Cosmetic and Reconstructive Breast Surgery

Breast Reconstruction with Free TRAM Flaps
47
encouraged. Exercise that involves the abdomen may be
resumed approximately 6 weeks after surgery.
Revisions
After creation of the breast mound, a second-stage opera-
tion may be needed to revise the reconstructed breast
to achieve the fi nal desired size and shape. Occasionally,
surgical intervention on the opposite breast will be needed
as well. Other procedures that may be done during this
second stage include excision of fat necrosis, correction of
inframammary fold asymmetry, scar revisions, minor
touch-ups to the abdominal donor area, and nipple–areolar
reconstruction.
During the initial reconstruction it is often not possible
to make a breast that exactly matches the size and shape
of the opposite breast. One reason is the position of the
patient. Even if the breast is shaped with the patient in a
sitting position as much as possible, the full effect of gravity
when the patient is standing cannot be duplicated on the
operating table. Also, there are limitations as to how much
shaping can be performed without jeopardizing the blood
supply and the viability of the fl ap. Finally, the initially
reconstructed breast rarely, if ever, completely retains its
original shape or size. Thus, it is reasonable to expect that
the fi nal product will need some touch-ups in many or even
most cases. As the fl ap and the surgical site heal together,
the reconstructed breast’s size and shape continue to evolve.
For these reasons, some revision of the reconstructed breast
is often necessary.
The extent of revision surgery needed can vary from
minor outpatient surgery with local anesthesia to major
intervention requiring general anesthesia. Often the type
and extent of the revision can be planned during the initial
reconstruction. That is, during the initial reconstructive
surgery, insetting and shaping of the fl ap can be performed
in such a way that the second-stage revision surgery, if
needed, will be minor.
CONCLUSIONS
The free TRAM fl ap is one of the most popular and reliable
methods of microsurgical autologous tissue breast recon-
struction and has spawned several variations, including the
free MS-TRAM fl ap, free DIEP fl ap, and free SIEA fl ap.
With proper patient selection and safe surgical technique,
each of these fl aps can transfer the lower abdominal skin
and subcutaneous tissue to provide an aesthetically
pleasing breast reconstruction with minimal donor site
morbidity.
REFERENCES
1. Holmstrom H. The free abdominoplasty fl ap and its use in breast
reconstruction. Scand J Plast Reconstruct Surg 1979; 13: 423.
2. Schusterman MA, Kroll SS, Weldon ME. Immediate breast
reconstruction: Why the free TRAM over the conventional TRAM
fl ap? Plast Reconstruct Surg 1992; 90: 255.
3. Elliott LF, Eskenazi L, Beegle PH. Immediate TRAM fl ap breast
reconstruction: 128 consecutive cases. Plast Reconstruct Surg
1993; 92: 217.
4. Grotting JC. Immediate breast reconstruction using the free
TRAM fl ap. Clin Plast Surg 1994; 21: 207.
5. Pennington DG, Pelly AD. The rectus abdominis myocutaneous
free fl ap. Br J Plast Surg 1980; 33: 277.
6. Bajaj AK, Chevray P, 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.
7. Nahabedian MY, Momen B, Galdino G, Manson PN. Breast
reconstruction with the free TRAM or DIEP fl ap: Patient selection,
choice of fl ap, and outcome. Plast Reconstruct Surg 2002; 110:
466–475.
8. Lipa JE, Youssef AA, Kuerer HM, et al. Breast reconstruction in
older women: Advantages of autogenous tissue. Plast Reconstruct
Surg 2003; 111: 1110–1121.
9. Chang DW, Reece G, Wang B, et al. Effect of smoking on
complications in patients undergoing free TRAM fl ap breast
reconstruction. Plast Reconstruct Surg 2000; 105: 2374–2380.
10. Chang DW, Wang B, Robb G, et al. The effect of obesity on fl ap
and donor site complications in free TRAM fl ap breast
reconstruction. Plast Reconstruct Surg 2000; 105: 1640–1648.
11. Kim JYS, Chang DW, Temple C, et al. Free TRAM fl ap breast
reconstruction in patients with prior abdominal suction-assisted
lipectomy. Plast Reconstruct Surg 2004; 113: 28e.
12. Moon H, Taylor GI. The vascular anatomy of the rectus
abdominis musculocutaneous fl aps based on the deep superior
epigastric system. Plast Reconstruct Surg 1988; 82: 815.
13. Mathes S, Nahai F. Clinical applications for muscle and
musculocutaneous fl aps. St Louis: CV Mosby, 1982; 44.
14. Taylor G, Palmer J. The vascular territories (angiosomes) of the
body: experimental and clinical applications. Br J Plast Surg 1987;
40: 113.
15. Boyd JB, Taylor GI, Corlett R. The vascular territories of the
superior and deep inferior epigastric systems. Plast Reconstruct
Surg 1984; 73: 1.
16. Duchateau J, Declety A, Lejour M. Innervation of the rectus
abdominis muscle: implications for rectus fl aps. Plast Reconstruct
Surg 1988; 82: 223.
17. Carramenha E, Costa M, Carriquiry C, et al. An anatomic study
of the venous drainage of the transverse rectus abdominis
musculocutaneous fl ap. Plast Reconstruct Surg 1987; 79: 208.
18. Schefl an M, Hartrampf CR, Black PW. Breast reconstruction with
a transverse abdominal island fl ap. Plast Reconstruct Surg 1982;
69: 908–909.

49
C H A P T E R
4
Breast Reconstruction-Perforator Flaps
(DIEP, SIEA)
Moustapha Hamdi and John Hijjawi
INTRODUCTION
Hartrampf et al introduced the transverse rectus abdominis
myocutaneous (TRAM) fl ap in the early 1980s and with it
the use of the lower abdomen for autologous breast recon-
struction. The TRAM fl ap quickly gained the reputation as
the gold standard in breast reconstruction for many plastic
surgeons and their patients. Technical advances since then
have been directed towards improving aesthetic outcomes
and minimizing donor site morbidity for patients under-
g oing reconstruction with lower abdominal tissue. These
goals also include improving the reliability of all lower
abdominal fl aps transferred to the chest for breast recon-
struction, and maintaining the excellent aesthetic results
achieved with the pedicled TRAM fl ap.2–4
A major advance toward these goals has been the devel-
opment of ‘perforator’ fl aps, most notably the deep inferior
epigastric artery perforator (DIEaP) fl ap5–10 and the superfi -
cial inferior epigastric artery (SIEA) perforator fl ap.11–13 The
use of these fl aps in autologous breast reconstruction is
the subject of this chapter. The introduction and popularity
of the perforator fl ap concept has its roots in the fi eld
of microvascular breast reconstruction. The reduction in
donor site morbidity of the DIEP and SIEA fl aps over the
TRAM fl ap has been well established.14–16
INDICATIONS AND CONTRAINDICATIONS
The DIEaP and SIEA fl aps are excellent choices for breast
reconstruction in any woman with an immediate or delayed
mastectomy defect who has an adequate volume of lower
abdominal donor tissue supplied by appropriate vessels
(Figs 4.1–4.5).
The DIEaP fl ap is contraindicated in patients who have
already had cosmetic abdominoplasty. Relative contraindi-
cations for DIEaP reconstruction include smoking, previous
abdominal liposuction, lack of adequate tissue volume, and
poor overall medical condition.31–33 However, a DIEaP free
fl ap can still be harvested if intact and appropriately sized
perforators are confi rmed by preoperative imaging tech-
niques such as Duplex ultrasound or computed tomographic
(CT) scan.34 In such cases two pedicles, such as bilateral
DIEA or DIEA/SIEA, may be required to ensure the viability
of required zones of the abdominal fl ap to reconstruct even
a unilateral breast defect. Obviously, a bipedicled DIEaP/
DIEaP gives the greatest latitude in fl ap shaping because of
the length of the pedicle (Fig. 4.6).
Use of the SIEA free fl ap may be limited by the anatomi-
cal considerations previously outlined. This fl ap is more
suited to clinical situations where only a moderate amount
of tissue (located in zones I and II) is required for unilateral
or bilateral breast reconstruction. Indeed, bilateral recon-
struction is an ideal indication for the SIEA fl ap because it
allows a shorter operative procedure without intramuscular
dissection relative to the DIEaP or TRAM fl ap options.
Another good indication is in partial breast reconstruction,
where a limited volume of tissue is required to correct a
secondary breast deformity following breast-conserving
surgery (tumorectomy and radiotherapy).35
The absence or interruption of the SIEA vessels due to
previous abdominal surgery (e.g. Pfannenstiel incision or
inguinal hernia repair) is an absolute contraindication to
the SIEA fl ap. The vein should also be explored carefully in
cases of previous saphenous vein surgery in case it is inter-
rupted at this level.
PREOPERATIVE CONSIDERATIONS
Surgical anatomy
The skin and fat of the lower abdominal wall are lax, with
zones of adherence at the linea alba and the umbilicus. The
soft consistency of the fat is ideal for breast reconstruction,

Cosmetic and Reconstructive Breast Surgery
50
branch prior to penetrating the rectus muscle. In about 28%
of patients there is no bifurcation, and in these cases the
vessel takes a central course. As the pedicle courses through
its intramuscular course it gives off muscular branches.18
An average of two to eight ‘major’ perforators, defi ned as
being more than 0.5 mm in diameter, penetrate the ante-
rior rectus sheath per side in an area extending between
2 cm cranial to the umbilicus and 6 cm caudal to it, and
1–6 cm lateral to the umbilicus.19,20 The lateral branch, or
lateral row, perforators may be larger and easier to dissect,
but the midline perforators supply better blood fl ow to zone
IV, which is farthest from the vascular pedicle.21,22 As such,
the medial row perforators perfuse larger areas than lateral
row perforators, but the dissection must be carried out over
a longer intramuscular course with more extensive longitu-
dinal muscle splitting. Perforators that pass through the
rectus muscle at the level of the tendinous insertions are
generally large, with few side branches. At this location, the
distance from the anterior rectus sheath to the main pedicle
is also shorter, which reduces the complexity of the dissec-
tion. The perforators branch either immediately above the
FIGURE 4.1 Flap territory and design. A The vascular territory of the lower abdomen is divided into four zones (I–IV). B The DIEaP design
(dotted line) compared to the SIEA fl ap design (dark line). C The SIEA vascular territory (dotted zone) is limited to the ipsilateral lower abdomen
(zones I and II) with some extension to half of the contralateral zone III.
IV
III
I
II
A
B
as it allows the creation of a soft, pliable breast mound. The
blood supply to the lower abdominal wall which is of inter-
est in free abdominal fl ap breast reconstruction arises pri-
marily from the external iliac artery. A variety of elliptical
fl aps can be harvested from the tissue between the umbili-
cus and the pubis. However, this abdominal region is tra-
ditionally divided into four zones (I, II, III, and IV) depending
on an ipsilateral blood supply.17 Zone IV is most remote
from the pedicle and is not usually included in the fl ap (Fig.
4.7A).
Primary blood supply
The deep inferior epigastric artery, which is the major blood
supply to the lower abdominal wall, is a branch of the
external iliac artery arising 1 cm cranial to the inguinal
ligament. The pedicle traverses deep to the transversalis
fascia in a superomedial direction and comes into close
contact with the posterior surface of the rectus abdominis
muscle as it passes superfi cial to the arcuate line. In most
patients, and at a variable distance cranial to the arcuate
line, the main pedicle bifurcates into a lateral and a medial

Breast Reconstruction-Perforator Flaps
51
FIGURE 4.2 A 51-year-old patient who planned for a secondary
breast reconstruction on the left side. A The DIEaP fl ap markings and
the perforators are marked on the lower abdomen. B The MDCT
fi ndings in a diff erent section and then transferred at the abdomen
skin in a 3D image. The best perforator is (K) at the left side
(ipsilateral) side.
C
IV
III
I
II
FIGURE 4.1, cont’d
anterior rectus sheath, just below Scarpa’s fascia, or above
Scarpa’s fascia. When branching occurs just above the ante-
rior rectus sheath, one needs to be cautious when perform-
ing the suprafascial dissection around the circumference of
the perforator (see below) to avoid injuring any important
draining veins that may not be visible from a lateral per-
spective. Once dissected, the pedicle is approximately
10.3 cm long, with an average diameter of 3.6 mm at the
origin of the vessel. Whereas perforators arising from the
medial branch of the DIEA have a longer intramuscular
course, they also tend to be more dominant and so allow
one to carry a greater bulk of tissue from the contralateral
abdomen without concern over fat necrosis.
Secondary blood supply
The SIEA, which is one of the secondary blood supplies to
the lower abdomen, has several anatomical variations, as
reported by Taylor and Daniel.23 The SIEA arises from the
common femoral artery 2–3 cm below the inguinal liga-
ment in 17% of cases, or from a common origin with the
superfi cial circumfl ex artery in 48% of cases. The artery is
entirely absent in 35% of specimens. The artery is usually
A
B

Cosmetic and Reconstructive Breast Surgery
52
FIGURE 4.2, cont’d C Intraoperative view shows the quality of the dominant perforator. This is totally freed from the surrounding tissue.
D Intramuscular dissection of the perforator (P) into the main pedicle DIE (vessel loop). The rectus abdominis muscle fi bers are split
longitudinally,but the intercostal motor nerve (ICN) is preserved (two arrows). A large side branch (arrow) is clipped and left to use if an
additional blood supply or venous drainage is required. E A separate incision is made obliquely at the lateral border of the rectus abdominis to
give access to the main pedicle. F The DIEaP fl ap is completely harvested. G The internal mammary vessels are prepared.
B
B
C
D
E
F

Breast Reconstruction-Perforator Flaps
53
FIGURE 4.3 Pre- and post-operative views
of a 48-year-old patient with an immediate
breast reconstruction by a DIEaP fl ap.
FIGURE 4.4 A 49-year-old patient who
underwent left immediate breast
reconstruction with a DIEaP and
immediate nipple reconstruction.
A Preoperative view. B The fl ap on the 4th
postoperative day. A skin paddle was left
for fl ap control in the vertical incision
which was excised under local anesthesia
on the 5th postoperative day. C The results
9 months postoperatively.
A
B
A
B

Cosmetic and Reconstructive Breast Surgery
54
FIGURE 4.5 A 54-year-old patient who underwent a left secondary breast reconstruction using a DIEaP fl ap and contra lateral breast
remodeling. A Preoperative views. B Postoperative views.
C
FIGURE 4.4, cont’d
A

Breast Reconstruction-Perforator Flaps
55
FIGURE 4.6 A 56-old-year patient who
had a secondary left breast reconstruction
with a DIEaP fl ap. A Preoperative views.
B Postoperative views.
FIGURE 4.5, cont’d
B
A
B

Cosmetic and Reconstructive Breast Surgery
56
accompanied by two venae comitantes, which drain into
the deep femoral vein or occasionally into the saphenous
bulb. In addition, there is a constant superfi cial inferior
epigastric vein (SIEV) draining the lower abdominal skin
and fat. The SIEV is a tributary of the greater saphenous
vein close to the fossa ovale. The superfi cial inferior epigas-
tric vessels pass superiorly and laterally in the femoral tri-
angle, crossing the inguinal ligament at its midpoint, lying
deep to Scarpa’s fascia. The vessels continue to course cra-
nially and superfi cially, penetrating Scarpa’s fascia well
above the inguinal ligament to lie in the superfi cial subcu-
taneous tissue. In a recent anatomical study Reardon et al.24
identifi ed the SIEA in 72% of specimens, with an average
diameter of 1.6 mm (range 0.75–3.5 mm) at the level of the
inguinal ligament. In 58% of cases the artery was present
bilaterally. The SIEA lies lateral to the SIEV. The length of
the pedicle ranged from 4 to 7 cm, with an average length
of 4 cm.
Operative approach
Preoperative assessment of the perforators
The authors’ current practice is to mark all available
perforators, with the dominant perforators distinguished
and clearly marked on the abdominal skin. Color Duplex
imaging is a reliable and valuable method to assess the
arterial and venous trees of the lower abdomen in addition
to the internal mammary vessels.18 However, we currently
use preoperative multidetector row CT (MDCT) scans to
determine the location of dominant perforators and have
A
B
FIGURE 4.7 A 52-old-patient with a right secondary breast reconstruction using a SIEA fl ap. A Preoperative views. B Postoperative views.

Breast Reconstruction-Perforator Flaps
57
done so for 2 years.25,26 Unidirectional Doppler allows us to
verify the exact location of the SIEA, generally midway
between the anterior superior iliac spine (ASIS) and the
pubis.
Flap marking
As is the case for all breast reconstructions using lower
abdominal tissue, the amount of fat available is estimated
by the ‘pinch test.’ The design of the DIEAP fl ap is an
ellipse approximately 13 cm high and 35–40 cm wide, with
the superior border of the fl ap at or just above the umbili-
cus. The upper edge of the fl ap is tapered laterally just above
the ASIS to facilitate closure without dog-ears (Fig. 4.7B).
In the SIEA fl ap the vascular territory is limited to the
ipsilateral lower abdomen, with some extension to half of
the contralateral zone III (Fig. 4.7B, C). In our hands, the
SIEA can support less tissue across the midline than a free
TRAM or DIEP fl ap. Therefore, the fl ap is designed exclu-
sively over zones I and II, any extension being laterally over
the iliac region. Using this method, a fl ap of up to 32 ×
13 cm can be harvested. The lower incision line is placed
more inferiorly towards the pubic tubercle than with the
A
B
C
FIGURE 4.8 A case of double-pedicle DIEaP fl ap for unilateral breast
reconstruction. A The DIEaP fl ap was harvested based on a two-
pedicles DIE. B One DIE pedicle was anastomosed to a side branch of
the second DIE pedicle to ensure blood supply to the required four
zones (I–IV). C The results, with good symmetry and breast contour.
DIEP fl ap in order to better visualize the vessels at this
level.
DIEAP fl ap
Flap dissection
After marking the perforators and the fl ap (Fig. 4.8A), the
patient is placed in a supine position. Depending on the
MDCT fi ndings, the dominant perforator is clearly marked
(Fig. 4.8B). A solution of 1% lidocaine with epinephrine is
used to infi ltrate the entire superior edge and the inferior
edge of the fl ap, except for the region of the superfi cial
inferior epigastric veins, approximately midway between
the ASIS and the pubis. The umbilicus is delivered by con-
necting three periumbilical stab incisions at 10 o’clock, 2
o’clock, and 6 o’clock. An orienting suture is placed at the
6 o’clock position.
The lower incision is made, taking care to identify and
preserve the SIEV bilaterally. The SIEV is always dissected
for approximately 3–5 cm toward the groin and clipped to
allow for anastomosis should additional venous drainage
be necessary later in the procedure. The upper incision is

Cosmetic and Reconstructive Breast Surgery
58
made with variable beveling (depending on the required fl ap
volume) and carried down through skin and fat to the ante-
rior rectus sheath. The fl ap is then elevated from lateral to
medial, with electrocautery just above the anterior rectus
sheath. As the dominant perforators are approached the
cautery is reduced signifi cantly to minimize thermal damage
to the perforators. Once the perforator is visualized from
its lateral aspect, it is carefully inspected to ensure that the
artery is pulsatile and that the vein is of adequate caliber.
Although MDCT has greatly facilitated and expedited fl ap
harvesting, it has not replaced clinical judgment in perfora-
tor selection. The selected perforator is dissected free of
surrounding connective tissue for 360º in a suprafascial
plane. Care is taken on the medial aspect of the perforator
to protect any branches that may not be directly visible
from the surgeon’s lateral perspective (Fig. 4.8C). The fascia
is then opened from directly within the natural fascial
opening for several centimeters in a cranial and caudal
direction, and an elastic hook is used on the lateral edge of
the opened fascia to expose the rectus muscle and begin the
intramuscular portion of the dissection. Any loose connec-
tive tissue around the base of the perforator is dissected
with a microbipolar cautery, allowing the surgeon to iden-
tify the cleavage plane in the rectus muscle through which
the perforator traverses. Once this plane is identifi ed it can
be easily developed cranially and caudally with bipolar
cautery and spreading maneuvers beginning the longitudi-
nal splitting of the muscle. Dissection of the perforator is
continued along its lateral aspect, ‘unroofi ng the perforator’
towards the main pedicle while splitting the muscle longi-
tudinally. The medial aspect of the perforator is left undis-
sected until the main pedicle is developed. As noted
previously, when perforators traverse the rectus at the level
of a tendinous inscription, they tend to be larger and to
have a shorter, more direct intramuscular course to the
main pedicle, which is convenient. Whether dissection
through a tendinous inscription is easier than dissection
through muscle is a matter of opinion. The natural cleavage
plane in the rectus muscle is progressively developed until
the main pedicle is visualized at the posterior aspect of the
rectus. This is the point at which one encounters motor
branches of the intercostal nerves passing superfi cial to the
pedicle. These must be preserved.
Once the main pedicle is identifi ed, self-retaining retrac-
tors are used to hold open the rectus muscle while muscular
branches from the perforator and the main pedicle are
ligated with either bipolar cautery or microvascular clips
(Fig. 4.8D). As the pedicle is developed caudally, one even-
tually reaches the point at which the deep inferior epigastric
vessels emerge from within the muscle into a submuscular
plane. The pedicle is followed caudally, releasing it from
surrounding fat until suffi cient length is obtained, generally
continuing dissection until the lateral edge of the rectus
muscle is reached. In an effort to avoid later hernias or
abdominal bulging, it is recommended to make a separate
incision at the lateral inferior border of the rectus muscle
near the inguinal ligament (Fig. 4.8E). This second incision
avoids a continuous area of weakness, thereby avoiding the
possibility of bulging, especially in obese patients. This
portion of the dissection is very similar to that in the free
TRAM dissection. In many patients the point at which the
DIEA bifurcates into its medial and lateral branches is
evident. A valuable strategy we have employed in the past
is to follow the largest side branch for 1–2 cm before ligating
it to provide an additional vessel to which the SIEV can be
anastomosed if the fl ap appears congested later in the pro-
cedure. For example, if the dominant perforator arises from
the medial branch of the DIEA, the lateral branch of the
DIEA can be dissected for 1–2 cm back in a cranial direction
prior to ligating it. After microvascular transfer, this branch
can serve as a recipient vein for the SIEV if additional
venous drainage is required, as in the case of a fl ap found
to have a dominant superfi cial venous drainage system.
Once the pedicle is totally dissected to the desired length,
the artery and vein(s) are separated in the groin or at the
lateral edge of the rectus. Attention then returns to the
perforator to dissect its medial aspect. A vessel loop with
gentle lateral retraction facilitates this portion of the dis-
section. When the donor site is ready, the pedicle is tran-
sected and pulled through the longitudinal split in the
rectus muscle and under the preserved motor nerves to
deliver the fl ap while preserving the entire muscle and its
innervation (Fig. 4.8F).
Preparing the recipient site
The major difference in delayed reconstruction is the need
to determine and establish the level of the inframammary
fold, taking into consideration the tendency of a fold marked
at the start of the procedure to migrate caudally as the
contracted mastectomy scar is opened and the abdominal
donor site is closed. Therefore, in delayed reconstruction
the level of the inframammary fold is marked more superi-
orly than the fi nal desired position. The mastectomy fl ap
skin below the level of the mastectomy scar is either entirely
excised in full-thickness fashion or de-epithelialized over
the area between the scar and the fold to increase the overall
volume of the reconstructed breast. The medial portion of
the pectoralis is still easily exposed.
Exposure of the recipient vessels
The ideal recipients for microvascular breast reconstruction
using perforator fl aps are the internal mammary vessels.27,28
Although several other options exist, more than 98% of our
reconstructions are accomplished using the internal
mammary vessels as recipient vessels.28
On the left side of the chest the internal mammary
bundle typically has only one vein and the vessels are
smaller than those on the right. Therefore, on the left it is
our preference to expose the vessels at the third intercostal
space, whereas on the right the fourth intercostal space is
used. This optimizes size match with the fl ap vessels. We
have not found that removing the entire rib cartilage at
either of these levels causes noticeable contour deformities,
as the fl ap and pectoralis muscle cover this area. If present,
medial mammary perforators, which typically emerge in
the region of the second or third intercostal spaces, are
preserved to provide additional sources of venous outfl ow
if this is found to be necessary. This is particularly impor-

Breast Reconstruction-Perforator Flaps
59
FIGURE 4.9 A DIEaP fl ap with additional venous drainage via the
SIEV. A The SIEV was dissected as long as possible. B The SIEV was
anastomosed directly to the second IMV.
tant on the left, where there tends to be only one internal
mammary vein. Depending on their diameter, the internal
mammary perforators can be used as an alternative to the
main internal mammary vessels as recipients for free fl ap
breast reconstruction.28
The pectoralis is split along its fi bers to expose the
entire length of the cartilaginous rib from the sternocostal
junction to the costochondral junction. A combination of
self-retaining retractors and elastic hooks is used to retract
the pectoralis muscle and expose the entire cartilaginous
portion of the selected rib, making it simple for a single
surgeon to perform the exposure. A narrow rongeur is then
used to progressively remove the cartilage from anterior to
posterior and from lateral to medial. Every effort is made
to leave the posterior perichondrium intact throughout this
portion of the procedure, so that fi nal exposure of the
vessels is controlled and deliberate. Unintentional injury to
the internal mammary vein when aggressively entering the
posterior perichondrium can consume valuable time, as
microsurgical repair is usually required, quite apart from
the increased thrombogenicity of an injured recipient vessel.
This is especially important in cases where the patient has
been previously irradiated and the fi eld is scarred, such as
in cases of mastectomy following failed lumpectomy and
radiation therapy. Once the cartilage has been removed, the
posterior perichondrium is incised laterally and elevated in
an avascular plane over the internal mammary vessels to
expose them. Fixing a narrow-gauge pediatric feeding tube
or drain on suction into the deepest portion of the micro-
surgical fi eld helps remove any irrigation fl uid or blood,
thereby keeping the fi eld clear (Fig. 4.8F). At this point the
microscope is brought into the fi eld to facilitate ligation of
any branches arising from the midportion of the exposed
vessels so that they are entirely free along their exposed
length. The vessels are ligated immediately prior to fl ap
transfer, with microvascular clamps placed at their proxi-
mal end and ‘fl ashed’ to ensure adequate infl ow of the
internal mammary artery (IMA).
Microvascular setup
Where two teams are available, the patient’s legs can be
raised to facilitate closure of the donor site during the
microvascular anastomosis, thereby expediting the proce-
dure. The fl ap is turned 180º and fi xed to the chest with a
moist laparotomy pad and staples. Because the internal
mammary vein is more medial than the artery, the venous
anastomosis is performed fi rst, followed by the arterial
anastomosis. The microvascular technique depends on the
training and practice of the surgeon. It is our habit to
perform end-to-end anastomoses in the vast majority of
cases.
Additional venous drainage of the DIEAP fl ap
Once the microanastomosis of the DIEA/V with the IMA/V
is complete, the fl ap is evaluated. If the fl ap appears totally
congested despite a patent venous anastomosis, this is an
indication that the lower abdominal tissue in that particu-
lar patient is drained predominantly by the SIEV (2% of our
cases). Frequently, during the initial fl ap dissection an SIEV
is noted to be large. If the SIEV has been dissected for
approximately 5 cm, it can usually reach the IM vessels
directly and then the SIEV is anastomosed to either a
second IMV (Fig. 4.9A,B) or a local medial mammary per-
forating vein (Fig. 4.10). Alternatively, the SIEV can be
anastomosed to either the medial or the lateral branch of
the DIEA/DIEV pedicle, as described above (Fig. 4.11).
When the SIEV is insuffi ciently long, an arterial graft
(usually the contralateral DIEA) is used to bypass the gap
between the SIEV and the recipient vein.29
It is critical to evaluate the SIEV several minutes after
re-establishing perfusion of the fl ap to determine whether
or not it has adequate venous drainage through the deep
inferior epigastric system alone (Box 4.1) An additional
indication for using the SIEV is when a large fl ap is har-
vested including most of zone III or a part from zone IV
(6% of our cases).30
Shaping the breast
In immediate reconstruction, shaping the breast begins
by assessing the volume of the total fl ap transferred for
A
B

Cosmetic and Reconstructive Breast Surgery
60
FIGURE 4.10 A DIEaP fl ap with additional venous drainage by the
SIEV, which is anastomosed to an internal mammary vein perforator
(IMV/P).
FIGURE 4.11 A DIEaP fl ap with additional venous drainage by the
SIEV, which is anastomosed to a side branch of the DIE vessels.
BOX 4.1 Managing venous outfl ow
●
Preserve medial mammary perforating veins as potential
backup venous outfl ow sources when they are present.
●
Always harvest 5 cm of SIEV when it is available.
●
If the SIEV is large and becomes engorged during dissection
of a DIEP fl ap, the fl ap most likely has a dominantly
superfi cial venous drainage system and may require
anastomosis of the SIEV.
●
When harvesting a DIEA fl ap based on a medial row
perforator, ligate the lateral row branch with suffi cient length
to provide an additional venous outfl ow source for the SIEV.
gross symmetry to the unoperated breast. In cases of
bilateral reconstruction this will not be an issue, as the
lower abdomen will simply be bisected. Excess volume is
usually debrided from zone IV. The fl ap is oriented by
placing its lateral tip on the side ipsilateral to the selected
perforator in a superolateral orientation, along the pectora-
lis tendon. One or two absorbable sutures can be placed to
position the lateral tip of the fl ap along the pectoralis
tendon, recreating the tail of Spence. A lateral suture is then
placed to close off the lateral breast pocket if this has been
violated during the ablative procedure. A single suture in
the inferolateral fl ap can recreate the lateral border of the
breast that lies inferior and slightly lateral to the anterior
axillary fold. Breast projection can be augmented by gather-
ing the fl ap towards the breast axis, or by folding the de-
epithelialized medial edge of the fl ap, now positioned at the
inferior pole of the reconstructed breast, under the bulk of
the fl ap, holding this position by suturing the de-epithelial-
ized dermis down to the pectoral fascia. The natural infra-
mammary fold is preserved. Medial sutures are rarely
required. Once this basic shaping is achieved, the fl ap is
tucked under the native mastectomy fl aps to determine the
extent of de-epithelialization needed. It is then delivered
back from under the mastectomy fl aps and de-epithelial-
ized. Before fi nal suturing, the pedicle is always rechecked
to ensure a natural lie that is free of any kinking or twisting
of the pedicle.
Delayed reconstruction requires more time for prepara-
tion of the pocket. The inferior mastectomy fl ap, which lies
in between the mastectomy scar and the inframammary
fold, is usually de-epithelialized, leaving the attachments to
the pectoral fascia intact. This adds signifi cant volume to
the reconstructed breast once the fl ap is positioned above
this de-epithelialized dermis and subcutaneous fat. The
superior mastectomy fl ap should be developed to provide
an adequate pocket to accept the fl ap. Adequate debride-
ment requires the excision of any scar or residual capsule
in cases where implants or expanders have been used.
Often, a tight band is present at the very edge of the supe-
rior mastectomy fl ap that should be scored sequentially to
allow expansion of this often contracted tissue. In cases
where the mastectomy fl aps have been left with signifi cant
subcutaneous tissue, they should be thinned to allow an
even and seamless transition between the skin paddle of
the transferred lower abdomen and the mastectomy fl ap.
Donor site closure
An upper abdominal fl ap is developed to the level of the
xiphoid centrally and the inferior costal margin laterally.
This can be done before performing the microanastomosis
to allow a two-team approach. Therefore, the abdomen
should be prepared for closure before setting the fl ap on the
thorax for the microanastomoses. This approach allows the
donor site to be closed while the microvascular portion of
the procedure is under way. Either the operating table is
placed into a refl exed position (with appropriate Trendelen-
burg positioning at the discretion of the microvascular
team), or the legs are elevated, keeping the back fl at. The
anterior rectus sheath is closed with a non-absorbable
braided 0 suture (Fig. 4.12). It is absolutely critical that both
layers of the anterior rectus sheath be visualized and
included in the closure to minimize postoperative abdomi-
nal bulging, particularly below the arcuate line. In patients
with risk factors such as major obesity or multiple previous

Breast Reconstruction-Perforator Flaps
61
team approach. Moreover, partial fl ap failure and/or fat
necrosis in DIEaP fl aps can be reduced by correctly selecting
the dominant perforator.
As noted above, MDCT can provide excellent preopera-
tive information regarding the arterial diameter of a given
perforator. However, the adequacy of draining veins is often
not clear until they can be directly inspected during surgery.
A perforator bundle that has a clearly pulsatile artery and
a vein that is at least 0.5 mm in diameter is ideal. When
no single perforator meets these guidelines, it may be neces-
sary to dissect more than one perforator in a given row
without sacrifi cing muscle or nerves (Fig. 4.13A). This is
often a matter of continuing the longitudinal split in the
muscle between two perforators. However, it may be neces-
sary to cut a small piece of rectus abdominis muscle to
allow the harvest of a fl ap having two perforators (Fig.
4.13B). It is also possible that the motor branch of an inter-
costal nerve passes between two perforators, requiring the
nerve to be sectioned and then reanastomosed after fl ap
harvesting (Fig. 4.13C).
Finally, there are situations where a lack of pulsatile
perforator arteries or the presence of multiple very small
perforators simply requires conversion to a muscle-sparing
TRAM fl ap. Conversion of a DIEaP fl ap to a TRAM or
muscle-sparing TRAM fl ap is often safer and easier than
dissecting three or more perforators, which may cause
similar damage to the rectus muscle as the use of a muscle-
surgical incisions with weakness of the abdominal muscu-
lature, the addition of mesh to the abdominal closure
should be considered.
Once the rectus sheath is closed, the abdominal wall
superior to the umbilicus is evaluated for rectus diastasis.
If this is present it is repaired using a 0 looped permanent
suture, just as in cosmetic abdominoplasty. The umbilicus
is then tacked to the anterior rectus sheath with a 4/0
absorbable suture. The suture is placed fi rst into the ante-
rior rectus sheath, then into the mid-dermis of the umbili-
cus at 10 o’clock, 2 o’clock, and 6 o’clock, and hemostats
placed. Once the abdominal fl ap is closed and the position
of the new umbilical aperture determined, these sutures are
fi nally placed into the dermis of the umbilical aperture and
tied.
Optimizing outcomes in DIEaP fl ap
The use of the DIEaP fl ap for breast reconstruction provides
a breast with a natural appearance and texture. Like other
perforator fl aps, the DIEaP fl ap relies on specialized har-
vesting techniques. As with any new technique, for begin-
ners or trainees the learning curve is obviously the main
challenge (Boxes 4.2 and 4.3). Because of this, perforator
fl aps would ideally be included in every training program.
Attending perforator fl ap courses and visiting centers where
large numbers of perforator fl aps are used will shorten the
learning period and signifi cantly reduce the rate of compli-
cations that may occur during early experience. Using
imaging technology such as duplex ultrasound or MDCT
scan in the preoperative planning is recommended to make
the technique of perforator fl aps more reliable in inexperi-
enced hands.25,26
Precise preoperative mapping of perforators will signifi -
cantly shorten the operative time and reduce complications
related to poor choice of perforators. A unilateral DIEaP fl ap
breast reconstruction takes 3 hours in our hands, thanks
in part to the precise preoperative planning now possible
using imaging technology in perforator mapping and a two-
FIGURE 4.12 Careful closure of the two incisions in the deep fascia
with non-absorbable stitches.
BOX 4.2 Technical pearls in harvesting
perforator fl aps
●
Place vessel clips with at least 2 mm of extra length in case
the clip falls off and needs to be replaced.
●
Perform perforator dissection in as bloodless a fi eld as
possible. Staining of tissues with blood can signifi cantly
hinder perforator dissection.
●
Develop wide exposure and resist the tendency to chase a
perforator into a hole.
●
Until signifi cant experience is gained, do not sacrifi ce any
reasonably sized perforator until you have identifi ed and
dissected a better perforator. This provides a backup vessel
in case the dominant perforator is injured.
BOX 4.3 Pitfalls in DIEaP and SIEA
breast reconstruction
●
Excessive tension during retraction by the assistant can lead
to intraluminal damage to the perforator.
●
Operating room lights can quickly desiccate a perforator.
Irrigate consistently throughout the dissection.
●
Always perform a second check of the pedicle for kinking or
torsion after the fl ap has been shaped and prior to fi nal
closure.
●
When harvesting an SIEA fl ap, excessive dissection of
perivascular fatty tissue will increase the incidence of groin
seromas.

Cosmetic and Reconstructive Breast Surgery
62
sparing free TRAM fl ap.16 Fortunately, these situations are
rarely encountered.
SIEA FLAP
Flap dissection
Because of anatomical variation in the SIE vessels, an algo-
rithmic approach is taken when considering harvesting of
the fl ap. We commonly select the contralateral abdomen to
reconstruct a breast, as this facilitates a two-team approach
and improves insetting of the fl ap. Dissection begins with
surgical exploration of the SIE vessels: the initial incision is
made along the inferior fl ap markings, but at this stage is
not deepened to the subcutis. The SIE vessels are identifi ed
at a point between the pubic tubercle and the ipsilateral
ASIS corresponding with the markings of the Doppler fi nd-
ings. The SIEA is found usually in association with two
venae comitantes directly above Scarpa’s fascia (Fig. 4.14A).
The SIEV is usually located 2–3 cm medial to the SIEA.
Side branches are meticulously coagulated or ligated. It is
easier to dissect close to the vessels, and dissection
includes a limited amount of the surrounding fatty tissue
(Fig. 4.14B). The vessels cross the inguinal ligament, and at
this point the artery descends vertically in the form of a loop
towards its origin, whereas the venae comitantes continue
distally to join the femoral or saphenous veins (Fig. 4.14C).
In almost 50% of cases the venae comitantes join the SIEV
before entering the deep venous system. If a larger skin ter-
ritory is required the superfi cial circumfl ex vessels can be
included with the SIEA fl ap. If the diameter of the SIEA is
over 1 mm, the fl ap can be safely harvested based on these
vessels. If not, the contralateral SIE vessels should be explored.
The fl ap must remain attached to the deep fascia until the
SIE vessels are explored and an appropriately sized artery
located, so as to retain the possibility of converting it to a
DIEaP fl ap. Pedicle length varies from 4 to 7 cm (Fig.
4.14D).
If no suitably sized arteries can be identifi ed then the
fl ap is converted to a conventional DIEaP fl ap and dissec-
tion of the perforators through the rectus abdominis
performed.
Microanastomoses
The internal mammary (IM) vessels are dissected and pre-
pared as described above. The IM vessels are dissected dis-
tally to obtain maximum recipient vessel length, which
makes microanastomosis more comfortable and at a level
above the pectoralis major (PM) muscle, thereby allowing
the SIE vessels to lie on the PM without kinking. If a size-
able internal mammary artery (IMA) perforator is encoun-
tered above the pectoralis major (PM) muscle, these
perforators are preferred, in keeping with our algorithm for
choosing recipient vessels for breast reconstruction.28 The
IMA perforators are usually a better size match with the
SIE vessels, and also create an ideal situation whereby recip-
ient site morbidity is minimized as well as donor site
morbidity.
A
B
C
FIGURE 4.13 DIEaP fl aps are raised on more than one perforator. P,
perforator; ICN, intercostal nerve; RA, rectus abdominis. A A DIEaP
fl ap is raised on three perforators on one row without sacrifi cing
muscle or motor nerves. B A DIEaP fl ap is raised on two perforators
with 1.5 cm sections of RA muscle (partial thickness). C A DIEaP fl ap is
raised on two perforators, with cutting one ICN in between. The
nerve is resutured after fl ap harvesting.

Breast Reconstruction-Perforator Flaps
63
A
B
C
D
FIGURE 4.14 A 51-year-old patient who planned for a secondary
breast reconstruction on the left side. A The DIEaP fl ap markings and
the perforators are marked on the lower abdomen. B The MDCT
fi ndings in a diff erent section and then transferred at the abdomen
skin in a 3D image. The best perforator is (K) at the left side
(ipsilateral) side. C Intraoperative view shows the quality of the
dominant perforator. This is totally freed from the surrounding tissue.
D Intramuscular dissection of the perforator (P) into the main pedicle
DIE (vessel loop). The rectus abdominis muscle fi bers are split
longitudinally, but the intercostal motor nerve (ICN) is preserved (two
arrows). A large side branch (arrow) is clipped and left to use if an
additional blood supply or venous drainage is required.
SIEA fl ap insetting
The shorter SIE vessels make fl ap insetting somewhat more
diffi cult than that of DIEaP or TRAM fl aps. Also, the SIE
vessels emerge from the subcutaneous level of the inferior
border of the fl ap, rather than from its deep surface, as in
the TRAM or DIEaP fl aps. This can become a problem in
breast reconstruction because the fl ap needs to be oriented
in a suitable manner to achieve adequate shaping without
kinking the pedicle. Positioning of the fl ap on the chest is
critical and has to be undertaken with the utmost care. We
have found that vertical orientation of the fl ap provides the
safest positioning of the vessels, as they lie almost horizon-
tally above the pectoralis muscle (Fig. 4.14E). In the case
of ipsilateral SIEA fl ap harvest, the fl ap should be oriented
in a more oblique direction, with folding of its lateral part
to obtain maximal medial fullness (Fig. 4.14F). The fi nal
shape achieved on the operating table should have less
lateral fullness and more tissue bulk medially. This pre-
empts lateral sagging due to gravity, which can become
apparent during follow-up.

Cosmetic and Reconstructive Breast Surgery
64
E
F
G
FIGURE 4.14, cont’d E A separate incision is made obliquely at the
lateral border of the rectus abdominis to give access to the main
pedicle. F The DIEaP fl ap is completely harvested. G The internal
mammary vessels are prepared.

Breast Reconstruction-Perforator Flaps
65
may all be used for monitoring. The patient’s core tempera-
ture should be maintained with a warm room, a warming
blanket, and warmed fl uids as needed, and the use of vaso-
constrictive agents should be avoided.
CONCLUSION
The DIEaP and SIEA fl aps are excellent options for autolo-
gous breast reconstruction. Flap-related complications and
aesthetic results are equivalent to those of the pedicled
or free TRAM fl aps, and donor site complications are
signifi cantly less common. Although the operation is con-
traindicated in patients who have had previous cosmetic
abdominoplasty, there are few other absolute contraindica-
tions. The advent of MDCT has reduced operative times
and facilitated reliable fl ap harvest even in the presence
of multiple previous abdominal operations by confi rming
the presence of adequate perforators. Increasingly, hospital
systems, third-party payers, and patients are demanding
shorter hospital stays following surgery and more rapid at-
home recovery. These goals need to be achieved with no
sacrifi ce of aesthetic outcome. Both the DIEaP and SIEA
fl aps can reliably achieve all of these goals.
REFERENCES
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a transverse abdominal island fl ap. Plast Reconstruct Surg 1982;
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2. Grotting JC. The free abdominoplasty fl ap for immediate breast
reconstruction. Ann Plast Surg 1991; 27: 351–354.
3. Feller AM. Free TRAM. Results and abdominal wall function. Clin
Plast Surg 1994; 21: 223–232.
4. Nahabedian MY. Defi ning the ‘gold standard’ in breast
reconstruction with abdominal tissue. Plast Reconstruct Surg
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5. Koshima I, Soeda S. Inferior epigastric artery skin fl aps
without rectus abdominis muscle. Br J Plast Surg 1989; 42:
645–648.
6. Allen RJ, Treece P. Deep inferior epigastric perforator fl ap for
breast reconstruction. Ann Plast Surg 1994; 32: 32–38.
7. Hamdi M, Weiler-Mithoff EM, Webster MH. Deep inferior
epigastric perforator fl ap in breast reconstruction: experience with
the fi rst 50 fl aps. Plast Reconstruct Surg 1999; 103: 86–95.
8. Blondeel P. One hundred free DIEP fl ap breast reconstructions: a
personal experience. Br J Plast Surg 1999; 52: 104–111.
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breast reconstruction using perforator free fl aps: a single center’s
experience. Plast Reconstruct Surg 2004; 114: 83–89.
10. Gill PS, Hunt JP, Guerra AB, et al. A 10-year retrospective review
of 758 DIEP fl aps for breast reconstruction. Plast Reconstruct Surg
2004; 113: 1153–1160.
11. Arnez ZM, Khan U, Pogorelec D, et al. Breast reconstruction using
the free superfi cial inferior epigastric artery (SIEA) fl ap. Br J Plast
Surg 1999; 52: 276–279.
12. Allen RJ, Heitland AS. Superfi cial inferior epigastric artery fl ap for
breast reconstruction. Semin Plast Surg 2002; 16: 35–44.
13. Chevray PM. Breast reconstruction with superfi cial inferior
epigastric artery fl aps: a prospective comparison with TRAM and
DIEP fl aps. Plast Reconstruct Surg 2004; 114: 1077–1083.
14. Blondeel N, Vanderstraeten GG, Monstrey SJ, et al. The donor site
morbidity of free DIEP fl aps and free TRAM fl aps for breast
reconstruction. Br J Plast Surg 1997; 50: 322–330.
15. Futter CM, Webster MH, Hagen S, et al. A retrospective
comparison of abdominal muscle strength following breast
reconstruction with a free TRAM or DIEP fl ap. Br J Plast Surg
2000; 53: 578–583.
The fl ap is attached to the thoracic wall inferiorly with
heavy absorbable stitches, especially in the lateral border.
One or two stitches are placed between the superfi cial fascia
and the PM fascia to ensure that there is no tension on the
microanastomosis site due to the weight of the fl ap. The
skin is closed using interrupted deep dermal 3/0 absorbable
suture and subcuticular running monofi lament absorbable
suture. Two drains are inserted between the breast skin and
the fl ap, far from the pedicle.
Donor site closure
The deep fascia is repaired at the level where the SIE vessels
join the deep system, using strong interrupted sutures. The
abdomen is closed as described above for a DIEaP fl ap, and
two drains are inserted. These are removed only when
drainage is less than 20 mL/24 hours.
Complications and side eff ects
In our center, the microanastomosis revision rate is esti-
mated at 5%, with a total failure rate of 1%. DIEaP partial
fl ap loss and/or fat necrosis is estimated at 8%. Limited
partial necrosis can be easily managed by excision and
closure or by local skin fl ap. Lipofi lling techniques have
allowed us to resolve many small to moderate contour
defects resulting from the excision of areas of fat necrosis
or partial fl ap necrosis. However, major partial fl ap necrosis
usually requires a secondary fl ap surgery. Pedicled thora-
codorsal artery perforator (TDAP) or lateral intercostal
artery perforator (LICAP) fl aps are mostly suitable for such
problems.35
Regarding donor site morbidity, bulging still occurs in
less than 1% of our patients. Patients who have factors that
increase intra-abdominal pressure or weaken the abdominal
wall, such as a high BMI, multiple abdominal operations,
or an active smoking history, have a higher potential risk
of developing abdominal bulging or asymmetry.36
The most common SIEA donor site complication is
seroma formation, reported in up of 50% of patients because
of disturbance to the lymphatic drainage during dissection
of the SIE vessels in the groin.11–13 The incidence of seroma
formation in the groin may be reduced by skeletonizing the
pedicle and not including the surrounding fatty tissue,
which may disturb the inguinal lymphatic structures. A few
patients (<4% in our series) report an area of paraesthesia
over the inner thigh after harvesting of an ipsilateral SIEA
fl ap.
POSTOPERATIVE CARE
All patients at our institution receive IV Nootropil (pirace-
tam) 12 g/24 hours for 5 days and as a solution 20% orally
25 mL q.i.d. for another 5 days. This increases the viability
of the distal portion of the skin fl ap by increasing capillary
blood fl ow.
The fl ap is monitored using a combination of methods.
Clinical evaluation of the color and capillary refi ll, tempera-
ture, handheld Doppler and implantable Doppler devices

Cosmetic and Reconstructive Breast Surgery
66
16. Nahabedian MY, Tsangaris T, Momen B. Breast reconstruction
with the DIEP fl ap or the muscle-sparing (MS-2) free TRAM fl ap:
is there a difference? Plast Reconstruct Surg 2005; 115: 436–444;
discussion 445–446.
17. Holm C, Mayr M, Hofter E, Ninkovic M. Perfusion zones of the
DIEP fl ap revisited: a clinical study. Plast Reconstruct Surg 2006;
117: 37–43.
18. Blondeel PN, Beyens G, Verhaeghe R, et al. Doppler fl owmetry in
the planning of perforator fl aps. Br J Plast Surg 1998; 51: 202–209.
19. Heitmann C, Felmerer G, Durmus C, et al. Anatomical features of
perforator blood vessels in the deep inferior epigastric perforator
fl ap. Br J Plast Surg 2000; 53: 205–208.
20. Kikuchi N, Murakami G, Kashiwa H, et al. Morphometrical study
of the arterial perforators of the deep inferior epigastric perforator
fl ap. Surg Radiol Anat 2001; 23: 375–381.
21. El-Mrakby Hamdy H, Milner RH. The vascular anatomy of the
lower anterior abdominal wall: A microdissection study on the
deep inferior epigastric vessels and the perforator branches. Plast
Reconstruct Surg 2002; 109: 539–543.
22. El-Mrakby Hamdy H, Milner RH. The suprafascial course of the
direct paraumbillical perforator vessels. Plast Reconstruct Surg
2002; 109: 1766–1768.
23. Taylor GI, Daniel RK. The anatomy of several free fl ap donor
sites. Plast Reconstruct Surg 1975; 56: 243–253.
24. Reardon CM, O’Ceallaigh S, O’Sullivan ST. An anatomical study
of the superfi cial inferior epigastric vessels in humans. Br J Plast
Surg 2004; 57: 515–519.
25. Hamdi M, Van Landuyt K, Van Hedent E, et al. Advances in
autogenous breast reconstruction: the role of preoperative
perforator mapping. Ann Plast Surg 2007; 58: 18–26.
26. Masia J, Clavero JA, Larrañaga JR, et al. Multidetector-row
computed tomography in the planning of abdominal perforator
fl aps. J Plast Reconstr Aesthet Surg 2006; 59: 594–599.
27. Nahabedian MY. The internal mammary artery and vein as
recipient vessels for microvascular breast reconstruction:
are we burning a future bridge? Ann Plast Surg 2004; 53:
311–316.
28. Hamdi M, Blondeel P, Van Landuyt K, et al. Algorithm in
choosing recipient vessels for perforator free fl ap in breast
reconstruction: the role of the internal mammary perforators.
Br J Plast Surg 2004; 57: 258–265.
29. Blondeel PN, Arnstein M, Verstraete K, et al. Venous congestion
and blood fl ow in free transverse rectus abdominis myocutaneous
and deep inferior epigastric perforator fl aps. Plast Reconstruct Surg
2000; 106: 1295–1299.
30. Mehrara BJ, Santoro T, Smith A, et al. Alternative venous outfl ow
vessels in microvascular breast reconstruction. Plast Reconstruct
Surg 2003; 112: 448–455.
31. Nahabedian MY, Momem B, Galdino G, et al. Breast
reconstruction with the free TRAM or DIEP fl ap: Patient selection,
choice of fl ap, and outcome. Plast Reconstruct Surg 2002; 110:
466–475.
32. Chang DW, Reece GP, Wang B, et al. Effect of smoking
on complications in patients undergoing free TRAM fl ap
breast reconstruction. Plast Reconstruct Surg 2000; 105:
2374–2380.
33. Heller L, Feledy JA, Chang DW. Strategies and options for free
TRAM fl ap breast reconstruction in patients with midline
abdominal scars. Plast Reconstruct Surg 2005; 116:
753–759.
34. Hamdi M, Khuthaila D, Van Landuyt K, et al. Double-pedicle
abdominal perforator free fl aps for unilateral breast reconstruction:
new horizons in microsurgical tissue transfer to the breast. J Plast
Reconstr Aesthet Surg 2007; 9 April (e-pub).
35. Hamdi M, Wolfl i J, Van Landuyt K. Partial mastectomy
reconstruction. Clin Plast Surg 2007; 34: 51–62.
36. Nahabedian MY, Dooley W, Singh N, et al. Contour abnormalities
of the abdomen after breast reconstruction with abdominal fl aps:
the role of muscle preservation. Plast Reconstruct Surg 2002; 109:
91–101.

67
C H A P T E R
5
Breast Reconstruction – Superior Gluteal
Artery Perforator (SGAP) Flap
Matthew D. Goodwin and Bernard W. Chang
INTRODUCTION
The superior gluteal artery perforator (SGAP) free fl ap is a
good alternative for autogenous breast reconstruction when
abdominal tissue is not available (e.g., because of a paucity
of tissue, previous abdominal surgery, including failed
transverse rectus abdominis musculocutaneous (TRAM) or
deep inferior epigastric artery perforator (DIEP) fl ap recon-
struction, or incisions or scarring that have affected the
blood supply to the abdomen). Suffi cient gluteal tissue is
usually present even in the very thin patient.
Gluteal tissue for autogenous breast reconstruction was
fi rst introduced by Fujino et al.1 in 1975 for patients with
congenital aplasia of the breast. Shaw,2 Codner and Nahai3
popularized the gluteal myocutaneous fl aps (both superior
and inferior gluteal), noting the disadvantage of a short
pedicle necessitating vein grafts. Koshima et al.4 described
the superior gluteal artery perforator fl ap for pedicled recon-
struction of sacral pressure sores. Allen and Tucker5 fi rst
reported the technique of SGAP fl ap breast reconstruction
in 1999, since when this fl ap has become an increasingly
used method of microsurgical breast reconstruction.
However, many breast microsurgeons still do not perform
this procedure because of lack of experience with the tech-
nique and the availability of more familiar alternatives (e.g.
TRAM, DIEP, and latissimus dorsi fl aps).
Although the procedure is technically demanding, the
anatomy of the superior gluteal donor site consistently has
adequate tissue and vessels for microsurgical transfer.
Plastic surgeons with good microsurgical experience should
be able to perform this procedure both safely and consis-
tently. Options for breast reconstruction from other auto-
genous donor sites (latissimus dorsi, anterolateral thigh
(ALT)) usually require an implant to obtain enough volume
for symmetry. SGAP breast reconstruction should be con-
sidered as an alternative method to complete a breast recon-
structive surgeon’s armamentarium.
INDICATIONS AND CONTRAINDICATIONS
Indications
Candidates for SGAP breast reconstruction may include
patients electing autogenous breast reconstruction but who
do not desire implant reconstruction. Implant reconstruc-
tion is less desirable in patients who have undergone previ-
ous chest wall radiation or failed previous reconstruction.
In our practice, SGAP reconstruction may be offered to all
patients choosing autogenous reconstruction; however, it is
usually a secondary choice if DIEP fl ap reconstruction is
available. The DIEP fl ap is usually more popular for donor
site cosmetic reasons. Advantages of the SGAP fl ap include
faster recovery than with the DIEP fl ap, no risk of hernia,
good projection, suffi cient tissue in thin patients, and a
donor site that is relatively well hidden.
Contraindications
Relative contraindications typically include patients in poor
general health for whom prolonged surgery and general
anesthetic expose them to excess risk. In patients who are
likely to require radiation the procedure is usually delayed
until after treatment to avoid radiation damage to the fl ap
and to replace recipient site radiation damage with healthy
fl ap tissue. In our practice, obesity and tobacco use are
usually not exclusionary criteria; however, the patient is
counseled that the risk of fl ap failure, either complete or
partial, or donor site complications is greater. We have
found a signifi cantly increased rate of fl ap failure in patients
with body mass index (BMI) >30, the increased risk being
related to the logistics of fl ap positioning during microsurgi-
cal anastomosis (i.e., increased fl ap thickness and a rela-
tively short pedicle); therefore, we tend not to recommend
SGAP reconstruction for this population The only absolute
contraindication is if there is inadequate tissue or previous

Cosmetic and Reconstructive Breast Surgery
68
surgery or trauma to either the donor or recipient sites that
would make the operation too diffi cult or impossible to
perform.
Disadvantages of the SGAP include slightly longer oper-
ative times (5–7 hours), the potential for vessel mismatch,
shorter pedicle length, thinner donor site veins, more tech-
nical skills required for fl ap dissection and anastomoses,
and a lower success rate than the DIEP fl ap. For these
reasons, not as many reconstructive surgeons offer this
technique, making it less widely available for patients.
therapy is needed, or if there is a high likelihood of local
recurrence. Some patients may have already undergone pre-
operative adjuvant chemotherapy or previous radiation
therapy as well. In patients having delayed reconstruction,
prior radiation to the chest wall or tight, thin skin may
necessitate pre-SGAP tissue expansion. Other risk factors
requiring assessment include smoking history, age, diabe-
tes, and other general health issues such as cardiac or
pulmonary problems. Past medical history and physical
examination pay close attention to the donor and recipient
sites for evidence of previous surgery or trauma that may
complicate the surgery.
In an effort to maximize postoperative breast symmetry,
the patient is examined with regard to the donor site as well
as the contralateral breast, assessing volume and skin
quality. Ptotic or large contralateral breasts may require a
mastopexy or reduction for balancing. In rare cases, the
patient may have a smaller breast on the contralateral side
that they wish to have augmented. This needs to be dis-
cussed carefully with the surgical oncologist and the patient
before being pursued. The upper buttock region is assessed
for adequate tissue by palpation. The tissue utilized is over
the greater sciatic foramen, which can be palpated and is
oriented in an oblique fashion (refer to technique section).
Patient education is very important and should employ
numerous modalities (e.g., consultation, video, brochure,
etc.). It is important to inform the patient fully so that they
know what to expect and how they can help to avoid com-
plications. This is especially important with regard to pos-
sible fl ap failure or the inability to perform reconstruction
intraoperatively. Secondary options, if available, should be
planned for and may be possible during the initial surgery
if the SGAP is not feasible (e.g., because recipient vessels
are inadequate). The timing for each stage of reconstruction
as well as the expected hospital stay should be explained to
the patient. They should be advised ahead of time to avoid
positions in the postoperative period that may cause kinking
or stretching of the vascular pedicle.
OPERATIVE APPROACH
There are numerous steps that should be anticipated by the
operating room team to facilitate effi cient use of time. The
patient is prepared and draped after each repositioning.
The microscope should be tested and prepared for use
before starting fl ap ischemia time. Microsurgical instru-
ments, clips, and sutures should be in the operative fi eld at
the time of fl ap harvest.
The operation begins with preparation of the recipient
site and vessels with the patient supine, followed by repo-
sitioning the patient in the lateral decubitus position for
donor site harvesting and pedicle dissection. The patient
should be placed on a suction bean bag to secure this posi-
tion, along with an axillary roll and Mayo stand for arm
protection. After fl ap harvest, the fl ap vessels are prepared
with microscope visualization on a side table while the
donor site is closed. Again, the patient is repositioned
supine for arterial and venous anastomosis, followed by
closure.
BOX 5.1 Indications and contraindications
●
Usually secondary choice to DIEP fl ap reconstruction
●
Most patients are eligible candidates
●
Avoid in obese patients because of shorter pedicle length
and bulk of fl ap
●
May be indicated for immediate or delayed reconstruction
●
Consider expanding skin for delayed reconstruction if skin
too tight or radiated
●
Bilateral reconstruction can be performed at once or each
side in two separate operations
●
Avoid internal mammary recipient vessels in patients with
cardiac history or a strong family history of cardiac disease
Patient selection
In the authors’ practice, the lower abdominal perforators
(DIEP and SIEA) and the SGAP are the workhorse fl aps for
autogenous breast reconstruction. All patients are carefully
examined for suffi cient donor site tissue in these locations,
and for the possibility of implant reconstruction. Concomi-
tant variables are assessed, including skin tightness, radia-
tion changes, and other medical issues. Patient education
is important, as well as assessing the patient’s understand-
ing of the processes involved in all types of reconstruction.
The patients are presented with all reasonable options,
along with associated risks and complications. Ultimately,
patients may choose the method of reconstruction with
which they feel most comfortable. Special consideration is
given to bilateral reconstruction if SGAP breast reconstruc-
tion is chosen. If only one microsurgeon with experience is
available, bilateral reconstruction is usually staged several
months apart because of the complexity and length of the
procedure. If two microsurgeons are available, bilateral
SGAP reconstruction may be possible with only a minimal
increase in operating room time, as fl ap harvest may be
performed simultaneously.
PREOPERATIVE HISTORY AND
CONSIDERATIONS
A thorough preoperative history and physical examination
is necessary prior to surgery because of the duration of
surgery and to minimize complications. In patients newly
diagnosed with breast cancer the type of tumor is important
as well as the potential for locoregional or distant spread.
These factors may directly affect the outcome if radiation

Breast Reconstruction – Superior Gluteal Artery Perforator (SGAP) Flap
69
Relevant surgical anatomy
Perforator fl ap reconstruction relies on the blood supply to
skin and fat emanating from perforating vessels which
travel between underlying muscle fi bers. These vessels are
dissected out as a pedicle through the muscle fi bers down
to their origin and terminate in the overlying skin and fat.
This pedicle is divided and reanastomosed to recipient
vessels at the site of reconstruction as a free tissue
transfer.
The primary choice of recipient vessel for SGAP recon-
struction is the internal mammary artery (IMA) and vein
(Fig. 5.1). In the authors’ practice the internal mammary
vessels are almost always available, even after failed DIEP
reconstruction, because the thoracodorsal vessels are our
preferred recipient vessels for DIEP reconstruction. The
second rib cartilage is easily palpated for reference, and the
third cartilage is usually removed medially through a split
in the pectoral muscle. The internal mammary vessels are
located fairly medially. Each respective IMA originates from
the fi rst part of the subclavian artery and descends behind
the costal cartilages 1–1.5 cm lateral to the sternum, with
numerous branches to the intercostals and perforators to
the overlying breast tissue and skin. The IMA ultimately
splits to supply the musculophrenic and superior epigastric
arteries at the level of the sixth costal cartilage. At the level
of the third costal cartilage the IMA diameter is approxi-
mately 2–3 mm and is usually accompanied by one or two
venae comitantes, which drain into the respective brachio-
cephalic veins. The diameter of the internal mammary vein
typically ranges from 2.5 to 3.5 mm.
Alternative recipient vessels include the thoracodorsal
vessels, but these are less ideal given the short fl ap pedicle
length of the SGAP. Cephalic vein turndown from the
shoulder may be used as a venous backup or for additional
venous drainage if necessary, and is identifi ed between the
clavicular and sternal heads of the pectoralis major muscle.
It can be dissected distal into the upper arm through several
small counter-incisions.
The superior and inferior gluteal arteries are the domi-
nant blood supply to the gluteus muscle. They supply 20–
25 cutaneous perforators overlying the muscle, with the
superior gluteal artery perforators supplying the superolat-
eral buttock region, and the inferior gluteal artery perfora-
tors supplying the inferior buttock region both medially and
laterally. The superior gluteal artery and vein emanate from
the pelvis through the greater sciatic foramen above the
piriformis muscle just beneath the subgluteal fat pad.
Several large branches exist at this level, traveling along the
periosteum and into the overlying muscle. The main vessels
and several small branches typically lie against the perios-
teum, making dissection diffi cult. Some surgeons have
referred to this region as ‘Medusa’s head’ owing to the
number of branches and the risk of following the wrong
vessel. Numerous perforating branches from the superior
gluteal artery and venae comitantes supply the superior
buttock tissue and skin, although usually one or two are
dominant. The pedicle length typically ranges from 6 to
10 cm. Several cadaveric anatomic studies of the vascular
anatomy for the SGAP fl ap have found perforator diameter
to range from 0.9 to 1.5 mm.6,7 At the level of the greater
sciatic foramen, the point at which the superior gluteal
vessels are divided, the superior gluteal artery diameter
ranges from 2 to 3.5 mm and the venae comitantes from 2
to 4 mm.
Operative technique
Recipient site markings
The outline of the breast for immediate reconstruction
should be marked in the standing upright position with
special reference to the medial, lateral, and inframammary
creases. These landmarks are especially important if these
areas have been disrupted by the surgical oncologist, and
need to be anchored at fl ap inset. If previous reconstruction
or a mastectomy has been performed and a delayed recon-
struction is planned, appropriate borders are marked based
on judgment using the contralateral breast as a guide, if
available. Previous scars are marked and appreciated to
make safe skin fl aps. The third costal cartilage is palpated
and marked.
Donor site markings
The fl ap design should be centered over the main perfora-
tors of the superior gluteal artery (Fig. 5.2). These can be
found by palpating the greater sciatic foramen (Figs 5.3 and
5.4) and are confi rmed by a handheld Doppler with the
patient prepared for surgery (Fig. 5.5). Often this will indi-
cate that perforators are located slightly differently from the
premarked greater sciatic foramen. The fl ap markings
should then be adjusted with these Dopplered points as the
central portion of the fl ap. The dominant perforators usually
lie a few centimeters below the upper edge of the greater
Internal mammary
artery and vein
Third cartilage
removed
FIGURE 5.1 Illustration of recipient site demonstrating the location
of the internal mammary vessels.

Cosmetic and Reconstructive Breast Surgery
70
sciatic foramen. In an effort to hide the scars under the
patient’s panties or swimsuit, the axis of the fl ap is made
slightly oblique or horizontal in orientation. The medial
extension of the fl ap design is usually located several cen-
timeters below the upper portion of the mid-gluteal crease,
and may be curved down to avoid a dog-ear. The width of
the fl ap is usually 8–12 cm, and may be closed with slight
undermining.
Recipient site preparation
The patient is prepared and draped in the supine position.
This may have been done prior to mastectomy by the onco-
logic breast surgeon. If a previous reconstruction had been
performed, remaining tissue or implant material is removed.
A capsulectomy is performed if capsular tissue is present.
The recipient bed is assessed for areas where the breast
borders may have been violated by the resection. These can
be re-established using interrupted 3/0 Vicryl sutures. The
third costal cartilage is then located by palpation in the
upper medial quadrant. Dissection by electrocautery is used
to split the pectoralis muscle along fi bers and expose the
costal cartilage. The perichondrium is dissected off using
electrocautery and a Freer elevator. Great care must be
maintained when under the cartilage because the vessels
and the parietal pleural are located immediately posteriorly.
The cartilage is removed by use of a rib cutter and rongeur
up to the edge of the sternum.
The posterior perichondrium is opened laterally with a
#15 blade and a Freer elevator is passed beneath the peri-
chondrium above the internal mammary vessels. The peri-
chondrium is opened longitudinally with scissors and the
vessels are exposed. Intercostal muscle is divided along the
entire interspace between the second and fourth costal car-
tilages. There will often be some remaining fascia overlying
the vessels that can be carefully removed with a Freer eleva-
FIGURE 5.2 SGAP donor site markings.
FIGURE 5.3 Palpating the greater sciatic foramen.
FIGURE 5.4 Relation of skin markings to the greater sciatic foramen.
FIGURE 5.5 Locating cutaneous perforators with a handheld Doppler
probe.

Breast Reconstruction – Superior Gluteal Artery Perforator (SGAP) Flap
71
tor and Metzenbaum scissors. The vessels themselves are
then separated along their extent to facilitate mobility upon
ligation prior to anastomosis (Fig. 5.6). Note the quality
and caliber of the vessels. A blue background is placed to
assist with visualization of the vessels (Fig. 5.7). The recipi-
ent site is temporarily closed with staples and a bio-
occlusive dressing.
Donor fl ap dissection
The patient is then repositioned in the lateral decubitus
position with the bean bag for support (Fig. 5.8). Attention
is paid to avoid brachial plexus stretch and joint injury
(axillary roll, pillows, Mayo stand, etc.). The patient is re-
prepared and draped. Using a handheld Doppler probe,
several arterial perforators may be identifi ed. These usually
lie a few centimeters inferior to the marked site of the
center of the greater sciatic foramen. If necessary, the fl ap
marking is adjusted so that these perforators lie at the
central portion of the fl ap. The skin is incised and dissec-
tion proceeds with electrocautery (power 30–40), beveling
away from the fl ap for improved contour. Dissection con-
tinues directly down to the underlying muscle. Flap eleva-
tion is performed lateral to medial. Upon encountering the
muscle at the lateral edge of the buttock, electrocautery is
reduced to begin a careful search for perforators. The ilio-
tibial band of the fascia lata is the most lateral structure.
The gluteal fat is lifted off this fascia until the insertion of
the gluteus maximus is encountered. This is noted when
muscle fi bers change from a cephalocaudal direction to an
oblique-downward lateral direction. At this point, the fascia
is incised and dissection proceeds directly on the muscle in
the subfascial plane, taking care to identify and protect
potential perforators (Fig. 5.9). The authors prefer to leave
the deep dermis intact in the medial fourth of the fl ap so
that the fl ap remains secure as the lateral side is dissected
through.
Usually up to three potential perforators are discovered
(Fig. 5.10). We typically use one perforator that has ade-
quate caliber; however, we will occasionally use two perfora-
tors, especially if they are close together and are lined up
in the same muscle split.
Dissection continues through the muscle adjacent to
the perforator with the use of a long hemostatic forceps/
clamp. Vessel clips are used liberally to divide the numer-
ous muscular branches (Figs 5.11 and 5.12). Self-retaining
FIGURE 5.6 Internal mammary vessel exposure.
FIGURE 5.7 Separation of internal mammary artery and vein.
FIGURE 5.8 Patient positioning for fl ap harvest.
FIGURE 5.9 Elevating SGAP fl ap lateral to medial.

Cosmetic and Reconstructive Breast Surgery
72
retractors are placed, splitting the muscle along its fi bers;
they are frequently adjusted to enable suffi cient visualiza-
tion of the deep dissection. Depending on which perforator
is selected, the pedicle dissection will usually lead to the
fascial edges of the gluteus medius, minimus, or piriformis
muscles. These must also be released for several centime-
ters to allow for adequate visualization. As the dissection
proceeds deeper beneath these fascial planes, numerous
large and small periosteal branches are encountered
(Medusa’s head) (Fig. 5.13). Care must be taken to examine
each branch to avoid damaging the pedicle. It is important
not to terminate dissection too early so as to preserve
pedicle length and to have adequate arterial diameter for a
good size match with the internal mammary artery. Pedicle
length typically ranges between 6 and 10 cm. At the deepest
extent of the dissection, the pedicle lies along the perios-
teum of the pelvis as it passes through the greater sciatic
foramen. As it does so, numerous small branches exist and
go under, in, and over the periosteum. Careful dissection
is necessary here to avoid deep bleeding. Once the pedicle
is free from the periosteum and branches are divided, the
artery and vein are cleaned and separated if possible with a
FIGURE 5.10 SGAP perforator.
FIGURE 5.11 SGAP pedicle dissection.
FIGURE 5.12 SGAP pedicle dissection.
FIGURE 5.13 ‘Medusa’s head.’

Breast Reconstruction – Superior Gluteal Artery Perforator (SGAP) Flap
73
right-angle clamp (Fig. 5.14). When preparing for pedicle
division, it is our practice to give the patient 5000 units of
intravenous heparin. Five minutes after this, the artery and
vein are divided with vessel clips and ischemia time is
noted. The medial portion of the fl ap that remains attached
is dissected off with electrocautery.
The fl ap is then removed from the fi eld and placed on
a side table for microdissection and separation of the artery
and vein within the pedicle using a sterile draped micro-
scope (Fig. 5.15). The artery is cleaned fi rst and a micro-
clamp is applied to the vein (Fig. 5.16). Sterile saline is then
infused antegradely to dilate the venous system. This facili-
tates preparation of the venous end, which normally is very
thin, friable, and fl oppy. Furthermore, the inside of the vein
must be assessed for nearby valves that could create an
obstruction. If a valve is noted near the end of the vein,
another site proximal to the valve should be selected and
prepared.
The donor site is irrigated and assessed for hemostasis.
The muscle is closed with interrupted 2/0 Vicryl sutures.
A single fl uted 15 Fr drain is placed, exiting at the superior
lateral end of the wound. The deep fat and Scarpa’s fascia
are closed with interrupted 2/0 Vicryl sutures. Extra sutures
are often placed in the central portion because this is the
area of greatest tension. The skin is closed with interrupted
3/0 Vicryl inverted dermal sutures, a running 4/0 Monocryl
subcuticular suture, and Dermabond.
Anastomosis and fl ap inset
The team member who closed the donor site, together with
operating room staff, re-prepares the patient, who is then
returned to the supine position and the bean bag is removed.
The recipient site is exposed with large retractors and
sutures to retract the skin.
Once fl ap preparation on the side table is complete, the
fl ap is brought into the surgical fi eld. It is placed in a surgi-
cal towel and secured with towel clips in a manner that
facilitates appropriate placement and exposure of the anas-
tomosis (Fig. 5.17). Given the thickness of an SGAP fl ap,
which can impede view of the anastomosis, we often elevate
the patient’s back to ease visualization. This is where opti-
mized pedicle and recipient vessel length is valuable. The
microscope is placed over the fi eld in a position appropriate
for both the microsurgeon and the assistant. The pedicle
FIGURE 5.14 Pedicle dissection complete.
FIGURE 5.15 Flap divided.
FIGURE 5.16 Separation of pedicle artery and vein.
FIGURE 5.17 Flap positioning on chest for anastomosis.

Cosmetic and Reconstructive Breast Surgery
74
and recipient sites are reassessed, further prepared, and
approximated for anastomosis.
The arterial anastomosis proceeds fi rst. The recipient
artery is clipped distally. This is usually just above the
fourth rib. A small double approximating vessel clamp is
placed on the proximal side. The artery is divided just
proximal to the clip with microscissors. The artery is then
assessed for patency and adequate blood pressure by quickly
and carefully releasing and then replacing the vessel clamp.
The recipient arterial end is then cleaned, dilated, and
freshened. The fl ap side artery is then placed in the other
side of the double approximating vessel clamp, approxi-
mating the two arterial sides. Using an 8/0 nylon micro-
suture in an interrupted fashion, the arterial ends are
anastomosed.
The venous anastomosis is next performed with a
venous coupler device (Synovis Micro Companies Alliance,
Birmingham, AL), using a vessel sizer to choose the appro-
priate size of coupler. We usually use coupler sizes ranging
from 2.0 to 3.5 mm. A small vessel clip is placed on the
distal end of the recipient vein, usually just above the fourth
rib. A single small vessel clamp is placed on the proximal
side. The vein is divided just proximal to the clip with
microscissors. The recipient side vein end is then cleaned,
dilated, and freshened. The fl ap side vein is placed in a
single vessel clamp. The two venous ends are placed within
the coupler holes and secured to the prongs (Fig. 5.18).
When ready, the coupler device is activated for
anastomosis.
The vessel clamps are removed in the following order:
distal vein, proximal vein, distal artery, proximal artery.
End of ischemia time is noted. The anastomoses are
assessed for patency and leaks. Occasionally, additional
sutures are needed to stop arterial leaks. Mild oozing is
monitored for several minutes; this will usually stop. Con-
tinued oozing from the venous side will usually require
removal and revision of the coupler device.
Once the anastomoses are deemed patent and intact,
the path of the pedicle is assessed for hemostasis and poten-
tial sites of compression or kinking. We will often divide
some pectoralis muscle on the edges to prevent compres-
sion on the pedicle. This is also a good point to ensure
recipient site hemostasis.
The retractors are then removed and the fl ap is inset.
Take care to avoid over-rotation and stretching of the
pedicle. Occasionally, we will place several deep absorbable
sutures securing the Scarpa’s fascia layer of the fl ap to the
chest wall to prevent the fl ap sliding, which may damage
Internal mammary
vein
Superior gluteal
vein
Superior gluteal
vein
Internal mammary
vein
A
Anastomosis of veins
B
C
D
FIGURE 5.18 Illustration of venous coupler device.

Breast Reconstruction – Superior Gluteal Artery Perforator (SGAP) Flap
75
FIGURE 5.19 Flap inset.
FIGURE 5.20 Flap inset with percutaneous Doppler marking.
the pedicle. Most often, however, we simply use the skin
envelope with dermal sutures to secure the fl ap. A fl uted
15 Fr drain is placed, exiting through the skin in the axilla.
The drain should be positioned away from the pedicle.
The mastectomy skin fl aps are trimmed and the SGAP
skin de-epithelialized as necessary for appropriate inset.
Care must be taken to avoid an overly tight skin envelope
that can compress the fl ap. A handheld Doppler probe is
used to re-identify the cutaneous arterial perforators. These
are marked and the SGAP skin paddle designed around
them for postoperative monitoring. The skin is closed with
interrupted 3/0 Vicryl deep dermal sutures, a running 4/0
Monocryl subcuticular suture, and Dermabond (Figs 5.19
and 5.20). The patient is undraped, cleansed, and anesthe-
sia terminated. This marks the end of the operation.
Revisions
Complete reconstruction with the SGAP fl ap usually
requires three or four procedures on separate occasions.
These include an initial free fl ap as described above, and
staged revision.
SGAP fl ap and mastectomy fl ap reshaping usually is
performed at least 3 months after the initial free fl ap opera-
tion. This usually involves trimming or removing the
remaining skin paddle and contouring the edges of the fl ap
to improve breast shape. Occasionally some liposuction is
necessary for shaping and softening areas of fat necrosis.
Often this is combined with a contralateral breast reduc-
tion, mastopexy, or augmentation as necessary to improve
symmetry.
The donor site scar is often revised at this point, with
trimming of dog-ears and liposuction of irregularities to
improve upper buttock contour. The contralateral buttock
is also sometimes treated with liposuction for symmetry.
Nipple reconstruction
Reconstruction of the nipple–areolar complex (NAC) can
sometimes be performed in the second stage when there is
adequate symmetry between the breasts. If a procedure for
symmetry is required beforehand, however, NAC recon-
struction should be delayed until a third stage, often per-
formed in the offi ce setting. There are numerous techniques
in the literature adequate for NAC reconstruction. Atten-
tion should be paid to skin perfusion of the NAC.
NAC tattooing
This is the fi nal procedure performed after all shaping and
symmetry procedures have healed.
Alternatives
Inferior gluteal artery perforator (IGAP)
fl ap reconstruction
Based on the other major blood supply to the gluteal muscle
(as stated in the surgical anatomy section), IGAP fl ap is
another alternative in breast reconstruction ideal for those
few patients with insuffi cient bulk in the upper buttock
region. It is designed over the inferior portion of the buttock,
with the resulting scar located just above the infragluteal
fold. The dissection and volume this fl ap provides are similar
to that of the SGAP fl ap. It is our preference not to use this
fl ap much because of the scar location and occasional sciatic
nerve irritation due to swelling around the nerve from adja-
cent dissection of the inferior gluteal pedicle.
Bilateral SGAP reconstruction
When the surgical team includes two microsurgeons, simul-
taneous bilateral SGAP reconstruction can be performed
safely and with reasonable operating times.8,9 Each side can
be operated on simultaneously for most of the pro cedure,
except for when using the microscope for anas tomosis.
Ideally, each side has its own separate team, including assis-
tant, surgical scrub technician, and surgical instruments.

Cosmetic and Reconstructive Breast Surgery
76
IMA perforators for recipient vessels
Occasionally, IMA perforators can be found that are ade-
quate for recipient vessel anastomosis. This requires their
having been left following the mastectomy and having suf-
fi cient caliber. This technique, however, can spare the
patient morbidity from harvesting of the rib cartilage, and
spares the vessels for potential future procedures, such as
coronary artery bypass.
Sensate SGAP fl ap
The inclusion of nerve repair in SGAP reconstruction has
been described in order to create a sensate breast recon-
struction.10 Typically, one or two nerve perforators are
repaired to the T4 thoracic nerve branch. The success of
this maneuver is variable.
Implantable Doppler fl ap monitoring
Some surgeons elect to use an implantable venous Doppler
probe (Cook Vascular, Inc., Leechburg, PA) to assist with
postoperative fl ap monitoring. This can provide an early
warning of venous or arterial occlusion before skin paddle
changes are apparent. In our practice, this device is typically
used in breast reconstruction to the thoracodorsal vessels,
such as the deep inferior epigastric artery perforator (DIEP)
fl ap. We feel that the pedicle in SGAP fl ap to the IMV is
too short, and the cuff on the probe can possibly contribute
to kinking of the vessels.
OPTIMIZING OUTCOMES
Outcomes are generally optimized by proper patient selec-
tion, meticulous operative technique, and attention to
detail. The SGAP fl ap is generally considered one of the
more diffi cult to harvest and the anastomosis can be diffi -
cult because of the short pedicle length or a small vessel
caliber. The arterial and venous anastomoses can be facili-
tated by selecting a perforating branch of the internal
mammary vessels in order to equalize vessel caliber. It is
sometimes necessary to perform an end-to-side arterial
anastomosis to the internal mammary artery when a per-
forating branch is not available.
COMPLICATIONS AND SIDE EFFECTS
Common and serious
The most serious complications of SGAP reconstruction
are similar to those of all operations requiring general anes-
thesia: myocardial infarction, deep venous thrombosis, pul-
monary embolism, possibly even death. SGAP surgery,
especially when combined with mastectomy, is prolonged
– usually more than 6 hours, which increases these risks.
Patient selection based on medical history, physical exami-
nation, and preoperative testing is paramount for avoiding
these disasters.
Flap failure, either partial or complete, is the most
serious complication specifi c to free fl ap reconstruction,
and can be a result of a multitude of factors, including
microsurgical technique, patient anatomy, patient risk
factors, and postoperative care. For published series of more
than 10 SGAP reconstructions, fl ap failure rates range from
0% to 7.7%.10,11 In our unpublished data of 106 fl aps on 90
patients over 7 years, the success rate has increased yearly
with experience, from 88.7% to 96.5%, with an overall
success rate of 92.5%.12
Even with these listed factors, surgical technique is
usually a component of every fl ap failure, especially com-
plete loss. Meticulous microsurgical technique will avoid
anastomotic obstruction. Details of technique are beyond
the scope of this chapter. Venous occlusion is responsible
for the vast majority of fl ap failures.13 The pedicle can be
compromised by kinking, stretching, a tight skin closure,
or an expanding hematoma or seroma. The importance of
attention to detail cannot be overemphasized.
Occasionally patient anatomy prohibits SGAP recon-
struction. Patients having had radiation may have scarred
or shrunken IMA vessels. Very rarely patients simply have
vessels that are too small for free fl ap reconstruction.
Patient risk factors, including smoking, atherosclerosis,
obesity, hypertension, and hypercholesterolemia, often
negatively affect outcome, most often these contributing to
partial fl ap loss. Various blood clotting disorders can also
lead to clotted venous pedicles or excessive bleeding.
Postoperative care is important in preserving the integ-
rity of the fl ap and its perfusion. Excessive motion or inap-
propriate patient positioning can compromise the fl ap
BOX 5.2 Optimizing outcomes
●
Choose patients carefully prior to surgery
●
Avoid performing SGAP reconstruction in obese patients
●
Gain experience in other microsurgical breast reconstruction
procedures and then advance to SGAP reconstruction
●
Optimize exposure of donor and recipient vessels
●
Be careful when dissecting near the origin of the superior
gluteal vessels; make sure you are following the pedicle and
not side branches
●
Do not retract too much on the fl ap pedicle during
dissection, especially near branch points, as this may lead to
thrombosis
●
Check for rotational defects in the pedicle after anastomosis
or kinking in the pedicle
●
Do not inset fl ap too tightly. If need be, leave some of the
wound open and allow to close by secondary intention or
delayed primary closure
●
Re-explore in the OR early if necessary
Implantable Doppler fl ap monitoring
●
Long complex procedure requires anticipation by operating
room team members to avoid excess OR time
●
Beware of Medusa’s head and of small periosteal branches
during dissection of donor fl ap
●
Vessel length in the pedicle and the recipient site will
facilitate visualization during anastomosis and fl ap
positioning for inset

Breast Reconstruction – Superior Gluteal Artery Perforator (SGAP) Flap
77
pedicle. Frequent monitoring by those knowledgeable on
the signs of fl ap compromise can potentially lead to a failing
fl ap being saved. Other complications include bleeding and
hematoma; seroma formation; infection; wound break-
down; scarring; pain; and pneumothorax.
How to prevent and manage complications
Bleeding and hematoma are prevented by meticulous hemo-
stasis. An enlarging hematoma can potentially lead to a
venous clot when it compresses the pedicle. An expanding
fl ap pocket, change in the color of the fl ap or mastectomy
skin, tachycardia, and anemia are all signs that should raise
suspicion. There should be a low threshold for returning to
the operating room for evacuation when these are present
in the immediate postoperative period.
Seroma is a long-term sequela that most often presents
at the donor site (>80% SGAP patients). Drains are left in
the reconstruction and donor sites until daily drainage
drops to consistently less than 30 mL/day. This is usually
1 week at the reconstruction site and 2–3 weeks at the
donor site. Despite this, seromas often form at the donor
site, requiring percutaneous aspiration during follow-up
visits. Seromas should not be left to expand without treat-
ment to avoid potential wound breakdown.
Wound infections at either surgical site are rare. Pre-
and intraoperative antibiotics should be given routinely.
The authors typically give a short course of postoperative
antibiotics as well. Erythema, swelling, and purulent drain-
age are signs of infection that should be aggressively treated
with antibiotics and/or surgical drainage as necessary. Inci-
sional dehiscence typically results from the aforementioned
complications and should be treated with standard local
wound care.
As with any surgery, scars are a sequela of every inci-
sion. Therefore, the surgeon must balance the need for
surgical exposure with the development of scarring. Patients
should be educated preoperatively about these scars in order
to have a realistic expectation of the fi nal cosmetic result.
Scar revision and the treatment of deeper fi brotic scars and
fat necrosis are usually performed in the revision stages.
The most acutely painful site in this surgery is typically
where the rib cartilage is removed. Patient-controlled anal-
FIGURE 5.21 Images of patient with bilateral staged SGAP fl ap breast reconstruction. A Prior to mastectomy. B Following right mastectomy
with immediate right SGAP fl ap reconstruction; 2 weeks postoperatively. C Final post-reconstruction results following left SGAP fl ap
reconstruction, revision stages with nipple reconstruction, and areolar tattooing. D Bilateral donor site scars.
A
B
D
C

Cosmetic and Reconstructive Breast Surgery
78
gesic (PCA) usually provides adequate pain relief. We prefer
to avoid the use of non-steroidal anti-infl ammatory drugs
(e.g., ketorolac) in the immediate postoperative period for
fear of bleeding complications. Patients will most often
have some degree of splinting; therefore, an incentive spi-
rometer should be routinely used to relieve atelectasis.
Long-term pain from scarring or pinched nerves is rare but
possible, and should be treated appropriately.
It is uncommon for patients to develop a symptomatic
pneumothorax from the rib cartilage resection. Careful dis-
section and rib removal should avoid damaging the parietal
pleura. If a pneumothorax is suspected, the diagnosis can
be confi rmed with radiographs. A small pneumothorax can
often be treated with a small suction tube and closed
immediately.
POSTOPERATIVE CARE
Immediate
Upon completion of the operation patients are extubated in
the operating room and may be transferred to the recovery
room or directly to the observation/intensive care unit.
Typically they will spend the fi rst postoperative night in
this unit, as the level of care required necessitates hourly
monitoring of both patient and fl ap. Nursing staff should
A
B
C
FIGURE 5.22 Images of patient with history of bilateral mastectomy
with bilateral latissimus dorsi fl ap reconstruction and implant
placement with postoperative left-sided radiation and implant failure.
A Preoperatively. B, C After right implant removal and DIEP fl ap.

Breast Reconstruction – Superior Gluteal Artery Perforator (SGAP) Flap
79
D
E
F
G
FIGURE 5.22, cont’d D Upper buttock shows ample tissue for a
potential SGAP donor site. E, F Final post-reconstruction results
following left SGAP fl ap reconstruction, bilateral revisions with nipple
reconstruction, and areolar tattooing; anterior and lateral views.
G SGAP donor scar.

Cosmetic and Reconstructive Breast Surgery
80
be aware of the signs of fl ap compromise, including color
changes, fl ap temperature, capillary refi ll times, loss of
Doppler pulse, and expanding hematoma. Patients remain
on bed rest and nil by mouth for the fi rst night, and receive
IV fl uid, antibiotics, and pain control by PCA. Postoperative
deep venous thrombosis (DVT) prophylaxis should be used
routinely with sequential compression devices. Adjuvant
DVT prophylaxis (e.g., subcutaneous heparin, enoxaparin,
etc.) should be considered, especially in overweight or obese
patients.
On postoperative day 1 the patient is transferred to the
surgical fl oor if the fl ap is judged successful. They are begun
on a clear diet and advanced as tolerated. Activity may also
include transferring to a reclining chair.
On postoperative day 2 the patient’s Foley catheter is
removed and she may begin ambulating. Pain control is
changed to oral medication. Occupational therapy and
drain care are taught to prepare the patient for discharge.
On postoperative day 3, if the patient is tolerating food,
oral pain control, ambulation, and voiding spontaneously,
she may be discharged with instructions for follow-up in
clinic 1 week later. Prescriptions for pain control and anti-
biotics are provided, but the patient is instructed to limit
activity, although she may shower. We often prescribe some
home nursing care to assist with drain care.
The fi rst week’s follow-up appointment usually consists
of drain removal from the breast pocket. The patient returns
for further follow-up appointments as necessary for removal
of the donor site drain and revision planning. As previ-
ously stated, percutaneous aspiration of seromas is often
required.
Long-term
The interval between steps is usually 3 months, hence the
process can take 6 months to 1 year, or longer if complica-
tions occur. Upon completion the patient should return for
yearly follow-up for cancer surveillance. The SGAP fl ap will
enlarge and shrink with weight fl uctuations and develop
progressive ptosis, similar to the contralateral breast. Unlike
with implant reconstruction, further surgery is usually
unnecessary.
A
B
FIGURE 5.23 Images of patient with history of left-sided mastectomy with postoperative radiation. Right-sided prophylactic mastectomy with
bilateral reconstruction is planned. A, B, C Left-sided mastectomy site demonstrating post-radiation skin changes; anterior, left, and right lateral
views.

Breast Reconstruction – Superior Gluteal Artery Perforator (SGAP) Flap
81
C
D
E
F
G
FIGURE 5.23, cont’d D The buttock shows ample tissue for potential
bilateral SGAP donor sites. E, F, G Final post-reconstruction results
following bilateral stage SGAP fl ap reconstruction, bilateral revisions
with nipple reconstruction, and areolar tattooing; anterior, left, and
right-sided views.

H
CONCLUSIONS
As autogenous tissue has become increasingly utilized for
breast reconstruction surgical techniques have evolved,
setting new standards and raising patient expectations. Tra-
ditional donor sites for breast reconstruction may not be
available, yet the same outcome is still expected. SGAP
reconstruction is a valuable option for patients who are not
candidates for reconstruction using their abdominal tissue.
Although this is challenging procedure, it has consistent
anatomy and provides excellent results, which makes it
an important part of the breast reconstructive surgeon’s
repertoire.
REFERENCES
1. Fujino T, Harashina T, Aoyagi F. Reconstruction for aplasia of the
breast and pectoral region by microvascular transfer of a free fl ap
from the buttock. Plast Reconstruct Surg 1975; 56: 178.
2. Shaw WW. Superior gluteal free fl ap breast reconstruction. Clin
Plast Surg 1998; 25: 267.
3. Codner MA, Nahai F. The gluteal free fl ap breast reconstruction:
making it work. Clin Plast Surg 1994; 21: 289.
4. Koshima I, Moriguchi T, Soeda S, et al. The gluteal perforator-
based fl ap for repair of sacral pressure sores. Plast Reconstruct
Surg 1993; 91: 678.
5. Allen RJ, Tucker C. Superior gluteal artery perforator free fl ap for
breast reconstruction. Plast Reconstruct Surg 1995; 95: 1207.
6. Mu LH, Yan YP, Luan J, et al. Anatomy study of superior and
inferior gluteal artery perforator fl ap. Zhonghua Zheng Xing Wai
Ke Za Zhi 2005; 21: 278–280.
7. Kankaya Y, Ulusoy MG, Oruç M, et. al. Perforating arteries of the
gluteal region. Ann Plast Surg 2006; 56: 409–412.
8. Guerra AB, Soueid N, Metzinger SE, et al. Simultaneous bilateral
breast reconstruction with superior gluteal artery perforator (SGAP)
fl aps. Ann Plast Surg 2004; 53: 305–310.
9. Della Croce FJ, Sullivan SK. Application of the superior gluteal
artery perforator free fl ap for bilateral simultaneous breast
reconstruction. Plast Reconstruct Surg 2005; 116: 87–104.
10. Blondeel PN. The sensate free superior gluteal artery perforator
(SGAP) fl ap: a valuable alternative in autologous breast
reconstruction. Br J Plast Surg 1999; 52: 185–193.
11. Feller AM, Richter-Heine I, Rudolf KD. The superior gluteal artery
perforator fl ap (S-GAP fl ap). Handchir Mikrochir Plast Chir 2002;
34: 257–261.
12. Huang K, Chang B. 106 Consecutive superior gluteal artery
perforator (SGAP) fl aps in a community hospital: A single
surgeon’s experience. Presented at the World Society of
Reconstructive Microsurgery meeting, Athens, Greece, June
2007.
13. Nahabedian MY, Momen B, Manson PN. Factors associated with
anastomotic failure after microvascular reconstruction of the
breast. Plast Reconstruct Surg 2004; 114: 74–82.
FIGURE 5.23, cont’d H Final bilateral donor site scars.
Cosmetic and Reconstructive Breast Surgery
82

83
C H A P T E R
6
Latissimus Dorsi Breast Reconstruction
Colleen M. McCarthy and Joseph J. Disa
INTRODUCTION
The latissimus dorsi myocutaneous (LDM) fl ap has evolved
over time to incorporate a wide range of applications in
breast reconstruction. For example, the LDM fl ap can be
used to transfer a large volume of well-vascularized soft
tissue to the anterior chest wall. Because of this, the LDM
fl ap is particularly useful in patients with a history of prior
chest wall irradiation who may not otherwise tolerate
expander/implant reconstruction. The LDM fl ap may be
similarly useful in women who are not candidates for an
abdominally based, autogenous tissue reconstruction (i.e.,
patients with a history of multiple abdominal operations, a
prior abdominoplasty, and/or thin patients with limited
infraumbilical fat). Because of the robust blood supply of
the latissimus dorsi muscle, the LDM fl ap may also be used
in women who are at high risk of wound complications
following either implant-based reconstruction and/or pedi-
cled transverse rectus abdominis (TRAM) fl ap reconstruc-
tion, including those who are diabetic, heavy smokers,
and/or morbidly obese. Finally, the latissimus dorsi muscle
may be used to reconstruct defects following lumpectomy
and/or quadrantectomy of the breast.
Most patients will be candidates for latissimus breast
reconstruction. The LDM fl ap can provide a skin island up
to 8 cm wide, a variable amount of fat, and a large surface
area of well-vascularized muscle.1 However, although the
anatomy of the fl ap is consistent, the volume of soft tissue
available to reconstruct a mastectomy defect often falls
short of that required to obtain adequate projection and/or
symmetry with the opposite breast. The most favorable
results following latissimus dorsi fl ap reconstruction alone
will be achieved in patients who have a small breast volume
and minimal ptosis. In fact, moderate- to large-volume
breasts will generally require the additional volume pro-
vided by the use of a prosthesis. Furthermore, in patients
with large or markedly ptotic breasts, some type of match-
ing procedure may be required in order to obtain
symmetry.
In cases where the latissimus dorsi fl ap adds suffi cient
skin to fully reconstruct the cutaneous envelope, it is pos-
sible to perform a single-stage procedure whereby a perma-
nent prosthesis is placed underneath the LDM fl ap.
Although our experience suggests that satisfactory results
can be obtained with single-stage reconstruction, in the vast
majority of patients a more reliable approach appears to
involve two-stage, combined LDM fl ap–expander/implant
reconstruction.2 A tissue expander is placed under the LDM
fl ap at the primary procedure. Postoperatively, tissue expan-
sion is performed over a period of weeks or months. This
allows the volume of the reconstructed breast to be adjusted
postoperatively to correct for an expected 20–30% shrinkage
in fl ap size. The temporary expander is exchanged for a
permanent implant at a subsequent operation. By perform-
ing a capsulotomy and/or ‘fi ne tuning’ the implant pocket
at the time of exchange, the procedure allows for the cre-
ation of a breast with greater ptosis and more natural
contours.
ANATOMY
The latissimus dorsi is a broad, fan-shaped muscle that
originates on the lower thoracic vertebra, lumbar sacral
processes, and iliac crest and inserts on the lesser tubercle
of the humerus. Contraction of the latissimus dorsi results
in the extension, adduction, and medial rotation of the
humerus. When contraction is compromised, the teres
major and subscapularis muscles compensate these actions.
The innervation of the latissimus dorsi muscle is through
the thoracodorsal nerve, from the posterior cord of the bra-
chial plexus. The thoracodorsal nerve joins the thoracodor-
sal artery and vein 3–4 cm before entering the lateral edge
of the muscle.3

Cosmetic and Reconstructive Breast Surgery
84
The blood supply to the latissimus dorsi arises from one
dominant pedicle and is supported by many segmental
vessels (type V pattern of circulation). The thoracodorsal
artery branches from the subscapular artery just distal to
the circumfl ex scapular artery and enters the muscle in the
posterior axilla, 10–11 cm inferior to the origin of its inser-
tion. Just proximal to the entrance of the thoracodorsal
artery into the muscle, it gives one or two branches to the
serratus anterior. This vascular architecture allows contin-
ued perfusion if the proximal portion of the artery is
damaged through collateral connections with the lateral
thoracic artery. The segmental arterial contribution is sepa-
rated into medial and lateral rows. The medial row origi-
nates from several segmental branches of the lumbar artery
and supplies the muscle origin around the lumbar spine.
The posterior intercostal arteries contribute four to six per-
forators to feed the inferior lateral muscle fi bers. Venous
drainage is accomplished by venae comitantes of the corre-
sponding arteries.1,3
INDICATIONS AND CONTRAINDICATIONS
Use of the LDM fl ap is indicated in patients who elect not
to undergo a TRAM or related fl ap, or in whom abdomi-
nally based reconstruction is contraindicated. This includes
patients in whom the infraumbilical soft tissues are limited,
those who previously have undergone abdominoplasty, and/
or those who have abdominal scars that may complicate
healing at the donor site. The latissimus dorsi fl ap can
also be used in patients who may have already undergone
a TRAM or related fl ap procedure. Finally, latissimus dorsi
reconstruction does not compromise the abdominal wall,
which may be important in patients desiring a future preg-
nancy, or those whose lifestyle does not allow for the poten-
tial diminution of truncal strength.
Autogenous latissimus dorsi reconstruction
Satisfactory results can be achieved with an LDM fl ap alone
in some patients (i.e., obese patients with small breasts, or
thin patients with very small breasts). Instead, most LDM
fl ap reconstructions require the use of an implant to obtain
adequate projection.
Immediate latissimus dorsi–
expander/implant reconstruction
In patients who require the additional volume provided by
the addition of a prosthesis to the latissimus reconstruc-
tion, two-stage expander/implant reconstruction is an
extremely reliable approach. A tissue expander is placed at
the time of the LDM fl ap harvest and inset. Postoperatively,
tissue expansion is performed over a period of weeks or
months. The expander is exchanged for a permanent
implant during the secondary procedure. By performing a
capsulotomy and/or ‘fi ne tuning’ the implant pocket at the
time of exchange, the procedure allows for the creation of
a breast with greater ptosis and more natural contours.
A large skin excision at the time of mastectomy, due
to previous biopsies or locally advanced disease, may
preclude primary coverage of a tissue expander. The
absence of an adequate skin envelope is an absolute con-
traindication to expander/implant reconstruction alone.
Thus, in patients without the volume of soft tissue required
to permit a tension-free closure over an expander, the ipsi-
lateral LDM fl ap can be used to provide additional soft
tissue.
LDM fl ap reconstruction may also facilitate immediate
expander/implant reconstruction in patients with a history
of prior chest wall irradiation. Ipsilateral breast tumor
recurrence occurs in approximately 8–20% of women 10
years after the treatment of breast cancer with lumpectomy
and postoperative radiotherapy.4–6 The standard surgical
treatment after a local recurrence is a ‘salvage mastectomy’.
Immediate post-mastectomy reconstruction in a patient
who has received prior chest wall irradiation is, however,
considered by many to be a contraindication to implant-
based reconstruction.7–9 Not only is tissue expansion
diffi cult in previously irradiated tissues, but the risks of
infection, expander exposure, and subsequent extrusion are
increased. Although autogenous tissue alone remains our
method of choice in the setting of prior chest wall irradia-
tion, many women are neither willing nor are candidates
for this form of reconstruction. Thus, the use of combined
LDMF–expander/implant reconstruction is a reliable option
for those who wish to undergo post-mastectomy recon-
struction yet are candidates neither for autogenous tissue
reconstruction alone nor for expander–implant reconstruc-
tion alone. Based on our experience, it appears that the use
of autogenous tissue fl aps provides pliable, well-vascular-
ized soft tissue which can facilitate both wound healing
and the process of tissue expansion in the setting of prior
irradiation.
Delayed post-mastectomy latissimus
dorsi reconstruction
For those who may not have access to or are unable to
decide on primary reconstruction while adjusting to their
cancer diagnosis, delayed expander–implant reconstruction
is an option. Similarly, those who have failed implant and/
or autogenous tissue reconstruction may elect to pursue
breast reconstruction in a delayed fashion.
In the setting of delayed post-mastectomy reconstruc-
tion, the amount of remaining mastectomy skin is often
greatly reduced because it comes from non-skin-sparing
mastectomies. Therefore, expansion may achieve less
volume, making the creation of breast ptosis more diffi cult.
The combination of a latissimus dorsi fl ap and tissue
expansion may thus be appropriate in cases in which the
remaining mastectomy skin is of insuffi cient quality to
tolerate tissue expansion. This is typically the case in the
insetting of delayed reconstruction after mastectomy and
postoperative radiation therapy (see immediate latissimus
dorsi–expander/implant reconstruction).

Latissimus Dorsi Breast Reconstruction
85
Reconstruction of the lumpectomy defect
As breast conservation is pushed further in terms of larger
resections in smaller patients, increasing distortion of the
breast is predictable. In addition, breast aesthetics may
deteriorate progressively with time as side effects of
radiation affect the fi nal shape of the breast. Although the
theoretical benefi t of breast conservation therapy is the
maintenance of cosmesis by preservation of breast form,
residual deformity and asymmetry are not uncommon.
Thus, despite surgical conservatism in these patients,
reconstruction of these defects is often necessary.
Several controversies exist with regard to the appropriate
management of a lumpectomy defect. A major concern is
the timing of the reconstruction with respect to tumor
resection.10 Other points of contention include the effec-
tiveness of postoperative cancer surveillance and the man-
agement of a recurrence. For example, if a local cancer
recurrence develops following reconstruction of a lumpec-
tomy defect, a potential reconstructive option has already
been used. Total mastectomy is currently the standard of
care for the surgical treatment of local recurrence. One of
the best reasons not to use autogenous tissue in the recon-
struction of lumpectomy defects is therefore its great utility
in reconstruction of the total mastectomy defect. For
example, if the latissimus fl ap is used for a partial defect
and a recurrence develops, the subsequent mastectomy
defect must be reconstructed from other remaining donor
sites. Critics suggest that the aesthetic outcome following
post-mastectomy reconstruction is similar or even superior
to outcomes following reconstruction of the lumpectomy
defect; thus, potentially subjecting a patient to multiple
procedures and multiple donor-site harvests increases mor-
bidity without substantial gain. Many would instead elect
to perform a completion mastectomy and post-mastectomy
reconstruction for a patient who presents with a lumpec-
tomy defect.
For those who elect to pursue reconstruction of a
lumpectomy defect the use of autogenous tissue is pre-
ferred, as the majority of these patients will have a history
of prior radiotherapy. Smaller defects, particularly those in
the superolateral portion of the breast, can be treated with
a pedicled latissimus dorsi muscle fl ap. A portion of the
latissimus dorsi muscle can be harvested through a trans-
verse or oblique incision, or with the assistance of an endo-
scope. As the inframammary fold, nipple, and overall breast
shape generally remain intact, their anatomy should be
preserved. Anteriorly, an incision is made by incorporating
pre-existing breast scars where possible. The latissimus fl ap
then is transferred into the defect and inset, either superfi -
cial to the pectoralis major beneath remaining breast tissue,
or deep to the elevated skin surrounding the defect.
RELATIVE CONTRAINDICATIONS (Boxes 6.1–6.4)
The loss of latissimus dorsi muscle function is generally
well tolerated and does not result in signifi cant upper-
extremity weakness.11 Latissimus harvest should be avoided,
BOX 6.1 Indications
●
Patients desiring immediate or delayed post-mastectomy
reconstruction
●
Patients with mastectomy skin fl aps of insuffi cient quality to
tolerate expansion, i.e. delayed reconstruction after chest
wall irradiation
●
Failed tissue expansion, failed implant, or failed abdominally
based reconstruction
●
Patients in whom microsurgical tissue transfer is not an
option
●
Patients wishing to avoid large abdominal scars or the risk of
reducing abdominal/truncal strength; patients desiring
future pregnancy
●
Women with considerable prior abdominal surgery or
abdominal radiation
●
Reconstruction of segmental or lumpectomy defects
BOX 6.2 Relative contraindications
●
Prior posterior thoracotomy with sacrifi ce/division of the
latissimus dorsi muscle
●
Patients who need functional latissimus dorsi, i.e., elite
athletes, wheelchair users
BOX 6.3 Advantages
●
Provision of additional vascularized skin and muscle to the
breast mound in a single operative procedure
●
Consistent neurovascular anatomy; highly reliable fl ap
●
Provides adequate volume for small-volume breasts without
the use of a prosthesis
●
Quicker convalescence than with abdominally based fl aps
●
No abdominal weakness after surgery
BOX 6.4 Disadvantages
●
Patient repositioning may be necessary after fl ap harvest
●
Slight cosmetic deformity from loss of posterior axillary fold
●
Propensity for donor-site seroma formation
●
Potential for functional loss in patients who may rely on
upper-body strength (wheelchair users, swimmers, rock
climbers, golfers, tennis players, etc.)
●
The need for an implant is not often eliminated, despite the
transfer of autogenous tissue
●
Permanent dependency on prosthesis can also lead to long-
term complications, such as implant leak or defl ation and
capsular contracture
however, in patients with lower-extremity weakness, where
the muscle plays an important role in gait by elevating the
hemipelvis and facilitating circumabduction. Latissimus
dorsi muscle function is also important for wheelchair
transfer.

Cosmetic and Reconstructive Breast Surgery
86
The latissimus muscle and/or its blood supply is usually
damaged by a posterolateral thoracotomy, and occasionally
during an axillary lymph node biopsy. Because of the rela-
tive approximation of the thoracodorsal vasculature to the
nerve, in patients in whom the thoracodorsal nerve is
damaged it may be safest to assume that the vessels are
injured. In patients with a history of prior chest and/or
axillary surgery, the function of the latissimus muscle
should therefore be assessed preoperatively.
Innervation of the latissimus dorsi can be tested indi-
rectly by evaluation of isometric contraction of the muscle.
With the patient’s hands positioned on her waist, she
should be instructed to push her elbows downwards. Con-
traction of viable muscle can then be assessed by palpation
of the lateral edge of the latissimus dorsi. In ambiguous
cases, electrical stimulation or electromyography may be
used to further evaluate function. If muscular contraction
is not elicited by any of the above techniques, however, it
must be assumed that the muscle has been denervated and
is atrophic. During such a harvest, the muscle layer will
appear extremely thin and pale. Although success has been
achieved under these conditions, acceptable aesthetic results
may be diffi cult to achieve because of the delicacy of the
atrophied muscle.
Signifi cant compromise of the thoracodorsal vessels
can similarly reduce the bulk of the proposed fl ap, warrant-
ing the consideration of alternative reconstruction options.
However, if the thoracodorsal vessels alone have been
damaged, the latissimus dorsi fl ap can often still be used
owing to retrograde fl ow through the serratus branches. In
patients who have undergone a previous axillary lymph
node dissection, care must be taken not to ligate the serra-
tus branches until the patency of the thoracodorsal artery
and vein has been demonstrated.
PREOPERATIVE CONSIDERATIONS
Preoperative planning is critical to achieving a successful
outcome. The following issues must be considered when
individualizing the reconstructive procedure.
Mastectomy skin fl aps
The goal of post-mastectomy reconstruction is to recreate
a breast that looks and feels like the removed breast. Place-
ment of the latissimus dorsi fl ap into the mastectomy
defect requires attention to the preservation of ptosis and
the breast’s natural contours. If the skin island of the LDM
fl ap is positioned too high on the chest wall, the bulk of
the muscle will be out of position to accomplish this goal.
Instead, by sacrifi cing the inferior mastectomy skin fl aps
down to the level of the inframammary fold, the skin island
of the LDM fl ap may be positioned more inferiorly. This
arrangement allows the bulk of the fl ap to provide ptosis
and a gives a more natural contour to the reconstructed
breast.
Similarly, in the setting of prior chest wall irradiation
expansion of mastectomy skin fl aps may be limited. By
excising the mastectomy fl aps in the inferior pole of the
breast at the time of expander placement, the skin island
of the LDM fl ap can be placed inferiorly. Overexpansion of
the native back skin in the lower pole of the breast can then
be performed. Ultimately, this serves to create a looser skin
envelope and a greater potential for breast ptosis.
Posterior scar location
If a skin paddle is required for reconstruction, it is usually
oriented either horizontally or obliquely, depending on
reconstructive requirements. The maximum width of the
skin paddle is usually 7–8 cm and depends on skin laxity.
Wider skin islands tend to be diffi cult to close primarily.
The scar resulting from a horizontal skin-paddle harvest
can usually be covered by the bra strap. By contrast, the
scar resulting from an obliquely oriented skin paddle may
be designed along the relaxed skin tension lines of the back,
thereby reducing the potential for hypertrophic scarring.
Creating a submuscular pocket
In the setting of implant-based reconstruction, both infec-
tious complications and wound healing problems can have
negative consequences. Not only can these outcomes neces-
sitate the explantation of a permanent prosthesis, thereby
delaying the reconstructive process, but more importantly,
they can delay the administration of adjuvant therapy for
breast cancer. By placing a prosthesis in a completely sub-
muscular position, the risk of expander exposure and con-
tamination in the setting of mastectomy fl ap necrosis is
minimized.
Placement of an expander beneath the pectoralis major
muscle allows for muscle coverage of the superomedial
portion only. In this setting, the inferolateral portion of the
device sits directly underneath the latissimus muscle. If the
pectoralis major is insuffi cient to cover the superior portion
of the implant, or is scarred and/or fi brotic secondary to
prior radiation treatment, the implant can be placed in the
mastectomy space and covered in its entirety with the latis-
simus fl ap.
Selecting an expander
Generally, textured, anatomic expanders are used. Textured
expanders may reduce the amount of device migration,
whereas anatomical expanders preferentially expand the
lower pole of the breast. Together, these improvements
result in improved breast shape. Low, medium and full/tall
height expanders are available for use. Generally, the
authors prefer a medium height expander. Intraoperatively,
the mastectomy weight is recorded and the width of the
expander pocket is then measured. An appropriate expander
is then selected based on its base dimensions and volume
capability.
Selecting a permanent implant
Before the exchange procedure patients must consider the
type of permanent implant (saline or silicone) to be used in

Latissimus Dorsi Breast Reconstruction
87
the reconstruction. Both types are currently available. The
use of silicone gel implants generally allows for a softer,
more natural-feeling breast. Although controversy sur-
rounding the use of silicone-fi lled implants still exists,
issues of silicone safety have been carefully investigated,12–14
and there is currently no defi nitive evidence linking breast
implants to cancer, immunologic diseases, neurologic prob-
lems, or other systemic diseases. Patients should, however,
be counseled regarding the recommendation that silicone
implants be changed approximately every 10 years to mini-
mize the risk of a silent leak.15
OPERATIVE APPROACH
Delayed latissimus dorsi–expander/implant
reconstruction
Patient positioning
The LDM fl ap is created with the patient in the lateral
decubitus position. The ipsilateral arm is completely pre-
pared so that it remains in the operative fi eld. For most of
the procedure it is kept fl exed to 90º, partially abducted,
and can be stabilized using a Mayo stand. This confi gura-
tion gives maximal exposure of both the axilla and the
adjacent thorax.
Preoperative markings
The patient can be marked preoperatively in the upright
sitting position or on the operating table in the lateral
decubitus position. The origin and insertion of the latissi-
mus dorsi muscle, as well as its relation to the scapula, are
outlined. A transverse or oblique skin paddle may be
planned as described above (Fig. 6.1).
Flap harvest
The incisions are created around the skin island. Skin fl aps
are elevated at the level of the subcutaneous fat both ante-
riorly and posteriorly above the latissimus dorsi muscle.
The incisions are beveled to maintain a layer of fat over the
latissimus muscle to provide extra bulk and improve con-
touring. The insertions of the latissimus muscle are incised
circumferentially and the fl ap is elevated. The plane of dis-
section is then identifi ed beneath the latissimus muscle yet
superfi cial to the remaining musculature of the posterior
thorax. The latissimus muscle is then elevated from its
origins, proceeding distally to proximally. Medially, caution
must be exercised to identify the medial and lateral rows of
the segmental arteries that feed the muscle. These perfora-
tors that arise from the lumbar and intercostal arteries
must be ligated or cauterized to ensure hemostasis and to
prevent postoperative hematoma.
In this area of the tip of the scapula, the teres major,
serratus anterior, and rhomboids meet the connective tissue
of the superior origin of the latissimus dorsi. The space
between the latissimus dorsi and serratus anterior muscles
is enlarged with blunt dissection. Caution must be observed
not to dissect under the serratus muscle, but between the
serratus and latissimus.
Once the latissimus is separated from the serratus, the
pedicle will become visible as the fl ap is elevated towards
the axilla. Flap dissection continues proximally to the level
of the branches from the serratus anterior muscle. If the
dissection is being performed in a previously undissected
axilla and the patency of the thoracodorsal vessels is certain,
then the serratus branches may be divided to gain addi-
tional anterior rotation of the fl ap. In addition, some sur-
geons will prefer to divide the thoracodorsal nerve in order
to eliminate the potential for muscle contraction, despite
the fact that the latissimus muscle will atrophy over time.
Once the fl ap is completely elevated, attention is turned
anteriorly.
Insetting of the fl ap and expander placement
The mastectomy incision is re-excised. Electrocautery is
used to elevate both the superior and inferior mastectomy
skin fl aps off the pectoralis major muscle. Superolaterally,
a subcutaneous tunnel is dissected in order to connect
the back incision with the mastectomy defect. The tunnel
must be wide enough to allow transfer of the fl ap without
tension, but not so wide that the implant can migrate
posteriorly.
The LDM fl ap is then transferred to the mastectomy
defect via the subcutaneous tunnel. Care is taken to avoid
avulsion of the nutrient vessels originating from the serra-
tus anterior. Maintaining the insertion of the muscle and
limiting dissection to the level of the serratus branches is
a safe way to avoid excessive tension on the pedicle, and is
usually adequate for mobilization of the fl ap. In some
patients, particularly thin patients, it may be necessary to
transpose the muscle origin to the chest to avoid excessive
fullness in the axilla. In fact, some surgeons will routinely
divide the muscle insertion to facilitate reconstruction of
the anterior axillary fold.
The fl ap can be placed into the anterior breast pocket
and tacked in place to avoid tension on the pedicle while
the donor defect is closed in layers. One or more closed
suction drains should be placed to prevent postoperative
seroma formation.
The inferior mastectomy skin fl aps are then excised.
When an acceptable position is attained, the fl ap is sutured
to the inferior, medial, and lateral mastectomy fl aps with
absorbable sutures. The width of the expander pocket is
then measured and the appropriate expander selected based
on its base dimensions and volume capability. Textured,
anatomic expanders are used in an attempt to limit the
amount of device migration. Anatomical expanders prefer-
entially expand the lower pole of the breast.
The expander is then placed in the pocket with its infe-
rior edge at the lower limit of the pocket. In the setting of
bilateral expansion, care must be taken to achieve symme-
try with respect to the height of expander placement. The
superior border of the latissimus fl ap is then inset to provide
complete muscular coverage of the expander. One or two
suction drains are placed in the mastectomy space. After
wound closure, intraoperative expansion is performed to
tissue tolerance. Up to 50% of the tissue expander volume

Cosmetic and Reconstructive Breast Surgery
88
is generally placed, which helps to fi ll the submuscular
cavity and prevent skin contracture.
Postoperative expansion
Drains are removed when output is less than 30 mL in 24
hours. In the absence of skin fl ap necrosis or infection,
postoperative expansion generally begins 10–14 days after
surgery. Expansion is performed weekly or biweekly, depend-
ing on patient comfort and skin tolerance. Approximately
60–100 mL of normal saline are injected percutaneously
through the integrated, expander port at each visit. The
fi nal expander volume is usually 20–30% greater than the
planned implant volume, or 20% greater than the recom-
mended volume of the expander. This overexpansion ulti-
mately creates a looser skin envelope and a greater potential
for ptosis.
Exchange procedure
The exchange procedure is performed a minimum of 4–6
weeks after the last expansion and/or 4–6 weeks after the
completion of postoperative chemotherapy. The patient is
positioned on the operating table such that it is made pos-
sible intraoperatively to position the table with the patient
sitting upright. The patient’s arms are placed across the
abdomen, appropriately padded and taped to the table. The
forehead is similarly padded and taped to prevent move-
ment during fl exion of the table. Perioperative antibiotics
are administered. The patient is prepared and draped so
that both breasts are in the operative fi eld. The mastectomy
incision is re-excised and sent for pathologic review. The
mastectomy fl aps are elevated in the subcutaneous plane,
to a point where an 8–10 cm incision parallel to the fi bers
of the latissimus muscle can be made in order to gain access
to the expander pocket. The expander is removed.
A
B
C
D
FIGURE 6.1 A The patient is positioned in the left lateral decubitus position. A lap sponge is the right size and shape to make an excellent
latissimus dorsi pattern. B Back view. The latissimus myocutaneous fl ap is elevated in a distal to proximal direction. C Anterior view. The
latissimus myocutaneous fl ap is transferred to the mastectomy defect anteriorly and used to cover a temporary expander. D Anterior view.
Wound closure obtained.

Latissimus Dorsi Breast Reconstruction
89
A circumferential capsulotomy and/or radial capsuloto-
mies are performed as needed to maximize breast ptosis
and inferior pole projection. Evaluation of the height and
width of the contralateral native breast facilitates the appro-
priate selection of a permanent implant. Various implant
sizers are trialed with the patient in the upright sitting
position, and the fi nal prosthesis is selected. The patient is
returned to the supine position, the pocket is irrigated with
normal saline, and hemostasis is obtained. The chest is
re-prepared and draped and the surgeon’s gloves are changed
to minimize the risk of contamination. The permanent
device is then placed in the pocket and carefully positioned.
The muscle layer is closed using a running, absorbable
suture. Double-layer skin closure is performed.
Immediate latissimus dorsi–
expander/implant reconstruction
Patient positioning
The mastectomy (and axillary lymph node dissection) may
be performed with the patient in the supine position, fol-
lowed by repositioning into the lateral decubitus position,
or with the patient in the lateral decubitus position, thereby
decreasing operative time.
Mastectomy
Perioperative antibiotics are administered. The mastectomy
is performed by the oncologic surgeon. At the conclusion
of the operation the entire fi eld is redraped over the mas-
tectomy drapes, and a separate set of sterile instruments is
used. Hemostasis within the mastectomy pocket is assured
and the viability of the mastectomy fl aps evaluated. Any
non-viable soft tissue is excised. The pectoralis muscle may
be elevated off the chest wall. The most inferomedial
attachments of the pectoralis major muscle are released,
but care is taken to leave the sternal attachments intact to
prevent medial displacement of the tissue expander. If the
pectoralis major muscle is insuffi cient to cover the expander
completely, or is too scarred or fi brotic, the device can be
placed instead in the mastectomy space and covered with
the latissimus fl ap. Neither the rectus abdominis fascia nor
the serratus muscle/fascia is elevated. The mastectomy
wound is then temporarily closed and a sterile occlusive
dressing applied (Figs 6.2, 6.3).
Harvesting of the LDM fl ap and placement of the
expander is undertaken as in a delayed procedure. Postop-
erative expansion and exchange of the temporary expander
for a permanent implant is similarly performed.
OPTIMIZING OUTCOMES (Box 6.5; Figs 6.4, 6.5)
Complications
Latissimus dorsi breast reconstruction is a relatively simple
technique that is generally well tolerated. The fl ap has a
vigorous blood supply and can be used with minimal risk
of necrosis, even in smokers, diabetics, and those who are
morbidly obese. Thus, LDM fl ap reconstruction can often
be performed on patients who might not be suitable candi-
dates for the more complex and lengthy autologous tissue
procedures.
Complications are generally minor, with few systemic
health implications and minimal overall morbidity. By far,
the most common complication is a donor-site seroma.11,16,17
Quilting sutures have been used in an attempt to reduce
the formation of a postoperative fl uid collection.18 Whether
or not quilting sutures are used, closed-suction drains
should be used and left in the donor site until their output
is less than 30 mL in 24 hours. Signifi cant LDM fl ap
necrosis is rare. Partial necrosis may occur in up to 10% of
cases.17,19
Early complications following combined latissimus fl ap–
expander insertion are signifi cantly more common than
following the exchange procedure. Early complications
include mastectomy skin fl ap necrosis, hematoma, seroma,
infection, and implant exposure/extrusion.20 Late com-
plications include device malfunction, such as implant leak
or defl ation, and capsular contracture.21 Whereas capsular
contracture occurs to some extent around all implants, in
some the degree of contracture will worsen over time. It is
similarly understood that patients who have undergone
postoperative radiotherapy have a signifi cantly higher inci-
dence of capsular contracture than controls.9,22 In patients
with signifi cant capsular contracture resulting in size or
shape distortions and/or symptomatology, revision proce-
dures are performed. At this stage, circumferential capsu-
lotomy and/or capsulectomy may be carried out.
CONCLUSIONS
For patients who undergo mastectomy for the treatment of
breast cancer, the restoration of a normal breast form
through reconstruction is important to body image and
quality of life. The use of an LDM fl ap has the capability
of producing excellent results in the well-selected patient.
Individualizing the selection of a reconstructive technique
will be the predominant factor in achieving reconstructive
success.
BOX 6.5 Optimizing outcomes
●
By insetting the latissimus dorsi muscle on the lower
mastectomy fl ap rather than suturing the fl ap to the chest
wall at the level of the desired inframammary fold, any
inadvertent elevation of the IMF will be avoided
●
A small, superior tunnel should be created in order to avoid
lateral displacement of the implant
●
Anatomic expanders are used to preferentially expand the
lower pole of the breast, facilitating the creation of breast
ptosis
●
Routine overexpansion of the lower pole of the breast
creates a relative abundance of soft tissue, which facilitates
the recreation of breast ptosis
●
A circumferential capsulotomy and/or radial capsulotomies
are routinely performed at the time of exchange when
necessary, in order to release the overlying soft tissue
envelope, thus enhancing both projection and ptosis of the
reconstructed breast

Cosmetic and Reconstructive Breast Surgery
90
A
B
C
D
E
FIGURE 6.2 Recurrent breast cancer 4 years after prior lumpectomy/
radiation to the left breast. Left salvage mastectomy with immediate
latissimus dorsi/tissue expander-implant (TE-I) reconstruction using a
360 mL silicone gel implant. Right reduction mammoplasty
performed. A Three years postoperatively. AP view. Breast with
natural contours and ptosis achieved. Excellent symmetry. Excellent
result. B Lateral view. Note well-healed donor-site scar. C Oblique
view. D Oblique view. E Donor site scar.

Latissimus Dorsi Breast Reconstruction
91
A
B
FIGURE 6.3 History of prior left lumpectomy/radiation. Salvage mastectomy left breast for recurrent breast cancer; prophylactic mastectomy
right breast. Immediate latissimus dorsi/TE-I reconstruction left; immediate TE-I reconstruction right. A AP view. Note radiation tattoos midline.
Excellent symmetry. Very good overall result. B Oblique view.
A
B
C
D
FIGURE 6.4 History of prior mastectomy and radiation right breast. Delayed, expander/implant reconstruction performed right; contralateral
augmentation/mastopexy left for symmetry. Failed reconstruction right breast secondary to exposure of permanent implant. Patient presents
for secondary reconstruction of right failed reconstruction. A Preoperative photo. B AP view. Postoperative photo. Right, two-stage combined
latissimus-expander/implant reconstruction performed. C Right oblique view. D Left oblique view.

Cosmetic and Reconstructive Breast Surgery
92
A
B
C
D
FIGURE 6.5 Immediate combined latissimus dorsi-expander/implant reconstruction performed left breast. Contralateral symmetry procedure
performed right breast. A Preoperative photo. B AP view. Postoperative result. Note latissimus dorsi skin paddle and reconstructed nipple–
areolar complex. C Left oblique view. D Right oblique view.
REFERENCES
1. Hammond DC. Latissimus dorsi fl ap breast reconstruction. Clin
Plast Surg 2007; 34: 75–82; abstract vi–vii.
2. Disa JJ, Cordeiro PG, Heerdt AH, et al. Skin-sparing mastectomy
and immediate autologous tissue reconstruction after whole-breast
irradiation. Plast Reconstruct Surg 2003; 111: 118–124.
3. Mathes SJ, Nahai F. Reconstructive surgery: principles, anatomy
and technique. New York: Churchill Livingstone, 1997.
4. McIntosh A, Freedman G, Eisenberg D, et al. Recurrence rates and
analysis of close or positive margins in patients treated without re-
excision before radiation for breast cancer. Am J Clin Oncol 2007;
30: 146–151.
5. McIntosh SA, Ogston KN, Payne S, et al. Local recurrence in
patients with large and locally advanced breast cancer treated with
primary chemotherapy. Am J Surg 2003; 185: 525–531.
6. Voogd AC, van Tienhoven G, Peterse HL, et al. Local recurrence
after breast conservation therapy for early stage breast carcinoma:
detection, treatment, and outcome in 266 patients. Dutch Study
Group on Local Recurrence after Breast Conservation (BORST).
Cancer 1999; 85: 437–446.
7. 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–
363; discussion 363–364.
8. Krueger EA, Wilkins EG, Strawderman M, et al. Complications
and patient satisfaction following expander/implant breast
reconstruction with and without radiotherapy. Int J Radiat Oncol
Biol Phys 2001; 49: 713–721.
9. Spear SL, Boehmler JH, Taylor NS, et al. The role of the
latissimus dorsi fl ap in reconstruction of the irradiated breast.
Plast Reconstruct Surg 2007; 119: 1–9; discussion 10–11.
10. McCarthy CM, Pusic AL, Disa JJ, et al. Breast cancer in the
previously augmented breast. Plast Reconstruct Surg 2007; 119:
49–58.
11. Clough KB, Louis-Sylvestre C, Fitoussi A, et al. Donor site
sequelae after autologous breast reconstruction with an extended
latissimus dorsi fl ap. Plast Reconstruct Surg 2002; 109:
1904–1911.
12. Eggertson L. Breast implant advisory panel: more study on silicone
leakage. CMAJ 2006; 174: 443–444.
13. Palley HA, Palley ML. The regulatory process, the Food and Drug
Administration, and the silicone breast implant controversy.
J Health Social Policy 1999; 11: 1–20.
14. Ault A. US Institute of Medicine panel deliberates on breast-
implant safety. Lancet 1998; 352: 380.
15. Heden P, Bone B, Murphy DK, et al. Style 410 cohesive
silicone breast implants: safety and effectiveness at 5 to
9 years after implantation. Plast Reconstruct Surg 2006; 118:
1281–1287.
16. Adams WP Jr, Lipschitz AH, Ansari M, et al. Functional donor
site morbidity following latissimus dorsi muscle fl ap transfer. Ann
Plast Surg 2004; 53: 6–11.
17. Apffelstaedt J. Indications and complications of LDM fl aps in
oncologic breast surgery. World J Surg 2002; 26: 1088–1093.
18. Daltrey I, Thomson H, Hussien M, et al. Randomized clinical trial
of the effect of quilting latissimus dorsi fl ap donor site on seroma
formation. Br J Surg 2006; 93: 825–830.

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19. Roy MK, Shrotia S, Holcombe C, et al. Complications of LDM fl ap
breast reconstruction. Eur J Surg Oncol 1998; 24: 162–165.
20. Cordeiro PG, McCarthy CM. A single surgeon’s 12-year experience
with tissue expander/implant breast reconstruction: part I. A
prospective analysis of early complications. Plast Reconstruct Surg
2006; 118: 825–831.
21. Cordeiro PG, McCarthy CM. A single surgeon’s 12-year experience
with tissue expander/implant breast reconstruction: part II. An
analysis of long-term complications, aesthetic outcomes,
and patient satisfaction. Plast Reconstruct Surg 2006; 118:
832–839.
22. Spear SL, Onyewu C. Staged breast reconstruction with saline-
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therapeutic implications. Plast Reconstruct Surg 2000; 105:
930–942.

95
C H A P T E R
7
Breast Reconstruction: Repair of the
Partial Mastectomy Defect
Steven J. Kronowitz
INTRODUCTION
In recent years there has been an increase in the proportion
of breast cancer patients treated with partial mastectomy
followed by radiation therapy (XRT), referred to as breast
conservation therapy (BCT). This trend is partly due to
increased mammographic screening with detection of early
breast cancers, but also to the increasing use of preoperative
chemotherapy in patients with locally advanced breast
cancer.1–3 Following BCT, 20–30% of patients are reported
to have a poor cosmetic result, with deformities of the
treated breast.4–7 Poor outcomes following BCT are likely
to be underestimated in the literature because many patients
are reluctant to seek additional surgical treatment.
Although patients treated with total mastectomy often
request breast reconstruction, those treated with partial
mastectomy usually do not. There are several reasons for
this. For some, the enhancement of body image through
breast preservation provides suffi cient psychological satis-
faction. Others may fear additional operations or may
simply not be aware of the reconstructive options.8 These
factors, along with the desire of many patients to preserve
their breast regardless of their perceived cosmetic outcome,
have led to a more aggressive use of partial mastectomy,
with more extensive local resections being classifi ed in the
category of partial mastectomy.8 As partial mastectomies
become more extensive, the risk of suboptimal cosmetic
results will most likely increase.9 The importance of incor-
porating immediate reparative techniques in the multidis-
ciplinary care of these patients has never been so critical.
Besides an obvious improvement in cosmetic outcome,
immediate repair of partial mastectomy defects offers many
other potential advantages. It can facilitate the breast sur-
geon’s ability to resect wider margins around the tumor,
which in turn has the potential to lower the rates of local
recurrence of breast cancer.9 Immediate repair of partial
mastectomy defects can also increase the eligibility of large-
breasted patients for BCT. Some radiation oncologists are
reluctant to treat large-breasted patients because of poor
aesthetic outcomes. Radiation delivered to a large breast
can lead to increased fi brosis owing to diffi culties with daily
set-up and the increased fat content of the breast.10 A
reduced breast size allows for a more uniform radiation
dose at a lower level, reducing unacceptable late radiation
reactions.11,12 Immediate repair of a partial mastectomy
defect using breast reduction techniques represents an
alternative for patients who would not otherwise be consid-
ered candidates for conservation therapy.
Immediate repair does not pose a problem with postop-
erative cancer surveillance.11 It also may provide some
medical benefi ts. Even though a contralateral breast reduc-
tion for symmetry is often required in patients who undergo
repair of a partial mastectomy defect, and although contra-
lateral breast reduction does increase the potential for com-
plications, a benefi t of this procedure is that it allows for
sampling of tissue from the contralateral breast. Occult
carcinomas have been found in approximately 4.5% of con-
tralateral breast reduction specimens in patients under-
going a symmetry procedure for breast reconstruction.10
Although the detection of occult carcinoma is not a reason
to perform a contralateral breast reduction, it may provide
a benefi t for high-risk patients. Breast reduction surgery has
also been shown to signifi cantly reduce the risk of breast
cancer, especially among women over the age of 40.13
The purpose of this chapter is to highlight the benefi ts
of immediate reparative approaches using local tissue tech-
niques to repair partial breast defects prior to the delivery
of radiation therapy because such techniques maintain the
color and texture of the breast. Patients who choose to

Cosmetic and Reconstructive Breast Surgery
96
undergo BCT often do so to limit the extent of surgery,
and are therefore not eager to undergo a major secondary
reconstructive procedure that is usually required after radio-
therapy. Although the details of the operative approach will
focus only on performing immediate repair using the
remaining breast tissue, other techniques will be mentioned
in the decision-making sections of the chapter, so that the
clinician can determine the best approach for each individ-
ual patient given a variety of presenting circumstances.
INDICATIONS AND CONTRAINDICATIONS
(Box 7.1)
Timing of repair
Waiting to repair a large partial mastectomy deformity
until after XRT usually necessitates a complex transfer of
a large volume of autologous tissue, which many patients
are unwilling to pursue. In addition, after XRT, the diffi cul-
ties associated with secondary repair within an irradiated
surgical fi eld limit the use of the adjacent irradiated breast
tissue, and breast implants are not a preferred option. In
the case of severe deformities after BCT, the only option
may be to abandon BCT and offer the patient a completion
mastectomy with total breast reconstruction. However, the
cosmetic outcomes of total breast reconstruction after BCT
are less than optimal, owing to the inelasticity of the irradi-
ated breast skin envelope and the increased risk of mastec-
tomy skin fl ap necrosis.
In the case of immediate repair, we prefer the use of
local breast tissue because of the simplicity of these
approaches and because such techniques maintain the color
and texture of the breast. Although breast reduction is
generally favored over local tissue rearrangement, the breast
reduction technique is usually limited to patients with large
breasts (D-cup bra size or larger). Local tissue rearrange-
ment can be a good alternative for patients with moderate-
sized breasts (B- or C-cup) who have minimal or no nipple
ptosis, especially when the partial defect is located in the
lower outer quadrant of the breast and involves minimal or
no skin resection. Although we usually prefer immediate
repair, if an unexpected deformity results after partial mas-
tectomy or the tumor margin status is unclear at the time
of the partial mastectomy, consideration should still be
given to performing the repair prior to XRT. In these cir-
cumstances, we also prefer to use the remaining breast
tissue.
Immediate reparative techniques also allow the plastic
surgeon to participate in the planning of the incisions and
the surgical approach to tumor resection. Even if recon-
struction is not required (because the defect is smaller than
anticipated, or the cancer is more extensive than antici-
pated and precludes partial mastectomy), the involvement
of the plastic surgeon in preoperative planning sim-
plifi es any subsequent breast reconstruction that may be
required.
Often, there is no choice but to perform a delayed recon-
struction. Delayed reconstruction after XRT usually requires
a latissimus dorsi musculocutaneous fl ap or thoracodorsal
artery perforator fl ap; however, use of these fl aps may
increase the likelihood of lymphedema and may limit future
reconstructive options. In some patients following XRT a
contralateral breast reduction alone, without repair of the
involved breast, will allow them to improve their symmetry
while limiting the extent of the surgical procedure.
Impact of breast size on repair
As the role of BCT continues to expand, it is important to
remember that most patients with an A-cup breast size, and
even some patients with B- or C-cup sizes, are not candi-
dates for BCT because of poor cosmetic outcomes. In these
patients there is usually inadequate remaining breast tissue
following BCT to perform a repair, thus necessitating the
use of a vascularized tissue fl ap to correct the deformity. In
small-breasted patients it may be preferable to perform a
mastectomy with immediate total breast reconstruction to
avoid the adverse effects of XRT on the breast skin envelope
and the resultant abnormal position of the nipple–areola
complex, which make these deformities so diffi cult to
correct. However, in large-breasted patients in whom the
partial mastectomy is predicted to result in a signifi cant
deformity, surgeons should consider incorporating immedi-
ate reparative techniques into the multidisciplinary care of
patients with breast cancer who undergo BCT.
Following breast augmentation, women who have been
diagnosed with breast cancer are sometimes considered for
BCT. Although these women appear to have large breast
BOX 7.1 Indications and contraindications
Indications
●
Large-sized breast: D-cup bra or larger
●
Ptotic-shaped breast
●
Immediate repair before XRT
●
Only required breast skin resection: (1) re-excision of a
previous biopsy site or (2) anticipated skin resection is
located within the Wise skin resection pattern
●
Suffi cient amount of breast tissue remaining after the partial
mastectomy to result in a reconstructed breast with an
adequate volume and a natural contour
●
Low risk of having a positive margin on the permanent
sections, even if the intraoperative tumor margin was
negative
Relative contraindications
●
Small-sized breast: C-cup bra or smaller
●
Medium or large tumor
●
Inner quadrant tumor
●
Non-ptotic-shaped breast
●
Delayed repair after XRT
●
Insuffi cient volume of remaining breast tissue after partial
mastectomy to reconstruct a breast with an adequate
volume and a natural-appearing contour
●
Concern that a negative intraoperative tumor margin may be
positive on the permanent sections
●
Extensive resection of breast skin located outside the Wise
skin resection pattern

Breast Reconstruction: Repair of the Partial Mastectomy Defect
97
volumes, most had A- or B-cup bra sizes prior to augmenta-
tion and should therefore be considered as small-volume.
The fact is that patients with A- and B-cup size breasts are
not good candidates for BCT because the resultant cosmetic
outcome is poor. Unfortunately, some women in this cate-
gory will have BCT and later present to a plastic surgeon
because of infection, deformity, pain or implant displace-
ment, requiring secondary operations. Subsequent recon-
struction for these patients can be diffi cult because of the
XRT; thus, the use of autologous tissue is necessary. Many
of these patients will often require a complex microsurgical
procedure, such as a gluteal fl ap, because small-breasted
patients tend to have minimal adipose tissue in their lower
abdominal regions. Better preoperative planning can poten-
tially obviate these problems. For some, consideration of
total mastectomy with immediate reconstruction may
reduce the incidence of poor outcomes.
Women with moderate breast volume, especially those
without breast ptosis, can also be a diffi cult management
problem. Usually, these women are not considered good
candidates for breast reduction because of insuffi cient resid-
ual breast tissue following the partial mastectomy, and
because their lack of breast ptosis does not require any
modifi cation to the position of their nipple–areola complex.
However, relatively small defects in these patients can be
repaired with satisfactory outcomes using the local tissue
rearrangement technique.
Infl uence of tumor margin status
Attention to tumor margin status prior to rearrangement
of the breast parenchyma is of the utmost importance. If at
the time of partial mastectomy the tumor margin status is
unclear, or an unexpected deformity occurs after the partial
mastectomy, consideration should still be given to perform-
ing the repair prior to XRT. In these circumstances, the use
of the breast reduction technique is preferred.
Where there is preoperative or intraoperative concern
regarding the ability to determine the adequacy of the tumor
margins, the partial mastectomy wound is closed primarily
without tissue rearrangement. After confi rmation of nega-
tive margins, the repair is performed within several weeks
of the partial mastectomy, and the start of XRT is not
usually delayed. Good decisions regarding the approach to
unexpected deformities after partial mastectomy require
good communication between the breast surgeon and the
plastic surgeon.
In the MD Anderson experience14 only 5% of patients
had a positive tumor margin after undergoing immediate
repair after partial mastectomy. This relatively low rate of
positive tumor margins refl ects the large defect sizes that
are usually encountered in patients who undergo partial
mastectomy and require repair. This is lower than rates for
positive margins in patients who do not undergo repair15
because the defect sizes reported in such patients are usually
smaller.
Given the low incidence of a positive tumor margin,
immediate repair of the partial mastectomy defect can be
considered. The experience at the MD Anderson Cancer
Center has demonstrated that many of these women who
are scheduled for delayed repair because of larger antici-
pated defects usually will proceed to completion mastec-
tomy with immediate breast reconstruction and not
additional re-excision.14 The relatively low (5%) incidence
of local recurrence of breast cancer14 is further evidence of
its safety, and should support the role of immediate repair
of partial mastectomy defects using the breast reduction
technique as a defi nitive method of breast reconstruction.
PREOPERATIVE HISTORY
AND CONSIDERATIONS
A number of considerations regarding the repair of a partial
mastectomy defect can be highlighted. To determine the
optimal technique for each patient, consideration should be
given to the following: the anticipated size and location of
the breast skin defect, the proximity of the anticipated
breast parenchymal defect to the nipple–areola complex,
and whether the patient may require a lower abdominal fl ap
(i.e., transverse rectus abdominis myocutaneous (TRAM)
fl ap, deep inferior epigastric perforator (DIEP) fl ap, or super-
fi cial inferior epigastric artery (SIEA) fl ap) to repair the
partial mastectomy defect.
Size and location of the skin defect
The anticipated size and location of the skin defect are
essential factors in the decision regarding the most appro-
priate repair technique. When the breast skin resection
(tumor extirpation) is located within the boundaries of the
Wise pattern, the situation is ideal. When this skin to be
resected is located outside the Wise pattern, it can be prob-
lematic. In such situations, consideration can be given to
modifying the Wise skin pattern to incorporate the resected
skin. If the skin to be resected involves only the re-excision
of an existing biopsy site, and if there is an adequate skin
bridge between the biopsy site and the Wise pattern, the
biopsy site can be re-excised separately and the tumor extir-
pation performed through an access incision located along
the superior or inferior limb of the Wise pattern. Although
the appropriateness of a separate access incision for tumor
resection is up to the breast surgeon, this approach can
result in an optimal cosmetic outcome with minimal dis-
tortion of the breast shape.
Several options are available when an extensive skin
resection is required outside the Wise pattern. The Wise
pattern can be rotated in either a clockwise or a counter-
clockwise direction to encompass the skin resection.
However, the resultant position of the vertical limb of the
Wise pattern closure (not located in the inferior aspect of
the breast) can result in a scar contracture, especially when
the tumor is located in the medial aspect of the breast,
resulting in a fl attened contour and distortion of the breast
shape. Another alternative, which has been described by
Kroll and Singletary,16 is a laterally based rotation–advance-
ment fl ap of redundant axillary skin and subcutaneous
tissue. Although excellent cosmetic results can be obtained
with this local tissue rearrangement technique, especially