Zone 2
-Inferolateral pedicle
-Wise skin pattern
Zone 3
-Inferomedial pedicle
-Wise skin pattern
Zone 4
-Amputative
-Inferomediolateral pedicle
Zone 5
-Superior pedicle
-Vertical skin pattern
Zone 6
-Inferomediolateral pedicle
-Wise skin pattern
Zone 7
-Inferomedial pedicle
-Wise skin pattern
Patient presents before
partial mastectomy
and XRT
Delayed reconstruction
before XRT
Extent of breast
skin resection
Brassiere
cup size
Small
tumor size
Breast
ptosis
D- cup
or larger
C- cup
? Intraoperative
tumor margin
Minimal or no
breast
skin resection
Immediate reconstruction
before XRT
Multifocal disease
Localised disease
*Prior to radiation therapy, only perform the breast reduction on the ipsilateral involved breast, and then 6 months later, use the same
pedicle design as used to repair the ipsilateral breast to perform the breast reduction for symmetry on the contralateral breast.
XRT = radiation therapy

485
Breast reconstruction and planning in the setting of radiation therapy
needing adjuvant radiation therapy. Radiation therapy
is the single most significant predictor of poor aesthetic
outcomes and of increased risk of complications such
as capsule contracture, fat necrosis, infection, seroma,
and reconstructive failure. As discussed previously,
tumor size and involvement of the axillary nodes
together determine the risk of loco-regional recurrence
and the need for adjuvant radiation therapy. Pre-
mastectomy imaging can often be used to estimate
tumor size; however, sentinel node biopsy is necessary
to assess whether there is nodal involvement. Recently,
consideration has been given to performing sentinel
lymph node biopsies prior to mastectomy – so called
“staged sentinel node biopsy” – in patients with
tumors staged T2 or greater with unknown status of
nodal involvement. Confirmation of nodal involve­
ment or lack thereof may offer the opportunity for
immediate reconstruction. However, the benefits of
staged sentinel node biopsy need to be weighed
against the risks of additional surgery and associated
potential complications, increased cost, and patient
inconvenience.8
An alternative to “staged sentinel lymph node biopsy”
is “delayed-immediate” reconstruction, pioneered by
Steven Kronowitz.9 In this approach, patients who may
need to receive adjuvant radiation therapy undergo
immediate placement of a tissue expander at the time
of mastectomy. Use of the tissue expander helps
preserve the mastectomy skin and breast footprint
for future definitive reconstruction and serves as a
place-holder until the final pathology report is received.
If the final pathology report indicates that adjuvant
radiation therapy is needed, definitive reconstruction
with either an implant or autologous reconstruction
can be planned. If the IM nodes will be included in the
radiation treatment protocol, the expander is often
deflated prior to irradiation to allow for adequate
dosimetry to the medial portion of the breast and chest
wall. However, not all institutions treat the IM nodes
and, therefore, deflation of the expander prior to irradia­
tion may not be necessary. Tissue expanders with
internal metal ports have not been shown to interfere
with radiation treatment plans and are suitable for
“delayed-immediate” reconstruction. Following com­
pletion of radiation therapy, expanders should be
re-inflated rapidly to preserve the previously expanded
breast envelope. Definitive reconstruction with an
implant or autologous tissue is then planned once the
irradiated skin has had sufficient time to heal and
recover. The “delayed-immediate” approach offers the
aesthetic advantage of immediate reconstruction
without compromising the ability to perform adjuvant
treatment.9 However, irradiated tissue expanders do
parenchyma. The skin envelope is then redraped over
the recontoured breast mound.6 Local tissue rearrange­
ment can be limiting, in particular in cases of minimal
remaining breast tissue. Patients should be advised
regarding its limitations and consideration given to
proceeding with a completion mastectomy and total
breast reconstruction.
As part of the multidisciplinary approach, patients
who elect to undergo breast conservation will be receiv­
ing adjuvant radiation treatment. There is no clinical
evidence that suggests immediate repair of partial
mastectomy defects interferes with adjuvant treatments;
however, it is important that radiation oncology consid­
erations are taken into account when deciding on the
best approach for reconstruction. Whole breast radia­
tion therapy is administered to the entire breast, with
an additional boost given to the tumor bed cavity.
Patients with large breasts can pose challenges when
using whole breast radiation, which has a higher pro­
pensity for dose-inhomogeneity when compared with
moderate breast patients.7 These patients, therefore,
benefit most from immediate reconstruction of partial
mastectomy defects using reduction type techniques to
reduce the overall size of the breast and improve dose
homogeneity.7 In these cases of immediate repair, the
tumor bed needs to be appropriately marked with
radio-opaque clips, as the tumor bed can be displaced
during the reduction and thus can be hard to localize
for adjuvant radiation treatment. On the other hand,
patients for whom partial breast irradiation is planned
should not be considered for immediate reconstruction,
as this procedure interferes with adjuvant treatment.
The advent of intraoperative partial breast radiation
therapy, however, may make immediate repair a more
feasible option in these patients.6
Reconstruction after total mastectomy
Following mastectomy, breast reconstruction involving
the entire breast and/or nipple often requires multiple
procedures. The optimal timing and technique of these
procedures in patients requiring post-mastectomy radia­
tion therapy are controversial and present many
challenges. A thorough understanding of the adjuvant
treatment plan is essential prior to deciding the best
approach for reconstruction, particularly for patients
needing adjuvant radiation.
Immediate breast reconstruction has a proven bene­
ficial impact on psychosocial well-being, a reduced
overall cost, and better aesthetic results compared with
delayed reconstructions. The main factor in deciding
whether a breast cancer patient is a candidate for
immediate reconstruction is the patient’s risk of

486
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CHAPTER 25 • Radiation therapy considerations in the setting of breast reconstruction
however, this strategy is also associated with high rates
of revision, capsule contracture, and implant loss.11
In addition, patients who have received neoadjuvant
chemotherapy and who will receive adjuvant radiation
therapy 4–6 weeks following mastectomy pose a logisti­
cal challenge: performing a two-stage reconstruction in
such a narrow time window. The small and select group
of patients who are candidates for direct to implant
(DTI) reconstruction at the time of mastectomy would
be a more feasible population to undergoing adjuvant
radiation therapy. However, we know from previous
studies that DTI reconstruction patients are inherently
at higher risk for wound healing problems and higher
revision rates than are patients undergoing standard
two-stage reconstructions. Thus, the use of adjuvant
radiation therapy in DTI reconstruction patients would
potentially magnify the revision rate in this high-risk
radiation implant population. Autologous fat grafting
has recently been implemented as a means to improve
outcomes of irradiated prosthetic breast reconstruc­
tions. In a case–control series of patients with irradi­
ated implants, Panettiere et al. compared outcomes of
61 patients who underwent fat grafting to outcomes of
41 patients who did not undergo fat grafting (control
group).12 Those patients who underwent fat grafting
were found to have a significantly better aesthetic score
than did control group patients.12 Despite the aesthetic
advantages of fat grafting in mastectomy patients, the
theoretical risk of injecting stem cells into a breast with
previous cancer remains. The safety of fat grafting in
breast cancer patients is controversial, and patients
should be educated about the potential risk of this
strategy and the paucity of available oncologic data on
this topic.
The gold standard for breast reconstruction in patients
needing adjuvant radiation therapy is delayed autolo­
gous reconstruction. Optional donor sites include but
are not limited to the latissimus flap, deep inferior epi­
gastric artery perforator (DIEP) flap, profunda artery
perforator (PAP) flap, transverse upper gracilis (TUG)
flap, superior and inferior gluteal artery perforator
(SGAP/IGAP) flaps, and lumbar artery perforator
(LAP) flaps. Historically, autologous reconstruction has
been performed after radiation therapy because of
concerns for possible radiation-induced flap thrombosis
and fat necrosis. In addition, immediate autologous
reconstruction can theoretically interfere with radiation
treatment planning in ways similar to the interference
by inflated tissue expanders, but without the flexibility
to “deflate” the autologous flap. However, recent data
from Crisera and colleagues found immediate free flap
breast reconstruction to be safe in oncologic settings.13
Also, recent studies comparing irradiated with
have a higher rate of complications than non-irradiated
expanders, and patients should be counseled appropri­
ately regarding this associated risk and the need to have
easy access to medical care in case of an emergency.
Immediate definitive reconstruction with placement
of an implant or autologous tissue in patients in whom
adjuvant radiotherapy is indicated has been shown to
result in poor aesthetic outcomes and, in some cases, to
interfere with the delivery of radiation. Alterations in
radiation treatment protocols have resulted in delivery
of either higher doses to lung parenchyma and the heart
or suboptimal doses to the targeted area.3 The clinical
significant of these findings, however, is unknown.
Studies evaluating outcomes of two-stage breast recon­
struction with tissue expanders consistently reveal high
rates of wound healing complications, capsule contrac­
ture, and poor aesthetic outcomes in the setting or
radiation. In one retrospective review of this popula­
tion, authors noted a 45.4% complication rate with the
use of irradiated tissue expanders and a 30% loss of
permanent implants in the setting of PMRT.10,11 Grades
III and IV capsule contracture occurred twice as often
in irradiated implants as in non-irradiated implants.
Patients with a prior history of radiation therapy, such
as previous breast-conserving therapy, were also associ­
ated with an elevated risk of complications and a need
for explantation.10 In a study of 482 patients who had
implant reconstruction, both prior radiation therapy
and post-mastectomy radiation therapy were found to
have a negative effect on patient satisfaction (p<0.001
and p = 0.002, respectively).10,11
Recently, acellular dermal matrix (ADM) was found
to have potentially protective effects against explanta­
tion in patients with radiated tissue expanders. In a
retrospective review by Seth and colleagues, irradiated
expanders without ADM were found to have a three
times higher complication rate than irradiated expand­
ers with ADM.8 In a larger study by Craig and colleagues
that included 1376 tissue expander reconstructions,
irradiated tissue expanders that used ADM had an
associated higher rate of seromas (13.6% vs 10.9%,
p<0.001), but a lower incidence of explantation (11.4%
vs 20.4%, p = 0.0012). During the body incorporation
period, ADM is associated with higher rates of seroma
and infection. However, if recognized early and treated
appropriately, ADM that incorporates into the body
may play a protective role in preventing explantation
by serving as an additional vascularized barrier.11
Further studies in this area are needed before definitive
conclusions can be made, however.
Given the risks associated with reconstruction using
irradiated expanders, attempts have been made to
place implants prior to adjuvant radiation therapy;

487
Conclusion
Delayed pedicle autologous reconstruction such as
latissimus flap reconstruction can theoretically be
offered sooner than 6 months to patients because of
the lack of concerns over radiation-induced recipient
vessel injury. For patients who do not have available
autologous tissue in free flap donor sites or patients
who are deemed poor candidates for free flap recon­
struction, pedicled latissimus flap reconstruction
remains a valuable option to improve the breast
contour and aesthetics, particularly in irradiated
implant-based reconstruction.3 In 2011, Selber was the
first to describe the minimally invasive harvest of the
latissimus muscle for breast reconstruction.19 Since that
time, subsequent studies of this technique have shown
superior results with associated low rates of infection,
delayed wound healing, and capsule contracture.
However, there is a significant learning curve with the
use of such techniques, and further studies are war­
ranted before adopting these strategies into every
plastic surgeon’s armamentarium.
In a recent study evaluating rates of patient satisfac­
tion with various breast reconstruction techniques,
patients reported autologous reconstruction to be far
superior to and more durable than implant-based recon­
struction.20,21 This finding is alarming, given that more
than 80% of the breast reconstructions performed in the
US are implant-based reconstructions. In addition,
women who underwent implant reconstruction had
satisfaction scores 8.6 points lower than did those
patients who underwent breast-conserving therapy. It is
not surprising that the softness of autologous tissue
in reconstruction, even when irradiated as in breast-
conserving therapy, is more desirable to patients than
the palpability of implants are. Latissimus flap recon­
struction received patient satisfaction scores similar to
those for breast-conserving therapy and also remains a
good option for thin patients who have a history of
radiation therapy.21 Given these findings, breast cancer
patients should be educated about the long-term dura­
bility and aesthetic outcome of autologous and alloplas­
tic breast reconstruction.
Conclusion
Radiation therapy is integral to multimodality treatment
and decreasing local recurrence in select breast cancer
patients. However, the effects radiation has on short-
and long-term complication rates, aesthetic outcomes,
and patient satisfaction pose significant challenges to
reconstructive surgeons. Understanding radiation treat­
ment protocols is paramount to minimizing complica­
tions and maximizing aesthetic outcomes.
non-irradiated DIEP flaps revealed that use of the irra­
diated flaps yielded improved aesthetic outcomes with
no statistical difference from the non-irradiated flaps in
fat necrosis, volume loss, flap loss, or wound healing
rates.14–17
The key factor in radiation therapy’s effects on imme­
diate autologous reconstruction outcomes is how the
radiation treatment plan is carried out. Consideration
and understanding of the radiation treatment plan is
necessary to predict realistic outcomes for these breast
cancer patients. For example, if the IM nodes or medial
breast is targeted for therapy, and if that target is also
the location of the flap anastomosis, then targeted
therapy will likely result in flap thrombosis and in
resultant volume deflation and fat necrosis. However,
not all institutions target the IM node and not all sur­
geons use the IM artery as the recipient vessel for the
flap. Choosing a recipient vessel that is outside the zone
of targeted radiation therapy can help limit these
radiation-induced flap changes and can optimize aes­
thetic outcomes in these select patients.
For patients who undergo standard delayed autolo­
gous free flap reconstruction, the optimal timing for
definitive reconstruction remains controversial. Physi­
ologically, the window between resolution of the acute
phase of radiation injury and the initiation of extensive
fibrosis would be ideal; however, it is often clinically
difficult to ascertain where this window lies. Vari­
ability among institutions in techniques of radiation
delivery, length of follow-up, and administration of
systemic therapy limits the ability to adequately deter­
mine the optimal timing for reconstruction. A 2001
retrospective review by investigators at MD Ander­
son Cancer Center compared complication rates for
irradiated immediate reconstruction transverse rectus
abdominus myocutaneous (TRAM) flaps with rates
for the non-irradiated TRAM flaps. While acute flap
complications such as flap thrombosis or failure did
not significantly differ between the two flap groups,
late complications such as fat necrosis and volume loss
were found to be significantly higher in the irradiated
TRAM flap group than in the non-irradiated TRAM
flap group.18 As emphasized earlier, however, the
radiation treatment plan at MD Anderson is noted
to include the medial breast and often the IM nodes
specifically; this therefore explains the higher rate of
volume loss in the irradiated TRAM flap cohort. In
general, delayed autologous free flap reconstruction
is described as being performed safely as early as
6–9 months after a patient’s completion of radiation
therapy; however, the timing and use of this breast
reconstruction technique should be determined on an
individual basis.