Reoperative Aesthetic & Reconstructive Plastic Surgery

1376
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
Alternatively, a pedicled ap, most often a latissimus dorsi muscle ap with or with-
out a skin island, can be used to supplement the TRAM ap. The choice of tech-
nique depends on the patient’s feelings about the use of implants and her physical
condition. A latissimus dorsi ap provides the best solution for obtaining additional
autologous tissue to supplement a de cient TRAM ap reconstruction, as skin de-
ciency is so often the cause of the problem.The problem with cutaneous augmen-
tation of a TRAM ap is the patchwork-like appearance that it creates.
This 43-year-old woman had a radical mastectomy and breast reconstruction with
a TRAM ap. Because there was not enough lower abdominal tissue available for
reconstruction of the axilla and anterior axillary fold, a latissimus dorsi ap was ro-
tated to provide this additional tissue. Because the patient also wanted to have larger
breasts, breast implants were placed for both breasts.

1377
Chapter 36
Finishing Touches After Breast Reconstruction With Pedicled Flaps
When a small area of TRAM ap is lost, the area is allowed to demarcate clearly, af-
ter which debridement is performed. Small areas may be closed primarily, but larger
areas should be allowed to granulate closed or treated with a vacuum-assisted de-
vice (WoundVac;Kinetic Concepts, Inc., San Antonio,TX).WoundVac therapy has
the advantage of maintaining a moist environment, which limits the risks of ongo-
ing fat necrosis from desiccation of the wound bed as a result of exposure.
Partial Tissue Loss
After partial loss of a TRAM ap, the preferred salvage technique is to excise the
nonviable tissue and reapproximate the tissues of the TRAM ap in the local area
to achieve a satisfactory breast reconstruction, assuming that the local skin is pliable
enough to advance. Small volume losses can often be salvaged in this fashion, al-
though they may require small adjustments to the contralateral breast for perfect
symmetry. If direct closure (or secondary intention healing) results in minor volume
losses, implant insertion may be possible, but given that the smallest implants are ap-
proximately 100 cc in volume, the surgeon may elect to use an asymmetrical aug-
mentation of both breasts rather than try to correct a small de ciency with a small
device that is still too large for the amount of discrepancy between the two sides.
Sometimes a breast implant can be used for the reconstruction at a subsequent
stage. Immediate implant insertion to augment a TRAM ap with a recent or ac-
tive open wound is contraindicated.
W hen the patient wants only autogenous tissue for reconstruction or
when there is a more substantial tissue loss after TRAM ap recon-
struction (25% or more) and autogenous tissue is needed, the latis-
simus dorsi ap is the rst and safest choice.
An approach should be planned to maximize ap survival. The administration of
steroids, maintaining the patient’s hematocrit level so that it is at least 30%, and the
use of systemic supplemental oxygen can all aid in optimizing surgical outcomes.
I prefer delayed rather than early ap debridement because it is dif cult to ascer-
tain the exact amount of ap compromise, especially in fat, for the rst few days.
Small Areas of Flap Loss

1378
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
When the TRAM ap is used for breast reconstruction, the best blood supply in the
pedicled tissue should be in the medial portion of the ap. With this strategy, if
there is partial loss of the ap, it occurs laterally. A lateral defect is not as critical as
a large central or medial defect. A latissimus dorsi ap or lateral thoracic ap can
easily ll a lateral de cit. A small area of ap nonviability can be directly excised in
the early postoperative period or, if the area of loss is large, a latissimus dorsi ap is
the safest salvage option.
The anatomic details and standard technique of elevation of the latissimus dorsi
ap are described in detail in other texts.l4 When the latissimus dorsi ap is used in
a secondary operation to improve the result after a TRAM ap complication, I pre-
fer not to make an additional back scar.
If the patient has excess lateral tissue at the site of the mastectomy and the mastec-
tomy scar extends under the arm, I usually use this excess tissue for the reconstruc-
tion or use the mastectomy scar as access to the latissimus dorsi muscle. A consid-
erable volume of autogenous tissue often can be obtained from the latissimus dorsi
muscle without the need for a major skin island and large back scar. An endoscop-
ically assisted harvest of muscle through the axilla or lateral mastectomy scar alone
can provide a scarless latissimus donor site on the back.
Extension of fat necrosis can occur from early debridement, desiccation, spreading
infection, and additional trauma, leading to additional tissue loss. It is preferable to
wait until a distinct skin margin develops with better delineation of the necrotic tis-
sue, which usually takes 1 to 2 weeks.TRAM aps should be positioned so that the
least vascular portion is laterally located. Placing this area medially leads to the risk
of medial ap loss, which can be inordinately dif cult to correct, although a tun-
neled latissimus ap may reach satisfactorily.

This 55-year-old nonsmoking patient, whose only risk factor was a vertical midline
laparotomy scar, had TRAM ap right breast reconstruction that was complicated
by lateral ap necrosis. She declined latissimus ap reconstruction, and the eschar
was debrided and closed by advancing adjacent chest wall skin up to the side of the
viable flap tissue. A reasonable match was achieved as the original flap was too
bulky de novo but lateral volume loss is still apparent.
1379
Chapter 36
Finishing Touches After Breast Reconstruction With Pedicled Flaps
When a lateral deformity results from tis-
sue loss after a TRAM flap, a latissimus
dorsi flap can be used to fill this deficit,
incorporating a skin island matched to the
defect size on the breast mound.

1380
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
The latissimus dorsi ap may be designed transversely to include some excess tis-
sue in the infraaxillary region or vertically along the lateral muscle border.This lat-
ter harvest scar is usually very unsightly and wherever possible I prefer a donor site
scar along Lange’s lines on the back.
The latissimus dorsi ap is elevated laterally, and the skin island is designed to pro-
vide suf cient ll.
The ap is transferred to supplement the de cient lateral area of the breast (left).The
latissimus dorsi ap restores breast symmetry without the need for a breast implant
(right).
Avascular
portion
removed
Musculocutaneous
latissimus dorsi flap
lifted from back
Latissimus
dorsi flap
sutured
in place
Avascular
portion of
previous
TRAM flap
Skin island
Flap design

1381
Chapter 36
Finishing Touches After Breast Reconstruction With Pedicled Flaps
This patient was a 50-year-old smoker who had a pedicled TRAM ap and devel-
oped lateral necrosis. She was referred for management. The necrotic tissue was
debrided, and an immediate segmental latissimus dorsi myocutaneous ap recon-
struction was performed with subsequent nipple reconstruction using a skate ap.
Total Flap Loss
When there is total loss of a TRAM ap, it is important that the secondary breast
reconstruction be successful with special consideration given to safety. Usually there
is insuf cient tissue for tissue expansion and the transfer of a second ap is needed.
The latissimus dorsi ap is the safest, most reliable alternative and can be a source
of autogenous tissue with additional subcutaneous harvest. A eur-de-lis ap may
be used when there is available back tissue, although the scarring produced by this
skin pattern is unsightly. When the TRAM ap has been completely lost, a major
latissimus dorsi ap is needed, usually supplemented by a textured-surface perma-
nent expander-implant to provide suf cient volume. Use of the extended autolo-
gous harvest provides additional soft tissue ll. An inferior or superior gluteal free
ap is considered when the latissimus dorsi ap is not available or when the patient
wants autogenous tissue breast reconstruction and not enough tissue is available
with the latissimus dorsi ap.The Rubens ap is another free ap alternative for au-
tologous reconstruction but few surgeons are familiar with this dif cult procedure.
Surgeons attempting these procedures should be able to offer success rates of 96%
to 98% with elective microsurgical operations.

1382
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
In this 45-year-old woman, total ap loss occurred after breast reconstruction with
a TRAM ap. Because she wanted only autogenous tissue used for the reconstruc-
tive surgery, reoperation with a latissimus dorsi ap was planned. A mastopexy was
performed on the remaining breast for symmetry.
This 43-year-old woman underwent immediate breast reconstruction with a free
TRAM ap. Unfortunately, the ap was lost. Reoperation was performed as a staged
breast reconstruction with a tissue expander. The nipple-areola was reconstructed
in a later operation with a tattoo planned as the nal procedure.

TISSUE EXCESS
Recontouring the TRAM Flap
Breast reconstructions may be too large or too small when compared with the op-
posite side; seldom are they exactly the right size. In my experience it is generally
better psychologically and aesthetically for patients to have a reconstructed breast
that is a little too big rather than the reverse; for this reason I prefer for the recon-
structed breast to be the same size or slightly larger than the opposite breast. In
such cases no correction is needed or only suction-assisted lipectomy or tissue ex-
cision is required to obtain the desired symmetry. Suction-assisted lipectomy re-
duces ap bulk, softens the breast, and improves symmetry. I usually wait at least 3
months after the TRAM ap procedure to perform this correction.
1383
Chapter 36
Finishing Touches After Breast Reconstruction With Pedicled Flaps
To avoid the possibility of ap or fat necrosis and atrophy of the TRAM ap, the
vascular pedicle should not be excised after the primary breast reconstruction.The
existence of this pedicle, however, may cause loss of de nition at the medial infra-
mammary crease when a contralateral pedicled ap has been transposed.The prob-
lem is far less common after ipsilateral transfer. Prevention by denervating the mus-
cle is better than cure but should revision be necessary, liposuction during a
secondary procedure can help to de ne the crease.

1384
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
In this 52-year-old woman the right breast was reconstructed with a TRAM ap.
After several years she gained 15 pounds, and the reconstructed breast became larger
than the opposite breast. Suction-assisted lipectomy of the TRAM ap would be a
good solution for improving breast symmetry and contour.
Repositioning the TRAM Flap
Occasionally a TRAM ap may appear too far lateral or too high or low on the
chest. Rarely, it is too medial. Repositioning is not a simple procedure as it involves
reelevating a substantial portion of the ap and resuspending it from the chest wall
with stay sutures of 2-0 Vicryl.The overlying skin of a skin-sparing mastectomy ap
can be stripped off the TRAM ap fairly easily, but the deeper plane is a little more
adherent and the pedicle is greatly at risk from these maneuvers. Extreme caution
should be exercised when dissecting and mobilizing a vascular pedicle whether
pedicled or free. Avoidance of this problem is far preferable to a dif cult reposition-
ing procedure and care should be taken with positioning and shaping at the initial
operation, ensuring that the ap is suspended superomedially to prevent inferolat-
eral drift with time as the ap sags under its own weight. In our experience most
of these procedures have been necessary in secondary operations when patients
have presented as referrals for correction of secondary deformities.

This 40-year-old woman was referred for correction of TRAM ap deformity. She
had had a pedicled TRAM ap reconstruction with immediate implant insertion
and subsequent nipple reconstruction.The TRAM ap was not sutured to the chest
wall superiorly and it drifted inferiorly.The implant was placed too high, exhibited
major rippling, and volume was excessive.The nipple reconstruction was misplaced
and lacked projection.
1385
Chapter 36
Finishing Touches After Breast Reconstruction With Pedicled Flaps
Correction involved a staged approach. The implant was exchanged for a smaller
device, and the TRAM ap was elevated carefully from the upper pole skin and
suspended from the chest wall superomedially. At the same operation, the TRAM
skin island and nipple reconstruction were resected and the mastectomy skin was
closed. An immediate improvement in shape was achieved. Subsequently the nip-
ple was reconstructed in the correct anatomic site on the new breast mound.

1386
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
Abdominal Wall Contouring and Scar Revision
The abdominal wall may require secondary correction to contour and reduce ar-
eas of excess. Usually the lower abdominal area is attened after a TRAM ap has
been harvested;however, the abdomen in general may still have excess tissue, espe-
cially at the site of the pedicle in the upper abdomen and mons pubis regions and
in the lateral hip area. If the nerves to the upper rectus abdominis muscle are not
divided, especially the eighth intercostal nerve, additional upper abdominal wall
fullness may be present. Although some of these areas can be contoured at the time
of the TRAM ap surgery, they may also require suction-assisted lipectomy at the
time of the finishing touches or during secondary procedures. Suction-assisted
lipectomy in this region can improve contour; however, it cannot be expected to
atten a protruding upper abdominal wall if the closure of the upper abdomen was
not tight and secure. Sometimes the abdominoplasty scar can also be improved with
scar revision.
One of the issues that may complicate donor site
aesthetics is grooving at the donor site incision
above the mons pubis. If Scarpa’s fascia is not re-
paired as a distinct layer, the subcutaneous fat
deep to this structure may pull away during heal-
ing resulting in grooving of the incision. This is
best prevented by closing Scarpa’s fascia at the
time of the initial ap but can be corrected by
reexcising the scar and reclosing the fascia sec-
ondarily. Areas of fat necrosis are most common
at the suprapubic area in obese patients or smok-
ers. Resection and revision at the time of nipple
reconstruction correct the problem. A typical ex-
ample of this problem in a smoker is shown illus-
trating the preoperative markings.

Seroma
Because of the large dead space created by the harvest of abdominal aps, a seroma
may form.The blood supply to the abdominal wall fat below Scarpa’s fascia comes
mostly from the super cial tissues. When a seroma develops after a TRAM ap,
excision of this layer beneath the Scarpa’s fascia along with the seroma capsule is the
best opportunity for correction. Prevention is preferable, and the judicious use of
quilting sutures and the long-term use of drains have reduced the problem of ab-
dominal seroma formation to negligible levels in my practice. The same is true of
the latissimus donor site where the additional use of brin glue spray and long-
term drainage have greatly reduced seroma formation. Drains may be left in place
for weeks or even months without the need for antibiotics.
Hernia and Bulge Repair
An abdominal wall bulge or hernia can develop in the postoperative period after
TRAM ap harvest.This condition usually develops within the rst year.16-18 Analy-
sis of our TRAM ap patients reveals that postoperative development of this con-
dition is most commonly related to the failure of the primary direct approximation
of well-vascularized healthy, strong fascia incorporating both the internal and ex-
ternal oblique fascial planes. Fascial tearing caused by tension may be an additional
factor. An accurate knowledge of the position of the periumbilical perforators per-
mits a selective fascial inclusion and muscle harvest in this region and allows for pri-
mary suture of the fascial margins even when a bipedicled TRAM ap is elevated.
Choice of anesthetic technique also in uences the risk of postoperative hernia.
When nitrous oxide is avoided, the gas is not deposited intraluminally and the
bowel is not distended, thereby facilitating primary closure. If fascial tearing oc-
curs during closure or the fascia appears tenuous and tight, insertion of mesh or
AlloDerm is preferred in an effort to minimize subsequent bulge formation. If
mesh is incorporated into the abdominal repair, it is best placed within the sheath,
suturing it from the linear semilunaris laterally to the medial concavity of the sheath
adjacent to the linea alba medially.The remaining anterior sheath can be sewn over
this onto the anterior surface of the mesh as far as it will come across both medi-
ally and laterally, which buries a substantial portion of the mesh beneath fascia.This
provides an exceptionally strong abdominal repair that I have never seen fail.
When a hernia of the abdominal wall is being repaired after TRAM ap harvest,
consideration should be given to the intraabdominal contents. Care must be taken
to avoid injury to the bowel; when in doubt concerning this area, the reconstruc-
tive surgeon should consult with a general surgeon. It is necessary to obtain wide
exposure of the defect by elevating the abdominal wall ap. The margins of the
defect must be clearly identi ed.With good muscular relaxation and bowel prepa-
ration without intraluminal gas (no nitrous oxide), a primary closure is sometimes
(but rarely) possible. Whether primary closure is possible or not, a double sheet
1387
Chapter 36
Finishing Touches After Breast Reconstruction With Pedicled Flaps

1388
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
of Prolene mesh is placed over the defect to prevent further protrusion. With the
re nement of laparoscopic surgery, it is now possible to repair these defects laparo-
scopically without the need for extensive abdominal wall incisions, thereby reduc-
ing postoperative pain and shortening the recovery time.
In many cases a true hernia is not present and the fascia has simply attenuated, or
the medial portions of the external and internal oblique muscles have suffered what
appears to be a denervation injury with ensuing weakness. In such cases the laxity
can be imbricated with heavy continuous sutures followed by an onlay of Prolene
mesh or AlloDerm to provide additional strength.The same procedures are useful
when abdominal wall bulges develop after free aps. These procedures are less in-
vasive than full blown hernia repairs.
Two years before referral, a ventral hernia developed in this 45-year-old woman af-
ter a right unilateral TRAM ap breast reconstruction.

Repair was accomplished by reelevation of the abdominal skin ap. The ventral
hernia was de ned, the attenuated margins of the fascia were approximated, and ad-
ditional plications were made laterally and centrally.
A double-thickness layer of Prolene mesh was sutured over the abdominal wall to
reinforce the repair.
1389
Chapter 36
Finishing Touches After Breast Reconstruction With Pedicled Flaps
Interestingly, this former heavy smoker, despite the previous elevation of the ab-
dominal skin ap, developed an area of delayed skin healing in the lower abdomen.
This site healed with conservative care, and the hernia repair remained intact.The
patient is shown 2 months after hernia repair.

1390
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
INFRAMAMMARY FOLD CORRECTION
Incorrect placement of the inframammary fold can be a problem with autogenous
tissue breast reconstruction because the tendency is to place the inframammary
fold too low. Several factors account for incorrect positioning. If the inframam-
mary fold is marked and cut symmetrical with the opposite breast, the abdominal
wall closure will release skin and allow it to settle lower.When the incision is made
at the inframammary fold, the tension on the tissues from the mastectomy wound
closure will lessen with time, and the inframammary fold will again assume a low
position.When breast de nition is combined with lower pole enhancement using
an abdominal wall advancement ap, the inframammary fold tends to drift down-
ward. If an immediate reconstruction is performed with a skin-sparing mastectomy,
the oncologist may dissect below the inframammary fold, thereby obliterating this
important landmark. Every effort should be made to preserve the fold at the initial
operation. If it is distorted or destroyed, quilting sutures of braided nonabsorbable
material such as Ethibond or Mersilene can be placed between the chest wall and
the deep dermis of the overlying skin to reestablish the contour. If the inframam-
mary crease must be de ned or rede ned at a second operation, the ap may need
to be repositioned (see p. 1385), or an abdominal wall advancement ap may be
necessary to correctly position the inframammary fold. Suction-assisted lipectomy
of the upper abdomen can further de ne the fold.
This woman had a modi ed radical mastectomy and implant breast reconstruc-
tion. She was disappointed with the resulting symmetry and requested a staged au-
togenous breast reconstruction. A TRAM ap breast reconstruction was performed
after the breast implant was removed. Unfortunately, the reconstructed breast was
larger and fuller than the opposite breast. Correction of this problem required re-
section and liposuction of the excess lower fullness of the TRAM ap and elevation
and advancement of the inframammary fold to position the fold so that is was sym-
metrical with the fold on the opposite side.

INADEQUATE CENTRAL BREAST PROJECTION
The normal breast, although it may be at when the patient is in the supine posi-
tion, has distinct central projection when the patient is upright. One of the prob-
lems with breast reconstruction has been difficulty in obtaining central mound pro-
jection that is symmetrical with that of the opposite breast. In this situation an
implant may be needed to restore projection.
1391
Chapter 36
Finishing Touches After Breast Reconstruction With Pedicled Flaps
This woman had a TRAM ap breast reconstruction after a modi ed radical mas-
tectomy. Postoperatively she believed that she did not have suf cient central breast
fullness. She also wished to have more breast volume, both in the reconstructed
breast and in the opposite breast, which she wanted augmented.To improve this sit-
uation, breast implants were placed bilaterally. To reduce the probability of capsu-
lar contracture, a textured-surface breast implant should be used behind the TRAM
ap.
REOPERATION AFTER A LATISSIMUS
DORSI FLAP
The latissimus dorsi ap is one of the most reliable pedicled aps19; the incidence
of tissue loss with this ap is usually less than 1%.15 Most secondary procedures af-
ter latissimus dorsi ap breast reconstruction are needed because of improper plan-
ning (for example, failure to transfer enough autogenous tissue to the chest wall to
provide symmetry with the opposite breast), aesthetic shortcomings related to un-
aesthetic positioning of the ap high on the reconstructed breast in the mastec-
tomy scar, and implant problems such as capsular contracture or incorrect implant
size.Volume or position discrepancies may also necessitate reoperation.The donor
site may require attention because of seroma or tightness.

1392
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
FLAP DEFICIENCY
Asymmetry
When there is breast asymmetry, the decision is made to modify the reconstructed
breast, the opposite breast, or both.
In principle, it is usually preferable to reshape the reconstructed breast
with the latissimus dorsi ap.
The tissue expander or breast implant can be repositioned or the shape or volume
of the reconstructed breast can be changed. Some atrophy of the latissimus dorsi
muscle is to be expected after the initial procedure.The placement of a saline- lled
adjustable implant behind the ap provides the best opportunity to plan for this oc-
currence and to keep the volume of the reconstructed breast symmetrical with that
of the opposite breast. If a xed-volume implant has been used in the initial recon-
struction, it may need to be exchanged for an adjustable implant. Alternatively, im-
plants can be avoided altogether and a TRAM ap could be used to provide addi-
tional volume.
Partial and Total Flap Loss
After the rare case of partial latissimus dorsi ap loss, the preferred correction is to
modify the reconstructed breast with a tissue expander or breast implant. Scarring
may limit the degree of successful expansion achieved, however. After complete
loss of the latissimus dorsi ap, which is an exceptionally rare occurrence, another
autogenous tissue breast reconstruction is usually needed; a TRAM flap or free
TRAM ap is usually the rst choice if available, but all too often the latissimus ap
was selected because the patient was a poor candidate for a TRAM ap initially.
Under such circumstances, the more remote free ap options such as gluteal aps
or Rubens aps are a solution.These are dif cult procedures and should only be un-
dertaken by surgeons who are intimately familiar with these demanding techniques.
INFRAMAMMARY FOLD PROBLEMS
As with the TRAM ap, inframammary fold contour problems may arise.Too high
a fold requires release with lowering of the implant. All too often, the weight of an
implant may result in descent with pseudoptosis of the implant beneath the ap, re-
sulting in lowering of the fold. Should this occur, or if the fold has been overdis-
sected, a crease pexy is required.This can take the form of a modi ed Ryan proce-
dure or suturing dermis to the chest wall with nonabsorbable sutures such as 0 or
2-0 Ethibond, which can effectively raise the crease or implant pocket.

These gures illustrate the use of this technique.This patient had a failed expander
reconstruction by her rst surgeon. A second surgeon attempted Rubens ap sal-
vage starting with the left breast, which failed. He attempted latissimus ap salvage,
which achieved a stable breast mound with asymmetry. Nipple position was grossly
asymmetrical. She presented for completion of the procedure. A latissimus ap was
performed on the right breast followed by insertion of implant in both breasts.
Postoperatively the patient developed the appearance of implant pseudoptosis when
in the recumbent position, and the inframammary fold began to descend. A crease
pexy with capsulorrhaphy was performed as described earlier.
1393
Chapter 36
Finishing Touches After Breast Reconstruction With Pedicled Flaps

1394
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
CAPSULAR CONTRACTURE AND BREAST ASYMMETRY
Experience with the latissimus dorsi ap for breast reconstruction after radical mas-
tectomy has demonstrated that the muscle ap atrophies over time, with resulting
deterioration of the shape of the reconstructed breast.The ap may not provide ad-
equate tissue to ll substantial upper chest wall tissue defects, particularly for patients
with a full opposite breast and thick subcutaneous tissues. In addition, capsular con-
tracture can develop, especially when a smooth-surface breast implant has been
placed under the latissimus dorsi ap. This problem is the most common compli-
cation after a latissimus dorsi ap breast reconstruction and worsens after radiation
therapy.20 Contracture along with the muscle atrophy can cause asymmetry and
breast distortion.
When a latissimus dorsi ap reconstruction has deteriorated and contracture occurs,
strategies for correction include replacement of the implant with autogenous tissue
(usually the TRAM ap) or capsulectomy with placement of a textured-surface
saline- lled implant or expander. My current approach to this problem is to per-
form a total capsulectomy and replace the smooth-surface silicone breast implant
with a textured-surface implant or textured-surface permanent expander implant.
A small subcutaneous ll valve can be retained to allow ne adjustments to the
volume of the reconstructed breast.The silicone breast implant is removed by ex-
posing it through a scar that does not require division of the latissimus dorsi mus-
cle;division could devitalize the distal ap. If a supplemental TRAM ap is used, it
may be bisected, with one ap used for additional upper breast ll and the second
ap employed for breast reconstruction. The latissimus dorsi ap is then used for
upper breast reconstruction and anterior axillary fold reconstruction (if a radical
mastectomy defect was reconstructed). A large skin island is deepithelialized to sup-
plement breast ll, and the latissimus dorsi muscle is transposed to the pectoralis
major insertion to satisfactorily restore the missing anterior axillary fold.

This woman had breast reconstruction with a latissimus dorsi ap and a breast im-
plant. Capsular contracture developed along with unsatisfactory symmetry. She had
a staged reoperative breast reconstruction to correct this problem:The implant was
removed, the latissimus dorsi ap was deepithelialized and used for upper breast
reconstruction, and the TRAM ap was transferred to reconstruct the lower breast
region.
1395
Chapter 36
Finishing Touches After Breast Reconstruction With Pedicled Flaps

1396
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
Because her TRAM flap donor site was thin and she was reluctant to undergo
TRAM ap surgery, this patient had a latissimus dorsi myocutaneous ap recon-
struction with gel implant insertion for cancer of the right breast. She developed
a Baker grade IV capsular contracture within 6 months of the procedure. Open
capsulotomy and implant exchange of the gel implant for a saline device resulted in
a stable soft result at 4 years.
DYSKINESIS OF LATISSIMUS FLAPS
When the thoracodorsal nerve is left intact, latissimus ap contraction may present
unattractive ripples beneath the skin of the reconstructed breast. This may be ex-
acerbated by suturing the latissimus dorsi muscle to the lower border of the pec-
toralis major muscle. When the patient moves her shoulder girdle, the two inner-
vated muscles can contract asynchronously resulting in severe distortion. Correction
requires division of the thoracodorsal nerve if possible, as well as dissection of the
muscle off the overlying skin and allowing the tissues to settle in a new position
without muscular contraction.
TIGHTNESS OR CONTRACTURE OF DONOR SITE
When there is tightness or contracture of the donor site of the latissimus dorsi ap,
at the time of the nishing touches the thoracodorsal pedicle is dissected and a seg-
ment of the thoracodorsal nerve is removed. When the tightness extends laterally

and the patient complains of dif culty when she brings the arm around to the op-
posite side, the insertion and the proximal portion of the latissimus dorsi muscle are
dissected and the latissimus dorsi muscle is separated from the teres major muscle.
1397
Chapter 36
Finishing Touches After Breast Reconstruction With Pedicled Flaps
Other donor site revisions may be needed after a latissimus dorsi ap transfer.When
the latissimus dorsi ap has been elevated incompletely at the time of the breast re-
construction and is still attached laterally to the teres major muscle and other lat-
eral structures, the patient often complains of tightness of the chest wall.This tight-
ness can be alleviated during a secondary procedure by releasing the latissimus dorsi
ap from the teres major muscle and dividing the latissimus dorsi tendon from the
insertion.
Latissimus dorsi
transected and
elevated from
lateral border
of scapula and
teres major muscle
Tendinous
origin on
humerus
Thoracodorsal nerve
(from C6-8)
Latissimus dorsi
muscle remains
attached to
lateral border
of scapula and to
teres major muscle
Scapula
Distal muscle
previously freed
to fill lower
breast mound
Teres major
muscle
Incision to
create flap

1398
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
The patient may also have symptoms related to muscle pull and silicone breast im-
plant distortion after latissimus dorsi ap reconstruction because the latissimus dorsi
muscle is contracting too much, thereby distorting the breast reconstruction. In
this situation the latissimus dorsi muscle can be denervated by dividing the thora-
codorsal nerve at the time of the secondary procedure.
ABSENCE OF THE ANTERIOR AXILLARY FOLD
When the anterior axillary fold is missing as a result of radical mastectomy or
Poland’s syndrome, the best correction is transfer of the latissimus dorsi tendon an-
teriorly to the insertion of the pectoralis major muscle on the humerus. If this
transfer is not performed at breast reconstruction, it may be needed at the time of
the nishing touches.
Cut end of
latissimus dorsi
Thoracodorsal
artery and vein
End of
thoracodorsal
nerve
Latissimus dorsi flap
sutured to pectoralis
major muscle
Latissimus dorsi
skin island
Thoracodorsal
artery and vein
Thoracodorsal
nerve (divided)
Skin island
Latissimus dorsi flap
transected at humerus

The deepithelialized skin island provides the best ll;however, the transposed mus-
cle can also give effective improvement.
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Finishing Touches After Breast Reconstruction With Pedicled Flaps
Reconstruction in young patients with Poland’s syndrome is usually a staged pro-
cedure, with necessary changes made over the years to accommodate growth and
development. This was the case for this 9-year-old girl with Poland’s syndrome:
She exhibited absence of the pectoralis major muscle, anterior axillary fold, and
breast.
The pectoralis major muscle was reconstructed with transfer of the latissimus dorsi
muscle. As the patient grew and developed, the breast was reconstructed with a
breast implant. For symmetry, a breast implant was also placed in the opposite breast
via an axillary incision. Today, rather than xed-volume breast implants, a perma-
nent expander implant with a valve for adjustment with saline solution is the pre-
ferred device for reconstruction in young women.

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AXILLARY HOLLOW NESS
Sentinel node sampling has reduced the need for axillary dissection in many pa-
tients. However, of those patients who require axillary node dissection, some will
complain of axillary hollowness. Correction of this defect poses an aesthetic and
functional problem for patients. When there is signi cant axillary hollowness, the
latissimus dorsi insertion can be divided and rotated to give the ll, or in a second-
ary procedure autogenous tissue from the TRAM ap can be used to ll the axilla.
This area also can be lled with a fasciocutaneous ap from the area of subaxillary
fullness, which usually exists along the lateral border of the mastectomy site.When
a large dog-ear is present laterally, a ap based on a subcutaneous pedicle can be
transposed for correction.
After primary breast reconstruction, this patient had good volume symmetry but
she was concerned about the hollowness of the left axilla and the fullness beneath
the axillary region.To correct this problem, an areola donor skin graft will be har-
vested from this axillary region.The remainder of the excess subaxillary tissue will
be used to ll the axilla. In addition to the full-thickness graft, an internal elevation
of the inframammary crease is also needed.This correction is accomplished with in-
ternal capsulorrhaphy of the inframammary crease (arrows).

This subcutaneous tissue is then mobilized and the axillary skin is undermined.
The ap is turned on itself (like a page in a book), placed into the axillary defect,
and sutured.The remainder of the incision is closed directly.This technique lls the
axillary concavity and provides donor skin for the areola. An open capsulotomy is
performed through this incision.The implant is removed, a lower capsulectomy is
performed, and the lower incision is resutured using a lighted retractor and long in-
struments.
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Finishing Touches After Breast Reconstruction With Pedicled Flaps
The full-thickness graft is harvested and will be used to reconstruct the areola.The
skin lateral to the areola donor site is deepithelialized. A fasciocutaneous ap based
on the subcutaneous tissue and fascia from the axilla is mobilized toward the axilla.

1402
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Another alternative for this area is autologous fat injection using the Coleman fat
transfer technique and equipment.21 This can be used in the anterior axillary fold
area as well the infraclavicular region where hollowing tends to be more of a prob-
lem. Fat harvested from the hip, ank, or abdomen may be centrifuged or simply
spread on Telfa pads to allow gentle wicking off of the liquid oils, creating a reliable
graft of particulate fat for injection through a 1 mm cannula. The technique is
more successful in patients who have not been irradiated. An irradiated bed tends
to be more adherent and the vascular paucity in the area may limit graft revascu-
larization. Concerns about fat necrosis affecting mammographic follow-up are
really only of importance in patients who have undergone breast conservation sur-
gery—in these women it is unwise to inject fat, which may develop microcalci -
cations visible on mammography.
This 45-year-old woman had undergone TRAM ap reconstruction of the right
breast 8 years previously with subsequent augmentation for volume. She had per-
sistent hollowing of the superomedial breast contour that showed in clothing when
she wore a bra. This was corrected with a single autologous fat injection of 50 cc
of fat injected using the Coleman system. The correction is shown at 9 months
postoperatively.

FINISHING TOUCHES AND SECONDARY
NIPPLE-AREOLA RECONSTRUCTION
After the initial breast reconstruction, nipple-areola reconstruction is usually per-
formed once the breasts are symmetrical. In the past, when nipple-areola recon-
struction was performed at the time of the breast reconstruction or before symme-
try of the breasts was obtained, the nipple-areolae often were not symmetrical and
their positions were not ideal. It is better to wait than to have the areolae placed and
reconstructed in the improper positions or to have the tissues stretch beneath them
and cause asymmetry of the diameter of the nipple-areolae.
The nipple-areola position is determined initially. Nipple-areola reconstruction is
usually now performed with available local tissues and without the need for special-
ized tissues from the opposite nipple or the upper inner thigh crease.
THE CV FLAP
In the patient with conventional mastectomy reconstruction, I prefer the modi ed
star ap (CV ap) with the areola tattooed.22 With this technique a layer of skin and
fat on the reconstructed breast is shifted to the center of what will be the future
nipple-areola area and formed into a nipple.The skin is used to create the nipple,
and the underlying fat is used to add bulk, fullness, and permanent shape.This tech-
nique permits closure of the donor sites for the nipple reconstruction.
When there is tissue available for a full-thickness skin graft, the skate ap or the
modi ed star ap can be used.15,23,24 The diameter and shape of the areola are de-
termined and drawn on the site to be reconstructed.
When the nipple-areola reconstruction is malpositioned or unattractive, the best
strategy is usually to remove the reconstructed nipple-areola with direct excision,
reconstruct a new one as a primary reconstruction with the CV or skate ap, and
either use a tattoo to provide a semblance of an areola or reconstruct the areola
with a full-thickness graft.When the areola diameter is so large that the areola can-
not be excised without distorting the breast, I remove it with a tangential excision
and allow the site to reepithelialize.
In some situations, after nipple-areola reconstruction when there is not enough
nipple projection and the opposite nipple is large, the surgeon may consider use of
a composite graft.
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Finishing Touches After Breast Reconstruction With Pedicled Flaps

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R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
MODIFIED SKATE FLAP IN SKIN-SPARING MASTECTOMY
R ECONSTRUCTION
The original skate ap required a skin graft to the nipple donor site making this a
more extensive procedure than the very simple, safe CV ap. The CV ap does
have a tendency to shrink with time, whereas the skate ap seems to maintain pro-
jection a bit better. A modi cation of the skate ap, suitable for skin-sparing mas-
tectomy reconstructions only, involves incising the entire periareolar scar of a skin-
sparing mastectomy after raising two horizontal centrally based wings of equal
length and width. The two tabs are wrapped as in the standard skate ap, and the
donor sites are closed with sutures. The periareolar inset is then pulled in with a
purse-string closure, which provides a very pleasing aesthetic result without dis-
torting the shape of the TRAM ap.
POSTOPERATIVE CARE
Postoperative care after reoperation focuses on general as well as local considera-
tions. When there has been a major ap reconstruction, the ideal combination of
blood ow and oxygen delivery is obtained with a hematocrit level of approxi-
mately 30% to 32%.When the hematocrit level is higher, there can be sludging of
the erythrocytes;when it is lower, poor oxygen delivery results.This titration of the
blood count is facilitated by having autologous blood available for these proce-
dures.
After TRAM ap reconstruction, it is important to consider the pos-
sibility of deep venous thrombosis and pulmonary embolism. These
complications are related to the patient’s history of pulmonary em-
bolism as well as to the length of the procedure (the risk of deep
venous thrombosis is increased when the procedure lasts more than
4 hours).

For these patients, intermittent lower extremity compression devices are used, and
the patients are instructed to get out of bed and begin walking the day after the op-
eration.
After a primary TRAM ap procedure or correction of an abdominal wall hernia,
the patient should not lift more than 5 kg (11 pounds) for 2 to 3 months. I also sug-
gest that she avoid other strenuous activities for 3 months.
AESTHETIC POSSIBILITIES AND LIMITATIONS
OF REOPERATIVE SURGERY
Reoperation and secondary surgery in the breast region offer the potential for sig-
ni cant improvement in most instances. Usually the surgeon has several options to
choose from when planning corrections or improvements. Modi cation of the op-
posite breast can also be considered to improve breast symmetry. Breast implants of-
fer the possibility of obtaining additional breast volume beyond what is ordinarily
possible with pedicled aps alone.The patient needs to make a decision, however,
as to whether she wants a breast implant or prefers only autogenous tissue. When
autogenous tissue is insuf cient and a breast implant is not used, the limitations are
obvious.
The use of a second pedicled ap should be considered when the rst procedure
falls short of the expected result and a volume de cit remains. In this situation the
latissimus dorsi flap can often enhance the upper breast reconstruction once a
TRAM ap restores the lower breast contour. A free ap is also a consideration but
involves another major surgical intervention that a patient may not be willing to
undergo unless the defect is extensive and only an autogenous tissue reconstruction
is desired.
The expected result following reoperation after pedicled ap reconstruction is of-
ten related to the condition of the reconstruction before this correction.The recon-
structive surgeon must know the realistic possibilities for these corrections and
should be sure that the patient understands and accepts them.
Textured-surface implants or expanders, which have been available for only a few
years, have a capsular contracture rate that is reported to be low. Realistically, how-
ever, I believe that the capsular contracture rate for reoperation in the situations
described in this chapter could be higher.
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Finishing Touches After Breast Reconstruction With Pedicled Flaps

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R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
The anticipated outcome after reduction of an autogenous breast reconstruction
with either direct excision or suction-assisted lipectomy is more predictable. The
patient should be advised, however, that the nal result can take months or even up
to 1 year to evolve because of the hematoma, bruising, and swelling that follow
every instance of suction-assisted lipectomy.
The key to producing a satisfactory result is scrupulous technical execution and
realistic expectations.The best approach to the anticipated outcome after reopera-
tion is to promise less than the ideal result because this is most often the true out-
come.
References—With Key Annotated References
1. Losken A, Carlson GW, Schoemann MB, et al. Factors that in uence the completion of breast
reconstruction. Ann Plast Surg 52:258-261; discussion 262, 2004.
This paper documented the results of 888 completed breast reconstructions as de ned by the endpoint
of completed nipple reconstruction with tattoo.The paper records the number of procedures required to
achieve completion and symmetry in 738 unilateral and 150 bilateral reconstructions.The average
number of procedures was 3.99 for unilateral and 5.54 for bilateral. It is important to understand that
“procedure”is meant to indicate an operative manipulation of the reconstruction and not the number
of visits to the operating room.TRAM aps had the highest number of interventions to achieve the
nal goal due in large part to the need for donor site revisions, which are absent in implant reconstruc-
tion. Not surprisingly, radiation therapy resulted in a higher number of procedures than nonirradiated
patients, as did risk factors. Delayed reconstruction was also associated with more revisionary procedures.
2. Losken A, Carlson GW, Jones GE, et al.Trends in unilateral breast reconstruction and manage-
ment of the contralateral breast:The Emory experience. Plast Reconstr Surg 110:89-97, 2002.
This study recorded the outcome of 1394 unilateral reconstructions of either immediate or delayed tim-
ing in relation to the index mastectomies.The techniques involved implants, latissimus dorsi aps, and
TRAM aps. Immediate reconstruction was associated with a signi cantly lower incidence of contralat-
eral surgery (22%) versus 67% for delayed procedures. Adjustment of the opposite side was necessary
most often following implant reconstruction (87%) and took the place of augmentation mammaplasty
in a majority of cases whereas autologous techniques most frequently required breast reductions. Of
particular interest is the fact that skin-sparing mastectomy was associated with a 50% reduction in
contralateral surgery because of the excellence of the initial results achieved with this procedure. The
results are all the more interesting in that they represent the outcomes of a busy multisurgeon group
with considerable experience in breast reconstruction.
3. Malyon AD, Husein M, Weiler-Mithoff EM. How many procedures to make a breast? Br J
Plast Surg 54:227-231, 2001.
4. Maxwell GP, Andochick SE. Secondary shaping of the TRAM ap. Clin Plast Surg 21:247-253,
1994.
5. Petit J, Rietjens M, Garusi C. Breast reconstructive techniques in cancer patients:Which ones,
when to apply, which immediate and long-term risks? Crit Rev Oncol Hematol 38:231-239,
2001.
6. Padubidri AN, Yetman R, Browne E, et al. Complications of postmastectomy breast recon-
structions in smokers, ex-smokers, and nonsmokers. Plast Reconstr Surg 107:342-349;discus-
sion 350-351, 2001.
7. Williams JK, Bostwick J III, Bried JT, et al. TRAM ap breast reconstruction after radiation
treatment. Ann Surg 221:756-764; discussion 764-766, 1995.

8. Codner MA, Bostwick J III, Nahai F, et al. TRAM ap vascular delay for high-risk breast re-
construction [comment]. Plast Reconstr Surg 96:1615-1622, 1995.
9. Paige KT, Bostwick J III, Bried JT, et al. A comparison of morbidity from bilateral, unipedicled
and unilateral, unipedicled TRAM ap breast reconstructions. Plast Reconstr Surg 101:1819-
1827, 1998.
10. Moon HK,Taylor GI.The vascular anatomy of rectus abdominis musculocutaneous aps based
on the deep superior epigastric system. Plast Reconstr Surg 82:815-832, 1988.
11. Holm C, Mayr M, Hofter E, Ninkovic M. Perfusion zones of the DIEP ap revisited: A clin-
ical study. Plast Reconstr Surg 117:37-43, 2006.
12. Restifo RJ, Syed SA, Ward BA, et al. Surgical delay in TRAM ap breast reconstruction: A
comparison of 7- and 14-day delay periods. Ann Plast Surg 38:330-333; discussion 333-334,
1997.
13. Taylor GI, Corlett RJ, Caddy CM, et al. An anatomic review of the delay phenomenon: II.
Clinical applications. Plast Reconstr Surg 89:408-416; discussion 417-418, 1992.
14. Miller MJ, Rock CS, Robb GL. Aesthetic breast reconstruction using a combination of free
transverse rectus abdominis musculocutaneous flaps and breast implants. Ann Plast Surg
37:258-264, 1996.
15. Bostwick J III. Plastic and Reconstructive Breast Surgery. St Louis: Quality Medical Publish-
ing, 1990.
16. Mizgala CL, Hartrampf CR Jr, Bennett GK. Abdominal function after pedicled TRAM ap
surgery. Clin Plast Surg 21:255-272, 1994.
17. Mizgala CL, Hartrampf CR Jr, Bennett GK. Assessment of the abdominal wall after pedicled
TRAM ap surgery: 5- to 7-year follow-up of 150 consecutive patients. Plast Reconstr Surg
93:988-1002; discussion 1003-1004, 1994.
One hundred fty patients were retrospectively questioned concerning their abdominal appearance
and function after pedicled TRAM ap surgery. Patients were equally distributed between single-
and double-pedicled aps;72% noted improved abdominal appearance, whereas 62% noted overall
improvement of the abdomen functionally and 20% felt their posture was improved. Although both
groups noted decreased abdominal wall strength and sit-up ability, with most the impact felt by the
double-pedicled patients, fewer than 5% noted any impact on activities of daily living. Hernias were
negligible, with bulges occurring in three patients, with only one requiring repair. Almost all patients
felt that the procedure was eminently worthwhile, and 96% would recommend the procedure to other
patients.This paper emphasizes the importance of abdominal contour improvement in the patients’
outcomes as well as reiterating the relatively minor impact that a well-performed abdominal closure can
have on patients functionally in the long term.
18. Petit JY, Rietjens M. [Complications and abdominal wall sequelae in pedicle TRAM breast re-
construction] Ann Chirurg Plast Esthet 42:131-137, 1997.
19. Schneider WJ, Hill HL Jr, Brown RG. Latissimus dorsi myocutaneous ap for breast recon-
struction. Br J Plast Surg 30:277-281, 1977.
20. Evans GR, Schusterman MA, Kroll SS, et al. Reconstruction and the radiated breast:Is there a
role for implants? Plast Reconstr Surg 96:1111-1115; discussion 1116-1118, 1995.
This author group, from the M.D.Anderson Cancer Center, highlighted the dif culties encountered in
dealing with the long-term outcomes of irradiated implant reconstructions.Their two major conclusions
were that 30% of irradiated implant reconstructions were complicated by pain and capsular contrac-
ture and that coverage of an implant by autologous tissue followed by radiation did not prevent the
development of serious complications. Although other authors have recently suggested that good results
may be achieved with irradiated implant reconstruction, it is by no means the experience of most sur-
geons, even when they are associated with highly skilled radiation oncologists af liated with excellent
major cancer centers. Any surgeon embarking on implant reconstruction followed by radiation therapy
should be prepared to face signi cant complication rates, with potential loss of the reconstruction. Re-
vision often requires autologous conversion.
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Finishing Touches After Breast Reconstruction With Pedicled Flaps

1408
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
21. Spear SL,Wilson HB, Lockwood MD. Fat injection to correct contour deformities in the re-
constructed breast. Plast Reconstr Surg 116:1300-1305, 2005.
In recent years, fat injection using the Coleman technique has resulted in signi cant improvements in
facial contouring, with improved graft retention with microinjection techniques. Spear reported the use
of this procedure in augmenting the minor contour deformities often associated with breast reconstruc-
tions.The procedure works well, although I personally nd it less ef cacious when performed into an
irradiated bed. Spear’s documentation of success with fat injection should be tempered by the under-
standing that this report comments only on the use of the technique in postmastectomy reconstruction,
where mammograms of the affected breast will not be required for cancer screening.The technique is
not advised in breast conservation cancer therapy as the injection sites could develop postinjection
calci cation, which could mimic or mask cancers on follow-up screening mammograms.
22. Berger K, Bostwick J III. A Woman’s Decision, 2nd ed. St Louis: Quality Medical Publishing,
1994.
23. Little JW III.The nipple-areolar reconstruction—Skate technique [abstr]. Plast Reconstr Surg
76:806, 1985.
24. Little JW III, Spear SL.The nishing touches in nipple-areolar reconstruction. Perspect Plast
Surg 2:1, 1988.

1409
Chapter 36
Finishing Touches After Breast Reconstruction With Pedicled Flaps
1. A patient complains of fullness at the costal margin where the pedicle crosses the
ribs 9 months after pedicled TRAM ap reconstruction.The correct treatment
should be:
a. Direct resection of the pedicle through an open incision
b. Reassurance that atrophy will take care of the problem during the next
year
c. Suction-assisted lipectomy of the fat overlying the pedicle
d. Exploration for and division of the eighth intercostal nerve at the costal
margin
2. A thin patient with a history of smoking undergoes pedicled TRAM ap recon-
struction and develops skin and fat necrosis laterally involving almost 50% of
the ap.The necrotic area is resected and an immediate latissimus dorsi salvage
is performed. Her latissimus dorsi donor site yields enough surface area to cover
the defect but it is clear at operation that a small implant will be required to re-
store adequate volume for symmetry.
a. An implant should be inserted immediately beneath the ap
b. An expander should be inserted immediately
c. An implant should be inserted once the latissimus ap is healed and the
wound is stable
d. The necrotic tissue should be debrided and an expander implant (Becker)
device should be inserted beneath the TRAM ap for subsequent volume
replacement.
3. A patient has a pedicled TRAM ap performed with good size and shape match
initially. She develops early and progressive infraclavicular hollowing with wors-
ening lower pole fullness and descent. By 6 months postoperatively the defor-
mity has stabilized but the patient is unhappy and requests revision.
a. An anatomic implant should be placed to ll the infraclavicular hollow
and the lower pole of the TRAM ap should be resected
b. The ap should be dissected off the overlying mastectomy skin and re-
elevated with careful suturing of the ap to the upper pole pectoral mus-
cle superiorly and medially to provide correct anatomic positioning of
the ap.
c. The upper pole should be injected with fat using the Coleman technique
and the lower pole should be suctioned to reduce volume
d. A segmental latissimus ap should be used to provide infraclavicular ll
with resection or suctioning of the lower pole of the TRAM ap
R EVIEW QUESTIONS

1410
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R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
4. A slim patient with a two pack per day smoking history has a skin sparing mas-
tectomy on the right side and a TRAM ap reconstruction which fails as a re-
sult of progressive fat and skin necrosis. A third of the mastectomy skin flap
necroses in the outer lower quadrant.The ap is debrided and the wound is al-
lowed to heal. She desires reconstruction and another surgeon performs a latis-
simus dorsi myocutaneous ap reconstruction with underlying expander, resect-
ing more native breast skin inferiorly in the process. Unfortunately the pedicle
is inadvertently twisted during ap transposition and the ap undergoes total
ischemic necrosis. It is debrided and the wound allowed to heal. The patient
still wants breast reconstruction. Her buttocks are small, and she is reluctant to
use them as a donor site.Which of the following options would be most appro-
priate for her?
a. A tissue expander with subsequent implant exchange
b. A contralateral free latissimus ap to the ipsilateral internal mammary ves-
sels on the right side
c. A contralateral free latissimus ap to the ipsilateral thoracodorsal vascular
stump
d. A free Rubens ap
5. A 55-year-old patient with grade 3 ptosis and thin skin has a bilateral implant re-
construction complicated by visible rippling and wrinkling of her cohesive gel-
lled implants. Bilateral latissimus dorsi muscle aps are transposed beneath the
skin to act as padding between the implants and the skin. The thoracodorsal
nerves are left intact to maintain muscle bulk. Six months postoperatively the pa-
tient is well healed and her implants are not visibly wrinkled, but her skin de-
velops a bizarre, rippled appearance whenever she moves her arms back. The
most appropriate intervention would be:
a. Do nothing and reassure her that the problem will settle
b. Replace the implants with overin ated saline lled devices
c. Replace the implants with deepithelialized TRAM aps
d. Explore the axillas and divide the thoracodorsal nerves to fully denervate
the muscles

1411
Reoperation Following
Free Flap Breast Reconstruction
James C. Grotting
C ha pter 3 7
Reoperative Problems
Failing free ap
Inframammary fold irregularities
Donor site contour irregularities
Missing axillary fold
Hernia
Inadequate central breast projection
Breast contour de ciencies
Breast mound asymmetry
or excesses
Nipple-areola deformities
Scars
Partial or total ap failure
Peripheral nerve injuries
Breast reconstruction is like a love affair:
Any fool can start it, but it takes a genius to end it.
Robert M. Goldwyn, MD
Free flap breast reconstruction remains a staged procedure for most surgeons;
therefore reoperations and revisions play an important role in planning and execut-
ing microsurgical breast reconstruction.There is considerable wisdom in Dr. Gold-
wyn’s quotation. Many surgeons nd it easier to successfully accomplish the free
tissue transfer to the chest wall than to secondarily mold the tissue into an aes-
thetically pleasing breast shape.

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Microsurgical breast reconstruction encompasses microsurgical skills and princi-
ples of aesthetic surgery, oncologic surgery, and general reconstructive surgery. As
such, it is one of the most challenging yet satisfying areas of our specialty. It de-
mands great attention to aesthetic details, yet the surgeon must not lose sight of
the fact that the patient has or has had breast cancer and is at risk for recurrence and
death. The surgeon must keep the “big picture” in mind, because some patients
may escape from concerns about the cancer by becoming deluded by false expec-
tations or by inappropriately worrying about minute details of the reconstruction.1,2
One must resist the urge to perform any procedure that is oncologically ill-advised
to achieve only a small improvement in aesthetics.
During initial consultation, patients should be counseled about the staged nature of
microsurgical breast reconstruction. Patients presenting for delayed breast recon-
struction are psychologically prepared for a second procedure, after they have recov-
ered from the initial mastectomy. However, patients who undergo immediate breast
reconstruction may never have had previous surgery and, unless well counseled,
may be reluctant to proceed with revisions and secondary surgery. Many times the
extent of secondary surgery after microsurgical breast reconstruction can be esti-
mated by carefully examining the ap donor site before breast mound construction.
Although we strive to achieve symmetry in the primary operation, sometimes a
ap cannot be safely trimmed to match the opposite breast without risking com-
promise of circulation. For example, a thick free TRAM ap, in which overcorrec-
tion of the upper pole is necessary because the ap is too thick in this area, must be
trimmed secondarily. To preserve the venous drainage of the ap, thinning should
be confined to the region beneath Scarpa’s fascia. However, occasionally the
amount of tissue beneath Scarpa’s fascia is limited, thereby necessitating second-
stage thinning rather than primary contouring. By carefully examining the thick-
nesses of the ap zones preoperatively and comparing the contour of the opposite
breast, this problem can be minimized by carefully planning which portion of the
ap will be used to reconstruct each segment of the breast.
The causes for reoperation in microsurgical breast reconstruction generally fall into
these following categories:(1) acute complications involving ap viability or bleed-
ing,(2) donor site problems,(3) improving the breast mound shape,(4) nipple-areola
complex reconstruction, (5) malpositioned or hypertrophic scars, and (6) mis-
cellaneous problems, including peripheral neuropathy and masses caused by fat
necrosis.
Each ap has an intrinsic set of potential problems, depending on donor site, recip-
ient site, and ap characteristics. For example, revisional breast mound surgery fol-
lowing a free TRAM ap might include attempts to increase projection, whereas
the gluteal ap, because of its inherent thickness, may overproject but fail to ll the
infraclavicular hollow as well as the free TRAM ap might. These compromises
are taken into consideration when the initial ap is chosen and will have an impact
the type and extent of secondary surgery required.

1413
Chapter 37
Reoperation Following Free Flap Breast Reconstruction
The free TRAM ap and the DIEP technique are the procedures of choice for
most patients undergoing microsurgical breast reconstruction.3-9 Although many
other aps have been used (see box), the free TRAM ap and the DIEP ap remain
the most suitable because of available donor tissue in the lower abdomen of most
postpartum women.10 For this reason most of this chapter relates to the free TRAM
ap. Speci c problems with other more common aps are discussed under separate
subheadings.
Transverse rectus abdominis musculo-
cutaneous (TRAM) ap11-19
Tensor fascia lata ap20
Lateral transverse thigh ap21
Lateral vertical thigh ap20
Superior gluteus ap22-25
Inferior gluteus ap26,27
Extended inferior gluteus (trefoil) ap28
Super cial inferior epigastric artery
(SIEA) ap29,30
Deep inferior epigastric perforator
(DIEP) ap3,4,7,8,19,31-35
Free Flap Options for Breast Reconstruction
Compiled from Blondeel PN, Beyens G,Verhaeghe R, et al. Doppler owmetry in the planning of perforator aps.
Br J Plast Surg 51:202-209, 1998;Taylor GI, Daniel RK.The anatomy of several free ap donor sites. Plast Recon-
str Surg 56:243-253, 1975; and Carramenha e Costa MA, Carriquiry C,Vasconez LO, et al. An anatomic study of
the venous drainage of the transverse rectus abdominis musculocutaneous ap. Plast Reconstr Surg 79:208-217,
1987.
Superior gluteal artery perforator
(SGAP) ap36
Inferior gluteal artery perforator
(IGAP) ap36
Latissimus dorsi perforator ap36
Groin ap37,38
Rubens’ ap39,40
Transverse gracilis ap41
Contralateral latissimus dorsi ap38,42
Lateral thoracic opposite breast ap43,44
Omental ap17
TIMING
Timing revisional surgery for microsurgical breast reconstruction is dictated by sev-
eral factors. If the original operation was performed as an immediate breast recon-
struction, then factors such as the adjunctive treatment of the breast cancer must be
considered. Our oncologists prefer to begin chemotherapy approximately 4 weeks
following the mastectomy and reconstruction. Not all wounds need to be totally
healed to initiate chemotherapy—proceeding with adjunctive treatment is more
important. As long as an open wound is kept well debrided and clean with dress-
ing changes, the wound will continue to heal, even in a patient immunosuppressed
by chemotherapy.
If a patient is a candidate for postoperative chemotherapy, we prefer to delay all re-
visional surgery until at least 1 month following completion of the treatment.This
allows time for the blood cell counts to return to normal before elective revisional
surgery is performed.

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PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
Postoperative radiotherapy to the chest wall is much less common in the immedi-
ate reconstruction group. I prefer to not perform immediate reconstruction in any
patient who might be a candidate for radiation to the chest wall. However, if a ap
reconstruction has been performed, and postoperative radiotherapy is required, re-
visional surgery should be delayed until all visible evidence of the acute effects of
radiation has disappeared. As a general rule, when the tissues are soft with no visi-
ble swelling or erythema, it is safe to proceed with secondary surgery.
This 40-year-old patient is an example of how radiation in uences the timing of
secondary surgery. She required postoperative radiotherapy following mastectomy
and immediate bilateral reconstruction using lateral vertical thigh aps. Once the
radiotherapy had been completed and the erythema and edema had subsided,
mound revision and nipple-areola reconstruction were performed.
For patients receiving immediate reconstruction who do not receive postoperative
chemotherapy or radiation treatment, secondary revisions are timed much like those
for patients undergoing delayed reconstruction. When the tissues have reached
“equilibrium”—are soft, pliable, and maximally elastic—they are maximally re-
sponsive to reoperative maneuvers.
In microsurgical breast reconstruction, I nd that about 3 months af-
ter the rst operation the patient is psychologically ready, and the tis-
sues have settled enough to allow for accurate planning and execution
of secondary procedures on the breast mound.
I prefer to complete microsurgical breast reconstruction in two operations. In the
rst procedure the ap is transferred and shaped to obtain symmetry with the op-
posite side as nearly as possible. I prefer to perform opposite breast revisions at the
time of the initial reconstruction because it is easier to match a corrected opposite
breast than it is to begin modifying it at the time of the secondary revisions on the

1415
Chapter 37
Reoperation Following Free Flap Breast Reconstruction
reconstructed side. One of the advantages of microsurgical breast reconstruction is
that aps can be liberally shaped, sutured, and folded to gain symmetry in the rst
operation. However, it is a rare event in my practice to have a reconstructed breast
mound that is so perfect that it would not bene t from a secondary revision, no
matter how minor.The planned second-stage revision plays a key role in achieving
excellent results with microsurgical breast reconstruction. Small alterations in shape
and contour of the breast mound, nipple-areola reconstruction, and opposite breast
revisions often can elevate a good reconstruction to a superior one.
PLANNING
The principles of planning any reoperation are problem speci c: the goal of the
procedure dictates the approach. For example, if faced with a failing free ap, the
surgeon must anticipate the possible need for vein grafts and discuss this option
with the patient as well as prepare a donor site in the operative eld.
The surgeon must also anticipate how one maneuver might affect another. For ex-
ample, if excising a widened superior mastectomy scar and a nipple-areola recon-
struction are planned, the latter procedure must be done second. If nipple-areola re-
construction is performed rst, the nal position of the nipple and areola would
necessarily be raised by the amount that the scar is narrowed, whereas if the scar is
revised rst, the nipple will almost always be in the correct location. As a rule, all
breast mound revisions must be completed before setting the nipple-areola complex.
Some groups advocate single-stage breast reconstruction, completing nipple-areola
reconstruction at the time of initial ap transfer. Of course, single-stage procedures
may still require revisions, but we nd it dif cult to make any substantial correction
of nipple position. Because a second procedure is a great opportunity to accomplish
small improvements in breast shape, projection, symmetry, and donor site contours,
we prefer to retain the second detailing procedure as a key component of the re-
construction sequence.
One additional judgment that must be considered is whether nipple-areola recon-
struction can be accomplished at the same time as a major revision of the breast
mound.
If mound revision requires major alterations such as placing an im-
plant beneath the free ap or considerably reducing its size, it is often
better to delay nipple-areola reconstruction until nal settling of the
mound has occurred.
With proper attention to the details of shaping in the rst operation, the need for
major revisions and third-stage procedures can be minimized.

1416
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
GOALS OF TREATMENT
When acute complications occur, the patient is usually faced with an emergent re-
turn to the operating room, and she must yield to the judgment of her surgeon en-
tirely. Conversely, the patient plays a much greater role in determining the reoper-
ative plan for refinements and revisions. After a patient has lived with a newly
reconstructed breast for several months, she can usually point out very speci c ar-
eas that continue to trouble her. The surgeon must listen carefully to these con-
cerns, because they should be the primary in uence on the approach that is taken.
Imperfections that the surgeon notices may cause the patient little concern, and
she may have no interest in undergoing additional procedures simply to enhance
the surgeon’s postoperative photographs. However, after the patient explains what
she would like to achieve with reoperative surgery, and the surgeon has evaluated
his goals and capabilities, an understanding of the expected result can be agreed on.
SPECIFIC PROBLEMS
THE FAILING FREE FLAP
Unfortunately, microsurgery and occasional microvascular thrombosis go hand in
hand. A failing free ap breast reconstruction represents a plastic surgical emer-
gency, and a return to the operating room is virtually always indicated. Under-
standably, this event is unnerving for both surgeon and patient.Yet at present there
is no other way to salvage a ap that is failing from either microarterial or venous
thrombosis.
However, the situation can be viewed optimistically: with timely return of the pa-
tient to the operating room, failing free aps can almost always be salvaged. In our
series of more than 220 free ap breast reconstructions, nine patients required re-
exploration because of evidence of thrombosis, and the aps were salvaged in every
case. We attribute this success in part to vigilant postoperative monitoring (see p.
1417);however, other important factors played a role. Because aps used for breast
reconstruction are mostly fat and skin, the aps can tolerate a long ischemic period
without irreversible tissue death. The muscle contained in these flaps generally
serves as a conduit for the major vascular pedicle.
Portions of the muscle carrier can experience ischemic necrosis without compro-
mising the vascular pedicle that traverses it. For this reason, in most cases a micro-
surgeon reexploring a failing free ap breast reconstruction can be optimistic that
the problem can be corrected.

1417
Chapter 37
Reoperation Following Free Flap Breast Reconstruction
Our most reliable monitoring system continues to be visual and tactile inspection
combined with using a handheld conventional Doppler device. Flaps are inspected
at hourly intervals for the rst 24 hours postoperatively, at 2-hour intervals for the
next 24 hours, and then every 4 hours for the next 2 days. The examiner inspects
color, temperature, capillary refill, and turgor of any exposed skin island. The
Doppler device is used to detect the typical sounds of arterial ow and, more im-
portantly, venous out ow. If the typical undulating continuous sound of venous
out ow is heard, one can be assured that both the artery and vein are open. If only
the arterial signal is detected, the vein may have failed. Fortunately, when a skin is-
land is left exposed, ap circulation can be assessed easily both visually and tactilely.
For this reason we always leave at least a small skin island or area of the ap exposed
so that if the circulation is in doubt, active bleeding can be veri ed with a needle
prick or No. 11 blade stab wound.
In our experience, aps that are most likely to thrombose postoperatively are those
that developed intraoperative technical problems (for example, if the arterial or ve-
nous anastomosis is revised intraoperatively to establish initial flow). Sometimes
mechanical factors play a role, such as a small branch off the pedicle that was divided
and is producing localized vasospasm. Anastomoses under tension have a high rate
of failure. Sometimes vessels kink following ow restoration, causing turbulence
and platelet aggregation. Also, pressure from a tight dressing or patient positioning
can compress the pedicle and lead to thrombosis. I am aware of two cases of axil-
lary pedicle avulsion in the early postoperative period apparently caused by pa-
tients reaching with the ipsilateral arm. None of our patients has experienced this
complication; however as a precaution we instruct our patients to maintain the
shoulder between 20 and 90 degrees of abduction for the rst 10 days postopera-
tively.
Our approach to treating a failing free ap breast reconstruction is to immediately
return the patient to the operating room. We usually administer heparin systemi-
cally with a bolus of 3000 to 5000 U. If the ap is pale and cool, one should sus-
pect an arterial thrombosis. If the ap is edematous and cyanotic, a venous throm-
FLAP MONITORING
Color
Turgor
Temperature
Capillary re ll
Doppler ultrasonography
(artery and vein)

1418
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
bosis is usually the cause. Dark venous blood exiting from the suction drains also
suggests a venous out ow problem.
The patient is positioned as for the initial free ap transfer, with the ipsilateral arm
prepared and draped free on an arm board. Placing an additional pad posterior to
the shoulder helps elevate the axillary contents slightly. Because microvascular re-
visions might require a vein graft to replace the thrombosed segment, we usually
prepare a donor site for that as well. In most cases I use the saphenous vein at the
ankle or one of the tributaries to the saphenous system in the upper medial thigh.
The ipsilateral cephalic vein might also be considered as a graft or as an alternate re-
cipient vein.
The vascular pedicle can usually be accessed by simply opening the lateral portion
of the wound. Often the entire incision must be opened to place retractors ade-
quately for reaching the segment of the pedicle that requires repair. If it exists, the
second deep inferior epigastric vein can be used to vent the built-up pressure of a
venous thrombosis;simply cut off the end of the clip while the pedicle is examined
under the microscope. If the ap pedicle has been thrombosed for many hours, a
longer segment of thrombosis may be encountered in either the artery or the vein.
Under these circumstances it is better to resect the segment and replace it with a
vein graft than risk placing any tension on the repair. Once the microvascular re-
pairs are completed, the incision is reclosed, and heparin is administered for 2 to 4
days, depending on the level of concern about the patient’s coagulation status.
Twenty-four hours after undergoing immediate reconstruction of the right breast
using a free TRAM ap, this patient presented with cyanotic discoloration of the
ap. She was returned to the operating room to correct venous out ow obstruc-
tion. Interestingly, the patient had had a venous thrombosis intraoperatively during
the primary procedure that required a revision of the anastomosis. On reexplo-
ration, the vein was found to be thrombosed again; it was replaced with a segment
of reversed saphenous vein from the ankle. Postoperatively, she had an uneventful
course and healing ultimately occurred.

1419
Chapter 37
Reoperation Following Free Flap Breast Reconstruction
If the ischemic interval has been long, some degree of fat necrosis or fat atrophy can
be anticipated over 3 to 6 months. Secondary revision in these patients is best post-
poned until the ap has maximally settled and softened.
HEMATOMA
Hematomas can occur following free ap breast reconstruction just as they can af-
ter virtually any surgical procedure. Although most hematomas are considered mi-
nor complications, one of the possible consequences of a hematoma in a free ap
breast reconstruction is critical compromise of the vascular pedicle. In addition, the
hematoma could be caused by leakage from the microvascular arterial or venous
anastomosis or the small branches therefrom. It is usually best to return these pa-
tients to the operating room for operative exploration.The hematoma may be re-
vealed by increased output from either the donor site or recipient site drains. If a
drain under or near the ap is collecting dark venous blood, a venous out ow ob-
struction may be present. For this reason the microvascular anastomosis must be
examined carefully during reexploration.
Not uncommonly, the source of the hematoma cannot be found when the area is
reexplored. It is best to remove all of the incisions and carefully mobilize the un-
dersurface of the ap to look for a “pumper.” There is nothing more frustrating
than to drain a hematoma, reclose the wound, and return the patient to her room,
only to nd that bleeding recurs.
DEEP VEIN THROMBOSIS AND PULMONARY EMBOLUS
Deep vein thrombosis and pulmonary embolus are very rarely reoperative condi-
tions, but their recognition and treatment could be lifesaving. The spectrum of
presentation can be unnerving. The condition can be totally asymptomatic, pro-
gressing quickly to cardiovascular collapse and respiratory arrest.The most common
presentation of deep vein thrombosis is a gradual unilateral swelling of the leg,
which may become tender to deep palpation. Proximal thigh deep vein thrombo-
sis is serious because of its propensity for producing emboli. Doppler duplex scan-
ning of the pelvis and lower extremity is the best diagnostic test to use initially be-
cause it is noninvasive and reliable. If Doppler studies are equivocal, phlebography
should be considered.
Pulmonary embolus classically presents with a pleuritic chest pain, hyperpnea or
dyspnea, and a left-axis shift on ECG readouts. Pulmonary angiography is de ni-
tive for diagnosing pulmonary embolus and may also be used for infusion of clot-
lysing substances. A ventilation perfusion scan is a rst-line diagnostic procedure.
Administering enoxaparin (Lovenox) immediately on suspecting pulmonary
thromboembolism may halt further progression of the clotting process.

1420
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
Prevention is the key to avoiding these two life-threatening complications. A sur-
gical team must be ever alert for these problems and maneuver to reduce their in-
cidence.
The patient is most vulnerable to developing a nidus of thrombus in
the venous sinuses of the lower extremity while anesthesia is being
induced.
For this reason prophylaxis is begun preoperatively by administering 5000 U of
heparin subcutaneously 30 minutes before inducting anesthesia.The patient is t-
ted with long leg-support stockings and a sequential pneumatic compression pump
device that must be activated during induction. Pneumatic compression is contin-
ued until the third postoperative day when the patient spends long periods up at the
bedside. She is encouraged to be up at the bedside during the rst 24 hours; she is
told to ex and extend the feet while in bed to maintain the normal pumping ac-
tion of the calf muscles. Subcutaneous heparin administration is not continued
postoperatively because of possible bleeding complications. Aspirin (325 mg) is
given once daily and continued as antiplatelet therapy for 2 months. We have not
added enoxaparin to the preventive regimen, but this may be considered.
SEROMA
Persistent seromas rarely occur with free ap breast reconstruction as long as ade-
quate drains are inserted initially and left in place until output is minimal. Two
drains are positioned beneath the ap with at least one in the axilla.We usually in-
sert at least two drains in the donor site as well.When a recurrent seroma does de-
velop, repeated aspiration is not as effective as simply placing another drain. Persis-
tent seromas are much more common in latissimus dorsi or lateral thigh donor sites.
We encountered one extremely unusual complication from simple drainage of an
axillary seroma. A 38-year-old patient underwent bilateral simple mastectomy with
immediate reconstruction using bilateral microvascular free TRAM aps. She recov-
ered exceedingly well and was discharged on the fth postoperative day. Drainage
from the axillary area and all of the other drains diminished to less than 30 ml per
day, and the drains were removed by the tenth postoperative day. By the time she
returned 1 week later for follow-up, an obvious seroma in the right axilla had de-
veloped. A Penrose drain was placed under sterile conditions in the of ce, and ap-
proximately 60 ml of straw-colored uid was drained. Six days after placing the
drain, the patient presented with a short history of fever to 40° C (104° F) and
shaking chills. During examination in the of ce, the patient was lethargic, mildly
hypotensive, and tachycardic. She had no symptoms of pain or tenderness. She was
admitted to the hospital, a full range of culture studies was performed, and broad-

1421
Chapter 37
Reoperation Following Free Flap Breast Reconstruction
spectrum antibiotics were administered. Staphylococcus aureus was eventually recov-
ered from both the blood and the drainage from the right axillary seroma; the di-
agnosis was staphylococcal toxic shock syndrome.The patient ultimately recovered
without sequelae.
INFECTION
Infection following free ap breast reconstruction is unusual. Nevertheless, infection
will present from time to time as cellulitis involving either the breast or the abdo-
men. Interestingly, most cases of cellulitis occur late after ap transfer (after 30 days).
This 32-year-old patient had previously undergone subcutaneous mastectomies
and implant reconstruction but had recurrent deformity and implant rupture. She
underwent bilateral implant removal and reconstruction using bilateral buried free
TRAM aps. Two months postoperatively she presented with swelling and ery-
thema of the right reconstructed breast. Most likely this was caused by an infection
from either retained implant material or possibly inadequate deepithelialization of
the buried ap.The patient responded quickly to systemic antibiotics.
Patients who undergo chemotherapy following immediate free ap breast recon-
struction seem to be slightly more susceptible to infection. Fortunately, such patients
generally respond rapidly to intravenous antibiotics and local care if an open wound
is present. In rare instances a collection may need to be drained.
Alloplastic mesh used to reinforce the abdominal wall closure following free TRAM
ap transfer may serve as a nidus of infection. Infection usually results when the
mesh is exposed following partial loss of the random abdominal skin ap. In this sit-
uation, it is not always essential that the mesh be removed. In fact, most of the mesh
may already be well incorporated;simply treating the wound with dressing changes
and antibiotics will allow it to granulate. Any excess edges or loose pieces of mesh
should be debrided like any other foreign body.

1422
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
On rare occasions, the mesh may be completely involved with infection (see Chap-
ter 44). A loose sheet of mesh or purulence involving the entire surface of the mesh
is an indication for its removal. It is usually best to remove the mesh and leave a
temporary hernia until the infection is under control and the tissues are healed and
soft. At that point, elective repair with autogenous tissue is preferred. If inadequate
local tissue is available, a fresh sheet of clean mesh can be inserted.
FAT NECROSIS
Fat necrosis following free ap reconstruction has not been observed to the same
extent as that following pedicle flaps. The incidence of fat necrosis among free
TRAM ap breast reconstruction patients is less than 2%.40,45 However, when fat
necrosis does occur, it usually results from one of the following:(1) inadequate ap
trimming during initial transfer (occurs in the distalmost random portions of the
ap), (2) attempts to preserve ap tissue on the opposite side of a previous scar that
divides the ap, (3) postoperative thrombosis that requires a ap salvage procedure.
Some degree of rmness may be observed in free ap breast reconstruction pa-
tients in the rst 2 months. However, these rm areas virtually always soften over
time, and nothing surgical needs to be done. However, a few patients will be left
with varying degrees of “stony-like” rm areas that may bene t from excision.The
main problem with not excising these areas is that the patient continues to be con-
cerned and fears the return of breast cancer. Similarly, oncologists and other exam-
ining physicians may be confused by these areas and may not understand the ration-
ale in leaving them alone. Therefore excision is usually the best option, and it can
be accomplished at the time of nipple-areola reconstruction or mound revision.
Baseline mammography of the reconstructed breast may reveal areas of microscopic
fat necrosis, indicated by typical calci cations. However, these calci cations are not
clinically signi cant and need not be further treated.
PARTIAL OR COMPLETE FLAP LOSS
Although partial ap loss is much more common with pedicle aps, it may occur
with free aps. The incidences of both fat necrosis and partial ap loss have been
considerably reduced in our experience by using the microvascular free ap proce-
dure rather than the pedicle ap procedure. Depending on the degree of ap loss,
various treatments might be required. If tissue loss is minor, it can usually be treated
conservatively and allowed to heal secondarily. For minor de ciencies it is often
possible to shift excess ap tissue into the de ciency from another quadrant to gain
symmetry.

1423
Chapter 37
Reoperation Following Free Flap Breast Reconstruction
This patient underwent delayed breast reconstruction using a microvascular free
TRAM ap. No previous abdominal surgery had been performed. Nevertheless,
circulation was marginal to the distalmost aspect of the ap, resulting in marginal
necrosis of the TRAM skin island with an area of fat necrosis beneath it as shown
2 weeks postoperatively.
Eight weeks postoperatively the rm area of fat necrosis was excised, and the ap
was advanced, creating a satisfactory result.
If ap loss is major, either an implant or a second ap may be required to round out
the breast mound.These techniques are discussed in Chapter 36;the techniques for
pedicle aps and free aps are similar. However, consideration must be given to us-
ing the ipsilateral latissimus dorsi ap, based on which recipient vessels were used for
the free ap transfer. My preference has been to use the thoracodorsal vessels end-
to-end for the free ap transfer.This vessel con guration preserves the serratus col-
lateral branch, which is able to provide axial ow to the latissimus dorsi muscle fol-
lowing division of the thoracodorsal pedicle. Therefore, if I am certain that this
collateral artery is intact, I do not hesitate to use the ipsilateral latissimus dorsi ap
to ll out a de cient mound when required. Color laser Doppler examination or
arteriography might be considered for clarifying the vascular anatomy.

1424
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
Total ap failure is, and should be, an exceedingly rare event. Nevertheless, the pos-
sibility must be carefully discussed preoperatively with each patient. In the event
that this were to occur, there is little choice but to debride the ap and attempt sec-
ondary wound closure. I prefer to delay a secondary attempt of breast reconstruc-
tion until the chest wall tissues have been allowed to completely heal and soften.
The secondary alternatives for ap reconstruction discussed in Chapter 36 also ap-
ply here. However, the factors that led to the choice of the free tissue transfer for the
primary operation might in uence the choice of a secondary procedure. A second
microvascular transfer may need to be considered if the medical and psychological
condition of the patient allows it.
Even though this patient was operated on 13 years ago,
she still represents the worst case of random ap necro-
sis that I have encountered. Because of her history of
steroid-dependent mixed connective tissue disease, we
elected immediate reconstruction using autogenous tis-
sue. A microvascular free TRAM flap was performed
with complete ap survival. However, the random aps,
including both the superior mastectomy flap and the
abdominal flap, underwent full-thickness ischemic
necrosis.These wounds gradually healed over the next 6
months.