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

230
SECTION II
CHAPTER 14 • Preoperative evaluation and planning for breast reconstruction following mastectomy
Breast Reconstruction Risk Assessment
(BRA) Score
To calculate the estimated risk for postoperative complications in a patient who underwent mastectomy with immediate tissue expander or autologous
reconstruction, complete the following worksheet.
Some models abstracted from participant use files of the Mastectomy Reconstruction Outcomes Consortium (MROC) database.
Some models abstracted from participant use files of the Tracking Operations and Outcomes for Plastic Surgeons (TOPS) database.
Some models abstracted from participant use files of the National Surgical Quality Improvement Program (NSQIP).
Do you have high blood pressure or are you taking
medications for high blood pressure?
Have you been diagnosed with diabetes mellitus?
Have you experienced difficult, painful, or labored
breathing?
(only count if 30 days or fewer prior to procedure)
Have you undergone chemotherapy?
(only count if 30 days or fewer prior to procedure)
American Society of Anesthesiologists (ASA)
Physical Status Classification
Smoking status
Are you having one or both breasts
reconstructed?

Have you had, or do you predict having,
radiation therapy?
Bleeding risks:
Vitamin K deficiency
Thrombocytopenia
Hemophilia
Other diagnosed clotting disorder
Coumadin, NSAIDs, or other anti-Coagulant NOT
discontinued prior to surgery
Chronic aspirin therapy
Have you ever had a:
Balloon angioplasty
Stent placement
Coronary artery bypass graft
Valve replacement/repair
Implantation of pacemaker/defibrillator
Other major cardiac surgery
Height
Weight
Age
2
Never
62
145
55
Both
No
Calculate Risk
Yes
What is this?
in
m
No
lb
kg
A
Fig. 14.2  User interface for the BRA Score web application. (A) Users may enter a series of data on patient demographics and medical comorbidities in order to obtain
individualized risk estimated for postoperative complications. Estimates are generated from the NSQIP, MROC, and TOPS databases.111,112,201 Web application is available at

an additional surgical site and scar as well as functional
and aesthetic concerns;148,205,206 and (3) that these proce­
dures are technically more challenging, often requiring
additional training and specialized equipment (see
Table 14.7).
Prosthetic-based reconstruction, in contrast, offers (1)
shorter individual procedures and faster recovery; (2)
reasonable control over breast volume and projection;
(3) avoidance of a donor site with concomitant morbidi­
ties; (4) specialized training or surgical equipment –
such as that needed for microsurgery – is generally
unnecessary207–212 (Table 14.8). Nonetheless, there are
sundry disadvantages, including additional surgery in
the case of a two-stage expander implant process (con­
versely direct-to-implant procedures may be subject to
limitations in volume and potentially higher rates of
secondary revision) limited with regards to symmetry
and implant size, and two-stage procedures necessarily
require an additional operation, frequent office visits for
expansion, and a prolonged period of time until defini­
tive reconstruction is achieved. Furthermore, patients
require long-term implant maintenance and are subject
to potential implant-related complications, including
capsular contracture, rippling and contour hollowing,

231
Risk/benefit communication
Table 14.7  Benefits of autologous reconstruction204–209
Benefits
• Allows for a more natural feel and appearance of the
reconstructed breast
• No risk for implant related complications or long-term maintenance*
• Improved reconstructive outcomes in the setting of prior
radiotherapy
• Offers skin paddle for functional or aesthetic enhancement or
supplementation
• Potential upside of excision of excess tissue from donor sites
• Possibly improved long-term patient satisfaction
• Generally a one-stage procedure
• In the case of perforator flaps, potentially amenable to
favorable reimbursement exceptions
Disadvantages
• Longer operative times
• Longer postoperative hospitalization and recovery period
• Potential complication of total flap loss
• Donor site morbidity including reconstructive complications,
functional disability, aesthetic deformity
• Heightened problems with flap contracture and volume loss if
subject to post-reconstruction radiotherapy
• Can be technically more challenging, potentially requiring
additional training and technology
*With the exception of a latissimus flap with prosthesis or other flap–implant
combinations
Table 14.8  Prosthetic reconstruction204–209
Benefits
• Relative technical simplicity
• Faster operation
• Shorter hospitalization
• More rapid postoperative recovery
• Lack of donor site morbidity
• Better potential control of breast size and projection
• Ideal for women with minimal tissue at potential donor sites
• Does not require specialized microsurgical training or
technology
Disadvantages
• Less able to replicate natural, ptotic breast
• Long-term implant maintenance and complications (i.e., need
for MRI surveillance with silicone implants, possible implant
rupture, capsular contracture, rippling and contour hollowing,
malposition, rupture, palpability or visibility, exposure)
• Less resistance to the deleterious effects of radiotherapy
• Potentially decreased long-term patient satisfaction
• Second surgery with expander/implant reconstruction
• Frequent clinic visits for expansion of tissue expander
Reconstructive Modality
Outcome
Tissue Expander
Pedicled Abdominal
(TRAM) Flap
Latissimus Flap
Microvascular
Reconstruction
Single-Stage Implant
Overall Complications
13.01%1 – 13.86%2
29.69%2 – 34.53%1
21.30%2 – 41.78%1
22.48%2 – 34.82%1
1.37%
4.99%
1.88%
10.9%
26.39%1
1 Abstracted from
MROC data
2 Abstracted from
TOPS data
3 Abstracted from
NSQIP data
Overall Medical
Complications3
13.86%
29.69%
21.30%
22.48%
Overall Medical
Complications2
5.20%
8.32%
3.84%
9.15%
30-Day Reoperation2
3.53%
5.64%
2.61%
5.83%
Surgical Site
Infection3
1.65%
2.87%
5.25%
2.48%
Seroma2
3.99%
14.30%
5.45%
6.71%
Dehiscence2
n/a
11.85%
3.40%
11.48%
Flap Loss
(Partial or Total)2
5.12%
n/a
n/a
n/a
Explantation2
B
Fig. 14.2, cont’d (B) Risks are presented for overall complications, including medical and surgical complications, as well as 30-day hospital readmission. Surgical
complications include surgical site infection, seroma, wound dehiscence, flap loss, or explantation. Complication rates are compared side by side for tissue expander based,
pedicled TRAM, latissimus, and microvascular reconstructions.

232
SECTION II
CHAPTER 14 • Preoperative evaluation and planning for breast reconstruction following mastectomy
Conclusion
Preoperative evaluation for breast reconstruction gen­
erally includes understanding a patient’s oncologic
status, treatment plan, past medical and surgical
history, medications, anatomy, and postoperative
expectations. Given the diverse array of reconstructive
techniques available, such preoperative evaluation can
also help generate risk–benefit profiles that can, in
turn, guide shared decision-making between surgeon
and patient. In this way, more thorough preoperative
planning not only enhances patient understanding but
may also yield superior, more predictable outcomes for
breast reconstruction.
malposition, rupture, implant palpability or visibility, or
frank exposure.213,214
The choice of immediate vs. delayed reconstruction
has a similar profile of divergent advantages and disad­
vantages.215 Immediate reconstruction may (1) minimize
psychosocial effects associated with the mastectomy
defect in the interim period; (2) combine reconstruction
with the oncologic resection in a single operation; 3)
potentially avoid the functional and aesthetic ramifica­
tions of scarring and loss of normal anatomy that occurs
with delaying reconstruction. On the other hand, the
delayed reconstruction can allow for demarcated tissue
healing without further stressing mastectomy flaps and,
in the setting of autologous reconstruction, can avoid
subjecting the flap to the tissue-deforming sequelae of
radiation.
16. Mallon P, Feron JG, Couturaud B, et al. The role of nipple-sparing
mastectomy in breast cancer: a comprehensive review of the
literature. Plast Reconstr Surg. 2013;131:969–984. Mallon and
colleagues provided a thorough review of the literature examining the
safety of nipple-sparing mastectomy and the factors influencing occult
nipple malignancy in breast cancer patients. Many of the tumor
characteristics they found to influence occult malignancy, including
tumor–nipple distance less than 2 cm, grade, presence of nodal
metasteses, lymphovascular invasion, HER-2 positivity, ER/PR
negativity, tumor size, location, and multicentricity, are widely used in
clinical decision-making regarding nipple-sparing techniques.
26. Mehrara BJ, Santoro TD, Arcilla E, et al. Complications after
microvascular breast reconstruction: experience with 1195 flaps.
Plast Reconstr Surg. 2006;118:1100–1109, discussion 1110-1111. The
authors examined nearly 1200 cases of microvascular breast
reconstruction, benchmarking the incidence of both major and minor
complications as well as elucidating many of the risk factors associated
with adverse events. The low major complication rate, and 0.5% total
flap loss rate in particular, highlights the safety of microvascular
techniques for breast reconstruction in highly-trained hands.
39. Alderman AK, Collins ED, Schott A, et al. The impact of breast
reconstruction on the delivery of chemotherapy. Cancer.
2010;116:1791–1800. Concerns regarding the potential for an undue
delay in the initiation of systemic chemotherapy in immediate breast
reconstructions remained a significant barrier for surgeons and patients
alike prior to this 2010 article by Alderman and colleagues. This
multicenter study of over 3600 patients provided strong evidence that
immediate breast reconstruction does not lead to omission of
chemotherapy and that the modest delay in the initiation of treatment is
unlikely to be of any clinical significance.
64. Kronowitz SJ, Robb GL. Radiation therapy and breast
reconstruction: a critical review of the literature. Plast Reconstr
Surg. 2009;124:395–408. This critical review of the literature provides
thoughtful discussion on the optimal timing and technique of breast
reconstruction in patients who may require postmastectomy radiation
therapy. The article weights the risks and benefits of both delayed and
immediate prosthetic reconstruction and autologous reconstrion, as well
the alternative “delayed-immediate” technique in light of the most
up-to-date evidence at the time of its publication, and provides a great
foundation for continued study of this important topic.
76. Kronowitz SJ, Hunt KK, Kuerer HM, et al. Delayed-immediate
breast reconstruction. Plast Reconstr Surg. 2004;113:1617–1628. In
this 2004 study, the authors describe their two-stage, “delayed-
immediate” approach to breast reconstruction. In an attempt to capitalize
on the benefits of an immediate reconstruction while minimizing the
deleterious effects of postmastectomy radiation therapy on the final
outcomes, the authors advocate for the immediate insertion of a tissue
expander at the time of mastectomy with definitive delayed
reconstruction following the completion of radiation therapy. The authors
also present the cases for 16 breasts treated in this manner and conclude
that “delayed-immediate” breast reconstruction can achieve the aesthetic
outcomes of immediate reconstruction while avoiding the aesthetic and
radiation-delivery concerns of immediate reconstruction.
79. Devereaux PJ, Mrkobrada M, Sessler DI, et al. Aspirin in patients
undergoing noncardiac surgery. N Engl J Med. 2014;370:1494–1503.
Perioperative medication management is an important part of ensuring
patient safety and minimizing adverse events. This randomized control
trial of aspirin use in non-cardiac surgery found that in all patients, even
those already taking aspirin routinely, the initiation or continuation of
aspirin therapy perioperatively did not significantly affect the rate of
death of non-fatal myocardial infarction at 30 days. Aspirin use was,
however, associated with a greater risk of major bleeding (4.6% in aspirin
group vs 3.8% in placebo; HR = 1.23; P = 0.04).
112. Kim JY, Khavanin N, Jordan SW, et al. Individualized risk of
surgical-site infection: an application of the breast reconstruction
risk assessment score. Plast Reconstr Surg. 2014;134:351e–362e.
Individualized risk calculators take the concept of preoperative risk
assessment one step beyond the traditional cohort study by
individualizing estimates given a patient’s unique combination of
demographic and clinical characteristics. The Breast Reconstruction Risk
Assessment score (BRAscore) risk calculator is the first individual risk
calculator available to plastic surgeons, leveraging data from a variety of
sources to provide relevant and accurate estimates for a number of
complications across the various breast reconstruction modalities. This
article by Kim and colleagues details the development and internal
validation of the first iteration of one of these models, focusing on a
patient’s risk for postoperative surgical site infection.
118. Miller RB, Reece G, Kroll SS, et al. Microvascular breast
reconstruction in the diabetic patient. Plast Reconstr Surg.
2007;119:38–45, discussion 46–48. Diabetes mellitus is a very common
and potentially significant risk factor in a number of surgical procedures
because of its tendency to affect endothelial and red blood cell function,
platelet function, and blood viscosity, among other effects. Miller and
colleagues’ retrospective review of nearly 900 free TRAM flaps aimed to
more clearly define the effects of this condition on microvascular breast
reconstruction. Their finding that flap complications did not differ
significantly between diabetic (type 1 or 2) and non-diabetic patients is
reassuring that this common condition is not a contraindication (relative
or absolute) to microvascular breast reconstruction.
122. Padubidri AN, Yetman R, Browne E, et al. Complications of
postmastectomy breast reconstructions in smokers, ex-smokers,
and nonsmokers. Plast Reconstr Surg. 2001;107:342–349, discussion
Access the complete reference list online at

233
Conclusion
350–351. Not unlike diabetes and hypertension, smoking is another
common risk factor in patients presenting for an evaluation for breast
reconstruction. The poor effects of smoking on wound healing and
surgical results in general are well defined; however, this study by
Padubidri et al. comprehensively quantifies its effects on the breast
reconstruction cohort, highlighting its negative influence on total
complication rates, mastectomy flap necrosis, and fat necrosis.
Interestingly, however many of these risks returned to rates similar to
those of non-smokers in ex-smokers who had quit at least 3 weeks prior
to surgery, suggesting an important role for smoking cessation in
improving patient safety and outcomes.
204. Hu ES, Pusic AL, Waljee JF, et al. Patient-reported aesthetic
satisfaction with breast reconstruction during the long-term
survivorship period. Plast Reconstr Surg. 2009;124:1–8. With
improving long-term survivorship within the breast cancer community,
patient reported outcomes, particularly regarding satisfaction with their
breasts following reconstruction, are becoming ever more important in
clinical decision-making on the modality of breast reconstruction. With
fairly well understood differences in the aging process of expander/
implant and autogenous reconstructions, the authors set out to evaluate
patient satisfaction, not only in the immediate postoperative period but
long-term as well, with these TRAM and expander/implant breast
reconstruction. While no difference was found in the short-term aesthetic
satisfaction between the cohorts, in the long term satisfaction with
expander/implants seemed to decrease, resulting in a significant
difference when compared to their TRAM counterparts.

233.e1
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233.e2
SECTION II
CHAPTER 14 • Preoperative evaluation and planning for breast reconstruction following mastectomy
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multicenter study of over 3600 patients provided strong evidence that
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operative outcomes in breast reconstruction? Microsurgery.
2008;28:516–523.
190. Offodile AC 2nd, Chatterjee A, Vallejo S, et al. A cost-utility
analysis of the use of preoperative computed tomographic
angiography in abdomen-based perforator flap breast
reconstruction. Plast Reconstr Surg. 2015;135:662e–669e.
191. Temple-Oberle C, Ayeni O, Webb C, et al. Shared decision-making:
applying a person-centered approach to tailored breast
reconstruction information provides high satisfaction across a
variety of breast reconstruction options. J Surg Oncol.
2014;110:796–800.
192. Heller L, Miller MJ. Patient education and decision making in
breast reconstruction. Semin Plast Surg. 2004;18:139–147.
193. Moyer A, Salovey P. Patient participation in treatment decision
making and the psychological consequences of breast cancer
surgery. Womens Health. 1998;4:103–116.
194. Street RL Jr, Voigt B. Patient participation in deciding breast cancer
treatment and subsequent quality of life. Med Decis Making.
1997;17:298–306.
195. Sun CS, Cantor SB, Reece GP, et al. Helping patients make choices
about breast reconstruction: a decision analysis approach. Plast
Reconstr Surg. 2014;134:597–608.
196. Causarano N, Platt J, Baxter NN, et al. Pre-consultation
educational group intervention to improve shared decision-
making for postmastectomy breast reconstruction: a pilot
randomized controlled trial. Support Care Cancer. 2015;23:
1365–1375.
197. Platt J, Baxter N, Jones J, et al. Pre-consultation educational group
intervention to improve shared decision-making in
postmastectomy breast reconstruction: study protocol for a pilot
randomized controlled trial. Trials. 2013;14:199.

233.e6
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198. Edwards A, Elwyn G, Mulley A. Explaining risks: turning
numerical data into meaningful pictures. BMJ. 2002;324:827–830.
199. Mohanty S, Liu Y, Paruch JL, et al. Risk of discharge to post acute
care: a patient-centered outcome for the American College of
Surgeons National Surgical Quality Improvement Program
surgical risk calculator. JAMA Surg. 2015;150:480–484.
200. Bilimoria KY, Liu Y, Paruch JL, et al. Development and evaluation
of the universal ACS NSQIP surgical risk calculator: a decision aid
and informed consent tool for patients and surgeons. J Am Coll
Surg. 2013;217:833–842.e1–3.
201. Khavanin N, Kim JY, Davila AA, et al. Abstract 46: The BRA Score:
creating a general risk calculator for breast reconstruction
outcomes. Plast Reconstr Surg. 2014;133:56–57.
202. Ng SK, Hare RM, Kuang RJ, et al. Breast reconstruction post
mastectomy: patient satisfaction and decision making. Ann Plast
Surg. 2016;76:640–644.
203. Ter Louw RP, Patel KM, Sosin M, et al. Patient-centred decision
making in breast reconstruction utilising the delayed-immediate
algorithm. J Plast Reconstr Aesthet Surg. 2014;67:477–482.
204. Hu ES, Pusic AL, Waljee JF, et al. Patient-reported aesthetic
satisfaction with breast reconstruction during the long-term
survivorship period. Plast Reconstr Surg. 2009;124:1–8. With
improving long-term survivorship within the breast cancer community,
patient reported outcomes, particularly regarding satisfaction with their
breasts following reconstruction, are becoming ever more important in
clinical decision-making on the modality of breast reconstruction. With
fairly well understood differences in the aging process of expander/
implant and autogenous reconstructions, the authors set out to evaluate
patient satisfaction, not only in the immediate postoperative period but
long-term as well, with these TRAM and expander/implant breast
reconstruction. While no difference was found in the short-term aesthetic
satisfaction between the cohorts, in the long term satisfaction with
expander/implants seemed to decrease, resulting in a significant
difference when compared to their TRAM counterparts.
205. Pulzl P, Schoeller T, Kleewein K, Wechselberger G. Donor-site
morbidity of the transverse musculocutaneous gracilis flap in
autologous breast reconstruction: short-term and long-term results.
Plast Reconstr Surg. 2011;128:233e–242e.
206. Clough KB, Louis-Sylvestre C, Fitoussi A, et al. Donor site
sequelae after autologous breast reconstruction with an extended
latissimus dorsi flap. Plast Reconstr Surg. 2002;109:1904–1911.
207. Cheng A, Losken A. Essential elements of the preoperative breast
reconstruction evaluation. Gland Surg. 2015;4:93–96.
208. O’Shaughnessy K. Evolution and update on current devices for
prosthetic breast reconstruction. Gland Surg. 2015;4:97–110.
209. Nahabedian MY. Achieving ideal donor site aesthetics with
autologous breast reconstruction. Gland Surg. 2015;4:145–153.
210. Nahabedian MY. Achieving ideal breast aesthetics with autologous
reconstruction. Gland Surg. 2015;4:134–144.
211. Sigurdson L, Lalonde DH. MOC-PSSM CME article: breast
reconstruction. Plast Reconstr Surg. 2008;121:1–12.
212. Zhong T, McCarthy CM, Price AN, Pusic AL. Evidence-based
medicine: breast reconstruction. Plast Reconstr Surg. 2013;132:
1658–1669.
213. Spear SL, Masden D, Rao SS, Nahabedian MY. Long-term
outcomes of failed prosthetic breast reconstruction. Ann Plast Surg.
2013;71:286–291.
214. INAMED. Making an Informed Decision [patient brochure]. Santa
Barbara: INAMED Aesthetics; 2005.
215. Fine N. Immediate and Delayed Breast Reconstruction [Internet].
Message to: Nima Khavanin. July 5, 2015.

SECTION II • Reconstructive Breast Surgery
15 
One- and two-stage prosthetic
reconstruction in nipple-sparing
mastectomy
Amy S. Colwell
SYNOPSIS
■ Nipple-sparing mastectomy is increasingly performed for treatment or
prevention of breast cancer.
■ Key points of the history and physical exam determine if the patient is
a candidate for nipple preservation.
■ Reconstructive goals include rebuilding the breast with nipple
centralization.
■ Outcomes data show excellent results in cosmesis and complication rates.
Introduction
Nipple-sparing mastectomy (NSM) and immediate
reconstruction are chosen when there is no oncologic
involvement of the nipple by cancer and when it is
in an acceptable anatomic location. Decision-making
centers on incision location, one- vs. two-stage recon­
struction, round or shaped implants, and utilization of
acellular dermal matrix (ADM) or mesh. Technical
pearls maximize results and minimize complications.
Reconstructive outcomes following NSM show low
rates of complications and high rates of nipple
retention.
Access the Historical Perspective section online at

Basic science
The breast is a glandular structure composed of ductal
and lobular units. The lactiferous ducts converge and
empty into the nipple (Fig. 15.1). Breast cancer most
commonly arises within the breast ducts. Treatment
involves surgery to remove gross pathology with a clear
margin, and this can be supplemented with chemo­
therapy and/or radiation for control of local, regional,
or metastatic disease. A mastectomy proceeds in an
anatomic plane between the breast tissue and subcuta­
neous fat to the sternum, clavicle, latissimus dorsi, and
inframammary fold (IMF).
A subcutaneous mastectomy was a preferred tech­
nique years ago to remove the majority of breast tissue
yet leave a small amount behind to ensure nipple and
skin survival. These patients had an overall higher risk
of breast cancer recurrence, and the technique was
largely abandoned. Anatomical studies then showed
lactiferous ducts empty into a central core of nipple
surrounded by a subdermal plexus of blood vessels.
Therefore, it was possible to remove the ductal tissue
from the nipple core while preserving blood supply.
Since then, NSM is gaining traction as a preferred
method for breast cancer treatment or prevention. Abso­
lute contraindications to NSM include involvement of
the nipple, locally advanced cancer with skin involve­
ment, inflammatory cancer, or bloody discharge from
the nipple.3 For each breast, the nipple ductal tissue is
sent as a separate specimen for pathological evaluation.
If this margin is positive for cancer, nipple removal is
warranted.
The anatomical considerations in breast reconstruc­
tion center on pocket control, restoration of desirable
breast contour, and nipple centralization. Mastectomy
boundaries extend laterally beyond the desired breast
border; thus, this border must be redefined. Further­
more, if the IMF is violated, then restoration is necessary
  Access video and video lecture content for this chapter online at expertconsult.com

234.e1
Historical perspective
Historical perspective
The first attempted breast reconstruction was performed
in conjunction with subcutaneous mastectomy using a
flank lipoma.1 The development of silicone gel implants
allowed immediate implant insertion at the time of
mastectomy. However, complications of skin necrosis
and capsular contracture limited success. Implants were
then placed submuscular under pectoralis major and
serratus. This improved skin survival and capsular
contracture, but it had limited cosmetic benefit in
medium to large breasts. Tissue expansion offered a
solution to women with breasts of any size and mini­
mized pressure on the mastectomy skin. This practice
was widely adopted and remains the most common
means of reconstructing the breast in the United States.
With ADM, there came an opportunity to re-explore
direct-to-implant one-stage reconstruction. Today, one-
stage breast reconstruction is gaining traction as a pre­
ferred means of reconstruction in select patients.2

235
Diagnosis/patient presentation
volume, and implant style are selected in order to opti­
mize these results.
Diagnosis/patient presentation
Patient history
The patient typically has breast cancer or high risk for
developing cancer. If the patient has genetic predisposi­
tion, the mastectomies are bilateral (Fig. 15.2). Patients
with unilateral breast cancer may choose unilateral
or bilateral mastectomy. The breast oncology surgeon
decides relative safety and feasibility of nipple preser­
vation, while the plastic surgeon determines if preserva­
tion would be beneficial to the aesthetic outcome. It is
relevant to know if the patient received neoadjuvant
chemotherapy or if they will receive postoperative
chemotherapy; it is critical to know if the patient
had prior radiotherapy. Planning for postoperative
radiotherapy most often occurs when the final pathol­
ogy is reported after the mastectomy, but on occasion
this is known preoperatively.
The overall health status of the patient determines
candidacy for immediate reconstruction. Poor prognos­
tic factors include congestive heart failure, stroke,
cardiac stent, requirement for home oxygen, and trans­
plant recipients. Select high-risk patients may receive
Fig. 15.1  The lactiferous ducts converge into the central nipple as shown on this
low power view of a nipple in cross-section (stained with H&E). These ducts can be
removed with a nipple-sparing mastectomy leaving the outer skin and subdermal
plexus of blood vessels intact.
Fig. 15.2  This 33-year-old female had the BRCA gene mutation. She underwent bilateral nipple-sparing mastectomies with direct-to-implant reconstruction using smooth
round moderate-plus profile 250 cc silicone gel implants.
for proper implant placement. The aesthetic goals of
many patients include more medial and superior full­
ness than is present in the native breast. Nipple preser­
vation imposes challenges in achieving medial fullness
while centralizing the nipple. Incision placement,

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CHAPTER 15 • One- and two-stage prosthetic reconstruction in nipple-sparing mastectomy
Fig. 15.3  For significant grade 2 or grade 3 ptosis, an inferior vertical incision is the safest approach to lift the nipple while keeping it centered. This patient is shown
following tissue expander reconstruction. (Right) Microfoam tape is placed laterally for expander support and nipple positioning.
delayed reconstruction. With diabetes, perioperative
sugar control is important. If possible, immunosuppres­
sants and anticoagulants should be discontinued peri­
operatively if medically safe. Mental health conditions
are optimized through a psychiatrist or therapist as
conditions may worsen with postoperative recovery
or complications. Smoking is strongly discouraged
and may require transition to delayed reconstruction.
Patients in healthcare or with MRSA exposure should
have a nasal swab sent for culture.
The patient’s reconstructive goals are considered.
Overall goals for size, preference for number of surger­
ies, and the desired amount of uplift factor into
decision-making.
Physical exam
The patient’s height and weight are noted. A general
inspection for skin quality, symmetry, and scars on the
breast and abdomen are performed. The breast notch-
to-nipple, nipple-to-fold, and breast base diameter are
measured. The vertical position of one IMF is compared
to the opposite breast. An overall estimate of volume is
obtained.
Assessment
The history and physical help decide if implant or autolo­
gous reconstruction is the procedure of choice. With
implant reconstruction, silicone is recommended over
saline due to the more natural look and feel. Further
discussion ensues to decide on nipple preservation, inci­
sions, one- or two-stage reconstruction, ADM or mesh,
and round or anatomic/shaped implants.
Patient selection
Nipple preservation
Surgical oncology determines if the patient is a candi­
date for nipple preservation based on tumor location
and characteristics. Plastic surgical considerations
focus on the degree of ptosis and desired uplift of the
breast. All patients with grade 1 ptosis and the vast
majority of patients with grade 2 ptosis are considered
surgical candidates for NSM. A 1 or 2 cm uplift of
the nipple is expected as a skin response to mastec­
tomy alone. If the patient desires a larger amount
of uplift, or if there is grade 3 ptosis, a skin-sparing
or areolar-sparing approach is typically preferred,
although an inferior vertical approach to NSM can
also be considered (Fig. 15.3). For prophylactic mas­
tectomies in patients with grade 3 ptosis, a vertical
mastopexy preserving circumareolar dermal blood
supply can be performed before NSM to lift the
nipple position; however, timing may not be optimal
for cancer patients. Circumvertical mastopexy at the
time of NSM has a higher potential risk for ischemic
complications.
Incisions on the breast, prior radiotherapy, or post-
mastectomy radiotherapy are not absolute contrain­
dications to NSM.4,5 Patients with prior lumpectomy,
breast augmentation, mastopexy, or reduction can
have successful NSM with immediate reconstruc­
tion.6 Previous breast surgery should be considered
in planning the mastectomy incision. Although prior
radiotherapy is a general risk factor for implant-based
reconstruction, NSM and immediate reconstruction
can be performed in properly selected patients with
minimal skin damage. If the patient will need post-
mastectomy radiation, NSM can be considered. Radia­
tion will often induce a tightening of the skin around
an implant with an overall superior shift of the recon­
struction superiorly. However, the nipple moves with
the reconstruction. Nipple reconstructions following
breast radiation of implants have limited success and
may lead to cellulitis or implant exposure. Therefore,
in select patients nipple preservation with mastectomy
may offer the best chance for a safe, effective outcome
(Fig. 15.4).

237
Patient selection
viability of the skin and nipple from prior breast surgery
or from an inexperienced breast surgeon. A radial inci­
sion takes away the least amount of blood supply from
the nipple and can be extended medially to remove the
nipple if necrosis ensues. An inferior radial incision
provides the most uplift to the breast and the best cen­
tralization of the nipple in cases where ptosis exists.
Although an ellipse of skin can be removed with the
inferior incision, it is typically not necessary and can lead
to a constricted inferior pole. If a patient has prior breast
surgery, these scars can be used and extended if neces­
sary for the mastectomy and reconstruction. If the scars
are medial or superior to the nipple, these are typically
ignored whereas a lateral or inferior scar is often utilized.
An inferior periareolar scar from a prior breast augmen­
tation can be utilized, or it can be ignored and a lateral
radial incision or IMF incision used instead, which is the
author’s preference. Radiated lumpectomy scars should
be avoided as these are associated with a higher risk of
complications and wound healing problems.6
One- or two-stage reconstruction
Decision-making in one- or two-stage reconstruction
centers on patient goals for size, minimizing number of
surgeries, and quality of the mastectomy skin envelope.8
In general, if the patient wants to be significantly larger
in size, this is more safely accomplished in two stages
(Fig. 15.6). In select cases with skin redundancy and an
excellent skin envelope, it is possible to increase the size
of the breast in one stage. Interestingly, if a patient wants
to be significantly smaller and retain the nipple, this is
also often better accomplished in two stages to allow
skin shrinkage and a mastopexy at the time of tissue
expander exchange. Breast and/or nipple asymmetry
and ptosis can often be improved in one stage; however,
two-stage surgery allows a second opportunity for
Fig. 15.5  Incisional approaches to nipple-sparing mastectomy combine ease of
access and overall cosmesis. IMF, inframammory fold. (Reproduced with
permission from Colwell AS, Tessler O, Lin A, et al. Breast reconstruction following
nipple-sparing mastectomy: predictors of complications, reconstruction outcomes,
and 5-year trends. Plast Reconstr Surg. 2014;133(3):496–506, Fig. 1.)
Incisions
The best incision is one that gives good access for
both the mastectomy and reconstruction while minimiz­
ing the scar burden if possible5 (Fig. 15.5). The inferolat­
eral IMF incision is an excellent option to meet these
goals for many patients.7 The incision starts at approxi­
mately the 6 o’clock position under the breast and
extends to approximately the 3 or 9 o’clock position
lateral on the breast. This incision provides good access
for sampling of axillary lymph nodes and avoids some
inframammary perforators located more medially. A
periareolar incision is often preferred by breast oncolo­
gists; however, this incision removes 50% of the blood
supply to the nipple and is associated with a higher
incidence of nipple necrosis in some series.5 A lateral
radial incision is a good option if there is concern about
Fig. 15.4  This 43-year-old female had right breast cancer. She underwent bilateral nipple-sparing mastectomy procedures with direct-to-implant reconstruction using
470 cc moderate height, full-projection anatomic implants. (Right) She is shown 6 months after radiation to the left breast.

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CHAPTER 15 • One- and two-stage prosthetic reconstruction in nipple-sparing mastectomy
Fig. 15.6  This 36-year-old female had the breast cancer gene mutation. She underwent tissue expander reconstruction with acellular dermal matrix and is shown following
her exchange to 495 cc full height, extra-full projection anatomic implants.
nipple and implant adjustment to optimize results. The
quality of the mastectomy skin envelope is influenced
by quality and thickness of the patient’s skin, and tech­
nical ability of the breast oncology surgeon to remove
all breast tissue in its natural plane atraumatically while
preserving the subcutaneous fat and subdermal blood
supply. The quality can also be damaged by the recon­
structive surgeon if sharp retractors and extensive
traction are used during the reconstruction, or if too
much pressure is placed on the skin from a large implant
or too much fill in the expander. Two-stage reconstruc­
tion is more common than one-stage; however, it is
becoming increasingly common for patients to request
one-stage reconstruction. A breast cancer diagnosis or
positive BRCA gene test often comes at an inconvenient
time with family life and jobs more important consider­
ations. Although a one-stage reconstruction does not
always offer the same opportunities for finesse and fat
grafting commonly employed with two-stage recon­
struction, it does get the patient back to her life more
quickly.
Round or anatomic/shaped implants
Silicone implants are preferred over saline for breast
reconstruction, as the cohesive gel more closely resembles
breast tissue in look and feel. Smooth round silicone
implants are the most common type of implant used in
the United States. Although the anatomic (shaped) tex­
tured silicone implants have been available for years
worldwide, only recently were they approved in the
United States. The advantages of round implants include
more upper pole fullness, mobility, and softer feel com­
pared to anatomic implants. The advantages of shaped
implants include less visible rippling, more natural shape
for a unilateral reconstruction, and more improvement
in ptosis (Fig. 15.7). Theoretically, the texturing of the
shaped implants may help mitigate the contractive forces
of radiation.
Acellular dermal matrix or mesh
Breast reconstruction was initially performed in the
subcutaneous plane over the muscle; however, capsular
contracture often ensued. Placement of the implant or
expander under the muscle improved capsular contrac­
ture, but it was hard to achieve a natural appearance
with ptosis. Partial muscle coverage offered the advan­
tage of submuscular placement and inferior pole release
to create a more normal-appearing breast. Creative
suture methods were employed to help prevent pecto­
ralis muscle retraction and tissue expander migration.
The development of ADM offered a more predictable
means of tissue expander or implant placement and
lower pole support. Human ADM is the most common
material used in the United States and is popular for its

239
Treatment/surgical technique
Fig. 15.8  Important preoperative markings include the inframammary fold and its relation to the opposite breast and fold. The ideal lateral border of the breast is marked
and serves as the lateral extension for the inferolateral inframammary fold incision.
Fig. 15.7  This 34-year-old female had right breast ductal carcinoma in situ and a BRCA mutation. She was turned down for a nipple-sparing procedure at another facility.
She underwent direct-to-implant reconstruction with an inferolateral inframammory fold incision and shaped full height, full projection 475 cc anatomic implants.
pliability, strength, integration into the tissues, and
potential role in the mitigation of capsular contracture.
A number of different products are currently available
including porcine and bovine dermal matrix as well as
synthetic silk, titanium, and vicryl mesh.8 The choice of
material may be guided by the needs for reconstruction.
The material should be strong enough to help support
the reconstruction initially and predictably for as long
as the body needs the support. It should not induce
enough inflammation to promote capsular contracture,
nor should it have risk for extrusion. In the setting of
infection, it should not be a permanent nidus for bacte­
ria. If the breast skin is thin, a material is selected to
integrate into the body’s tissue and provide an extra
layer of support and coverage.
Treatment/surgical technique
Preoperative planning
Important preoperative markings include the IMF on
both sides and desired lateral border of the breast
(Fig. 15.8). An incision is planned with the surgical
oncologist. A paravertebral block can be performed to
provide analgesia in the first 24–36 hours following the
surgery and decrease overall narcotic requirement. Pre­
operative intravenous antibiotics are administered 30
minutes before start of the procedure, most commonly a
first generation cephalosporin. This can be combined
with gram-negative coverage if the patient is high risk.
Some hospital policies advise preoperative Hibiclens®

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CHAPTER 15 • One- and two-stage prosthetic reconstruction in nipple-sparing mastectomy
from lateral to medial until the pectoralis insertion to the
sternum is encountered. The inferior pectoralis muscle
is then divided while on stretch using electrocautery. If
the inframammary fold is intact, the muscle is released
approximately 1 cm superior to the insertion to avoid
lowering the fold. If the fold is not intact, the muscle can
be released at its insertion. The inferior release is per­
formed to approximately the 4 o’clock or 8 o’clock posi­
tion on the chest wall. If the muscle is not released to this
extent, the implant is often lateralized. It is sometimes
necessary to extend the release to the 3 or 9 o’clock
position. However, with extended release of muscle,
scrubs three days before surgery. The skin is prepped
with chlorhexidine or DuraPrep™. After the mastectomy,
the skin is reprepped with an antiseptic solution and new
drapes are placed over pre-existing drapes placed at the
surgical start. The arm position is angled downward
to approximately 75 degrees with the operating room
table. Paralysis is administered to make subpectoral dis­
section easier and facilitate implant placement. The
mastectomy specimens are weighed on each side. It is
helpful to double-glove for this procedure for sterility.
Technique for one- or two-stage breast
reconstruction with partial pectoralis muscle
release and acellular dermal matrix or mesh
The technique for one- or two-stage breast reconstruction
follows a similar progression of events. Reconstruction
is most commonly performed immediately with the
mastectomy and with partial pectoralis muscle cover­
age and ADM or mesh. Total muscle coverage can be
used in two-stage reconstruction and for small breasts
in one-stage reconstruction following principles similar
to those used in skin-sparing mastectomy.
Initial inspection
The skin is first inspected for color, thickness, and trau­
matic injury. If the skin and/or nipple has pink, red, blue,
or gray discoloration, it suggests ischemic injury and
may not be suitable for one-stage reconstruction. If there
is severe damage, delayed reconstruction is considered.
If the undersurface of the flap has exposed dermis, it is
less conducive to one-stage reconstruction. The ideal
skin envelope has a normal skin color and marbling of fat
on the undersurface of the skin flaps (Fig. 15.9). The
extent of dissection is then assessed. If the inframam­
mary fold has been violated it will need to be re-established
with sutures and/or ADM. The lateral extent of the dis­
section is the latissimus dorsi muscle. The lateral pocket
border must be medialized with ADM, a serratus muscle
flap, and/or suturing of the lateral skin envelope to the
chest wall. If the medial extent of the dissection is medial
to the sternal attachment of the pectoralis muscle, this
may require fat grafting in the future.
Pectoralis muscle elevation (Video 15.1 )
The pectoralis muscle is placed on stretch and the fine
subpectoral areolar tissue is divided with electrocautery
to create a subpectoral pocket (Fig. 15.10). This is most
easily performed with a short lighted retractor with
serrated edges. This retractor is not used on the skin
flaps. If subpectoral vessels are visualized, care is taken
to grasp the vessel with a forceps in two places and use
electrocautery before dividing. Dissection proceeds
Fig. 15.9  The ideal skin envelope has a normal color and capillary refill on exam
and a mottling of fat on the undersurface of the skin envelope.
Fig. 15.10  A subpectoral pocket is created and the muscle is released from its
inferior border to approximately the 4 or 8 o’clock position on the chest wall.

241
Treatment/surgical technique
Acellular dermal matrix (Video 15.2 )
ADM is used as an extension of the pectoralis muscle
for complete implant coverage (Fig. 15.12). Although
partial muscle release with two-stage reconstruction
can be performed without ADM, it is less predictable.
The addition of ADM or mesh allows precise position­
ing of the implant or expander, which is important for
reconstruction of NSM. With skin-sparing mastectomy,
expander malposition can often be corrected at the
second stage with capsulotomy and capsulorrhaphy.
However, with NSM, attaining symmetrical results
relies in large part on the initial reconstruction for both
one- and two-stage surgery.
A rectangular or contour ADM is chosen for recon­
struction. The contour ADM is easy to use and adapts
well to most breast base diameters, whereas most
rectangular ADM will need to be trimmed. The size of
ADM is chosen to fit the breast base width and antici­
pated volume. In general, a smaller piece is needed for
tissue expander reconstruction compared to one-stage
reconstruction.
Suturing the ADM can begin superiorly to the pecto­
ralis muscle or inferiorly to the chest wall/inframammary
fold according to surgeon preference. The diameter of
the inferior suture line will be longer than the diameter
of the superior suture line; thus, it is expected to have
some bunching or pleating of the superior suture line.
With human ADM, these pleats are not palpable or
visible. However, if a stiffer material is used, it is
there is more muscle retraction. This leads to less muscle
coverage, a greater proportion of subcutaneous/ADM
coverage, and requires a larger piece of ADM to span the
inferior pole. It is not necessary to limit superior subpec­
toral dissection as the natural inclination of the implant
with gravity is inferior. The lateral attachment of the
pectoralis muscle to the pectoralis minor is also released
to allow redraping around the implant and to prevent
indentation at the attachment, which often lies medial to
the lateral border of the implant.
Determine pocket dimensions
Once the pectoralis muscle is released, ADM is used to
define the lateral border of the implant. To determine
where to sew the ADM laterally, consideration is given
to the breast base diameter measured preoperatively,
the volume of the breast/desired new volume of breast,
and expander or implant base diameter options. The
pocket is typically created about 1 cm narrower than the
anticipated implant or expander diameter to account for
the stretch inherent in human ADM. If using a more
rigid type of ADM or mesh, the pocket diameter may
more closely approximate the diameter of the expander/
implant. Once the diameter is determined, a ruler is
used to measure from the medial subpectoral border to
the position on the serratus muscle laterally (Fig. 15.11).
For bilateral procedures, the same distance is measured
on both sides.
Fig. 15.11  A ruler is used to measure from the released medial border of the
pectoralis muscle to the desired extent on the lateral chest wall.
Fig. 15.12  The acellular dermal matrix (ADM) acts as the inferior and lateral
extension of the pectoralis muscle to form a complete pocket around the implant or
expander. The ADM is typically sewn to the chest wall using buried braided
non-absorbable sutures, though it is possible to use absorbable sutures and sew to
an intact inframammary fold.

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CHAPTER 15 • One- and two-stage prosthetic reconstruction in nipple-sparing mastectomy
implant and potentially leave a small space medially
uncovered. These small areas are rarely visible clinically.
One or two absorbable figure-of-eight or horizontal mat­
tress sutures are then placed from the ADM to the pecto­
ralis muscle medial and lateral. These help assess the
pocket with sizer placement and furthermore help hold
the implant in the pocket with initial insertion.
Variation: If desired, the serratus muscle can be elevated
to provide the lateral border to the implant pocket. In
this case, the serratus is dissected laterally to the desired
width of the implant pocket. The ADM is then sewn to
the serratus flap laterally. The advantage of this approach
is that a smaller piece of ADM is needed for the inferior
pole. In addition, the muscle flap sometimes spans the
inferolateral IMF incision, which can be helpful in cases
of incisional breakdown or radiotherapy.
Check pocket dimensions/size (Video 15.3 )
Once the pocket has been created, a sizer is placed to
check pocket dimensions and to determine the volume
of implant or fill the skin will allow. Although silicone
sizers are optimal, saline sizers are widely used as they
are inexpensive and convenient. The saline sizers can be
filled with air or saline. The sizer is placed into the
pocket and tacking stitches are placed to hold the sizer
in place (Fig. 15.14). Increasing pinkness or redness with
addition of volume to the sizer is indicative of ischemia
(Fig. 15.15). The patient is sat upright to 90 degrees on
the operating room table and symmetry is assessed. The
final implant is chosen based on the acceptable volume
and breast base diameter. A moderate classic or
sometimes necessary to excise these pleats and suture
the material closed. The author finds it easiest to sew the
ADM to the chest wall first to create the desired pocket
dimensions. If the IMF is intact, the ADM can be sewn to
the IMF directly. However, it is expected that round sili­
cone implants will drop 1–2 cm using this technique and
that textured anatomic implants will also drop but to a
lesser degree. For less anticipated drop, ADM is sewn
directly to chest wall at the level of the fold (Fig. 15.13).
If the IMF is not intact, suturing ADM to chest wall is
important to prevent bottoming out. Suturing begins
medially with the ADM sewn to the released pectoralis
muscle medial border with a buried simple stitch. The
second stitch is sewn from the ADM to the inframam­
mary fold to avoid medial restriction of the implant with
a chest wall stitch. Care is taken to leave redundancy
horizontally between stitches medially in anticipation of
space needed for an implant or partially filled tissue
expander. Suturing progresses laterally. If needed, the
ADM can be trimmed if it is too wide for the pocket.
Horizontal mattress sutures are preferred laterally from
ADM to chest wall with the knots on the chest wall side.
The author prefers a non-absorbable braided stitch (0
Ethibond) for the chest wall stitches, but Vicryl or PDS
can be used. If the ADM does not reach the lateral/
superior junction of the pectoralis muscle, a figure-of-
eight suture can be placed from the lateral border of the
pectoralis muscle to the chest wall in anatomic align­
ment with the newly created lateral border of the breast.
If the surgeon anticipates the ADM is going to be too
narrow for the pocket, suturing can start laterally to
control the lateral and then inferior borders of the
Fig. 15.13  This 47-year-old female had right ductal carcinoma in situ and underwent bilateral nipple-sparing mastectomy procedures. She had immediate direct-to-implant
reconstruction using smooth round moderate classic 320 cc implants. Sewing the acellular dermal matrix to the chest wall allows raising the inframammary fold with
redraping of the skin envelope.

243
Treatment/surgical technique
upon breast base diameter and size goals. A tabbed
expander can help maintain position but is more expen­
sive than expanders without tabs. A higher profile
implant is often chosen in two-stage reconstruction
since the final volume is larger than the original breast
volume with the same breast base width.
Preparation for implant or tissue expander
The pocket is assessed for hemostasis and irrigated with
a triple antibiotic solution composed of 1 gram cefazolin,
50 mg gentamycin, and 50 000 units of bacitracin per
liter. Two 15 bard drains are tunneled 1–2 cm away from
the pocket. If the skin exit site is above the IMF, the scars
are hidden with most bathing suits. One drain is placed
inside the ADM pocket along the inframammary fold,
and the other is placed into the axilla and over the
pectoralis muscle. Drains serve to remove fluid and also
to oppose the skin to the ADM for vascularization and
integration and prevent dead space. The skin is washed
with an antibiotic-soaked sponge, and the surgeon’s
gloves are changed. The anesthesiologist ensures the
patient has complete muscle relaxation.
Implant or tissue expander placement
Two retractors are placed inside the pectoralis–ADM
pocket. The implant or tissue expander is inserted and
expander filled to desired size using a closed system.
Proper orientation is obtained. The ADM is sutured to
the pectoralis with figure-of-eight or horizontal mattress
absorbable braided sutures (2-0 Vicryl) (Fig. 15.16).
Although it may be tempting to use permanent stitches
here, the knots can often be palpated and serve as a
concern for cancer. Excess ADM in the vertical dimen­
sion is trimmed whereas sutures may be tied more
loosely or spanned if the vertical height is short.
moderate plus profile implant most commonly fits the
volume and diameter goals for small to medium-size
breasts while centralizing the nipple for one-stage
reconstruction. A higher profile implant with a more
narrow base width may lead to nipple lateralization or
a medial pocket divot in smaller breasts; however, for
larger breasts (>500 cc) the higher profile implant is
used more frequently. A tissue expander is chosen based
Fig. 15.14  A sizer is placed into the subpectoral–acellular dermal matrix pocket
and sewn in place. The skin envelope is stapled shut, and the sizer is inflated to
assess the pocket and determine implant size or expander fill.
Fig. 15.15  If the sizer is inflated and the skin appears deep pink/red or blue/gray,
this indicates relative ischemia at that volume. In this patient who had a prior
inferior pedicle breast reduction followed by nipple-sparing mastectomies, the deep
pink discoloration indicated that direct-to-implant reconstruction would not be
possible. Instead, a tissue expander was placed with minimal volume fill, and she
recovered uneventfully with no nipple or skin necrosis.
Fig. 15.16  Once the implant or expander is placed, braided absorbable sutures are
used to close the muscle–acellular dermal matrix pocket.

244
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CHAPTER 15 • One- and two-stage prosthetic reconstruction in nipple-sparing mastectomy
Fig. 15.17  The skin edges are trimmed and closed in two layers using absorbable
stitches. The incision is dressed with surgical glue and/or Steri-Strips. The drain
exit sites are covered with Biopatches. Tegaderm is used to cover the drain exit
sites and incisions, which allows the patient to shower after discharge from the
hospital.
Fig. 15.18  It is common to see a scab on the nipple following nipple-sparing mastectomy (NSM) and immediate reconstruction. This is treated with a topical antimicrobial
agent and typically falls off in a few weeks with no clinical sequelae. This patient is shown after NSM and direct-to-implant reconstruction one week after surgery (middle)
and four weeks after surgery (right).
Closure
The skin edges are trimmed or de-epithelialized 2–3 mm
and closed in layers with absorbable sutures. Incisions
are dressed with a surgical glue (Dermabond) and/or
Steri-Strips. Microfoam tape is often used for implant
stabilization and nipple positioning. Biopatches are
placed around the drains. Tegaderm is then placed over
the incisions and drain sites (Fig. 15.17).
Postoperative care
The patient stays in the hospital for 1 or 2 nights. On
the first postoperative day, a loose-fitting surgical bra or
ace wrap is placed for mild compression. Constricting
garments are avoided to prevent additional ischemic
injury to the skin. Showering is permitted if Tegaderm
covers the incisions. Drain removal is performed when
output is less than 30 cc per day, and oral antibiotics are
maintained until the drains are out. Most commonly,
one drain per breast is removed one week after surgery
and the other is removed two weeks after surgery.
Drains are not kept in place longer than 4 weeks. The
skin often appears bruised and lumpy immediate after
surgery, and a scab may form on the nipple (Fig. 15.18).
These changes often worsen the first week following
surgery but improve thereafter. The nipple may appear
dusky with purple discoloration, but it has a remarkable
ability to recover from ischemia. Nipple removal for
necrosis is often best delayed 3–4 weeks following
surgery to determine how much is viable. An antibiotic
ointment is used on the nipple during the recovery
phase. Walking is encouraged immediately after surgery,
and patients may return to light activity and exercise in
6 weeks. However, more vigorous exercise and immer­
sion in a pool or ocean are best delayed for 3 months.
Tissue expander fills start 3 weeks after surgery and can
occur weekly thereafter. The second surgery for tissue

245
Outcomes, prognosis, and complications
Fig. 15.19  Direct-to-implant (DTI) is performed most commonly in bilateral reconstructions; however, it can be performed in unilateral reconstructions. DTI offers good
symmetry with small breasts such as in this 59-year-old female with left breast cancer that had immediate reconstruction with a smooth round moderate classic 325 cc implant.
expander exchange to implant typically occurs three
months after the initial surgery. Once the reconstruction
is complete, patients are followed every 1–2 years for
implant checks.
Outcomes, prognosis, and complications
Outcomes following NSM and immediate reconstruc­
tion are largely successful in experienced hands with a
high rate of nipple retention5,9 (Figs. 15.19–15.20). In 500
consecutive one- and two-stage reconstructions after
NSM, the overall complication rate was low and over
90% of nipples were retained.5 Complications included
hematoma, seroma, skin necrosis, and nipple necrosis.
The risk of infection was 3.3%, which is comparable to
some of the lowest reported rates of infection in implant-
based reconstruction, and suggests nipple preservation
does not increase overall risk of infection. There were
Fig. 15.20  This 45-year-old female desired one-stage reconstruction if possible. However, her skin was thin and relatively ischemic at the time of surgery, so she had
tissue expanders placed with exchange to smooth round 500 cc silicone gel implants and fat transfer to the upper poles three months later.

246
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CHAPTER 15 • One- and two-stage prosthetic reconstruction in nipple-sparing mastectomy
centralization that can be performed while keeping the
blood supply intact. The nipple may be removed at the
second stage if it is in an unacceptable position.
Nipple removal (with or without
reconstruction)
If the pathology on the nipple specimen is positive for
cancer, nipple removal with a margin of areolar tissue
is warranted. This can be performed 3 weeks to several
months following the initial surgery depending upon
adjuvant treatment and can be performed with tissue
expander exchange. Nipple reconstruction is offered
three months after nipple removal.
Revision
Revisional surgery in one- or two-stage breast recon­
struction is performed for implant malposition or
size change, fat grafting, mastopexy, or capsular con­
tracture. In our experience, the rate of revisions follow­
ing reconstruction for skin-sparing or NSM was similar
between one- and two-stage reconstruction with an
overall rate of about 20% at 5 years.10 Nipple position
can be shifted with crescent mastopexy, a crescent with
lateral extension, circumvertical or partial circumverti­
cal mastopexy, or by changing the implant position (Fig.
15.21). A free nipple graft can be performed if there is
enough laxity in the skin to allow skin closure and
adequate soft tissue to support the graft.
no recurrences of cancer in the nipple, and the explant
rate was less than 2%. Risk factors for complications
included radiotherapy, smoking, and a periareolar
incision.
Secondary procedures
Tissue expander exchange to implant
The tissue expander is filled to goal size. Position changes,
mastopexy, and/or fat grafting can be performed at the
second-stage surgery. The prior scar is typically used to
access the expander, which is punctured and removed. A
capsulotomy is routinely performed medial and superior
to allow the implant to fill these areas. Capsulotomy is
avoided inferior and lateral if possible with the partial
muscle release technique due to unpredictable final
implant position; however, in select cases it is required
and ADM reinforcement of new position can be consid­
ered. Capsulorrhaphy is performed to medialize the
pocket or raise the inframammary fold position. Most
women who have two-stage reconstruction after NSM
choose a size larger than their native breast. Therefore, a
high profile implant diameter is often suitable for both
nipple centralization and maximal projection. Fat graft­
ing is performed to fill in divots and help minimize
postoperative implant visibility. A mastopexy can be
performed to help lift and centralize nipple position;
however, there is a limit to the amount of lift and
Fig. 15.21  With tissue expander exchange to implant or in revisional surgery, a mastopexy can be performed to shift nipple position and tighten the skin envelope. A
crescent mastopexy and preoperative markings for a partial circumvertical mastopexy are shown.

247
Secondary procedures
mastectomy procedures with immediate reconstruction. The authors find a
low overall complication rate in one- and two-stage implant reconstruction
and outline risk factors for complications and reconstructive failures.
6. Frederick MJ, Lin AM, Neuman R, et al. Nipple-sparing
mastectomy in patients with previous breast surgery: comparative
analysis of 775 immediate breast reconstructions. Plast Reconstr
Surg. 2015;135:954e–962e. The authors present a consecutive series of
775 implant-based reconstructions where 187 reconstructions had prior
breast surgery. They find that NSM was successful in patients with prior
scars from lumpectomy, breast augmentation, or breast reduction without
an increased risk of nipple loss or reconstructive failure.
7. Colwell AS, Gadd M, Smith BL, Austen WG Jr. An inferolateral
approach to nipple-sparing mastectomy: optimizing mastectomy
and reconstruction. Ann Plast Surg. 2010;65:140–143. In this paper, the
authors describe an inferolateral inframammary fold incision for
nipple-sparing mastectomy that offers excellent access for both mastectomy
and reconstruction.
8. Scheflan M, Colwell AS. Tissue reinforcement in implant-based
breast reconstruction. Plast Reconstr Surg Glob Open. 2014;2:e192.
This paper reviews patient selection and technique in implant-based
reconstruction with acellular dermal matrix or mesh to optimize breast
reconstruction.
9. Spear SL, Willey SC, Feldman ED, et al. Nipple-sparing mastectomy
for prophylactic and therapeutic indications. Plast Reconstr Surg.
2011;128:1005–1014. In this paper, the authors provide early experience
and guidance for patient selection in nipple-sparing mastectomy.
10. Colwell AS, Clarke-Pearson E, Lin A, et al. Revision rates in
implant-based breast reconstruction: how does direct-to-implant
measure up? Plast Reconstr Surg. 2016;137:1690–1699. The authors
follow a cohort of direct-to-implant and tissue expander-implant
reconstructions for an average of 5 years. They find a similar rate of
complications and revisions in the two cohorts of patients.
References
1. Uroskie TW, Colen LB. History of breast reconstruction. Semin Plast
Surg. 2004;18:65–69. This paper offers a historical perspective on breast
reconstruction and allows the reader to learn from prior trials and
tribulations of the past.
2. Colwell AS, Damjanovic B, Zahedi B, et al. Retrospective review of
331 consecutive immediate single-stage implant reconstructions
with acellular dermal matrix: indications, complications, trends,
and costs. Plast Reconstr Surg. 2011;128:1170–1178. This paper was one
of the first comparative outcomes studies on direct-to-implant breast
reconstruction with ADM compared to traditional two-stage tissue
expander-implant reconstruction without ADM. In this series, single-
stage reconstruction had similar complication rates and costs compared to
two-stage reconstruction.
3. Coopey SB, Tang R, Lei L, et al. Increasing eligibility for nipple-
sparing mastectomy. Ann Surg Oncol. 2013;20:3218–3222. In this
paper, the authors offer new guidance on who is a candidate for nipple-
sparing mastectomy. They suggest that if the nipple is not involved by
cancer grossly or radiologically that the patient may be considered for the
nipple-sparing approach.
4. Reish RG, Lin A, Phillips NA, et al. Breast reconstruction outcomes
after nipple-sparing mastectomy and radiation therapy. Plast
Reconstr Surg. 2015;135:959–966. The authors perform an outcomes
study on breast reconstruction after NSM and radiotherapy. They find
that in patients with preoperative or postoperative radiotherapy, the
complication rate is slightly higher, but most patients have successful
reconstructions with implant and nipple retention.
5. Colwell AS, Tessler O, Lin AM, et al. Breast reconstruction
following nipple-sparing mastectomy: predictors of complications,
reconstruction outcomes, and 5-year trends. Plast Reconstr Surg.
2014;133:496–506. This paper presents 500 consecutive nipple-sparing

SECTION II • Reconstructive Breast Surgery
16 
Skin-sparing mastectomy: Planned two-
stage and direct-to-implant breast
reconstruction
Mitchell H. Brown, Brett Beber, and Ron B. Somogyi
SYNOPSIS
■ Alloplastic breast reconstruction is the most common approach used
today for postmastectomy breast reconstruction.
■ Traditional breast implant reconstruction is performed as a planned
two-stage procedure with the use of a tissue expander followed by
exchange to a breast implant.
■ Changing demographics of the mastectomy patient, improved devices
and support matrices, as well as refinements in mastectomy
techniques have allowed for expanded indications of direct-to-implant
breast reconstruction.
■ Enhanced collaboration between oncologic surgeons and plastic
surgeons is necessary in order to maximize outcomes in immediate
breast reconstruction.
■ Increasing awareness of the indications for skin and nipple
preservation together with improved devices, internal scaffolds, and
judicious use of fat transfer allow for results that may approximate the
appearance and feel of a natural non-operated breast.
Access the Historical Perspective section, including Fig.
16.1, online at

Introduction
Alloplastic reconstruction is the most common type of
postmastectomy breast reconstruction worldwide. The
increasing frequency of this form of reconstruction can
be explained by several factors, including changing
demographics of the mastectomy patient, improvements
in devices and technologies used in reconstruction, and
an increased appreciation for the morbidity associated
with autologous reconstruction.
Traditional alloplastic breast reconstruction begins
with the insertion of a tissue expander followed by a
period of serial expansions. The expander is exchanged
for a permanent prosthesis in a second procedure, which
is often performed in conjunction with balancing surgery
or other adjunctive procedures. This planned two-stage
approach is predictable, allows for reconstruction of
variable breast sizes, provides a period for review of
pathology, and minimizes early tension on the skin
envelope. Unfortunately, it necessitates a minimum of
two surgeries as well as repeated visits for expansion of
the device.
Direct-to-implant breast reconstruction, often referred
to incorrectly as a single-stage procedure, attempts to
create the final breast mound at the time of mastectomy.
In carefully selected patients, this approach offers the
benefit of fewer surgeries, a more rapid return to normal
life, and avoidance of the period of expansion. Chal­
lenges include limitations on breast size, the potential
for early skin or nipple necrosis, a higher priority for
excellence in one procedure, and the risk of postopera­
tive radiation of the permanent breast prosthesis.
This chapter will present the current thoughts on
indications, contraindications, patient selection, and
surgical technique in both the planned two-stage as
well as the direct-to-implant postmastectomy breast
reconstruction.
Patient presentation
The ideal alloplastic reconstruction should provide a
close degree of symmetry with a soft and natural-feeling
breast. It should be predictable and require the fewest
number of surgeries possible, with minimal morbidity
and minimal time to full recovery. Surgeons and patients
  Access video content for this chapter online at expertconsult.com

248.e1
Historical perspective
Historical perspective
Following the development of the first breast implant in
the 1960s, surgeons began to use internal breast pros­
theses for reconstruction of the breast. Constraints from
minimal tissue and tight soft-tissue envelopes limited
the use of implants alone. In 1984, Radovan published
on his approach to tissue expansion with the use of a
smooth surface expander with remote port.1 The ability
to stretch or recruit tissue enabled surgeons to offer
implant reconstruction to a wider number of patients.
Early reconstructions focused primarily on volume,
and the surgeon had few tools available for refining the
breast shape. Textured surfaces were developed to allow
stability of the expander within the pocket and to modify
the soft-tissue response of the surrounding capsule.
Further developments including shaped expanders
with integrated ports, and eventually suture tabs,
allowed for a more predictable result from expansion.
In parallel to expander development, breast implants
evolved through five generations, giving today’s
surgeon varied selection of surface, fill material, shape,
projection, and gel cohesivity. As a result, outcomes can
be based more on dimensional, anatomic planning
rather than volume alone.
As device technology changed, so did the approach
to mastectomy. In comparison to the radical mastectomy,
patients today are managed with breast conservation
surgery or less aggressive methods of total mastectomy.
With earlier diagnosis, improved surgical methods, and
the arrival of technologies to monitor and assess tissue
perfusion, the skin can be considered separately from
the breast gland, and many women are offered breast
removal with preservation of the skin envelope and
possibly preservation of the nipple. Combined with
newer technologies including internal tissue matrices
and lipofilling of the breast, today’s alloplastic breast
reconstructions have the potential to restore near normal
aesthetic outcomes following mastectomy (Fig. 16.1).

248.e2
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CHAPTER 16 • Skin-sparing mastectomy: Planned two-stage and direct-to-implant breast reconstruction
Fig. 16.1  Bilateral nipple-sparing mastectomy through inframammary fold incision. Direct-to-implant reconstruction with shaped cohesive gel implants and acellular
dermal matrix. (A,B) Preoperative. (C,D) One year postoperative.
A
B
C
D

249
Direct-to-implant breast reconstruction
discomfort of the expansions as well as the need for a
second surgery for exchange of the expander. With the
recent increase in high risk and gene positive patients,
there is an additional population that is highly motivated
to decrease their cancer risk through prophylactic mas­
tectomy while maximizing their aesthetic outcomes and
minimizing the number of procedures and postoperative
recovery time. There have also been significant psycho­
logical benefits demonstrated with earlier completion of
reconstruction,2 and cost savings described with the use
of a direct-to-implant approach.3–6 A direct-to-implant
approach for immediate reconstruction would be ideal
for many of these reasons. This approach, however, is
limited by the difficulty in providing adequate stable
soft-tissue coverage for an implant in a fresh mastectomy
pocket. Placement of an implant in a partial subcutane­
ous plane can cause significant stress to the lower pole
mastectomy flaps leading to soft-tissue necrosis in the
short term and significant thinning in the long term. Total
submuscular coverage, while possible, limits the size of
an implant that can be placed and does not allow for a
natural fill of the lower pole. In both these cases, the
lateral and inframammary folds are disrupted and poor
definition is seen postoperatively. The recent addition of
various soft-tissue support matrices to cover the implant
in the lower pole has significantly improved our ability
to perform safe and aesthetically pleasing direct-to-
implant reconstruction. Nevertheless, given the increased
constraints regarding patient selection and the increased
material costs, direct-to-implant reconstruction is still
used in a limited fashion and ultimately makes up only
10–15% of all reconstructed breasts.2
The concept of a direct-to-implant reconstruction can
satisfy all our reconstructive goals and represents an
attractive alternative to more established reconstruc­
tive techniques. Ultimately, the success of direct-to-
implant reconstruction will depend on four key factors:
(1) careful patient selection; (2) accurate device and
material selection; (3) planning and execution of a
mastectomy that leaves behind healthy, viable skin
flaps; and (4) the timely and effective management of
complications.
Patient selection
The ideal patient for a direct-to-implant reconstruction
is a healthy woman with small to moderate sized breasts
who desires to stay about the same breast size or slightly
larger. Women with larger size and ptotic breasts may
be candidates for skin reduction mastectomy with
direct-to-implant reconstruction; however, the ability to
preserve the nipple will be limited by the degree of
ptosis and overall breast size.
would clearly prefer a single-stage approach to breast
reconstruction, but not at the expense of inferior out­
comes or unnecessary risks. The traditional and most
common approach is a planned two-stage procedure
involving the insertion of a tissue expander followed by
a period of expansion and then exchange to a permanent
prosthesis. In some circumstances, consideration can be
made for avoidance of the period of expansion with
insertion of the final prosthesis at the time of the mas­
tectomy. Initially, this was called a single-stage alloplas­
tic reconstruction; however, the term “direct-to-implant”
reconstruction is more accurate. The advantages and
disadvantages of direct-to-implant versus planned two-
stage reconstruction are summarized in Fig. 16.2.
Patient selection for direct-to-implant reconstruction
is critical. Patients must be good candidates based upon
the shape and size of their breasts, nipple position on
the breast mound, indication for mastectomy, likelihood
of adjuvant therapy, size expectations, and risk factors
for vascular compromise to the skin or nipple. The ideal
candidate is a healthy non-smoker with an A–B cup
breast who desires a similar or slightly larger size,
minimal ptosis, prophylactic or early stage disease, and
low likelihood for postoperative adjuvant therapy.
Direct-to-implant patients must also have realistic
expectations.
Direct-to-implant breast reconstruction
The combination of skin-sparing or nipple-sparing
mastectomy with immediate reconstruction has allowed
for excellent results in implant-based reconstruction.
The advantages of implant-based reconstruction have
always been the relative straightforward nature of the
procedure as well as the avoidance of distant donor site
morbidity. The disadvantages, however, have been the
need for tissue expansion with the inconvenience of
repeated office visits and the inherent risks and
Fig. 16.2  Advantages and disadvantages of direct-to-implant versus planned
two-stage breast reconstruction.
Creates a balance
Fewer procedures
Fewer recoveries
No expansion period
More rapid return to "life"
More difficult
Less predictable
Limited indications
One shot only
Size limitations
Direct to implant
Get two chances
Less risk of skin or nipple
compromise
Broader indications
Delays final outcome
Expansion period
More surgery
More recovery
Planned two stage

250
SECTION II
CHAPTER 16 • Skin-sparing mastectomy: Planned two-stage and direct-to-implant breast reconstruction
The main concerns with direct-to-implant reconstruc­
tion are skin flap viability and stable soft-tissue cover­
age. The consultation and surgical planning must
adequately assess all factors related to these two issues.
These factors include tumor location and biology, the
ablative plan, the size and shape of the breast, access
incision, as well as patient comorbidities. Of course, the
aesthetic goals of the patient, including their willingness
or desire to have contralateral balancing procedures,
must also be considered.
There are few absolute contraindications to direct-to-
implant breast reconstruction. Patients with poor skin
quality or medical comorbidities that affect vascularity
to mastectomy skin flaps are not good candidates. Obese
patients and those with large, ptotic breasts that require
significant adjustments to the skin envelope are difficult
to reconstruct in a direct-to-implant approach. Patients
with a history of breast radiation and those likely to
require postmastectomy radiation have traditionally
been offered autologous reconstruction or a two-stage
implant-based reconstruction. Boundaries for implant-
based reconstruction in these patients are being extended
and several recent studies have shown good aesthetic
results with acceptable complication profiles through
the use of direct-to-implant reconstruction using acel­
lular dermal matrix.7,8
Several recent studies have looked at predictors of
failure in direct-to-implant reconstruction. Factors asso­
ciated with less favorable aesthetic outcomes and higher
rates of complications include active smoking, periareo­
lar incisions, increasing body mass index, increasing
breast cup size, preoperative irradiation, and prolonged
operative time.4,9–11
Implant and material selection
The two primary requirements for direct-to-implant
reconstruction are a breast implant as well as a support matrix
to hold the implant in place under the pectoral muscle. There
are multiple reasons for using an internal support matrix.
These include:
1. Support the implant under the pectoral muscle
2. Maintain position of the pectoral muscle
3. Define the inframammary fold and lateral mammary fold
4. Eliminate the need to elevate serratus or rectus muscle/
fascia
5. Minimize tension on the skin of the lower pole
6. Add soft-tissue cover to the lower pole and over the implant
A further benefit that has been attributed to some
acellular dermal matrices is the potential to resist capsular
contracture.10,12 Although debate continues as to whether or
not a protective effect truly exists, if it does, this would have
particular benefit in patients who have either been radiated or
are expected to undergo post-reconstruction radiation.
Table 16.1  Types of soft-tissue support matrices used in breast
reconstruction
Biologic
Human dermis
Autoderm
Human acellular dermal matrix
AlloDerm
Allomax
FlexHD
Dermacell
DermaMatrix
Porcine acellular dermal matrix
Strattice
Bovine acellular dermal matrix
Veritas
Surgimend
Silk
Seri Surgical Scaffold
Synthetic
Absorbable
Vicryl mesh
Non-absorbable
Prolene mesh
Marlex mesh
Internal support matrices can be classified as biologic or
synthetic. Current options are summarized in Table 16.1.
There are three ways in which the body can respond
to an internal tissue matrix. Material that is not recog­
nized as self will stimulate the natural immune defenses
of the body. Less complex materials such as absorbable
mesh will undergo resorption.
If a material is more complex and unable to be
resorbed, the body will respond through a process of
encapsulation. On the other hand, if the body recog­
nizes a material as self, then it will respond through
a process of revascularization and cell repopulation.
This is the outcome that we expect to see with the use
of biologic devices. Acellular dermal matrix (ADM)
is a tissue prepared from human, bovine, or porcine
tissue from which cellular components that promote
rejection have been removed. The resulting structur­
ally intact tissue matrix provides the biologic scaffold
necessary for normal tissue in-growth and cellular
repopulation.
There are several reasons why the use of ADM has
not been universally accepted. First, these materials are
expensive and therefore not available at all institutions.
Their cost can even offset the potential economic benefit
of performing breast reconstruction in a single stage. In
addition, there are several published reports of increased
complications with the used of ADM including higher
rates of infection, seroma, mastectomy flap necrosis,
and explantation.4,13–20

251
Direct-to-implant breast reconstruction
relationship will ultimately decrease the number of
revisionary procedures.
Size selection begins during the initial consultation.
Chest wall dimensions must be accurately measured
specifically focusing on breast width, height, and projec­
tion. This allows the surgeon to estimate the existing
breast volume. Additionally, a three-dimensional volu­
metric computer program, such as the VECTRA 3D may
be helpful with implant selection. Intraoperatively,
mastectomy weights together with the use of steriliz­
able implant sizers and clinical judgment are used to
select the final implant. A small overcorrection from the
mastectomy weight is suggested in order to accommo­
date for the laxity created in the skin envelope as a result
of the mastectomy.23
Immediate direct-to-implant
reconstruction – surgical technique
Effective collaboration between the oncologic and the
reconstructive surgeon is paramount to a successful
patient outcome. This includes a discussion regarding
the type of mastectomy, importance of gentle tissue han­
dling, preservation of the inframammary fold (IMF)
as well as the serratus fascia, and minimizing unneces­
sary lateral dissection of the breast pocket. Preoperative
selection of the incision should be discussed to ensure
access to the entire breast gland for excision while
minimizing tension placed on flaps during retraction.
A longer, strategically placed incision that minimizes
the need for flap retraction is preferred to a shorter, well-
hidden scar that causes the breast surgeon to struggle
while performing the mastectomy.
The most common incision for a skin-sparing mastec­
tomy (with nipple removal) is a mid-breast incision. The
length of the incision is determined by the size of the
breast and the need to reduce excess skin (Fig. 16.3).
When a nipple-sparing mastectomy is indicated, an
inframammary approach is preferred as this will mini­
mize visualization of the scar (Fig. 16.4).
There is benefit for the plastic surgeon to assist the
oncologic surgeon during the mastectomy. Not only does
this provide an opportunity for improved collaboration,
it also allows an opportunity to educate regarding the
importance of gentle tissue handling, minimal skin flap
retraction, uniform mastectomy flaps, and preservation
of deep fascia. Once the mastectomy is performed, the
skin flaps are carefully assessed for viability as described
below. Any doubt as to skin flap viability would neces­
sitate conversion to expander-based reconstruction or to
a delayed procedure. The pectoralis muscle is elevated
beginning at its inferomedial attachment on the sternum
and divided from its inferior rib attachments working
Vicryl mesh is widely available, relatively inexpen­
sive, resistant to bacteria biofilm formation, and easy to
use. It demonstrates little inflammatory response, is
non-allergenic, and has a low complication profile in
many surgical settings. Recent reports using Vicryl
mesh instead of ADM in the lower pole during immedi­
ate direct-to-implant breast reconstruction have shown
similar complication profiles with equally pleasing
results and significant cost savings over both two-stage
reconstruction or direct-to-implant reconstruction with
ADM.20–22 Longer term studies that assess soft-tissue
changes in the lower pole as well as the incidence of
capsular contracture will be important in assessing the
efficacy of absorbable mesh. Also, these materials do not
provide additional soft-tissue coverage and may not
protect the implant if skin necrosis or wound dehiscence
leads to a small area of exposure.
Characteristics of the ideal internal support matrix
are summarized in Table 16.2.
Implant selection
The choice of a round or shaped implant is based on
multiple factors and is highly dependent on surgeon
and patient preference. Factors to consider in implant
selection include desired breast shape, quality of overly­
ing soft tissues, requirement for a form-stable gel, and
ability to control the dimensions of the implant pocket.
Of course, in unilateral reconstruction, this choice is
heavily influenced by what shape will best match the
opposite breast. Regardless of the device used, it is
important to follow accepted principles of dimensional
planning with attention paid to the base width of the
breast, the breast footprint on the chest wall, and the
anatomy of the underlying chest wall. With the pocket
created, the implant selected must provide a hand-in-
glove fit to limit seroma formation, undesirable implant
movement, or rotation. A stable implant and soft-tissue
Table 16.2  Characteristics of ideal internal soft-tissue support
matrix in breast reconstruction
Safe
Biologically inert
Body responds through revascularization
Low cost
Readily accessible
Long shelf life
Ease of storage
Sterile
Ready to use
Range of size and shape options
Consistency of thickness
Low risk of disease transmission

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CHAPTER 16 • Skin-sparing mastectomy: Planned two-stage and direct-to-implant breast reconstruction
used, it is easier to first place the matrix along the IMF
and then close over the top of the implant to the free
edge of the muscle. It is helpful to transpose the IMF
and LMF from the skin markings onto the chest wall
using methylene blue in order to ensure accurate fold
placement. Following initial placement of the support
matrix, sizers are inserted and the patient is placed in
a sitting position. Breasts are inspected for symmetry,
and the appropriate implant is selected. The patient is
returned to a supine position, and the pockets are irri­
gated with antibiotic solution. A drain is placed along
the inframammary crease in the subcutaneous plane
and brought out through a separate incision in the ante­
rior axillary line. Many surgeons place a second drain
within the submuscular/ADM pocket. The authors
have found that it is rare for fluid to collect deep to the
muscle, and therefore they typically use a single drain.
Several support matrices used today are fenestrated or
laterally to the lateral mammary fold (LMF). At this
point, the elevation includes part of the serratus fascia
and ultimately results in a rectangular flap of pectoralis/
serratus fascia that maintains a well-defined medial and
lateral breast pocket. Pocket dissection is determined by
the implant selection. When using shaped implants, it is
important to make the pocket an appropriate size to fit
the implant. A “hand-in-glove fit” is necessary to avoid
implant rotation and malposition. Dissection is similar
with the use of textured round devices; however, when
a smooth surface implant is selected, the pocket is made
slightly larger to allow for postoperative displacement
exercises. This will help to minimize the risk of capsular
contracture.
The internal support matrix can be inserted in two
ways. When using an IMF incision, the matrix is first
sutured to the free edge of the muscle and final closure
is carried out along the IMF. If a mid-breast incision is
Fig. 16.3  Skin-sparing mastectomy with direct-to-implant reconstruction performed through transverse mid-breast incision. (A,B) Preoperative. (C,D) Six months
postoperative.
A
B
C
D

253
Direct-to-implant breast reconstruction
Special consideration should be given to the patient
that desires a significant decrease in their breast size at
the time of mastectomy. In this case, the decision to
forego preservation of the nipple in light of decreased
complications should be considered. Direct-to-implant
reconstruction is an excellent option in conjunction with
skin-reducing mastectomies. In these cases, both Wise
pattern and vertical skin patterns can be used and excess
de-epithelialized skin can be used to provide additional
implant coverage to the lower pole. When using a Wise
pattern skin reduction, it is critical to preserve the
medial perforators at the time of the mastectomy as the
medial flap is most at risk for skin necrosis (Figs. 16.6
& 16.7).
perforated, which makes the need for a second drain
less important (Fig. 16.5).
The implant is inserted using a minimal touch tech­
nique, and final closure of the pocket is performed. It is
important to avoid excessive superior migration of the
muscle, and therefore the muscle should be advanced
inferiorly until the desired upper pole contour is
achieved. The matrix is then trimmed as necessary to
create a tight and supportive pocket. When a mid-breast
incision is used, the muscle should be advanced inferi­
orly enough to place the muscle deep to the incision.
This will be helpful in the event of any wound dehis­
cence or breakdown. Final closure is carried out in two
layers, and a light protective dressing is applied.
Fig. 16.4  Nipple-sparing mastectomy with direct-to-implant reconstruction performed through inframammary fold incision. (A,B) Preoperative. (C,D) One year
postoperative.
A
B
C
D

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CHAPTER 16 • Skin-sparing mastectomy: Planned two-stage and direct-to-implant breast reconstruction
Fig. 16.5  Techniques for insertion of acellular
dermal matrix (ADM) at lower pole of the breast.
(A) Lateral pectoralis major muscle (PMM) elevation
with ADM placed inferior and lateral. (B) Inferior
PMM elevation with ADM placed inferior.
Pectoralis major muscle
Serratus anterior muscle
A
B
Fig. 16.6  Skin reduction mastectomy with inverted T pattern. (A) Skin markings. Note location of medial perforators. (B) Mastectomy completed. (C) Implant placed under
pectoralis major muscle and dermal flap. Acellular dermal matrix to be sutured laterally.
A
B
C

255
Direct-to-implant breast reconstruction
including laser-assisted ICG angiography have signifi­
cantly decreased rates of skin flap necrosis.25 Although
promising, the use of these technologies must be deter­
mined based on institutional rates of tissue compromise
versus cost of the technology itself.
Under any circumstance, if there is doubt as to the
intraoperative viability of the skin flaps, the procedure
should be converted to an expander-based reconstruc­
tion or a delayed procedure. When an expander is used,
it can be inflated to gently fill the skin envelope, but
without unnecessary tension on the overlying mastec­
tomy skin flaps. This approach also provides the oppor­
tunity for postoperative expander deflation in the event
of continuing tissue compromise.
Postoperative care
Postoperatively, patients are placed into supportive
surgical bras. A tight compressive bra or wrap is avoided
Assessment of skin flap viability
The success of breast reconstruction is dependent on
avoidance of complications. Mastectomy skin flap
necrosis, which occurs at a rate of 10–15%, can have sig­
nificant consequences including major morbidity, delays
in further oncologic treatment, implant loss or revision
procedures, as well as poor aesthetic outcomes.24
Ischemic injury to the breast skin may occur during
the mastectomy if the skin flaps are made too thin or
if there is excessive traction on the skin flaps. Ischemic
injury can also occur during reconstruction as place­
ment of an implant can put direct stress on the skin
flaps, thereby limiting perfusion. Traditional methods
for assessing the likelihood of mastectomy skin flap
necrosis rely almost exclusively on clinician judgment
that includes intraoperative skin color, dermal edge
bleeding, capillary refill time, and skin temperature.
More recently, the incorporation of objective measures,
Fig. 16.7  Skin reduction mastectomy with two-stage reconstruction. (A,B) Preoperative. (C,D) Six months postoperative.
A
B
C
D

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CHAPTER 16 • Skin-sparing mastectomy: Planned two-stage and direct-to-implant breast reconstruction
are necessary in 10–30% of patients, depending on
patient selection and surgeon experience.4,10,27 Common
indications include adjustment of implant size, refine­
ment of the inframammary or lateral mammary folds,
or managing soft-tissue contour irregularities. Lipofill­
ing has become a common adjunct to improve contours
and camouflage the periphery of the implant. It is our
practice to discuss secondary lipofilling with all of our
patients. As techniques improve to monitor skin flap
viability, primary lipofilling of both the pectoral muscle
as well as the subdermal component of the mastectomy
flap will be considered more frequently. This may assist
in decreasing the need for secondary minor revisions.
Planned two-stage breast
reconstruction
Patient selection
Regardless of timing of the reconstruction, patients
undergoing planned two-stage implant-based recon­
struction should ideally be healthy non-smokers who
have good quality expandable chest wall skin and soft
tissues. Patients seeking larger breast sizes may be
reconstructed with implants; however, the surgeon
should assess whether the native soft tissues are of suf­
ficient quality to support the weight of larger implants.
Where this concern exists, consideration is made for
autologous reconstructive options. Patients who are
undergoing unilateral reconstruction to match a moder­
ately ptotic breast may also achieve a better result with
autologous options.
Contraindications to planned two-stage alloplastic
reconstruction include a lack of available expandable
skin or a lack of underlying bony support to withstand
the forces of the overlying expansion. Patients with
existing chronic postmastectomy chest wall pain may
also be poor candidates. Although an accepted risk
factor, pre- or post-reconstruction radiation is not an
absolute contraindication to expansion. In the delayed
setting, we have found two-stage implant reconstruc­
tion to provide acceptable results in the radiated patient
provided the chest wall tissues are soft and compliant
and the patient desires a smaller breast size. Increas­
ingly we have incorporated pre-treatment of the mas­
tectomy flaps with fat grafting to improve the quality,
thickness, and compliance of the mastectomy flaps.28,29
Immediate two-stage implant reconstruction in
patients requiring postoperative radiotherapy has also
been well established.8,30–33 Various protocols exist,
some advocating rapid expansion and expander to
implant exchange prior to radiation versus exchanging
as it may compromise blood flow to the breast skin.
Patients are maintained on oral antibiotics until the
drains are removed. Gentle arm range-of-motion exer­
cises are encouraged immediately. Activity is limited for
4–6 weeks after surgery. When smooth surface devices
are used, displacement massage is started two weeks
after surgery or as tolerated by the patient.
Complications
Significantly lower complication rates are currently
being reported as compared to those published in earlier
studies owing to better materials, increased surgeon
experience, and better coordination between breast sur­
geons and plastic surgeons.6,26 Major complications have
been reported with an overall incidence as low as 6%,
and individual complications including implant loss,
skin necrosis requiring re-operation, infection, hema­
toma, seroma, and capsular contracture as low as 2%
each.10,23 Minor complications such as suture exposure,
delayed healing, and epidermolysis are rare and usually
self resolving with conservative and supportive care.
The largest multi-institutional report comparing early
complications of direct-to-implant reconstruction with
two-stage reconstruction found a higher rate of overall
complications (6.8% compared with 5.4%) and prosthe­
sis failure (1.4%, compared with 0.8%) in direct-to-
implant reconstruction. No significant difference was
found with regard to infection, re-operation, or major
medical complications. Overall, low rates of early com­
plications were found in both groups.2 It is important to
remember that complication rates will be highly depen­
dent on the type of mastectomy performed as well as
the selection of mastectomy incision.27
In direct-to-implant reconstruction, postoperative
complications must be managed aggressively and in
a timely fashion. Seromas and hematomas must be
drained immediately to prevent excess tension on the
overlying skin flaps and to minimize long-term implant
malposition. Skin flap necrosis must be followed closely
and if not healing quickly should be excised and closed
primarily to avoid the possibility of implant exposure.
Skin edge necrosis (2–5 mm) can often be managed with
debridement and closure under local anesthesia. If the
area of necrosis is larger, the implant may need to be
downsized, replaced with an expander, or removed
altogether.
Refinements and secondary procedures
When first described, the insertion of a permanent
prosthesis at the time of mastectomy was erroneously
referred to as a “single-stage reconstruction”. Today, we
understand that secondary revisions and refinements

257
Planned two-stage breast reconstruction
By contrast, in the setting of immediate reconstruc­
tion, the vascularity of the mastectomy flaps are less
predictable, therefore less skin tension on wound closure
is recommended. In addition, the anterior surface of the
pectoralis major is completely detached from the over­
lying skin envelope. As a result the muscle must be
controlled by either maintaining lower pole attachments
to the rectus fascia, or by using internal support matrices
to function as a pectoral extender down to the IMF.
Finally, the lateral border of the mastectomy pocket
often extends well beyond the desired lateral border of
the tissue expander, necessitating the use of either ser­
ratus anterior flaps or an internal support matrix to
control the lateral position of the expander.
Immediate two-stage reconstruction –
surgical technique
The insertion of a tissue expander in breast reconstruc­
tion can be looked at as a “dress rehearsal” for the final
outcome. The process of planning in reverse requires the
surgeon to estimate the size and shape of the final
implant and then select an expander to produce a pocket
that is acceptable for the final device. This is especially
critical when planning to use a shaped implant. Under­
expansion is the key to success. The footprint of the
expander should be narrower and shorter than the final
implant. The authors prefer to use aggressively textured
shaped tissue expanders with integrated ports due to
their ability to provide preferential expansion of the
lower pole of the breast. Suture tabs may help to decrease
expander rotation and malposition. The base width of
the expander is determined by the desired final width
of the reconstructed breast, which may differ from the
width of the original breast. Expander height and pro­
jection is then determined based on the patient’s goals
and on the proportions of the contralateral breast in the
case of unilateral reconstruction.
Markings are made with the patient in the sitting
position, and a team approach is used with both the
oncologic and plastic surgeon present for the markings.
Anatomic landmarks are then marked including the
chest midline, breast meridians, medial and superior
breast borders, and LMFs and IMFs. The choice of inci­
sion is based on a variety of factors including the pre­
operative size and shape of the breast, the desired
postoperative breast size and position, and the location
of pre-existing scars. Ultimately, skin incisions are per­
formed in order to allow the surgeon to carry out a safe
oncologic mastectomy with acceptable margins around
the tumor.
There are several incision options for a skin-sparing
mastectomy in conjunction with immediate expander
the expander for the implant post-radiotherapy. The
authors’ preference in this scenario is to rapidly expand
and exchange prior to radiation when possible. In situ­
ations where postoperative radiation therapy is antici­
pated, the use of ADM as a lower pole support may
assist in minimizing the risk of capsular contracture.
Fig. 16.8 shows the interface between normal capsule
and ADM at the time of expander exchange. The lack of
formation of a capsule in the area of the ADM decreases
the ability of the capsule to tighten in a circumferential
manner, making clinical contracture less likely.
Differences in approach for
delayed and immediate two-stage
alloplastic reconstruction
Important differences exist in the approach to the
delayed versus the immediate two-stage breast recon­
struction. In the delayed setting, the quality, compliance,
and vascularity of soft tissues is already known. This
results in less uncertainty regarding the possibility
of mastectomy flap necrosis, wound dehiscence,
and expander exposure. As these effectively represent
delayed skin flaps, they may be more tolerant of the
tension created by the initial fill of the expander.
In addition, in the delayed setting, the position and
extent of the expander pocket dissection is controlled by
the plastic surgeon, not determined by the existing
mastectomy pocket. This confers a greater degree of
control over the expander position, eliminating the need
for muscle flaps or internal support matrices to control
the lateral position of the expander. Finally, the pectora­
lis major is adhered to the overlying mastectomy flaps,
therefore inferior pectoralis attachments to the ribs can
be divided as in the case of a primary augmentation,
facilitating anterior projection during the expansion
process without the risk of over-retraction of the free
muscle edge superiorly.
Fig. 16.8  Incorporated acellular dermal matrix showing absence of capsule
formation over matrix surface. ADM, acellular dermal matrix.

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CHAPTER 16 • Skin-sparing mastectomy: Planned two-stage and direct-to-implant breast reconstruction
Patients are positioned on the operating table in the
supine position with arms abducted at 90° and sup­
ported on arm boards. All patients receive perioperative
antibiotic prophylaxis. Several staples or sutures are
placed along the IMF in case the inked markings are lost
during the mastectomy procedure.
Following completion of the mastectomy, skin flap
viability is assessed clinically. Any questionable tissue
is conservatively removed, and the decision as to
whether to proceed with immediate reconstruction is
made. Precise hemostasis is achieved with electrocau­
tery. No blunt dissection is performed. In cases where
the expander is to be placed in a total submusculo­
fascial pocket, the pectoral muscle is elevated on its
lateral border and dissected down to the rectus fascia.
The rectus fascia is elevated to a point just inferior
to the IMF. The serratus muscle is lifted laterally,
and then the serratus is closed over the expander to
the lateral edge of the pectoral muscle (Fig. 16.12).
Transverse division of the rectus fascia below the level
insertion. In large breasts with vertical skin excess, a
traditional transverse ellipse provides the opportunity
to decrease the size of the skin envelope with minimal
risk for skin flap compromise (Fig. 16.9). In cases where
the breast should be lifted and narrowed, the ellipse
can be oriented in a more oblique fashion (Fig. 16.10).
Nipple-sparing mastectomies with immediate recon­
struction are becoming increasingly common due to the
large number of prophylactic mastectomies performed
at our center. In smaller breasts, mastectomies are
generally performed through inframammary or lateral
mammary incisions. Occasionally, periareolar incisions
with or without a lateral extension are used for moderate
sized breasts. When significant breast ptosis exists, skin
reduction with nipple sacrifice is usually indicated. Mas­
tectomies are designed using either a vertical or inverted
“T” incision (Fig. 16.11). The inverted “T” skin-reducing
mastectomy can be designed with an inferiorly based
dermal flap to provide better lower pole soft-tissue cov­
erage in case of delayed healing at the “T” junction.34,35
Fig. 16.9  (A) Preoperative view of large breasts with vertical skin excess.
(B) Postoperative view following left mastectomy and reconstruction using a
horizontal mastectomy incision. (C) Final view of same patient following left nipple
areolar reconstruction and right breast balancing reduction.
A
B
C

259
Planned two-stage breast reconstruction
Patients are kept on postoperative oral antibiotics
until the drain is removed. This is performed when the
output falls below 30 cc per 24 hours for two consecu­
tive days. Dressings are kept dry and intact for 5 days,
at which point they are removed. Heavy lifting and
strenuous activity is restricted for 6 weeks. Expander
inflation begins approximately 2 weeks postoperatively
and can be performed weekly as tolerated by the patient.
Injection volumes per expansion can vary between 25
and 150 cc (average of 60 cc per inflation) and are based
on patient comfort and avoidance of signs of skin
blanching or over-tightening. Expansions are continued
until patients are satisfied with breast volume and
before tissues show signs of thinning or become overly
tight. Overexpansion of the breast tissue is not recom­
mended due to consequent thinning of the soft tissues,
increased risk of exposure, and over-dissection and loss
of control of the breast pocket. Depending on the skin
quality, second-stage exchange is performed 1–3 months
following completion of expansion.
of the mastectomy pocket can then be performed to
facilitate anterior projection during the expansion
process.
Today, many surgeons choose to minimize muscle
dissection by lifting the pectoral muscle with a lateral
serratus extension and covering the lower pole of the
expander with an internal support matrix. In this case,
the pectoral muscle is lifted along the IMF maintaining
the lateral attachments to the serratus muscle (Fig.
16.13). This approach allows for improved definition of
the IMF and the LMF as well as accelerating early lower
pole expansion. The pocket is then irrigated with anti­
biotic solution and the skin re-prepped. Using a minimal
touch technique the expander is prepared by bathing it
in antibiotic solution, removing the air, and positioning
it in the pocket. A drain is placed in the subcutaneous
pocket. Meticulous closure is performed with two layers
of absorbable suture. The expander is then partially
inflated with saline, avoiding unnecessary tension on
the incision (see Video 16.1
).
Fig. 16.10  (A) Preoperative view of breast showing vertical and horizontal skin
excess with planned left oblique mastectomy incision indicated. (B) Postoperative
view of same patient following left mastectomy and reconstruction using an oblique
mastectomy incision. (C) Final result following nipple areolar reconstruction.
A
B
C

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CHAPTER 16 • Skin-sparing mastectomy: Planned two-stage and direct-to-implant breast reconstruction
symmetry. The height of the expander is then chosen
based on the desired footprint of the final reconstructed
breast. We prefer to avoid full height expanders to avoid
unnecessary stretching of the upper pole tissues. As
well, overexpansion of the upper pole of the breast
beyond the desired final footprint may lead to loss of
control of the pocket and the potential for superior
implant malposition or rotation of shaped devices.
The patients are marked in the sitting position. Par­
ticular attention is paid to the position of the IMF, as this
can often be blunted or obliterated as a result of the
Delayed two-stage reconstruction –
surgical technique
In the delayed setting, the size of the expander is chosen
preoperatively using the same dimensional approach
described above. The base width of the expander is
determined by direct measurement of the width of the
chest wall. In unilateral reconstructions, the presence of
a wide contralateral breast may necessitate the use of a
wider tissue expander than the chest wall width mea­
surement would suggest in order to achieve optimum
Fig. 16.11  (A) Preoperative view showing significant bilateral breast ptosis and
planned inverted “T” pattern mastectomy with inferiorly based dermal flap.
(B) Intraoperative view showing elevated pectoralis major muscle and undersurface
of inferiorly based dermal flap reflected caudally. (C) Postoperative view of same
patient prior to nipple areolar reconstruction.
A
B
C

Fig. 16.12  (A) Intraoperative view of submuscular pocket dissection showing
elevated pectoralis major (PMM) and serratus anterior muscles, and unelevated
pectoralis minor muscle. (B) Tissue expander positioned in submuscular pocket.
(C) Intraoperative view showing suture line (arrows) following closure of lateral
border of PMM to anterior border of serratus anterior over the tissue expander.
A
Pec Minor
Serratus
PMM
B
C
Fig. 16.13  (A) Intraoperative view of submuscular pocket dissection from an inferior approach with division of inferior pectoralis major fibers while maintaining
attachments between pectoralis major and serratus anterior muscles. (B) Inset of acellular dermal matrix for inferior pole support and tissue expander coverage.
A
B

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CHAPTER 16 • Skin-sparing mastectomy: Planned two-stage and direct-to-implant breast reconstruction
soft tissues to camouflage the shape of the underlying
implant. When patients desire more upper pole fullness,
either as an aesthetic preference or to better balance a
contralateral breast, a round implant is chosen. When
less fullness and a more gradual slope is desired in the
upper pole of the breast, a textured, shaped, form-stable
device is recommended.
In most cases, a portion of the existing scar is reopened
for access. However, in cases where the anterior skin is
very thin, when postoperative radiation to the expander
has occurred, or when excision of the existing scar
would significantly reduce the skin envelope, a new
incision in the IMF is made. A circumferential capsu­
lotomy is performed in the majority of cases, but this
decision is based on the expander position. Selective
capsulectomy is reserved for cases where the anterior
capsule restricts breast expansion or to promote adher­
ence of a textured surface device. Special attention is
made to the position of the IMF. If the fold has become
blunted from the expansion process, permanent sutures
are passed through the superficial fascia at the level of
the IMF via the capsulotomy incision, and then sutured
to the chest wall fascia to create a more defined crease.
In cases where the IMF has been completely obliterated
by the expansion process, then a similar technique is
used, but in this case the superficial fascia is grasped
more inferiorly and elevated up to the planned IMF in
order to try and recreate ptosis at the level of the fold
(Fig. 16.14). Similar techniques are used to adjust the
lateral mammary fold as indicated. Sizers are used to
confirm the adequacy of pocket shape and size in both
the sitting and supine positions prior to implant
insertion.
Following all pocket modifications, the implants are
prepared and inserted. Drains are occasionally used
depending on the degree of capsule manipulation. Fol­
lowing skin closure, the soft tissues are inspected and
lipofilling can be considered for areas of implant visibil­
ity or contour irregularity. Care must be taken to avoid
injection within the implant pocket. If the tissues are too
thin to allow for immediate lipofilling, then this can be
performed in a delayed fashion. Representative cases
are shown in Figs. 16.15 and 16.16.
Complications
Complications in two-stage alloplastic breast recon­
struction are related to either the device or the soft
tissues. Device complications include contracture,
rupture, malposition, rotation, visibility, rippling, or late
problems related to double capsule or seroma. Tissue
complications include infection, thinning or stretching,
necrosis, delayed healing, and dysesthesias of the breast.
previous mastectomy. If absent, the IMF is marked
according to the contralateral breast in unilateral cases,
and according to the patient’s bra position if available
in bilateral cases. Patients are positioned and prepped
as described above.
Typically the existing mastectomy scar is used for
access. If the mastectomy flaps are robust with a
healthy amount of subcutaneous fat, the authors prefer
to open the incision laterally and approach the subpec­
toral pocket from the lateral border of the pectoral
muscle. If, however, the mastectomy flaps are thin lat­
erally, the authors will open the scar centrally, judi­
ciously elevate skin flaps a few centimeters superiorly
and inferiorly, and split the pectoral major muscle
parallel to its fibers to enter the subpectoral pocket. All
dissection is performed using electrocautery with pre-
emptive hemostasis. No blunt dissection is used. The
pocket is dissected exactly to the marked borders and
the muscle is divided inferiorly as with a dual plane
breast augmentation dissection. This facilitates greater
projection of the lower pole during the expansion
process. As the pectoralis major is in continuity with
the overlying skin, windowshading of the muscle
superiorly does not occur. After completion of the
pocket dissection, expander preparation, insertion, and
intraoperative inflation proceeds as described for
immediate reconstruction (see Video 16.2
). Drains
are not routinely used. Dressings are kept dry and
intact for 5 days at which point they are removed and
the patients are allowed to shower. Heavy lifting and
strenuous activity is restricted for 4 weeks.
Expander to implant exchange –
surgical technique
The second stage provides an opportunity to refine the
breast shape and maximize symmetry between the two
breasts. Today, many tools exist to assist the surgeon,
including various implant styles, ADM, and selective
lipofilling. Maxwell describes this as the bioengineered
breast.36 Implant selection is based on the patient’s tissue
characteristics, goals, and the final volume of the tissue
expander. To account for the volume of the expander
shell/port construct, as well as the greater compress­
ibility of implants compared to expanders, the authors
tend to insert implants which are 10–20% larger than
the final expander volume. Silicone implants are almost
exclusively used except in rare circumstances when the
patient expresses a preference for saline. Debate exists
regarding the ability of patients and plastic surgeons to
reliably detect the visual differences between shaped and
round implants. However, in the reconstructive popula­
tion, the absence of breast tissue limits the ability of the

263
Planned two-stage breast reconstruction
A
Skin
Superficial fascia
Pectoralis major
Implant capsule
B
Skin
Superficial fascia
Pectoralis major
Implant capsule
C
Skin
Superficial fascia
Pectoralis major
Implant capsule
Fig. 16.14  (A) Loss of inframammary fold definition secondary to mastectomy
over-dissection and/or tissue expander process; (B) multiple permanent sutures can
be placed between the superficial fascial layer anteriorly and the chest wall
posteriorly to re-define the inframammary fold; (C) placement of the anterior suture
more inferiorly can recruit anterior skin to reproduce ptosis as necessary.

264
SECTION II
CHAPTER 16 • Skin-sparing mastectomy: Planned two-stage and direct-to-implant breast reconstruction
Fig. 16.15  (A) Preoperative view of patient undergoing right delayed and left immediate nipple-sparing mastectomy with two-stage breast reconstruction using 133MV12
tissue expanders. (B) Preoperative oblique view of same patient. (C) Postoperative view following bilateral exchange procedure with insertion of MX410 form-stable silicone
implant and lipofilling to right breast. (D) Postoperative oblique view of same patient.
A
B
C
D

265
Planned two-stage breast reconstruction
Fig. 16.16  (A) Preoperative view of BRCA2-positive patient undergoing bilateral prophylactic mastectomy using an inframammary fold incision and immediate two-stage
breast reconstruction using 133MV500 tissue expanders. (B) Oblique view of same patient. (C,D) Postoperative view of final result following exchange procedure with
insertion of round silicone 540 cc full projection implants and upper pole lipofilling.
A
B
C
D
Asymmetry or concerns with the aesthetic appearance
are other concerns that are often raised by patients.
Careful patient selection, dimensional planning, think­
ing in reverse, precise surgical technique, and a defined
postoperative process will help to keep complications
to a minimum.
Bonus image for this chapter can be found online at

Fig. 16.1 Bilateral nipple-sparing mastectomy through inframammary fold
incision. Direct-to-implant reconstruction with shaped cohesive gel implants
and acellular dermal matrix. (A,B) Preoperative. (C,D) One year postoperative.

266
SECTION II
CHAPTER 16 • Skin-sparing mastectomy: Planned two-stage and direct-to-implant breast reconstruction
2. Davila AA, Mioton LM, Chow G, et al. Immediate two-stage tissue
expander breast reconstruction compared with one-stage permanent
implant breast reconstruction: a multi-institutional comparison of
short-term complications. J Plast Surg Hand Surg. 2013;47:344–349.
One of the largest multi-institutional reviews comparing complications in
immediate one-stage versus two-stage alloplastic breast reconstruction.
Series included over 10 000 patients and showed increased complication
rates among those undergoing immediate implant placement.
4. Gdalevitch P, Ho A, Genoway K, et al. Direct-to-implant single-
stage immediate breast reconstruction with acellular dermal matrix:
predictors of failure. Plast Reconstr Surg. 2014;133:738e–747e.
Retrospective cohort study to identify predictors of failure in single-stage
immediate alloplastic breast reconstruction. Results shold help guide
readers in patient selection for one-stage reconstruction and avoid those at
high risk of early revision surgery.
6. Colwell AS, Damjanovic B, Zahedi B, et al. Retrospective review of
331 consecutive immediate single-stage implant reconstructions
with acellular dermal matrix. Plast Reconstr Surg. 2011;128:1170–
1178. This retrospective review of 331 consecutive single-stage implant
reconstructions with ADM provides insight into the learning curve
associated with incorporating single-stage implant reconstruction into a
practice, as well as data on surgical complications, and a cost comparison
between single and two-stage alloplastic reconstruction.
11. Wink JD, Fischer JP, Nelson JA, et al. Direct-to-implant breast
reconstruction: an analysis of 1612 cases from the ACS-NSQIP
surgical outcomes database. J Plast Surg Hand Surg. 2014;48:375–381.
Retrospective review of direct-to-implant outcomes from the ACS-NSQIP
database highlighting the importance of patient selection and providing
population level data identifying groups of patients at higher risk of
complications, including obese patients and smokers.
15. Hoppe IC, Yueh JH, Wei CH, et al. Complications following
expander/implant breast reconstruction utilizing acellular dermal
matrix: a systematic review and meta-analysis. Eplasty. 2011;11:e40.
Meta-analysis of available studies evaluating the complications rates of
ADM-assisted expander/implant breast reconstruction compared to
traditional expander/implant breast reconstruction without ADM. The
final analysis included 8 studies representing 977 ADM-assisted
expanders and 3840 expanders without ADM. Data indicates a two-fold
increase in infections when ADM was used and a three-fold increase in
seroma formation when ADM was used. The use of ADM facilitated
higher intraoperative expander filling in the ADM group.
21. Ganz OM, Tobalem M, Perneger T, et al. Risks and benefits of using
an absorbable mesh in one-stage immediate breast reconstruction.
Plast Reconstr Surg. 2015;135:498e–507e. Retrospective review of
immediate one-stage implant reconstruction with total submuscular pocket
compared to partial submuscular pocket with vicryl mesh. The authors
conclude the use of vicryl mesh allows for larger implant volumes, better
pocket control, and decreased need for contralateral balancing mastopexy.
The authors advocate the use of vicryl mesh as a lower cost alternative to
the use of biologic scaffolds or traditional two-stage reconstruction with
expanders.
23. Salzberg CA. Focus on technique: one-stage implant-based breast
reconstruction. Plast Reconstr Surg. 2012;130:95S–103S. Seminal article
describing the technique of ADM-assisted one-stage immediate breast
reconstruction, including indications, preoperative planning, implant
selection, and detailed description of surgical staps and execution. Includes
online videos of the technique.
28. Sarfati I, Ihrai T, Kaufman G, et al. Adipose-tissue grafting to the
post-mastectomy irradiated chest wall: preparing the ground for
implant reconstruction. J Plast Reconstr Aesthet Surg. 2011;64:1161–
1166. One of the first publications demonstrating the benefits of
autologous fat transfer to the irradiate mastectomy bed prior to performing
implant-based breast reconstruction in patients who refused or were not
candidates for autologous reconstruction. The authors describe their
grafting technique, complications, and ratings of cosmetic outcomes.
31. Cordeiro PG, Albornoz CR, McCormick B, et al. The impact of
postmastectomy radiotherapy on two-stage implant breast
reconstruction: an analysis of long-term surgical outcomes, aesthetic
results, and satisfaction over 13 years. Plast Reconstr Surg.
2014;134:588–595. The authors present the largest prospective long-term
outcomes evaluation of women undergoing immediate two-stage alloplastic
breast reconstruction with postmastectomy radiation compared to those
not having radiation. The authors report that despite higher rates of
implant loss, converting to flap reconstruction, and capsular contracture
in the irradiated group, 90% of those who received radiation had good to
excellent cosmesis and patient satisfaction.
32. Nava MB, Pennati AE, Lozza L, et al. Outcome of different timings
of radiotherapy in implant-based breast reconstructions. Plast
Reconstr Surg. 2011;128:353–359. Comparison of outcomes between
delivery of radiation during tissue expansion versus radiating the final
implant following expander to implant exchange. The authors report a
six-fold increase in failure of the reconstruction when radiation was
administered during the expansion phase.
Access the complete reference list online at

266.e1
References
References
1. Radovan C. Tissue expansion in soft-tissue reconstruction. Plast
Reconstr Surg. 1984;74:482–492.
2. Davila AA, Mioton LM, Chow G, et al. Immediate two-stage tissue
expander breast reconstruction compared with one-stage permanent
implant breast reconstruction: a multi-institutional comparison of
short-term complications. J Plast Surg Hand Surg. 2013;47:344–349.
One of the largest multi-institutional reviews comparing complications in
immediate one-stage versus two-stage alloplastic breast reconstruction.
Series included over 10 000 patients and showed increased complication
rates among those undergoing immediate implant placement.
3. De Blacam C, Momoh AO, Colakoglu S, et al. Cost analysis of
implant-based breast reconstruction with acellular dermal matrix.
Ann Plast Surg. 2012;69:516–520.
4. Gdalevitch P, Ho A, Genoway K, et al. Direct-to-implant single-
stage immediate breast reconstruction with acellular dermal matrix:
predictors of failure. Plast Reconstr Surg. 2014;133:738e–747e.
Retrospective cohort study to identify predictors of failure in single-stage
immediate alloplastic breast reconstruction. Results shold help guide
readers in patient selection for one-stage reconstruction and avoid those at
high risk of early revision surgery.
5. Jansen LA, Macadam SA. The use of AlloDerm in postmastectomy
alloplastic breast reconstruction: part II. A cost analysis. Plast
Reconstr Surg. 2011;127:2245–2254.
6. Colwell AS, Damjanovic B, Zahedi B, et al. Retrospective review of
331 consecutive immediate single-stage implant reconstructions
with acellular dermal matrix. Plast Reconstr Surg. 2011;128:1170–
1178. This retrospective review of 331 consecutive single-stage implant
reconstructions with ADM provides insight into the learning curve
associated with incorporating single-stage implant reconstruction into a
practice, as well as data on surgical complications, and a cost comparison
between single and two-stage alloplastic reconstruction.
7. Alperovich M, Choi M, Frey JD, et al. Nipple-sparing mastectomy
in patients with prior breast irradiation: are patients at higher risk
for reconstructive complications? Plast Reconstr Surg. 2014;134:
202e–206e.
8. Nahabedian MY. AlloDerm performance in the setting of prosthetic
breast surgery, infection, and irradiation. Plast Reconstr Surg.
2009;124:1743–1753.
9. Colwell AS, Tessler O, Lin AM, et al. Breast reconstruction
following nipple-sparing mastectomy. Plast Reconstr Surg.
2014;133:496–506.
10. Salzberg CA, Ashikari AY, Koch RM, Chabner-Thompson E. An
8-year experience of direct-to-implant immediate breast
reconstruction using human acellular dermal matrix (AlloDerm).
Plast Reconstr Surg. 2011;127:514–524.
11. Wink JD, Fischer JP, Nelson JA, et al. Direct-to-implant breast
reconstruction: an analysis of 1612 cases from the ACS-NSQIP
surgical outcomes database. J Plast Surg Hand Surg. 2014;48:375–381.
Retrospective review of direct-to-implant outcomes from the ACS-NSQIP
database highlighting the importance of patient selection and providing
population level data identifying groups of patients at higher risk of
complications, including obese patients and smokers.
12. Cheng A, Lakhiani C, Saint-Cyr M. Treatment of capsular
contracture using complete implant coverage by acellular dermal
matrix: a novel technique. Plast Reconstr Surg. 2013;132:519–529.
13. Chun YS, Verma K, Rosen H, et al. Implant-based breast
reconstruction using acellular dermal matrix and the risk of
postoperative complications. Plast Reconstr Surg. 2010;125:429–436.
14. Collis GN, TerKonda SP, Waldorf JC, Perdikis G. Acellular dermal
matrix slings in tissue expander breast reconstruction. Ann Plast
Surg. 2012;68:425–428.
15. Hoppe IC, Yueh JH, Wei CH, et al. Complications following
expander/implant breast reconstruction utilizing acellular dermal
matrix: a systematic review and meta-analysis. Eplasty. 2011;11:e40.
Meta-analysis of available studies evaluating the complications rates of
ADM-assisted expander/implant breast reconstruction compared to
traditional expander/implant breast reconstruction without ADM. The
final analysis included 8 studies representing 977 ADM-assisted
expanders and 3840 expanders without ADM. Data indicates a two-fold
increase in infections when ADM was used and a three-fold increase in
seroma formation when ADM was used. The use of ADM facilitated
higher intraoperative expander filling in the ADM group.
16. Kim JYS, Davila AA, Persing S, et al. A meta-analysis of human
acellular dermis and submuscular tissue expander breast
reconstruction. Plast Reconstr Surg. 2012;129:28–41.
17. Lanier ST, Wang ED, Chen JJ, et al. The effect of acellular dermal
matrix use on complication rates in tissue expander/implant breast
reconstruction. Ann Plast Surg. 2010;64:674–678.
18. Liu AS, Kao H-K, Reish RG, et al. Postoperative complications in
prosthesis-based breast reconstruction using acellular dermal
matrix. Plast Reconstr Surg. 2011;127:1755–1762.
19. Nguyen M-D, Chen C, Colakoğlu S, et al. Infectious complications
leading to explantation in implant-based breast reconstruction with
alloderm. Eplasty. 2010;10:e48.
20. Tessler O, Reish RG, Maman DY, et al. Beyond biologics. Plast
Reconstr Surg. 2014;133:90e–99e.
21. Ganz OM, Tobalem M, Perneger T, et al. Risks and benefits of using
an absorbable mesh in one-stage immediate breast reconstruction.
Plast Reconstr Surg. 2015;135:498e–507e. Retrospective review of
immediate one-stage implant reconstruction with total submuscular pocket
compared to partial submuscular pocket with vicryl mesh. The authors
conclude the use of vicryl mesh allows for larger implant volumes, better
pocket control, and decreased need for contralateral balancing mastopexy.
The authors advocate the use of vicryl mesh as a lower cost alternative to
the use of biologic scaffolds or traditional two-stage reconstruction with
expanders.
22. Maman D, Austen W. Immediate single-stage breast implant
reconstruction with absorbable mesh. Plast Reconstr Surg.
2012;130:490–491.
23. Salzberg CA. Focus on technique: one-stage implant-based breast
reconstruction. Plast Reconstr Surg. 2012;130:95S–103S. Seminal article
describing the technique of ADM-assisted one-stage immediate breast
reconstruction, including indications, preoperative planning, implant
selection, and detailed description of surgical staps and execution. Includes
online videos of the technique.
24. Munabi NCO, Olorunnipa OB, Goltsman D, et al. The ability of
intra-operative perfusion mapping with laser-assisted indocyanine
green angiography to predict mastectomy flap necrosis in breast
reconstruction: a prospective trial. J Plast Reconstr Aesthet Surg.
2014;67:449–455.
25. Komorowska-Timek E, Gurtner GC. Intraoperative perfusion
mapping with laser-assisted indocyanine green imaging can predict
and prevent complications in immediate breast reconstruction. Plast
Reconstr Surg. 2010;125:1065–1073.
26. Scheflan M, Colwell AS. Tissue reinforcement in implant-based
breast reconstruction. Plast Reconstr Surg Glob Open. 2014;2:e192.
27. Salgarello M, Visconti G, Barone-Adesi L. Nipple-sparing
mastectomy with immediate implant reconstruction: cosmetic
outcomes and technical refinements. Plast Reconstr Surg.
2010;126:1460–1471.
28. Sarfati I, Ihrai T, Kaufman G, et al. Adipose-tissue grafting to the
post-mastectomy irradiated chest wall: preparing the ground for
implant reconstruction. J Plast Reconstr Aesthet Surg. 2011;64:1161–
1166. One of the first publications demonstrating the benefits of
autologous fat transfer to the irradiate mastectomy bed prior to performing
implant-based breast reconstruction in patients who refused or were not
candidates for autologous reconstruction. The authors describe their
grafting technique, complications, and ratings of cosmetic outcomes.
29. Ribuffo D, Atzeni M, Guerra M, et al. Treatment of irradiated
expanders: protective lipofilling allows immediate prosthetic breast
reconstruction in the setting of postoperative radiotherapy. Aesthetic
Plast Surg. 2013;37:1146–1152.
30. Cordeiro PG, Pusic AL, Disa JJ, et al. Irradiation after immediate
tissue expander/implant breast reconstruction: outcomes,
complications, aesthetic results, and satisfaction among 156
patients. Plast Reconstr Surg. 2004;113:877–881.
31. Cordeiro PG, Albornoz CR, McCormick B, et al. The impact of
postmastectomy radiotherapy on two-stage implant breast
reconstruction: an analysis of long-term surgical outcomes, aesthetic
results, and satisfaction over 13 years. Plast Reconstr Surg.
2014;134:588–595. The authors present the largest prospective long-term
outcomes evaluation of women undergoing immediate two-stage alloplastic

266.e2
SECTION II
CHAPTER 16 • Skin-sparing mastectomy: Planned two-stage and direct-to-implant breast reconstruction
breast reconstruction with postmastectomy radiation compared to those
not having radiation. The authors report that despite higher rates of
implant loss, converting to flap reconstruction, and capsular contracture
in the irradiated group, 90% of those who received radiation had good to
excellent cosmesis and patient satisfaction.
32. Nava MB, Pennati AE, Lozza L, et al. Outcome of different timings
of radiotherapy in implant-based breast reconstructions. Plast
Reconstr Surg. 2011;128:353–359. Comparison of outcomes between
delivery of radiation during tissue expansion versus radiating the final
implant following expander to implant exchange. The authors report a
six-fold increase in failure of the reconstruction when radiation was
administered during the expansion phase.
33. Ho A, Cordeiro P, Disa J, et al. Long-term outcomes in breast cancer
patients undergoing immediate 2-stage expander/implant
reconstruction and postmastectomy radiation. Cancer.
2012;118:2552–2559.
34. Mattteucii P, Fourie LR. Skin sparing mastectomy using the Wise
pattern: protecting the T-junction with a dermal pedicle. Br J Plast
Surg. 2004;57:473–475.
35. Torstenson T, Boughey JC, Saint-Cyr M. Inferior dermal flap in
immediate breast reconstruction. Ann Surg Oncol. 2013;20:334–339.
36. Maxwell GP, Gabriel A. Possible future development of implants
and breast augmentation. Clin Plast Surg. 2009;36:167–172, viii.

SECTION II • Reconstructive Breast Surgery
17 
Secondary procedures following prosthetic
breast surgery
G. Patrick Maxwell and Allen Gabriel
SYNOPSIS
■ Breast augmentation is the most common aesthetic procedure
performed in the US.
■ Revisionary breast surgeries are complex, challenging, and
unpredictable.
■ The four main drivers for revisionary surgery are capsular contracture,
implant malposition, ptosis, and implant visibility or palpability.
■ Revisionary surgery techniques are introduced that utilize a site change
operation with the use of acellular dermal matrix (ADM).
■ Detailed recommendations are provided so that the reader can utilize
advanced techniques to treat any secondary breast complication
related to implants.
Access the Historical Perspective section online at

Introduction
It is estimated that over 300 000 primary breast augmen­
tations were performed in the US in 2014, and therefore
there are now over 3 million women with augmented
breasts in this country.1–3 Based on current data, between
15% and 30% of these women will have a re-operation
within 5 years of their initial procedure.1–3 Unfortunately,
this rate climbs to 35% in patients with prior history
of revisionary breast augmentation.4 As procedures
become more complex in nature and number, new
techniques and solutions are required of surgeons
who perform these challenging operations in order to
improve long-term patient outcomes.
Capsular contracture has historically been the most
common complication of aesthetic and reconstructive
breast surgery and remains the primary reason for most
revisionary surgeries.2,3,5,6 While increasing data sug­
gests capsular contracture can be minimized in primary
augmentation by adhering to specific technical factors,
such as precise, atraumatic, and bloodless pocket dis­
section; appropriate antibiotic irrigation of the breast
pocket; and minimizing any points of contamination
during the procedure,4,7 treatment of an established
capsule remains even more challenging than the appli­
cation of these techniques alone.
With the enforcement of the United States Food and
Drug Administration (FDA) restrictions on silicone gel
implants in the early 1990s, many plastic surgeons in the
US began to use saline implants.1 Prior to the 1992
“moratorium”, the majority of silicone gel implants
were placed in the subglandular position, whereas
saline implants (due to their palpability) were placed in
the subpectoral position in an effort to conceal the
untoward contour irregularities of these implants.8
Many of these implants were of larger volumes, thus
many patients experienced thinning of the breast
parenchyma and the overlying soft tissues. This was
independent of whether the implants were located in
subglandular or subpectoral positions. The thinned
parenchymal tissues in turn led to long-term complica­
tions that instigated some key drivers of revisionary
breast surgery.
The four primary reasons (or “drivers”) for aesthetic
revisionary surgery in the premarket approval (PMA)
studies were9 (1) capsular contracture, (2) implant mal­
position, (3) ptosis, and (4) implant visibility or palpa­
bility. Frequently, these indications were not singularly
distinct but were combined, with two or more being
present in a given patient.