Reoperative Aesthetic & Reconstructive Plastic Surgery

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This 58-year-old woman requested breast reconstruction.The right chest wall had
been irradiated following mastectomy. She was considerably underweight.
In the rst stage the right breast mound was reconstructed with placement of a
latissimus dorsi ap and tissue expander.

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Reoperation Following Implant Breast Reconstruction
The patient requested, at the second stage, that the left breast be enlarged.To do this
for her would have made it impossible to achieve symmetry because of the limita-
tions of what could be accomplished on the right side.Therefore a small reduction
on the left side ultimately produced a breast that we could come closer to match-
ing with a permanent silicone gel implant on the right.
The 6-month postoperative result is shown with the patient awaiting tattooing of
the nipple-areola complex.
CORRECTION OF PROBLEMS ASSOCIATED W ITH
SALINE IMPLANTS
In atable saline implants have been widely used for reconstruction since 1993.30,31
Although these devices have been satisfactory for breast augmentation, they have
not produced the same degree of success in reconstruction. Prospective studies of
saline- lled breast implants have shown reoperation rates of 39% to 40% at 3 years
and 43% to 45% at 5 years for reconstruction patients. The same studies revealed
implant removal rates of 23% to 27% at 3 years and 28% to 30% at 5 years for re-
construction patients. Saline de ation rates following breast reconstruction are 6%
to 9% at 3 years and 8% to 18% at 5 years. Capsular contracture rates of grades III

1328
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R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
or IV (the breast is rm and looks abnormal or is hard and painful) are 25% to
30% at 3 years and 29% to 36% at 5 years.The wrinkling phenomenon seems to be
more common with saline implants.Wrinkling or rippling is clearly related to un-
der lling and will occur in all under lled implants in the upright position. How-
ever, even properly lled saline devices will display rippling, wrinkling, pleating.
With textured-surface silicone in atable implants in which the surrounding capsule
is adherent to the outer surface of the implant, wrinkling can be a source of dissat-
isfaction, especially if the soft tissue coverage is thin.Textured-surface implants are
not freely mobile within the capsule and therefore wrinkling may be more visible.
Sometimes these corrugations are simply palpable, but other times they are visible
through the skin. As the capsule adheres into the surface folds in the implant, the
overlying subcutaneous tissue and skin will deform into this corrugated pattern. It
is dif cult to either prevent or treat this problem. Overin ation of implants is effec-
tive at reducing wrinkling only temporarily. It will almost always recur; therefore
overin ation can merely exacerbate the problem. Use of a smooth-surface implant
rather than a textured-surface implant increases implant mobility within the pocket
but does not necessarily diminish upper pole wrinkling. However, the wrinkling
may not be as visible with the smooth-surface implants, especially as the capsule
thickens.
This 41-year-old patient underwent bilateral breast reconstruction with saline in-
atable implants. She had an in ltrating ductal carcinoma of the right breast and
premalignant changes of the left breast. Simple mastectomies were performed on
successive occasions with saline implant insertion. Notice the rippling in the upper
pole of the reconstructed left breast. Six months after completion of the recon-
struction she presented with the de ation of the left-sided implant. At surgery a
small perforation was found on the base of the implant away from the valve area.
The implant was removed through the lateral mastectomy scar, a perimeter capsu-
lotomy was performed, and an identical implant was replaced into the same pocket.
She has experienced no further problems.

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Reoperation Following Implant Breast Reconstruction
Correction of the base diameter of the reconstructed breast can be accomplished
simply by measuring the base diameter of the opposite breast. The expander or
previous implant is then replaced by a saline implant of appropriate base diameter.
In actuality, the base diameter is a much more important factor than the ultimate
volume in terms of achieving symmetry. Capsular alterations may also be necessary.
Occasionally it is helpful to place an adjustable implant rather than a xed-volume
implant in the second stage. When treating recurrent capsular contracture, some
surgeons have advocated maintaining slight overcorrection for a period of 3 to 6
months while the new capsule is forming; then saline solution is withdrawn from
the implant to achieve the appropriate volume. However, one must be aware of
the possibility of “uncovering” upper pole wrinkling as the saline solution is with-
drawn.
For the past decade, virtually all implant reconstruction in the United States has
necessarily required the use of saline implants.This is currently changing;however,
the restriction on silicone gel devices led to new technology for anatomically
shaped textured saline implants. As long as these devices are not over lled and de-
pending on the type of texturing, they can produce a more anatomically shaped re-
constructive breast despite the limitations of saline as a ller. My experience, how-
ever, is that silicone gel devices, particularly the textured and anatomically shaped
ones, yield the highest quality of implant reconstruction.
This patient was seen 5 years after bilateral subcutaneous mastectomies with saline
implant reconstruction. She presented with a left saline deflation. It can be ob-
served from the preoperative appearance that the patient had substantial breast tis-
sue or fat left behind as the implant was fully de ated.

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We decided to electively de ate the right implant in the of ce and allow the tissues
to contract over a 30-day period so that implant replacement and vertical masto-
pexy could be more accurately planned.
Following conversion to silicone gel anatomically shaped implants and vertical
mastopexy, the shape and size were greatly improved.
INFRAMAMMARY FOLD ALTERATIONS
The inframammary fold is the key to achieving a good result no matter what kind
of breast reconstruction is being performed. Unless this fold is set at the proper
level, all other natural curves of the breast will be dif cult to simulate.32,33

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Reoperation Following Implant Breast Reconstruction
Inframammary Fold Too High
A high inframammary fold is a common problem after breast reconstruction; for-
tunately, it is also the easiest to correct during reoperative breast implant surgery. An
inframammary fold that is too high may result from the initial implant or expander
being placed too high or from the natural elevation that occurs with encapsulation.
With the patient standing preoperatively, the proper inframammary fold level is
marked on the chest wall. Usually the fold can be lowered by simply incising the
perimeter of the capsule in the lower pole of the breast and dissecting the subcu-
taneous tissue off the muscle fascia to the marked level.To produce the appearance
of ptosis, the capsule may have to be “diced” or removed to allow soft tissue redrap-
ing. However, it is possible to lower the fold too much by dissecting too low. In ad-
dition, in patients who have thick subcutaneous tissues, the fold is easily blunted so
that there is not a distinct emergence of the lower pole of the breast from the chest
wall.This appearance is unaesthetic and dif cult to correct.Therefore in these pa-
tients I prefer to thin the fat slightly and place internal plication sutures between
Scarpa’s fascia and the chest wall. If this maneuver does not give the distinct, crisp
inframammary fold that I am trying to achieve, it may be necessary to actually pli-
cate the dermis to the chest wall using 2-0 Prolene sutures.These sutures may need
to be placed from the medialmost extent of the inframammary fold all the way to
the anterior axillary line. More commonly, however, only a portion of the infra-
mammary fold will need to be plicated in this way.This determination is best made
in the operating room with the patient in the upright position. It must be kept in
mind that the fold will often elevate 1 to 2 cm postoperatively as the capsule de-
velops, especially with smooth-surface implants.Therefore this correction is taken
into account when the fold level is chosen preoperatively.

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Expander
View through lateral incision
Fibers of pectoralis
major muscle
(pectoralis fascia)
Old scar
Extent of lateral incision in old scar varies
according to amount of capsular alteration
necessary and size of implant to be inserted;
it is prudent to divide the muscle and capsule
at a different level to avoid implant exposure
in the event of skin incision separation
Radial release incisions
Transverse incisions will increase
vertical dimension of pocket and
also allow greater projection
Capsule
Fat removed
from depth of pocket
Depth of pocket
Suture necessary only
if soft tissues are thick
and inframammary fold
is not well defined
Thinned fat

1333
Chapter 35
Reoperation Following Implant Breast Reconstruction
The following case represents a much more dif cult challenge in lowering a high
reconstructed inframammary fold.
This 44-year-old patient presented 3 years after an immediate left breast recon-
struction with a latissimus dorsi ap and small saline implant. Preoperative evalua-
tion revealed profound asymmetry, with a left inframammary fold that was consid-
erably higher than the right.
The operative plan is shown, requiring complete remobilization of the latissimus
ap so that it could be transposed into the lowered inframammary fold. A lower
capsulectomy and lowering of the saline implant will also be necessary to project
the reconstructed breast in the inferior pole.

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Intraoperatively, the latissimus ap is carefully dissected away from the overlying
mastectomy skin aps and off of the underlying pectoralis major muscle. After cap-
sulectomy, a new saline implant is placed and the ap used to provide coverage pri-
marily in the lower pole.The skin island is mobilized enough to be moved into an
appropriate future position for the nipple-areola complex.
A small augmentation of the right breast completes the reconstruction of the breast
mound giving much improved size and shape.

The above sequence demonstrates the use of a shared nipple graft from the right
breast transplanted into a U-shaped dermal ap on the left side. Part of the left skin
island is removed to improve the nipple position.
1335
Chapter 35
Reoperation Following Implant Breast Reconstruction
The postoperative result demonstrates a nicely lowered left inframammary fold and
symmetrical shape of the reconstructed left breast.

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R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
Inframammary Fold Too Low
Purposely constructing a low inframammary fold has been suggested as a way of
simulating a ptotic opposite breast. Although this technique can give the visual im-
pression of ptosis on anterior view, particularly in a photograph, the patient nds it
dif cult to wear a brassiere or other tted clothing when the inframammary folds
are at different levels.Therefore I prefer not to use this technique for creating pto-
sis. However, if the fold is too low from a low expansion or a descended implant,
this problem can be corrected in the second stage of a planned staged reconstruc-
tion. I prefer to use the internal plication technique rather than external dermal ap
procedures as proposed by Ryan.34-36
The lateral portion of the previous skin incision is reopened, and a short subcuta-
neous ap is developed so that the muscle pocket can be entered at a different level.
This approach is taken so that if one of the incisions opens postoperatively, implant
exposure or extrusion is less likely to result.The pectoralis major muscle is divided
along its bers to expose the capsule.
The capsule is then entered and opened wide enough so that the entire lower por-
tion of the capsule can be visualized after the removal of the expander or previous
implant. If the skin and subcutaneous tissue overlying the capsule in the lower pole
are quite thin, the inframammary fold can sometimes be re-created by capsular pli-
cation sutures alone that extend from the medialmost aspect to the anterior axillary
line. Heavy sutures of 2-0 Prolene are most effective. If the subcutaneous tissues
are thick or if capsular plication sutures do not create a crisp inframammary fold
when the patient is in the sitting position, then the capsule must be opened and a
capsular ap dissected from the level of the old inframammary fold up to the level
of the new one.
The subcutaneous tissues beneath the capsule are then thinned because this tissue
is being converted to abdominal wall skin rather than breast skin.The capsular ap
is then advanced superiorly and plicated to the posterior capsule on the chest wall.
In addition, I nd it helpful to place heavy sutures through either the Scarpa’s fas-
cia or the dermis to the chest wall in a manner similar to that described for lower-
ing the inframammary fold. A double row of sutures will help to secure the new in-
framammary fold and prevent descent of the new implant. A textured-surface
implant is a good choice under these circumstances as it is more likely than a
smooth-surface implant to stay xed in position.

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Chapter 35
Reoperation Following Implant Breast Reconstruction
Level of skin incision
Level of muscle incision
Deep sutures
Incision in base of capsule
Capsule incised and
sutured to pectoralis fascia
or rib periosteum

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R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
Altering the projection of a saline implant reconstruction is dif cult, because if one
simply adds volume, the shape may be adversely affected and an unnatural fullness
may result, particularly in the upper pole. If breast attening is caused by capsular
contracture in the lower pole, this problem can be improved in the second stage.
Preoperatively the horizontal level that corresponds with the point of maximum
projection on the opposite breast is marked.This marking is continued over the re-
constructed breast. Below this level the capsule must be either removed or incised.
The capsule is entered as before; the level of the skin incision and the capsular in-
cision laterally can vary.
ALTERATION OF PROJECTION
The implant or expander is removed. The initial horizontal capsular incision de-
marcates the upper from the lower pole. Perpendicular radial incisions are then
made to expand the capsule and the lower pole soft tissue envelope in the anterior
and horizontal direction.“Dicing” the capsule or removing it entirely in the lower
pole allows the soft tissue envelope to expand in all directions.These incisions will
Capsule
Fat removed
from depth of pocket
Incisions

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Chapter 35
Reoperation Following Implant Breast Reconstruction
allow an increase in projection in the lower pole of the breast reconstructed with
saline or gel implants.They also increase the ability of a more projecting implant to
expand the lower pole of the breast anteriorly. However, one must take great care
not to overthin the soft tissue coverage in this area and risk implant extrusion.
CORRECTION OF LATERAL IMPLANT DISPLACEMENT
The youthful breast is full medially, is nonptotic, and does not extend beyond the
anterior axillary line. However, as a result of the effects of gravity, implants or ex-
panders inserted for immediate reconstruction that develop soft capsules may shift
laterally or descend into the inferior part of the axillary dissection.This problem is
bothersome to patients and is a frequent source of asymmetry and dissatisfaction.
Lateral implant displacement is best corrected internally. Preoperatively with the pa-
tient in the standing position, the implant is manually compressed into the proper
position and a line is drawn on the skin extending from the inframammary fold lat-
erally to mark the lateral limit of the base of the breast.This line will be translated
to the capsule and chest wall for the plication.
With the patient under general anesthesia, the mastectomy scar is reopened later-
ally and the capsule is entered at a separate level.The implant can sometimes sim-
ply be distracted medially while these sutures are placed. Other times it is best to
temporarily remove the implant, particularly if any other capsular surgery is to be
performed.The capsule and chest wall are then marked internally according to the
preoperative skin markings. The marking is scored with electrocautery to create a
fresh tissue plane to promote healing. A double row of running 2-0 Prolene sutures
is used to plicate the lateral capsule to the chest wall. After the plication is com-
pleted, the implant can be reinserted, and the patient is placed in a sitting position
to check the correction.

1340
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R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
This patient underwent a right simple mastectomy for recurrent cystosarcoma phyl-
loides. An integrated-valve textured-surface expander was placed at the time of
mastectomy. Overexpansion has created an ample soft tissue envelope. However,
the inframammary fold is at least 2 cm too low and laterally displaced.
The second stage required both a change of the device and the alteration of the soft
tissue envelope. The inframammary fold needed to be raised 2 cm, and the lateral
portion of the capsule had to be plicated. A scar revision of the lateral mastectomy
scar was accomplished at the same time.

After the resection of the mastectomy scar, the inferior mastectomy ap was ele-
vated from the muscle cover so that the muscle could be entered at a separate level
from the skin incision.This approach ensures that if either the skin incision or the
muscular closure were to dehisce postoperatively, neither would necessarily result in
implant exposure. The textured-surface implant was separated bluntly from the
capsule rst over the dome of the implant and then at its base. The expander was
then removed.
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Chapter 35
Reoperation Following Implant Breast Reconstruction

1342
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
In this case a textured-surface saline implant was custom-designed based on mea-
surements taken from the opposite normal breast. One can see the increased projec-
tion and decreased base diameter of the custom implant compared to those of the
expander. Intraoperatively the patient was placed in a sitting position to make nal
adjustments.The capsule was scored over its inferior half as well as plicated inferi-
orly and laterally to raise the position of the reconstructed breast on the chest wall.
The early postoperative result is shown.

OPPOSITE BREAST ADJUSTMENTS
Although we should strive to match the opposite breast without altering it, this is
not always possible, particularly when breast implants are used.
My philosophy is to keep opposite breast alterations to a minimum.
The surgeon should never do anything to the opposite breast that
would signi cantly affect the patient’s ability to peform a breast self-
examination or to be followed for the development of breast cancer.
It is dif cult to match a very small opposite breast without augmenting it. If aug-
mentation is acceptable to the patient, I prefer an implant in the submuscular po-
sition to optimize mammographic screening.
If a reduction mammaplasty is to be performed, I try to select a technique that will
minimize the chances of fat necrosis and subsequent parenchymal calci cation. In
a very large breast this might mean employing a free nipple graft technique. In a
moderate-sized breast a superior pedicle using a vertical or short-scar technique
might be selected. If an inferior pedicle technique is used, the blood supply to the
pedicle must be maximized by keeping the base wide and chest wall attachments
liberal. In any event preoperative screening mammography should be performed
before reduction.
In circumstances in which I am quite certain that an opposite side correction will
be required, my preference has been to proceed with opposite breast corrections at
the time of the initial mastectomy and implant or expander placement. I then have
the opportunity to adjust the opposite side correction at the time of expander re-
placement or nipple-areola reconstruction. It is often dif cult to perform a pri-
mary opposite breast correction at the second stage and achieve perfect symmetry
because recurrent settling of the breast after reduction or mastopexy can lead to
persistent asymmetry. However, by 3 months postoperatively, at the time most ex-
panders are exchanged for permanent implants, this anticipated settling will have
occurred and a small adjustment of the previously altered normal breast can be
completed at that time to optimize symmetry.
Women who have a small nonptotic breast on the opposite side are difficult to
match with use of expansion and an implant alone. Most often symmetry is
achieved only by altering the opposite breast by the placement of a submuscular
implant. Or, if the patient is a candidate for prophylactic mastectomy of the oppo-
site breast, then bilateral expander breast reconstruction can be accomplished.
1343
Chapter 35
Reoperation Following Implant Breast Reconstruction

1344
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
This 36-year-old woman underwent a left modi ed radical mastectomy for stage I
carcinoma of the breast. She did not require postoperative chemotherapy or radio-
therapy. Evaluation of the deformity starts with the opposite breast. Her oncologist
recommended a right prophylactic mastectomy because of a signi cant family his-
tory of breast cancer. Because of this, the reconstructive plan was affected, and bi-
lateral tissue expansion became a more viable option.Therefore we planned an im-
mediate reconstruction on the right and delayed reconstruction on the left.
Following full expansion using anatomically shaped expanders, the inframammary
folds were developed symmetrically.

The expanders were removed and replaced using anatomically shaped silicone gel
implants. Although nipple reconstruction can be performed at this stage, our pref-
erence is to wait until we are absolutely certain we have produced symmetrical
breast mounds.
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Chapter 35
Reoperation Following Implant Breast Reconstruction
Five years after reconstruction, the patient has a stable and symmetrical result.

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R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
In this patient the second stage included removal of the right expander and place-
ment of a permanent implant along with augmentation of the left breast. Nipple-
areola reconstruction was performed simultaneously. She is shown 3 years postop-
eratively.
NIPPLE-AREOLA R ECONSTRUCTION
With implant reconstructions the technique of nipple-areola reconstruction de-
pends most on the thickness of the subcutaneous tissue overlying the pectoralis
major muscle. I prefer the modi ed sh-tail ap (see Chapter 31), unless the oppo-
site nipple is large and therefore available for a composite graft–sharing technique.
The pectoralis major fascia if present should be included in the “wings” of the sh-
tail, particularly if the subcutaneous tissue is thin.
Nipple-areola reconstruction can usually be performed at the planned second stage
after an implant reconstruction. However, there are situations in which it is dif cult
to ascertain whether the ultimate breast mound will be satisfactory to both the
surgeon and the patient. If I am still unsure intraoperatively as to whether accept-
able symmetry has been achieved in the second stage, I will defer nipple-areola re-
construction until healing has occurred, and this determination can be accurately
made. Otherwise nipple-areola reconstruction is accomplished at the same time as
mound correction during the second stage. I usually try to preselect the location for
the nipple-areola reconstruction while manually adjusting the expander or implant

1347
Chapter 35
Reoperation Following Implant Breast Reconstruction
to simulate what the corrected mound will look like. This maneuver gives me at
least some idea as to the general location for the ultimate reconstruction once the
patient is in the operating room and again supine. Following mound correction,
pendulum sutures at the sternal notch and xiphoid can be used to determine the
proper position of the nipple-areola based on that of the opposite breast (see Chap-
ter 31). Usually, if the nipple-areola complex is less than 1 cm off in terms of per-
fect symmetry, the eye will not detect this minor difference. Therefore, if there is
slight persistent mound asymmetry, I offset the nipple by less than 1 cm so that it
appears in the proper location relative to the size and shape of the reconstructed
breast rather than exactly symmetrical with the opposite side.
Excellent execution of the rst stage in breast reconstruction simpli es the require-
ments for the second stage.This patient had a small in ltrating ductal carcinoma of
the right breast with premalignant changes of the left breast. Bilateral simple mas-
tectomies and immediate reconstruction using bilateral latissimus dorsi musculocu-
taneous aps and tissue expanders were performed for the initial reconstruction.
Expansion proceeded only to the desired volume.The use of a ap in this case im-
proved coverage in the lower pole and provided tissue for a more natural, ptotic ap-
pearance. The second stage required skin envelope modi cation and elevation of
the nipple-areola complex location on the left side. Although there is still slight
asymmetry between the nipples, each is placed accurately with respect to breast
contour. Nipple-areola tattooing will complete the reconstruction.

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EARLY PROBLEMS AFTER BREAST IMPLANT
RECONSTRUCTION
Although implants remain the mainstay of most breast reconstructions, they cannot
match all opposite breast shapes. Recognition of this fact before embarking on an
implant reconstruction may in uence the surgeon to select an alternate technique
or to alter the opposite breast.
PROBLEMS ASSOCIATED W ITH FLAPS USED IN
CONJUNCTION W ITH IMPLANTS
Some of the best results in breast reconstruction can be achieved using aps and im-
plants in combination. Flaps used in this context are generally among the most re-
liable in any type of reconstructive plastic surgery.37 However, total or partial ap
failure continues to occur and leads to the need for secondary breast surgery. More
commonly, however, choosing the wrong ap, placing or shaping it poorly, or giv-
ing inadequate attention to technique leads to less than satisfactory results.When an
implant has been used in combination with a flap, capsular contracture38 is less com-
mon but de ation or leak may still occur. Accordingly, reoperative procedures may
range from small adjustments performed with the patient under local anesthesia in
the clinic to complex microsurgical ap transfers when primary reconstruction has
resulted in ap failure.
COMPLICATIONS
Immediate breast reconstruction using implants or expanders has a higher compli-
cation rate than delayed reconstruction does.39 This is understandable when one
considers the wider eld of dissection, thin mastectomy aps, axillary dissection, and
wider eld of exposure that is open for a longer period. Most surgeons nd that in
time their own success with immediate reconstruction using implants increases,
and the complications diminish. Nevertheless, a certain number of immediate re-
constructions can be expected to fail.13
Infection is probably the most common cause of total failure, both in immediate
and delayed reconstruction using implants.11 Infection is heralded by cellulitis that
if treated early and vigorously with antibiotics may occasionally resolve without
the need for immediate implant removal. Some surgeons have reported success in
salvaging an infected implant by open irrigation and drainage, with reclosure over
a suction irrigation system. Capsulectomy and replacement of the implant are also
possible methods of treating minor chronic recurrent infection. However, most of-
ten in the face of signi cant infection, the implant will need to be removed and the

wound drained and allowed to heal. Although one might be tempted to reinsert the
implant within 2 months after the infection has resolved, this move is usually a mis-
take. It is best to wait at least 3 months, or in the case of immediate reconstruction,
until the patient has completed chemotherapy before considering replacement of
the expander or implant.
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Chapter 35
Reoperation Following Implant Breast Reconstruction
This patient presented 8 weeks after reconstruction of both breasts using latissimus
dorsi musculocutaneous aps and tissue expanders. She had cellulitis with impend-
ing expander extrusion. Interestingly, these problems developed approximately 10
days after a severe dental infection and may have been related. Management re-
quired removal of the implant and drainage of the purulence with irrigation and
the placement of Penrose drains. Four months later the expander was replaced.
Hematoma is also more common following immediate reconstruction with im-
plants than delayed reconstruction, probably because of the increased amount of
sharp dissection. Hematoma becomes apparent in the rst 24 hours postoperatively
with pain, swelling, and bluish discoloration beneath the mastectomy flaps. The
mastectomy aps might even become compromised because of the pressure ex-
erted from the hematoma beneath them. Under these circumstances immediate
evacuation of the hematoma is indicated.The implant or expander can usually be
left in place unless the viability of the mastectomy aps is in question. In this case
saline solution may need to be removed from an expander or an implant might
need to be removed. Hematoma has been implicated as a cause of capsular contrac-
ture, and therefore operative evacuation is almost always preferred to conservative
management.
Seromas most commonly occur in the axilla and usually can be treated by serial sy-
ringe evacuation or the placement of a dependent Penrose drain.

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Skin loss is an early complication almost entirely limited to immediate reconstruc-
tion.The use of tissue expanders has diminished the incidence of this complication
but has not entirely eliminated it. The viability of mastectomy skin aps during
immediate reconstruction should be assessed by observing the quality of skin-edge
bleeding or the use of intravenous uorescein and Wood’s lamp evaluation. Any
portion of the mastectomy skin aps that is in question should be debrided.When
areas of partial-thickness or full-thickness loss appear to be developing in skin aps
in the early postoperative period, operative debridement and reclosure should be
performed. Areas of skin that become progressively more cyanotic will virtually al-
ways progress to full-thickness loss and possible late implant or expander exposure.
At that point the expander or implant may need to be removed. Certainly early ex-
pansion will not be possible.Therefore it is best to return the patient directly to the
operating room for excision of these areas and closure of unquestionably viable
skin edges.
Remote valves on tissue expanders can be a cause of early complications as well.
Valve leakage is a possibility and is sometimes related to the use of large-bore ll-
ing needles.Valves can also turn over or ip up on their sides, making lling dif -
cult or impossible. Occasionally they can retract into the pocket of the expander it-
self so that they are no longer palpable and lling cannot be accomplished. If this
happens, a minor operation performed with the patient under local anesthesia to
reposition the valve is necessary.
This patient underwent bilateral subcutaneous mastectomy and expander recon-
struction for premalignant mastopathy.The remote valve is visible beneath the in-
framammary fold on the left side. However, the valve on the right side retracted un-
der the expander, making any further volume adjustments impossible. Fortunately,
expansion was nearly complete by this time, and we were able to make nal adjust-
ments and remove the valves as an outpatient procedure performed with the patient
under local anesthesia.

This patient demonstrates two additional minor problems associated with tissue
expander valves.40 With the type of sleeve connector shown, encapsulation around
the connector may occur to the point at which removal is dif cult and the tubing
can be pulled apart. In addition, the uid on the drapes represents a small seroma
that formed around the valve itself. All of these problems can be eliminated by us-
ing tissue expanders with incorporated valves.
LATE PROBLEMS AFTER BREAST IMPLANT
RECONSTRUCTION
CAPSULAR CONTRACTURE
The most common late problem following breast implant reconstruction is capsu-
lar contracture.38 Capsular contracture may present in a variety of ways. Usually
the patient notices progressive hardening of the reconstructed breast. Pain may de-
velop in speci c portions of the reconstructed breast. This pain may be intermit-
tent, occurring more commonly with certain activities or positions. The patient
may not be able to sleep on the reconstructed breast any longer without discom-
fort. Sometimes the pain may radiate into the axilla or around to the back. The
source of this discomfort is often dif cult to pinpoint; sometimes it is attributable
to the capsule pulling on rib periosteum.41
We no longer perform closed capsulotomy for the release of capsular contracture.
The maneuver may be associated with implant rupture or even injury to the sur-
geon’s hands! However, some plastic surgeons continue to perform this maneuver
within the rst 3 months after implant placement for cases of early capsular con-
tracture. Late capsular contracture cannot be effectively released by closed capsulo-
tomy and is not recommended. Open capsulotomy and percutaneous endoscopic
capsular release are alternatives for treatment of this condition (see Chapter 28).
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CHRONIC PAIN
Costochondritis
Costochondritis is more common with submuscular implants, which most breast
reconstruction patients have, than with subglandular implants. Costochondritis has
a waxing and waning course. It usually can be easily localized by physical examina-
tion;the affected site can be quite tender and the disease can be debilitating. It will
usually respond to local measures such as moist heat and antiin ammatory agents.
I prefer to prescribe a 2-week course of a nonsteroidal antiin ammatory agent.
Neuroma
Neuromas usually do not become apparent until at least 6 months to 1 year after
implant reconstruction. The patient can usually localize the affected site quite
speci cally and avoids any type of brassiere or clothing that rubs on this region.
Tinel’s sign may be present. Relief can be achieved by the injection of local anes-
thesia into the speci c area. Although this information is anecdotal, I have had two
patients with neuromas who have required reoperation for other reasons. In both
cases the symptoms improved after the lateral capsular area was redissected. In one
patient I was able to nd what appeared to be two subcutaneous nerve branches in
this area. I trimmed these branches back and allowed them to retract into a thicker
pad of subcutaneous fat; ultimate relief of symptoms was achieved.
FAILED AESTHETICS IN IMPLANT BREAST R ECONSTRUCTION
Implants are manmade devices and have a limited life expectancy. Rupture, leak, and
recurrent capsular contracture are possible modes of failure among implant recon-
struction patients. Furthermore, failure to achieve an aesthetic result because of in-
appropriate choice of technique or poor execution can also result in reoperation.
Because implants tend to deteriorate with time, it is important that patients under-
stand that reoperations are common years after initial implant reconstruction.
When evaluating an implant reconstruction patient for secondary surgery, the sur-
geon has three options: (1) the implant itself can be changed for a different size or
shape, (2) soft tissue can be added to improve coverage or increase volume to im-
prove symmetry, or (3) the entire direction of the reconstruction can be converted
to natural tissue.

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Altering the Size and Shape of the Implant
Fortunately, we are reentering a time when a greater variety of implant shapes,
sizes, and technologies are again becoming available. It is our bias that silicone gel
devices generally yield a higher quality result in breast reconstruction than saline
implants do.The newer “cohesive gel” devices, even when covered only by skin and
muscle, can produce a natural-appearing breast mound without the obvious rip-
pling that has plagued saline reconstructions.Therefore we are more often able to
avoid the necessity of bringing in additional soft tissue in secondary reconstruction.
As discussed earlier, the opposite breast is the template for the operative plan.When
the opposite breast has any amount of signi cant ptosis, it is very dif cult to match
with an implant reconstruction alone. The best candidates for secondary recon-
struction using an implant alone are those with a relatively high round breast on the
opposite side or those who would bene t by breast augmentation on the normal
side.
Adding Additional Soft Tissue
In patients with a larger opposite breast especially those with ptosis, we prefer to
add autogenous tissue in secondary reconstruction. The latissimus dorsi muscle or
musculocutaneous ap continues to be the primary source for additional coverage
or contour.
This 48-year-old woman presented with an
asymmetrical silicone gel implant reconstruc-
tion characterized by painful capsular contrac-
ture and a high right inframammary fold. She
had had a left mastopexy by the original treat-
ing surgeon. He had made an additional attempt
to release the right implant and drop the fold,
but the contracture recurred. Keying in on the
opposite breast, it becomes clear that consider-
able expansion of the lower pole will be neces-
sary to allow the implant to drop into a sym-
metrical pocket. Therefore we planned a right
latissimus dorsi musculocutaneous ap to allow
expansion in an area that was otherwise thin
and tight.

1354
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R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
With the additional soft tissue from the latissimus, the implant is able to be well sup-
ported in a lower position and the tendency toward capsular contracture is relieved.
Although the patient was satis ed with this, it would have been possible to pedicle
the right nipple-areola reconstruction to a more acceptable, symmetrical position
as a secondary procedure.
Autogenous Conversion
Although autogenous conversion represents the most complex form of secondary
breast reconstruction, it has the advantage of producing a permanent, natural recon-
struction without the necessity of an implant. For patients with failed implant re-
constructions, it can represent a life-changing surgical treatment by giving them the
opportunity to have their breasts be fully and naturally reconstructed. It can be a
dif cult decision for the plastic surgeon, however, especially if he or she is the one
who started the implant reconstruction, because the surgeon must recognize that it
is necessary to backtrack before a satisfactory nal result can be achieved. Neverthe-
less, as mentioned earlier, a change of course is frequently necessary in patients who
continue to experience failure with implant-type reconstruction.
Patients who are candidates for conversion to autogenous tissue reconstruction
generally fall into two categories. First, there are the women who have had previ-
ous implant reconstructions who for one reason or another no longer wish to have
breast implants but still desire breast reconstruction.42

This patient is an example of a woman with a reasonably good implant reconstruc-
tion following subcutaneous mastectomy for premalignant disease. However, her
main problem was pain surrounding the left implant. The reconstructed breasts
were quite rm as a result of capsular contracture. Although the patient tolerated
this pain for a period of time, once she became concerned about the safety of sili-
cone gel, she could no longer accept the implant reconstruction and wanted the
implants removed.
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Reoperation Following Implant Breast Reconstruction
TRAM ap reconstruction ultimately produced a softer and more natural result.
Replacing the pectoralis major muscles against the chest wall seems to provide re-
lief in a number of women with painful implant reconstructions.The postoperative
result is shown.

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R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
The second group of women who may bene t by autogenous conversion are those
who have had one or more previous implant reconstructions but have continued to
experience asymmetry, distortion, recurrent implant failure, or recurrent capsular
contracture. This group of women seems to have the most satisfactory outcome
following autogenous conversion.
This 46-year-old patient is shown 12 years after bilateral subcutaneous mastec-
tomies and implant reconstruction. Her postoperative course was complicated by
hematoma, implant rupture, and implant replacement. She has undergone several at-
tempts at closed capsulotomy for capsular contracture that subsequently developed.
Her preoperative condition demonstrated distortion, asymmetry, and contracture.

This group of patients bene ts greatly by autogenous conversion.The surgical ap-
proach consists of implant removal with total or subtotal capsulectomy, replace-
ment of the pectoralis major muscles against the chest wall, and autogenous recon-
struction using bilateral free TRAM aps in the subcutaneous position.
Although this approach carries signi cant risks, the postoperative results are un-
paralleled, in my opinion.
Patients who have been through breast reconstruction using implants may not be
prepared for the commitment and the magnitude of autogenous reconstruction.
They must be very carefully counseled regarding the commitment, risks, and com-
plications associated with this major operation. Nevertheless, our ability to use au-
togenous tissue for breast reconstruction has allowed us to greatly improve the re-
sults of patients who did not have aesthetic reconstructions using implants. This
type of reoperative breast reconstruction demands excellent patient rapport and
cooperation, careful patient education, and precise technical execution to mini-
mize further complications. Most patients who desire or require autogenous con-
version do not wish to have any other implants used for reconstruction.Therefore
the TRAM ap and the latissimus dorsi ap are the mainstays of autogenous con-
version. Other microsurgical aps can be considered. If the patient has suf cient tis-
sue available in the lower abdomen, the TRAM ap is my preference. It is also my
personal preference to transfer the TRAM ap as a microsurgical free ap, partic-
ularly in the case of bilateral reconstruction in which more rectus abdominis mus-
cle can be left in the abdominal wall. Nevertheless, the conventional TRAM ap is
a perfectly satisfactory solution for autogenous conversion of implant patients.
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The Complex Problem
From time to time we have encountered patients who have had multiple failed at-
tempts at implant reconstruction and local aps.These individuals may have under-
gone as many as 10 or 20 operations to try to salvage a “sinking ship.” As they pres-
ent with complex issues, they most often require a complex solution. It is in this
group of patients that microsurgical breast reconstruction has had the most to
offer.
This 47-year-old woman rst underwent tissue expansion after a modi ed radical
mastectomy on the left and subcutaneous mastectomy on the right. Her postoper-
ative course was complicated by infection around the left expander.The expander
was removed and replaced but subsequently extruded. A left latissimus dorsi mus-
culocutaneous ap was attempted but failed. Clearly, another expander reconstruc-
tion would be ill advised because of the heavy scar tissue and the thin coverage as
well as the poor track record for implants in this patient.Therefore, because of the
midline scar in her lower abdomen, we converted her to autogenous bilateral re-

construction using muscle-sparing free TRAM aps. This was a one-stage proce-
dure that produced a permanent stable reconstruction.
The increased use of postoperative radiotherapy as well as preoperative radiother-
apy protocols has greatly impacted the use of implants in both immediate and de-
layed reconstruction. The negative effects of ionizing radiation on the healing
process include degenerative changes in the basement membrane and increased
permeability leading to brotic hypocellular tissues with a paucity of blood vessels.
There is decreased endothelial cell turnover which further compounds the pro-
gressive loss of blood vessels. Late changes include brosis of the arteriolar wall
with thrombosis and necrosis. The broblast and endothelial cell population de-
creases.
It is our bias that implants are simply not well tolerated by an irradiated chest wall.
Although in rare cases, where there are no visible soft tissue effects of radiation, an
expander and implant reconstruction might yield a satisfactory result,43 the vast
majority of patients receiving radiation are better candidates for ap reconstruc-
tion.44 Some authors have advocated placement of a tissue expander that is alter-
nately in ated and de ated coinciding with radiation to preserve the chest wall
skin. We prefer to delay the initial reconstruction until after the patient has com-
pleted radiotherapy and the soft tissues have recovered maximally. Most often un-
der these circumstances we will select either the TRAM or the latissimus dorsi ap
as the procedure of choice.
References—With Key Annotated References
1. Bostwick J. Breast reconstruction: A comprehensive approach. Clin Plast Surg 6:143, 1979.
2. Lemperle G. Unfavorable results after breast reconstruction with silicone breast implants. Acta
Chir Belg 79:159, 1980.
3. McShane RH, Omotunde O, Weatherly-White RC. Individualized muscle coverage of im-
plants in breast reconstruction. Plast Reconstr Surg 67:318, 1981.
4. Woods JE, Irons GB Jr, Arnold PG.The case for submuscular implantation of prostheses in re-
constructive breast surgery. Ann Plast Surg 5:115, 1980.
5. Woods JE. Unusual complication of submuscular placement of implants in breast surgery. Plast
Reconstr Surg 73:972, 1984.
6. Becker H.The expandable mammary implant. Plast Reconstr Surg 79:631, 1987.
An expandable saline-gel implant having a detachable injection dome is described.The implant func-
tions initially as a tissue expander. Once the correct size has been obtained, the injection dome is re-
moved, leaving the implant in position.
7. Becker H. Breast reconstruction using an in atable breast implant with detachable reservoir.
Plast Reconstr Surg 73:678, 1984.
An in atable breast implant having a detachable lling reservoir is described. Once in position, the
implant can be lled under controlled conditions postoperatively.The implant functions either as a tis-
sue expander or as a delayed- lling implant in the initial stages of the procedure. Once the desired
breast size is achieved, the reservoir is removed, leaving the lled implant in position.This implant
has been used successfully in various types of breast reconstructive procedures.
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R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
8. Bostwick J III. Breast reconstruction using modi ed tissue expansion for matching a small op-
posite breast. Perspect Plast Surg 1:79, 1987.
The author presents a case example and step-by-step surgical technique for tissue expansion to match
a hypoplastic breast.The author concludes that most patients are satis ed with the results of this
technique which provides them with reasonably matched breasts without having to undergo an oper-
ation on their remaining breast.
9. Ward J, Cohen IK, Knaysi GA, et al. Immediate breast reconstruction with tissue expansion.
Plast Reconstr Surg 80:559, 1987.
This article discusses a series of patients who underwent primary breast reconstruction with tissue
expansion, utilized for breast reconstruction when the remaining muscle and skin following modi ed
radical mastectomy was insuf cient to accommodate a prosthesis that matched in size and shape the
opposite breast. Complications are also described.The article concludes that primary breast reconstruc-
tion with tissue expansion following modi ed radical mastectomy is safe, simple, and produces a breast
with excellent shape, size, texture, and patient satisfaction.
10. Pakiam AI,Young CS.Submuscular breast reconstruction:A one-stage method of tissue expan-
sion. Ann Plast Surg 19:312, 1987.
11. Dickson MG, Sharpe DT.The complications of tissue expansion in breast reconstruction:A re-
view of 75 cases. Br J Plast Surg 40:629, 1987.
Seventy- ve consecutive cases of breast reconstruction using tissue expansion are reviewed and the com-
plications encountered are discussed.The article concludes that with careful patient selection, tissue ex-
pansion offers a simple, safe and reliable method of breast reconstruction.
12. Dowden RV. Achieving a natural inframammary fold and ptotic effect in the reconstructed
breast. Ann Plast Surg 19:524, 1987.
13. Gibney J.The long-term results of tissue expansion for breast reconstruction. Clin Plast Surg
14:509, 1987.
14. Little JW III, Golembe EV, Fisher JB. The “living bra” in immediate and delayed reconstruc-
tion of the breast following mastectomy for malignant and nonmalignant disease. Plast Recon-
str Surg 68:392, 1981.
15. Hartrampf CR, Sche an M, Black PW. Breast reconstruction following mastectomy with a
transverse abdominal island flap: Anatomical and clinical observations. Plast Reconstr Surg
69:216, 1982.
A rectus abdominis musculocutaneous island ap for breast reconstruction following mastectomy is pre-
sented. Cadaver dissections are shown, demonstrating the anatomy, arc of rotation, and design alter-
natives of the rectus abdominis ap.The surgical technique is demonstrated and representative patients
are shown.
16. Hester TR Jr, Nahai F, Bostwick J, et al. A 5-year experience with polyurethane-covered mam-
mary prostheses for treatment of capsular contracture, primary augmentation mammoplasty,
and breast reconstruction. Clin Plast Surg 15:569, 1988.
This paper reviews a 5-year experience using polyurethane-covered mammary prostheses in the treat-
ment of capsular contracture after placement of smooth-walled devices, primary augmentation
mammaplasty, and breast reconstruction after mastectomy.The rate of occurrence of clinically signi -
cant capsular contracture has been reduced in all patient groups. Results in terms of aesthetic and
functional improvement have been excellent. Major complications have been rare.
17. Tran NV, Chang DW, Gupta A, et al. Comparison of immediate and delayed TRAM ap breast
reconstruction in patients receiving postmastectomy radiation therapy. Plast Reconstr Surg
108:78, 2001.
This study compares the outcome of immediate and delayed free TRAM ap breast reconstruction in
patients who received postmastectomy radiation therapy. Early and late complications are compared.
Findings indicate that, in patients who are candidates for free TRAM ap breast reconstruction and
need postmastectomy radiation therapy, reconstruction should be delayed until radiation therapy is
complete.

18. Williams JK, Bostwick J III, Bried JT, et al. TRAM ap breast reconstruction after radiation
treatment. Ann Surg 221:756, 1995.
This article compares patients with and without radiation treatment before breast reconstruction in or-
der to study the relationship of radiation to ap-related complications. In this series, radiation therapy
was associated with increased fat necrosis and major infection.The use of the TRAM ap was not
found to be prohibitive in irradiated patients and should still be the rst choice in this subgroup of pa-
tients.
19. Williams JK, Carlson GW, Bostwick J III, et al.The effects of radiation treatment after TRAM
ap breast reconstruction. Plast Reconstr Surg 100:1153, 1997.
The authors review the effects of radiation therapy on pedicled TRAM aps to evaluate complication
rates and aesthetic results. Overall complication rates are discussed.
20. Rogers NE, Allen RJ. Radiation effects on breast reconstruction with the deep inferior epigas-
tric perforator ap. Plast Reconstr Surg 109:1919, 2002.
Immediate breast reconstruction has important advantages over delayed reconstruction, including a
shorter operative time and decreased psychological distress for the patient.The authors’discuss their ex-
periences with the deep inferior epigastric perforator ap to demonstrate variable aesthetic outcomes
among patients who undergo radiation postoperatively. Results suggest that when possible, reconstruc-
tion should be delayed until after radiation therapy is complete. Persons who smoke or are obese may
be at particular risk for complications after radiation therapy.
21. Spear SL, Ducuc I, Low M.The effect of radiation on pedicled TRAM ap breast reconstruc-
tion: Outcomes and implications. Plast Reconstr Surg 115:84, 2005.
The purpose of this study was to examine the effect of postreconstruction radiation therapy on patients
undergoing pedicled TRAM ap breast reconstruction.The authors recommend that TRAM ap
breast reconstruction be postponed in those patients known or expected to receive postmastectomy ra-
diation.
22. Kroll SS, Coffey JA, Winn RJ, et al. A comparison of factors affecting aesthetic outcomes of
TRAM ap breast reconstructions. Plast Reconstr Surg 96:860, 1995.
The aesthetic results of TRAM ap breast reconstructions were assessed in 237 consecutive breast can-
cer patients.
23. Kronowitz SJ, Robb GL. Breast reconstruction with postmastectomy radiation therapy:Current
issues. Plast Reconstr Surg 114:950, 2004.
Two recent trials have demonstrated superior locoregional control, disease-free survival, and overall
survival in node-positive breast cancer patients with the addition of postmastectomy radiation therapy
to mastectomy and chemotherapy. Based on these results, there has been an increased use of postmas-
tectomy in patients with early-stage breast cancer.The inability to determine which patients will re-
quire postmastectomy radiation therapy has increased the complexity of planning for immediate breast
reconstruction.There are two potential problems with performing an immediate breast reconstruction
in a patient who will require postmastectomy radiation therapy. One problem is that postmastectomy
radiation therapy can adversely affect the aesthetic outcome of an immediate breast reconstruction.
Several studies have evaluated the outcomes of breast reconstructions that were performed before radi-
ation therapy and have revealed a high incidence of complications and poor aesthetic outcomes. Fur-
thermore, these studies have found that often an additional ap is required to restore breast shape and
symmetry.The other potential problem is that an immediate breast reconstruction can interfere with
the delivery of postmastectomy radiation therapy. During planning for immediate breast reconstruction,
it is imperative to carefully review the stage of disease and the likelihood the patient will require post-
mastectomy radiation therapy. Unfortunately, the ability to detect and predict the presence or extent of
axillary lymph node involvement is limited, and the need for postmastectomy radiation therapy is usu-
ally not known until after mastectomy. In all cases of decision-making regarding possible postopera-
tive radiation therapy and whether or not to perform immediate breast reconstruction, the situation
should be discussed at a multidisciplinary conference or addressed among the various medical, surgi-
cal, and radiation teams, with active participation by the patient. Immediate breast reconstruction
probably should be avoided in patients known to require postmastectomy radiation therapy and de-
layed until it is certain the therapy will be needed in patients who may require the therapy.
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24. Buchholz TA, Kronowitz SJ, Kuerer HM. Immediate breast reconstruction after skin-sparing
mastectomy for treatment of advanced breast cancer:Radiation oncology considerations. Ann
Surg Oncol 9:820, 2002.
25. Evans GRD, Schusterman MA, Kroll SS, et al. Reconstruction and the radiated breast:Is there
a role for implants? Plast Reconstr Surg 96:1111, 1995.
The use of breast implants in irradiated patients is controversial.The authors compare 39 irradiated
implants with 338 nonirradiated implants in 297 patients between January 1975 and October
1994 at The University of Texas M.D.Anderson Cancer Center. Results showed that irradiation has
signi cant negative effects on the reconstructive outcome with implants.Autogenous reconstruction did
not appear to offer a protective role when placed over implants.
26. Kronowitz SJ, Hunt KK, Kuerer HM, et al. Delayed-immediate breast reconstruction. Plast
Reconstr Surg 113:1617-1628, 2004.
In patients with early-stage breast cancer who are scheduled to undergo mastectomy and desire breast
reconstruction, the optimal timing of reconstruction depends on whether postmastectomy radiation
therapy will be needed. Immediate reconstruction offers the best aesthetic outcomes if postmastectomy
radiation therapy is not needed, but if postmastectomy radiation therapy is required, delayed reconstruc-
tion is preferable to avoid potential aesthetic and radiation-delivery problems.The authors describe a
two-stage approach, delayed-immediate breast reconstruction, to optimize reconstruction in patients at
risk for requiring postmastectomy radiation therapy when the need for postmastectomy radiation ther-
apy is not known at the time of mastectomy.
27. Elliott LF, Seify H. Avoidance and management of complications.Innov Plast Surg 1:115, 2005.
28. Kronowitz SJ.The role of tissue expansion in patients who may require postmastectomy radi-
ation therapy and desire breast reconstruction. Innov Plast Surg 1:41, 2005.
The author discusses breast reconstruction in the face of radiation therapy. He provides a comprehen-
sive overview of the indications for PMRT and tackles the debate surrounding the use of PMRT
in patients with three or fewer involved axillary lymph nodes.The author presents a combination
of early expansion with de ation during PMRT followed by slow reexpansion as a key element to
success.
29. Spear SL, Majidian A. Immediate breast reconstruction in two stages using textured, inte-
grated-valve tissue expanders and breast implants: A retrospective review of 171 consecutive
breast reconstructions from 1989 to 1996. Plast Reconstr Surg 101:53, 1998.
A 7-year experience with 171 consecutive immediate breast reconstructions by one surgeon using a
textured integrated-valve tissue expander is reviewed.All patients were reconstructed in multiple stages
using a temporary biodimensional tissue expander followed months later by a long-term implant.
Ninety-eight percent of a subgroup of 42 consecutively queried patients expressed satisfaction with
their reconstruction, whereas only 2% of the queried patients were dissatis ed.
30. Francel TJ, Ryan JJ, Manson PN. Breast reconstruction utilizing implants: A local experience
and comparison of three techniques. Plast Reconstr Surg 92:786, 1993.
Breast reconstruction patients require accurate information about complications, failures, and addi-
tional surgeries associated with implant reconstruction. In this article, the authors present a series of
consecutive patients and examine three methods of implant reconstruction.The data showed immedi-
ate implant reconstructions to be safe, require more capsular intervention procedures, have a greater ex-
pense, and have good aesthetic results because of revisional surgery.
31. Goodwin SJ, McCarthy CM, Pusic AL, et al. Complications in smokers after postmastectomy
tissue expander-implant breast reconstruction. Ann Plast Surg 55:16, 2005.
32. May JW Jr, Attwood J, Bartlett S. Staged use of soft-tissue expansion and lower thoracic ad-
vancement ap in breast reconstruction. Plast Reconstr Surg 79:272, 1987.
A single patient is presented in whom breast reconstruction after mastectomy for breast cancer has
been achieved by sequential use of soft tissue expansion followed by permanent silicone implant place-
ment and thoracic ap advancement to de ne the inframammary fold.

33. Spear SL, Spittler CJ. Breast reconstruction with implants and expanders. Plast Reconstr Surg
107:177; quiz 188, 2001.
34. Ryan JJ. A lower thoracic advancement ap in breast reconstruction after mastectomy. Plast
Reconstr Surg 70:153, 1982.
A lower thoracic advancement ap for use in postmastectomy breast reconstruction is described.This
ap allows modest supplementation of prethoracic skin coverage and creation of a stable, well-de ned
inframammary fold.Advantages include good match of skin color and texture, con nement of donor-
site scarring to the relatively inconspicuous inframammary fold area, a more natural ptotic breast
shape, and relative ease of performance.
35. Versaci AD. A method of reconstructing a pendulous breast utilizing the tissue expander. Plast
Reconstr Surg 80:387, 1987.
It is possible to reconstruct a breast mound of almost any size by utilizing tissue expansion.To pro-
duce a pendulous breast that is also ptotic, the tissue-expansion technique has been combined with two
other procedures.This article presents the technique of elevating the lower third of the mature breast
capsule surrounding the tissue expander at the time the permanent prosthesis is to be exchanged for
the expander.The established techniques of inframammary fold reconstruction of Pennisi and Ryan are
used to provide pedicle skin coverage for the undersurface of the breast and the bed of the elevated cap-
sule. Internal and external surgical approaches are described, and two examples of each are illus-
trated.
36. Versaci AD. Reconstruction of a pendulous breast utilizing a tissue expander. Clin Plast Surg
14:499, 1987.
37. Maxwell GP. Latissimus dorsi breast reconstruction: An aesthetic assessment. Clin Plast Surg
8:373, 1981.
38. Asplund O. Capsular contracture in silicone gel and saline- lled breast implants after recon-
struction. Plast Reconstr Surg 73:270, 1984.
39. Nahabedian MY,Tsangaris T, Momen B, et al. Infectious complications following breast recon-
struction with expanders and implants. Plast Reconstr Surg 112:467, 2003.
The purpose of this study was to analyze a set of factors that may predispose women to infection of
the expander or implant.The factors that were analyzed included axillary lymph node dissection,
chemotherapy, radiation therapy, tumor stage, timing of implant insertion, number of sides (unilateral
versus bilateral), tobacco use, and presence or absence of diabetes mellitus. No signi cant association be-
tween implant infection and age, diabetes, tobacco use, tumor stage, timing of implant insertion, or
chemotherapy was found.
40. Darnell EK, Demars RV. Ultrasonographic localization of breast tissue expander valves. J Ultra-
sound Med 6:531, 1987.
41. McKinney P, Edelson R,Terrasse A, et al. Chest-wall deformity following soft-tissue expansion
for breast reconstruction. Plast Reconstr Surg 80:442, 1987.
42. Copeland M, Kressel A, Spiera H, et al. Systemic in ammatory disorders related to brous
breast capsules after silicone implant removal. Plast Reconstr Surg 92:1179, 1993.
43. Spear SL, Onyewu C. Staged breast reconstruction with saline- lled implants in the irradi-
ated breast: Recent trends and therapeutic implications. Plast Reconstr Surg 105:930, 2000.
44. Cordeiro PG, Pusic AL, Disa JJ, et al. Irradiation after immediate tissue expander-implant breast
reconstruction:Outcomes, complications, aesthetic results, and satisfaction among 156 patients.
Plast Reconstr Surg 113:877-881, 2004.
Chest wall irradiation is becoming increasingly common for mastectomy patients who have opted for
immediate breast reconstruction with tissue expanders and implants.The optimal approach for such
patients has not yet been de ned.This study assesses the outcomes of a reconstruction protocol for pa-
tients who require irradiation after tissue expander/ implant reconstruction.The results of this study
suggest that tissue expander/ implant reconstruction is an acceptable surgical option even when followed
by postoperative radiotherapy and should be considered in the reconstruction algorithm for all pa-
tients, particularly those who may not be candidates for autogenous reconstruction.
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1. The operative options for the second stage of expander reconstruction include:
a. Placement of a saline or silicone gel device
b. Alteration of the soft tissue envelope or capsule
c. Alteration of the opposite breast to improve symmetry
d. Use of a custom device
e. All of the above
2. All of the following might aid in the elevation of a low inframammary fold at
the time of placement of the permanent implant except:
a. Placing a smooth saline implant with postoperative use of an underwire bra
b. Internal capsulorrhaphy of the inferior capsule
c. Use of a textured implant with partial capsulectomy to increase adherence
d. Ryan advancement to de ne the fold at a higher position
e. Inferior capsulectomy with percutaneous suture placement to elevate the
fold
3. The preferred method of breast reconstruction in a patient who has had multi-
ple failed implant reconstructions is:
a. No reconstruction
b. Gradual subpectoral tissue expansion
c. Anatomic silicone gel implants
d. Autogenous conversion
e. Adjustable saline implants
4. The best method of creating ptosis in delayed implant reconstructions is:
a. Internal suture plication of Scarpa’s fascia to rib periosteum
b. Lower pole expansion
c. Addition of latissimus
d. Use of anatomic cohesive gel implants
e. External Ryan advancement ap
5. When faced with a patient who will require postoperative radiotherapy, the best
course of action is:
a. Immediate reconstruction using a permanent implant
b. Immediate reconstruction using an adjustable saline implant
c. Delayed reconstruction
d. Immediate DIEP ap
e. To evaluate the mastectomy skin aps and if viable insert a silicone gel
implant
R EVIEW QUESTIONS

1365
Finishing Touches
After Breast Reconstruction
With Pedicled Flaps
Glyn E. Jones and John Bostwick III†
C ha pter 3 6
Reoperative Problems
Tissue de ciency
Donor site contracture
Asymmetry
Missing anterior axillary fold
Tissue loss
Axillary hollowness
Excess fullness
Malpositioned nipple-areola reconstruction
Seroma
Excess tissue in abdominal wall
Inadequate central breast
Hernia
projection
Incorrect placement of inframammary fold
Capsular contracture
Few things are impossible to
diligence and skill. Great works are performed
not by strength, but perseverance.
Samuel Johnson
†Deceased.

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Before the introduction of the silicone breast implant in the early 1960s, pedicled
aps were the only viable method of breast reconstruction. These were random
aps from the lateral and inferior abdominal wall that were transferred as tubed
pedicles;they required multiple-stage procedures and were characteristically fraught
with complications, including tissue loss and poor aesthetic results. Despite the in-
troduction of silicone breast implants, pedicled aps remained the method of choice
because of the prevalence of radical mastectomies. Current breast reconstruction
techniques have evolved considerably since the introduction of pedicled tube aps.
Several free aps have entered the mainstream of autologous breast reconstruction,
including the various perforator aps, of which the deep inferior epigastric perfo-
rator ap remains the most popular. Despite the more widespread use of free aps,
pedicled flaps remain by far the most widely used autologous procedure today.
Modern pedicled flap operations require far fewer stages, with the promise of
greater reliability and predictability, and superior results. With the advent of the
latissimus dorsi ap and the TRAM ap, the two most popular and effective sources
of autogenous tissue for these operations, a woman can now expect to have a nat-
ural, well-contoured breast reconstruction with her own tissues and without many
of the problems that plagued earlier ap operations.
Although the results of the TRAM ap and the latissimus dorsi ap are far superior
to those possible with earlier techniques and most women today have less signi -
cant deformities to reconstruct, these operations are not simple or trouble free.
These procedures are artistically and technically demanding and may require sec-
ondary procedures to attain the desired result. In general, all techniques will re-
quire multiple minor adjustments to achieve an excellent result at the second op-
eration when nipple reconstruction is performed.1-5 Careful patient selection,
detailed preoperative planning, knowledge of the pertinent anatomy, and diligent
care postoperatively all contribute to the ultimate quality of the result expected af-
ter a pedicled TRAM or latissimus dorsi ap breast reconstruction.These operations
should be performed by a reconstructive surgeon experienced in these procedures
who has an excellent aesthetic eye and can properly position and shape the ap
into a breast that is symmetrical with the opposite breast. Ideally, the ap should be
positioned and shaped for optimal breast appearance, size, form, and symmetry dur-
ing the rst operation.The initial procedure gives the surgeon the best opportunity
to shape both the skin envelope and the underlying fat to create a well-contoured
breast mound. Secondary operations can then focus on nipple-areola placement
and minor corrections. In reality, however, additional modi cations may be needed
to improve breast contour, volume, or shape after breast reconstruction with the
TRAM or latissimus dorsi ap. Fine adjustments of the volume and position of the
autogenous tissue or tissue expander and adjustments of the donor site may be nec-
essary. Suction-assisted lipectomy and scar revision may also be required. Nipple-
areola reconstruction should be delayed until good symmetry is obtained. In re-
viewing our data at the Emory Clinic, we have found an average of 2.9 additional
procedures are required after pedicled ap reconstruction to achieve an excellent
completed reconstruction.

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Finishing Touches After Breast Reconstruction With Pedicled Flaps
This chapter addresses the most common problems that require revision surgery af-
ter pedicled TRAM or latissimus dorsi ap breast reconstruction.These secondary
procedures may be necessary revisions as a part of a staged procedure, aesthetic im-
provements to re ne the results of the primary operation, or maneuvers to treat
complications or improve on less than ideal aesthetic outcomes.
PATIENT EVALUATION
Women seeking breast reconstruction express a desire to return to wholeness and
want a breast reconstruction that approximates normality as closely as possible.The
reconstructive surgeon is ill advised, however, in believing that mere restoration of
breast form is suf cient to satisfy the patient. Most women expect the same artistry
as would be demanded from an aesthetic operation and with the rise in media-
driven exposure to plastic surgery, patient expectations are higher than ever. Pa-
tient expectations for breast reconstruction must be accurately determined before
the primary breast reconstruction and again before any reoperative procedures. Al-
though some patients say they would be satis ed if their breasts were to appear
symmetrical in a brassiere without the need for an external prosthesis, usually this
is not the case. Most patients who seek breast reconstruction desire a reconstructed
breast that is symmetrical with the opposite breast when they are naked and a
donor site that is unobtrusive and enhances their overall appearance.These patients
are highly motivated to have their breasts symmetrical and are often willing to un-
dergo additional procedures to achieve this goal. They want to have this part of
their life resolved, and an acceptable breast reconstruction is needed for them to be
satis ed.
Because of the complexity of ap reconstruction, patients are warned
preoperatively that a minimum of two procedures are needed to achieve
the expected result. This eliminates unforeseen occurrences because
the need for reoperation is considered part of the operative plan. It is
crucial to point out to patients that restoration of what is normal for
them may not be desirable or possible.
Recreating a severely ptotic breast with a collapsed upper pole is hardly a desirable
(or feasible) goal, and patients should be apprised of the aesthetic re nements that
are possible through mastopexy, reduction, or augmentation in an effort to provide
a reconstruction and also a rejuvenation of the breast contour.When a patient is eval-
uated for secondary breast reconstruction or for nishing touches, the reconstruc-
tive surgeon should take the time to listen to the patient and consider her requests.
Patient communication and understanding are most important before a secondary
operation. An adequately informed patient can best understand the procedure and
its limitations and approach it with realistic expectations.
When a complication occurs, whether severe (such as total ap loss) or minor, hon-
esty and a careful explanation are essential. The patient needs to understand why
this problem has occurred and that there is a solution. It is helpful to outline the op-

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erative plan for the patient to relieve her anxiety and to convince her that the prob-
lem is under control.
When the patient is referred by another reconstructive surgeon, the referring physi-
cian should be contacted to obtain important information about the patient. If the
patient has a relatively satisfactory result yet voices intense displeasure with either
the result or with previous surgeons, she may have unrealistic expectations or psy-
chological conditions that cannot be resolved within the limits of improving the
breast reconstruction.The wisest course for some of these patients is not to perpet-
uate their dissatisfaction with another operation.
Patients with a long history of cigarette smoking may have signi cant complications
related to previous pedicled aps or breast reconstruction with available tissue or tis-
sue expanders.6 Whereas the TRAM ap is susceptible to smoking-related compli-
cations, the latissimus dorsi ap is much less seriously affected by smoking. Patients
with previous breast reconstruction complications who are heavy cigarette smok-
ers should be instructed to refrain from cigarette smoking for approximately 4
weeks before secondary procedures. Prior radiation therapy increases the ap’s risk
of fat necrosis and wound infection.7 The use of vascular delay of the TRAM ap
is a means of enhancing the superior ow into the ap as well as improving venous
drainage.8 Vascular delay or a free ap is considered when the patient has risk fac-
tors such as cigarette smoking, radiation to the chest wall, or obesity.
Most patients who have breast reconstruction have had breast cancer
and that breast cancer is generally a chronic disease.The surgeon must
always consider the oncologic aspects of the patient’s treatment and be
alert to the possibility of a local or systemic recurrence. Before mod-
i cation of the opposite breast, this breast should be evaluated onco-
logically and aesthetically.
Treatment needs to be coordinated with the other members of the breast manage-
ment team to provide adequate surveillance and follow-up.
A complete medical history is necessary to identify any psychological or medical
conditions that may increase risk of complications or contraindicate plans for reop-
eration. Systemic conditions such as diabetes mellitus and autoimmune conditions
such as lupus erythematosus and scleroderma are associated with problems with
flap microcirculation and survival and may be contraindications to flap surgery.
These patients also may not be candidates for breast implants.The presence of a hy-
percoagulable state such as polycythemia or a history of deep venous thrombosis
will also affect the success of a pedicled ap reconstruction, especially with a TRAM
ap with which there is a ne line between satisfactory microcirculation and inad-
equate perfusion.
The patient’s weight and general medical condition are important considerations in
planning reoperation. Breast reconstruction with aps has physical limitations. Pa-

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Finishing Touches After Breast Reconstruction With Pedicled Flaps
tients who are signi cantly overweight (that is, more than 50 pounds over their
ideal body weight) often have unsatisfactory breast reconstructions because of phys-
ical limitations of the procedure, possible complications of moving large pedicled
aps, or psychological dynamics of the patient who can have serious complaints
related to the appearance of the breast reconstruction or the donor site.The signif-
icantly overweight patient experiences an increased incidence of complications
from pedicled ap procedures and is more likely than a patient of normal weight
not to be satis ed with the result despite additional operations.9 They are also less
suitable candidates for expander-implant reconstruction because of their often gen-
erous breast size.This is becoming a more serious issue in the United States where
obesity is becoming such a common occurrence, challenging surgeons who per-
form large numbers of autologous procedures.
PLANNING
In preparing for revision surgery the surgeon should take the following questions
into consideration:
Is the ap adequately shaped?
Is the ap in the correct position?
Is ap volume acceptable for symmetry?
Is the inframammary crease at an appropriate level and shape?
Is there any hollowing of the anterior axillary fold or infraclavicular areas?
Does the opposite breast require augmentation, mastopexy, or reduction to
achieve symmetry?
After a pedicled TRAM ap or latissimus dorsi ap breast reconstruction, the recon-
structive surgeon should determine whether the reconstructed breast has adequate
volume and is shaped properly before proceeding with a nipple-areola reconstruc-
tion.The position of the ap is crucial for acceptable aesthetics.The opposite breast
is the model for the breast reconstruction and for any secondary procedures that
may be necessary to improve breast form, assuming that the opposite breast has an
acceptable form and size. If a match with the opposite breast is not possible, the cor-
rected opposite breast is the model for the nishing touches be it by mastopexy, re-
duction, augmentation, or mastopexy-augmentation. The reconstructive surgeon
should consult with the patient to determine whether the opposite breast is to be
changed to match the reconstructed breast, the reconstructed breast should be
modi ed, or both.
When either the opposite breast or the patient is so large that the breast recon-
struction cannot be done safely, the opposite breast may need to be reduced to
achieve an adequate breast reconstruction. After a TRAM ap or latissimus dorsi
flap breast reconstruction when the opposite breast is somewhat ptotic and a
mastopexy is planned, periareolar purse-string mastopexy is a reasonable choice,
although this technique produces a breast with some central attening, which of-
ten matches the pro le produced by a TRAM ap breast reconstruction.This cen-
tral attening of the opposite breast can be modi ed to more closely resemble a

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breast reconstructed with a TRAM ap.The surgeon should bear in mind, however,
that central ap projection may be increased by coning the initial TRAM ap con-
struct, and in such cases the contralateral breast would bene t more from a verti-
cal or Wise-pattern mastopexy result. If a breast implant has been used under the
TRAM or latissimus dorsi ap, to achieve symmetry the placement of a smooth or
textured-surface breast implant on the side of the mastopexy can be considered.
When a small breast reduction is also needed, this can be performed through the
periareolar approach with the breast maintained as a central parenchymal pedicle.
Another excellent alternative is the vertical mastopexy using the central breast
mound as a parenchymal pedicle, which may be imbricated inferiorly to increase
projection as needed. This procedure eliminates the problem of central attening
and creates an extremely attractive breast contour that tends to maintain its shape
well with the passage of time.
Breast implants can be used to supplement the breast reconstruction and thus pro-
vide additional breast volume, which is sometimes lacking with pedicled aps. In
this case the patient will need to decide whether she wants a silicone breast implant
or prefers only autologous tissue. Adjustable devices such as the Siltex Spectrum
implants or the Becker devices (Mentor Corp., Santa Barbara, CA) can be valuable
in providing postoperative adjustability. The surgeon should warn the patient that
secondary implant placement beneath a ap is technically more dif cult because of
established scar tissue, which constrains the ultimate result. When the ap recon-
struction is too small to match the opposite breast and implant or expander place-
ment is planned, consideration must be given as to whether there is suf cient tis-
sue cover in the primary reconstruction.
When tissue cover is insuf cient, the latissimus dorsi muscle can be transferred to
cover and protect the lower portion of the breast implant.This muscle transfer also
serves to provide an additional source of blood ow and tissue oxygenation to the
region. If coupled with an extended autologous harvest of the fat overlying the
muscle, signi cant additional volume may be incorporated into the reconstruction
for both volume and padding to camou age an underlying implant.
Alternatively, when autogenous tissue is insuf cient, resulting in a volume de cit,
and a silicone breast implant is not wanted, transfer of a second pedicled ap should
be considered.The latissimus dorsi musculocutaneous ap can be used to enhance
the upper breast reconstruction after a TRAM ap restores the lower breast con-
tour. For example, for a radical mastectomy defect, the TRAM ap can be used for
the lower breast and the latissimus dorsi ap can be used for replacement of the up-
per breast and axillary region.This does create a somewhat “patchwork” effect but
may achieve the desired goals of reconstruction.
In this situation, breast reconstruction is carried out in two stages. At the rst op-
eration a bilateral lower TRAM ap procedure is performed.The ipsilateral ap is
deepithelialized and positioned to provide upper chest ll and some axillary ll.The
contralateral ap is used for the right breast reconstruction. Such “stacking” of aps
is rarely needed, however, and requires very careful three-dimensional planning.

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Finishing Touches After Breast Reconstruction With Pedicled Flaps
During a second stage a right latissimus dorsi muscle ap with a small deepithelial-
ized skin island is transferred to the divided insertion of the pectoralis major mus-
cle to further de ne the anterior axillary fold.
When capsular contracture occurs with a silicone breast implant under a latissimus
dorsi ap, a TRAM ap can be used to provide a soft breast reconstruction. If the
volume of tissue required for reoperation is not available from pedicled aps, recon-
struction with either implants or free aps is needed to obtain the proper volume.
ANATOMIC CONSIDERATIONS
When reoperative surgery is performed after a pedicled ap reconstruction, the
primary concern is to avoid harming the remaining breast reconstruction or wors-
ening the deformity. Familiarity with the surgical anatomy of the TRAM ap and
the latissimus dorsi ap and with the position of the vascular pedicles after transfer
for breast reconstruction is a requirement.This is particularly true of free ap recon-
structions where flap loss may occur even years after free tissue transfer is per-
formed.The location of the primary ap blood supply should always be considered,
because any interventions that compromise vasculature can result in serious prob-
lems. I know of several instances of partial TRAM ap loss that occurred because
the muscle pedicle was thinned or divided to reduce fullness in the epigastrium.
To minimize pedicle fullness, the pedicled TRAM flap should be
brought up as an ipsilateral ap if possible, a maneuver that produces
remarkably little costal margin fullness.
In addition, the eighth intercostal nerve should be actively sought and divided at the
costal margin at the time of initial ap transposition so as to completely denervate
the muscle.The resulting atrophy usually creates an unobtrusive muscle contour at
the rib margin. Any residual fullness remaining by 9 to 12 months postoperatively
may be dealt with effectively using localized liposuction of the subcutaneous fat
over the pedicle. Similarly the proximal muscle and pedicle of the latissimus dorsi
ap can produce unwanted fullness or even a mass in the axilla. The bulk of this
muscle bulge may be reduced by dividing the insertion of the latissimus muscle
and limiting autologous fat harvest over that portion of the muscle from the region
of the tip of the scapula to its insertion into the humerus. Care should be taken not
to confuse this anatomic appearance with an axillary recurrence, which might lead
to involved and unnecessary workups. Division of the thoracodorsal nerve at the
time of latissimus harvest induces atrophy and aids in shrinking this axillary volume.
TRAM FLAP R EVISION
The TRAM ap is unforgiving of technical shortfalls. Its blood supply is less reli-
able when patient selection, operative technique, and perioperative management
are extended beyond recognized limits. For instance, if the pedicle of a TRAM ap
is divided while an implant is placed to enlarge the reconstructed breast, the blood
supply to the TRAM ap can be compromised and portions of the ap lost.

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Knowledge of the blood ow in the TRAM ap is particularly important when re-
operative surgery involves the use of this transferred tissue with another technique,
such as an implant reconstruction or a latissimus dorsi ap reconstruction.
The vertical epigastric vascular system provides the major source of blood supply to
the rectus abdominis muscle and the overlying musculocutaneous territories of the
anterior abdominal wall.10
The superior epigastric artery, a terminal branch of the internal mammary artery,
nourishes the superiorly based TRAM ap. Musculocutaneous arterial perforators
extend from the vertical epigastric system within the rectus abdominis muscle and
pass through the anterior rectus sheath, providing nourishment to the skin and sub-
cutaneous tissue of the anterior abdominal wall.
These perforating vessels branch into axially coursing vessels that are primarily lo-
cated above the super cial layer of the abdominal wall fascia and are especially con-
centrated in the subdermal plexus. In the upper abdomen these vessels supply the
primary ow into the thoracoepigastric ap, with the subdermal plexus providing
signi cant collateral ow.
Axial vessels branching from the direct periumbilical rectus abdominis muscular
perforators perfuse the lateral extensions of the TRAM ap that are not directly
over the rectus abdominis muscle. A rich vascular network of interconnected ves-
sels branches through the subcutaneous tissues across the midline of the abdomen.
The vascular network is present primarily at the level of the subdermal plexus. It
communicates with the axial vascular system and subdermal plexus of the con-
tralateral anterior abdominal wall, providing ow to the skin on the contralateral
side.TRAM ap elevation across the entire anterior abdominal wall laterally to the
anterior axillary line is dependent on this collateral ow and that of the subdermal
plexus across the midline into the opposite sides of the abdominal wall subcuta-
neous vascular network. Recent work by Ninkovic has shed further light on this
cross-midline perfusion and has con rmed our long-standing suspicion that cross-
midline ow is not as robust as once believed. This may result in a change to the
vascular nomenclature applied to the TRAM ap’s zonal blood supply.11
Radiation, atherosclerosis, age-associated problems, anatomic variations, previous
operations, and vasoconstrictors can affect normal ow in this vascular network. A
midline incision effectively destroys this midline vascular connection. After an ab-
dominoplasty, the perforators that supply the TRAM ap are divided. It is inadvis-
able to consider performing a TRAM ap in patients with previous abdomino-
plasty, although there have been anecdotal reports of successful TRAM flap
elevation in such patients years after their abdominoplasties.

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Finishing Touches After Breast Reconstruction With Pedicled Flaps
Smokers are at risk for developing skin and fat necrosis.Vascular delay of the ap
may substantially improve ap blood ow, thereby reducing this risk. Division of the
super cial and deep inferior epigastric vascular pedicles a week before de nitive
ap transposition allows greater ow into the system from the superior deep epi-
gastric artery. This phenomenon forms the basis of the vascular delay procedure
and may be active in as little as 3 days after the delay procedure is performed.12,13
For patients with multiple risk factors, a free TRAM ap may be a better option
than a pedicled TRAM ap, because it offers an alternative pattern of blood ow.
The dominant blood supply to this area is that derived from the musculocuta-
neous perforating branches of the deep inferior epigastric artery (DIEA) through
the rectus abdominis muscle and the super cial inferior epigastric artery (SIEA).
The entire lower abdominal ellipse of skin and subcutaneous tissues may be elevated
as a muscle-sparing or perforator-based free ap on either of these vessels.
LATISSIMUS DORSI FLAP
The anatomy of the latissimus dorsi musculocutaneous ap is more forgiving than
that of the TRAM ap.The latissimus dorsi ap is based on the thoracodorsal pedi-
cle, a branch of the subscapular artery arising from the axillary artery, which is usu-
ally spared with the present-day method of axillary lymph node dissection. In the
past this was not the case with a radical mastectomy.
The thoracodorsal artery is a consistently reliable vessel and has a relatively large di-
ameter of 1 to 2.5 mm. It offers a particularly robust blood supply to the entire
latissimus dorsi muscle and much of its overlying skin. An intramuscular pattern of
vasculature radiates from the thoracodorsal pedicle to nourish the latissimus dorsi
muscle, cutaneous perforators passing through the muscle to supply the overlying
skin ap. Successful latissimus dorsi ap reconstruction, both primary and second-
ary, depends on the reconstructive surgeon’s knowledge of this intramuscular
branching of the thoracodorsal artery. The primary intramuscular vessel courses
vertically in the same direction as the pedicle, approximately 3 cm inside the lateral
edge of the latissimus dorsi muscle.The intramuscular network, radiating from the
entrance of the thoracodorsal pedicle into the latissimus dorsi muscle 10 cm below
the axilla, permits the splitting of the latissimus dorsi muscle into two or three mus-
cle strips that can support several skin islands, if necessary, for specialized secondary
procedures.The largest perforators branch from this primary vessel;therefore a ver-
tical lateral orientation of a latissimus dorsi ap provides the safest skin island. Sev-
eral other major branches extend in a radial manner from the primary pedicle.The
intramuscular branching pattern permits division of the latissimus dorsi muscle
while preserving the proximal blood supply and the integrity of the musculocuta-
neous unit. A collateral pedicle from the serratus anterior fascia is also usually pre-
served and is a constant vessel in this region.The latissimus dorsi ap can survive on
this vessel when the thoracodorsal pedicle has been injured or divided.

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A word of caution should be sounded in patients with an axilla that is
heavily radiation-damaged: radiation brosis may compromise the ow
to the muscle to the extent that the skin island may be compromised
and less reliable.
The ap can be harvested laterally, obliquely, or transversely for a variety of ap
designs that can be customized to replace the tissue needed for the reconstructed
breast. It is our preference to raise the ap with an oblique-transverse orientation
based on Langer’s relaxed skin tension lines.The resulting scar closure lying within
the relaxed skin tension lines provides the optimal scar quality in the long term.
When an axillary lymph node dissection has been performed previously, the re-
constructive surgeon should always assume that the thoracodorsal pedicle has been
injured. He or she should check with the original surgeon and the operative report
to determine whether the pedicle has been divided. Clinical examination of func-
tion in the latissimus dorsi muscle is performed by palpating the muscle while the
patient’s arm is abducted and the patient pushes down. Absence of latissimus dorsi
muscle function indicates pedicle division.There is still some ow into the muscle
through the serratus collateral artery, but ap reliability in our experience is usually
about 75%.With these ndings, it may be best to select another ap or to use a free
ap. Patient selection also plays a role in the use of the latissimus dorsi ap; when
there is heavy radiation damage in the axilla, there may be concern about the qual-
ity of the thoracodorsal pedicle and for the ultimate perfusion of the flap. I am
aware of several patients in whom severe radiation damage to the thoracodorsal
axis resulted in vascular compromise to the skin island.
The thoracodorsal nerve, arising from the C6-8 roots of the posterior cord of the
brachial plexus, is the motor nerve to the latissimus dorsi muscle.This nerve, along
with the thoracodorsal vessels, passes downward through the axilla and enters the
muscle with the thoracodorsal vascular pedicle.The thoracodorsal nerve is respon-
sible for muscular contraction of the latissimus dorsi muscle. If muscle contraction
is a problem to the patient after a latissimus dorsi ap reconstruction, the nerve can
be divided during a secondary procedure.This division paralyzes the muscle and in-
duces denervation atrophy of the latissimus dorsi muscle without compromising
the blood ow to the ap through the muscle and skin island, as long as the collat-
eral arteries from the serratus anterior muscle are preserved.
The surgeon should also be familiar with the anatomy of the insertion of the latis-
simus dorsi muscle. The insertion is through a 3 cm broad tendon attached to the
bottom of the intertubercular groove of the humerus. The tendon and proximal
latissimus dorsi muscle actually encircle the teres major muscle, which is the mus-
cle that primarily contributes to the form of the posterior axillary fold. In many re-
operative situations the result can be enhanced by dividing and transferring the
proximal latissimus dorsi muscle and its tendon around to the pectoralis major mus-
cle insertion or to the axilla and the upper outer chest wall.