Plastic and Reconstructive Surgery Board Review Pearls of Wisdom 3th

CHAPTER 20 Breast Cancer
173
Arpino G, Laucirica R, Elledge RM. Premalignant and in situ breast disease: biology and clinical implications. Ann Intern Med.
2005;143:446–457.
Axelsson CK, Moundsen H , Zedeler K. Axillary dissection o level I and II lymph nodes is important in breast cancer classi cation.
T e Danish Breast Cancer Cooperative Group (DBCG). Eur J Cancer. 1992;28A:1415–1418.
Bellon JR, Come SE, Gelman RS, et al. Sequencing o chemotherapy and radiation therapy in early-stage breast cancer: updated results
o a prospective randomized trial. J Clin Oncol. 2005;23:1934–1940.
Carney PA, Miglioretti DL, Yankaskas BC, et al. Individual and combined e ects o age, breast density, and hormone replacement
therapy use on the accuracy o screening mammography. Ann Intern Med. 2003;138:168–175.
Children’s Oncology Group Long-term Follow-up Guidelines. Version 3, October 2008.
Costantino JP, Gail MH, Pee D, et al. Validation studies or models o projecting the risk o invasive and total breast cancer incidence.
J Natl Cancer Inst. 1999;91:1541–1548.
Davides C, Pan H, Godwin J, et al. Long-term e ects o continuing adjuvant tamoxi en to 10 years versus stopping at 5 years a ter
diagnosis o oestrogen receptor-positive breast cancer: A LAS, a randomized trial. Lancet. 2013;381:805–816.
Donker M, Litiere S, Werutsky G, et al. Breast-conserving treatment with or without radiotherapy in ductal carcinoma in situ: 15-year
recurrence rates and outcome a ter a recurrence, rom the EOR C 10853 randomized phase III trial. J Clin Oncol. 2013;31:4054–
4059.
Early Breast Cancer rialists’ Collaborative Group. Polychemotherapy or early breast cancer: an overview o the randomised trials.
Lancet. 1998;352:930–942.
Early Breast Cancer rialists’ Collaborative Group. amoxi en or early breast cancer: an overview o randomised trials. Lancet.
1998;351:1451–1467.
Early Breast Cancer rialists’ Collaborative Group. E ects o chemotherapy and hormonal therapy or early breast cancer on recurrence
and 15-year survival: an overview o the randomised trials. Lancet. 2005;365:1687–1717.
Edge SB, Byrd DR, Compton CC, et al; American Joint Committee on Cancer. AJCC Cancer Staging Manual. 7th ed. New York, NY:
Springer; 2010.
Fisher B, Costantino JP, Wickerham DL, et al. amoxi en or prevention o breast cancer: report o the National Surgical Adjuvant
Breast and Bowel Project P-1 Study. J Natl Cancer Inst. 1998;90:1371–1388.
Fortunato L, Loreti A, Andrich R, et al. When mastectomy is needed: is the nipple-sparing procedure a new standard with very ew
contraindications? J Surg Oncol. 2013;108:207–212.
Gail MH, Brinton LA, Byar DP et al. Projecting individualized probabilities o developing breast cancer or white emales who are being
examined annually. J Natl Cancer Inst. 1989;81:1879–1886.
Gail MH, Costantino JP. Validating and improving models or projecting the absolute risk o breast cancer. J Natl Cancer Inst.
2001;93:334–335.
Haagensen CD, Bodian C, Haagensen DE Jr. Breast carcinoma Risk and Detection. Philadelphia, PA: WB Saunders;1981.
Hellman S. Stopping metastases at their source. N Engl J Med. 1997;337:996–997.
Francis PA, Regan MM, Fleming GF, et al. Adjuvant ovarian suppression in premenopausal breast cancer. N Engl J Med. 2015;372:
436–446.
Iglehart JD, Kaelin CM. Diseases o the breast. Sabiston Textbook of Surgery. 17th ed. Philadelphia, PA: Elsevier Saunders.
Kau mann M, Honat W, Hil rich J, et al. Improved overall survival in postmenopausal women with early breast cancer a ter anastrozole
initiated a ter treatment with tamoxi en compared with continued tamoxi en: the ARNO 95 study. J Clin Oncol. 2007;25:
2664–2670.
Kiricuta CI, ausch J. A mathematical model o axillary lymph node involvement based on 1446 complete axillary dissections in
patients with breast carcinoma. Cancer. 1992;69:2496–2501.
Korde LA, Zujewski JA, Kamin L, et al. Multidisciplinary meeting on male breast cancer: summary and research recommendations.
J Clin Oncol. 2010;28(12):2114–2122.
Lakhani SR. In-situ lobular neoplasia: time or an awakening. Lancet. 2003;361:96.
Lehman CD, Smith RA. T e role o MRI in breast cancer screening. J Natl Compr Canc Netw. 2009;7:1109–1115.
Mangi AA, Smith BL, Gadd MA, anabe KK, Ott MJ, Souba WW. Surgical management o phyllodes tumors. Arch Surg. 1999;134:487–492.
Moyer VA, U.S. Preventive Services ask Force. Risk assessment, genetic counseling, and genetic testing or BRCA-related cancer in
women: U.S. Preventive Services ask Force Recommendation Statement. Ann Intern Med. 2014;160:271–281.
National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology. Version 1.2014. Breast Cancer Risk Reduction; 2014.
National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology. Version 1.2014. Breast Cancer Screening and
Diagnosis; 2014.

174
Plastic & Reconstructive Surgery Board Review
National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology. Version 1.2015. Breast Cancer; 2015.
Oef nger KC, Fontham Elizabeth H, Etzioni R, et al. Breast cancer screening or women at average risk. JAMA. 2015;314(15):
1599–1614.
Overgaard M, Hansen PS. Overgaard J, et al. Postoperative radiotherapy in high-risk premenopausal women with breast cancer who
receive adjuvant chemotherapy. Danish Breast Cancer Cooperative Group 82b trial. N Engl J Med. 1997;337:949–955.
Overgaard M, Jensen MB, Overgaard J, et al. Postoperative radiotherapy in high-risk postmenopausal breast-cancer patients given
adjuvant tamoxi en. Danish Breast Cancer Cooperative Group DCBG 82c randomised trial. Lancet. 1999;353:1641–1648.
Parmigiani G, Berry D, Aguilar O. Determining carrier probabilities or breast cancer-susceptibility genes BRCA1 and BRCA2. Am J
Hum Genet. 1998;62:145–158.
Ragaz J, Olivotto IA, Spinelli JJ, et al. Locoregional radiation therapy in patients with high-risk breast cancer receiving adjuvant
chemotherapy: 20-year results o the British Columbia randomized trial. J Natl Cancer Inst. 2005;97:116–126.
Rebbeck R, Domchek SM. Variation in breast cancer risk in BRCA1 and BRCA2 mutation carriers. Breast Cancer Res. 2008;10:108.
Recht A, Come SE, Henderson IC, et al. T e sequencing o chemotherapy and radiation therapy a ter conservative surgery or early-
stage breast cancer. N Engl J Med. 1996;334:1356–1361.
Recht A, Edge SB, Solin LJ, et al. Postmastectomy radiotherapy: clinical practice guidelines o the American Society o Clinical
Oncology. J Clin Oncol. 2001;19:1539–1569.
Rockhill B, Spiegelman D, Byrne C, Hunter DJ, Colditz GA. Validation o the Gail et al. model o breast cancer risk prediction and
implications or chemoprevention. J Natl Cancer Inst. 2001;93:358–366.
Sakora as GH, Blanchard K, Sarr MG, Farley DR. Paget’s disease o the breast. Cancer Treat Rev. 2001;27:9–18.
Saslow D, Boetes C, Burke W, et al. American Cancer Society guidelines or breast screening with MRI as an adjunct to mammography.
CA Cancer J Clin. 2007;57:75–89.
Speigelman D, Colditz GA, Hunter D, Hertzmark E. Validation o the Gail et al. model or predicting individual breast cancer risk.
J Natl Cancer Inst. 1994;86:600–607.
omasi-Cont N, Lambertini M, Hulsbosch S, Fedro Peccatori A, Amant F. Strategies or ertility preservation in young early breast
cancer patients. Breast. 2014;23:503–510.
Whelan JOI, Ackerman I, Chapman JW, et al. NCIC-C G MA.20: An intergroup trial o regional nodal irradiation in early breast
cancer. J Clin Oncol ASCO Annual Meeting Proceed (Post-Meeting Edition) 2001, 29.

175
Ranjna Sharma, MD

What is the de nition o a skin-sparing mastectomy (SSM)?
• Simple mastectomy (resection o the breast tissue or cancer diagnosis or risk reduction) that preserves the skin
envelope.

What are indications or SSM?
• Not being a candidate or adjuvant radiation therapy as part o the Breast Conservation T erapy approach:
previous breast or chest wall radiation therapy, certain connective tissue disorders, p53 mutation carriers
• Size o tumor precludes breast conserving surgery (large tumor to breast size ratio).
• Multicentric disease
• Persistently positive margins a ter multiple lumpectomies
• Cancer recurrence in breast where there was previous lumpectomy and radiation therapy
• Risk reduction
• Desire or immediate breast reconstruction
• Patient pre erence

What are advantages o SSM over traditional simple mastectomy?
• Preservation o native skin envelope
• Maintenance o natural contour and anatomic landmarks
• Improved cosmesis with immediate breast reconstruction
• Psychologic bene t to the patient

What are contraindications to the SSM approach?
• Inf ammatory breast cancer
• Locally advanced breast cancers with extensive skin involvement; i skin only ocally involved, can still consider
SSM with ocal resection o involved skin
Skin-Sparing
Mastectomy (SSM)
CHAPTER 21

176
Plastic & Reconstructive Surgery Board Review

What is the consensus on oncologic sa ety with use o SSM?
• T e rates o local recurrence, distant metastases, and survival are clinically equivalent when compared to simple
mastectomy.

What incision is routinely used when per orming an SSM?
• Circumareolar (periareolar) incision resecting nipple–areolar complex
• Incision may be extended radially and laterally as transverse incision line in larger breasted patients to acilitate
dissection (tennis racket incision)
• Circular periareolar incision used i autologous tissue f ap is being used or immediate reconstruction; elliptical
periareolar incision used in immediate expander-implant based reconstruction
• Reduction-pattern incision may also be used i trying to decrease amount o native ptosis
• Size and shape o incision make SSM more technically challenging than simple mastectomy

What are the borders o a mastectomy?
• Superior: clavicle
• Medial: lateral border o sternum
• Lateral: anterior border o latissimus dorsi muscle or mid-axillary line
• In erior: in ramammary old or upper rectus abdominus muscle
• Posterior: ascia overlying pectoralis major muscle is resected en bloc with mastectomy specimen

Describe the operative procedure used in SSM.
• Elevation o the skin envelope anterior to the investing ascia o the breast, dissecting between subcutaneous at
and underlying breast tissue
• Raise f aps to anatomic borders o the breast
• Resection o nipple–areolar complex en bloc with breast specimen
• Removal o ascia overlying the pectoralis major muscle

What primary patient actor determines thickness o the SSM skin f ap?
• Body habitus

What is the generally accepted thickness o an SSM skin f ap?
• Generally, 5 mm or less. However, may be thicker or obese patients.

What is the blood supply to the mastectomy skin f aps once an SSM has been per ormed?
• Peripheral intracutaneous blood vessels

I a sentinel lymph node biopsy needs to be per ormed, what incision will be used?
• Usually able to use the SSM periareolar incision; but i not able to reach axilla, can make a counter transverse
incision at lower axillary hairline.

CHAPTER 21 Skin-Sparing Mastectomy (SSM)
177

I an axillary lymph node dissection needs to be per ormed, what incision will be used?
• Usually a counter incision at in erior axillary hairline is needed to ensure complete dissection o Level 1 and 2
lymph nodes.
• A counter incision will minimize stretch injury to SSM skin f aps.

What reconstructive options are available or patients undergoing SSM and immediate breast
reconstruction?
• All types o breast reconstruction. SSM does not limit options or breast reconstruction.

What is the most common complication speci c to the SSM technique?
• Skin f ap necrosis

What are the clinical consequences o developing skin f ap necrosis?
• Delay in adjuvant therapy administration (chemotherapy and radiation therapy)
• Diminished cosmesis
• In ection

What are other common complications occurring a ter SSM?
• In ection
• Hematoma
• Seroma

Which patient population/clinical conditions are associated with a high risk o complications with SSM?
• Uncontrolled diabetics
• Active smokers
• Obesity
• Previous history o breast or chest wall irradiation

What is the routine surveillance plan in patients who have undergone SSM?
• Yearly physical examination o reconstructed breast, chest wall, and regional lymph node basins
• No routine surveillance imaging per ormed or the reconstructed breast
• I the contralateral breast is intact, then routine age and risk appropriate screening to be per ormed or the
native breast

Where is the most common site o local recurrence a ter an SSM?
• Native skin overlying reconstruction/chest wall

What is the clinical course i a new mass is palpated within the reconstructed breast?
• T is situation warrants urther work-up with imaging, and possible biopsy.
• I an autologous reconstruction was per ormed, a mass within the reconstruction may be at necrosis. However,
ormal work-up to exclude a recurrence is still indicated.

178
Plastic & Reconstructive Surgery Board Review
REFERENCES
Agrawal A, Grewal M, Sibbering DM, Courtney CA. Surgical and oncological outcome a ter skin-sparing mastectomy and immediate
breast reconstruction. Clin Breast Cancer. 2013;13(6):478–481.
Agrawal A, Sibbering DM, Courtney CA. Skin sparing mastectomy and immediate breast reconstruction: A review. Eur J Surg Oncol.
2013;39(4):320–328.
Baildam AD. Skin-sparing mastectomy. Eur J Cancer. 2011;47(Suppl 3):S342–S343.
Boughey JC, Rosenkranz KM. Skin-sparing mastectomy. In: Kuerer HM, ed. Kuerer’s Breast Surgical Oncology. New York, NY: McGraw-
Hill; 2010:705–710.
Donker M, Hage JJ, Woerdeman LA, Rutgers EJ, Sonke GS, Vrancken Peeters MJ. Surgical complications o skin-sparing mastectomy
and immediate prosthetic reconstruction a ter Neoadjuvant chemotherapy or invasive breast cancer. Eur J Surg Oncol. 2012;38(1):
25–30.
Kasem A, Mokbel K. Evolving role o skin sparing mastectomy. World J Clin Oncol. 2014;5(2):33–35.
Lemaine V, Hoskins L, Farley DR, et al. Introducing the SKIN Score: a validated scoring system to assess severity o mastectomy skin
f ap necrosis. Ann Surg Oncol. 2015;22(9):2925–2932.
Missana MC, Laurent I, Germain M, Lucas S, Barreau L. Long-term oncologic results a ter 400 skin-sparing mastectomies. J Visc Surg.
2013;150(5):313–320.
Narui K, Ishikawa , Satake , et al. Outcomes o immediate per orator f ap reconstruction a ter skin-sparing mastectomy ollowing
neoadjuvant chemotherapy. Eur J Surg Oncol. 2015;41(1):94–99.
Patani N, Mokbel K. Oncologic and aesthetic considerations o skin-sparing mastectomy. Breast Cancer Res Treat. 2008;111:391–403.
Rainsbury RM. Skin-sparing mastectomy. Br J Sur. 2006;93:276–281.
aha HM, Ferguson D. Surgical retraction tabs: sparing the skin in skin-sparing mastectomy. J Plast Reconstr Aesthet Surg. 2015;68(1):
134–136.
orresan RZ, dos Santos CC, Okamura H, Alvarenga M. Evaluation o residual glandular tissue a ter skin-sparing mastectomies. Ann
Surg Oncol. 2005;12(12):1037–1044.
Yi M, Kronowitz SJ, Meric-Bernstam F, et al. Local, regional, and systemic recurrence rates in patients undergoing skin-sparing
mastectomy compared with conventional mastectomy. Cancer. 2011;117(5):916–924.

179
Kari Kansal, MD

What is the blood supply to the nipple?
Branches o the external and internal mammary arteries (described as contributions rom the internal mammary,
lateral thoracic, and posterior intercostal arteries).

When the ducts are removed at the time of nipple sparing mastectomy (NSM) what percentage of the
microvasculature remains?
T e nipple viability is based on microvasculature. 29% o the blood vessels are within the duct bundle approaching
the skin and remainder are within 3 mm under the dermis. T is remains unchanged a ter radiation therapy.

What is the cutaneous innervation to the breast and the nipple?
T e cutaneous innervation o the breast is derived rom the anterior and lateral cutaneous branches o the
intercostal nerves. T e nipple areola complex is supplied by the anterior and lateral cutaneous branches o
the ourth intercostal nerve with additional innervation by the cutaneous branches o the third and the th
intercostal nerves.

What are absolute and relative contraindications for NSM?
Absolute contraindications: involvement o the nipple areola complex with cancer, locally advanced breast cancer
with skin involvement, inf ammatory breast cancer, and bloody nipple discharge.
Relative contraindications: smoking, diabetes, obesity, and large, ptotic breasts.

What are the common complications after nipple-sparing mastectomy and immediate reconstruction?
Nipple necrosis, mastectomy f ap skin necrosis, in ection, hematoma, and nipple malposition. T e rate o these
complications is < 5% and comparable to skin-sparing mastectomy with reconstruction. T ere is a higher rate o
skin and nipple necrosis with surgeons who are inexperienced.

What are predisposing factors that increase the risk of nipple necrosis at the time of NSM?
Smoking, diabetes, surgeon inexperience and periareolar incision.
Nipple-Sparing
Mastectomy
CHAPTER 22

180
Plastic & Reconstructive Surgery Board Review

What procedure is performed if the subareolar margin is positive for cancer?
Removal o the nipple or nipple/areolar complex.

What types of breast reconstruction can be used after NSM?
All types o breast reconstruction have been described a ter nipple-sparing mastectomy. T e most common
reconstruction is placement o a tissue expander or direct to implant reconstruction.

Are patients who undergo a nipple-sparing mastectomy at a higher risk for recurrence at the nipple?
T ere is no higher risk or recurrence at the nipple (0–2% reported in the literature) or ipsilateral breast when
compared with skin-sparing or simple mastectomy. Possible risk actors or recurrence at the nipple are Her2+
breast cancer and young (< 40) age.

What are the most common incisions used?
Common incisions include: radial, in erolateral in ramammary old, and circumareolar.

What patients need to have post mastectomy radiation therapy?
Absolute: umor > 5 cm, 4 or more positive lymph nodes, positive margin, 4 disease.
Possible: < 40 years old, grade 3 tumor, positive lymphovascular invasion, extracapsular extension o disease in the
axilla, and < 6 lymph nodes removed at the time o axillary lymph node dissection.

What are common complications involving the breast reconstruction that can occur with post mastectomy
radiation therapy?
Complications include: in ection, capsular contracture, explant o implant, and/or nipple loss due to malposition
or necrosis.
REFERENCES
Coopey SB, ang R, Lei L. Increasing eligibility or nipple-sparing mastectomy. Ann Surg Oncol. 2013;20:3218–3222.
Jaspars JJ, Posma AN, van Immerseel AA, Gittenberger-de Groot AC. T e cutaneous innervation o the emale breast and nipple-areola
complex: implications or surgery. Br J Plast Surg. 1997;50(4):249–259.
Koike-Shimo A, sugawa K, Kawamoto H, Kanemaki Y, Maeda I. Oncologic outcome and technical consideration o nipple-sparing
mastectomy in breast cancer: T e St. Marianna experience with 384 patients. J Clin Oncol. 2014;32.
Rusby JE, Brachtel EF, Michaelson JS, Koerner FC, Smith BL. Breast duct anatomy in the human nipple: three-dimensional patterns
and clinical implications. Breast Cancer Res Treat. 2007;106(2):171–179.
okin C, Weiss A, Wang-Rodriguez J, Blair SL. Oncologic sa ety o skin-sparing and nipple-sparing mastectomy: a discussion and
review o the literature. Int J Surg Oncol. 2012;2012:921821.
Warren Peled A, Foster RD, Stover A C, et al. Outcomes a ter total skin-sparing mastectomy and immediate reconstruction in 657
Breasts. Ann Surg Oncol. 2012;19(11),3402–3409.

181
Olivia Ho, MD, FRCSC and
Emily M. Clarke-Pearson, MD, MEd

What actors are important in selecting the most appropriate procedure or breast reconstruction?
1. Laxity and thickness o the remaining chest skin
2. Condition o the pectoralis and serratus anterior muscles
3. Size o the opposite breast
4. Availability o ap donor sites

What are the bene ts o immediate breast reconstruction?
1. Decreased psychosocial morbidity
2. Superior aesthetic outcome (in ramammary old and skin envelope maintained)
3. Decreased surgical morbidity (single general anesthetic and recovery period)
4. Reduced overall cost

What are the potential disadvantages o immediate breast reconstruction?
1. Higher-patient expectations
2. Higher-risk mastectomy skin ap necrosis (10%)
3. Delay in determination o nal margins and need or additional surgery and/or radiation therapy

Who are candidates or immediate breast reconstruction?
Patients in good general health with stage I or stage II disease, determined by the size and location o the tumor.
Reconstruction has also been described or the selected stage III patients with good prognosis. Some surgeons will
per orm immediate reconstruction even in cases when the patient will require radiation therapy.

When should delayed breast reconstruction be considered?
1. I tumor clearance is uncertain.
2. Patients in whom immediate postoperative chemotherapy and radiation is expected.
Expander–Implant
and Nipple–Areolar
Reconstruction
CHAPTER 23

182
Plastic & Reconstructive Surgery Board Review

Who rst described tissue expansion or breast reconstruction?
Radovan in 1982.

What types o tissue expanders are available or breast reconstruction?
issue expanders di er in their:
1. shape (round, oval, tear drop, anatomic, crescentic)
2. sur ace (smooth, textured)
3. duration (temporary, permanent)
4. ll characteristics (uni orm, di erential)
5. lling ports (internal port, remote external valve)
6. size or ll volume
7. number o chambers (single chamber, dual chamber)

What are the advantages o tissue expansion in breast reconstruction?
1. Creates new donor tissue o similar texture, color, and sensation
2. No additional scar
3. No additional donor site
4. Decreased operating time
5. Shorter recovery period
6. echnical ease

What are the relative indications or tissue expansion and implant reconstruction?
1. Small- or medium-sized breast
2. Nonobese patient
3. Patient not opposed to implant use
4. Patient pre ers not to undergo more extensive surgery
5. Medical contraindications to a more lengthy operation
6. Patient objection to scars o ap reconstruction
7. Patient not a candidate or autogenous reconstruction (multiple scars, limited donor tissue)
8. Bilateral reconstruction

What are the relative contraindications to expander/implant reconstruction?
1. Prior or anticipated chest wall irradiation
2. Morbid obesity
3. Atrophic, tight skin with poor/no pectoralis muscle
4. Mastectomy skin aps o questionable viability
5. Active in ection at the expansion site
6. Residual gross tumor

CHAPTER 23 Expander–Implant and Nipple–Areolar Reconstruction
183

What are potential problems with expander/implant reconstruction?
1. Pain/discom ort/pressure with expansion
2. In ection + /− prosthesis removal
3. Skin erosion or extrusion
4. Skin ap necrosis
5. Leakage or de ation
6. Malposition
7. Remote injection port mal unction or kinking
8. Internal valvular ailure
9. Capsular contracture
10. Hematoma
11. Seroma
12. Implant olds, “knuckles,” or wrinkling
13. Indistinct in ramammary old
14. Longer reconstruction period (up to 1 year)
15. Need or multiple operative procedures + /− additional revisional surgeries
16. Rounder appearance without natural ptosis
17. Chest wall de ormity
18. Pneumothorax

Where should the tissue expander be placed within the mastectomy pocket?
T e expander should ideally be placed under muscle and may be either completely submuscular (under pectoralis
major, serratus anterior, and the asciae o rectus abdominis and external oblique) or partially submuscular
(covered by pectoralis major at its upper pole alone).
Smooth expanders should be placed slightly below the level o the in ramammary old, as they tend to rise upward
with expansion.
extured tissue expanders can be placed at the level o the in ramammary old, as their adherent sur ace prevents
migration and enables lower pole expansion and subsequent ptosis.

What is the blood supply to each o the three muscles in a “totally submuscular” placement o a tissue
expander/implant?
Pectoralis major—pectoral branch o the thoracoacromial artery, pectoral branches o the lateral thoracic artery,
per orators rom the internal mammary artery and intercostal arteries
Serratus anterior—lateral thoracic artery, serratus branch o thoracodorsal artery
Rectus abdominis—deep superior epigastric artery, deep in erior epigastric artery

What are potential advantages and disadvantages o complete submuscular coverage?
Potential advantages include lower incidence o in ection, exposure, and extrusion. Disadvantages may include
ine ective expansion o the lower-pole o the breast mound. Complication rates have been ound to be equal
between these methods.

184
Plastic & Reconstructive Surgery Board Review

When does the expansion process begin a ter surgery?
At the time o closure, up to 300 mL o sterile saline is added to the expander, or as much as will allow tension-
ree closure without skin blanching. At 2 weeks, 50 to 100 cc is injected at weekly or twice weekly intervals. End
points or in ation volume include blanching o the skin over the expander and/or patient discom ort; saline is
removed until these conditions are reversed.

By how much should the breast pocket be overexpanded once the ideal size has been reached, and how long
should overexpansion be maintained or?
Overexpansion is generally 20% to 30% above the nal desired volume. T e pocket and capsule are allowed
to mature or 3 to 6 months in the overexpanded state be ore removal o the expander and replacement with a
permanent prosthesis.

What types o implants are available or breast reconstruction?
All breast implants have a silicone-based shell. In North America, implants are either saline lled or silicone lled.
Silicone implants may be cohesive gel ( rm) or liquid/responsive gel (more viscous).

Which dimensional eatures must be considered when selecting an implant type?
1. Base diameter
2. Height
3. Projection
4. Volume
5. Sur ace characteristics
6. Shape
7. Fill material

Which implant types are associated with the ormation o a brous capsule?
All oreign bodies induce a oreign-body reaction and ormation o a discrete brous shell. Certain actors are
associated with a higher incidence o capsular contracture, including:
1. older-generation silicone implants
2. subglandular rather than submuscular/subpectoral placement
3. postoperative hematoma
4. postoperative in ection
5. smooth rather than textured sur ace

What is the Becker implant?
A permanent combined expander–implant or breast reconstruction or augmentation. T is double-lumen
prosthesis contains an outer silicone gel- lled lumen surrounding an inner expandable saline- lled lumen with
removable ller tube. A ter achieving overexpansion, the saline reservoir can be de ated to its nal desired volume
and the ller tube removed under local anesthesia at the time o nipple reconstruction. T e common types are
Becker 25 (25% silicone outer lumen, 75% saline inner lumen) and Becker 50 (50% silicone outer lumen, 50%
saline inner lumen).

CHAPTER 23 Expander–Implant and Nipple–Areolar Reconstruction
185

Do breast implants inter ere with chemotherapy or radiation postoperatively?
No. Chemotherapy may proceed as usual postoperatively, although tissues are usually allowed to heal or 4 weeks
be ore starting therapy. Implants neither block nor enhance the absorbed radiation dose. However, the tissue expander
port can inter ere with radiation beams, depending on the targeted nodes and the method o radiation delivery.

How does radiation a ect tissue expansion and skin f ap viability?
Radiation treatment given be ore skin expansion:
1. decreases the tissue expansion rate
2. decreases the total area o expanded skin
3. decreases the viability o skin aps raised on expanded skin

Radiation during implant reconstruction results in:
1. higher rate o capsular contracture
2. increased risk o implant extrusion
3. increased risk o negative aesthetic outcome

What is the complication rate and ailure rate associated with tissue expander/implant to a previously
radiated breast?
Complication rates have been reported as high as 70%, with a 40% rate o ailure, addition o , or replacement by
a ap or salvage o the reconstruction.

When may a tissue expander require premature removal?
Causes or premature removal include in ection, exposure, skin necrosis, pain, patient dissatis action, or persistent
breast cancer.

What layer o skin and so t-tissue thickens when a tissue expander is placed and inf ated?
Epidermis.

What layers o skin and so t tissue become thin when a tissue expander is placed and inf ated?
Dermis, at, muscle.

List materials used in breast reconstruction that is not the patient’s native tissue.
Acellular dermal matrix (human, porcine, bovine), silk sca old, vicryl mesh.

What process does acellular dermal matrix undergo that synthetic sca old do not?
Revascularization.

What are the advantages o using acellular dermal matrix with a tissue expander during immediate reconstruction?
1. Increased initial ll o the expander
2. Fewer subsequent of ce expansions and return visits to clinic
3. Decreased capsular contracture rates

186
Plastic & Reconstructive Surgery Board Review

What are debated disadvantages o using acellular dermal matrix with a tissue expander during immediate
reconstruction?
1. Increased seroma rate
2. Increased in ection rate
3. Increased cost
4. Possibility o reaction to the material (e.g., red breast syndrome)

What techniques may be used to recreate or reconstruct an indistinct in ramammary old?
1. External suturing, with direct incision and advancement o a de-epithelialized thoracoepigastric ap to the
prethoracic wall ascia.
2. Internal suturing, using sutures rom the deep dermis or anterior capsule to the prethoracic ascia.

What is the prevalence o breast implant rupture?
Historically, 30% at 5 years a ter implantation, 50% at 10 years, and 70% at 17 years. T e median age o implant
rupture is about 10.8 years.

What is the FDA recommendation or type and requency o screening or implant rupture in women with
silicone implants?
MRI 3 years postoperatively a ter implantation and every 2 years therea ter.

What is the sensitivity o mammography versus ultrasound versus MRI in detecting implant rupture?
Mammography 68%, US 77%, MRI 93%.

What are common MRI signs o intracapsular implant rupture?
1. Linguini sign (appearance o wavy prosthetic gel oating in ree silicone gel)
2. Keyhole sign, noose sign, teardrop sign (appearance o silicone on both sides o a radial old)
3. Salad oil sign (mixing o the saline and silicone)
4. In extracapsular implant ruptures or leaked silicone gel, silicone signal material extruding rom the capsule or
silicone granuloma ormation can be seen.

What are common ultrasound signs o implant rupture?
Snowstorm sign (extracapsular rupture, echogenic lines), stepladder sign (intracapsular rupture).

I anaplastic large cell lymphoma (ALCL) is suspected, what specimens should be sent?
Fresh seroma uid and representative portions o the capsule.

What diagnostic evaluation should be included i ALCL is suspected?
Cytologic evaluation o seroma uid with Wright–Giemsa stained smears and cell block immunohistochemistry
testing or cluster o di erentiation and anaplastic lymphoma kinase markers. Any con rmed cases o ALCL in
women with breast prostheses must be reported to the FDA.

CHAPTER 23 Expander–Implant and Nipple–Areolar Reconstruction
187

What speci c markers should be ordered i ALCL is suspected?
CD30+ and ALK–.

What is the most likely progression o ALCL in a patient with breast prosthesis in comparison to a patient
who has ALCL but no breast prosthesis?
A more indolent clinical course and a more avorable prognosis.

What actor is associated with an increased risk o nipple–areolar complex (NAC) necrosis in nipple sparring
mastectomies?
Periareolar incisions. T e type o reconstruction, breast size, patient age have not been shown to be linked to
increased rates o NAC necrosis.

List the three main techniques described or nipple reconstruction.
1. Composite autogenous gra ts (contralateral nipple, ear lobule, toe or nger pulp, labia minora, umbilicus,
cartilage, dermal- at gra ts)
2. Local tissue aps
3. Alloplastic implants

Which local f aps have been described or nipple reconstruction (Figs. 23-1 to 23-3)?
1. Maltese cross ap
2. Skate ap
3. Star ap
4. C–V ap
5. S ap
6. ap
7. Mushroom ap
8. Double opposing tab ap
9. H ap
10. Double opposing pennant ap
11. Propeller ap
12. Inchworm ap
13. Fishtail ap
14. Quadrapod ap
15. Pinwheel ap
16. Bell ap

188
Plastic & Reconstructive Surgery Board Review
Figure 23-2 Star ap, Cylindrical ap, Arrow ap.
OR
FTSG
Star flap

Cylindrical flap

Arrow flap
Figure 23-1 Pinwheel ap, H ap, Skate ap.
FTSG
FTSG
Thinned
FTSG
Pinewheel flap

H flap

Skate flap
Skin graft
base FTSG
Do not cut
around circle
h
h
d d

d

CHAPTER 23 Expander–Implant and Nipple–Areolar Reconstruction
189

What is the potential risk o banking the ipsilateral NAC at the time o mastectomy or later reconstruction?
Autotransplantation o malignant cells.

What complications are associated with nipple sharing?
1. Cicatricial distortion
2. Loss o pigmentation
3. Loss o at least 50% height o the donor nipple
4. Decreased sensation o the contralateral nipple

What is the most common complication associated with nipple–areolar reconstruction?
Loss o projection (noted in most studies to be at least 50% by 6 months).

Have there been any controlled trials between types o nipple–areolar reconstruction?
T ere have been two, one comparing arrow and star aps and the other comparing skate and star aps. Both
studies con rmed that the projection o the star ap at 12 months was signi cantly less than the other aps.

When can nipple reconstruction be per ormed?
raditionally, nipple reconstruction is done about 8 to 12 weeks or later a ter the breast reconstruction. However,
there are reports o immediate nipple reconstruction with autologous aps such as the latissimus dorsi and RAM.
Figure 23-3 S ap (or double opposing tab ap), Maltese cross ap (or modi ed quadripod ap).
Scar
OR
FTSG
FTSG
S-Flap or
double opposing tab flap
Modified quadripod flap
or
maltese cross flap

190
Plastic & Reconstructive Surgery Board Review

Are there advantages or disadvantages to immediate nipple reconstruction?
Advantages: less time to completion o breast reconstruction process, lower number o operative procedures or the
patient, psychological bene t o total breast reconstruction in a single stage.
Disadvantages: higher incidence o asymmetric nipple placement with healing and ptosis, higher incidence o
complications including necrosis and delayed wound healing.

What are the goals o nipple–areolar reconstruction?
Symmetry with the contralateral side, localization at the most prominent point on the breast, projection rom the
breast mound.

What f aps can be used when a scar crosses the area o proposed nipple–areolar reconstruction?
S- ap, double-opposing-tab ap, double-opposing-pennant ap.

What are some autologous methods or increasing nipple projection?
Dermal- at gra ts, autologous at injection, auricular/costal cartilage.

What are some nonautologous methods or increasing nipple projection?
Acellular dermal gra ts, injectable llers (calcium hydroxyapatite, hyaluronic acid, polymethylmethacrylate), P FE
gra ts, purse-string sutures at the base o the reconstruction (top hat technique).

How can nipple reconstruction be achieved in patients with limited so t tissue available?
Per orm autologous at injection 8 weeks prior to nipple reconstruction to build a good so t-tissue base.

What are the reasons behind loss o projection o the reconstructed nipple?
Inadequate rigid connective tissue support, wound contracture, tattooing, external pressure rom dressings
(e.g., tie-over bolsters).

What are the most common complications o nipple reconstruction and their incidence?
T e most common complication is inadequate projection (more than 50% o cases), but other complications
related to wound healing, necrosis, etc., are low (1–4%).

Are there any limitations to per orming nipple–areolar reconstruction in the irradiated patient?
Only in patients who have implant reconstruction with limited so t-tissue thickness (less than 1 cm) and have
compromised skin quality. It should be noted, though, that when NAC reconstruction is per ormed in irradiated
patients that the incidence o complications is higher (25%).

What are the methods o nipple sharing and are there any drawbacks?
1. Bisection: used in wide nipples, a midline vertical incision is made through the nipple, hal is removed and
gra ted to the other side, and the apex o the donor site is closed to the base.
2. Coronal section: used in tall nipples, the distal 50% o the nipple is removed and gra ted to the contralateral
side and the donor site is closed with a purse-string suture.
Overall satis action 60% to 80%, nipple symmetry reported in 90% o cases.
T ese techniques cannot be used when inadequate tissue is present or in those individuals considering childbirth
and breast eeding.

CHAPTER 23 Expander–Implant and Nipple–Areolar Reconstruction
191

How can you create the appearance o Montgomery tubercles?
Placement o injectable llers, autologous cartilage gra ts, or incisions with subsequent scarring, tattooing.

What is the average areolar diameter?
Round nipples, 35 to 45 mm in women.
90% male nipples oval, 20:27 mm vertical:horizontal proportions.

What is the average nipple diameter and projection in women?
T e nipple is on average 5 to 8 mm in diameter and projects 4 to 6 mm.

How can you reconstruct the male NAC?
Autologous aps/gra ts, injectable llers. T e same methods as emale NAC reconstruction.

Where is the ideal nipple position in emales? Males?
Classically, the ideal nipple position was described by Penn to be an equilateral triangle o 21 cm rom sternal
notch to nipple and between the nipples. For the purposes o nipple reconstruction, the nipple should be
positioned on the most prominent part o the reconstructed breast at the same height as the contralateral nipple in
unilateral reconstruction and symmetrically with bilateral reconstructions.
In males, both vertical and horizontal coordinates are used in re erence to the sternal length and the chest
circum erence. Horizontal position at ourth to th intercostal space.

What techniques are available or areolar reconstruction?
Skin gra ting and tattooing. Skin gra t donor sites include the contralateral areola, groin, labia minora, or other
redundant skin olds. Intradermal tattooing is used to closely match the contralateral side.

How does nipple areolar tattooing work?
A handheld device with a tip that is made up o multiple needles deposits tattoo pigment into the dermis. Pigment
is taken up by macrophages. Scar tissue takes up less pigment than nonscarred tissue and o ten requires re-tattooing.

How does a reconstructed nipple di er rom a native nipple on radiological imaging?
T e reconstructed nipple may have an enhancement pattern similar to that o adjacent skin. In contrast, the normal
nipple appears bilayered, with a peripheral variably enhancing portion and a central nonenhancing portion.
REFERENCES
Anton MA, Eskenazi LB, Hartramp CR. Nipple reconstruction with local aps: star and wrap aps. Perspect Plast Surg. 1991;5:67–78.
Austad ED, Pasyk KA, McClatchey KD, Cherry GW. Histomorphologic evaluation o guinea pig skin and so t tissue a ter controlled
tissue expansion. Plast Reconstr Surg. 1982;70(6):704–710.
Basu CB, Leong M, Hicks JM. Does acellular cadaveric dermis (ACD) a ect breast implant capsule ormation in reconstructive breast
surgery? A histopathologic comparison o breast capsule and ACD. Plast Reconstr Surg. 2009;124(4S):62–63.
Carlson GW, Chu CK, Moyer HR, Duggal C, Losken A. Predictors o nipple ischemia a ter nipple sparing mastectomy. Breast J.
2014;20(1):69–73.
Caskey CI, Berg WA, Hamper UM, Sheth S, Chang BW, Anderson ND. Imaging spectrum o extracapsular silicone: correlation o US,
MR imaging, mammographic, and histopathologic ndings. Radiographics. 1999;19:S39–S51; quiz S261–S262.

192
Plastic & Reconstructive Surgery Board Review
Center or Devices and Radiological Health, US Food and Drug Administration. Anaplastic Large Cell Lymphoma (ALCL) in
Women with Breast Implants: Preliminary FDA Findings and Analyses. 2011. Available at: da.gov/MedicalDevices/
ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/ucm239996.htm
Chun YS, Verma K, Rosen H, et al. Implant-based breast reconstruction using acellular dermal matrix and the risk o postoperative
complications. Plast Reconstr Surg. 2010;125(2):429–436.
Chung KC, Malay S, Shauver MJ, Kim HM. Economic analysis o screening strategies or rupture o silicone gel breast implants. Plast
Reconstr Surg. 2012;130(1):225–237.
Cohen IK, Ward JA, Chandrasekhar B. T e pinwheel ap nipple and barrier areola gra t reconstruction. Plast Reconstr Surg. 1986;77:
995–999.
Colwell AS, essler O, Lin AM, et al. Breast reconstruction ollowing nipple-sparing mastectomy: predictors o complications,
reconstruction outcomes, and 5-year trends. Plast Reconstr Surg. 2014;133(3):496–506.
Cordeiro PG, Snell L, Heerdt A, McCarthy C. Immediate tissue expander/implant breast reconstruction a ter salvage mastectomy or
cancer recurrence ollowing lumpectomy/irradiation. Plast Reconstr Surg. 2012;129(2):341–350.
Cronin D, Upton J, McDonough JM. Reconstruction o the breast a ter mastectomy. Plast Reconstr Surg. 1977;59:1–14.
Da Costa D, addese A, Cure ML, et al. Common and unusual diseases o the nipple-areolar complex. Radiographics. 2007;27(suppl 1):
S65–S77.
de Jong D, Vasmel WL, de Boer JP, et al. Anaplastic large-cell lymphoma in women with breast implants. JAMA. 2008;300(17):2030–2035.
Di Benedetto G, Cecchini S, Grassetti L, et al. Comparative study o breast implant rupture using mammography, sonography, and
magnetic resonance imaging: correlation with surgical ndings. Breast J. 2008;14(6):532–537.
Disa JJ, Ad-El DD, Cohen SM, Cordeiro PG, Hidalgo DA. T e premature removal o tissue expanders in breast reconstruction. Plast
Reconstr Surg. 1999;104:1662–1665.
Dvali L , Dagum AB, Pang CY, et al. E ect o radiation on skin expansion and skin ap viability in pigs. Plast Reconstr Surg.
2000;106(3):624–629.
Farhadi J, Maksvytyte GK, Schae er DJ, Pierer G, Scheu er O. Reconstruction o the nipple-areola complex: an update. J Plast Reconstr
Aesthet Surg. 2006;59:40–53.
Ganske I, Hoyler M, Fox SE, Morris DJ, Lin SJ, Slavin SA. Delayed hypersensitivity reaction to acellular dermal matrix in breast
reconstruction: the red breast syndrome? Ann Plast Surg. 2014;73(Suppl 2):S139–S143.
Georgiade GS. Nipple areola reconstruction. In: Georgiade GS, Rie kohl R, Levin LS, eds. Georgiade Plastic, Maxillo acial and
Reconstructive Surgery. 3rd ed. Baltimore, MD: Williams & Wilkins; 1997:817–819.
Georgiade GS, Sundine MJ. Breast reconstruction a ter mastectomy: overview and implant reconstruction. In: Georgiade GS, Rie kohl R,
Levin LS, eds. Georgiade Plastic, Maxillo acial and Reconstructive Surgery. 3rd ed. Baltimore, MD: Williams & Wilkins; 1997:777–782.
Goodman CM, Miller R, Patrick CW Jr et al. Radiotherapy: e ects on expanded skin. Plast Reconstr Surg. 2002;110:1080–1083.
Gorczyca DP, Gorczyca SM, Gorczyca KL. T e diagnosis o silicone breast implant rupture. Plast Reconstr Surg. 2007;120(7 Suppl 1):
49S–61S.
Guerra AB, Khoobehi K, Metzinger SE, Allen RJ. New technique or nipple areola reconstruction: arrow ap and rib cartilage gra t or
long-lasting nipple projection. Ann Plast Surg. 2003;50:31–37.
Hallock GG, Altobelli JA. Cylindrical nipple reconstruction using an H ap. Ann Plast Surg. 1993;30:23–26.
Hedén P, Boné B, Murphy DK, Slicton A, Walker PS. Style 410 cohesive silicone breast implants: sa ety and e ectiveness at 5 to 9 years
a ter implantation. Plast Reconstr Surg. 2006;118(6):1281–1287.
Hedén P, Bronz G, Elberg JJ, et al. Long-term sa ety and e ectiveness o style 410 highly cohesive silicone breast implants. Aesthetic Plast
Surg. 2009;33(3):430–436; discussion 437–438.
Hirsch EM, Seth AK, Dumanian GA, et al. Outcomes o tissue expander/implant breast reconstruction in the setting o prereconstruction
radiation. Plast Reconstr Surg. 2012;129(2):354–361.
Hölmich LR, Fryzek JP, Kjoller K, et al. T e diagnosis o silicone breast-implant rupture: clinical ndings compared with ndings at
magnetic resonance imaging. Ann Plast Surg. 2005;54(6):583–589.
Hölmich LR, Vejborg I, Conrad C, Sletting S, McLaughlin JK. T e diagnosis o breast implant rupture: MRI ndings compared with
ndings at explantation. Eur J Radiol. 2005;53(2):213–225.
Hoover SJ, Kenkel JM. Breast cancer, cancer prevention, and breast reconstruction. Select Read Plast Surg. 2002;9(30):1–40.
Jewell M, Spear SL, Largent J, Oe elein MG, Adams WP Jr. Anaplastic large -cell lymphoma and breast implants: a review o the
literature. Plast Reconstr Surg. 2011;128(3):651–661.
Johnson M, Lowe L, Brown MD, Sullivan MJ, Nelson BR. Histology and physiology o tissue expansion. J Dermatol Surg Oncol.
1993;19(12):1074–1078.

CHAPTER 23 Expander–Implant and Nipple–Areolar Reconstruction
193
Kim B, Roth C, Young VL, et al. Anaplastic large cell lymphoma and breast implants: results rom a structured expert consultation
process. Plast Reconstr Surg. 2011;128(3):629–639.
Lipworth L, arone RE, McLaughlin JK. Breast implants and lymphoma risk: a review o the epidemiologic evidence through 2008.
Plast Reconstr Surg. 2009;123(3):790–793.
Little JW 3rd, Munasi , McCulloch D . One-stage reconstruction o a projecting nipple: the quadrapod ap. Plast Reconstr Surg.
1983;71:126–133.
Malata CM, Williams NW, Sharpe D . issue expansion: an overview. J Wound Care. 1995;4(1):37–44.
Margolis NE, Morley C, Lot P, et al. Update on imaging o the postsurgical breast. Radiographics. 2014;34(3):642–660.
Miller MJ. Immediate breast reconstruction. Clin Plast Surg. 1998;25:145–156.
Netter FH. Atlas o Human Anatomy. 5th ed. Philadelphia, PA: Saunders; 2011.
Pope L Jr. Aunt Minnie’s Atlas and Imaging-Specif c Diagnosis. Philadelphia, PA: Lippincott Williams & Wilkins; 2003.
Sa vi A. Linguine sign. Radiology. 2000;216(3): 838–839.
Sbitany H, Sandeen SN, Amal AN, Davenport MS, Langstein HN. Acellular dermis-assisted prosthetic breast reconstruction versus
complete submuscular coverage: a head-to-head comparison o outcomes. Plast Reconstr Surg. 2009;124(6):1735–1740.
Shusterman MA. Microsurgical breast reconstruction. In: Aston SJ, Beasley RW, T orne CHM, eds. Grabb and Smith’s Plastic Surgery.
5th ed. Philadelphia, PA: Lippincott-Raven; 1997:785–790.
Spear SL, Onyewu C. Staged breast reconstruction with saline- lled implants in the irradiated breast: recent trends and therapeutic
implications. Plast Reconstr Surg. 2000;105:930–942.
Spear SL, Spittler CJ. Breast reconstruction with implants and expanders. Plast Reconstr Surg. 2001;107:177–187.
Story SK, Schowalter MK, Geskin LJ. Breast implant-associated ALCL: a unique entity in the spectrum o CD30 +lymphoproli erative
disorders. Oncologist. 2013;18(3):301–307.
Strauch B, Vasconez LO, Hall-Findlay EJ, eds. Breast, chest wall, and trunk reconstruction. In: Grabb’s Atlas o Flaps. Vol 3. 2nd ed.
Philadelphia, PA: Lippincott-Raven; 1998:1259–1372.
aylor KO, Webster HR, Prince HM. Anaplastic large cell lymphoma and breast implants: ve Australian cases. Plast Reconstr Surg.
2012;129(4):610e–617e.
yrone JW, Losken A, Hester R. Nipple areola reconstruction. Breast Dis. 2002;16:117–122.
U.S. Food and Drug Administration. FDA Update on the Sa ety o Silicone Gel-f lled Breast Implants. Silver Spring, MD: Center or
Devices and Radiological Health; 2011.

This page intentionally left blank

195
Olivia Ho, MD, FRCSC

List considerations in selecting an appropriate method or breast reconstruction.
1. Laxity and thickness o remaining breast skin
2. Condition o the pectoralis major and serratus anterior muscles
3. Size o the opposite breast
4. Availability o ap donor sites
5. Patient wishes
6. Surgeon training and pre erence

List the advantages o autogenous tissue breast reconstruction.
1. More natural shape than implants
2. Natural consistency
3. Less need to alter the contralateral breast
4. Reconstruction is permanent
5. Reconstruction ages with the patient

What are indications or autogenous tissue breast reconstruction?
1. Patient pre erence
2. Mastectomy-site skin de ciency
3. Failed implant reconstruction
4. Coverage o implants at risk or extrusion
5. History o collagen vascular disease
6. Previous chest wall irradiation
Breast Reconstruction:
Alternative Flaps
CHAPTER 24

196
Plastic & Reconstructive Surgery Board Review

What are some relative contraindications o autogenous tissue breast reconstruction?
1. Inadequate donor-site so t tissue and skin
2. Injury to donor or recipient vessels
3. Uncontrolled hypertension or diabetes
4. Morbid obesity
5. Heavy smoking
6. Severe pulmonary, cardiac, or renal disease
7. Autoimmune disease
8. Anticoagulation therapy
9. Hypercoagulable disorders

What are the aesthetic subunits o the breast?
1. Nipple
2. Areola
3. Expanded areola
4. In erolateral crescent
5. In erior hal
6. otal breast
Autogenous reconstruction using these perceived subunits or skin paddles may improve the overall aesthetic
appearance o the breast mound. Less aesthetic subunits include the upper inner quadrant, medial hal ,
in eromedial quadrant, and random patch o ap skin.

Which pedicled aps have been described or breast reconstruction?
1. Latissimus dorsi
2. Pedicled RAM/VRAM ap
3. T oracoepigastric ap
4. Omental ap
5. External oblique ap
6. Lateral abdominal skin ap

What is the blood supply o the thoracoepigastric ap?
Per orators o the superior epigastric artery and subcostal arteries.

What is the blood supply o the omental ap?
Right gastroepiploic vessels.

What is the blood supply and classi cation o the external oblique ap?
Lateral cutaneous branches o in erior eight posterior intercostal arteries and venae comitantes. ype IV.

CHAPTER 24 Breast Reconstruction: Alternative Flaps
197

Which random aps have been described or breast reconstruction?
1. Sliding skin ap rom the abdomen
2. Composite cone (“dog-ear”) ap
3. Midabdominal skin ap
4. Contralateral breast ap
5. Deepithelialized arm ap
6. ubed abdominal ap
7. Adipo ascial anterior rectus sheath ap

List the ree aps that have been described or breast reconstruction.
1. Free RAM ap
2. VRAM ap
3. DIEP ap
4. SIEA ap
5. Rubens (DCIA) ap
6. FL (lateral transverse thigh) ap
7. AL ap
8. Omental ap
9. Groin ap
10. Adipo ascial/anterior rectus sheath ap
11. In erior or superior gluteal ap
12. S-GAP ap
13. I-GAP ap
14. Vertical gracilis ap
15. UG ap (transverse upper gracilis)
16. Free LD ap
17. AP ap
18. Intercostal artery per orator ap
19. SEAP ap (superior epigastric artery per orator)
20. PAP ap (pro unda artery per orator)

What is the blood supply and classi cation o the latissimus dorsi (LD) ap?
T e main pedicle is the thoracodorsal artery and vein, which arises rom the third part o the subscapular artery,
and enters the undersur ace o the muscle 8 to 12 cm rom its insertion. In 86% o cases, it divides into a vertical
descending branch and a transverse horizontal branch within the muscle. T e LD is a type V ap, with secondary
segmental pedicles rom the posterior intercostal and lumbar artery per orators.

What is the nerve supply o the LD muscle?
T oracodorsal nerve.

Describe the origins and insertion o the LD muscle.
Origins include:
1. Lower six thoracic spines and supraspinous ligaments
2. Posterior layer o lumbar ascia
3. endinous attachments to posterior iliac crest
4. Interdigitations with external oblique muscle
5. Lower 3 to 4 ribs
6. Scapula
It inserts via a 10-cm-long tendon into the oor o the bicipital/intertubercular groove o the humerus, behind the
tendon o the long heard o biceps brachii.

198
Plastic & Reconstructive Surgery Board Review

What shoulder unction de cit will a patient who had a pedicled LD musculocutaneous ap demonstrate?
Decreased shoulder extension, adduction and medial rotation.

What muscle compensates or the loss o the LD muscle when used as a pedicled ap and becomes
hypertrophied?
eres major muscle.

Which variations o the LD ap have been described or breast reconstruction?
1. LD muscle only ap (+ /− implant)
2. LD myocutaneous ap (+ /− implant)
3. “extended” LD ap (no implant)
4. “total autogenous” LD ap (no implant)
5. Endoscopically harvested LD ap
6. Free LD ap
7. LD with immediate nipple reconstruction (with or without implant)

Which con gurations o skin paddles have been described or the LD ap?
ransverse, vertical, crescentic, oblique, eur-de-lis pattern.

How can the LD pedicle be lengthened?
By (1) dividing the tendinous insertion to the humerus, (2) dividing the serratus anterior branch, or (3) dividing
cutaneous branches to the lateral chest wall. T e tendon may be transposed anteriorly and repositioned to recreate
an absent anterior axillary old.

What are the advantages and disadvantages o the LD ap or breast reconstruction?
Advantages include:
1. reliable vascular pedicle
2. large diameter vessels (artery 2.5 mm, vein 3.5 mm)
3. avorable geometry or breast reconstruction
4. well-vascularized tissue to prevent radiation-related complications
Disadvantages include:
1. implant required or projection in most cases
2. large, visible scar on the back
3. requent postoperative seroma

What is the average maximal width o the LD ap skin paddle to allow or direct skin closure?
Approximately 7 to 9 cm o back skin can be harvested with the ap, with primary closure o the donor site.

CHAPTER 24 Breast Reconstruction: Alternative Flaps
199

What is done with the thoracodorsal nerve upon transposition o the latissimus muscle to the anterior chest?
T e motor nerve may be divided primarily upon ap transposition to the chest in order to avoid involuntary
muscle contraction. T e nerve may also be preserved to preserve muscle bulk, and secondarily divided i problems
with movement occur.

How has the LD ap been success ully harvested when the main thoracodorsal pedicle was damaged/
unavailable?
By retrograde ow rom the collateral serratus anterior branch to the lateral thoracic artery. T e thoracodorsal
artery gives o one to two branches to the serratus muscle prior to entering the LD muscle.

What methods can be employed to increase size and volume in a pedicled LD ap?
Extended LD ap
Folding over a de-epithelialized portion o the LD ap
Fleur-de-lis skin paddle design
Fat gra ting the LD ap

List the most common LD donor-site complications rom most to least common.
Seroma ormation (35%–60%), chest wall pain, dorsal wound dehiscence, partial ap necrosis, shoulder sti ness.

What are the advantages o microvascular ree tissue trans er over conventional pedicled trans er o
autogenous tissue?
1. Enhanced vascular per usion/reliability
2. Ability to trans er large volumes o tissue and per orm shaping maneuvers without tethering rom pedicle
3. Easier ap insetting without pedicle
4. No tunnel or de ormity rom transposed pedicle
5. Occasionally improved donor-site morbidity
6. Greater choice o donor sites, with ability to tailor ap to body habitus o patient
7. Less risk o complications rom smoking or diabetes on larger, higher ow vessels

What are disadvantages o ree ap breast reconstruction?
Requirements o microsurgical training and potential or partial or complete ap loss.

What are the indications or ree ap reconstruction o the breast?
1. Large chest wall de ects ollowing radical mastectomy + /− radiation, where regional aps will not suf ce
2. Previously ailed regional aps
3. Desire to minimize donor-site morbidity
4. Inadequate RAM tissue
5. Violation o RAM ap pedicle, previous RAM or abdominoplasty
6. Surgeon’s pre erence or ree tissue trans er
7. Patient risk actors such as tobacco use or obesity

200
Plastic & Reconstructive Surgery Board Review

What would an analysis o the tissue o a patient’s previously radiated (> 6 weeks ago) mastectomy site
would show an increase o ?
Vessel thrombosis.

Vascular compromise is most likely to occur during which time period postoperatively?
12–24 hours.

What are potential bene ts o immediate breast reconstruction with ree tissue trans er?
1. Psychologic bene t: immediate return o body image
2. so t, uncontracted skin envelope o skin-sparing mastectomy una ected by scar tissue and contracture
3. Remaining breast skin easily assumes the normal breast contour once volume restored
4. Only skin removed during mastectomy requires replacement
5. In ramammary old and other breast landmarks are preserved and used
6. Exposed recipient vessels in chest or axilla
7. Fewer revisional and contralateral procedures to improve symmetry
8. Single hospitalization
9. Less time away rom home or work
10. Less overall cost in the long-term

What anatomical landmark is a mastectomy carried out to that makes the lateral in ramammary old
important to reconstruct in an immediate breast reconstruction?
Anterior edge o the LD muscle. T e recreation o the in ramammary old is important or shaping the breast
reconstruction. Both the in erior and lateral components o the in ramammary old should be evaluated and
repaired a ter mastectomy and be ore reconstruction.

What are the advantages and disadvantages o the internal mammary vessels over the thoracodorsal vessels
or microvascular anastomosis?
Advantages include:
1. more versatile and medial insetting o breast ap
2. vascular pedicle ree rom arm and shoulder movement
3. avoidance o brachial plexus complications
4. vessels available despite previous axillary surgery or radiation
5. excellent arterial ow rom proximity to heart and large caliber
6. surgeon and assistant com ort operating over center o chest
7. good size match with DIEA system
8. does not disrupt the main blood supply to the pedicled LD ap or salvage i needed
9. less concern or disruption o anastomosis should the patient require a completion axillary lymph node
dissection later on based on nal pathology results o sentinel lymph node biopsy

CHAPTER 24 Breast Reconstruction: Alternative Flaps
201
Disadvantages include:
1. requires medial chest scar exposure in delayed reconstruction
2. additional time and dissection or rib cartilage removal
3. delicate, thin-walled, ragile internal mammary veins
4. compromise o uture availability o IMA or coronary bypass surgery
5. risk breaching parietal pleura with hemothorax or pneumothorax
6. movement o the thorax in and out o microscopic ocus with respirations
7. vein may be single or diminutive on the le t side
8. risk o contour depression with rib cartilage harvest in thin patients with signi cant ptosis

What are potential advantages and disadvantages o internal mammary artery per orating vessels or
microsurgical breast reconstruction?
Advantages include sparing o the IMA or possible uture cardiac surgery, thoracic de ormity with rib removal
avoided, limited dissection decreases operative time. Disadvantages include limited surgical exposure, caliber
incompatibility with ap vessels (0.5–0.8 mm), and technical challenge.

When would ree aps other than the TRAM, DIEP, or SIEA aps be considered or breast reconstruction?
1. Inadequate abdominal at
2. High-risk abdominal scars
3. Patient pre erence
4. Previous abdominal ap harvest/ ailure
5. Previous abdominoplasty
6. Li estyle choice
7. Pregnancy plans: although normal pregnancies have been reported a ter RAM ap surgery

Which scars are sa e in harvesting abdominal tissue or breast reconstruction?
1. Appendectomy
2. Hysterectomy
3. C-section
4. Laparoscopic cholecystectomy
5. Other laparoscopic scars

In which situations would abdominal tissue be inappropriate or breast reconstruction?
1. Inadequate abdominal at
2. High-risk abdominal scars (paramedian, abdominoplasty, colostomy, ileostomy)
3. Patient pre erence
4. Previous RAM ap ailure
5. Previous abdominoplasty
6. Pregnancy plans

202
Plastic & Reconstructive Surgery Board Review

Which area o the donor site a ter an abdominal based ap harvest is most likely to develop a decrease in
long term overall sensation?
In raumbilical.
T e area below the umbilicus and above the abdominal incision is most likely to have decreased sensation in the
long term (a ter more than 3 years).

What is a “per orator”?
A vessel that has its origin in one o the axial vessels o the body and that passes through structures besides
interstitial connect tissue and at be ore reaching the subcutaneous at layer. Per orators may be direct (piercing the
deep ascia without traversing any other structural tissue), or indirect, running rst through muscle, septum, or
epimysium.

Is the SIEA ap a “per orator ap”?
By de nition, no. T e super cial in erior epigastric artery (SIEA) is a type A asciocutaneous axial ap, supplied
directly rom the SIEA, super cial to Scarpa ascia. T e SIEA arises rom the emoral artery hal way between the
pubic tubercle and the anterior superior iliac spine, 2 to 3 cm in erior to the inguinal ligament in the emoral
triangle.

What are the anatomic variations o the SIEA origin?
T e SIEA and super cial circum ex iliac artery (SCIA) share a common origin rom the emoral artery 48% to
79% o the time, the SIEA and SCIA arise independently in approximately 17%, and the SIEA is absent in up to
35% o cases.

What are the advantages and disadvantages o the SIEA ap or breast reconstruction?
Advantages include:
1. same abdominal tissue as in RAM or DIEP aps, with zero risk o abdominal wall hernia, bulge, or weakness
2. can design ap more in eriorly with resultant low and inconspicuous scar
3. shorter recovery time and less postoperative pain
Disadvantages include:
1. absent or diminutive vessels in 30% to 40% o cases
2. short pedicle (2–6 cm)
3. small-diameter vessels (artery 1.5–2.5 mm, vein 2–3 mm) with challenging vascular anastomosis
4. vascular territory only reliable to midline (can only harvest a hemiabdomen)
5. higher requency o total ap loss
6. higher requency o at necrosis

CHAPTER 24 Breast Reconstruction: Alternative Flaps
203

What are advantages and disadvantages o per orator aps over traditional musculocutaneous aps?
Advantages include:
1. less donor-site morbidity
2. muscle sparing
3. versatility in design to include as little or as much tissue as required
4. improved postoperative recovery
Disadvantages include:
1. require meticulous dissection o per orators through underlying tissue
2. increased operative time
3. variability in position and size o per orator vessels
4. i suf ciently traumatized, per orators have tendency to stretch, kink or twist, causing vasospasm or thrombosis

What are the I-GAP and S-GAP aps?
Per orator aps supplied by branches o in erior and superior gluteal artery, respectively. T e gluteal arteries
are terminal branches o the internal iliac artery and are codominant pedicles o the gluteus maximus muscle,
separated by the piri ormis muscle.

What are the advantages and disadvantages o the S-GAP ap or breast reconstruction?
Advantages include:
1. abundant adipose tissue or breast mound reconstruction
2. can lengthen vascular pedicle by intramuscular dissection
3. easily concealed donor-site scar
4. excellent projection o sti adipose tissue
5. preserves entire gluteus maximus muscle
6. avoids exposure and retraction o the sciatic nerve
Disadvantages include:
1. technically demanding ap harvest with steep learning curve
2. dif cult hemostasis
3. short vascular pedicle (3–5 cm)
4. increased size discrepancy between diameter o donor and recipient vessels as the pedicle is lengthened
5. postoperative contour de ormity with unilateral ap harvest
6. smaller skin paddle available
7. requent donor-site seroma
8. dif culty molding gluteal at
9. intraoperative positioning (need or position change and more dif cult or second team to work)

204
Plastic & Reconstructive Surgery Board Review

How is the S-GAP blood supply identi ed?
T e superior gluteal artery emerges rom the edge o the sacrum through the suprapiri orm oramen, one-third the
distance along a line drawn rom the posterior superior iliac spine (PSIS) to the greater trochanter tuberosity. T e
skin paddle is designed as a horizontal ellipse centered over per orators that are detected by preoperative Doppler
ultrasound. T e ap can be sa ely raised on a single per orator.

What structures exit the sciatic notch and may be encountered when raising an I-GAP ap?
1. In erior gluteal artery and vein
2. Sciatic nerve
3. Pudendal nerve
4. In erior gluteal nerve
5. Posterior cutaneous nerve o thigh
6. Pudendal artery and vein

Which structures are key to identi ying the vascular pedicle o the I-GAP ap?
T e posterior cutaneous nerve o thigh and accompanying posterior thigh vessels, which arise rom the in erior
gluteal artery. T ese vessels can be traced superiorly under the in erior border o the gluteus maximus muscle,
toward the sciatic notch and over the belly o the piri ormis muscle. T e sciatic nerve lies just deep to this plane.

Describe the ideal patient or gluteal artery per orator ap breast reconstruction.
T in patient, nulliparous, high-risk abdominal scars or otherwise not a RAM candidate, with insuf cient volume
in alternative donor sites. Bilateral reconstructions are best per ormed to limit operative time, repositioning
intraoperatively, blood loss, and surgeon atigue.

What is the blood supply o the Rubens ap?
Cutaneous per orators rom the descending branch o the deep circum ex iliac artery (DCIA) and vein. T e
Rubens ap is the cutaneous component o the DCIA osteocutaneous ap, described by aylor. T is redundant at
collection over the iliac crest was named or the 16th-century painter Peter Paul Rubens’ depiction o this area in
the emale orm.

Who is the ideal patient or the Rubens ap?
A “gynecoid” (pear-shaped) emale o normal weight, who has had a previous abdominoplasty or RAM ap and
desires autogenous breast reconstruction.

What are potential complications o the Rubens ap?
1. Detailed donor-site closure: the abdominal wall muscles must be reattached rmly to the iliac crest, using drill
holes and sturdy sutures or bone anchors;
2. Risk o hernia with insuf cient donor-site repair;
3. Signi cant postoperative pain;
4. Sensory nerve de cits (paresthesias, anesthesia, neuroma);
5. Signi cant donor-site seroma; and
6. Donor-site de ormity necessitating contralateral procedure or symmetry.

CHAPTER 24 Breast Reconstruction: Alternative Flaps
205

Which nerves are at risk in dissection o thigh and buttock area aps?
T e emoral nerve is at risk with the FL (lateral thigh) ap harvest. T e sciatic nerve is at risk with the I-GAP ap. T e
cutaneous branch o 12 (lateral emoral cutaneous nerve o thigh) is at risk during the DCIA (Rubens) ap harvest.

Describe the TAP ap or breast reconstruction.
T e thoracodorsal artery per orator ( AP) ap may be trans erred pedicled or ree to the chest or breast reconstruction.
T e lateral branch o the thoracodorsal artery supplies per orators to skin and at overlying the LD muscle.

What are the advantages o the TAP ap?
1. Improved aesthetic appearance with intact LD muscle
2. Preservation o muscle unction aids with rehabilitation
3. Vasculature: possibility o ow-through anastomosis
4. Anastomosis: reliable, wide diameter vessels
5. Follow-up: 1-weighted MRI acilitates postoncologic ollow-up, i required
6. Pedicle: average 20 cm, out o the zone o injury/radiation
7. Sensation: neurorrhaphy or sensation with intercostal nerves
8. Low incidence o seroma: no dead space

What are potential disadvantages o the TAP ap?
1. Size: limited to 10 to 12 cm × 25 to 30 cm
2. Per orators variable
3. Steep learning curve or experience
4. Requires lateral decubitus positioning or harvest
5. May not enable two-team surgery
6. Interposition nerve gra ts o ten required or neurorrhaphy

What is the TUG ap or breast reconstruction?
T e ree transvers upper gracilis myocutaneous ap, supplied by the ascending branch o the medial circum ex
emoral artery. Pedicle length averages 6 cm, and vessel diameter, 1.6 mm. Vascular studies reveal the main
cutaneous per orating vessels supply a transverse orientation o skin and subcutaneous tissue reliably approximately
10 cm distal to the pubic tubercle. Donor-site closure creates a medial thigh li t.

What are advantages to using the TUG ap or breast reconstruction?
1. Option when abdominal or buttock donor sites not available or not desired by patient
2. Creates a medial thigh li t
3. Hidden scar
4. issue similar consistency to breast tissue
5. Low unctional morbidity
6. Relatively rapid harvesting time
7. Does not require position change (can remain supine)

206
Plastic & Reconstructive Surgery Board Review

What are disadvantages to using the TUG ap or breast reconstruction?
1. Small ap size
2. Distortion o labia majora
3. Lowering o scar over time
4. Proximity to groin region

How does cigarette smoking af ect ap blood ow?
1. Nicotine activates the sympathetic nervous system and produces cutaneous vasoconstriction, leading to
compromise o tissue capillary blood ow.
2. Carbon monoxide binds to hemoglobin and shi ts the oxygen–hemoglobin saturation curve to the le t, causing
tissue hypoxia.
3. Increased platelet aggregation rom increased plasma brinogen levels, potentiating vascular thrombosis.
4. Decreased endothelial synthesis o nitric oxide that impairs endothelium-dependent vasodilation o arteries.

How does smoking af ect the results o autogenous tissue breast reconstruction?
Smoking inter eres with wound healing and is associated with a signi cantly higher rate o mastectomy skin
ap necrosis, abdominal wound dehiscence, postoperative in ection, and at necrosis. Nicotine slows blood
ow to aps and increases platelet adhesiveness. Smoking has not been ound to increase complications with
microvascular anastomoses or to increase the rate o ree ap loss.

What complications are smoking breast reconstruction patients most at risk o developing?
Mastectomy skin necrosis.

What is the recommended time to stop smoking be ore ree ap breast reconstruction?
At least 4 weeks be ore surgery.

What hormonal adjuvant treatment or breast cancer should be discontinued preoperatively be ore
autologous ree ap breast reconstruction?
amoxi en. It can increase the risk o thromboembolic events.

What is the recommended duration to stop Tamoxi en be ore autologous ree ap breast reconstruction?
At least 28 days be ore surgery.

What percentage o patients who receive at gra ting or post mastectomy reconstruction develop at necrosis
and oil cysts?
75%.

Based upon recommendations rom the American Society o Plastic Surgeons VTE Task Force, what are VTE
risk reduction strategies that should be employed in patients undergoing elective or reconstructive surgical
procedures who have a Caprini risk assessment model score o 7 or more?
Perioperative subcutaneous heparin, SCDs, limiting operating room times, weight reduction, discontinuation o
hormone replacement therapy, early postoperative mobilization.

CHAPTER 24 Breast Reconstruction: Alternative Flaps
207

What mammographic changes may be visible ollowing breast reconstruction with autologous tissue?
1. Reconstructed breast composed o muscle, at, vascular structures, and skin in no orderly arrangement
2. No remaining parenchymal structures, ducts, or Cooper’s ligaments
3. Vascular clips may be present at or near the muscle ap
4. Areas o skin thickening
5. Patchy tissue densities or at necrosis
6. Lucent oil cysts + /− calci ed walls
7. Implant, i used

Which additional steps may urther delineate a mammographic nding post reconstruction?
1. Eklund displacement views
2. Spot views
3. Magni cation lms
4. Correlation with clinical examination
5. Fine needle aspiration cytology or core biopsy to rule out malignancy
REFERENCES
Allen RJ. T e superior gluteal artery per orator ap. Clin Plast Surg. 1998;25(2):293–302.
Arnez ZM, Khan U, Pogorelec D, Planinsek F. Breast reconstruction using the ree super cial in erior epigastric artery (SIEA) ap.
Br J Plast Surg. 1999;52(4):276–279.
Arnez ZM, Pogorelec D, Planinsek F, Ahcan U. Breast reconstruction by the ree transverse gracilis ( UG) ap. Br J Plast Surg. 2004;
57(1):20–26.
Beckenstein MS, Grotting JC. Breast reconstruction with ree-tissue trans er. Plast Reconstr Surg. 2001;108(5):1345–1353.
Blondeel PN, Hijawi J, Depypere H, Roche N, Van Landuyt K. Shaping the breast in aesthetic and reconstructive breast surgery: an easy
three-step principle. Part II–Breast reconstruction a ter total mastectomy. Plast Reconstr Surg. 2009;123(3):794–805.
Blondeel PN, Van Landuyt K, Hamdi M, Monstrey SJ. So t tissue reconstruction with the superior gluteal artery per orator ap. Clin
Plastic Surg. 2003;30(3):371–382.
Blondeel PN, Van Landuyt KH, Monstrey SJ. T e “Gent” consensus on per orator ap terminology: preliminary de nitions. Plast
Reconstr Surg. 2003;112(5):1378–1383.
Blondeel PN. T e sensate ree superior gluteal artery per orator (S-GAP) ap: a valuable alternative in autologous breast reconstruction.
Plast Reconstr Surg. 1999;52(3):185–193.
Broughton G 2nd, Janis JE, Attinger CE. Wound healing: an overview. Plast Reconstr Surg. 2006;117(7 Suppl):1e-S–32e-S.
Brumback RJ, McBride MS, Ortolani NC. Functional evaluation o the shoulder a ter trans er o the vascularized latissimus dorsi
muscle. J Bone Joint Surg Am. 1992;74(3):377–382.
Bui D , Cordeiro PG, Hu QY, Disa JJ, Pusic A, Mehrara BJ. Free ap reexploration: indications, treatment, and outcomes in 1193 ree
aps. Plast Reconstr Surg. 2007;119(7):2092–2100.
Buntic RF, Horton KM, Brooks D, Althubaiti GA. ransverse upper gracilis ap as an alternative to abdominal tissue breast
reconstruction: technique and modi cations. Plast Reconstr Surg. 2011;128(6):607e-613e.
Chang D, Yousse A, Cha S, Reece GP. Autologous breast reconstruction with the extended latissimus dorsi ap. Plast Reconstr Surg.
2002;110(3):751–761.
Chang DW, Reece GP, Wang B, et al. E ect o smoking on complications in patients undergoing ree RAM ap breast reconstruction.
Plast Reconstr Surg. 2000;105(7):2374–2380.
Chen K , Mardini S, Chuang DC, et al. iming o presentation o the rst signs o vascular compromise dictates the salvage outcome
o ree ap trans ers. Plast Reconstr Surg. 2007;120(1):187–195.

208
Plastic & Reconstructive Surgery Board Review
Chevray PM. Breast reconstruction with super cial in erior epigastric artery aps: a prospective comparison with RAM and DIEP
aps. Plast Reconstr Surg. 2004;114(5):1077–1983.
Claro F Jr, Figueiredo JC, Zampar AG, Pinto-Neto AM. Applicability and sa ety o autologous at or reconstruction o the breast. Br
J Surg 2012;99(6):768–780.
Delay E, Gounot N, Bouillot A. Zlato P, Rivoire M. Autologous latissimus breast reconstruction: a 3-year clinical experience with 100
patients. Plast Reconstr Surg. 1998;102(5):1461–1478.
Delay E. Breast reconstruction with an autologous latissimus ap with and without immediate nipple reconstruction. In: Spear SL, ed.
Surgery of the Breast. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006;1:631–655.
DellaCroce FJ, Sullivan SK. Application and re nement o the superior gluteal artery per orator ree ap or bilateral simultaneous
breast reconstruction. Plast Reconstr Surg. 2005;116(1):97–105.
Dupin CL, Allen RJ, Glass CA, Bunch R. Discussion: the internal mammary artery and vein as a recipient site or ree- ap breast
reconstruction: a report o 110 consecutive cases. Plast Reconstr Surg. 1996; 98:690–692.
Elliott LF, Beegle PG, Hartramp CR Jr. T e lateral transverse thigh ree ap: an alternative or autogenous-tissue breast reconstruction.
Plast Reconstr Surg. 1990;85(2):169–178; discussion 179–181.
Elliott LF, Hartramp CR Jr. T e Rubens ap. T e deep circum ex iliac artery ap. Clin Plast Surg. 1998;25(2):283–291.
Fansa H, Schirmer S, Warnecke IC, Cervelli A, Frerichs O. T e transverse myocutaneous gracilis muscle ap: a ast and reliable method
or breast reconstruction. Plast Reconstr Surg. 2008;122(5):1326–1333.
Farah AB, Nahas FX, Ferreira LM, Mendes Jde A, Juliano Y. Sensibility o the abdomen a ter abdominoplasty. Plast Reconstr Surg.
2004;114(2):577–582; discussion 583.
Fisher B, Costantino JP, Wickerham DL, et al. amoxi en or prevention o breast cancer: report o the National Surgical Adjuvant
Breast and Bowel Project P-1 Study. J Natl Cancer Inst. 1998;90(18):1371–1388.
Fisher J, Bostwick J 3rd, Powell RW. Latissimus dorsi blood supply a ter thoracodorsal vessel division: the serratus collateral. Plast
Reconstr Surg. 1983;72(4):502–509.
Fraulin FO, Louie G, Zorrilla L, illey W. Functional evaluation o the shoulder ollowing latissimus dorsi muscle trans er. Ann Plast
Surg. 1995;35(4):349–355.
Geddes CR, Morris SF, Neligan PC. Per orator aps: evolution, classi cation, and applications. Ann Plast Surg. 2003;50(1):90–99.
Germann G, Steinau HU. Breast reconstruction with the extended latissimus dorsi ap. Plast Reconstr Surg. 1996;97:519–526.
Guerra AB, Metzinger SE, Bidros RS, Gill PS, Dupin CL, Allen RJ. Breast reconstruction with gluteal artery per orator (GAP) aps. a
critical analysis o 142 cases. Ann Plast Surg. 2004;52(2):118–125.
Guerra AB, Metzinger SE, Lund KM, Cooper MM, Allen RJ, Dupin CL. T e thoracodorsal artery per orator ap: clinical experience
and anatomic study with emphasis on harvest techniques. Plast Reconstr Surg. 2004;114(1):32–41.
Hallock GG, Morris SF. Skin gra ts and local aps. Plast Reconstr Surg. 2011;127(1):5e–22e.
Hammond DC. Latissimus dorsi musculocutaneous ap breast reconstruction. In: Spear SL, ed. Surgery of the Breast. 2nd ed.
Philadelphia, PA: Lippincott Williams & Wilkins; 2006;1:601–623.
Hartramp CR Jr, Anton MA, Bried J . Breast reconstruction with the transverse abdominal island ( RAM) ap. In: Georgiade GS,
Rie kohl R, Levin LS, eds. Georgiade Plastic, Maxillofacial and Reconstructive Surgery. 3rd ed. Baltimore, MD: Williams & Wilkins;
1997:786–797.
Hartramp CR Jr, Noel R , Drazan L, Elliott FL, Bennett GK, Beegle PH. Ruben’s at pad or breast reconstruction: a peri-iliac so t
tissue ree ap. Plast Reconstr Surg. 1994;93(2):402–407.
Hidalgo DA. Aesthetic re nement in breast reconstruction: complete skin-sparing mastectomy with autogenous tissue trans er. Plast
Reconstr Surg. 1998;102(1):63–70.
Hokin JA, Sil verskiold KL. Breast reconstruction without an implant: results and complications using an extended latissimus dorsi ap.
Plast Reconstr Surg. 1987;79(1):58–66.
Hoover SJ, Kenkel JM. Breast cancer, cancer prevention, and breast reconstruction. Select Readings Plast Surg. 2002;9(30):1–40.
Kaplan JL, Allen RJ, Guerra A, Sullivan SK. Anterolateral thigh ap or breast reconstruction: review o the literature and case reports.
J Reconstr Microsurg. 2003;19:63–68.
Kelley BP, Valero V, Yi M, et al. amoxi en increases the risk o microvascular ap complications in patients undergoing microvascular
breast reconstruction. Plast Reconstr Surg. 2012;129(2):305–314.
Kundu N, Chopra K, Morales R, Djohan R, Chung , Gastman BR. Superior epigastric artery per orator (SEAP) ap: A novel approach
to autologous breast reconstruction. J Plast Reconstr Aesthet Surg. 2015;68(4):519–524.
Leibman AJ, Styblo M, Bostwick J 3rd. Mammography o the postreconstruction breast. Plast Reconstr Surg. 1997;99(3):698–704.
Margolis NE, Morley C, Lot P, et al. Update on imaging o the postsurgical breast. Radiographics. 2014;34(3):642–660.

CHAPTER 24 Breast Reconstruction: Alternative Flaps
209
Mathes S, Nahai F. Reconstructive Surgery: Principles, Anatomy & Technique. New York, NY: Churchill Livingstone; 1997.
Mathes SJ, Hentz VR, eds. Plastic Surgery. 2nd ed. Vol 6. Philadelphia, PA: WB Saunders; 2005.
Maxwell GP, Hammond DC. Breast reconstruction ollowing mastectomy and surgical management o the patient with high-risk breast
disease. In: Aston SJ, Beasley RW, T orne CHM, eds. Grabb and Smith’s Plastic Surgery. 5th ed. Philadelphia, PA: Lippincott-Raven;
1997:763–784.
Mehrara BJ, Santoro D, Arcilla E, Watson JP, Shaw WW, Da Lio AL. Complications a ter microvascular breast reconstruction:
experience with 1195 aps. Plast Reconstr Surg. 2006;118(5):1100–1109.
Munhoz AM, Ishida LH, Montag E, et al. Per orator ap breast reconstruction using internal mammary per orator branches as a
recipient site: an anatomical and clinical analysis. Plast Reconstr Surg. 2004;114(1):62–68.
Murphy RX Jr, Alderman A, Gutowski K, et al. Evidence based practices or thromboembolism prevention: summary o the ASPS
Venous T romboembolism ask Force Report. Plast Reconstr Surg. 2012;130(1):168e–175e.
Oslin BD, Grotting JC. Microsurgical breast reconstruction. In: Georgiade GS, Rie kohl R, Levin LS, eds. Georgiade Plastic, Maxillofacial
and Reconstructive Surgery. 3rd ed. Baltimore, MD: Williams & Wilkins; 1997:798–806.
Pannucci CJ, Bailey SH, Dreszer G, et al. Validation o the Caprini risk assessment model in plastic and reconstructive surgery patients.
J Am Coll Surg. 2011;212(1):105–112.
Papp C, McCraw JB. Autogenous latissimus breast reconstruction. Clin Plast Surg. 1998;25:261–266.
Reus WF III, Colen LB, Straker DJ. obacco smoking and complications in elective microsurgery. Plast Reconstr Surg. 1992;89:490–494.
Rizzuto RP, Allen RJ. Reconstruction o a partial mastectomy de ect with the super cial in erior epigastric artery (SIEA) ap. J Reconstr
Microsurg. 2004;20(6):441–446.
Russell RC, Pribaz J, Zook EG, Leighton WD, Eriksson E, Smith CJ. Functional evaluation o latissimus dorsi donor site. Plast Reconstr
Surg. 1986;78(3):336–344.
Schoeller , Huemer GM, Wechselberger G. T e transverse musculocutaneous gracilis ap or breast reconstruction: guidelines or ap
and patient selection. Plast Reconstr Surg. 2008;122(1):29–38.
Selber JC, Samra F, Bristol M, et al. A head-to-head comparison between the muscle-sparing ree RAM and the SIEA aps: is the rate
o ap loss worth the gain in abdominal wall unction? Plast Reconstr Surg. 2008;122(2):348–355.
Shaw WW, Watson J, Ahn CY. Alternatives in autologous ree- ap breast reconstruction. In: Georgiade GS, Rie kohl R, Levin LS, eds.
Georgiade Plastic, Maxillofacial and Reconstructive Surgery. 3rd ed. Baltimore, MD: Williams & Wilkins; 1997:807–816.
Smith BL, Souba WW. Breast procedures. In: Souba WW, Fink MD, Jurkovich GJ, et al., eds. ACS Surgery: Principles and Practice. 4th
ed. New York, NY: WebMD inc; 2004:187–201.
Spear SL, Davison SP. Aesthetic subunits o the breast. Plast Reconstr Surg. 2003;112(2):440–447.
Spear SL, Hess CL, Elmaraghy MW. Evaluation o abdominal sensibility a ter RAM ap breast reconstruction. Plast Reconstr Surg.
2000;106(6):1300–1304.
Spear SL, Hess CL. A review o the biomechanical and unctional changes in the shoulder ollowing trans er o the latissimus dorsi
muscles. Plast Reconstr Surg. 2005;115(7):2070–2073.
Sternberg EG, Perdikis G, McLaughlin SA, erkonda SP, Waldor JC. Latissimus dorsi ap remains an excellent choice or breast
reconstruction. Ann Plast Surg. 2006;56(1):31–35.
Strauch B, Vasconez LO, Hall-Findlay EJ, eds. Breast, chest wall, and trunk reconstruction. In: Grabb’s Atlas of Flaps. Vol 3. 2nd ed.
Philadelphia, PA: Lippincott-Raven; 1998:1259–1372.
Wechselberger G, Schoeller . T e transverse myocutaneous gracilis ree ap: a valuable tissue source in autologous breast reconstruction.
Plast Reconstr Surg. 2004;114(1):69–73.
Wei FC, Suominen S, Cheng MH, Celik N, Lai YL. Anterolateral thigh ap or postmastectomy breast reconstruction. Plast Reconstr
Surg. 2002;110(1):82–88.

This page intentionally left blank

211
John B. Hijjawi, MD, FACS
Kuylhee Kim, MD, and
Samuel J. Lin, MD, MBA, FACS

As the rate o contralateral prophylactic mastectomy in breast cancer patients increases, more women are
seeking immediate bilateral breast reconstruction. What are the main indications o preventive mastectomy
o contralateral breast?
BRCA1 or BRCA2 mutation positive.

In what percentage o patients is the RAM ap not available or autologous breast reconstruction?
25%. T is is secondary to history o abdominal surgery or inadequate bulk o abdominal tissue.

What are the three well-described risk actors or microsurgical breast reconstruction?
Smoking, obesity, history o radiotherapy.

What important actors should be considered when deciding between implant based versus autologous
breast reconstruction?
Patient’s desires, medical condition, body habitus, and possibility o additional adjuvant therapy.

What is the dominant blood supply to the ree RAM ap?
Deep in erior epigastric vessels.

What are the our main unctions o the rectus abdominis muscles?
T e rectus abdominis muscles are involved in the rst 30 degrees o lumbar spine exion, stabilize the upper body,
provide the site o insertion or the oblique and transversus abdominis muscles, and assist in raising
intra-abdominal pressure.

What other muscles are involved in torso exion?
Iliopsoas muscles (strongest upper body exors) and the vertically oriented bers o oblique muscles (lesser role).
Breast Reconstruction:
Microsurgery and
Autologous Reconstruction
CHAPTER 25

212
Plastic & Reconstructive Surgery Board Review

What is the “usual” relationship between the DIEA (deep in erior epigastric artery) per orators and the
SIEA (super cial in erior epigastric artery)?
Inverse relationship; when the DIEA per orators are large or abundant, the SIEA is usually small and vice versa.

How much abdominal wall ascia is taken with the SIEA ap?
None.

Where does the SIEA pierce the Scarpa’s ascia and then run super cially?
In erior to and within 1cm o the midpoint o the inguinal ligament.

Is the SIEA usually deep or super cial to Scarpa’s ascia BELOW the inguinal ligament?
Deep.

Is the SIEA usually deep or super cial to Scarpa’s ascia ABOVE the inguinal ligament?
Super cial.

How do you design an SGAP (Superior Gluteal Artery Per orator) ap?
T e ap is designed along a central axis ormed by origin o the SGA at 5 cm in erior to posterior iliac spine and
the dome o maximum lateral ullness. Dissection is carried over gluteus maximus rom lateral to medial. T e
medial origin o the muscle is taken down to expose the pedicle.

What ap dimensions can be obtained with the SGAP ap?
1. Skin: width 6 to 13 cm
2. Length 20 to 33 cm
3. Pedicle length: 6 to 8 cm

Where are the per orators o SGAP ap ound most requently?
One-third o the distance on a line rom the posterior superior iliac crest to the greater trochanter.

What is a substantial disadvantage o the SGAP ap?
Harvest requires prone or lateral repositioning during surgery.

Can the SGAP ap be sensate?
Yes, by the repairing the dorsal branches o the lumbar segmental nerves to the 4 intercostal nerve.

Lateral septocutaneous SGAP ap was introduced to address the short pedicle length which is one o the
limitations o traditional SGAP ap. What are the two muscles that the superolateral per orator comes
through?
Gluteus maximus and medius muscle.

CHAPTER 25 Breast Reconstruction: Microsurgery and Autologous Reconstruction
213

Which nerve is sacri ced in the harvest o an in erior gluteal ap?
Posterior cutaneous nerve o thigh.

What are the advantages o IGAP ap over SGAP ap?
1. Removal o excessive in erior buttock tissue while maintaining superior ullness o the buttock
2. Longer pedicle (8–11 cm vs. 6–8 cm)

What is the vascular supply to the Ruben’s ap?
Deep circum ex iliac system.

What is the average pedicle length o the Ruben’s ap?
7 cm.

What is a common donor site complication with this ap?
Hernia due to inadequate repair o the abdominal wall at the iliac crest.

Why per orm the DIEP ap with its dif cult dissection?
Minimize donor site morbidity.

How many per orators does this ap require to succeed?
One good per orator.

Will a per orator rom the medial or lateral row provide better per usion to zone 4?
Medial row.

Which system, deep or super cial in erior epigastric, reliably supplies a greater area o the lower abdominal
wall?
Super cial in erior epigastric.

Doppler ultrasound has been supplanted by Computed opographic angiography (C A) as the standard
method o preoperative per orator identi cation. What kind o in ormation can be gathered rom C A
nding?
Location, size, course, branching pattern o per orator.

Intraoperative real-time angiographic imaging has been gaining popularity or the evaluation o tissue
per usion and angiosome de nition. What is the uorescent agent used or this intraoperative per usion
scanning?
Indocyanine green.

214
Plastic & Reconstructive Surgery Board Review

Which orientation (horizontal or transverse) o the skin paddle is most reliable when harvesting a gracilis
musculocutaneous ap?
ransverse.

What is an advantage o this ap?
Medial thigh li t, hidden donor scar, and minimal patient repositioning.

At what level is the skin paddle centered or the transverse upper gracilis ( UG) ap?
Level o the pedicle, also level o major per orator.

What is the dominant blood supply to the UG ap?
Gracilis vessels rom the medial emoral circum ex system.

Which vessels have become the most pre erred recipient vessels in microsurgical breast reconstruction?
T e internal mammary vessels (internal thoracic).

What are the advantages o the IM vessels?
Good size match with DIE vessels, improved positioning o the ap on the chest (more medial), avoid axillary
dissection need or thoracodorsal vessels, preserve the dominant pedicle or the latissimus dorsi muscle (li eboat or
reconstruction).

T e IMV is usually smaller on the le t or right side?
Le t.

What are the advantages to the use o an IMA per orator as a recipient vessel?
T e IMA is preserved or uture cardiac surgery, reduces the possibility o thoracic de ormities, and simpler
dissection.

What vessels are available as recipients or microsurgical breast reconstruction?
T oracodorsal, IMA, IMA per orators, thoracoacromial artery, lateral thoracic, circum ex scapular arteries (branch
o subscapular artery).

How many branches does the thoracoacromial artery usually have?
Four main branches:
1. pectoral
2. deltoid
3. clavicular
4. acromial

How many centimeters lateral to the sternal border are the internal mammary vessels?
1.5 cm.

CHAPTER 25 Breast Reconstruction: Microsurgery and Autologous Reconstruction
215

At which intercostal interspace is anastomosis to the IM vessels usually per ormed in breast reconstruction?
T ird.

T e angle o Louis can be used as a landmark to count the rib. Which rib cartilage is attached to the angle o
Louis?
Second.

What are two li eboat veins in microsurgical breast reconstruction?
Cephalic vein and external jugular. Both can be transposed and have been used success ully in venous anastomosis
problems.

o create aesthetically pleasing breast shape in reconstructive breast surgery, preserving and de ning the
“ ootprint” o the natural breast is important. What is the ar most lateral boundary o the ootprint?
1 to 2 cm behind the anterior axillary line. (T e ootprint never extends to the mid-axillary line.).

T ere is an increased number o women requesting conversion o their implant breast reconstruction to
autologous breast reconstruction. List in order the most common reasons or this request.
Physical discom ort (some are caused by capsular contracture)
Dissatis action o aesthetic outcome
Implant ailure
REFERENCES
Arnez ZM, Khan U, Pogorelec D, Planinsek F. Breast reconstruction using the SIEA ap. Br J Plast Surg. 1999;52(4):276–279.
Arnez ZM, Pogorelec D, Planinsek F, Ahcan U. Breast reconstruction by the ree transverse gracilis ( UG) ap. Br J Plast Surg.
2004;57(1):20–26.
Blondeel PN, Hijjawi J, Depypere H, Roche N, Van Landuyt K. Shaping the breast in aesthetic and reconstructive breast surgery: an
easy three-step principle. Plast Reconstr Surg. 2009;123(2):455–462.
Blondeel PN. T e sensate ree superior gluteal artery per orator (S-GAP) ap: a valuable alternative in autologous breast reconstruction..
Br J Plast Surg. 1999;52(3):185–193.
Buncke HJ. Microsurgery: Transplantation and Replantation: an Atlas-Text. Philadelphia, PA: Lea and Febiger; 1991.
Harris JR, Lueg E, Genden E, Urken ML. T e thoracoacromial/cephalic vascular system or microvascular anastomosis in the vessel-
depleted neck. Arch Otolaryngol Head Neck Surg. 2002;128(3):319–323.
Lantieri LA, Mitro anof M, Rimareix F, Gaston E, Raulo Y, Baruch JP. Use o circum ex scapular vessels as recipient or autologous
breast reconstruction. Plast Reconstr Surg. 1999;104(7):2049–2053.
Lo empio MM, Allen RJ. Breast reconstruction with SGAP and IGAP aps. Plast Reconstr Surg. 2010;126(2):393–401.
Mathes DW, Neligan PC. Preoperative imaging techniques or per orator selection in abdomen-based microsurgical breast reconstruction.
Clinics in plastic surgery. 2010;37(4):581–591.
Mehrara BJ, Santoro , Smith A, et al. Alternative venous out ow vessels in microvascular breast reconstruction. Plast Reconstr Surg.
2003;112(2):448–455.
Munhoz AM, Ishida LH, Montag E, et al. Per orator ap breast reconstruction using internal mammary per orator branches as a
recipient site. Plast Reconstr Surg. 2004;114(1):62–68.
Rao S, Stolle EC, Sher S, Lin CW, Momen B, Nahabedian MY. A multiple logistic regression analysis o complications ollowing
microsurgical breast reconstruction. Gland surgery. 2014;3(4):226–231.

216
Plastic & Reconstructive Surgery Board Review
Schoeller , Meirer R, Otto-Schoeller A, Wechselberger G, Piza-Katzer H. Medial thigh li t ree ap or autologous breast augmentation
a ter bar iatric surgery. Obes Surg. 2002;12(6):831–834.
Vandervoort M, Vranckx JJ, Fabre G. Per orator topography o the deep in erior epigastric per orator ap in 100 cases o breast
reconstruction. Plast Reconstr Surg. 2002;109(6):1912–1918.
Visser NJ, Damen H, imman R, Ho er SO, Mureau MA. Surgical results, aesthetic outcome,and patient satis action a ter microsurgical
autologous breast reconstruction ollowing ailed implant reconstruction. Plast Reconstr Surg. 2010;126(1):26–36.
Volpe AG, Rothkop DM, Walton RL. T e versatile super cial in erior epigastric ap or breast reconstruction. Ann Plast Surg.
1994;32(2):113–117.
Weschedlberger G, Schoeller . raverse myocutaneous gracilis ree ap. Plast Reconstr Surg. 2004;114(1):69–73.
Weschelberger G, Schoeller , Bauer , et al. Surgical technique and clinical application o the transverse gracilismyocutaneous ree ap.
Br J Plast Surg. 2001;54:423–427.
Yousi NJ, Matloub HS, Kolachalam R, Grunert BK, Sanger JR. T e traverse gracilis musculocutaneous ap. Ann Plast Surg.
1992;29:482–490.

217
Edin Hajder, MD,
Pieter G.L. Koolen, MD,
Nicholas Do, MD, and
Samuel J. Lin, MD, MBA, FACS
BASIC PRINCIPLES OF RADIATION THERAPY

What is radiation?
Radiation is a orm o energy. T ere are two basic types: particulate radiation and electromagnetic radiation.
Particulate radiation is caused by the movement o subatomic particles and thus has a mass. T is is contrary to
electromagnetic radiation which is pure energy with no mass and is transmitted by massless photons.

What are the subatomic particles used as therapeutic radiation?
T ere are three particles that radiation oncologists utilized or therapeutic ends:
• Electrons: these are the standard particles delivered in the vast majority o therapeutic radiation.
• Protons: the opposite charge o electrons these have a unique dose distribution.
• Neutrons: these particles have a high mass and there ore have 20 to 100 times the energy o electrons.

What is ionizing radiation opposed to nonionizing?
Radiation is called ionizing when it contains enough energy so that during interaction with an atom it can remove
tightly bound electrons rom the orbit o an atom. T is causes the atom to become charged or ionized. Ionizing
radiation damages DNA. Nonionizing radiation does not, or example, radio, in rared, and microwave.

What are gamma rays opposed to x-rays?
Both gamma and x-rays are a orm o electromagnetic radiation, that is, weightless packets o energy. T ey are
similar to visible light, but with much more energy. X-rays are arti cially produced by a roentgen tube, whereas
gamma rays originate rom an atomic nucleus with subsequent de ned characteristics.
Radiation Therapy and
Reconstruction
CHAPTER 26

218
Plastic & Reconstructive Surgery Board Review

What are ree radicals?
Atoms or molecules with an unpaired electron which makes them highly chemically damaging.

What is radiosensitivity?
T e relative susceptibility o cells, tissues, or organs to the action o radiation. T e most actively dividing cells or
those not ully mature are most at risk rom radiation.

Which tissues possess high radiosensitivity and which contain low?

What is absorbed dose?
T e amount o energy that ionizing radiation imparts to a given mass is called absorbed dose. T e SI unit is the
gray (Gy). One gray is de ned as a dose o 1 joule per kilogram.

What is dose equivalent?
T e dose equivalent relates the absorbed dose to the biological e ect o the absorbed dose. It takes into account
the biological e ectiveness o radiation which is dependent on radiation type and energy. A sievert (Sv) is the unit
used or dose equivalent. Radiation doses in medical imaging are expressed as millisieverts (mSv).

What is the average natural background radiation?
On average 3 mSv (milli-sievert) per year or US citizens.

How can radiation cause cancer?
Ionization o water molecules can create radicals that may damage DNA. Although most damage is repaired,
misrepair can occur leading to mutations, chromosome translocations, or gene usions. It is estimated that 2% o
the cancers in the United States is related to computed tomography (C ).

Is all ionizing radiation stochastic?
Yes. It can occur at any level o radiation exposure. With increasing dose, the risk increases as well.
High Radiosensitivity
Lymphoid organs, bone marrow, blood, testes, ovaries, intestines
Fairly High Radiosensitivity
Skin and other organs with epithelial cell lining (cornea, oral cavity, esophagus, rectum, bladder, vagina,
uterine cervix, ureters)
Moderate Radiosensitivity
Optic lens, stomach, growing cartilage, f ne vasculature, growing bone
Fairly Low Radiosensitivity
Mature cartilage or bones, salivary glands, respiratory organs, kidneys, liver, pancreas, thyroid, adrenal and
pituitary glands
Low Radiosensitivity
Muscle, brain, spinal cord

CHAPTER 26 Radiation T erapy and Reconstruction
219

What is the usual interval between radiation exposure and a possible cancer?
T e period between exposure and cancer diagnosis is at least 5 years, but in most cases 10 to 20 years or longer.

Which doses are associated with radiation-induced cancer?
T ere is clear evidence that doses above 100 mSv are stochastic. However, in normal medical imaging these
levels are rarely reached. Only in cases o multiple high-dose examinations (e.g., C or complex interventional
radiology) in a short time this can be reached. T e risk at doses between 10 and 100 mSv is controversial, but this
is more requently seen in normal medical practice, or instance a single multiphasic C .

What is the in uence o the cell cycle phase on radiation damage?
T e phase in which cells are most susceptible to damage is M phase as this is where chromosomes condense
and there ore result in a higher probability o double-strand breaks.
T e phase in which cells are most resistant is S phase where enzymes and proteins responsible or replication and
repair overexpressed thereby con erring more protective capability o the cell to recover rom DNA damage.

How are cancer cells inherently more susceptible to radiation than normal cells?
Radiation therapy capitalizes on two essential di erences in cancer cell biology: (1) rapid growth and (2) DNA
repair ability. T e comparatively rapid growth o cancer cells rom more requent cell division means that they
spend more time in the most radiation susceptible o the cell cycle (M phase). Cancer mutations are o ten DNA
repair mutations and thus cancer cell populations are less able to prevent the accumulation o lethal mutations.

What radiation dose is given by medical imaging?
Computed tomography
Sinuses 0.6 mSv
Head 2.0
Chest 7.0
Chest (pulmonary embolism) 10.0
Abdomen and pelvis 10.0
Multiphase abdomen and pelvis 31.0
Radiography
Extremity 0.001
Chest 0.1
Lumbar spine 0.7
Abdomen 1.2
Mammography 0.7
Bone densitometry (DEXA) 0.001
Nuclear medicine
Lung ventilation/per usion 2.0
Bone scan 4.2
Cardiac per usion (sestamibi) 12.5
Fluoroscopy
Barium swallow 1.5
Coronary angiography 5 to 15

How can radiation dose be reduced?
One can decide not to per orm the study. Alternatively, alternatives without ionizing radiation can be sought or
less radiation can be used (e.g., low-dose C in case o suspected urinary stone disease).

Which patients are most at risk and why is that?
Younger patients and pregnant patients are at increased risk due to high radiosensitivity. Furthermore, patients
with a high BMI and those undergoing multiphasic C are at higher risk as a result o higher radiation dose.

220
Plastic & Reconstructive Surgery Board Review

What is the ALARA principle?
ALARA is an acronym or “As Low As Reasonably Achievable,” which re ers to the radiation sa ety principle o
keeping radiation doses and releases o radioactive materials to the environment as low as can be achieved, based
on technologic and economic considerations.
RADIATION ONCOLOGY

How is radiation delivered?
Delivery o radiation can be divided into two major routes: external (beam) and internal (brachytherapy).

What is external beam radiation?
T e therapeutic radiation is delivered rom a source external to the patient. T e most common method o delivery
is via a linear accelerator (LINAC) which accelerates charged subatomic particles (i.e., electrons) via an accelerator
tube and beam transport system to deliver to target areas o a patient’s anatomy.

What is particle therapy?
T e various particles in particle radiation have all been used to therapeutic e ect. Electrons are most commonly
used and tend to deposit their energy more super cially in the body. T us they are commonly used or skin
cancers, breast cancer, oral cancers, etc.
Protons have a unique dose distribution as they travel through, deposit their peak energy deeper in tissue and have
a steeper drop o a terward theoretically limiting the absorbed radiation to super cial and surrounding structures.
T ey are ideal or deep lesions like skull base tumors such as chordomas or pediatric craniospinal tumors such as
medulloblastomas. However, protons require a cyclotron to be delivered and these devices are not only expensive
to construct and maintain but also require substantial space.
Neutrons deliver a much higher degree o radiation than either electrons or protons and are there ore more
e ective at treating traditionally radioresistant tumors such as sarcomas. However, the collateral damage to
surrounding tissues is more severe given the higher amount o radiation delivered.

What is meant by ractionation?
Fractionation is the distribution o delivered therapeutic radiation over time. ypes o ractionation are:
• Hypo ractionation: smaller total dose with larger doses per raction
• Hyper ractionation: smaller doses per raction over the same time period
• Accelerated ractionation: same dose delivered over shorter period o time

What is the rationale behind ractionation?
Fractionation o radiation dosing is both to better target cancer cells and spare normal tissue. In between ractions,
cancer cells are allowed to re-oxygenate thereby leading to more ree radical when radiation is administered. In
addition, in between ractions cancer cells are allowed to progress through the cell cycle transitioning into the
more susceptible M phase. Normal tissue is allowed to progress through cellular repair in between ractions.

What is meant by boost?
A boost is an additional dosage o external beam radiation delivered to speci c treatment targets (i.e., mastectomy
incision, lumpectomy cavity).

CHAPTER 26 Radiation T erapy and Reconstruction
221

What is meant by bolus?
Usually in re erence to electron beam therapy, a bolus is a tissue density mimicking material placed on the sur ace
o a patient’s targeted anatomy such that the peak amount o radiation absorbed ends up being more super cial
than it would be had not the bolus material been there. It is used commonly in breast irradiation to deliver a
ocused dose more super cially.
RADIATION, WOUND HEALING, AND RECONSTRUCTIVE SURGERY

How does radiation alter wound healing?
Radiation a ects wound healing in 4 ways:
1. Hypovascularity: T ere is a progressive narrowing o vessels and thus a decrease in tissue per usion with
concomitant decrease in oxygen delivery and cellular actors (neutrophils, monocytes, etc.).
2. Hypoxia: Decreased oxygen has several consequences. Oxygen is required or the oxidative burst used by
neutrophils to kill bacteria thus hypoxia results in diminished capacity against battling in ection. Oxygen
is also needed or the hydroxylation o lysine and proline as well as collagen cross-linking there ore hypoxia
results in diminished collagen ormation. Angiogenesis requires an oxygen gradient which is altered hypoxia
and thus vessel ormation is blunted.
3. Fibroblast and epithelial cell e ects: Radiation depletes broblasts and results in the disorganized collagen
deposition rom remaining broblasts thereby leading to decreased wound breaking strength. Decreased
epithelial cell mitotic activity results in atrophic and thinned epithelium.
4. Alterations in cellular signaling: GF-B, VEGF, NF-a, IFN-g, proin ammatory cytokines (IL-1, IL-8) are
all overexpressed leading to extra cellular matrix accumulation with resultant brosis. Reduced levels o nitric
oxide (NO) lead to less collagen deposition. Finally dysregulation o metallomatrix protein 1 (MMP-1) results
in disorganized collagen deposition.

What is the e ect o radiation upon ree ap anastomoses?
While there is arterial tunica media brosis and subendothelial smooth muscle proli eration there is no change in
patency. In addition, arterial patency is maintained whether radiation is received 2 weeks prior, the day o , or
2 weeks a ter surgery. As discussed later in this chapter, papers evaluating clinical outcomes seem to re ect the
basic science data.

What is the e ect o a ree ap upon a previously irradiated wound bed?
Neovascularization occurs at the recipient- ree ap inter ace but is delayed. However, this process decreases with
increasing dose size and decreasing time rom radiation. T ere appears to be no decrease in the tensile strength nor
collagen content at the recipient- ree ap inter ace and the tissue repair at the inter ace seems to approach that or
nonradiated surgical incisions.
HEAD AND NECK CANCER AND RADIATION

Why is radiation requently used as the primary treatment or laryngeal and hypopharyngeal carcinoma as
opposed to surgery?
T e Department o Veterans A airs Laryngeal Cancer Study Group NEJM 1991 was the landmark study
promoting radiation alone as the primary treatment in an attempt to preserve the larynx. Primary chemoradiation
with laryngeal preservation rate was 64% o surviving patients. Cure rates with radiation only were equivalent to
total laryngectomy with postop radiation (68% both).