Cosmetic and Reconstructive Breast Surgery

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First published 2009
ISBN: 978-0-7020-2915-8
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A catalogue record for this book is available from the British Library
Cosmetic and reconstructive breast surgery. – (Procedures in reconstructive surgery series)
1. Mammaplasty
I. Nahabedian, Maurice
618.1′9059
ISBN-13: 9780702029158
Library of Congress Cataloging in Publication Data
A catalog record for this book is available from the Library of Congress
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vii
SERIES PREFACE
When I was studying for my Plastic Surgery Oral Boards
and during my training, I was struck by the lack of a book
that would explain common procedures in plastic surgery
for specifi c problems. This is probably due to the unique
and creative drive of our specialty and its emphasis on
multiple approaches. Spurred by this seeming lack of a one
volume book to carry to the operating room or utilize for
studying, we produced an atlas for plastic surgery that
would focus of common approaches to commonly seen
problems. Now eight years later, the continued interest in
such a book has produced this four volume set. The purpose
of these volumes is to allow the student, resident or plastic
surgeon to read and absorb common approaches to plastic
surgery problems seen routinely. It is our hope that the
procedures discussed in these volumes will allow quick in
depth approaches, proposing common indications, surgical
techniques, postoperative care and avoidance of pitfalls for
common surgical problems. The student, resident or plastic
surgeon should be able to utilize each of these volumes as
a quick and easy access to treatment options for their
patients. It is our desire that these volumes will become as
popular as our fi rst volume eight years ago and that a new
generation of plastic surgeons will use, benefi t and enjoy
the books for years to come.

G.R.D.E.

ix
VOLUME PREFACE
Cosmetic and Reconstructive Breast Surgery represents a
novel approach in the preparation of a learning tool for
plastic surgeons. The text is structured in a ‘how-to’
approach with a basic template that has been applied to all
chapters. It has been highly illustrated with clinical pearls
that should be useful to those who perform these opera-
tions. Many of the chapters have an audiovisual component
that is intended to take the reader step-by-step through an
operation. We feel that the combination of written and
audiovisual material sets it apart from all previously pub-
lished textbooks on cosmetic and reconstructive breast
surgery and should facilitate one’s ability to perform these
operations at a higher level of understanding and ability.
The book is intended for all surgeons interested in breast
surgery to review many of the essential principles, concepts,
and techniques associated with cosmetic and reconstructive
breast surgery and to provide some insight and clinical
pearls that will facilitate one’s ability to better master these
procedures. There is a mix of reconstructive and cosmetic
operations that were selected based on interest, need, and
frequency. The contributors for each chapter were selected
based on talent, ability, reputation, and a commitment to
the educational process. The fi nal product represents a
compendium of breast operations that the plastic surgeon
should be able to perform and master.
There are several individuals that I would like to thank
for, without them, completion of the text would not have
been possible. The fi rst is Gregory R. D. Evans, MD who
invited me to be the principal editor of the section on breast
surgery. Greg and I were residents together at Johns Hopkins
and have maintained a friendship since. Greg has always
been a source of inspiration because he works as hard
as anyone I know. I would also like to thank the staff at
Elsevier for their hard work and commitment towards pub-
lishing a truly outstanding series on Procedures in Recon-
structive Surgery. Finally, I would like to thank my family,
Anissa, Danielle, and Sophia, for their support, patience,
and understanding during the many hours spent in the
preparation of this work.
M.Y.N.

xi
Contributors
Siamak Agha-Mohammadi, MD, PhD
Clincial Assistant Professor of Surgery
(Plastic)
University of Pittsburgh Medical School
Hurwitz Center for Plastic Surgery
Pittsburgh, PA
USA
Diane Z. Alexander, MD, FACS
Artisan Plastic Surgery
Atlanta, GA
USA
Bernadette Wang Ashraf, MD, FACS
Artisan Plastic Surgery
Atlanta, GA
USA
Kristin A. Boehm, MD, FACS
Clinical Professor, Emory University
Paces Plastic Surgery
Atlanta, GA
USA
Bernard W. Chang, MD
Chief of Plastic Surgery
Mercy Medical Center;
Associate Professor of Surgery
Johns Hopkins School of Medicine
Plastic and Reconstructive Surgery at
Mercy
Baltimore, MD
USA
David W. Chang, MD, FACS
Professor of Surgery
Department of Plastic Surgery
The University of Texas M.D. Anderson
Cancer Center
Houston, TX
USA
Mark W. Clemens, MD
Resident
Department of Plastic Surgery
Georgetown University Medical Center
Washington, DC
USA
Steven P. Davison, MD, DDS, FACS
Associate Professor of Surgery
Department of Plastic Surgery
Georgetown University Medical Center
Washington, DC
USA
Joseph H. Dayan, MD
Chief Resident
Georgetown University Hospital
Washington, DC
USA
Joseph J. Disa, MD, FACS
Associate Attending Surgeon
Memorial Sloan-Kettering Cancer Center
Plastic and Reconstructive Surgery Service
New York, NY
USA
Matthew D. Goodwin, MD
Plastic and Reconstructive Surgeon
Boca Raton, FL
USA
Elizabeth J. Hall-Findlay, MD, FRCSC
Private Practice
Mineral Springs Hospital
Banff, AB
Canada
Moustapha Hamdi, MD
Associate Professor of Plastic Surgery
Department of Plastic and Reconstructive
Surgery
Gent University Hospital
Gent
Belgium
Dennis C. Hammond, MD
Center for Breast and Body Contouring
Grand Rapids, MI
USA
John Hijjawi, MD
Stephen Kroll Clinical Fellow, 2006
Department of Plastic and Reconstructive
Surgery
Gent University Hospital
Gent
Belgium;
Assistant Professor of Plastic Surgery
Department of Plastic Surgery
Medical College of Wisconsin and
Froedtert Hospital
Milwaukee, WI
USA
Dennis J. Hurwitz, MD, FACS
Clinical Professor of Surgery (Plastic)
University of Pittsburgh Medical School
Hurwitz Center for Plastic Surgery
Pittsburgh, PA
USA
Steven J. Kronowitz, MD, FACS
Associate Professor of Plastic Surgery
Department of Plastic Surgery
The University of Texas M.D. Anderson
Cancer Center
Houston, TX
USA
Colleen M. McCarthy, MD, MSc, FRCSC
Fellow
Memorial Sloan-Kettering Cancer Center
Plastic and Reconstructive Surgery Service
New York, NY
USA
Ali N. Mesbahi, MD
Resident in Plastic Surgery
Department of Plastic Surgery
Georgetown University Hospital
Washington, DC
USA
Maurice Y. Nahabedian, MD, FACS
Associate Professor of Plastic Surgery
Georgetown University
Washington, DC
USA
Foad Nahai, MD, FACS
Clinical Professor
Emory University;
Paces Plastic Surgery & Recovery Center
Atlanta, GA
USA

xii
Kenneth C. Shestak, MD
Plastic Surgery Service
Magee Women’s Hospital
Pittsburgh, PA
USA
Scott L. Spear, MD
Chairman
Department of Plastic Surgery
Georgetown University Hospital
Washington, DC
USA
Michael R. Zenn, MD, FACS
Associate Professor
Division of Plastic and Reconstructive
Surgery
Duke University Medical Center
Durham, NC
USA
Contributors

1
C H A P T E R
1
Breast Reconstruction with Tissue
Expanders and Implants
Maurice Y. Nahabedian and Ali N. Mesbahi
INTRODUCTION
Prosthetic devices for breast reconstruction following mas-
tectomy have been available since the 1980s, and the use
of expanders and implants is arguably the most commonly
used technique. Over the past decade there have been sig-
nifi cant advancements regarding the devices themselves
and the methods of insertion that have promoted the safety
and effi cacy of this technique. This chapter focuses on
many of the salient aspects of breast reconstruction using
tissue expanders and/or implants. Emphasis will be placed
on patient selection, device selection, one- versus two-
stage reconstruction, immediate versus delayed reconstruc-
tion, delayed-immediate reconstruction, expander–implant
reconstruction in the setting of radiation therapy, expander–
implant reconstruction using bioprosthetic materials, and
the management of complications.
INDICATIONS AND CONTRAINDICATIONS
Patient selection
Patient selection is becoming increasingly recognized as an
important consideration when deciding on reconstructive
options. As the techniques and methods to reconstruct a
breast have improved, so have patient expectations been
enhanced. It is no longer acceptable to merely create a
mound on the chest wall: most women are interested in
both volume and contour symmetry following either uni-
lateral or bilateral reconstruction. With the variety of
devices currently available, the ability to create a breast
with symmetry of volume, position, and contour has
increased.
Perhaps one of the most important aspects of patient
selection is to understand their expectations. It is critical
for women interested in breast reconstruction to under-
stand that the reconstructed breast will not look exactly like
the natural breast. The appearance may improve or it may
not: the point is that it will be different. Women should
understand that breast reconstruction is a staged procedure
and that sometimes, several procedures will be necessary
before a fi nal desirable outcome can be achieved. Complica-
tions can occur regardless of the method of reconstruction
selected. These may be minor or major and can include
bleeding, infection, and reconstructive failure, which in the
case of prosthetic devices includes premature removal,
rupture, and capsular contracture.
Current options for women interested in breast recon-
struction include autologous tissue or prosthetic devices.
Although there is signifi cant overlap in the criteria that
would allow these procedures to be performed in a given
woman, various factors should be considered that may
result in the selection of one method rather than another.
It is important to recognize that just about any size breast
can be reconstructed with a prosthetic device. The most
commonly used method of assessing breast size is via bra
size. Although there are more quantifi able methods to
make this assessment, such as three-dimensional imaging
techniques, most women have a reasonable understanding
of breast volume using bra sizing mechanics.
Relative contraindications for breast reconstruction with
tissue expanders and implants are recognized. Body habitus
will usually correlate with breast size. Morbid obesity is a
relative contraindication for prosthetic reconstruction
because the outcomes are often less satisfactory than in
women with a moderate body habitus. In these situations,
the expander or implant will have a signifi cant volume that
is below the projecting surface of the chest wall and will
result in a breast with poor projection and contour. The
delivery of radiotherapy before breast reconstruction with
prosthetic devices is also a relative contraindication because
the fi brosis that occurs following radiotherapy will often
make breast expansion diffi cult. When making these

Cosmetic and Reconstructive Breast Surgery
2
decisions, it is important to assess patient expectations and
recognize the inherent strengths and limitations of a given
technique.
During the initial consultation with a woman regarding
options for breast reconstruction following mastectomy, it
may become very evident that she is interested in a proce-
dure that is relatively quick, results in little downtime, and
is associated with minimal morbidity. For many women
considering prosthetic reconstruction, it is important to
resume activities of daily living quickly, or to be able to
continue with their physical activity with little disruption.
Prosthetic devices are excellent in this regard because there
are no additional operative sites, which facilitates postop-
erative recovery. In addition, women who choose to proceed
with prosthetic reconstruction will continue to remain can-
didates for autologous reconstruction in the event of pros-
thetic failure or patient desire.
Prosthesis selection
The traditional patient for breast reconstruction with pros-
thetic devices is one who is generally thin, with small
breasts, and with none or only mild breast ptosis. Fortu-
nately, with the variety of implantable devices now avail-
able, these characteristics have expanded and can include
women with a variety of body and breast shapes. It is now
possible to create a breast with natural contours using
prosthetic devices with volumes based on bra cup sizes
ranging from A to D. Plastic surgeons have the luxury of a
large number of devices at their disposal that will allow the
creation of a breast with good to excellent aesthetic out-
comes. The implants that are currently available vary in
shape, surface texture, size, and fi ller material (Figs 1.1–1.3)
Selection of the optimal device can at times be perplexing;
however, there are several principles and concepts to facili-
tate the process. In general, decisions regarding the shape
of the device are based on the physical appearance of the
natural breast and patient expectations. Contoured and
high-profi le devices will usually enhance breast projection,
whereas round and mild to moderate-profi le devices will
result in less projection and have the potential for increased
ptosis. A textured surface is used for contoured devices to
prevent malrotation. A smooth surface is usually used for
round implants and will permit increased mobility of the
breast. Silicone gel devices will more closely mimic the
natural ‘feel’ of the breast compared to saline-fi lled devices.
They also improve appearance because there is usually less
wrinkling and rippling associated with silicone gel than
with saline. Breast implant size is guided by patient expec-
tations but optimized based on the volume, base diameter,
and surface characteristics of the natural breast as well as
the body habitus.
FIGURE 1.1 Contour profi le tissue expander. This is the most
common type of tissue expander used for the fi rst stage of a two-
stage breast reconstruction. It has a textured surface, an integrated
fi ll valve, and is fi lled with saline.
FIGURE 1.2 Postoperatively adjustable expander/implant. This device
can be used for one-stage reconstruction or as the permanent
implant during the second stage of a two-stage reconstruction. The
remote valve is secured to the chest wall and removed as a separate
procedure when postoperative volume symmetry is achieved.
FIGURE 1.3 Contour profi le implant. These devices are ideal for the
second stage of a two-stage reconstruction. The highly cohesive
silicone gel implants are form-stable and can promote ideal breast
contours.

Breast Reconstruction with Tissue Expanders and Implants
3
The use of silicone gel implants for breast reconstruc-
tion has been receiving increasing attention. These devices
have been available since 1963, but since 1990 have been
subject to signifi cant controversy and debate, especially in
the United States. Since that time, there have been hun-
dreds of scientifi c studies and publications supporting the
safety and effi cacy of these devices. Currently, silicone gel
implants are available to all women for breast reconstruc-
tion, and in this author’s practice are preferred by the
majority because of their superior qualities. Improvements
in gel cohesiveness and shell integrity, as well as scientifi c
and epidemiologic studies demonstrating no adverse health
consequences, have resulted in widespread acceptance of
these devices.
The consultation
There are many important issues that must be discussed
before proceeding with prosthetic breast reconstruction.
These points are the opinion of the primary author and may
not apply to everyone. One of the fi rst is that prosthetic
devices can result in a beautiful reconstruction. However,
the devices will not last forever. They all have a fi nite life-
span and will more likely than not have to be removed or
replaced at some future date. Reasons for failure include
capsular contracture, rupture, infection, and poor aesthetic
outcome. In general, implant-based breast reconstruction
tends to deteriorate over time because of the body’s response
to foreign substances.
The issue of patient expectations is important to reiter-
ate. It must be understood that more than one operation
may be necessary before the fi nal result is achieved. Second-
ary operations are usually spaced apart by at least 3 months
to allow for the previous procedure to mature. The recon-
structed breast can look good, but it will be different from
the non-operated breast.
Pre- and postoperative photographs should be reviewed
in order to review possible outcomes, which may be excel-
lent, average, or poor. Some women are under the impres-
sion that breast reconstruction with implants is similar to
breast augmentation with implants. It must be explained
that the reconstructed breast will usually project more and
feel different from the natural breast, because the implant
is essentially responsible for 90–95% of the projecting
volume, whereas with augmentation a much larger percent-
age of the projecting volume is natural breast tissue. Fol-
lowing a mastectomy there is very little subcutaneous fat
remaining. The photographs will also help women to under-
stand the nature and location of the scars, as well as the
fact that they may be pink to red for 1 or 2 years after the
operation.
OPERATIVE APPROACH
Immediate breast reconstruction using
prosthetic devices
Immediate reconstruction using prosthetic devices is cur-
rently the most commonly performed breast reconstruction
technique
for
women
following
mastectomy.
The
reasons for this are multifactorial and include a relatively
simple operation, facilitated recovery, and little downtime.
Many women are averse to removing tissues from remote
parts of their body resulting in additional scars, potential
donor site morbidity, and prolonged recovery. The technol-
ogy and practice of breast reconstruction with prosthetic
devices have signifi cantly changed and improved over the
recent past, but controversies have always existed and still
continue. There has always been debate over whether to
proceed with one- or two-stage reconstruction using pros-
thetic devices. The reality is that both methods are appro-
priate and acceptable in certain situations, and will be
reviewed here.
Two-stage breast reconstruction with
expanders and implants
Two-stage prosthetic reconstruction is arguably more com-
monly performed than its one-stage counterpart. The prin-
ciple behind two-stage reconstruction is that the mastectomy
skin is fi rst expanded with a temporary device or tissue
expander in order to attain the desired volume. During the
second stage the tissue expander is removed and a per-
manent implant inserted. This creates a breast that is
optimally shaped, contoured, and positioned (Fig. 1.4).
One-stage immediate breast reconstruction can be per-
formed when there is little need to expand the skin follow-
ing the mastectomy, for example after mastectomy with
nipple/areolar preservation, or following skin-sparing mas-
tectomy in a woman with a small or non-ptotic breast. Both
techniques are capable of delivering an acceptable outcome.
Outcome is ultimately linked to proper patient selection,
device selection, and surgeon experience.
Planning: Stage 1
In formulating a plan for breast reconstruction using a
tissue expander, various factors should be considered. These
include the type of mastectomy (nipple/areolar sparing, skin
sparing, or non-skin sparing), type of implant (profi le height,
length and volume of implant), quality of the mastectomy
BOX 1.1 Two-stage immediate breast reconstruction
with expanders and implants
●
The amount of skin preserved at the time of mastectomy
correlates inversely with the need for expansion: the more
skin envelope present, the less need for volume or
expansion.
●
Options for expander placement include total muscular
coverage, ‘dual-plane’ technique, and pectoralis extender
method with bioprosthetic material.
●
Potential pitfalls associated with total muscular coverage
include patient discomfort during the expansion process and
the potential for superior displacement of the device due to
muscle spasm.
●
Consider potential for adjuvant radiation and chemotherapy.

Cosmetic and Reconstructive Breast Surgery
4
mined in the operating room based on the weight of the
mastectomy specimen.
Stage 1 using a tissue expander only
The preoperative markings include the sternal midline, the
inframammary and lateral mammary folds, and delineation
of a proposed mastectomy incision. Rather than performing
a circular incision around the nipple–areolar complex, a
small elliptical incision incorporating the complex is pre-
ferred in order to facilitate closure. Skin-sparing mastecto-
mies are benefi cial because as the quantity of the natural
breast skin envelope is increased, the amount of relative
expansion is reduced. In addition, a greater amount of
saline can be instilled into the expander during this initial
operation.
Following the mastectomy, the plastic surgeon has two
options for expander placement. The fi rst is total muscular
coverage under the pectoralis major muscle, and the second
is partial muscular coverage under the pectoralis major.
This second method is currently referred to as the ‘dual-
plane’ technique, in which the upper two-thirds of the
expander is covered by the pectoralis major and the lower
one-third is covered by the lower mastectomy skin fl ap. A
A
B
C
FIGURE 1.4 A Preoperative photograph following bilateral
mastectomy. B The fi rst stage of a two-stage reconstruction using
a 450 mL tissue expander. A breast mound is created, but the
inframammary fold is poorly defi ned. C The second stage of a two-
stage reconstruction is completed. A 400 mL smooth, round
permanent implant has been inserted. The inframammary fold has
been recreated using a thoracoepigastric advancement.
skin fl aps, history of prior or upcoming radiation therapy,
and whether or not to use biosynthetic materials such as
acellular dermal matrix. Most mastectomies today are per-
formed using a skin-sparing pattern in which only the
nipple–areolar complex and glandular tissue are excised.
The advantage of this is that the majority of the skin enve-
lope is preserved and will minimize the amount of expan-
sion required, facilitating the obtaining of contour and
volume symmetry.
Selection of the tissue expander is based upon preopera-
tive measurements of the breast, including the base diam-
eter, tissue compliance, and volume. Current methods of
expander selection are primarily based on the base diameter
of the breast. This dimension should correlate with the base
diameter of the implant. This will permit the device to be
optimally positioned along the anterior chest wall and infra-
mammary fold, and to more closely mimic the size of the
natural breast. It is important to assess patient expectations
and determine whether the reconstructed breast should be
larger, smaller, or equal to the natural breast in terms of
size. Volume assessment is important because a given base
diameter can correlate with a variety of implant shapes and
heights. Volumes can be estimated in the offi ce or deter-

Breast Reconstruction with Tissue Expanders and Implants
5
third option is possible involving the use of bioprosthetic
materials to serve as a pectoralis extender. This will be
described later.
It is important to review the fundamental concepts
regarding the handling of tissue expanders and implants.
Many of the specifi cs are the preferred methods of the
primary author, whereas others are recommended by the
manufacturers (Mentor Corporation, Santa Barbara, CA
and Allergan Corporation (formerly Inamed), Irvine, CA).
Sterility must be maintained during the insertion. Gloves
should be changed or washed with an antibiotic solution.
Sharp objects and cautery devices should not come in
contact with the implants. Following the removal of the
expander from its container it is soaked in an antibiotic–
saline solution. All air is evacuated from the expander using
a large syringe with an appropriate needle. It is the authors’
practice to partially fi ll the expander with 50 mL of saline
prior to insertion into the subpectoral space.
Total muscular coverage of the tissue expander has
been commonly performed by many plastic surgeons. This
achieves stable coverage of the expander but often results
in an uncomfortably high-riding device that frequently
encroaches on the clavicle. This has been thought to be
secondary to muscle spasm and contraction, which has the
effect of pushing the expander superiorly. The dual-plane
technique has obviated many of the shortcomings of total
muscular coverage by positioning the base of the expander
at the inframammary fold. With this technique, the pecto-
ralis major muscle is draped over the expander and secured
via marionette sutures or via direct sutures to the dermis
or to the subcutaneous tissues of the lower mastectomy
skin fl ap. When properly performed, the dual-plane tech-
nique essentially eliminates the risk of a high-riding
expander. The technique is illustrated in Figure 1.5. In the
event of a narrow chest wall and a tissue expander with a
larger base diameter than that of the subpectoral pocket, it
may be necessary to undermine along the lateral border of
the serratus anterior muscle in order to create a cul-de-sac
to prevent lateral displacement of the expander. One to two
drains are used and usually remain in place for 1 week.
Following completion of the operation, patients are
usually discharged home on postoperative day 1 with a
prescription for oral antibiotics. Serial infl ation of the tissue
expander is performed in the offi ce and begun 2 weeks after
the operation. Generally 50–100 mL are instilled weekly
until the desired volume is obtained. In the event of adju-
vant therapy such as chemotherapy or radiation, it is the
authors’ practice to discontinue the expansion process.
However, studies have demonstrated that expansion can be
safely continued during chemotherapy if so desired. In the
event of radiation therapy, ongoing expansion is contrain-
dicated during treatment to avoid disturbance of dosimetry
and the target site. Some radiation oncologists recommend
that the partially infl ated tissue expander be defl ated during
radiation treatment. Once all adjuvant treatments are
completed and the tissue expander is optimally fi lled, the
expander may be exchanged for a permanent implant.
When no radiation therapy was administered, this usually
occurs 1 month after the fi nal expansion. When radiation
therapy has been administered, this usually occurs 3–6
months following the fi nal expansion, or when the skin has
suffi ciently healed and softened.
Stage 1 with a tissue expander and
bioprosthetic material
Perhaps one of the most signifi cant advancements in breast
reconstruction using tissue expanders has resulted from the
application of bioprosthetic materials. These are composed
of decellularized cadaveric dermis in the form of a tissue
matrix. The advantage of this material is that, when prop-
erly used, it will revascularize and integrate into the sur-
rounding tissues and assume the tissue characteristics of
the host. The most recognized and used bioprosthetic mate-
rial today is AlloDerm (LifeCell Corporation, Branchburg,
NJ). AlloDerm has been used in a variety of clinical sce-
narios and most recently in breast reconstruction. Its role
as a ‘pectoralis extender’ is becoming widely accepted as a
means of improving outcomes.
The technique of tissue expander placement using Allo-
Derm is straightforward but does require additional steps.
The AlloDerm comes in variously sized sheets, but the two
sizes currently in use for this purpose measure 4 × 16 cm
and 6 × 16 cm. AlloDerm requires hydration in a saline
solution until it is soft and pliable, usually for approxi-
mately 10–20 minutes, according to the thickness of the
material. Therefore, the hydration process should be begun
at the start of the reconstruction procedure.
The technique of AlloDerm insertion to be described is
that used by the primary author (Fig. 1.6). There may be
differences in technique based on surgeons’ preference. Fol-
lowing the mastectomy, the inferior border of the pectoralis
major muscle is detached using electrocautery and extended
laterally towards its humeral insertion. The AlloDerm is
inserted adjacent to the inferior border of the pectoralis
major and should be orientated with its basement mem-
brane (shiny) side up. This is the side that will tend to
revascularize with the greatest effi ciency and therefore
should be in contact with the lower mastectomy skin fl ap.
The medial border of the AlloDerm is sutured to the infero-
medial corner of the pectoralis major using a 2/0 monofi la-
ment absorbable suture. The inferior border of the AlloDerm
is then sutured to the inframammary fold using the same
technique. The tissue expander fi lled with 50 mL of saline
is inserted in the dual-plane position at this time. The
suture points of the AlloDerm along the lateral chest wall
are also adjusted at this time. The location along the lateral
chest wall where the AlloDerm is attached to recreate the
lateral mammary fold is based on both the diameter of the
tissue expander and the delineated natural position of
the lateral mammary fold. Sometimes the length of Allo-
Derm is excessive and shortening is required. It is impor-
tant to compartmentalize the expander and not allow for
lateral or medial displacement. Once set, two closed suction
drainage tubes are inserted. The fi rst is placed between the
AlloDerm and the tissue expander, and the second between
the AlloDerm and the lower mastectomy skin fl ap. The
upper border of the AlloDerm is sutured to the lower border
of the pectoralis major. Additional saline is instilled into

Cosmetic and Reconstructive Breast Surgery
6
A
B
C
D
E
F
FIGURE 1.5 The dual-plane technique A A skin-sparing elliptical incision is preferred for the mastectomy pattern. This will permit linear closure
with minimal ‘dog-ear’ formation. B The inferior border of the pectoralis major muscle is incised extending from its medial origin and extending
to its inferolateral origin. C The subpectoral pocket is created with suffi cient space to accommodate the tissue expander. The lateral border
of the serratus anterior muscle is sometimes elevated to create a lateral cul-de-sac for the expander. D The tissue expander is inserted into
the subpectoral space. The base of the expander is positioned at the inframammary fold. When the fold has been undermined during the
mastectomy, it must be reapproximated. E The inferior border of the pectoralis major muscle is sutured to the subcutaneous tissue of the lower
mastectomy skin fl ap using absorbable sutures. F The entire inferior border of the pectoralis major muscle is sutured to the lower mastectomy
skin fl ap. The upper portion of the expander is covered by muscle and the lower portion by subcutaneous tissue.

Breast Reconstruction with Tissue Expanders and Implants
7
A
B
C
D
E
F
FIGURE 1.6 Technique of AlloDerm insertion. A Preoperative photograph. The important landmarks are the sternal midline and the
inframammary folds. The inframammary fold is measured to assist with AlloDerm sizing. B Following the mastectomy, the inferior and lateral
borders of the pectoralis major muscle are elevated. The serratus anterior muscle is undisturbed. C The AlloDerm is hydrated in a warm saline
solution. D The AlloDerm is inserted and oriented horizontally with the basement membrane side up. The medial border of the AlloDerm is
sutured to the inferomedial corner of the pectoralis muscle. The inferior border of the AlloDerm is sutured to the inframammary fold. The lateral
border of the AlloDerm is trimmed and adjusted to accommodate the base dimension of the expander. E The tissue expander is aspirated of all
air, fi lled with 50 mL saline, and inserted into the subpectoral pocket in the dual plane. F The inferior border of the pectoralis major muscle is
temporarily stapled to the superior border of the AlloDerm. Additional saline is instilled until mild to moderate tension is achieved.

Cosmetic and Reconstructive Breast Surgery
8
the expander at this time, the amount varying depending
on the implant size, degree of internal tension, and amount
of mastectomy skin present.
Stage 2 – the permanent implant
The advantage of breast reconstruction in two stages is that
during stage 1, the tissue expander will effectively stretch
the skin and underlying structures, and during stage 2 is
replaced by a permanent implant to optimize the aesthetic
outcome. The decision as to which permanent device to
select can be perplexing, especially when one considers that
the shape can be round or contoured, the surface can be
textured or smooth, and the fi ller can be saline or silicone
gel. The benefi t of using silicone gel devices is most appreci-
ated following the second stage of a breast reconstruction
in which a silicone gel device has been selected as the per-
manent implant. It is important to appreciate that the per-
manent implant following a mastectomy is responsible for
95% of the contour, appearance, and feel of the recon-
structed breast. For these reasons, it is the authors’ opinion
that silicone gel-fi lled implants have an advantage over
saline-fi lled devices. Silicone gel mimics the natural feel of
the breast more closely than saline. In addition, there is
less rippling and wrinkling associated with silicone gel
implants. Currently, silicone gel implants are available as
smooth round devices and as textured contoured devices.
Both can achieve excellent aesthetic results and can be
selected based on surgeon recommendation, patient accep-
tance, and patient expectations.
The second stage of the two-stage reconstruction is
technically simpler than stage 1 but requires attention to
detail. It is explained that during this procedure the location
and position of the implant will be optimized, the feel of
the device will be improved as the scar tissue is released
and a new implant inserted, and the aesthetic appearance
of the breast will be enhanced. The technical aspects of an
implant exchange are relatively straightforward. The previ-
ous incision scar is usually excised. The dissection proceeds
toward the inferior edge of the pectoralis major muscle (Fig.
1.7). The capsule of the implant is incised and the expander
removed. The remaining capsule is incised or excised as
necessary. All breast specimens are sent to pathology to rule
out carcinoma. The permanent implant is inserted and a
drain is usually used.
Postoperative recovery is characterized by drain care
instructions, oral antibiotic therapy for 5–7 days, and
restriction of physical exercise for 4–6 weeks. This is neces-
sary in order for the newly inserted device to settle into its
new position with minimal risk of displacement. Patients
are permitted to shower on postoperative day 2 or 3. Drains
are usually removed between postoperative days 5 and 7,
although extra time may be necessary depending on the
drains’ output.
Clinical outcomes following immediate breast recon-
struction in two stages can be excellent. Because the natural
breast landmarks are preserved, the re-establishment of the
inframammary and lateral mammary folds is facilitated. In
the case of unilateral reconstruction, contralateral proce-
dures may be necessary. However, following bilateral recon-
struction, symmetry is the rule rather than the exception.
Figures 1.8 and 1.9 illustrate the outcome following unilat-
eral and bilateral reconstructions.
One-stage reconstruction with implants
An alternative method to two-stage reconstruction using
prosthetic devices is the one-stage technique. This method
does not require the use of the classic tissue expander
G
FIGURE 1.6, cont’d G The pectoral muscle and AlloDerm are sutured
and the staples removed. Two drains are inserted, one above and one
below the AlloDerm.
FIGURE 1.7 Second-stage implant exchange. The mastectomy scar is
incised. The inferior border of the pectoralis major muscle is incised
and the expander removed. A permanent implant is inserted with or
without a remote port.

Breast Reconstruction with Tissue Expanders and Implants
9
but rather uses a permanent implant that is adjustable
postoperatively.
The adjustable implant with a remote port is ideally
designed for women who desire or are candidates for one-
stage reconstruction. In general, these include women with
small breasts and minimal ptosis as well as women follow-
ing nipple- or skin-sparing mastectomy, in which the need
to expand the mastectomy skin fl aps is minimal. The
adjustable implants that are available for this purpose
include both saline and silicone gel devices, such as the
Spectrum and the Becker implants (Mentor Corporation,
Santa Barbara, CA) (Fig. 1.10). Spectrum implants are
saline devices that are available in a smooth or textured
surface and in a round or contoured shape. The Becker
implant is a dual-compartment device in which the outer
A
B
A
B
FIGURE 1.8 Immediate unilateral two-stage breast reconstruction.
A Preoperative photograph demonstrating grade 2 ptosis and
symmetry. B Following the second stage, grade 2 ptosis is re-
established and breast symmetry is achieved without a contralateral
procedure.
FIGURE 1.9 Immediate bilateral two-stage breast reconstruction.
A Preoperative photograph demonstrating grade 2/3 ptosis.
B Following two-stage reconstruction, there is a slight contour
asymmetry with an overall outcome rated as excellent by the patient.
BOX 1.2 One-stage immediate breast reconstruction
with implants
●
Typically employs the use of devices that are postoperatively
adjustable through a remote port.
●
Candidates are women with small breasts and minimal
ptosis, or other cases in which the need for expansion is
minimal, such as nipple- or skin-sparing mastectomy.
●
One-stage reconstruction is usually limited to women who
will have immediate reconstruction.

Cosmetic and Reconstructive Breast Surgery
10
lumen is composed of silicone gel and the inner lumen of
saline. The advantage of the Becker implant is that the
device will feel like a silicone gel implant and have the
adjustability of a saline implant. Use of these implants for
one-stage reconstruction is usually limited to women who
will have immediate reconstruction. For women interested
in delayed reconstruction using prosthetic devices the two-
stage technique is usually recommended.
The technique for one-stage reconstruction using adjust-
able implants is similar to the fi rst phase of the two-stage
reconstruction. Following the mastectomy, the subpectoral
plane is created. The implant, with the attached remote
port, is positioned such that its inferior base is at the level
of the inframammary fold. The dual-plane technique is the
authors’ preferred method of implant placement. In cases
where the mastectomy results in substantial undermining
of the inframammary fold, absorbable sutures are used to
reposition and secure this important anatomic landmark.
The remote port is then sutured to a stable base. In these
cases, this is usually to the lateral chest wall or to the
anterior chest wall just below the inframammary fold (Figs
1.11, 1.12). The inferior edge of the pectoralis major muscle
is then secured as previously described using either Allo-
Derm or suture ligation to the inferior mastectomy skin
fl ap. The implant is then fi lled with saline. Devices prefi lled
with silicone gel can also be used for one-stage breast recon-
Outer membrane
Inner membrane
Filled implant
Saline
Gel
Inner and outer valve sealed
Injection dome
Filling tube
FIGURE 1.10 Postoperatively adjustable implants. The Spectrum
and Becker implants are characterized by the remote port. The
Becker implant is compartmentalized. The outer non-adjustable
compartment is silicone gel and the inner adjustable compartment is
saline.
A
B
FIGURE 1.11 Remote valve position. Through the mastectomy
opening, the lower border of the pectoralis major is incised, the
subpectoral plane is created, and the postoperatively adjustable
implant is inserted. The remote valve can be positioned along the
inframammary fold (A) or along the lateral mammary fold (B).

Breast Reconstruction with Tissue Expanders and Implants
11
struction; however, subpectoral insertion can be compro-
mised by considerations of volume.
DELAYED BREAST RECONSTRUCTION USING
TISSUE EXPANDERS AND IMPLANTS
When immediate breast reconstruction is not recom-
mended for women with breast cancer following mastec-
tomy, delayed reconstruction is often a possibility. Many
women are not considered good candidates for immediate
reconstruction because of advanced tumor stage, cutaneous
involvement, or the need for aggressive tumor surveillance.
In these women, the oncologic considerations take prece-
dence over the aesthetic and psychological advantages of
immediate reconstruction.
The approach to prosthetic reconstruction in the delayed
setting is different from the immediate setting. In the
immediate setting the normal breast landmarks, such as
the inframammary fold, the lateral mammary fold, and the
cutaneous envelope, are well defi ned and present. In the
delayed setting, the inframammary and the lateral mammary
folds are obliterated. The soft, supple breast is replaced by
a layer of scar. There is also a skin defi cit following excision
of the cutaneous envelope of the breast. Thus two-stage
reconstruction is the rule rather than the exception for
delayed reconstruction with prosthetic devices. The role of
the tissue expander in the woman having delayed recon-
struction is amplifi ed because of the need to stretch the
limited amount of remaining skin.
Delayed breast reconstruction:
preoperative considerations
Delayed reconstruction can pose different challenges to the
surgeon because the primary landmarks of the breast are
usually no longer present and the cutaneous envelope has
been removed. The goal is therefore to create a three-
dimensional breast from a two-dimensional surface. This
is best achieved following a two-stage breast reconstruction
using a combination of tissue expanders and implants.
During the preoperative evaluation it is important to
assess the quality of the chest wall skin following the mas-
tectomy. Ideally it should be soft and supple, but in the
event of pre- or post-mastectomy radiation this may not be
the case. Delayed breast reconstruction using tissue expand-
ers and implants is not usually recommended in the setting
A
B
C
FIGURE 1.12 Delayed bilateral two-stage breast reconstruction.
A Preoperative photograph following bilateral mastectomy without
radiation therapy. B Stage 1 of the reconstruction using 350 mL tissue
expanders. C The tissue expander has been removed and replaced
with a 350 mL contour profi le silicone gel implant.

Cosmetic and Reconstructive Breast Surgery
12
of previous radiation therapy because of the diffi culties
encountered with skin expansion. The skin has com-
promised vascularity and a relative inelasticity due to the
radiation fi brosis that has ensued. Contrary to the
irradiated chest wall, the non-irradiated chest will expand
easily and is very amenable to tissue expansion. The size
of the implant required is best determined by measuring
the base width of the opposite breast or by estimating the
base width of the chest wall based on the distance between
the anterior axillary line and the medial border of the
sternum.
Operative approach
Delayed breast reconstruction – stage 1
Before entering the operating room, the landmarks of the
breast are delineated, including the lateral and inframam-
mary folds as well as the sternal midline. In the operating
room, the mastectomy scar is excised and submitted to
pathology. Dissection proceeds posteriorly to the level of
the pectoralis major, and then inferiorly along the adipo-
pectoral plane to the inferior border of the pectoralis major.
Usually this is a very short distance, ranging from 1 to
2 cm. Dissection proceeds in the subpectoral plane and a
space is created to accommodate the expander that con-
forms to the delineated breast landmarks. The expander is
prepared as previously described. The use of bioprosthetic
material can be considered for delayed breast reconstruc-
tion, but in the primary author’s practice is not normally
used. Use of a single drain is recommended to prevent the
accumulation of a seroma and to prevent rotation of the
contoured expander. Once the expander is inserted,
the pectoral muscle is either reapproximated or sutured to
the lower mastectomy skin fl ap using absorbable sutures.
Skin closure is the fi nal step. Additional sterile saline can
be instilled as tolerated, based on skin elasticity. The usual
amount ranges from 50 to 100 mL in this setting.
Postoperative recovery is much as for immediate recon-
struction with an expander. The drains are usually removed
after 5–7 days, or when the output is less than 30 mL/day.
Expansion is commenced after 2 weeks and continues up
to the maximum permitted, based on expander volume or
when the patient is happy with the volume. It is advised to
expand 50–100 mL beyond the fi nal desired volume because
there will be some skin contraction when the expander is
removed. The additional skin can be used to create a better
inframammary fold during the second stage.
Delayed breast reconstruction – stage 2
The technical aspects of the second stage of delayed breast
reconstruction are similar to those of the second stage of
an immediate reconstruction. The main difference is that
the cutaneous envelope has been more stretched than in
the latter. This will result in some degree of elastic recoil
when the expander is removed. Overexpansion will be ben-
efi cial in these situations for the reasons given above. The
primary objective of the second stage is to ensure adequate
breast volume and projection; however, a secondary objec-
tive is to recreate the inframammary fold adequately.
Breast volume and projection are best achieved in this
setting using contoured implants or high-profi le round
implants. These can be saline or silicone gel-fi lled. In the
primary author’s practice the silicone gel devices have pro-
vided the best outcomes based on appearance and texture.
There is less rippling and wrinkling, and the breast recon-
structed with silicone gel devices mimics the natural breast
more closely. Before inserting these devices, the soft tissue
capsule created by the tissue expander is scored or excised
depending on its thickness and the degree of contracture.
The authors’ preferred technique is to score the capsule
circumferentially at the base and then to score the lower
and/or upper poles of the expanded skin envelope radially.
This will effectively increase the elasticity of the cutane-
ous envelope and allow for enhanced breast shaping and
positioning.
The inframammary fold is best recreated by undermin-
ing the thoracoepigastric soft tissue plane slightly below
the level of the proposed fold. The tissue is advanced in a
cephalad direction and then sutured to the inframammary
fold. This effectively provides additional skin that can be
used to create breast ptosis at the level of the fold.
Outcomes following delayed reconstruction can be
excellent for both unilateral and bilateral reconstructions.
The creation of an inframammary fold can be diffi cult but
is best achieved with a thoracoepigastric advancement fl ap.
In the event of a unilateral reconstruction, a contralateral
procedure is sometimes necessary and may include breast
augmentation or reduction. Clinical examples are illus-
trated in Figs 1.12–1.14.
DELAYED-IMMEDIATE BREAST
RECONSTRUCTION
The technique of delayed-immediate breast reconstruction
was introduced in 2004 and has proved very useful because
of the increasing trend for post-mastectomy radiation
therapy following immediate breast reconstruction with
autologous tissue. The untoward effects of radiation on an
autologous reconstruction are well known and include fl ap
shrinkage, fat necrosis, generalized fi brosis, progressive dis-
tortion, and contour abnormalities. The effects of radiation
on the quality of prosthetic reconstruction can be equally
deleterious, and include capsular contracture, delayed
BOX 1.3 Delayed-immediate breast reconstruction
●
Placement of a tissue expander when immediate autologous
tissue reconstruction is desired but the need for post-
mastectomy radiation is uncertain.
●
If radiation is necessary, expander is infl ated beforehand,
allowing expansion of the cutaneous envelope and
preservation of normal breast landmarks. Autologous
reconstruction can be completed after the radiation is
complete.
●
Final outcome will resemble that of an immediate
reconstruction despite being performed on a delayed basis.

Breast Reconstruction with Tissue Expanders and Implants
13
rary tissue expander can be inserted immediately after the
mastectomy. Once the fi nal pathology and tumor staging
are completed, usually 1 week after the operation, the deci-
sion to proceed or not with radiation therapy is clear. If
radiation is not necessary, the patient can be scheduled for
autologous reconstruction as soon as possible. If radiation
is necessary, the expander can be infl ated beforehand. Fol-
lowing the radiation, the tissue expander is removed and
replaced with autologous tissue. The reason to proceed in
A
B
C
D
FIGURE 1.13 Delayed unilateral two-stage breast reconstruction with contralateral augmentation. A Preoperative photograph following
unilateral mastectomy without radiation therapy. B Postoperative photograph following right breast reconstruction and left breast
augmentation. C Lateral view of the right breast following reconstruction. D Lateral view of the left breast following augmentation.
healing, infection, progressive distortion, and premature
removal. The difference between autologous reconstruction
and prosthetic reconstruction is that the fi rst is permanent
and the second can be temporary. The radiated tissue
expander can easily be removed, whereas the fl ap cannot.
The premise of delayed-immediate reconstruction is
that when immediate breast reconstruction with autolo-
gous tissue is being considered or desired and the need for
post-mastectomy radiation therapy is uncertain, a tempo-

Cosmetic and Reconstructive Breast Surgery
14
this fashion is because the fi nal outcome resembles that of
an immediate reconstruction despite the fact that it is
delayed. This is because the inframammary fold is pre-
served and the cutaneous skin envelope stretched prior to
radiation.
Operative approach
The patient is marked as previously described. A skin-
sparing mastectomy is preferred when possible. Following
the mastectomy, the technique is identical to that of imme-
diate tissue expansion without the use of bioprosthetic
materials. Despite the temporary nature of this procedure,
subcutaneous placement of the expander is not recom-
mended. Delayed healing can occur and has resulted in
premature removal of the temporary expander, hence the
subpectoral position is preferred. After radiation the patient
will have a choice between continuing with prosthetic
reconstruction or changing to autologous reconstruction.
Should implant reconstruction be selected, the expander is
removed and replaced with a permanent implant. The spe-
cifi cs of this are described in the section on technique of
second-stage implant reconstruction. If fl ap reconstruction
is desired, the salient features are described. The expander
is removed, and the pectoralis major muscle separated from
the superior mastectomy skin fl ap. The muscle is reinserted
inferiorly using absorbable sutures to reapproximate its
natural position. Autologous reconstruction then proceeds
as desired by the patient and directed by the surgeon.
A
B
C
FIGURE 1.14 Delayed unilateral two-stage breast reconstruction with
contralateral reduction mammoplasty. A Preoperative photograph
following left mastectomy without radiation therapy. B Following the
tissue expansion of the left breast, there is signifi cant asymmetry. C
Following stage 2, the left expander is removed and replaced with a
permanent implant and the right breast is reduced to achieve volume
and contour symmetry.
BOX 1.4 Two-stage delayed breast reconstruction
with expanders and implants
●
Often more challenging owing to loss of normal breast
landmarks, such as the inframammary fold, and scarring of
the cutaneous envelope.
●
Goal is to create a three-dimensional breast from a two-
dimensional surface.
●
Potential pitfall: expansion of an irradiated chest wall has the
potential for higher complication rates and diffi cult
expansion due to the lack of skin elasticity. Autologous
tissue reconstruction is preferred in such cases.
●
Second stage generally involves more breast shaping with
capsule manipulation and recreation of the inframammary
fold.

Breast Reconstruction with Tissue Expanders and Implants
15
COMPLICATIONS
As with all surgical procedures, complications are possible
and must be explained and reviewed with the patient
preoperatively. They include bleeding, infection, scars,
delayed healing, premature removal of the device, rippling
and wrinkling, capsular contracture, fi ll port failure, implant
rupture, pain, seroma, distortion, asymmetry, and second-
ary procedures.
Implant rupture
The main limitation of all implants is that they are mechan-
ical devices and as such will not last forever. The long-term
failure rate is directly proportional to the length of time the
device has been in place. Failure can be the result of techni-
cal factors related to the surgical procedure, shell character-
istics of the implant, and the body’s response to a foreign
substance. Implants that are fi lled with less than the rec-
ommended volume are at increased risk for rupture due to
fold fatigue of the shell. The shells are relatively thin to
allow for a soft implant, but are subject to the pressure,
shear, and stress forces exerted from capsules, surrounding
tissues, and activities of daily living.
Ruling out a rupture can sometimes be diffi cult, espe-
cially with the newer cohesive gel implants. Silent rupture
is a known entity and is best diagnosed with magnetic reso-
nance imaging (MRI). The classic ‘linguini sign’ (Fig. 1.15)
is characteristic of rupture in an early-generation silicone
gel implant, whereas the ‘teardrop sign’ is characteristic of
rupture in current devices. Rupture of saline implants, on
the other hand, is relatively easy to diagnose because the
breast will fl atten or shrink as the implant defl ates and the
saline is absorbed. In either case, the implant should be
removed and replaced as desired. With silicone gel ruptures,
all implant material, including the capsule, should be
removed.
Capsular contracture
Capsular contracture is a well-described occurrence with a
poorly understood etiology. Etiologic factors include sub-
clinical infection, blood products around the implant, and
a normal body reaction to a foreign material. Capsular
contracture is known to increase over time and often causes
distortion and hardening of the breast mound (Fig. 1.16).
Techniques to prevent or minimize its occurrence are
related to meticulous handling of the implant, ensuring
BOX 1.5 Potential advantages of
prosthetic reconstruction
●
A simpler surgical procedure.
●
Use of adjacent tissue of similar color, texture and sensation.
●
Less donor site morbidity.
●
Less incisional scarring.
●
Shorter operative time and postoperative recovery.
●
Leaving autologous tissue for a later date.
●
The psychological benefi t of a more rapidly reconstructed
breast.
BOX 1.6 Indications and contraindications
●
Patient preference
●
Patients who do not have suffi cient autologous donor site
tissue
●
Women interested in a quicker recovery for return to
activities of daily living and physical activity
●
Bilateral mastectomies in which symmetry can be more
readily achieved
Contraindications
●
Radiation therapy a relative contraindication to implant
reconstruction alone
●
Failed previous prosthetic reconstructions: relative
contraindication
●
Morbid obesity: relative contraindication
Patient selection
●
Patient preference
●
Patient expectations
BOX 1.7 Optimizing outcomes
●
Consider likelihood of postoperative radiation or
chemotherapy
●
Evaluate opposite breast in unilateral reconstructions for
symmetry procedures such as augmentation, mastopexy, or
breast reduction
●
Reserve immediate reconstruction for those cases in which
the likelihood of skin healing is not in question
●
Proper device and patient selection are important
components aff ecting fi nal outcome
FIGURE 1.15 Linguini sign. The classic MRI fi nding of a ruptured
silicone gel implant is the linguini sign representing folds in the
implant shell.

Cosmetic and Reconstructive Breast Surgery
16
a bloodless operative fi eld, and antibiotics. The debate
between textured surface devices resulting in less capsular
contracture than smooth shell devices has been ongoing for
many years but has yielded no signifi cant differences from
the current devices in use today.
The management of capsular contracture is surgical and
may include capsulotomy, partial capsulectomy, and total
capsulectomy. Patients who are predisposed to severe cap-
sular contracture or who have recurrences may be better
candidates for autologous reconstruction.
Implant infection
Infection following breast reconstruction with prosthetic
devices can be a devastating complication. Fortunately this
is not a common event, occurring in probably less than 5%
of patients. Common presenting signs and symptoms
include cellulitis, pain, and swelling (Fig. 1.17); fever and
elevated leukocytosis may also occur. The most common
bacteria associated with infection is Staphylococcus epider-
midis, but other bacteria may also be implicated. The diffi -
culty with this diagnosis is differentiating the superfi cial
skin infection from deep space infections. The manage-
ment of implant-related infection is immediate hospitaliza-
tion and broad-spectrum intravenous antibiotics. Superfi cial
infections will usually subside by 24–48 hours, but deep
infections will not. For these patients, operative exploration
is necessary. It is the authors’ opinion that the infected
breast implant must be removed, especially when purulence
is encountered (Fig. 1.18). Secondary prosthetic reconstruc-
tion should be deferred for at least 6–12 months.
Fill port failure
Problems and complications specifi c to the adjustable
implant are primarily related to the fi ll port. In some women
the port can become dislodged from the subcutaneous
pocket in which it was placed, resulting in an inability to
access it. This has been observed despite suturing the port
to the chest wall and closing the opening to the pocket with
sutures. Kinking of the fi ll port tubing is possible when it
is too long and tortuous. Twisting of the tube that connects
the remote port to the implant can result in a tear and
defl ation of the implant (Fig. 1.19). This has been observed
following dislodgement and repeated twisting of the remote
port. The management of fi ll port dysfunction usually
FIGURE 1.16 Capsular contracture. The right breast is severely
distorted and painful, which is characteristic of a grade IV capsular
contracture.
FIGURE 1.17 Cellulitis around breast implant. In this patient
following bilateral mastectomy and implant reconstruction, the right
breast is characterized by redness and swelling, which is consistent
with cellulitis.
FIGURE 1.18 Purulence around breast implant. Following incision
and drainage, purulent fl uid is demonstrated. The implant was
removed.

Breast Reconstruction with Tissue Expanders and Implants
17
requires a surgical procedure. The implant is usually
replaced with a permanent device.
Hematoma
Postoperative hematoma following breast reconstruction
with prosthetic devices is uncommon and may complicate
the reconstruction in 1–2% of cases (Fig. 1.20). The use of
closed suction drainage tubes is very helpful in preventing
and diagnosing this problem. Left untreated, a hematoma
will organize and promote the formation of a thick, disfi gur-
ing, and uncomfortable capsule. Therefore, it is recom-
mended that all patients with a hematoma be prepared for
surgical evacuation following diagnosis. On exploration
some patients will have a bleeding vessel along the surface
of the pectoralis muscle or subcutaneous tissue. Other
patients may have a previously undiagnosed bleeding dis-
order and will benefi t from an appropriate workup. Most of
the time the bleeding has subsided on its own and all that
is necessary is clot evacuation, thorough irrigation, and
placement of new closed suction drains.
Seroma
The seroma that follows breast reconstruction with a pros-
thetic device can be troubling. This is usually caused either
by lymphatic fl uid that accumulates following lymph node
removal, or by excess production of serous fl uid following
the operation. The drainage tubes are usually very effective
in controlling excess fl uid production and are normally
removed after 1–2 weeks. In some cases the fl uid produc-
tion persists, necessitating use of the drainage tubes for 2–4
weeks. In the event that the drainage tubes are removed
and a fl uid collection accumulates, it is the authors’ prac-
tice to allow the seroma to resorb spontaneously. This may
require 1–2 months and may be associated with rotation of
the expander. The other option is to return to the operating
room and place a new drain. If persistent, lymphoscinti-
graphy may be needed to identify and clip the source.
Rippling and wrinkling
Rippling and wrinkling are sometimes observed following
breast reconstruction with prosthetic devices (Fig. 1.21),
more commonly with permanent implants rather than
tissue expanders. It becomes evident once the soft tissue
edema and swelling has subsided and is usually visible in
the upper mastectomy fl ap, and sometimes palpable in the
lower mastectomy fl ap. It has been observed that textured
FIGURE 1.19 Fill tube failure. Dislodgment with repeated twisting of
the remote port and tubing eventually resulted in failure of the
device.
FIGURE 1.20 Hematoma complicating tissue expansion. A
postoperative hematoma occurred after breast reconstruction with a
tissue expander. The hematoma was surgically evacuated.
FIGURE 1.21 Rippling and wrinkling are sometimes seen with
implants and are due to thin skin and the nature of the prosthetic
device.

Cosmetic and Reconstructive Breast Surgery
18
and saline devices are more prone to this phenomenon,
although it can occur with any type of implant. Treatment
can be diffi cult, especially in women with thin skin.
The simplest solution is to remove a textured-surface or
saline-fi lled device and exchange it for a silicone-fi lled or
smooth-surfaced one. It is often tempting to insert a larger
device, thinking that the added compartment pressure will
fi ll out the wrinkles and ripples. Unfortunately, these will
become evident as the skin stretches, and so upsizing is not
recommended. Another option is to use non-vascularized
autologous fat transfer in the form of a graft to add to the
thickness of the cutaneous envelope. This technique is cur-
rently being studied and the reader is referred to the appro-
priate sources. In the event that all attempts to correct this
are unsuccessful, autologous tissue can be considered.
Delayed healing
Delayed healing can complicate any prosthetic-based
breast reconstruction but is most prevalent following
immediate reconstruction using tissue expanders or perma-
nent implants (Figs 1.22, 1.23). Delayed healing is most
often attributed to the poor vascularity of the remaining
skin fl aps following the mastectomy. Most surgeons will
perform a skin-sparing mastectomy, and some will rou-
tinely undermine below the level of the inframammary fold,
across the sternal midline, and up to the clavicle. This will
compromise the vascularity of the remaining mastectomy
skin fl aps. Determining the perfusion of these skin fl aps
can be diffi cult. Techniques include assessment of dermal
edge bleeding that includes both arterial and venous fl ow;
assessment of skin color for signs of congestion, ecchymo-
sis, or pallor; and fl uorescein lamps. In all cases non- or
poorly perfused skin should be excised to minimize skin
necrosis and delayed healing.
If healing is delayed, it must be ascertained whether the
process is superfi cial or deep. Superfi cial wounds, such as
a minor cutaneous dehiscence of skin ulceration, can be
managed conservatively with local care and oral antibiotics.
More advanced wounds involving the deep structures should
be managed aggressively with surgical debridement. The
decision as to whether or not to retain the implant is based
on the judgment of the operating surgeon.
CONCLUSIONS
Breast reconstruction using prosthetic devices has improved
dramatically over the past several years. With the acknowl-
edgment and acceptance that these devices are safe and
effective, further refi nements will be made to enhance out-
comes. It is hopefully recognized that proper patient and
device selection, as well as adherence to the basic princi-
ples, concepts, and techniques, will allow surgeons to
deliver predictable and reproducible results.
FURTHER READING
1. Salzberg CA. Nonexpansive immediate breast reconstruction using
human acellular tissue matrix graft (AlloDerm). Ann Plast Surg
2006; 57: 1–5.
2. Breuing KH, Warren SM. Immediate bilateral breast reconstruction
with implants and inferolateral AlloDerm slings. Ann Plast Surg
2005; 55: 232–239.
3. Spear SL, Mesbahi AN. Implant based reconstruction. Clin Plast
Surg 2007; 34: 63–73.
4. Cordeiro PG, McCarthy CM. A single surgeon’s 12 year experience
with tissue expander/implant breast reconstruction: part 1. A
prospective analysis of early complications. Plast Reconstruct Surg
2006; 118: 825–831.
5. Cordeiro PG, McCarthy CM. A single surgeon’s 12 year
experience with tissue expander/implant breast reconstruction:
part 2. An analysis of long-term complications, aesthetic
outcomes, and patient satisfaction. Plast Reconstruct Surg 2006;
118: 832–839.
6. McCarthy CM, Pusic AL, Disa JJ, et al. Unilateral chest wall
radiotherapy in bilateral tissue expander/implant reconstruction
patients: A prospective outcomes analysis. Plast Reconstruct Surg
2005; 116: 1642–1647.
FIGURE 1.22 Soft tissue necrosis. Delayed healing due to poor
vascularity of the mastectomy skin fl aps.
FIGURE 1.23 Impending implant exposure. Delayed healing due to
increased internal pressure, poor skin quality, and localized infection.

Breast Reconstruction with Tissue Expanders and Implants
19
7. Nahabedian MY, Tsangaris T, Momen B, Manson PN. Infectious
complications following breast reconstruction with expanders and
implants. Plast Reconstruct Surg 2003; 112: 467–476.
8. Nahabedian MY. Symmetrical breast reconstruction: analysis of
secondary procedures following reconstruction with implants and
with autologous tissue. Plast Reconstruct Surg 2005; 115:
257–260.
9. Disa JJ, Ad-El DD, Cohen SM, et al. The premature removal of
tissue expanders in breast reconstruction. Plast Reconstruct Surg
1999; 104: 1662.
10. Krueger EA, Wilkins EG, Strawderman M, et al. Complications
and patient satisfaction following expander/implant breast
reconstruction with and without radiotherapy. Int J Radiation
Oncol Biol Phys 2001; 49: 713.
11. Forman DL, Chiu J, Restifo RJ, et al. Breast reconstruction in
previously irradiated patients using tissue expanders and
implants: A potentially unfavorable result. Ann Plast Surg 1998;
40: 360.
12. Spear SL, Majidian A. Immediate breast reconstruction in two
stages using textured, integrated-valve tissue expanders and breast
implants: A retrospective review of 171 consecutive breast
reconstructions from 1989 to 1996. Plast Reconstruct Surg 1998;
101: 53.
13. Tallet AV, Salem N, Moutardier V, et al. Radiotherapy and
immediate two-stage breast reconstruction with a tissue expander
and implant: complications and esthetic results. Int J Radiation
Oncol Biol Phys 2003; 57: 136.
14. Ascherman JA, Hanasono MM, Newman MI, Hughes DB. Implant
reconstruction in breast cancer patients treated with radiation
therapy. Plast Reconstruct Surg 2006; 117: 359.
15. Spear SL, Pelletiere CV. Immediate breast reconstruction in two
stages using textured integrated valve tissue expanders and
implants. Plast Reconstruct Surg 2004; 113: 2098–2103.
16. Kronowitz SJ, Hunt KK, Kuerer HM, et al. Delayed-immediate
breast reconstruction. Plast Reconstruct Surg 2004; 113:
1617–1628.
17. Nahabedian MY. The adjustable breast implant. In: Jackson IT,
Noone RB, eds. Innovation in breast surgery. Vol. 1. St Louis:
Quality Medical Publishing, 2005; 109–121.
18. Becker H. Breast reconstruction using an infl atable breast implant
with a detachable reservoir. Plast Reconstruct Surg 1984; 73:
678–683.

21
C H A P T E R
2
Pedicled TRAM Flap
Breast Reconstruction
Dennis C. Hammond
INTRODUCTION
Breast reconstruction after mastectomy has become an
important part of the overall recovery process for women
undergoing treatment for breast cancer. To that end, the
results of breast reconstruction have improved steadily over
the past 20 years as experience with the various techniques
has grown. Perhaps the most important development to
dramatically infl uence these improved results was the
description of the transverse rectus abdominis musculocu-
taneous or TRAM fl ap.1,2 By using the patient’s own tissues
to fashion the reconstructed breast mound without the
need for a prosthetic device, outstanding results can be
obtained with few long-term complications.
The original description of the TRAM fl ap based the
blood supply to the skin and fat of the lower abdomen on
an arteriovenous pedicle which passed along the length of
the rectus abdominis muscle, running from under the
costal margin to the perforators located in the lower
abdomen. This technique involved elevating the rectus
abdominis muscle in continuity with the skin and fat of
the lower abdomen to preserve the vascular supply. This
direct communication between the fl ap and the muscle led
to the term ‘pedicled’ TRAM fl ap breast reconstruction.2
Over the years, alternative microsurgical methods of
manipulating the vascular infl ow to the fl ap have been
developed, including the free TRAM fl ap as well as the
deep inferior epigastric artery perforator or DIEP fl ap.
Although these procedures are associated with several
advantages, including improvement in blood supply to the
fl ap and fewer donor site complications, many surgeons
are reluctant to incorporate these more complicated and
technically intensive procedures into their breast recon-
struction armamentarium. As a result, the pedicled TRAM
fl ap remains a very important method of autogenous breast
reconstruction.3
INDICATIONS AND CONTRAINDICATIONS
Because the technique is autogenous in nature, TRAM fl ap
breast reconstruction is the single best method for obtain-
ing high-quality, long-lasting results.1 Because no prosthetic
device is required, all of the complications associated with
breast implants are obviated. However, the potential com-
plications associated with TRAM fl ap reconstruction are
signifi cant and every effort must be made to perform the
procedure safely on appropriately selected patients using
sound surgical technique. To understand which patients
might be the best candidates for pedicled TRAM fl ap breast
reconstruction, it is helpful to review the most common
complications associated with the procedure, so that the
variables that lead to complications can be identifi ed and
controlled.
Perhaps the most damaging of complications regarding
pedicled TRAM fl ap breast reconstruction relates to insuf-
fi cient blood supply to the fl ap. When a signifi cant portion
of the fl ap necroses, the short-term wound healing issues
and the long-term breast shape issues that result can
severely detract from the overall success of the procedure.
For this reason, any condition associated with diminished
cutaneous blood supply must be considered a relative con-
traindication to the use of a pedicled TRAM fl ap. Examples
include a history of hypertension, diabetes mellitus, con-
nective tissue disease, or any general debilitating condition
that could be considered a stressor to the patient’s overall
vitality. It is the author’s practice to reserve the use of a
pedicled TRAM fl ap for those patients who are in excellent
health. All other patients are considered for other methods
of reconstruction, including free tissue transfer techniques,
combined latissimus dorsi with expander/implant tech-
niques, or expander/implant techniques alone. Thus the
best chance of success can be ensured with a minimum of
complications.

Cosmetic and Reconstructive Breast Surgery
22
Special mention must be made of the issue of smoking.
It has been demonstrated in many studies that a history of
smoking generally doubles the complication rate of many
types of procedure.4 This is particularly true for fl ap proce-
dures, and a smoking history, no matter how brief or
intense, must be considered a relative contraindication for
a pedicled TRAM fl ap. At the very least, full informed
consent must be given before patient and surgeon embark
upon a pedicled TRAM fl ap procedure in the face of a
smoking history.
Obesity is also a variable that must be carefully consid-
ered when choosing the pedicled TRAM fl ap technique.
Certainly there must be a relative excess of lower abdomi-
nal skin and fat to permit a breast of suffi cient volume to
be reconstructed. However, in patients with signifi cant
obesity the risk for insuffi cient vascular infl ow to the excess
amount of fat present in the TRAM fl ap, as well as in the
abdominal donor site, is high. Therefore, although success-
ful pedicled TRAM fl ap breast reconstruction can be per-
formed in the obese, it must be realized that the potential
for vascular infl ow-related complications with tissue necro-
sis and wound healing problems can be signifi cant.5
PREOPERATIVE HISTORY AND
CONSIDERATIONS
Apart from questions concerning the general health of the
patient and documentation of any smoking history, several
anatomic factors can affect the use of a pedicled TRAM
fl ap for reconstruction. Specifi cally, it must be ascertained
whether or not any previous abdominal surgery has been
performed. Perhaps the most obvious potential problem
relates to the patient who has had an open cholecystec-
tomy: clearly, a scar across the right upper quadrant should
alert the surgeon that the rectus muscle has probably been
divided, thereby cutting the peripheral extension of the
superior epigastric artery through the muscle down to the
lower abdominal skin and fat. In such cases the use of a
left pedicled TRAM fl ap is still possible, as is the use of a
free TRAM fl ap or a DIEP fl ap. Also, any scar that runs
from the umbilicus down to the pubis in the midline will
probably adversely affect the ability of cutaneous blood fl ow
to pass across the midline when a unipedicled TRAM fl ap
technique is used. In patients who have undergone cardiac
bypass, the left – and less commonly both – internal
mammary artery can be divided as they are rerouted into
the coronary vessels. In these patients, although the inter-
costal vessels can provide some infl ow to the superior epi-
gastric system, the pressure head must be considered to be
severely diminished, making a pedicled TRAM fl ap a much
less attractive option. Also, any midline scar raises the sug-
gestion that the continuity of one or both rectus muscles
could potentially be divided, thereby cutting the blood
supply to a pedicled TRAM fl ap. In these circumstances, a
clear understanding of the previous surgical procedures
must be elicited to ensure that the superior epigastric
system is intact.
Special mention must be made regarding scars from a
cesarian section. This is an exceedingly common clinical
scenario, and in the vast majority of patients such scars
have no bearing on the successful use of a TRAM fl ap. In
fact, in some circumstances it can prove helpful, as some
obstetricians/gynecologists will tie off the inferior epigastric
vessels in the course of exposing the abdominal cavity. This
essentially constitutes a delay procedure, which can greatly
enhance the likelihood that the superior epigastric circula-
tion will be dominant and will provide vigorous vascular
support to the pedicled TRAM fl ap. Obtaining previous
surgical notes may help clarify these issues to allow appro-
priate preoperative surgical planning.
OPERATIVE APPROACH
Anatomy
The TRAM fl ap is a musculocutaneous fl ap that takes
advantage of the lower abdominal vascular territory served
by perforators of the superior and inferior epigastric arteries
and veins as they course through the rectus abdominis
muscle.6,7 The paired muscle originates from the ventral
aspect of the conjoined medial lower rib cartilages on each
side, and inserts via a narrow tendon into the superior
border of the pubis. At variable intervals along the length
of the muscle, two to four fi brous confl uences or inscrip-
tions separate it into distinct compartments that are usually
paired. These inscriptions create the widely recognized
contour breaks in the surface of the muscle that can be seen
through the thin abdominal fatty layer in fi t individuals,
creating the so-called ‘six pack.’
The superior epigastric artery is the terminal branch of
the very robust internal mammary artery. It exits from
under the rib margin approximately one to two fi nger-
breadths lateral to the xiphoid process and curves laterally
to run along the underside and down the length of the
rectus muscle. The artery will arborize variably within the
muscle as it passes inferiorly. In selected cases the artery
can be large and distinct enough to be visualized as an
identifi able vessel passing along the junction of the lateral
third and the medial two-thirds of the muscle. In other
cases the vascular pedicle arborizes quickly within the sub-
stance of the muscle. The inferior epigastric artery enters
the lower lateral margin of the rectus four to fi ve fi nger-
breadths below the umbilicus and runs along the underside
of the muscle. Again, the main substance of the pedicle
runs along the junction of the lateral third and the medial
two-thirds of the muscle, where it then variably arborizes
with the superior epigastric pedicle. Along the way, laterally
based intercostal branches course to the pedicle axis, where
they join up with the vascular arcade. These intercostal
branches consist of an artery, vein, and nerve that contain
sympathetic, parasympathetic, and autonomic fi bers.8 Soon
after the inferior epigastric pedicle enters the underside of
the muscle, a separate umbilical branch courses supero-
medially toward the umbilicus, where it then courses
through the fascia to the underside of the abdominal wall.
With this as a basic vascular framework, several distinct
perforators arise from this combination vascular arcade to
serve the overlying skin and fat. Laterally, very typically a

Pedicled TRAM Flap Breast Reconstruction
23
‘key perforator’ arises from the vascular axis at the inscrip-
tion of the rectus muscle located at the level of the umbili-
cus. Below this, separated by 2–3 cm, arise two or three
additional perforators that tend to be slightly smaller than
the key perforator. These two to four perforators form the
vascular basis of a pedicled TRAM fl ap. There are also very
typically additional perforators that arise from the umbilical
branch, again with a prominent perforator being noted at
the level of the umbilical inscription of the rectus abdominis
muscle. These perforators can add additional vascular
support to a pedicled TRAM fl ap. Above the level of the
umbilical muscle inscription, scattered perforators arise
from the muscle. However, these tend to be so small as to
be of little value compared to the main perforators running
directly from the epigastric vascular axis (Fig. 2.1).
The clinical signifi cance of this vascular arrangement
directly affects the vascularity of a pedicled TRAM fl ap. The
main vascular supply to the soft tissues of the lower
abdomen is the inferior epigastric vascular arcade. Once the
muscle is dissected free and the inferior epigastric pedicle
is divided, the continued viability of the fl ap will depend on
the superior epigastric arcade effectively communicating
with the inferior system through the choke region located
just above the umbilical inscription. If this communication
is robust, a pedicled TRAM fl ap will survive reliably. If the
communication is tenuous, the skin and fat of the fl ap
might be at risk for ischemia. Fortunately, in the majority
of cases the communication between the superior and infe-
rior vascular arcades is suffi cient to maintain fl ap viability.
However, in at-risk patients such as smokers or diabetics,
the ability of the superior circulation to supply the fl ap
adequately can be limited, and many surgeons will use free
tissue transfer techniques instead.
The vascular supply to the skin occurs predominantly
through the lateral perforators. Once in the soft tissue,
fairly distinct zones of perfusion can be identifi ed that can
variably overlap. Typically, the perforators coming through
the rectus abdominis muscle on one side will serve mainly
the skin and fat on that side of the abdomen, and there will
be variable and often diminished collateral fl ow across the
midline to the other side of the fl ap.9 This has clinical
implications for operative planning when the entire fl ap
will be needed to reconstruct the breast. Because of the
uncertainty over the vascular supply to the fl ap across the
midline, many surgeons will use a double pedicle fl ap to
accomplish the reconstruction. In my experience, a double
pedicle TRAM fl ap provides the same level of reliability as
a free TRAM fl ap as far as vascular perfusion is concerned.
The disadvantage is centered on the need to harvest both
rectus muscles and the subsequent donor site complica-
tions that can ensue.
The fascial anatomy of the rectus muscle plays a key
role in successfully elevating a TRAM fl ap without creating
donor site morbidity. The muscle itself is surrounded by an
anterior and a posterior rectus sheath. At each inscription,
the anterior rectus sheath attachments are densely adher-
ent to the inscription, creating a prominent crease running
horizontally along the width of the muscle. Laterally the
confl uence of the internal and external oblique muscles
merges with the lateral margin of the rectus sheath to
provide a fi rm support layer for the abdominal wall. Several
centimeters below the level of the umbilicus, the orienta-
tion of the rectus sheath changes and the posterior sheath
switches location and merges with the anterior sheath. As
a result, a prominent crease is formed at the inferiormost
portion of the posterior rectus sheath, called the ‘line of
Douglas.’ Recognizing and reconstituting these relation-
ships is important in achieving closure of the abdominal
wall donor site after TRAM fl ap elevation.10,11
Marks
The main aim of the marking procedure is to identify the
landmarks that defi ne the location of the muscle, and to
outline the cutaneous vascular territory of the perforators.
It is best to mark the patient in the standing position to
ensure symmetric application of the skin pattern. Also, it
is in this position that the vertical width of the fl ap can be
best estimated. The major focus of the marking procedure
is to correctly identify the margins of the skin paddle. Typi-
Umbilical branch
Deep superior
epigastric artery
and vein
Costal margin
Rectus muscle
Deep inferior
epigastric artery
and vein
Perforators
FIGURE 2.1 The vascular anatomy of the epigastric vessels in relation
to the rectus abdominis muscle.

Cosmetic and Reconstructive Breast Surgery
24
cally, a mark is made just above the umbilicus and extended
laterally in a curvilinear fashion to the lateral aspect of the
abdominal wall. Near the midline, the mark jogs slightly
superiorly to ensure that the tissues surrounding the ‘key’
perforator are included in the fl ap. The exact location of the
lateral fl ap extension varies according to the soft tissue
relationships of the skin and fat of the lower abdominal
wall. The goal is to draw the fl ap in such a way as to mini-
mize the creation of a lateral dog-ear after closure of the
skin donor site. Once the lateral limits of the fl ap are deter-
mined, the lower border is estimated based on the elasticity
of the skin and the tissue requirements of the reconstructed
breast. Typically this line will course just above the hair-
bearing portion of the pubic area.
Once the limits of the fl ap location have been deter-
mined, the muscle location as well as the estimated loca-
tion of the perforators is diagrammed. Ultimately, the
origin of the muscle along the costal margin will be released,
and the location of the costal cartilages is palpated and
marked for future reference. The location of the tunnel that
will be used to pass the fl ap is drawn, and orientation marks
are made on the fl ap that will subsequently assist in plan-
ning its shape. The skin pattern for the mastectomy is also
drawn. In immediate cases a skin-sparing mastectomy
pattern is used and applied according to the dictates of
breast volume as well as the size of the skin envelope. In
delayed cases, the dimensions of the planned breast are
outlined using the old mastectomy scar as an access inci-
sion (Fig. 2.2).
If the opposite breast requires alteration, either to
provide symmetry or to improve the overall esthetic result,
this procedure is performed along with the fi rst-stage TRAM
fl ap reconstruction and the breast is marked accordingly.
In this fashion, any postoperative settling that may occur
in the normal breast after mastopexy, reduction, or aug-
mentation can stabilize during the postoperative recovery
period. Then, at the second-stage procedure, the normal
breast will function as a stable construct against which the
reconstructed breast can be matched.
Operative technique
Single-pedicle TRAM fl ap
In cases of immediate reconstruction, the dimensions of
the mastectomy defect and the condition of the mastec-
tomy fl aps and the inframammary fold are assessed after
the mastectomy has been completed. If the fold has been
lowered, it is best to resuspend it back into the proper posi-
tion using permanent sutures placed along the midline of
the fold and extending laterally. This will avoid the medial
inframammary corner where the communicating tunnel
will ultimately be located. If necessary, fl uorescein can be
used to assess the viability of the mastectomy fl ap, and
debridement can be performed as indicated. The goal of this
assessment is to stabilize the mastectomy defect so that
appropriate decisions can be made during subsequent eleva-
tion and insetting of the TRAM fl ap. In some cases it is
possible to begin working on TRAM fl ap elevation even as
the oncologic surgeons are removing the breast, in an effort
to save time and shorten the duration of the procedure.
This is an excellent strategy; however, once the mastec-
tomy has been completed, it is recommended to assess the
mastectomy fl ap as described to optimize further operative
planning.
In cases of delayed reconstruction, the mastectomy scar
is excised and the fl aps elevated to the proper dimension to
set the proposed borders of the reconstructed breast. Any
scar tethering in the mastectomy fl aps is released by scoring
the underside as needed to create a soft, pliable fl ap. Once
the defect has been re-created, the TRAM fl ap can be
elevated.
Flap elevation begins by incising the skin at the upper
border and dissecting down to the abdominal wall at a slight
angle, directed superiorly to increase the eventual volume
of the fl ap. The upper abdominal panniculus is elevated
away from the abdominal wall up to a level up and over the
costal margin on each side. Communication is then made
with the mastectomy defect through the inferomedial corner
FIGURE 2.2 Marks in preparation for bilateral TRAM fl ap breast
reconstruction.

Pedicled TRAM Flap Breast Reconstruction
25
of the inframammary fold, creating a tunnel of suffi cient
width to allow the hand to easily be inserted. The upper
panniculus is then pulled down to the lower proposed
TRAM fl ap mark to be certain that the donor site abdomi-
nal wound will be closed without diffi culty. The patient can
be elevated to about 20° at the waist to assist in this deter-
mination. Once the location of the lower incision has been
confi rmed, the skin is incised and the dissection carried
straight down to the abdominal wall, through the two fatty
layers of the abdomen separated by Scarpa’s fascia. As well,
the umbilicus is released from the fl ap to allow eventual
umbilical relocation.
It is my preference to use an ipsilateral pedicle for recon-
struction of a single breast.12–14 With this in mind, the
attachments of the fl ap to the overlying muscle on the side
of the reconstructed breast are identifi ed and preserved as
the lateral wings of the fl ap are elevated away from the
abdominal wall. On the opposite side of the abdomen, away
from the muscle perforator zone, the fl ap is elevated from
the underlying rectus muscle and dissection proceeds across
the midline until the medial perforators on the target
muscle are identifi ed. On the muscle side, the fl ap is ele-
vated laterally from the abdominal fascia until the lateral
row of perforators is identifi ed coming up from the underly-
ing rectus muscle. This dissection identifi es the segment of
fascia that must be taken with the muscle to preserve the
perforators passing up into the fl ap (Fig. 2.3). Above and
below this perforator zone the zone of fascial harvest is
tapered off to allow a contoured closure of the fascia once
the muscle is released. The proposed fascial incisions are
then made, and superiorly the remaining segment of ante-
rior rectus sheath is divided in the midline to allow access
to the muscle. The medial and lateral anterior rectus sheath
fl aps are then elevated from the underlying rectus muscle,
and the muscle itself is carefully released from any deeper
attachments, particularly along the area of the inscriptions.
Laterally the intercostal branches are divided up to the level
of the costal margin. Inferiorly, the inferior epigastric vas-
cular pedicle is divided and the muscle is released from the
pubis through the smaller but well-delineated tendinous
area just above the pubic attachment. The muscle is sutured
to the underside of the TRAM to prevent inadvertent trac-
tion injury to the perforators, and any remaining attach-
ments of the muscle are released as the muscle is lifted
away from the fascial bed. Superiorly the lateral portion of
the rectus muscle is divided above the costal margin, with
release extending superomedially until only 2–3 cm of
muscle remain attached just lateral to the xiphoid. This
release is completely safe, as the superior epigastric pedicle
lies deeper under the costal margin and is not in danger of
injury as long as muscle release is performed on top of the
cartilaginous border. This maneuver offers signifi cant
advantage in easing the arc of rotation of the fl ap without
creating excessive bunching or kinking at the rotation point.
The fl ap is then passed through the subcutaneous tunnel
created previously by turning the muscle 180°, such that
the deep portion of the muscle stays deep as the adipo-
cutaneous portion is passed to the mastectomy defect. This
is as opposed to a double fl ip of the muscle, which can
potentially create a kink resulting in fl ap ischemia. Once
the fl ap is positioned in the mastectomy defect, it is tem-
porarily inset with staples and allowed to recover from the
shock of elevation that is associated with the newly ori-
ented vascular patterns.
Abdominal closure begins by reapproximating the ante-
rior rectus sheath incision directly with a 0 or #1 sized
permanent monofi lament suture. By beginning above at the
level of the xiphoid process and below at the level of the
pubis, and running toward the center of the incision, a
direct approximation of the fascial edges can be obtained.
It is important to be sure that the fascial edge of the internal
oblique is included in the closure, particularly inferiorly, as
it tends to separate away from the combined fascial edge of
the anterior rectus sheath. It is also usually necessary to
‘overdo’ the closure above and below the area of fascial
harvest to prevent the creation of a fascial dog-ear. The
opposite anterior rectus sheath is then plicated as needed
to further reinforce the abdomen and create a contoured
abdominal profi le. This maneuver also serves to pull the
umbilicus back to the midline and prevent umbilical mal-
position. Using this fascial sparing strategy it will always
be possible to accomplish primary fascial repair using a
unipedicled TRAM fl ap. No mesh is needed, and adding an
onlay mesh to reinforce the closure is unnecessary. Two
drains are placed in the abdominal dissection space, and
the lower skin incision is closed in layers. The umbilicus
is inset into the abdominal fl ap to complete the abdominal
closure.
Double-pedicle TRAM fl ap–bilateral TRAM fl ap
In cases of bipedicled TRAM fl ap breast reconstruction
or bilateral breast reconstruction, both rectus abdominis
muscles will be harvested to supply one or both fl aps.
Because of this, the perforator zone over each muscle must
Zone of harvest
Perforators
Unipedicle TRAM flap elevation
Bipedicle TRAM flap elevation
Rectus muscle
FIGURE 2.3 Schematic diagram comparing the perforator and fascial
dissections required for a unipedicled and bipedicled TRAM fl ap
elevation. The zone of fascial harvest is dictated by the location of the
medial and lateral perforators.

Cosmetic and Reconstructive Breast Surgery
26
be preserved during the dissection. In bilateral cases this is
easily accomplished, as the fl ap is divided in the midline and
the medial perforators from each muscle are directly exposed.
In a bipedicled procedure, a dissection tunnel is created
under the midline of the fl ap as the medial perforators are
identifi ed and the fascial incisions are made. Flap elevation
then proceeds exactly as for a single-pedicle TRAM fl ap. In
bilateral procedures the two hemifl aps are simply passed to
the mastectomy defects as before, and in bipedicled proce-
dures the entire fl ap is passed to one side. In either circum-
stance, the fl aps are rotated and not fl ipped as described
previously. In bipedicled procedures, the two muscles can
create more bulk at the costal margin rotation point. This
effect can be minimized by appropriate muscle release at the
costal margin, as described previously.
The major difference between unipedicled and bipedi-
cled TRAM fl ap procedures is in the abdominal closure.
Even when the fascial sparing technique is used as described,
in some patients it will be diffi cult to close the fascial edges
directly. If both anterior rectus sheaths cannot be closed
primarily, it is my practice to close one and then use a
Marlex mesh interposition fascial replacement in the other.
Typically, the mesh is placed exactly in the area where the
fascia was harvested to preserve the integrity of the perfora-
tors. Using this strategy, reliable fascial closure of the
abdomen can be accomplished with a very low incidence of
TRAM fl ap hernia formation or bulging. In all other respects
fl ap elevation, transfer, and skin closure are the same.
TRAM fl ap shaping
If fl ap elevation represents the technical side of TRAM fl ap
breast reconstruction, shaping represents the artistic side.
Basically, the goals of TRAM fl ap shaping include com-
pletely fi lling the mastectomy defect and adequately restor-
ing the integrity of the skin envelope. Skin envelope issues
mainly become a concern in cases of delayed reconstruc-
tion. All of this must be done with an eye to creating an
esthetic shape.
Once the TRAM fl ap has been transferred to the mas-
tectomy defect, there are three orientations that can be used
to position the volume of the fl ap anatomically in such a
way as to create an esthetic breast shape: transverse, oblique,
and vertical (Fig. 2.4A–C).
● Transverse This orientation is best used when a wide-
base diameter is required and the vertical height of the
breast is not excessive. Typically with this type of breast,
A
B
FIGURE 2.4 The three orientations used in TRAM fl ap shaping. A transverse; B oblique; C vertical.

Pedicled TRAM Flap Breast Reconstruction
27
a signifi cant volume requirement exists and it is most
commonly used with a bipedicled TRAM fl ap.
● Oblique This orientation can be used in either single- or
double-pedicle procedures and is a very versatile way to
shape a fl ap. By slightly orienting the fl ap such that the
tip is in the upper outer quadrant of the breast, appropri-
ate vertical height can be created in the reconstructed
breast in a way that preserves an appropriate base width.
The oblique orientation is a reasonable ‘compromise’
position that allows both parameters to be controlled in
many patients.
● Vertical The vertical orientation is perhaps the easiest
and most versatile for TRAM fl ap shaping. The basic
anatomy of the fl ap sets up well for the task, as the thin
lateral tip of the fl ap is inset into the superior portion
of the reconstructed breast. As a result, a smooth and
contoured upper pole can be created very easily. The
triangularly shaped fl ap can then be trimmed at the
corners to create rounded contours and a very esthetic
breast shape. Also, the muscle bulk sutured to the infe-
rior portion of the fl ap further accentuates the projection
of the fl ap. Finally, vertical orientation does not require
any excess twisting of the fl ap that might result in posi-
tional ischemia.
The borders of the TRAM fl ap must be inset into the
mastectomy defect in a way that creates smooth contours.
One very effective technique for this is to use the de-
epithelialized edges of the cutaneous portion of the fl ap as
a scaffold to suspend it from the chest wall. By suturing
these fl ap edges into the margin of the mastectomy defect,
the entire defect can be fi lled without creating any stepoffs.
This is as opposed to suturing the fatty layers of the TRAM
into the margins, as this can create a ridge along the periph-
eral borders of the reconstructed breast. Once the periphery
of the mastectomy defect has been esthetically controlled,
the remainder of the fl ap is inset as needed to hold the fl ap
in the correct position. Once the position of the fl ap has
been set, the requirements for the skin island can be fi nal-
ized and the appropriate areas of the fl ap de-epithelialized.
Insetting of the skin island over a drain completes the
procedure.
Postoperative recovery generally proceeds uneventfully.
A hospital stay of usually 3–5 days is required to allow suf-
fi cient recovery for discharge. Typically an abdominal binder
is worn for several weeks to provide comfort and a sense of
support to the abdominal wall. By 6 weeks the patient has
generally returned to full normal function.
Second-stage procedure
Whereas fi rst-stage TRAM fl ap surgery requires both a tech-
nical and an artistic eye, it is as a result of the second-stage
revision that truly outstanding results are created. The
second-stage procedure is performed after the edema associ-
ated with the fi rst procedure has resolved. This occurs
anywhere from 4 to 6 months after the initial operation. At
this procedure, any alteration in the reconstructed breast
that will improve the overall result is performed. Very com-
monly this will include liposuction to the reconstructed
breast, excision of redundant skin, resetting of the contours
of the breast including the inframammary fold, and fi nally
reconstructing the nipple–areolar complex (NAC). Altera-
tions in the abdominal donor site can also be made, includ-
ing scar revision, dog-ear correction, and liposuction
recontouring.15 Occasionally reinforcement of the abdomi-
nal wall is necessary in cases where abdominal laxity,
bulging, or more uncommonly hernia formation has
occurred. This is typically performed under general anesthe-
sia as an outpatient procedure and in most instances
requires no more than 1 week of recovery time.
RESULTS
Because the breast is reconstructed with autologous tissue,
once the initial healing has occurred the size and shape of
the reconstructed breast remain stable as long as the body
habitus of the patient does not change dramatically. It is
for this reason that the TRAM fl ap is widely recognized
as the most attractive option for breast reconstruction. All
the potential complications associated with implant-based
techniques are avoided; the technique can applied in cases
of unilateral or bilateral reconstruction,16,17 either immedi-
ate or delayed, and is generally very compatible with the
C
FIGURE 2.4, cont’d

Cosmetic and Reconstructive Breast Surgery
28
delivery of postoperative chemotherapy. Special circum-
stances, including reconstruction after subcutaneous or
partial mastectomy, can be easily managed with the tech-
nique, and skin-sparing mastectomy strategies complement
the procedure and combine to give outstanding results for
many patients (Figs 2.5–2.7).
COMPLICATIONS
Although most patients tolerate TRAM fl ap breast recon-
struction without diffi culty, several well-recognized compli-
cations can occur and may require operative attention.
These can be either related to the fl ap itself or to the donor
site.
Flap-related complications
These relate almost exclusively to the vascularity of the
fl ap. If any portion of the skin or fat of a TRAM fl ap
necroses, the result will suffer. Small areas of fat or skin
necrosis can simply be managed conservatively and allowed
to heal by secondary intention during the recovery from the
A
B
C
initial procedure. Larger areas may require intervention to
debride necrotic skin or fat and achieve a healed wound.
In either circumstance, revision can be performed at the
second stage to remove necrotic fat, revise scars and reshape
the breast. Should the tissue loss be extensive, restoration
of a pleasing breast contour can be accomplished with the
addition of a latissimus dorsi fl ap.18 In this fashion, the
autologous nature of the procedure is preserved.
Abdominal complications
Necrosis of skin and fat can also occur in the abdomen.
Typically, such areas are allowed to heal by secondary
intention and are then revised later at the second stage.
Occasionally laxity or bulging of the abdominal wall is
noted, and second-stage reinforcement of these areas via
suture placation, with or without the addition of mesh, can
be performed to restore abdominal competence. Rarely, a
patient can present with persistent abdominal pain after a
TRAM fl ap procedure. In these cases, point injections with
local anesthetic mixed with steroid can confi rm and poten-
tially treat the condition. Operative exploration can be
FIGURE 2.5 A Preoperative appearance of a patient who presents with a left-sided intraductal breast carcinoma. B, C Preoperative marks in
preparation for skin-sparing modifi ed radical mastectomy followed by immediate bipedicled TRAM fl ap breast reconstruction.

Pedicled TRAM Flap Breast Reconstruction
29
D
E
FIGURE 2.5, cont’d D Appearance after fi rst-stage reconstruction. E Marks in preparation for second-stage reconstruction, which will include
liposuction contouring of the reconstructed breast, reconstruction of the NAC, and revision of the TRAM scar.

Cosmetic and Reconstructive Breast Surgery
30
A
F
FIGURE 2.5, cont’d F One-year postoperative appearance
demonstrating an esthetic and symmetric result.
FIGURE 2.6 A Preoperative appearance of a patient after previous
modifi ed radical mastectomy.

Pedicled TRAM Flap Breast Reconstruction
31
B
C
FIGURE 2.6, cont’d B Preoperative marks in preparation for left unipedicled TRAM fl ap breast reconstruction along with right-sided breast
reduction. C Appearance after fi rst-stage reconstruction.

Cosmetic and Reconstructive Breast Surgery
32
E
D
FIGURE 2.6, cont’d D Second-stage marks. E One-year postoperative appearance.

Pedicled TRAM Flap Breast Reconstruction
33
A
B
FIGURE 2.7 A Preoperative appearance of a patient with a strong family history of breast cancer who desired prophylactic mastectomy with
immediate TRAM fl ap breast reconstruction. B Preoperative marks in preparation for bilateral subcutaneous mastectomy followed by pedicled
TRAM fl ap breast reconstruction.

Cosmetic and Reconstructive Breast Surgery
34
performed in the event of failure of conservative measures
to potentially release a cut nerve trapped in scar, repair any
scar tethering that may be present, or even reinforce a weak
area in the abdominal wall.
CONCLUSIONS
The pedicled TRAM fl ap remains one of the procedures of
choice for many patients seeking breast reconstruction after
mastectomy. The procedure is technically straightforward,
reliable, and can provide outstanding results in appropri-
ately selected patients. It remains a mainstay of treatment
in the armamentarium of breast reconstruction techniques
for many surgeons.
REFERENCES
1. Kroll SS. Why autologous tissue? Clin Plast Surg 1998; 25:
135–143.
2. Schefl an M, Hartrampf CR, Black PW. Breast reconstruction with
a transverse abdominal island fl ap. Plast Reconstruct Surg 1982;
69: 908–909.
3. Jones G. The pedicled TRAM fl ap in breast reconstruction. Clin
Plast Surg 2007; 34: 83–104.
4. Padubidri AN, Yetman R, Browne E, et al. Complications of
postmastectomy breast reconstruction in smokers, ex-smokers, and
nonsmokers. Plast Reconstruct Surg 2001; 107: 350–351.
5. Kroll SS, Netscher DT. Complications of TRAM fl ap breast
reconstruction in obese patients. Plast Reconstruct Surg 1989; 84:
886–892.
6. Moon HK, Taylor GI. The vascular anatomy of rectus abdominis
musculocutaneous fl aps based on the deep superior epigastric
system. Plast Reconstruct Surg 1988; 82: 815–832.
7. Taylor GI, Corlett RJ, Boyd JB. The versatile deep inferior
epigastric (inferior rectus abdominis) fl ap. Br J Plast Surg 1984; 37:
330–350.
8. Hammond DC, Larson DL, Severinac RN, Marcias M. Rectus
abdominis muscle innervation: implications for TRAM fl ap
elevation. Plast Reconstruct Surg 1995; 96: 105–110.
9. Yamaguchi S, De Lorenzi F, Petit JY, et al. The ‘perfusion map’ of
the unipedicled TRAM fl ap to reduce postoperative partial
necrosis. Ann Plast Surg 2004; 53: 205–209.
10. Kroll SS, Schusterman MA, Mistry D. The internal oblique repair
of abdominal bulges secondary to TRAM fl ap breast
reconstruction. Plast Reconstruct Surg 1995; 96: 100–104.
11. Reece GP, Kroll SS. Abdominal wall complications: Prevention and
treatment. Clin Plast Surg 1998, 25: 225–227.
12. Olding M, Emory RE, Barrett WL. Preferential use of the ipsilateral
pedicle in TRAM fl ap breast reconstruction. Ann Plast Surg 1998;
40: 349–353.
13. Clugston PA, Gingrass MK, Azurin D, et al. Ipsilateral pedicled
TRAM fl aps: the safer alternative? Plast Reconstruct Surg 2000;
105: 77–82.
14. Marin-Gutzke M, Sanchez-Olaso A, Fernandez-Camacho FJ,
Mirelis-Otero E. Anatomic and clinical study of rectus abdominis
musculocutaneous fl aps based on the superior epigastric system:
ipsilateral pedicled TRAM fl ap as a safe alternative. Ann Plast Surg
2005; 54: 356–360.
15. Maxwell GP, Andochick SE. Secondary shaping of the TRAM fl ap.
Clin Plast Surg 1994; 21: 247–253.
16. Simon AM, Bouwense CL, McMillan S, et al. Comparison of
unipedicled and bipedicled TRAM fl ap breast reconstructions:
assessment of physical function and patient satisfaction. Plast
Reconstruct Surg 2004; 113: 136–140.
17. Wagner DS, Michelow BJ, Hartrampf CR Jr. Double-pedicle TRAM
fl ap for unilateral breast reconstruction. Plast Reconstruct Surg
1991; 88: 987–997.
18. Hammond DC, Simon AM, Khuthaila DK, et al. Latissimus dorsi
fl ap salvage of the partially failed TRAM fl ap breast reconstruction.
Plast Reconstruct Surg 2007; 120: 383–389.
C
FIGURE 2.7, cont’d C Three-year postoperative appearance.

35
C H A P T E R
3
Breast Reconstruction with
Free TRAM Flaps
David W. Chang
INTRODUCTION
Since it was fi rst described in 1979, the free transverse
rectus abdominis myocutaneous (TRAM) fl ap has become
one of the most popular and reliable methods of microsurgi-
cal breast reconstruction.1 The free TRAM fl ap has many
features that make it well suited for breast reconstruc-
tion.2–5 Most patients have adequate lower abdominal skin
and subcutaneous tissue available for incorporation into the
fl ap to reconstruct a breast. Its vascular pedicle is large,
long, constant, and reliable. The robust blood supply of the
free TRAM fl ap reduces the risk of fat necrosis and also
enables aggressive folding, trimming, and shaping of the
fl ap to optimize the aesthetic outcome of breast reconstruc-
tion. In addition, in most cases the free TRAM fl ap requires
minimal donor site sacrifi ce. And fi nally, the fl ap can be
harvested with the patient in a supine position, while mas-
tectomy is being performed.
Over the years, variations on the free TRAM fl ap,
including the free muscle-sparing (MS) TRAM fl ap, the
deep inferior epigastric perforator (DIEP) fl ap, and the free
superfi cial inferior epigastric artery (SIEA) fl ap, have been
developed to further minimize donor site morbidity by har-
vesting less muscle and less anterior rectus fascia.6,7 Each
fl ap transfers the same lower abdominal skin and subcuta-
neous tissue and is able to provide an aesthetically pleasing
breast reconstruction.
INDICATIONS AND CONTRAINDICATIONS
(Box 3.1)
Indications
A free TRAM fl ap can be used for breast reconstruction in
the overwhelming majority of mastectomy patients.8 A pos-
sible candidate for reconstruction with a free TRAM fl ap is
a healthy patient with moderate amounts of abdominal
skin laxity and fat, and a minimal to moderate volume
requirement for breast reconstruction. The patient must be
willing to undergo a long, complex procedure with possible
prolonged postoperative recovery. She must understand and
accept additional scars in the abdomen and potential donor
site morbidities.
Contraindications
Contraindications to the use of a free TRAM fl ap are:
● A patient who is unwilling to accept additional donor
site scars and potential donor site morbidities.
● A patient who is unwilling to undergo a long, complex
procedure with prolonged postoperative recovery.
● An abdominal donor site that cannot be closed pri-
marily because the patient is too thin or has a pot-belly
habitus.
● A previous TRAM fl ap or an abdominoplasty.
● A previous abdominal operation in which the deep infe-
rior epigastric vessels were divided or damaged.
● Signifi cant medical comorbidities that make the patient
a poor surgical candidate.
High-risk patients
Smokers
Because of the free TRAM fl ap’s excellent blood supply, a
history of smoking is not by itself an absolute contraindica-
tion. In our experience, the use of a free TRAM fl ap recon-
struction in tobacco smokers is not associated with a
signifi cant increase in the rates of vessel thrombosis, fl ap
loss, or fat necrosis compared to rates in non-smokers.9
However, smokers are at signifi cantly higher risk for
mastectomy skin fl ap necrosis, abdominal fl ap necrosis,
and hernia than non-smokers. These smoking-related

Cosmetic and Reconstructive Breast Surgery
36
complications can be signifi cantly reduced when the patient
stops smoking at least 4 weeks before surgery.
Obese patients
The decision about whether to use a free TRAM fl ap for
breast reconstruction in an obese patient should be indi-
vidualized. In our experience, obese patients have sig-
nifi cantly higher fl ap and donor site complications than
normal-weight patients.10 Specifi cally, compared to normal-
weight patients, obese patients have signifi cantly higher
rates of total fl ap loss, fl ap seroma, mastectomy skin
fl ap necrosis, abdominal hernia, donor site infection, and
seroma. In fact, there appears to be an almost linear
relationship between complications of all kinds and body
weight. Thus, for markedly and morbidly obese patients
(body mass index = 40), TRAM fl ap breast reconstruction
should probably be avoided if possible. For patients who are
obese but not markedly or morbidly so (body mass index =
30 but <40), free TRAM fl ap reconstruction may be con-
sidered if they are otherwise in good health and well
informed of the increased risk of fl ap failure and complica-
tions. Obese patients undergoing delayed breast reconstruc-
tion should be encouraged to reduce the risk by losing
weight prior to the surgery.
Previous abdominal suction-assisted lipectomy
There is debate about whether a free TRAM fl ap can be
reliably used following abdominal liposuction. The obvious
concern is that the perforating vessels to the fl ap and the
microvasculature to the fl ap may have been damaged by the
prior suction-assisted lipectomy (SAL) procedure, which
could compromise the viability of the fl ap. However, a few
cases of free TRAM fl ap breast reconstruction following
SAL of the abdomen have been reported.11 When this is
being considered, preoperative Doppler ultrasonography
can be used to confi rm the presence and the patency of the
perforating vessels of the abdominal wall. Additionally, the
surgeon should consider incorporating the maximum
number of perforators into the fl ap to render it more robust
for transfer.
PREOPERATIVE CONSIDERATIONS
Free fl ap procedures impose major surgical stress on the
patient. Fluid loss is considerable with two operative sites,
and patients tend to become hypothermic because of the
lengthy nature of these procedures. Thus candidates for free
fl ap reconstruction must have their cardiac, pulmonary,
and renal status carefully evaluated preoperatively.
Patients must be advised to abstain from smoking pre-
operatively to reduce the risks of anesthetic complications
and wound-healing problems. Avoiding aspirin-containing
products for 2 weeks before surgery is also important so
that the baseline coagulation status is normal.
Preoperatively, the patient’s abdomen should be evalu-
ated to make sure that she is a good candidate for a TRAM
fl ap. In particular, the abdomen should be examined for any
scars. If there are scars, their location, length, duration, and
cause must be considered to determine whether a free
TRAM fl ap can be performed safely. The abdomen should
be examined with the patient in a supine position with the
knees fl exed to ensure that the abdomen can be closed pri-
marily after harvesting of the fl ap. In addition, the integrity
of the abdominal wall must be examined for the presence
of hernias and for pot-belly habitus.
Once it is determined that the patient is a good candi-
date for a free TRAM fl ap, the design of the fl ap is marked
with the patient standing. The inframammary folds are
marked bilaterally. The TRAM fl ap is designed in the lower
abdomen with a transverse skin fl ap. The upper marking
is usually just at or above the umbilicus, and the lower
marking is just above the pubis, generally following the
natural skin fold there. The design of the fl ap is then
tapered to the anterior superior iliac spine so that closure
of the donor site will not result in a dog ear (Fig. 3.1).
ANATOMY
Rectus abdominis muscle
The rectus abdominis muscles are a pair of long, straight
muscles that fl ex the spine and tighten the intra-abdominal
wall. They arise from the symphysis pubis and the pubic
crest and insert on the linea alba and at the fi fth, sixth, and
seventh costal cartilages. Each rectus abdominis muscle is
subdivided by two to fi ve tendinous inscriptions, with the
most caudal one at the level of the umbilicus.12 The tendi-
nous inscriptions are adherent to the overlying anterior
rectus sheath but not to the posterior sheath. The inscrip-
tions do not usually extend completely through the muscle
and may pass only halfway across it.13
Rectus sheath
The rectus abdominis muscles are enclosed by a thick
sheath, except for the posterior part below the arcuate line.
The rectus sheath is attached to the anterior aspect of the
muscles by fusion to the tendinous inscriptions. The apo-
neurotic extensions of the muscles of the intra-abdominal
wall merge to form the anterior portion of the rectus sheath
fascia.
An important transition is in the posterior sheath at
the arcuate line (semicircular line, or arc of Douglas). The
arcuate line is generally located halfway between the umbi-
licus and symphysis pubis, though this is variable. The
arcuate line marks the transition point where the internal
oblique aponeurosis ceases to split and the aponeuroses of
all three muscles pass ventral to the rectus abdominis. The
BOX 3.1 Indications and contraindications
●
A healthy patient with an adequate abdominal donor site
Contraindications
●
Inadequate abdominal donor site
●
A poor surgical candidate because of medical co-morbidities

Breast Reconstruction with Free TRAM Flaps
37
transversalis fascia is the only layer present below the
arcuate line, and is thus a region of weakness and potential
herniation after fl ap dissection.
The linea alba represents the decussation of the fused
aponeuroses in the midline. The linea alba is wider in the
region of the xiphoid process and narrows to a fi ne line
below the umbilicus. The lateral border of the rectus sheath
is often discernable externally and is referred to as the linea
semilunaris.
Blood supply
The rectus abdominis muscle has two vascular pedicles,
one composed of the deep superior epigastric artery (DSEA)
and the other of the deep inferior epigastric artery (DIEA).12
The DSEA and DIEA pedicles arborize as they approach
each other under the surface of the rectus abdominis. These
two systems connect above the umbilicus through a system
of small-caliber vessels that Taylor and Palmer14 refer to as
‘choke’ vessels.
The DSEA arises from the internal mammary artery at
the level of the sixth intercostal space. It generally has two
venae comitantes. There is a small branch of the DSEA that
courses along the costal margin to join the intercostal artery
lateral to the rectus sheath.15
The DIEA usually originates 1 cm above the inguinal
ligament from the medial aspect of the external iliac artery,
directly opposite the deep circumfl ex iliac artery. The main
DIEA pierces the transversalis fascia and enters the rectus
sheath just below the arcuate line. It then ascends obliquely
and medially between the rectus abdominis muscle and
the posterior wall of the sheath. Generally, the DIEA divides
into two or three large branches below the level of the
umbilicus. Through cadaveric studies, the degree of arbori-
zation of the DIEA has been classifi ed into three different
types. In type 1, the DIEA does not divide and remains as
a single vessel as it courses under the surface of the rectus
abdominis (29%). Type 2 refers to a DIEA that divides into
two dominant branches (57%). The type 3 pattern is a tri-
furcation of the DIEA (14%).15
The DIEA has two venae comitantes, which usually join
to form a single vein prior to their junction with the exter-
nal iliac vein. In the study by Boyd et al., the deep inferior
epigastric veins (DIEV) entered the external iliac vein as a
single trunk in 68% of cases and as a double trunk in
32%.15
Perforators
The deep arteries supply the TRAM fl ap’s overlying abdom-
inal skin by a system of perforators. These vessels are ter-
minal branches of the DIEA and DIEV. Cadaveric studies
by Taylor and Palmer14 demonstrated a rich connection
between the DIEA system and the abdominal wall skin.
Many perforating arteries emerge through the anterior
rectus sheath, but the highest concentration is in the peri-
umbilical area. The fewest number of perforators is found
in the suprapubic area. The branches of the periumbilical
perforators have the appearance of the radiating spokes of
a wheel whose hub is located at the umbilicus. Thus, incor-
poration of the periumbilical perforators permits the har-
vesting of a skin fl ap with virtually any orientation from
the midline.16
The perforators communicate with the other regional
superfi cial vessels through a system of choke vessels that
link these territories and allow the design of large skin
islands based on the DIEA. The dominant connections
between these systems occur within the subdermal
plexus.
TRAM fl ap
The blood supply to the TRAM fl ap is a two-tiered arrange-
ment of muscular and subcutaneous networks (Fig. 3.2).
The superior and inferior epigastric artery systems form a
deep longitudinal blood supply that is linked to the lower
six intercostal vessels and the ascending branch of the deep
circumfl ex iliac artery within the muscles of the abdominal
wall. The DIEA is the dominant vessel of the rectus abdom-
inis muscle and the TRAM fl ap. Injection of this vessel
with dye will stain the abdominal wall as high as midway
between the umbilicus and xiphoid process, whereas injec-
tion of the DSEA with dye rarely results in staining
below the umbilicus. The subcutaneous network consists
FIGURE 3.1 A TRAM fl ap design.

Cosmetic and Reconstructive Breast Surgery
38
of branches of the superfi cial epigastric artery, superfi cial
circumfl ex iliac artery, external iliac artery, superfi cial
superior epigastric artery, and the intercostal arteries. The
subcutaneous and deep systems are connected by perfora-
tors that traverse the rectus abdominis muscles.
Extensive studies of the venous circulation of the TRAM
fl ap have revealed both superfi cial and deep systems.17 The
veins of the superfi cial system are above Scarpa’s fascia and
communicate extensively across the midline. The superfi -
cial veins drain into the deep venous system by way of the
veins accompanying the musculocutaneous arterial perfora-
tors. Valves located in the connecting veins regulate the
direction of blood fl ow from the superfi cial towards the deep
system.
A TRAM fl ap incorporates skin from the entire lower
abdomen. Four different skin zones can be included in a
TRAM fl ap (Fig. 3.3).18 Zone 1 refers to the skin overlying
each lateral rectus abdominis muscle. Zone 2 denotes skin
of the contralateral lower abdomen overlying the opposite
rectus abdominis muscle. The skin territory on each side
of the abdomen lateral to the linea semilunaris is referred
to as zone 3, and the skin lateral to the opposite linea
semilunaris is zone 4. The blood supply to zone 4 is the
most tenuous.
Innervations
The rectus abdominis muscles are innervated in a segmen-
tal fashion from the lower six intercostal nerves, derived
from T7–T12, which traverse the plane between the trans-
versus abdominis and the internal oblique muscles. These
mixed motor and sensory nerves provide innervation to the
rectus abdominis muscles and sensory supply to the overly-
ing skin. The intercostal nerves enter the mid-portion of
the rectus muscles at the posterior surface.16
OPERATIVE APPROACH (see also Box 3.2)
All fl ap and recipient site dissection is done under loupe
magnifi cation, and the author fi nds it useful to wear a
headlight for optimal visualization of the operative fi eld.
Medial
perforators
Lateral
perforators
Superior
epigastric artery
Deep inferior
epigastric artery
FIGURE 3.2 The blood supply to the TRAM fl ap (Redrawn from
Schusterman MA (ed) Microsurgical reconstruction of the cancer
patient. Lippincott-Raven, 1997).
IV
II
I
III
FIGURE 3.3 Four zones of a TRAM fl ap based on vascularity (Redrawn
from Schusterman MA (ed) Microsurgical reconstruction of the cancer
patient. Lippincott-Raven, 1997).

Breast Reconstruction with Free TRAM Flaps
39
Patient positioning
The patient should be placed supine, lying symmetrically
and straight on the table. Her waist should be at the proper
bend of the table so that she can be placed in a sitting posi-
tion during fl ap insetting and shaping. With most operating
tables, in order to place the patient in a sitting position the
table needs to be reversed so that her head is at the table’s
foot. The patient’s arms are extended out and placed on
arm boards, with ample foam padding at the elbows and
wrists. Both arms are then secured to the boards with gauze
rolls. This allows the surgeons access to the axilla for lymph
node dissection if necessary.
For immediate reconstruction, the fl ap harvest and the
breast resection are accomplished simultaneously to reduce
operating time. For delayed reconstruction, the recipient
site preparation and the fl ap harvest can be performed
simultaneously by two teams of surgeons.
The fi rst step of fl ap harvest is to dissect out the umbi-
licus. It helps to make four small stab incisions with a #11
blade at the 12, 3, 6, and 9 o’clock positions. Skin hooks
are then placed into the incisions to provide retraction
while incisions are made to connect the stab incisions.
Using a tenotomy scissors, the umbilical stalk is dissected
down to its base. There is no need to make the umbilical
stalk overly thin or thick. A marking stitch is placed at
the 12 o’clock position of the umbilicus for use as a guide
during the insetting of the umbilicus and to prevent twist-
ing of the stalk.
The border of the skin island is incised down to
the abdominal wall. The superfi cial inferior epigastric vein
(SIEV) and SIEA are identifi ed and preserved (Fig. 3.4). If
the SIEA is signifi cant in size, and if the patient is a good
candidate, an SIEA fl ap can be used for breast reconstruc-
tion. Even if an SIEA fl ap is not planned, it is important to
preserve and dissect out the SIEV for about 4–5 cm. With
the increasing use of DIEP and free MS-TRAM fl aps with
fewer and smaller perforators being included with the fl ap,
occasionally the SIEV needs to be used as a second means
of venous drainage if the deep venous drainage alone is not
adequate.
Full-muscle TRAM fl ap
For patients with high-risk factors such as smoking and
obesity, a priority is to optimize perfusion to the fl ap
by including as many major perforators as possible. In
these instances, a full-muscle TRAM fl ap may be the
best choice.
The TRAM fl ap is carefully dissected off the rectus
sheath, preserving all major perforators on the preferred
side (Fig. 3.5). A fascia-sparing technique is used to open
the rectus sheath fascia, incorporating only a small cuff of
fascia around the perforators and then connecting these
islands of fascia to each other (Fig. 3.6). When the fascia is
opened in this manner only a minimal amount is sacrifi ced,
facilitating primary closure of the fascia without tension or
the use of synthetic mesh. The rectus sheath incision is
extended inferiorly and laterally to expose the underlying
rectus abdominis muscle.
The anterior rectus sheath fascia is dissected off the
underlying rectus abdominis and its tendinous inscriptions.
The rectus sheath attachments are divided to the medial
and lateral borders of the muscle. Care must be taken when
separating the inscriptions to the anterior rectus sheath,
BOX 3.2 Optimizing outcomes
●
Careful patient selection
●
Understand patient’s goals and expectations of breast
reconstruction

●
Evaluate and address patient’s risk factors
●
A precise and meticulous surgical technique
●
Atraumatic dissection of recipient and donor vessels,
including perforators

●
Minimal sacrifi ce of rectus fascia

●
Minimal dissection of rectus muscle

●
Maximize preservation of innervations to the remaining
rectus muscle
●
Use only well-vascularized portion of the fl ap for breast
reconstruction
●
Discard zone 4
●
Ensure optimal and error-free microvascular anastomoses
●
Focus on proper set-up so that microvascular
anastomoses can be performed in a comfortable
position

●
Ensure that the vascular pedicle is not twisted or kinked

●
Use atraumatic and precise microsurgical technique
●
Optimal donor site closure
●
The fascia repair should be tension-free

●
Do not leave dog ears

●
Pay attention to details such as the size, the location and
the type of an umbilical repair
●
Attempt to create a breast that is aesthetically optimal and
natural, yet easy to revise if needed
●
Focus on creating an adequate cleavage volume

●
Better to create a breast that is slightly larger than too
small
FIGURE 3.4 The superfi cial inferior epigastric vein (SIEV) and artery
(SIEA) are identifi ed and preserved.

Cosmetic and Reconstructive Breast Surgery
40
where they are densely adherent. Several intercostal nerves
and vessels will be seen on the surface of the posterior
rectus sheath. The intercostal branches are isolated and
ligated. The lateral border of the muscle is identifi ed and
dissected inferiorly, where the DIEA pedicle is found at the
lateral border of the lower part of the muscle above the
pubic tubercle. The rectus abdominis muscle is separated
from the posterior sheath.
The rectus abdominis muscle is then gently retracted
to expose the deep inferior epigastric vessels that course
beneath it. Once the vascular pedicle has been identifi ed
and isolated, the inferior muscle attachment at the sym-
physis pubis and pubic crest is detached to facilitate expo-
sure and dissection of the deep inferior epigastric pedicle.
This is then traced toward its origin at the external iliac
vessels to obtain optimal vascular pedicle length. The upper
muscle attachment is divided, and the superior epigastric
artery and vein are ligated. Superiorly, the muscle can be
divided at any level above the perforators to the fl ap, even
at its insertion at the costal margin if necessary. The deep
inferior epigastric pedicle is left intact until the recipient
site is prepared.
Once the recipient vessels are dissected and the mastec-
tomy pocket is prepared, the TRAM fl ap harvesting is com-
pleted by individually ligating the DIE artery and veins
using either hemoclips or suture ligatures. After the fl ap is
harvested, the muscle is secured to the overlying fl ap with
several sutures so as to minimize any undue tension or
twisting of perforators.
MS-TRAM fl ap
The skin and subcutaneous tissues are elevated off the
anterior rectus sheath from lateral to medial until the
lateral perforators are seen. At this time, the lateral perfora-
tors from both the right and the left side are evaluated, and
the decision is made as to which will be kept. The size,
number, and orientation of the perforators should be con-
sidered when making this evaluation. The lateral row of
perforators on the side that will not be used are hemo-
clipped and divided, and then the fl ap is elevated to expose
the medial row of perforators. Once again, perforators on
both sides are evaluated and the preferred ones are kept;
the others are hemoclipped and divided. This maneuver is
continued until two or more of the best perforators remain,
having been selected for inclusion in the fl ap. All things
being equal, the author prefers medially located perforators
on the contralateral side of the abdomen to the breast
defect. Medial perforators provide longer pedicles and their
harvest results in less functional damage to the remaining
rectus muscle, as the muscle is innervated from lateral to
medial. Also, compared to the laterally located perforators,
more medially located perforators may provide better perfu-
sion to the tissues across the midline of the fl ap. Generally,
two or three moderate to large perforators will provide suf-
fi cient circulation to the TRAM fl ap.
The anterior rectus sheath fascia is dissected off the
underlying rectus abdominis muscle and its inscriptions,
and the orientation and course of the perforators within the
rectus muscle are evaluated. The decision to perform an
Lateral perforators
(pedicle side)
Lateral to medial
dissection
Medial perforators
(pedicle side)
Non-pedicle
perforators
Linea alba
Lateral to medial
dissection
FIGURE 3.5 The TRAM fl ap is carefully dissected off the rectus
sheath, preserving all major perforators (Redrawn from Schusterman
MA (ed) Microsurgical reconstruction of the cancer patient.
Lippincott-Raven, 1997).
Fascia incision
along perforators
FIGURE 3.6 A fascia-sparing technique is used to open the rectus
sheath fascia (Redrawn from Schusterman MA (ed) Microsurgical
reconstruction of the cancer patient. Lippincott-Raven, 1997).

Breast Reconstruction with Free TRAM Flaps
41
MS-TRAM or a DIEP fl ap is based on the number, caliber,
and location of perforators as well as their orientation and
course within the rectus muscle. A DIEP fl ap is selected
when there is a single large perforator, or when two or more
perforators are located within the same intramuscular
septum (Fig. 3.7). If the perforators are located in different
intramuscular layers, the muscle fi bers between them would
need to be divided for a DIEP fl ap; under these circum-
stances, a small cuff of muscle fi bers between and around
the perforators is incorporated, and a free MS-TRAM fl ap
is performed (Fig. 3.8A,B). The author prefers to perform a
DIEP fl ap only if it can be harvested without signifi cant
damage to the rectus abdominis muscle.
Three types of free MS-TRAM fl ap can be performed
(Fig. 3.9). The medial portion of the rectus abdominis
muscle can be preserved and a lateral portion of the rectus
muscle harvested with the fl ap (MS-1M).6,7 A lateral portion
of the muscle can be preserved and the medial portion of
the rectus muscle harvested with the fl ap (MS-1L). Finally,
a small cuff of muscle around the perforators can be har-
vested with the fl ap, leaving the majority of the muscles
intact (MS-2).
The type of free MS-TRAM fl ap harvested depends
for the most part on the location and orientation of the
FIGURE 3.7 A DIEP fl ap is selected when there is a single large
perforator, or when two or more perforators are located within the
same intramuscular septum (Redrawn from Bajaj AK, Chevray PM,
Chang DW. Comparison of donor-site complications and functional
outcomes in free muscle-sparing TRAM fl ap and free DIEP fl ap breast
reconstruction. Plast Reconstruct Surg 2006; 117: 737–746).
A
B
FIGURE 3.8 A, B If the perforators are located in diff erent
intramuscular layers, a small cuff of muscle fi bers between and
around the perforators is incorporated, and a free MS-TRAM fl ap is
performed (Redrawn from Bajaj AK, Chevray PM, Chang DW.
Comparison of donor-site complications and functional outcomes in
free muscle-sparing TRAM fl ap and free DIEP fl ap breast
reconstruction. Plast Reconstruct Surg 2006; 117: 737–746.)

Cosmetic and Reconstructive Breast Surgery
42
perforators. If the perforators are located very medially,
then the MS-1L is usually used. If the perforators are located
in the middle of the muscle, usually the MS-2 is used. If
the perforators are located laterally, then the MS-1M can
be harvested. Also, the orientation of the perforators within
the rectus muscle is a determining factor in how much of
the rectus abdominis will be taken with the perforators.
If the perforators are coming directly up through the
muscle, then only a small amount of muscle needs to be
sacrifi ced. However, if the perforators are coursing obliquely
through the muscle, then more muscle will need to be
sacrifi ced.
Once the extent of the muscle that needs to be taken
with the fl ap is decided, the muscle is split in the direction
of its fi bers within the intramuscular septum medially and
laterally down to the posterior rectus sheath (Fig. 3.10).
Under the rectus abdominis muscle, the main branch
to the perforators can usually be visualized at this time.
Inferior to the most inferior perforator, the muscle fi bers
between the lateral and medial dissected plane are then
divided. The author prefers to use a bipolar device for divid-
ing the muscles to minimize bleeding. All vascular branches
should be either hemoclipped or cauterized with the bipolar
device. It is important to maintain a hemostatic, clean
operative fi eld to optimize visualization and exposure.
Once the inferior portion of the muscle is divided, the
main pedicle should be exposed. The rectus muscle fi bers
are then split inferiorly to further expose and dissect
out the main pedicle. With a free MS-TRAM or a DIEP
fl ap, the pedicle does not usually need to be dissected all
the way down to the origin, as it is already fairly long.
Finally, the muscle fi bers at the superior aspect of the per-
forators are divided between the medially and laterally
dissected planes of the rectus muscle. At this time, the
superior blood supply to the rectus muscle is seen and
ligated (Fig. 3.11).
Once the recipient vessels are dissected and the mastec-
tomy pocket is prepared, the fl ap harvesting is completed
by individually ligating the DIE artery and veins using
either hemoclips or suture ligatures. After the fl ap is har-
vested, the muscle is secured to the overlying fl ap with
several sutures so as to minimize any undue tension or
twisting of perforators.
FIGURE 3.9 Three types of free MS-TRAM fl ap can be performed
(Redrawn from Bajaj AK, Chevray PM, Chang DW. Comparison of
donor-site complications and functional outcomes in free muscle-
sparing TRAM fl ap and free DIEP fl ap breast reconstruction. Plast
Reconstruct Surg 2006; 117: 737–746.)
FIGURE 3.10 The muscle is split in the direction of its fi bers within
the intramuscular septum medially and laterally down to the
posterior rectus sheath (Redrawn from Schusterman MA (ed)
Microsurgical reconstruction of the cancer patient. Lippincott-Raven,
1997.)
FIGURE 3.11 A free MS-TRAM fl ap.

Breast Reconstruction with Free TRAM Flaps
43
Preparation of the recipient site
For immediate reconstruction, after the mastectomy is
completed the mastectomy skin fl ap and defect are carefully
evaluated before the recipient vessels are dissected. For
delayed reconstruction, the previous mastectomy scar is
excised and sent for pathologic evaluation. The skin fl ap is
then elevated off the pectoralis major muscle superiorly and
inferiorly to recreate the mastectomy defect. Inferiorly,
careful attention is paid to avoid excessive dissection, which
would create a low inframammary fold.
Currently, the author uses the internal mammary
vessels as the primary recipients of choice (Fig. 3.12). The
intercostal spaces are palpated to fi nd an optimal space that
is wide and readily accessible for comfortable microvascular
anastomoses. This is usually at the second or third inter-
costal space. Then, the region above the pectoralis muscle
is scanned to identify any perforator vessels that may be
usable as recipients. Occasionally, fairly large perforator
vessels can be seen medially coming out of the pectoralis
muscle fi bers (Fig. 3.13). Usually, perforating veins are large
with a very thin wall, and perforating arteries are small.
Furthermore, most perforators will pose a size mismatch
with the main DIEA and DIEV, making anastomoses chal-
lenging. Only experienced microsurgeons who are comfort-
able with these types of anastomosis should use perforators
as recipient vessels.
If no suitable perforators are noted above the pectoralis
major muscle, then the pectoralis muscle at the desired
intercostal space is split in the direction of its fi bers to
expose the intercostal space. There is no need to detach the
pectoralis muscle from the sternum. Usually, more perfora-
tors can be seen underneath the pectoralis coming out of
the intercostal muscles. Again, the perforators are evaluated
for their suitability, and if the surgeon feels they are large
enough they can be used as recipient vessels.
To expose the internal mammary vessels, the overlying
intercostal muscle fi bers are carefully divided layer by layer
with a bipolar device. Usually, within 1–3 cm from the edge
of the sternum the internal mammary vein and artery are
identifi ed. If there is a single vein, it is medial to the artery.
If there are two veins, then the artery is between the veins.
It is critical to keep the operative fi eld bloodless for optimal
exposure. Extreme care must be taken to control bleeding
from small branches. Adjacent cartilage does not need to
be removed routinely; however, if the intercostal space is
narrow or deep, making anastomoses diffi cult, then the
overlying cartilage should be removed to better expose the
vessels. Either the cartilage above or that below can be
resected. To accomplish this, the perichondrium is incised
and dissected off the cartilage, 2–3 cm of cartilage is removed
directly over the internal mammary vessels using a rib dis-
sector or rongeur, and then the perichondrium is carefully
dissected off the internal mammary vessels. Once again,
extreme care must be taken to control bleeding from all
small branches. Final preparation of the recipient vessels is
best performed under a microscope.
Flap insetting and shaping
The overall goal of autologous tissue breast reconstruction
is to transfer well-vascularized tissue to the mastectomy
site and create a breast mound that appears as anatomically
and aesthetically normal as possible.
The author prefers to place the TRAM fl ap vertically for
breast reconstruction. This is best done using a fl ap from
the contralateral side of the abdomen (Fig. 3.14). That way,
the fl ap lies vertically on the chest with the vascular pedicle
oriented medially, in an anatomically natural position,
toward the internal mammary recipient vessels. The SIEV
will also be oriented medially, so that if a second source of
venous drainage is needed the SIEV can be anastomosed to
an internal mammary perforator vein or to a second inter-
nal mammary vein. The thin zone 3 tissue is inset in the
superior region, and the tissue of zones 1 and 2, the thickest
portion of the fl ap, is at the mound of the reconstructed
breast. The corner of the fl ap from zone 3 is usually
FIGURE 3.12 The internal mammary vessels as the primary recipients
of choice.
FIGURE 3.13 The internal mammary perforator vessels.

Cosmetic and Reconstructive Breast Surgery
44
discarded, and zone 4 is always discarded. In certain situa-
tions, zone 2, i.e., the fl ap across the midline, can be
folded to increase the fl ap’s projection or to create a ptotic-
appearing breast.
During the insetting and the shaping of the fl ap the
surgeon must always be aware of the tension, the rotation,
and the status of the vascular pedicle. Some surgeons like
to secure the fl ap to the chest wall, but I fi nd this is unnec-
essary in most cases and that the sutures create an unna-
tural contour of the reconstructed breast. Usually, the
mastectomy skin fl ap alone will provide good support for
the TRAM fl ap. However, when the fl ap is signifi cantly
smaller than the mastectomy defect, it needs to be secured
medially and superiorly so that it does not fall down within
the pocket, which can also cause excessive tension on the
vascular pedicle.
The TRAM fl ap is temporarily placed into the mastec-
tomy defect, and the mastectomy fl ap is draped over the
TRAM fl ap. The mastectomy fl ap is then temporarily
secured over the TRAM fl ap with skin staples. The patient
is placed in a sitting position, and the TRAM fl ap is shaped
into a breast (Fig. 3.15).
When shaping a TRAM fl ap for breast reconstruction,
it is important to focus on the superior and medial areas
of the breast to ensure adequate cleavage volume
(Fig. 3.16A,B). A slightly overcorrected cleavage region can
be easily revised with SAL. However, undercorrected cleav-
age, resulting from defi cient tissue volume in the superior
and medial portions of the breast, can be diffi cult to correct;
usually, the fl ap needs to be re-elevated and advanced to fi ll
the hollow area, which can be a major procedure.
It is better to make the initial breast mound volume
slightly larger than the contralateral breast. In most
instances, mild shrinkage of the reconstructed breast will
occur. Furthermore, a slightly too-large breast can usually
be readily revised with SAL or direct excision. However, an
Internal mammary
artery and vein
Superficial inferior
epigastric
Deep inferior epigastric
vein and artery
Thin
Thick
Right breast reconstruction
III
I
II
FIGURE 3.14 The author prefers to place the TRAM fl ap vertically for
breast reconstruction.
FIGURE 3.15 The patient is placed in a sitting position for insetting
and the shaping of the TRAM fl ap.
overzealous attempt at achieving a ‘perfect’ volume match
at the time of initial reconstruction can sometimes result
in a breast that is smaller than desired. If the initial recon-
structed breast is signifi cantly smaller than the opposite
breast, this can be corrected only by augmentation of the
reconstructed breast or reduction of the opposite native
breast. Attention also needs to be paid to make sure the
inframammary fold is placed in the correct location, as it
is very diffi cult to adjust this later on.
Once the optimal size and shape have been achieved
compared to the contralateral breast, the skin paddle is
marked. The patient is then placed back in a supine posi-
tion, and the buried portion of the skin is de-epithelialized.
One drain is placed underneath the fl ap.
In unilateral breast reconstruction, the contralateral
native breast is used as a guide to achieve volume and shape
symmetry for the reconstructed breast. When immediate
reconstruction is performed following skin-sparing mastec-
tomy, the remaining mastectomy skin envelope can facili-
tate the shaping of the fl ap for breast reconstruction.
In delayed breast reconstruction, the surgeon must
decide how to manage the inferior portion of the mastec-
tomy skin fl ap. If the skin fl ap is abundant and soft, the
author prefers to preserve it and use it for the breast recon-
struction, as this allows for more ‘natural’-appearing shape.
If the skin fl ap is fi brotic due to irradiation, it may be better
to discard it and replace that area with TRAM fl ap skin.
One of the most diffi cult parts of delayed breast recon-
struction is achieving an optimal inframammary fold. A
careful and accurate preoperative marking with the patient
in a standing position is essential to create an inframam-
mary fold in the proper location. A fold that is created too

Breast Reconstruction with Free TRAM Flaps
45
A
B
FIGURE 3.16 A, B When shaping a TRAM fl ap for breast reconstruction, it is important to focus on the superior and medial areas of the breast
to ensure adequate cleavage volume.
high or too low during the initial reconstructive procedure
is often diffi cult to correct. However, it is probably better
to err on the side of making the fold slightly too high than
too low. I personally fi nd it easier to lower an inframam-
mary fold that is too high than to move up an inframam-
mary fold that is too low.
Management of the donor site
Meticulous closure of the donor site defect is necessary to
prevent weakening or herniation of the anterior abdominal
wall. If the fascia was harvested using a fascia-sparing tech-
nique, the medial and lateral cuffs of the anterior rectus
sheath can be closed primarily where it was split longitu-
dinally without creating any tension, even in cases of bilat-
eral fl ap harvest. The rectus fascia sheath is closed primarily
with non-absorbable sutures using an interrupted and
running technique (Fig. 3.17A,B). However, if the integrity
of the overlying fascia is poor, or if a signifi cant amount of
fascia was harvested and tension-free primary closure is
diffi cult, synthetic mesh is used to reinforce the closure.
Synthetic mesh can be placed using an inlay or onlay tech-
nique, depending on the surgeon’s preference. The anterior
rectus sheath should be carefully repaired below the level
of the arcuate line where herniation is more likely to occur,
as the posterior rectus sheath is defi cient in this area.
Closed-suction drains are placed above the fascia closure in
the subcutaneous tissue.
After the abdomen is closed, the umbilicus is brought
out through an incision made in the midline of the abdomi-
nal fl ap and secured with sutures. Care should be taken to
ensure that the umbilicus is in the correct anatomic loca-
tion in the midline and that it is not twisted at its stalk.
There are many different ways to inset the umbilicus. The
author prefers to make a ‘frown’ incision and to resect a
small wedge from the inferior portion of the umbilicus for
a more youthful appearance (Fig. 3.18).
COMPLICATIONS
Flap loss
The success of even the most elegantly designed free
TRAM fl ap breast reconstruction is ultimately dependent
on the success of the arterial and venous anastomoses. The
most common cause of vessel thrombosis leading to fl ap
loss is probably technical error during the microvascular
anastomoses. Thus, it is critical that the surgeon have a
thorough understanding of the physiologic factors that