Operative Technique in Plastic Surgery – Kevin C.Chung

Lateral IMF access incision and black arrows depict
passes of the cannula. The area to be liposuctioned is
shown in blue. The superolateral adherent zone over
the pectoralis major is shown as a red circle that
should be avoided by the cannula. Inferiorly, the
cannula is used to disrupt the IMF and allow for a
smooth contour onto the upper abdomen.
Removal of Persistent Tissue
■ Often dense subareolar tissue persists despite target liposuction (not
uncommon even in mild gynecomastia), requiring morcellation or direct
excision.
■ Arthroscopic shaver morcellation, using a standard orthopedic arthroscopic
system connected to an endoscopic shaver cannula with a rotating dentated
cutting tip.11
■ The arthroscopic shaver cannula is inserted through the lateral IMF stab
incision with the dentated opening on the tip directed away from the skin.
■ With the cannula oscillation speed set between 4000 and 6000 rpm, the
shaver is repeatedly passed through the residual subareolar fibrous tissue
until the desired result is achieved.
■ Direct excision through an inferior semicircular periareolar incision (TECH
FIG 2).
■ An inferior periareolar incision is made with a no. 15 blade that can be
extended to encompass the entire inferior half of the areola if necessary.
■ Cautery is used to circumferentially dissect out the readily palpable firm
glandular tissue. Roughly 1 cm of immediately subareolar glandular tissue
should be left to avoid a depression or saucer deformity.

TECH FIG 2 • A. Location of periareolar incision for
direct excision of glandular tissue. B. Dense fibrous
tissue not amenable to liposuction is excised directly.
■ Redundant Skin Excision
Markings
■ With the patient standing, the IMF, midclavicular line, and breast boundaries
are marked.
■ A horizontal ellipse is drawn with its inferior aspect, following the IMF.
■ The superior line of the ellipse is drawn to mark the area of planned skin
excision based on the amount of skin laxity.
■ Following completion of parenchymal liposuction, the patient should be
positioned sitting upright on the operating table to assess the breast skin
envelope and degree of excess/ptosis.
■ Mark the IMFs bilaterally again. This will serve as the inferior border of the
ellipse for skin excision.
■ Along the length of the IMF, use the pinch test to determine the width of the

ellipse needed to remove the excess skin and close under minimal tension.
Mark the superior border of the ellipse to be excised accordingly.
Excision and Completion
■ Incise the marked ellipse through the dermis and remove the excess skin
using cautery in a subcutaneous plane.
■ This exposure provides an excellent opportunity to confirm complete
disruption of the IMF as well. Any residual bands or attachments should be
divided with cautery.
■ After hemostasis is obtained, place a closed suction drain with a remote
egress laterally.
■ Reapproximate skin with resorbable buried deep dermal sutures and a
running subcuticular stitch.
■ Breast Amputation With Free Nipple Grafting
Markings
■ With the patient standing, the IMF, midclavicular line, and sternal notch are
marked.
■ Similar to the excess skin excision pattern described, a horizontal ellipse is
drawn with its inferior aspect following the length of the IMF.
■ Because of the severe ptosis requiring mastectomy, the superior line of the
ellipse is drawn to mark the area of planned skin excision based on the
amount of skin laxity and includes the NAC (TECH FIG 3).
Tissue Excision
■ Infiltrate the breast parenchyma and planned incisions (TECH FIG 4A) with
a dilute solution of 0.5% lidocaine with 1:200 000 epinephrine.
■ Outline the NAC and excise it as a full-thickness graft. Debride any fat from
the underside of the graft and store it in saline-soaked gauze.
■ Incise the superior aspect of the ellipse through dermis using a no. 15 blade.
■ Elevate the superior breast skin and subcutaneous tissue in the superficial
fascial plane similar to a mastectomy flap, using cautery, knife, or scissors as
preferred (TECH FIG 4B).

TECH FIG 3 • Grade III gynecomastia with
preoperative markings for mastectomy with free nipple
grafting. Inner ellipse excised to make defatting the
free nipple graft easier, and the planned skin excision
(outer ellipses) is resected parallel to IMF and
estimated by pinch test.

TECH FIG 4 • A. Planned incisions for subcutaneous
mastectomy with free nipple grafting. The
subcutaneous tissue shown in green is excised. The
scar is placed along the level of the IMF. B. The breast
tissue is elevated off the pectoralis fascia. C.
Mastectomy specimen with short stitch marking
superior and long stitch lateral. Notice how far
superiorly the glandular resection extends. D.
Resulting defect after mastectomy, which is closed in
layers.
■ Once the superior aspect of the breast tissue is reached, it is elevated off the
pectoralis fascia from superior to inferior until reaching the level of the IMF
and the inferior aspect of the ellipse.
■ Ensure that the superior and inferior skin flaps of the ellipse will close

without tension, and then incise the inferior aspect of the ellipse and remove
the breast tissue (TECH FIG 4C,D).
■ Confirm hemostasis and close the new IMF incision primarily in layers.
■ Repeat the same procedure on the contralateral side.
Nipple Grafting
■ Draw the new NAC position as a 3-cm-wide oval centered in the
midclavicular line over the fourth intercostal space.
■ Once satisfied with nipple position and symmetry, de-epithelialize the 3-cm
ovals.
■ Trim the free nipple grafts to fit with the nipples centered on the oval and
secure using 4-0 chromic suture on a taper needle (TECH FIG 5A).
■ Apply bolster dressings of cotton soaked with mineral oil and wrapped in
Xeroform gauze. Secure these with silk sutures over bilateral NACs (TECH
FIG 5B).
■ These bolsters remain in place for 5 to 7 days postoperatively.
TECH FIG 5 • A. Free nipple grafts are inset over de-
epithelialized area above the IMF incision. B. Bolsters
applied to free nipple grafts for 5 to 7 days.
PEARLS AND PITFALLS
Subglandular
■ Consider excising residual subareolar fibrous tissue at the time of

excision
UAL using either the arthroscopic shaver or direct excision
technique.
■ Maintain 1 cm of subcutaneous tissue under NAC to avoid a
saucer deformity.
Liposuction
technique
■ Focus UAL on the subdermal adipose tissue to achieve maximal
skin retraction.
■ Avoid suctioning the adherent area over the superolateral
pectoralis muscle.
■ Completely undermine/disrupt the IMF to create a smooth inferior
chest transition.
Intraoperative
assessment
■ In order to adequately evaluate the surgical result, sit the patient
upright on the operating table following resection to ensure
satisfactory contour and symmetry.
Revisions
■ Wait more than 6 months for maximal skin retraction prior to
performing resection of residual excess skin/tissue.
Duration of
gynecomastia
■ Gynecomastia present for more than 12 months is unlikely to
resolve spontaneously due to parenchymal fibrosis and typically
requires surgical intervention.
Postoperative
care
■ Chest compression dressings should be worn continuously for 2
weeks postoperatively.
POSTOPERATIVE CARE
■ Except in rare instances of extremely large resections, these cases are
performed as ambulatory procedures with patients going home the same day.
■ Patients are instructed to wear a chest compression garment or Ace wrap for 2
weeks postoperatively. This maintains pressure on the chest to minimize
hematoma and seroma formation.
■ Closed suction drains are placed only for procedures that include more than
liposuction. These are typically removed at the first postoperative visit.
■ Postoperative follow-up visits are scheduled at 1 week, 4 weeks, and 4 to 6
months.
■ Patients who underwent UAL-only resection should be re-evaluated around 6
months to allow time for skin retraction before determining the need for
revision with excision of excess skin and residual parenchymal tissue.7,8
OUTCOMES
■ Gynecomastia reduction surgery outcomes show high overall patient

satisfaction rates. Overall complication rates range from 14.5% to 53% with
hematoma being the most common.12–14 Hematoma rates appear higher in open
subcutaneous mastectomies (11%–16%), compared to cases treated with
liposuction alone (1%).9,12–14 Inadequate resection with the need for revision is
the most common long-term complication.7,8
COMPLICATIONS
■ Hematoma
■ Seroma
■ Infection
■ Inadequate resection
■ Poor scarring
■ Contour deformity/asymmetry
■ Sensory changes
ACKNOWLEDGMENT
The authors thank our research coordinator, Grace Poudrier, for her significant
contribution to this chapter. We sincerely appreciate her hard work and
dedication.
REFERENCES
1. Braunstein GD. Clinical practice. Gynecomastia. N Engl J Med.
2007;357:1229-1237.
2. Mathur R, Braunstein GD. Gynecomastia: pathomechanisms and treatment
strategies. Horm Res. 1997;48:95-102.
3. Deepinder F, Braunstein GD. Drug-induced gynecomastia: an evidence-based
review. Expert Opin Drug Saf. 2012;11:779-795.
4. Hultborn R, Hanson C, Kopf I, et al. Prevalence of Klinefelter’s syndrome in
male breast cancer patients. Anticancer Res. 1997;17:4293-4297.
5. Bowers SP, Pearlman NW, McIntyre RC Jr, et al. Cost-effective management
of gynecomastia. Am J Surg. 1998;176:638-641.
6. Johnson RE, Murad MH. Gynecomastia: pathophysiology, evaluation, and
management. Mayo Clin Proc. 2009;84:1010-1015.
7. Rohrich RJ, Ha RY, Kenkel JM, Adams WP Jr. Classification and
management of gynecomastia: defining the role of ultrasound-assisted
liposuction. Plast Reconstr Surg. 2003;111:909-923.
8. Brown RH, Chang DK, Siy R, Friedman J. Trends in the surgical correction of

gynecomastia. Semin Plast Surg. 2015;29:122-130.
9. Wong KY, Malata CM. Conventional versus ultrasound-assisted liposuction in
gynaecomastia surgery: a 13-year review. J Plast Reconstr Aesthet Surg.
2014;67:921-926.
10. Lista F, Ahmad J. Power-assisted liposuction and the pull-through technique
for the treatment of gynecomastia. Plast Reconstr Surg. 2008;121:740-747.
11. Prado AC, Castillo PF. Minimal surgical access to treat gynecomastia with
the use of a power-assisted arthroscopic-endoscopic cartilage shaver. Plast
Reconstr Surg. 2005;115:939-942.
12. Colombo-Benkmann M, Buse B, Stern J, Herfarth C. Indications for and
results of surgical therapy for male gynecomastia. Am J Surg. 1999;178:60-63.
13. Li CC, Fu JP, Chang SC, et al. Surgical treatment of gynecomastia:
complications and outcomes. Ann Plast Surg. 2012;69:510-515.
14. Petty PM, Solomon M, Buchel EW, Tran NV. Gynecomastia: evolving
paradigm of management and comparison of techniques. Plast Reconstr Surg.
2010;125:1301-1308.

11
CHAPTER
Section IV: Breast
Reconstruction for Partial
Mastectomy Defects
Partial Breast
Reconstruction With Local
Tissue Rearrangement
Moustapha Hamdi
DEFINITION
■ The treatment of breast cancer is an evolving field. Different modalities are
continuously being developed to maximize patient survival while minimizing
the treatment’s morbidity.1–5
■ Currently, the two main options for the management of primary breast cancer
are total mastectomy and lumpectomy/quadrantectomy with radiation.1–5
■ Studies have shown that women diagnosed at early stages of invasive breast
cancer have equivalent outcomes when they are treated with lumpectomy and
radiation therapy or modified radical mastectomy.2–5
■ Oncoplastic surgery is a combination of breast conservative surgery and an
immediate partial breast reconstruction.6
■ This chapter reviews partial breast reconstruction after partial mastectomy.
ANATOMY7
The Blood Supply
■ The blood supply of the breast is a rich anastomotic network derived from the
axillary, internal thoracic (internal mammary), and two intercostal arteries.

■ Multiple factors can influence how robust each of these sources of inflow may
be (age, endocrine activity, overall health, systemic diseases, eg,
diabetes/atherosclerosis, smoking, radiotherapy).
■ The major inflow sources, from medial to lateral, are the internal mammary
segmental perforators, the intercostal perforators, the thoracoacromial
perforators, and the external mammary artery.
■ The anteromedial and anterolateral intercostal perforators are major
contributors to the vascularization of the nipple-areola complex (NAC).
■ The venous drainage is a dual system: a superficial subdermal plexus, which
eventually meets up in the deep system, and a deep system, which accompanies
the mentioned arterial system.
The Nerve Supply
■ The medial and central breast sensations come from the second through the
sixth anteromedial intercostal nerves.
■ The nipple-areola sensation is contributed by the third, fourth, and fifth
anteromedial and anterolateral intercostal nerves.
■ Careful consideration of the nerve supply helps to maximize nipple sensation.
When pedicled flaps (see Chapter 22) are passed into partial mastectomy
defects, the tunnel should be created high enough to avoid lateral denervation
to the breast.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Breast and plastic surgeons must have a thorough understanding of breast
anatomy, physiology, and the qualities of an aesthetically pleasing breast shape.
■ Surgeons performing the oncoplastic approach should consider the aesthetic
subunits when planning cosmetic quadrectomies, resections, and
reconstructions.
■ Also, knowledge of the anatomical landmarks, breast proportions, and shape is
essential to achieve a pleasing outcome.
■ Preoperative evaluation of the patient and her breasts must be standard and
detailed.
■ The examination must include the following:
■ Evaluation of breast skin, elasticity, thickness, scars, and any defining marks
such as tattoos, stretch marks, contour irregularities, and previous breast
surgery should be taken into account when planning breast-conserving
therapy (BCT).

■ Palpation for masses or abnormalities in the breast parenchyma, nipple
inspection, and detailed documentation of breast sensation are integral.
■ Breast shape, grade of ptosis, and size are determinants of success in surgical
treatment.
■ The base and width of the breast, the width of the NAC, the height of the
nipple, and the distance from the sternal notch, midline and inframammary
crease, must be recorded in detail.
■ Any natural breast asymmetry should be pointed out to the patient before
surgery.
■ Different body types, skin laxity, and fat distribution are important factors in
the decision-making process.
SURGICAL MANAGEMENT
Oncological Approach
■ Indications: Most early-stage cancers (T1 and T2 cancers with or without
nodal involvement) are indicated for BCT.6,8
■ Contraindications: Patients with a high probability for recurrence, especially
those with multicentric disease, those who are pregnant or have collagen
vascular disease, or those who have a history of prior radiation therapy.6,8
■ Relative contraindications include the following:
■ Patients with a high probability of subsequent cancers (BRCA mutations)
■ Patients who are likely to have a poor cosmetic result, which includes
patients with a high tumor/breast ratio
■ Medially and inferiorly based tumors
■ Tumors that require removal of the NAC
Clinical Approach
■ The success of this procedure depends on the size of the cancer, the anatomical
position, and the volume of resection needed to achieve clear margins in
relation to the volume of the breast.
■ The choice of the technique used depends on many factors, including the
extent of resection, the time of surgery, the breast size and tumor location, and
patient preferences.
■ Preoperatively, incision lines and preservation of the NAC should be discussed
with the oncologic surgeon and patient.
■ The estimation of the defect size after tumor resection and breast size/tumor

ratio is a guideline to the choice of the reconstructive method (FIG 1).
■ Immediate correction of asymmetry by a contralateral mastopexy or reduction
should also be discussed (Table 1).
■ There are two basic types of surgery techniques in partial breast
reconstruction: volume displacement and volume replacement.
■ Volume displacement techniques refer to advancement, rotation, or
transposition of large local breast flaps into the smaller created defect,
redistributing the volume loss. The dissection involves the advancement of a
full-thickness segment of breast fibroglandular tissue to fill the dead space.
Volume displacement procedures and surgical scars are optimal when
combined with mastopexy-reduction techniques. The tumor is excised within
the planned markings of the reduction specimen in medium, large, or ptotic
breasts, and the remaining parenchyma is sufficient enough to reshape the
breast mound.
■ Volume replacement techniques are technically more difficult and are used in
small to moderate-size breasts or when the tumor/breast ratio is large and the
remaining breast tissue is insufficient for the rearrangement and the
replacement of the defect. Volume replacement with the use of nonbreast
local or distant flaps provides both tissue for the filling of the glandular
defect and the skin deficiency of the reconstructed breast (see Chapter 22).
Table 1 Important Considerations in Partial Breast Reconstruction
1.
Incision lines
2.
Nipple-areola preservation
3.
Estimation of defect size after tumor resection
4.
Reconstructive method depending on breast size/tumor size ratio
5.
Consider delayed immediate reconstruction if doubt about margins
6.
Status of contralateral breast: no surgery vs mastopexy/reduction or
prophylactic mastectomy
Preoperative Planning
■ The patient is preferably marked before surgery. The breast size, tumor size,
and location as well as the final defect size are estimated.
■ Good communication between teams, oncological and reconstructive, if this is
being performed by a two-team approach

■ It is important to understand the importance of blood supply to the nipple,
placement of skin incisions, and have an understanding of breast aesthetics.
■ It is equally important that the reconstructive surgeon realize the size and
location of the tumor, importance of margin status, and locoregional control.
■ Both surgeons should review the radiographic imaging and discuss the
anticipated defect location and defect size, as well as whether or not the
resection would include skin.
■ This will assist with determination of the most appropriate glandular pedicle
required to maintain nipple viability and reshape the mound.
■ Anticipate a backup plan, as occasionally the defect is different to that
anticipated, and an alternative approach is required. The incisions for the tumor
resection are chosen from an oncological aspect but in the most aesthetically
pleasing fashion.
■ Planning of skin incisions and parenchymal excisions follow templates using
reduction mammaplasty and mastopexy techniques.
■ The pattern can be rotated laterally or medially to fit the location of the tumor.
The choice of the pedicle is related to the tumor location (Table 2).
■ Tumors involving the lower pole are the most easily treated because this
region is removed during most reduction techniques.
FIG 1 • An algorithm to partial breast reconstruction.
Table 2 Choice of Pedicle Based upon Location of the Defect
Location of the Defect
Choice of Pedicle
Inferior, inferomedial, or
Superior, superomedial or superolateral

inferolateral
pedicle
Superior
Inferior or centroinferior pedicle
Superomedial
Superolateral pedicle with an inferocentral
component to fill the defect
Superolateral
Superomedial pedicle with an inferocentral
component to fill the defect
Central
Inferior pedicle
■ A similar mammoplasty technique is performed on the contralateral breast to
match the size and shape of the tumor-affected breast.
■ If radiation is planned, consider keeping the tumor-affected breast about 10%
larger in size compared to the contralateral remodeled breast because some
shrinking and volume changes of the radiated breast are likely to occur.
■ However, immediate partial reconstruction should be delayed if the surgeon is
uncertain about the margins or tumor extension (eg, tumors with large in situ
component) despite the preoperative radiological assessment. A delayed
immediate reconstruction can still be performed within a few days after the
definitive margins become known.
T E C H N I Q U E S
■ Tumor Resection
■ Tumor removal is performed in the usual fashion using safe and effective
oncological principles.9,10
■ Intraoperative margin assessment could include radiographical imaging,
macroscopic assessment, frozen section, or touch cytology.
■ We have found that patient selection, cavity sampling, and generous
resection further reduce the incidence of positive margins.
■ The cavity is then clipped for postoperative surveillance and guidance for
radiation boosts to the tumor bed if required.
■ Principles of Rearrangement Techniques6

■ For nipple pedicle choice, the shortest pedicle will maximize nipple viability
and allow additional glandular manipulation without worrying about nipple
compromise.
■ As a general rule, if the pedicle points to or can be rotated into the defect, it
can be used (Table 2).
■ When it is not possible to preserve the nipple, either because of the size of
the breasts or because of the location of the tumor, options include
amputation and free nipple graft, or nipple reconstruction at a later date.
■ The pedicle is de-epithelialized and dissected enough to allow rotation into
the proposed nipple position (TECH FIG 1).
TECH FIG 1 • A 48-year-old patient who was a

candidate for BCT for a T2 tumor over the
superolateral quadrant. A. Preoperative view shows
ptotic breasts. B. The surgical plan consisted of a
vertical scar mammaplasty with a superomedial
pedicle technique. C. A glandular flap extension was
planned to fill the defect in the lateral quadrant after
tumor removal. D. The pedicle was deepithilized. E.
The lumpectomy was done through the lateral
mammoplasty incision. F. The tumor was oriented and
sent to the pathology analysis. G. The result: front
view showed a good breast symmetry. H. The result: a
lateral view showed a good breast contour without any
deformity.
■ If the defect is removed within the reduction specimen, it is then adequately
filled through glandular displacement with the pedicle or remaining glandular
tissue (TECH FIG 2).
■ If it is thought that additional glandular flaps are required to fill the dead
space, a decision is made based on what tissue is available:
■ Single pedicle technique: If the defect can be filled by rotating an extended
portion of the original nipple pedicle, this is often the technique of choice.
This works well for smaller defects in women with smaller or moderate-
sized breasts, or when tissue can be taken with the pedicle from a less
cosmetically sensitive area and rotated to fill a defect.
■ Secondary pedicle technique: This is used in larger defects with large
breasts if the primary pedicle or residual parenchyma is not sufficient. A
second pedicle is designed to fill the dead space separate from the nipple
pedicle.
■ Glandular shaping is performed using absorbable sutures where necessary,
and the skin is then redraped over the mound.
■ Drains are used if the defect is in communication with the axillary
dissection.

TECH FIG 2 • A 64-year-old patient who was
diagnosed with T2 ductal carcinoma of the left breast.
A 3-cm tumor was located in the inferolateral
quadrant. An inverted-T mammaplasty with superior
pedicle was planned in order to perform a
quadrantectomy with immediate partial reconstruction
and contralateral remodeling for symmetrization. A.
Preoperative view shows the mammaplasty markings.
B. The quadrantectomy was planned within the
inverted-T mammaplasty pattern. C,D. The result after

radiotherapy at 1 year postoperatively.
PEARLS AND PITFALLS
Timing
■ Delayed partial breast reconstruction should be considered in
every situation where tumor margins could not be adequately
determined preoperatively.
Marking
■ The contralateral nondiseased side should be designed to be a bit
higher to anticipate the long-term breast sagging.
■ The affected breast (cancer side should be marked to end up with
larger volume comparing to the contralateral breast to anticipate
postoperative irradiation effect).
Tumorectomy
■ Tumor specimen should be clearly oriented for pathology.
■ Posttumorectomy defect should be marked by surgical clips.
Pedicles
■ Avoid large tissue detachment in high-risk patients.
■ Avoid dead space, especially in the lower breast.
Follow-up
■ Close collaboration and communication between plastic surgery,
radiologist, and oncologist is mandatory to discuss breast changes
after breast rearrangement surgery.
POSTOPERATIVE CARE
■ Patients receive VTE prophylaxis during the time of relative immobilization.
■ Patients leave the hospital when the drains are removed, which is in average 1
to 2 days.
■ A sports bra is applied for 4 weeks postoperatively.
■ Adjuvant irradiation of the breast, if indicated, can be started at 6 weeks
postreconstruction. Adjuvant chemotherapy can start 3 weeks postoperatively.
OUTCOMES AND COMPLICATIONS
■ The 5-year survival of partial mastectomy with radiation is not statistically
different when compared to mastectomy alone in patients with stage I or II
breast cancer.2–5
■ The 5-year incidence of in-breast tumor recurrence was higher in the
lumpectomy and radiation patients compared to the quadrantectomy and

radiation patients (8.1% vs 3.1%).2,3
■ In lumpectomy, the goal is tumor excision with clear surgical margins.
■ In quadrantectomy, a wide excision is performed with an additional 1 to 2 cm
or even more of healthy parenchyma around the tumor, including skin and
underlying muscle fascia.
■ The majority of local recurrences occur at the site of initial tumor excision
(57% to 88%) or in the same breast quadrant (22% to 28%).11
■ The presence of DCIS at the surgical margin is associated with the
identification of residual DSIC in 40% to 82% of re-excised specimens and is
correlated with margin widths of 41% at 1 mm, 31% at 1 to 2 mm, and 0%
with 2 mm of clearance.3
■ A recent meta-analysis showed lower positive margins after oncoplastic
surgery (12%) compared to breast conservative surgery without oncoplastic
reconstruction (21%).12
■ Local recurrences were also lower after oncoplastic surgery (4.2% compared
to 7% with BCT alone).12–14
■ Approximately 10% to 30% of patients are dissatisfied with the aesthetic result
after partial mastectomy with radiation.15,16
■ Oncoplastic surgery or partial breast reconstruction allows for wider tumor
resection with aesthetic favorable outcomes and lower positive margins.15–21
■ Incorporating a reduction mammoplasty with partial mastectomy can
potentially be a complex procedure.22,23
■ The aesthetic outcome was considered good or very good in 81% of
patients.12,18–21
■ Recent literature, however, suggests that early complications are similar to
mere reduction mammoplasty. In a review by Spear et al., none of the
complications significantly interfered with healing, radiation, chemotherapy, or
the quality of the result.22,23
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breast carcinoma. CA Cancer J Clin. 1998;48:83-107.
2. Veronesi U, Cascinelli N, Mariani L, et al. Twenty-year follow-up of a
randomized study comparing breast-conserving surgery with radical
mastectomy for early breast cancer. N Engl J Med. 2002;347:1227-1232.
3. Patani N, Khaled Y, Al Reefy MK. Ductal carcinoma in-situ: an update for

clinical practice. Surg Oncol. 2011;20:e23-e31.
4. Fisher B, Anderson S, Bryant J, et al. Twenty-year follow-up of a randomized
trial comparing total mastectomy, lumpectomy, and lumpectomy plus
irradiation for the treatment of invasive breast cancer. N Engl J Med.
2002;347:1233-1241.
5. Huston TL, Simmons RM. Locally recurrent breast cancer after conservative
therapy. Am J Surg. 2005;189:229-235.
6. Losken A, Hamdi M. Partial breast reconstruction: current perspectives. Plast
Reconstr Surg. 2009;124(3):722-736.
7. van Deventer PV, Graewe FR. The blood supply of the breast revisited. Plast
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Plast Surg. 2007;34(1):51-62.
9. Vicini FA, Recht A. Age at diagnosis and outcome for women with ductal
carcinoma-in-situ of the breast: a critical review of the literature. J Clin Oncol.
2002;20(11):2736-2744.
10. Dillon MF, Hill AD, Quinn CM, et al. A pathologic assessment of adequate
margin status in breast-conserving therapy. Ann Surg Oncol. 2006;13(3):333-
339.
11. Osborne MP, Borgen PI, et al. Salvage mastectomy for local and regional
recurrence after breast conserving operation and radiation therapy. Surg
Gynecol Obstet. 1992;174:189-194.
12. Losken A, Dugal C, Styblo T, Carlson G. A meta-analysis comparing breast
conservation therapy alone to the oncoplastic technique. Ann Plast Surg.
2014;72(2):145-149.
13. Fehlauer F, Tribius S, et al. Long-term radiation sequelae after breast-
conserving therapy in women with early-stage breast cancer: an observational
study using the LENT-SOMA scoring system. Int J Radiat Oncol Biol Phys.
2003;55(3):651-658.
14. Eaton B, Losken A, Okwan-Duodu D, et al. Local recurrence patterns in
breast cancer patients treated with oncoplastic reduction mammoplasty and
radiotherapy. Ann Surg Oncol. 2014;21:93-99.
15. Berrino P, Campora E, Santi P. Postquadrantectomy breast deformities;
classification and techniques of surgical correction. Plast Reconstr Surg.
1987;79(4):567-572.
16. Clough K, Kroll S, Audretsch W. An approach to the repair of partial
mastectomy defects. Plast Reconstr Surg. 1999;104(2):409-420.

17. Mcculley SJ, Macmillan RD. Therapeutic mammaplasty—analysis of 50
consecutive cases. Br J Plast Surg. 2005;58(7):902-907.
18. Munhoz A, Montang E, et al. Critical analysis of reduction mammaplasty
techniques in combination with conservation breast surgery for early breast
cancer treatment. Plast Reconstr Surg. 2006;117(4):1091-1103.
19. Fitoussi AD, Berry MG, Fama F, et al. Oncoplastic breast surgery for cancer:
analysis of 540 consecutive cases (outcomes article). Plast Reconstr Surg.
2010;125:454-462.
20. Song HM, Styblo TM, Carlson GW, Losken A, The use of oncoplastic
reduction techniques to reconstruct partial mastectomy defects in women with
ductal carcinoma in situ. Breast J. 2010;16(2):141-146.
21. Kronowitz SJ, Kuerer HM, Buchholz TA, et al. A management algorithm and
practical oncoplastic surgical techniques for repairing partial mastectomy
defects. Plast Reconstr Surg. 2008;122(6):1631-1647.
22. Spear LS, Pelletiere CV, et al. Experience with reduction mammaplasty
combined with breast conservation therapy in the treatment of breast cancer.
Plast Reconstr Surg. 2003;111(3):1102-1109.
23. Losken A, Schaefer TG, Newell M, Styblo TM, The impact of partial breast
reconstruction using reduction techniques on postoperative cancer
surveillance. Plast Reconstr Surg. 2009;124(1):9-17.

12
CHAPTER
Local Flaps in Partial Breast
Reconstruction
Moustapha Hamdi and Fadi Bakal
DEFINITION
■ Partial breast reconstruction is an area of evolving interest with improving
surgical techniques; it is indicated in breast conservation therapy (BCT), which
is on its own a popular treatment option for women with breast cancer.1,2 The
rate of its use has increased from 40% in 1991 to 60% in 2002 when compared
with mastectomy, and that trend continues to rise.1
■ Oncoplastic surgery within multidisciplinary approach is standard in BCT.
■ The oncoplastic surgical approach allowed surgeons to tailor the techniques to
prevent deformities, minimize involved margins, and reduce the potential for
local recurrence.
■ Partial breast reconstruction with pedicled flap is alternative to mastectomy in
selected patients as such in patients with a high tumor/breast size ratio.
■ Every case requiring partial breast reconstruction should be addressed within a
multidisciplinary approach.
■ Pedicled perforator flaps provide adequate partial breast reconstruction with
minimal donor-site morbidity.
ANATOMY
■ The latissimus dorsi (LD) flap has a constant anatomy.3–5 The blood supply of
the latissimus dorsi comes from a terminal branch of the subscapular artery.
The subscapular artery runs about 5 cm before dividing into the scapular
circumflex and thoracodorsal arteries.
■ The thoracodorsal artery gives off one or two branches to the serratus anterior
muscle and one branch to the skin (FIG 1).
■ Perforating vessels from the intercostal and lumbar arteries supply the muscle

and overlying skin.11,12
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Breast and plastic surgeons must have a thorough understanding of breast
anatomy and physiology and the qualities of an aesthetically pleasing breast
shape.
■ Surgeons performing the oncoplastic approach should consider the aesthetic
subunits when planning cosmetic quadrantectomies, resections, and
reconstructions.3
■ Also, knowledge of the anatomical landmarks, breast proportions, and shape is
essential to achieve a pleasing outcome.
■ Preoperative evaluation of the patient and her breasts must be standardized and
detailed.
■ The examination must include the following:
■ Evaluation of breast skin, elasticity, thickness, scars, and any defining marks
such as tattoos, stretch marks, contour irregularities, and previous breast
surgery should be taken into account when planning BCT.

FIG 1 • The TD vessels most commonly divide into five
branches, but two are dominant muscular branches: the
transverse branch, and the lateral or vertical branch.
Both branches give musculocutaneous perforator to the
skin. A direct branch can also be found, which courses

anteriorly around the LD muscle toward the skin.
■ Palpation for masses or abnormalities in the breast parenchyma, nipple
inspection, and detailed documentation of breast sensation are integral.
■ Breast shape, grade of ptosis, and size are determinants of success in surgical
treatment.
■ The base and width of the breast, the width of the NAC, the height of the
nipple, and the distance from the sternal notch, midline, and inframammary
crease must be recorded in detail.4
■ Any natural breast asymmetry should be pointed out to the patient before
surgery.
■ Different body types, skin laxity, and fat distribution are important factors in
the decision-making process.
SURGICAL MANAGEMENT
■ Depending on the location and the size of the breast defect, different flaps can
be used for partial mastectomy reconstruction based on the thoracodorsal-
serratus, intercostal, or superior epigastic vessels.2–18
■ A small lateral defect can easily be closed with a skin rotation flap or lateral
thoracic axial skin flap. However, most of these flaps become unavailable
when axillary lymph node dissection is performed.
■ Lateral breast defects are usually reconstructed using a flap based on the
thoracodorsal system. The LD musculocutaneous flap is the most commonly
used.
■ Currently, perforator flaps are more often used to spare muscle function.
■ The pedicled perforator flaps mostly used by us for partial breast
reconstruction, classified according to the basic nutrient arteries and
recommended by the “Gent” Consensus update in 2002,6 are
• Thoracodorsal artery perforator (TDAP) flap
• Serratus anterior artery perforator (SAAP) flap
• Intercostal artery perforator (ICAP) flap
• Superior epigastric artery perforator (SEAP)
■ A similar skin paddle to the classical LD musculocutaneous flap can be raised
on perforators either from the thoracodorsal or intercostal vessels.
Types of Flaps

TDAP Flap
■ The TDAP flap is based on perforators originating from the descending
(vertical) or horizontal branches of the thoracodorsal vessels (see FIG 1) (FIG
2). Anatomic studies on cadavers have reported the presence of 2 to 3
musculocutaneous perforators from the vertical branch.7–9
■ The proximal perforator enters the subcutaneous plane obliquely 8 to 10 cm
distal to the posterior axillary fold and 2 to 3 cm posterior to the anterior border
of the muscle. The second perforator is found 2 to 4 cm distally to the first one.
■ Occasionally, a direct cutaneous perforator arising from the thoracodorsal
vessel passes around the anterior border of the muscle, making flap harvesting
easier (see FIG 1).
■ There may not be always a single reliable perforator for the TDAP flap, due to
anatomical variations. In this case, the surgeon must be aware and prepared to
modify the flap dissection intraoperatively, as a muscle-sparing TDAP flap.

(Trang không có chữ)

FIG 2 • Illustrations show: TDAP flap with
musculocutaneous perforators (A). B. TDAP flap with
perforator still attached to 4 × 2 cm muscle segment
(muscle-sparing TDAP type I). C. TDAP flap raised on
the descending branches and its perforators (muscle-
sparing TDAP flap type II). Reprinted from Hamdi H, et.
al. Pedicled perforator flaps in breast reconstruction: a
new concept. Br J Plast Surg. 2004;57(6):531-539, with
permission from Elsevier.
■ The TDAP flaps are classified as follows9:
■ TDAP flap, when no muscle component is included in the flap.
■ TDAP-MS-I, where a small segment of muscle (4 × 2 cm) is kept attached to
the back of the perforator vessels. The muscle segment protects the perforator
from excessive tension and provides more freedom in flap positioning (FIG
2B).
■ TDAP-MS-II is indicated when multiple but small perforators are
encountered. A larger segment, up to 5 cm wide along the anterior border of
the LD muscle together with the descending branch of the thoracodorsal
vessels, is then included within the flap in order to ensure maximal blood
supply to the skin paddle (FIG 2C).
ICAP Flap
■ The ICAP flap is based on perforators, arising from the intercostal vessels.
■ The intercostal vessels form an arcade between the aorta and the internal
mammary vessels and divide in 4 segments: vertebral, intercostal,
intermuscular, and rectus segments (FIG 3A).11,12
■ The ICAP flaps are classified as follows (FIG 3B):
■ The dorsal intercostal artery perforator (DICAP) flap. The flap is based on
perforators originating from the vertebral segment of the intercostal vessels.
■ The lateral intercostal artery perforator (LICAP) flap, based on perforators
arising from the intercostal segment.
■ The anterior intercostal artery perforator (AICAP) flap. The nutrient
perforators of this flap arise from the muscular or rectal segment.
■ The intercostal segment, which is the longest (12 cm), is very important

because it gives 5 to 7 musculocutaneous perforators.11
■ The LICAP, commonly used in breast surgery, originates from the costal
segment of the intercostal vessels. The largest perforator is most frequently
found in the 6th intercostal space, 0.8 to 3.5 cm from the anterior border of the
LD muscle.12 The pedicle has adequate length, allowing the rotation of the flap
up to 180 degrees without tension and with no need to extend the dissection
into the costal groove. An intercostal nerve may be included in the harvesting
as an ICAP-sensate flap.
■ For small defects, the LICAP is designed on the lateral aspect of the thorax.
For moderate-large defects, the distal limit of the skin pad can reach the
posterior thoracic region, planned in a fashion similar to the skin pad of an LD
flap.12
■ The AICAP flap is outlined over the upper abdomen, so that the final scar will
be hidden under the brassiere strap. The donor site can be closed primarily if it
is up to 6 cm wide (preoperative pinch test to be assured) or else in a reversed
abdominoplasty fashion. The advantage of AICAP and SEAP flaps (see below)
is that the patient is prepped in a supine position throughout the whole
procedure. These flaps are mostly known for defects in the inferomedial
quadrant of the breast.
SAAP Flap
■ The SAAP flap is based on a connection between the thoracodorsal artery
branch to the serratus anterior muscle and the intercostal perforators. It is not a
constant perforator; 21% of cases there is a connection between the serratus
anterior branch & the intercostal perforators.12
■ When an appropriately sized perforator is identified in front of the anterior
border of the LD, it can be followed back to the nutrient artery, which in this
case is the serratus anterior branch, by dissecting the pedicle within the fascia
and the fibers of the aforementioned muscle.

FIG 3 • The anatomy of the intercostal perforators. A.
Four segments to the intercostal vessels: the vertebral,
intercostal, intermuscular, and rectus segment. B.
Intercostal perforator flap classification: PICAP,
posterior intercostal artery perforator; LICAP, lateral
intercostal artery perforator; AICAP, anterior intercostal
artery perforator.
FIG 4 • Algorithm for using flaps for partial breast
reconstruction. TDAP, thoracodorsal artery perforator;
MS-LD, muscle-sparing latissimus dorsi; LICAP, lateral
intercostal artery perforator; AICAP, anterior intercostal
artery perforator.

SEAP Flap
■ The SEAP flaps are based on perforators arising from either the superficial or
the deep branch of the superior epigastric artery, and the perforator flaps are
named SSEAP and DSEAP, respectively.15
■ The SEAP flap has similar indications as the AICAP flap15; however, it has a
longer pedicle that allows it to reach the defect with less tension.
■ Pedicled SEAP flaps should be used only in selected cases, because it excludes
the secondary use of abdominal tissue for autologous breast reconstruction
(DIEAP, SIEAP, TRAM flaps) if completion mastectomy is later on indicated
(FIG 4).
Preoperative Planning
■ Perforator mapping with correct flap design is the keystone in these
oncoplastic techniques.3
■ To localize the thoracodorsal perforators, a unidirectional Doppler (8 Hz)
ultrasonography examination is performed for perforator mapping in the
planned skin flap area. This device, although quite handy and less costly, has
the disadvantage of generating false-negative and false-positive signals and
provides less detailed anatomic vessel information.
■ This is due to the misleading background signal from the thoracodorsal
vessels, which can be confusing and difficult to distinguish from the
perforator signal. To avoid this, the patient is positioned, as in surgery, at a
lateral position with 90 degrees of shoulder abduction and 90 degrees of
elbow flexion.
■ Also, multidetector (MD) row CT scan can be used with accuracy to localize
the perforator.3
■ The patient is marked before surgery. The breast size, tumor size, and location
as well as the final defect size are estimated.
■ The incisions for the tumor resection are chosen from an oncological aspect
but in the most aesthetically pleasing fashion.
■ The TDAP (thoracodorsal artery perforator) flap planned for the partial breast
reconstruction is designed to include the located perforators (one or more) at
the proximal part if feasible, in the directions of relaxed skin lines, the
brassiere line, or even horizontally according to the patient’s preference.
■ Skin laxity and fat excess in the lateral thorax and back area are estimated by
the pinch test. The size of the flap is determined by the need for defect

coverage and is an average of 20 × 8 cm.
■ The skin drawings are applied at first with the patient in an upright position,
and the anterior border of the LD muscle is palpated and marked also.
■ Then the patient is placed in a lying position on her side, with the
reconstruction side facing upward, as in surgery, for the perforator mapping
and the flap design in the lateral thorax. The skin island is always extended
over the anterior border of the LD to include the premuscular perforators if
present.
■ If the defect is more medially, the flap is designed more distally, further in the
back. The same design is applied for the LICAP; however, the flap is placed
more anteriorly, toward the breast. The AICAP or SEAP flaps are usually
designed under the inframammary fold along the rib.
Positioning
■ The patient is prepped and positioned in the supine position for the tumor
excision. After the lumpectomy/quadrantectomy at clear margins, clips are
placed in the wound bed and left there, in order to indicate the area for future
radiation therapy.
■ If the plan is to proceed with TDAP, LICAP, or SAAP flap, the patient is
positioned and prepped again in the lateral position as in the typical LD
musculocutaneous flap dissection.
■ For AICAP/SEAP flap, the patient remains in the original position.
T E C H N I Q U E S
■ Basics of Flap Harvesting
■ The flap harvesting starts with skin incisions.
■ A posterior approach is usually used in TDAP flap. The surgeon continues
dissection down to the LD suprafascial plane while beveling in favor of the
flap in order to gain as much of extra tissue as possible. Harvesting proceeds
from the back to the axillary region. Further harvesting under loop
magnification continues meticulously, until the perforator vessel is
visualized. If the perforator is visibly pulsatile and adequate in caliber
(greater than 0.5 mm for the whole bundle), the dissection continues along

the perforator course up to the nutrient thoracodorsal pedicle. If a large
pedicle length is required, the TD vessels can be dissected up to their
subscapular vessel origin and included in the flap.
■ If the perforators have an intramuscular course, dissection is performed in
the direction of the muscle fibers, and any nerves that come across are
carefully preserved. Within the muscle, all the perforator side branches are
either ligated or coagulated. If two perforators are found along the same
course, they can both be included within the flap, without sacrificing any
muscle fibers.
■ In case the perforators are inadequate in size, the flap harvesting is continued
as muscle-sparing LD, preserving a small piece of muscle attached to the
posterior wall of the perforators, sacrificing only minimum fibers and, most
important, salvaging the muscle innervation. This modification is also useful
when the flap is intended for the medial breast area, because it protects the
perforators from presumed tension.
■ The flap harvesting carries on, with the skin incisions continued proximal to
the axilla and lateral to the LD, and the dissection proceeds anteriorly, until
the flap is freed from the donor-site tissues and left connected only to the
vascular pedicle. The pedicle is carefully passed under a subcutaneous tunnel
in the axilla–lateral thoracic area that has been previously prepared to the
recipient breast area, avoiding any avulsion of the pedicle.
■ The donor site is sutured in three anatomical layers with a drain in place, and
the patient is returned again to the supine position.
■ Before final closure of the defect, the flap can be partially or totally de-
epithelialized (depending on the native skin reservations of the recipient site)
and folded accordingly, to give extra projection to the reconstructed breast
mount but always in a tension-free manner.
■ In LICAP flap dissection, an anterior approach is performed from the breast
side toward the anterior-free border of LD muscle. Perforator dissection is
done within the serratus muscle until its origin from the costal grove. Further
dissection is usually not needed.
■ TDAP Flap
Flap Design
■ The patient is positioned in lateral decubitus with the shoulder in 90 degrees

of abduction and the elbow in 90 degrees of flexion.
■ In this position, the anterior border of the LD muscle is palpated through the
skin and marked.
■ A 5- to 8-MHz Doppler probe allows accurate location of the perforators in
the posterior axillary line, 8 cm below the axillary crease and within 5 cm
from the anterior border of the LD muscle.
■ More recently, CT scanning has been successfully used to preoperatively
detect the best perforator and will certainly become a great tool for
thoracodorsal perforator mapping in the future.
■ Subsequently, the skin island is designed to include the audible perforators
and can be oriented in different directions depending on the reconstructive
needs and anticipated orientation of the scar (TECH FIG 1).
■ The flap paddle is better oriented to fit into the skin lines and parallel to the
rib direction, which provides the best inclusion of the angiosome territory.
Flap Harvesting
■ The incision starts at the inferior anterior border of the flap, which allows for
identification of the anterior border of the LD muscle and eventual
repositioning of the anterior border of the flap.
■ The dissection proceeds from distal to proximal and from medial to lateral at
the level just above the LD muscle fascia until a suitable perforator is
identified (TECH FIG 2).
■ A perforator originating from the vertical branch is preferred because
dissection is easier due to fewer connections with other vessels and a
shorter intramuscular course.
■ If two perforators lie along the same line, both can be incorporated within
the flap without cutting additional muscle.
■ A perforator should be visibly pulsatile and have a diameter suitable for
microvascular anastomosis.
■ Once a suitable perforator is identified, intramuscular dissection is rather
straightforward.
■ The muscle is split longitudinally and the perforator dissected cranially.
Flap Placement and Completion
■ The next step is to free the anterior border of the LD muscle and look
underneath.
■ Total pedicle length depends on the location of the perforator on the muscle,

as the length of the intramuscular course adds up with the length of the
oblique course on top of the muscle and the length of the thoracodorsal
pedicle itself (TECH FIG 3A).
TECH FIG 1 • Surgical technique of TDAP flap
harvesting. Flap design. The perforator is located

using unidirectional Doppler and is usually found 6 to
8 cm from the posterior axillary fold. The flap is
designed within the brassiere region (dotted line) and
crosses the anterior border of the LD muscle (dashed
line).
TECH FIG 2 • The flap is dissected from the LD
muscle until the perforators are encountered.
■ This usually yields a pedicle length of 7 to 12 cm.
■ The motor nerves to the LD run on a deeper plane, which allows for
complete freeing of the pedicle without injuring the nerves.
■ Once the complete intramuscular trajectory has been dissected, harvesting
the thoracodorsal pedicle proceeds.
■ The skin paddle is carefully passed through the split muscle and
subcutaneously into the defect through the axilla (TECH FIG 3B).
■ At the end, closed suction drains are placed and donor site is closed
primarily in three layers.
■ The technique is illustrated in a clinical case (TECH FIG 4).

TECH FIG 3 • A. The LD muscle is split and the
perforator dissected back to the main pedicle. The TD
nerve is preserved. B. The flap is pulled through the
axillary incision and into the breast defect.

TECH FIG 4 • A patient undergoing a quadrantectomy
for a tumor of the superolateral quadrant of the right
breast. The quadrantectomy specimen weighed 195 g.
Reconstruction is with a completely de-epithelialized
TDAP flap based on one perforator. A–C.
Preoperative views. D. The flap design with the
marked perforators, located by Doppler. E. The
dissection of the perforator through the split LD
muscle. The TD nerve is preserved (arrow). F,G. The
TDAP flap is passed through the split LD muscle and
then through the axilla. H. The LD muscle is left intact.

I–K. Postoperative views. L. Donor site.
PEARLS AND PITFALLS
Indications
■ Any immediate partial reconstruction should be delayed if the
surgeon is uncertain about the margins or tumor extension.
■ A delayed reconstruction can still be performed within a few days
after the definitive margin status is known.
Flap
markings
■ Using Doppler or CT scan imaging is essential to locate the
perforators.
■ Skin paddle should be extended anteriorly toward the
inframammary fold.
Perforator
flap
harvesting
■ Perforators must be pulsating and have a good diameter (more
than 0.5 mm) if a flap is to be harvested.
Outcome
■ Seroma incidence at the donor site after harvesting perforator flap
is reduced to 0%.
■ Long-term aesthetic result after pedicled flaps is very satisfactory
despite the irradiation.
POSTOPERATIVE CARE
■ Postoperatively, protocol perforator flap monitoring is implemented.
■ Patients are administered VTE prophylaxis during the time of relative
immobilization.
■ Patients leave the hospital when the drains are removed, which is in average 3
to 5 days.
■ The arm is hold in 45-degree abduction. Arm stretching is restricted for a
week. Physiotherapy can be started afterward. Most of patients required
between 9 and 14 sessions of shoulder physiotherapy.
■ Patients treated for BCT with pedicled perforator flaps have a short
rehabilitation course.18
■ Adjuvant irradiation of the breast, if indicated, can be started at 6-week
postreconstruction. Adjuvant chemotherapy can start 3 weeks postoperatively.

OUTCOME AND COMPLICATIONS
■ Donor-site morbidity after harvesting locoregional pedicle perforator flaps for
partial breast reconstruction is reduced to a minimum. Only a very limited rate
of seroma formation has been observed and treated mainly conservatively.
Wound dehiscence of the donor site usually when closed under tension is
another infrequent event managed with local treatment.
■ Data from a recent study show a seroma rate of 5.5% in MS-TDAP II flaps,
compared to no seroma formation in perforator flaps. Other postoperative
complications observed were wound dehiscence (4%), infection (2%), and
hematoma (2%).9
■ Partial or total flap losses are rare incidents and one must exclude
coagulopathies or other medical diseases and conditions.
■ Palpable (partial) fat necrosis of the flap has been observed and can be treated,
if necessary, by excision and primary closure or reconstruction by a local flap.
Or if necrosis is too extensive, a mastectomy with total breast reconstruction
can be indicated.9
■ Unpleasing scars, flap contractures, and volume loss are less rare sequelae and
may need secondary surgical treatment.
■ Flap reconstruction of breast defect may give a “plugged-in” appearance,
which seems to slightly improve after radiation therapy. It is hard to predict the
long-term outcomes of partial breast reconstruction with pedicled perforator
flaps due to the indefinite impact of irradiation to the final result.
■ Some patients who undergo partial breast reconstruction with a TDAP flap
document an initial decrease in forward arm elevation and passive abduction,
which recovers over time.18
Prognosis
■ Many concerns have been raised about oncologic safety of oncoplastic
surgery.
■ A recent meta-analysis showed that oncoplastic surgery is an oncological safe
procedure, with even lesser recurrence rates (4%) compared to breast
conservative surgery (7%) alone.19
■ After oncoplastic reduction mammoplasty, resection margins are more often
negative, and if recurrences occur, they most often occur in the preoperative
quadrant of the tumor and not the location after displacement techniques.20
■ As stated earlier, if DCIS is present, oncoplastic techniques should be used

cautiously.
■ Local recurrence rates reported in the literature for oncoplastic surgery vary
from 0% to 7% of the patients.19–21
Oncological Follow-Up
■ Oncological follow-up after oncoplastic procedures remains important.
■ Given the rearrangement of parenchymal tissues, scar tissue or fat necrosis is
not uncommon and might be suspicious on several radiological imaging
modalities.
■ Biopsy with fine needle aspiration, core biopsy, or excisional biopsy can be
necessary to rule out tumor recurrence (up to 25%).21
■ The addition of breast remodeling procedures does not seem to affect
mammographic sensitivity, and qualitative changes are similar to those found
following BCT alone.21
REFERENCES
1. Losken A, Hamdi M. Partial breast reconstruction: current perspectives. Plast
Reconstr Surg. 2009;124(3):722-736.
2. Honart JF, Reguesse AS, Struk S, et al. Indications and controversies in partial
mastectomy defect reconstruction. Clin Plast Surg. 2018;45(1):33-45.
3. Hamdi M, Van Landuyt K, Van Hedent E, Duyck P. Advances in autogenous
breast reconstruction: the role of preoperative perforator mapping. Ann Plast
Surg. 2007;58(1):18-26.
4. Bostwick J III, Nahai F, Wallace JG, Vasconez LO. Sixty latissimus dorsi
flaps. Plast Reconstr Surg. 1979;63(1):31-41.
5. Bartlett SP, May JW Jr, Yaremchuk MJ. The latissimus dorsi muscle: a fresh
cadaver study of the primary neurovascular pedicle. Plast Reconstr Surg.
1981;67(5):631-636.
6. Blondeel PN, Van Landuyt K, Hamdi M, Monstrey SJ. Perforator flap
terminology: update 2002. Clin Plast Surg. 2003;30(3):343-346.
7. Angrigiani C, Grilli D, Siebert J. Latissimus dorsi musculocutaneous flap
without muscle. Plast Reconstr Surg. 1995;96(7):1608-1614.
8. Spinelli HM, Fink JK, Muzaffar A. The latissimus dorsi perforator-based
fasciocutaneous flap. Ann Plast Surg. 1996;37:500-506.
9. Hamdi M, Van Landuyt K, Hijjawi JB, et al. Surgical technique in pedicled
thoracodorsal artery perforator flaps: a clinical experience with 99 patients.
Plast Reconstr Surg. 2008;121(5):1632-1641.

10. Hamdi M, Van Landuyt K, Monstrey S, Blondeel P. Pedicled perforator flaps
in breast reconstruction: a new concept. Br J Plast Surg. 2004;57(6):531-539.
11. Hamdi M, Van Landuyt K, de Frene B, et al. The versatility of the inter-costal
artery perforator (ICAP) flaps. J Plast Reconstr Aesthet Surg. 2006;59(6):644-
652.
12. Hamdi M, Spano A, Van Landuyt K, et al. The lateral intercostal artery
perforators: anatomical study and clinical application in breast surgery. Plast
Reconstr Surg. 2008;121(2):389-396.
13. Losken A, Hamdi M. Partial breast reconstruction: current perspectives. Plast
Reconstr Surg. 2009;124(3):722-736.
14. Munhoz AM, Montag E, Arruda E, et al. Immediate conservative breast
surgery reconstruction with perforator flaps: new challenges in the era of
partial mastectomy reconstruction? Breast. 2011;20(3):233-240.
15. Hamdi M, Van Landuyt K, Ulens S, et al. Clinical applications of the superior
epigastric artery perforator (SEAP) flap: anatomical studies and preoperative
perforator mapping with multidetector CT. J Plast Reconstr Aesthet Surg.
2009;62(9):1127-1134.
16. Hamdi M, Wolfli J, Van Landuyt K. Partial mastectomy reconstruction. Clin
Plast Surg. 2007;34(1):51-62.
17. Hamdi M. Oncoplastic and reconstructive surgery of the breast. Breast.
2013;22(suppl 2):S100-S105.
18. Hamdi M, Decorte T, Demuynck M, et al. Shoulder function after harvesting
a thoracodorsal artery perforator flap. Plast Reconstr Surg. 2008;122(4):1111-
1117.
19. Losken A, Dugal C, Styblo T, Carlson G. A meta-analysis comparing breast
conservation therapy alone to the oncoplastic technique. Ann Plast Surg.
2014;72(2):145-149.
20. Eaton B, Losken A, Okwan-Duodu D, et al. Local recurrence patterns in
breast cancer patients treated with oncoplastic reduction mammoplasty and
radiotherapy. Ann Surg Oncol. 2014;21:93-99.
21. Losken A, Schaefer TG, Newell M, Styblo TM. The impact of partial breast
reconstruction using reduction techniques on postoperative cancer
surveillance. Plast Reconstr Surg. 2009;124(1):9-17.

13
CHAPTER
Section V: Prosthetic
Breast Reconstruction
Delayed Tissue Expansion
Hana Farhang Khoee, Edward C. Ray, and Joseph J. Disa
DEFINITION
■ Delayed breast tissue expansion occurs after mastectomy skin has healed and
after all adjuvant therapy has been completed.
ANATOMY
■ Diagram of the chest wall (sagittal) showing tissue planes of the breast (FIG
1). From superficial to deep, layers include the skin, subcutaneous tissue,
breast parenchyma, and pectoralis major muscle.
■ The dissection involves creating a pocket deep to the pectoralis major muscle
but above the pectoralis minor muscle.
PATIENT HISTORY AND PHYSICAL FINDINGS
History Taking
■ Cancer history
■ Previous adjuvant therapy, including radiation and chemotherapy
■ Define the goals and expectations of the patient
■ Psychosocial
■ Overall fitness for surgery
Physical Exam
■ Breast dimension: base width, height, projection, position, and symmetry of
inframammary fold (IMF)
■ Skin integrity

■ Changes in skin due to prior irradiation
■ Scars
■ Contralateral breast
■ Presence of a functioning ipsilateral latissimus dorsi muscle
IMAGING
■ Imaging usually not necessary
■ May consider ultrasound to assess thickness of skin flap
SURGICAL MANAGEMENT
■ Delayed tissue expansion
Preoperative Planning
■ Tissue expander (TE) selection
■ Size is determined by breast width of patient.
■ Most TE are anatomical and textured with integrated valves.
■ Assessment of skin integrity and suitability for expansion
■ Irradiated skin or poor skin quality may suggest the need for latissimus dorsi
myocutaneous flap.
■ Markings
■ Should be done with patient in standing position prior to the operation
■ The most important is to identify the IMF.
• Achieve symmetry with contralateral breast or, if bilateral, create a natural-
appearing fold that is not too high.
■ Mark breast footprint.
• Superior, medial (2 cm from midline), IMF, and anterior axillary fold (AAF)
Positioning
■ Supine with arms either extended on arm boards (preferred) or tucked
■ Ensure body and shoulders are centered on the table.
Approach
■ One standard approach for delayed tissue expanders

FIG 1 • Relevant anatomy of the chest wall: Sagittal
cross section: Note skin, subcutaneous tissue, breast
parenchyma, pectoralis major, and minor muscle on
diagram.
T E C H N I Q U E S

Video p4-c013
■ Creation of Submuscular Tissue Expander Pocket
(TECH FIG 1)
■ Excise mastectomy scar.
■ Elevate mastectomy skin flaps.
■ Expose pectoralis major muscle enough to allow entry of TE.
■ Enter the submuscular layer either at the inferior or lateral border of the
pectoralis major muscle or split the muscle in the direction of its fibers.
■ Avoid elevation of pectoralis minor muscle.
■ If needed, dissection of the pectoralis major muscle can be extended either
to the subcutaneous plane inferiorly and laterally or into the
submuscular/subfascial plane (ie, elevating serratus anterior muscle).
■ The decision is based on the quality of the mastectomy skin flaps.
00:00 / 00:00

TECH FIG 1 • A. Creating the submuscular pocket
using a lighted retractor. B. Showing the extent of
submuscular pocket dissection. Solid line indicates the
extent of dissection.
■ Release of Capsule Scar
■ Must release any scar tissue that will restrict expansion of the mastectomy
flaps
■ Capsulotomy performed as needed (if there was a prior implant)
■ Typically, limited to a superior and medial capsulotomy
■ Care taken to avoid allowing the TE to migrate too far laterally
■ When lowering of IMF or greater lower pole expansion is desired, an
inferior capsulotomy is performed.
■ Capsulectomy as needed
■ Can facilitate better expansion
■ Insertion of Tissue Expander
■ Expander is placed such that the zone of maximum expansion is located in
the lower pole of the reconstructed breast.
■ May insert some fluid in TE, depending on the amount of skin laxity.
■ Ensure proper orientation of the TE (markings on TE can be helpful) (TECH
FIG 2).
■ When coverage of the expander by the muscle is insufficient, an engineered
tissue substitute may be used.
■ The most common is acellular dermal matrix (ADM) such as AlloDerm.
(LifeCell, Bridgewater, NJ).
■ These may be fenestrated to minimize the risk of undrained submuscular
seromas and to optimize incorporation into the overlying subcutaneous
tissue.

TECH FIG 2 • A,B. Show marking and filling of TE.
■ Closure of Wound
■ Layered closure of the muscle and skin
■ Use of drains is optional, depending on surgeon preference, expected fluid
accumulation, or use of ADM.
PEARLS AND PITFALLS
Tissue expander
selection
■ Based on breast width and volume
Tissue expander
placement
■ Ideally, should establish IMF in the preoperative setting, with
patient in a standing position
Skin quality
■ Thin or radiation-damaged skin may require latissimus dorsi
myocutaneous flap to facilitate expansion.
POSTOPERATIVE CARE
■ If used, drains are kept in place until output drops below a given threshold.
■ Drains may be subcutaneous, submuscular, or both.
■ Postoperative antibiotics are used according to surgeon preference and patient
risk factors.
■ The patient is placed in a loosely fit surgical brassiere.
■ The use of an underwire brassiere is avoided for several weeks after surgery.